Complaint to Chiropractic Board of Australia about Barham Chiropractic …€¦ · In May 2010 the...

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Complaint to Chiropractic Board of Australia about Barham Chiropractic Clinics Page 1 of 11 The following chiropractors are listed on the Barham Clinic web site (http://barhamchiro.com.au/) and presumably are collectively responsible for its content: Dr Chris Barham CHI0001358745 Registered at: TOOWOOMBA CITY QLD 4350 Practice at: 222 Herries St, Toowoomba QLD 4350, Dr Daniel Barham CHI0001952680 Registered at: TOOWOOMBA CITY QLD 4350 Practice at: 16 Herbert St, Goondiwindi QLD 4390 Ms Emma Barham CHI0001683259 Registered at: TOOWOOMBA CITY QLD 4350 Practice at: 55 North St, Gatton QLD 4343 & 16 Herbert St, Goondiwindi QLD 4390 & 222 Herries St, Toowoomba QLD 4350, Dr Mary Lou Barham CHI0001389508 Registered at: TOOWOOMBA CITY QLD 4350 Practice at: 222 Herries St, Toowoomba QLD 4350, Brent Von Blankensee CHI0000955965 Registered at: TOOWOOMBA CITY QLD 4350 Practice at: 222 Herries St, Toowoomba QLD 4350 Dr Doug Clarke CHI0000957536 Registered at: KINGAROY QLD 4610 Practice at: 221 Haly St, Kingaroy QLD 4610 Dr Gavin Crouch CHI0001399023 Registered at: WAVELL HEIGHTS QLD 4012 Practice at: 225 Shaw Rd, Wavell Heights QLD 4012 No longer works there Dr Laura Harding CHI0001875973 Registered at: KINGAROY QLD 4610 Practice at: 221 Haly St, Kingaroy QLD 4610 Dr Shaka Hatcher CHI0000971772 Registered at: MOOLOOLABA QLD 4557 Practice at: 1/168 Brisbane Rd, Mooloolaba QLD 4557 Ms Alexandra Skjervheim CHI0001957948 Registered at: ALBANY CREEK QLD 4035 Practice at: 2/717 Albany Creek Road Mr Matt Wild CHI0001954335 Registered at: WAVELL HEIGHTS QLD 4012 Practice at: 225 Shaw Rd, Wavell Heights QLD 4012 Dr James Winyard CHI0000952772 Registered at WISHART QLD 4122 Practice at: 15/590 Mt Gravatt Capalaba Road, Wishart QLD 4122 We allege that certain claims made by the above chiropractors on their web site breach Section 133 of the National Law that prohibits advertising that: is false, misleading or deceptive or is likely to be so; creates an unreasonable expectation of beneficial treatment, and encourages the indiscriminate or unnecessary use of health services.

Transcript of Complaint to Chiropractic Board of Australia about Barham Chiropractic …€¦ · In May 2010 the...

Page 1: Complaint to Chiropractic Board of Australia about Barham Chiropractic …€¦ · In May 2010 the General Chiropractic Counc il, the statutory regulatory body for chiropractors in

Complaint to Chiropractic Board of Australia about Barham Chiropractic Clinics

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The following chiropractors are listed on the Barham Clinic web site (http://barhamchiro.com.au/) and presumably are collectively responsible for its content:

Dr Chris Barham CHI0001358745 Registered at: TOOWOOMBA CITY QLD 4350 Practice at: 222 Herries St, Toowoomba QLD 4350,

Dr Daniel Barham CHI0001952680 Registered at: TOOWOOMBA CITY QLD 4350 Practice at: 16 Herbert St, Goondiwindi QLD 4390

Ms Emma Barham CHI0001683259 Registered at: TOOWOOMBA CITY QLD 4350 Practice at: 55 North St, Gatton QLD 4343 & 16 Herbert St, Goondiwindi QLD 4390 & 222 Herries St, Toowoomba QLD 4350,

Dr Mary Lou Barham CHI0001389508 Registered at: TOOWOOMBA CITY QLD 4350 Practice at: 222 Herries St, Toowoomba QLD 4350,

Brent Von Blankensee CHI0000955965 Registered at: TOOWOOMBA CITY QLD 4350 Practice at: 222 Herries St, Toowoomba QLD 4350

Dr Doug Clarke CHI0000957536 Registered at: KINGAROY QLD 4610 Practice at: 221 Haly St, Kingaroy QLD 4610

Dr Gavin Crouch CHI0001399023 Registered at: WAVELL HEIGHTS QLD 4012 Practice at: 225 Shaw Rd, Wavell Heights QLD 4012

No longer works there

Dr Laura Harding CHI0001875973 Registered at: KINGAROY QLD 4610 Practice at: 221 Haly St, Kingaroy QLD 4610

Dr Shaka Hatcher CHI0000971772 Registered at: MOOLOOLABA QLD 4557 Practice at: 1/168 Brisbane Rd, Mooloolaba QLD 4557

Ms Alexandra Skjervheim CHI0001957948 Registered at: ALBANY CREEK QLD 4035 Practice at: 2/717 Albany Creek Road

Mr Matt Wild CHI0001954335 Registered at: WAVELL HEIGHTS QLD 4012 Practice at: 225 Shaw Rd, Wavell Heights QLD 4012

Dr James Winyard CHI0000952772 Registered at WISHART QLD 4122 Practice at: 15/590 Mt Gravatt Capalaba Road, Wishart QLD 4122

We allege that certain claims made by the above chiropractors on their web site breach Section 133 of the National Law that prohibits advertising that:

• is false, misleading or deceptive or is likely to be so;• creates an unreasonable expectation of beneficial treatment, and• encourages the indiscriminate or unnecessary use of health services.

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We also believe that the claims documented below are not in accord with the Chiropractic Board of Australia, Code of Conduct, (March 2014):

• s.2.2 (g): providing treatment/care options based on the best available information and practising in an evidence-based context and not being influenced by financial gain or incentives;

• s.2.4 (d): investigating and treating patients on the basis of clinical need and the effectiveness of the proposed investigations or treatment/care, providing necessary services and not providing unnecessary services or encouraging the indiscriminate or unnecessary use of health services, and

• s.9.6 (a): complying with the National Board’s Guidelines on advertising regulated health services, (the Advertising guidelines) and relevant state and territory legislation and Commonwealth law;

• s.9.6 (b) making sure that any information published about services is factual and verifiable.

The details of these allegations follow.

Claim 1: Screenshot 1 (from: http://barhamchiro.com.au/can-barham-help-me/)

Comment: We are unaware of any good scientific evidence that supports this claim which appears to promote routine chiropractic examination and manipulation in the absence of patient symptoms.

Conclusion Claim 1: “Everybody, from a newborn baby to the very elderly, can benefit from having their spine checked and adjusted to ensure their body functions at its best” lacks substantiation and thus is in breach of s.6.2 of the AHPRA Advertising Guidelines for Registered Health Practitioners (March 2014) and also the Chiropractic Board of Australia Code of Conduct (March 2014), s.2.2 (g), ss2.4 (d) and s.9.6 (a) & (b).

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Claims 2: Screenshot 2 (from: http://barhamchiro.com.au/can-barham-help-me/)

The above marketing video comes from: http://www.educhiro.com/ and is also found on a number of other chiropractor web sites

The following transcript starts at 01.45 min.

“If the spine is not moving freely it's referred to as a vertebral subluxation complex or for short a subluxation. This is where two or more vertebrae have lost their normal motion and or position. This can cause interruption to the normal nerve flow and interfere with the communication from the brain to the body and from the body back to the brain.

So what happens when you have a subluxation? That area can start to degenerate in as little as two weeks. This degeneration causes scar tissue to develop which leads to more scar tissue. This degenerative process can continue as long as the immobilisation is present. And this type of degeneration is preventable.

Subluxations can interfere with normal communication between the brain and the body. So, for example, the nerve supply from your neck goes to the immune system, pituitary gland, sinuses, face, middle and inner ear, eyes, tonsils, neck teeth and shoulder muscles...”

Comment: In 2005 in an article titled, “Subluxation: dogma or science?” Keating JC, et al,1 said:

“The dogma of subluxation is perhaps the greatest single barrier to professional development for chiropractors. It skews the practice of the art in directions that bring ridicule from the scientific community and uncertainty among the public. Failure to challenge subluxation dogma perpetuates a marketing tradition that inevitably prompts charges of quackery. Subluxation dogma leads to legal and political strategies that may amount to a house of cards and warp the profession's sense of self and of mission. Commitment to this dogma undermines the motivation for scientific investigation of subluxation as hypothesis, and so perpetuates the cycle.”

1 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1208927/

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In May 2010 the General Chiropractic Council, the statutory regulatory body for chiropractors in the United Kingdom, issued guidance for chiropractors stating that the chiropractic vertebral subluxation complex "is an historical concept" and "is not supported by any clinical research evidence that would allow claims to be made that it is the cause of disease.2 Chiropractors were also reminded that, when advertising, claims for chiropractic care “must be based on best research of the highest standard” only. (GCC Guidance on Advertising, March 2010) In addition, we are unaware of any scientific evidence that supports “degeneration” and “scar tissue” caused by a “vertebral subluxation complex” as shown graphically in the video and stated in the commentary.

An additional inaccuracy in this video is the statement that “the nerve supply from your neck goes to the”……“pituitary gland, sinuses, face, middle and inner ear, eyes, etc.” In fact, these areas are innervated by cranial nerves, not spinal nerves that emerge through the vertebrae.

Conclusion Claim 2: we assert that statements concerning the “vertebral subluxation complex” alleged to cause “degeneration” and “scar tissue” and the details of the “nerve supply from your neck” lack substantiation and thus are in breach of s.6.2 of the AHPRA Advertising Guidelines for Registered Health Practitioners (March 2014) and also the Chiropractic Board of Australia Code of Conduct (March 2014), s.2.2 (g), ss2.4 (d) and s.9.6 (a) & (b).

Claim 3 & 4: (from http://barhamchiro.com.au/faq/)

Comment: The N.Z report cited appears to be: “Chiropractic in New Zealand: Report of the Commission of Inquiry. (1979). Hasselberg PD, Government Printer, Wellington, New Zealand”.3

However, in 2002, sixty-two Canadian Neurologists issued a warning to the Canadian public and provincial governments about the dangers of neck manipulation.4 They noted that stroke and death due to neck manipulation has been reported in the scientific literature for over 50 years and that manipulation is one of the leading causes of stroke in the under 45-age group.

A 2007 literature review5 titled, “Adverse events associated with pediatric spinal manipulation: a systematic review” concluded that,

“Serious adverse events may be associated with pediatric spinal manipulation; neither causation nor incidence rates can be inferred from observational data. Conduct of a prospective population-based active surveillance study is required to properly assess the

2 http://www.gcc-uk.org/UserFiles/Docs/What%20Can%20I%20Expect/Vertebral%20Subluxation%20Complex.pdf 3 https://www.scribd.com/doc/273272858/CHIROPRACTIC-IN-NEW-ZEALAND-REPORT-1979 4 http://www.chirobase.org/15News/neurol.html 5 http://www.ncbi.nlm.nih.gov/pubmed/17178922

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possibility of rare, yet serious, adverse events as a result of spinal manipulation on pediatric patients”.

This review was updated in 20106 and the author concluded,

“There is currently insufficient research evidence related to adverse events and manual therapy. However, clinical studies and systematic reviews from adult patients undergoing manual therapy, particularly spinal manipulation report that mild to moderate adverse events are common and self-limiting. However serious adverse events are rare and much less than for medication commonly prescribed for these problems. More high quality research specifically addressing adverse events and pediatric manual therapy is needed”.

A 2012 literature review7 titled, “Adverse events from spinal manipulation in the pregnant and postpartum periods” recorded 4 cases of stroke following cervical manipulation (2 performed by chiropractors, 1 by a physiotherapist and one by a GP). It was concluded that while it was possible that such injuries are relatively rare, future research into efficacy of this treatment for these populations and the rates of occurrence of adverse events is necessary to determine whether or not this is true.

In 2014, Dr Laurie Tassell, president of the Chiropractors’ Association of Australia (CAA), reported that his association was working towards implementing an adverse events reporting system but, to-date, we have no information on whether this project has been implemented.8

A 2014 review, “Adverse Events of Massage Therapy in Pain-Related Conditions: A Systematic Review”9 noted,

“The real serious incidence of AEs [adverse events] has been estimated to be ranging from 5 strokes in 100,000 manipulations to 1.46 case series in 10 million manipulations, and a rate of 2.68 deaths in 10 million manipulations has been reported. The Danish insurance industry claimed data support a risk of stroke as 1 per 2 million manipulations. 99% of all chiropractors practicing in Denmark completed a survey; they estimated that one case of cerebrovascular accident occurred for every 1.3 million cervical treatment sessions. The occurrence increased to 1 in every 900,000 treatment sessions for upper cervical manipulations, and they noted that techniques using rotational thrusts were overrepresented in the frequency of injury”.

Another 2014 review, “Cervical Arterial Dissections and Association with Cervical Manipulative Therapy” (Oct 2014)10 concluded:

“Cervical artery dissections (CD) is an important cause of ischemic stroke in young and middle-aged patients. CD is most prevalent in the upper cervical spine and can involve the internal carotid artery or vertebral artery. Although current biomechanical evidence is insufficient to establish the claim that cervical manipulative therapy (CMT) causes CD, clinical reports suggest that mechanical forces play a role in a considerable number of CDs and most population controlled studies have found an association between CMT and vertebral artery dissection (VAD) stroke in young patients. Although the incidence of CMT-

6 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2890687/ 7 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3348005/ 8 https://www.mja.com.au/insight/2014/7/support-chiropractor-reporting 9 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4145795/ 10 http://stroke.ahajournals.org/content/early/2014/08/07/STR.0000000000000016.full.pdf+html

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associated CD in patients who have previously received CMT is not well established, and probably low, practitioners should strongly consider the possibility of CD as a presenting symptom, and patients should be informed of the statistical association between CD and CMT prior to undergoing manipulation of the cervical spine”.

In the light of the above we believe that merely citing an undated N.Z. government report that stated (in 1979) chiropractic care is “remarkably safe” is misleading &/or deceptive.

The claim that, “Studies have shown that, in relation to the treatment of neck and back pain, a course of chiropractic care is 250 times safer than a course of anti-inflammatory drugs” appears to be based on a 1995 literature review, “A Risk Assessment of Cervical Manipulation vs NSAIDs for the Treatment of Neck Pain”.11 The abstract noted:

Although there are a small number of well-performed trials of cervical manipulation for neck pain, we were unable to locate even a single randomized, controlled trial examining NSAID use specifically for neck pain.

A search of PubMed12 failed to find any additional studies on the comparative safety of chiropractic manipulation compared to NSAIDS for the treatment of either neck or back pain.

It is accepted that NSAID’s have a number of potentially serious side-effects (especially when used long-term)13 However, we do not believe that the 1995 review cited justifies the statement, “Studies have shown that, in relation to the treatment of neck and back pain, a course of chiropractic care is 250 times safer than a course of anti-inflammatory drugs”.

Conclusion Claims 3 & 4: we argue that:

• citing a 1979 (undated) New Zealand government study that found that adjustments and chiropractic care is “remarkably safe” without warning of the uncommon association between cervical manipulation and cervical artery dissections and stoke, and

• stating that “a course of chiropractic care is 250 times safer than a course of anti-inflammatory drugs”,

breach s.6.2 of the AHPRA Advertising Guidelines for Registered Health Practitioners (March 2014) and also the Chiropractic Board of Australia Code of Conduct (March 2014), s.2.2 (g), ss2.4 (d) and s.9.6 (a) & (b).

11 http://www.ncbi.nlm.nih.gov/pubmed/8583176 12 http://www.ncbi.nlm.nih.gov/pubmed 13 http://www.nps.org.au/conditions/nervous-system-problems/pain/for-individuals/medicines-treatments-for-pain/nsaids_pain_relievers

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Claim 5 & 6: (from http://barhamchiro.com.au/faq/)

Comment: We are unaware of any good scientific evidence that supports these claims which appear to promote unnecessary chiropractic examination and manipulation of the newborn.

A 2010 review titled, “Effectiveness of manual therapies: the UK evidence report”14 (authored by Chiropractors) concluded that spinal manipulation is not effective for infantile colic.

Furthermore, a 2012 Cochrane review titled, “Manipulative therapies for infantile colic”15 concluded there was no evidence that manipulative therapies improved infant colic when they only included studies where the parents did not know if their child had received the treatment or not.

We could not find any good evidence to support the claim that, spinal distress in babies can include, but not be limited to colic, unusual crying, poor appetite or erratic sleeping habits.

Conclusion Claims 5&6: the statements:

• “it’s a good idea to get your newborn checked as early as possible for any spinal health problems” and

• “Signs of spinal distress in babies can include, but not be limited to colic, unusual crying, poor appetite or erratic sleeping habits”,

breach s.6.2 of the AHPRA Advertising Guidelines for Registered Health Practitioners (March 2014) and also the Chiropractic Board of Australia Code of Conduct (March 2014), s.2.2 (g), ss2.4 (d) and s.9.6 (a) & (b).

14 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2841070/ 15 http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD004796.pub2/epdf/abstract

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Claims 7-9 (from http://barhamchiro.com.au/faq/)

Comment: We are unaware of any good scientific evidence that supports the claim that regular chiropractic “check-ups” may avoid (unspecified) health complaints seen later in adults.

A search of PubMed for Nilsson [auth] AND ("chiropractic"[MeSH Terms] OR "chiropractic"[All Fields]) produced a number of studies with Nilsson as a co-author. However we were unable to identify a study that reported that:

Children under chiropractic care are healthier than other children, miss less school, are more attentive and have less need for drugs.

We did find a study with Nilsson as a co-author16 that concluded that:

Spinal manipulation is effective in relieving infantile colic. However, the number of patients studied was small, (control (dmiethicone) n=25, intervention (chiropractic) n=25); the parents who recorded symptoms were aware of the different treatments (they were not blinded) and 9 patients dropped out of the dmiethicone group. As noted above, a 2012 Cochrane review concluded there was no evidence that manipulative therapies improved infant colic when they only included studies where the parents did not know if their child had received the treatment or not.

Furthermore, a 2010 review titled, “Effectiveness of manual therapies: the UK evidence report”17 concluded that,

In children, the evidence is inconclusive regarding the effectiveness for otitis media and enuresis, and it is not effective for infantile colic and asthma when compared to sham manipulation.

16 http://www.ncbi.nlm.nih.gov/pubmed/10543581 17 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2841070/

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Conclusion Claims 7-9: we argue that the statements,

• “Regular chiropractic checkups with us … may help avoid some of the (unspecified) health complaints seen later in adults”,

• “Children under chiropractic care are healthier than other children, miss less school, are more attentive and have less need for drugs” and

• “Children with conditions such as earaches, colic, bed wetting, scoliosis, “growing pains” and asthma generally respond wonderfully to chiropractic care”

breach s.6.2 of the AHPRA Advertising Guidelines for Registered Health Practitioners (March 2014) and also the Chiropractic Board of Australia Code of Conduct (March 2014), s.2.2 (g), ss2.4 (d) and s.9.6 (a) & (b).

Claim 10: (from http://barhamchiro.com.au/faq/)

Comment: A search of http://www.ncbi.nlm.nih.gov/pubmed/?term=chiropractic+pregnancy failed to find any scientific evidence to substantiate this statement.

Conclusion Claim 10: we assert that the statement,

• “[chiropractic manipulations] often gives babies in a breech position more room to move into the correct head-down position, reducing the need for a caesarean birth”,

breaches s.6.2 of the AHPRA Advertising Guidelines for Registered Health Practitioners (March 2014) and also the Chiropractic Board of Australia Code of Conduct (March 2014), s.2.2 (g), ss2.4 (d) and s.9.6 (a) & (b).

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Claim 11: (from http://barhamchiro.com.au/wellness/)

Comment: We are unaware of any good scientific evidence that supports the claim that regular chiropractic manipulation results in patients dealing with stress more effectively or suffer less from re-occurring symptoms like indigestion, sinus problems, stress, etc.

Conclusion Claim 11: we assert that the statement, “Research … show us that people who participate in a regular program of chiropractic care suffer less from re-occurring symptoms like indigestion, sinus problems, stress, etc.”, breaches s.6.2 of the AHPRA Advertising Guidelines for Registered Health Practitioners (March 2014) and also the Chiropractic Board of Australia Code of Conduct (March 2014), s.2.2 (g), ss2.4 (d) and s.9.6 (a) & (b).

In conclusion, the Chiropractors involved in the Barham Chiropractic Clinics make a number of therapeutic claims that are not supported by sound evidence. We agree with Ernst and Gilbey (article appended) that these unsubstantiated claims constitute both an ethical and public health issue.

We ask the Chiropractic Board of Australia to determine if Barham Chiropractic Clinics and the chiropractors involved have breached both:

• AHPRA Advertising Guidelines for Registered Health Practitioners (March 2014), s.6.2 & the • Chiropractic Board of Australia Code of Conduct (March 2014), s.2.2 (g), s.2.4 (d) and s.9.6

(a) & (b)

If so, we ask that the chiropractors involved be ordered to retract the offending claims and the determinations made in this case be published as a deterrent to others.

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Yours sincerely,

Dr Ken Harvey 35a Mary St Hawthorn VIC 3122 M: 0419 181910 W: www.medreach.com.au E: [email protected]

Mal Vickers 2/45 Banff St Reservoir VIC 3073 [email protected]

Cc Mr Scott Gregson Executive General Manager, Consumer Enforcement Australian Competition & Consumer Commission Level 3, 23 Marcus Clarke St, Canberra, ACT, 2601 23 August 2015

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THE NEW ZEALAND MEDICAL JOURNAL

Journal of the New Zealand Medical Association

NZMJ 9 April 2010, Vol 123 No 1312; ISSN 1175 8716 Page 36

URL: http://www.nzma.org.nz/journal/123-1312/4054/ ©NZMA

Chiropractic claims in the English-speaking world

Edzard Ernst, Andrew Gilbey

Abstract

Background Some chiropractors and their associations claim that chiropractic is

effective for conditions that lack sound supporting evidence or scientific rationale.

This study therefore sought to determine the frequency of World Wide Web claims of

chiropractors and their associations to treat, asthma, headache/migraine, infant colic,

colic, ear infection/earache/otitis media, neck pain, whiplash (not supported by sound

evidence), and lower back pain (supported by some evidence).

Methods A review of 200 chiropractor websites and 9 chiropractic associations’

World Wide Web claims in Australia, Canada, New Zealand, the United Kingdom,

and the United States was conducted between 1 October 2008 and 26 November

2008. The outcome measure was claims (either direct or indirect) regarding the eight

reviewed conditions, made in the context of chiropractic treatment.

Results We found evidence that 190 (95%) chiropractor websites made

unsubstantiated claims regarding at least one of the conditions. When colic and infant

colic data were collapsed into one heading, there was evidence that 76 (38%)

chiropractor websites made unsubstantiated claims about all the conditions not

supported by sound evidence. Fifty-six (28%) websites and 4 of the 9 (44%)

associations made claims about lower back pain, whereas 179 (90%) websites and all

9 associations made unsubstantiated claims about headache/migraine. Unsubstantiated

claims were made about asthma, ear infection/earache/otitis media, neck pain,

whiplash in at least half of all chiropractor websites.

Conclusions The majority of chiropractors and their associations in the English-

speaking world seem to make therapeutic claims that are not supported by sound

evidence, whilst only 28% of chiropractor websites promote lower back pain, which is

supported by some evidence. We suggest the ubiquity of the unsubstantiated claims

constitutes an ethical and public health issue.

The raison d'être of chiropractic “is to enhance the natural healing abilities of the

body by correcting a malfunction of the spine called a vertebral subluxation through

adjustment”.1 Chiropractic is advocated as being “much more than a way of seeking

relief from back pain”,1 “the third largest healthcare profession in the world”,

2 and

“entering the healthcare mainstream”.3

The relationship between chiropractic and mainstream medicine has, at times, been

somewhat uneasy. For example, Chiropractic’s founder, DD Palmer, was once

imprisoned for practising medicine without a licence in America4—and, in New

Zealand in the 1970s, the medical profession argued that chiropractic is “an unproven

treatment directed at an unlimited range of disorders”.5 More recently, in a survey of

chiropractic brochures provided by 9 national organisations in the United States and

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URL: http://www.nzma.org.nz/journal/123-1312/4054/ ©NZMA

Canada, all were found to have made “claims for chiropractic services that have not

been scientifically validated”.6

Similarly, a survey of World Wide Web claims of chiropractic colleges in the United

States and Canada found that 8 out of 16 made “unsubstantiated claims for the value

of chiropractic clinical care”.7 In response to a fictitious email enquiry sent to 13 New

Zealand chiropractors, purportedly from a concerned parent about their child’s asthma

and recurrent ear infection (conditions for which there is no sound evidence to support

chiropractic interventions), 12 encouraged a consultation, 9 suggested that they could

treat asthma, and 8 that they could treat ear infection.8

In a small pilot study of chiropractors’ claims in their World Wide Web websites, 9 of

10 United Kingdom clinics were found to have made unsubstantiated claims about the

effectiveness of chiropractic.9

Criticisms regarding unsubstantiated claims have been raised even by Doctors of

Chiropractic, two of whom suggested that those outside the chiropractic profession

may interpret widespread unsubstantiated claims of effectiveness as “evidence of a

lack of professionalism and of quackery” that have evolved within a “tradition of

dogma, fallacious reasoning, and unconventional attitudes about research and

science”.6

Contrarily, many chiropractic associations and practitioners believe chiropractic is

essentially based in scientific principles and supported by research, the same as is

orthodox medicine.10,11

This debate may be of esoteric interest only, as chiropractic is

clearly thriving irrespective of criticism.3,12

Although there is evidence that some chiropractic brochures, colleges, and phone

advice make claims not supported by evidence,6,7,8

apart from a small pilot-study of

10 UK chiropractors,9 no studies have so far tested claims made or implied on

chiropractors’ Websites, from which potential first-time users of chiropractic may

seek information.

The purpose of the current study was therefore to investigate the websites of

chiropractic associations and practitioners, in Australia, Canada, New Zealand, the

United Kingdom, and the United States, regarding direct or indirect claims to treat

seven conditions that are not supported by sound evidence from well-designed

controlled trials: asthma, headache/migraine, infant colic, colic, ear

infection/ache/otitis media, neck pain, and whiplash (Table 1). These conditions were

chosen for investigation as from experience we were aware that they frequently

appear in chiropractic literature, despite a lack of sound supporting evidence.

We accept that some studies purportedly demonstrate the effectiveness of

chiropractic. However, when case studies, non-controlled, non-randomised, or non-

peer reviewed studies were excluded, as they do not constitute quality evidence in any

hierarchy of which we are aware, and systematic reviews or randomised control trials

(if systematic reviews were not available) were consulted instead, we could find no

evidence of chiropractic effectiveness for the seven conditions. Claims regarding

lower back pain were also reviewed as evidence suggests it may respond to

chiropractic spinal manipulations13

and thus might reasonably be expected to be

robustly promoted in chiropractors’ websites.

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Table 1. The best current evidence for conditions commonly referred to by

chiropractors

Condition Type of evidence (ref) Conclusions

Asthma Cochrane review 14

There is insufficient evidence to support the use

of manual therapies for patients with asthma*

Back pain (lower) Cochrane review13

No evidence that spinal manipulation is superior

to other standard treatments for acute or chronic

low back pain*

Colic None found No evidence

Infant Colic Health Technology Report 15

No convincing evidence*

Ear infection/ache/otitis media Only a feasibility study is

available16

No sound evidence

Headache/migraine Systematic review 17

…no rigorous evidence…*

Neck pain Cochrane review 18

…evidence did not favour spinal

manipulation/mobilisation done alone…*

Whiplash Systematic review19

No controlled clinical trials…* *Verbatim.

Method

A search for chiropractors’ websites and chiropractic associations on the World Wide Web was carried

out between 1 October 2008 and 26 November 2008, using the internet search engine Google, with the

appropriate domain extension for Australia, Canada, New Zealand, the United Kingdom, and the

United States. The keywords, were ‘chiropract*’AND ‘association’, ‘chiropract*’AND ‘organisation’,

‘chiropract*’AND ‘society’, and ‘chiropractor’.

All international and national associations and the first 40 chiropractors’ websites returned for each

country would form the sample for review. Sponsored links were not included, as these may be high

profile practices with little in common with the average practice.

Our convenience sample was limited to 40 websites for each country as most chiropractors were clearly

using one of two common templates for their websites and further data collection would therefore

contribute little. We believe that a convenience sample is the best strategy for the current study as it

would replicate the results of a World Wide Web based search by a member of the public seeking

information about chiropractic; had we randomly sampled from a register of practitioners in each

country, then we may have found websites not readily returned on a member of the public’s search of

the World Wide Web.

In the first 300 New Zealand search results, using the keyword ‘chiropractor’, 32 chiropractor websites

were returned. To increase the New Zealand sample size, a second search using the keyword

‘chiropractic’ was conducted; as a result, 8 further chiropractor websites were returned. All reviewed

materials were saved in both electronic and hard copy.

The material thus located was systematically checked by one author (AG) for evidence of claims

regarding any of the above-named conditions. The criterion deemed sufficient to conclude evidence of

a claim was that the condition would be mentioned by name on the website. Evidence would thus

include direct claims (e.g. chiropractic may help with headaches) or indirect claims (e.g. conditions for

which people consult chiropractors include headache).

If an association or advertisement mentioned a condition of interest as not suitable for chiropractic

treatment (e.g. a person suspecting they had condition X should consult their general medical

practitioner), then it would not be interpreted as an unsubstantiated claim. Whenever the phraseology

used in the reviewed materials was ambiguous about a particular condition, we (EE & AG) classified

the website or association as not making an unsubstantiated claim. Evidence of claims for other

conditions was also noted in a non-systematic fashion if they seemed sufficiently extraordinary to be

noted.

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Results

Two international and 7 national chiropractic associations were identified (see note 1

to Table 2 for names/countries of the associations). Chiropractic associations and

chiropractors’ claims (direct or indirect) about the 8 conditions are shown in Table 2.

Table 2. Chiropractic association and chiropractor website claims regarding the

eight conditions

There was evidence that 190 (95%) chiropractor websites make unsubstantiated

claims regarding at least one of the conditions. Only 56 (28%) chiropractor websites

and 4 of the 9 (44%) associations appeared to explicitly mention lower back pain,

although tentative evidence suggests it may respond to chiropractic manipulation,13

whilst 179 (90%) websites and all 9 associations mentioned headache/migraine,

which is not supported by sound evidence. When claims for colic and infant colic

were collapsed into a single heading, 76 (38%) of chiropractor websites were found to

make unsubstantiated claims about all the conditions for which there is a lack of

sound supporting evidence.

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There was evidence that some chiropractic associations make unsubstantiated claims

about conditions outside the scope of this survey; for example, allergies, arthritis,

immune system, longevity, osteoarthritis. There was also evidence that some

chiropractor websites make unsubstantiated claims regarding conditions outside the

scope of this survey; for example, attention deficit hyperactivity disorder, cancer,

epilepsy, immune function, infertility. In the case of infertility, one chiropractor’s

website printed what we believe is the extraordinary claim of research showing that

14 of 15 women unable to conceive, some for up to 10 years, had given birth after

beginning regular chiropractic care.

Discussion

Our results provide evidence that the professional chiropractic organisations of

Australia, Canada, New Zealand, the United Kingdom, and the United States make or

imply therapeutic claims that are not backed up by sound scientific evidence. Perhaps

as a consequence, many chiropractor websites of these countries follow suit.

Most healthcare professionals associate chiropractic with musculoskeletal problems.

Yet, several of the conditions claimed to respond to treatment are clearly not

musculoskeletal by nature (e.g., asthma, otitis, colic). One way to understand this

finding is to consider it within the wider context of chiropractic history.

The birthday of chiropractic is said to be September 18, 1895. On this day, D. D.

Palmer manipulated the spine of a deaf janitor allegedly curing him of his deafness.20

Palmer’s second patient, a man suffering from heart disease, was also claimed to be

cured.21

Following these early successes, Palmer articulated his theory of chiropractic,

coining the term “innate intelligence” (or “innate”) for the “energy” or “vital force”

he believed to be the essence of life. The “innate” is said to regulate all body

functions. The presence of a “vertebral subluxation” inhibits, according to Palmer, its

flow. Chiropractic is “a system of healing based on the premise that the body requires

unobstructed flow through the nervous system of…innate intelligence”.22

Based upon this notion, chiropractors use spinal manipulations to correct subluxations

to treat a very broad range of conditions: “95% of all diseases are caused by displaced

vertebrae, the remainder by luxations of other joints”.23

Broadly similar to our

findings, early chiropractic pamphlets hardly mention back pain or neck pain, but

assert that, “chiropractic could address ailments such as insanity, sexual dysfunction,

measles and influenza”.24

More recently the chiropractic profession split into those aligned to Palmer’s original

teachings (the “straights”) and those who also used treatments other than spinal

manipulation and focussed on musculoskeletal problems (the “mixers”). For many

years it seemed that the mixers dominated and chiropractors tended to fashion

themselves as back pain specialists using many forms of non-pharmacological

treatments. Now there is evidence that this process might be reversing. In 1991,

hardly any UK chiropractors admitted treating conditions other than spinal

problems.25

In 2003, 69% of all UK chiropractors felt confident to treat

visceral/organic conditions,26

currently this figure stands at 74%.27

In the US, “nearly 80% of chiropractors teach a relationship between subluxation and

internal health”,28

88% of US chiropractors believe that subluxation contributes to

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over 60 % of all visceral ailments and 90% feel that chiropractic treatments should not

be limited to musculoskeletal conditions.29

The American Chiropractic Association

stresses that chiropractic care is not limited to back pain, neck pain or other

musculoskeletal disorders,30

and most chiropractic texts discuss spinal manipulation

as a treatment for “visceral disorders”e.g.31,32,33,34

Based on the data presented here, the

situation seems to be similar in the other English-speaking countries.

Unsubstantiated claims of the nature described above may put patients at risk and are

simply at odds with the notion that chiropractic is in any way scientific. As evidence

of these claims is so widespread, we suggest this amounts to a public health issue. If,

for instance, a child suffering from severe asthma is treated with ineffective spinal

manipulation instead of effective drug therapy, there is an increased chance that this

patient’s life might be lost. In this context, one must, of course, also consider the

direct risks of spinal manipulation, which evidence suggests may be

considerable35,36,37

(although it is noted that orthodox medicine is by no means free of

risk38

).

A survey of UK chiropractors shows that 90% of them believe they support evidence-

based practice principles,39

and their code of ethics states that “chiropractor’s

provisions of care must be evidence-based...”.40

The data summarized above suggest

that chiropractors fail to abide by their own rules, although we suspect this is not

intentionally but due to the paucity of science in their curriculum.

The same code of ethics also regulates chiropractor’s advertising and provides that

“the information used must be factual and verifiable. The information must not be

misleading or inaccurate in any way.”40

The ethical guidelines in Canada, New

Zealand, and the United States are similar, but the Chiropractors’ Association of

Australia does not appear to prescribe guidelines for advertisements. Claims such as

those disclosed here in chiropractors’ websites, in our view, violate the most

fundamental rules of medical ethics: beneficence, non-maleficence and autonomy.41

This has further important practical implications; for instance, informed consent is not

a realistic possibility if it is given based on misleading information.42

Our analyses have some important limitations. Web-based information can only

generate an indirect picture of what might happen in actual clinical practice, even

although it may be the first place that potential patients may use. However, more

direct ways to ascertain such information seem to confirm the bleak impression

gained by our surveys: direct questioning of chiropractors, for instance, revealed that

the advice issued by them is frequently not responsible. New Zealand and UK

chiropractors have been shown to recommend chiropractic for childhood asthma,8,43

Canadian chiropractors have recommended treatment for an 11 year old female

assessed as healthy by an experienced paediatric orthopaedic surgeon,37

and many UK

chiropractors advise parents against immunisation of their children.43

Future research in this area should seek to explore differences in the degree to which

the practices of “mixers” and “straights” are successful; that is, does claiming to treat

conditions that are clearly not of musculoskeletal origin lead to a more successful

practice; for example, in number of consultations and financial remuneration. The

extent to which chiropractor websites make unsubstantiated claims could also be

explored in relation to length of time since graduating in chiropractic, as new

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graduates are more likely to believe their scope of practice extends beyond the

treatment of back, head, and neck pain.37

Finally, the healthcare community at large might investigate ways of minimizing the

risk to patients caused by unsubstantiated claims, particularly insofar as patients may

delay or fail to seek out orthodox care.

In conclusion, we have presented evidence that many of the direct or indirect claims

made by chiropractors and their organisations around the world are not supported by

current sound evidence. This, we feel, raises important issues and may even put lives

at risk. We therefore urge the chiropractic community to address this situation

adequately and urgently.

Competing interests: None known.

Author information: Edzard Ernst, Director, Complementary Medicine, Peninsula

Medical School, University of Exeter, Exeter, England; Andrew Gilbey, Lecturer,

College of Business, Massey University (Turitea Campus), Palmerston North,

New Zealand

Correspondence: Andrew Gilbey, College of Business, Massey University,

Private Bag 11 222, Palmerston North, New Zealand. Email:

[email protected]

References:

1. New Zealand Chiropractor’s Association. Frequently asked questions: Do I still need to see a

chiropractor if there is no pain? http://www.chiropractic.org.nz/frequently-asked-questions

Accessed 1 December 2008.

2. Roughan S. Setting the record straight: New Zealand Chiropractors' Association response. N Z

Med J. 2008;121(1280):72–73. http://www.nzma.org.nz/journal/121-1280/3222/content.pdf

3. Meeker WC, Haldeman S. Chiropractic: A profession at the crossroads of mainstream and

alternative medicine. Ann Intern Med; 2002;(136):216–27.

4. Kremer R. Strength in diversity: Professional and legislative opportunities in primary care by

the recognition, defining and promotion of the licensure of chiropractic medical education,

competencies and skills. J Chiropr Med. 2002;1(4):139–148.

5. Dew, K. Apostasy to orthodoxy: debates before a commission of inquiry into chiropractic.

Sociol Health Illn. 2002;22(3):1310–1330.

6. Grod JP, Sikorski D, Keating JC. Unsubstantiated claims in patient brochures from the largest

state, provincial and national chiropractic associations and research agencies. J Manipulative

Physiol Ther. 2001;24:514–9.

7. Sikorski D, Grod JP. (2003). The Unsubstantiated Web Site Claims of Chiropractic Colleges

in Canada and the United States. J Chiropr Educ. 2003;17(2):113–119.

8. Holt S. The responses of alternative practitioners when approached about common childhood

illnesses. N Z Med J. 2008;121(1283):114–116.

9. Ernst E. The ethics of chiropractic. N Z Med J. 2008;(121)1281:96.

10. Roughan S. Colquhoun's opinion versus science—a response from the New Zealand

Chiropractors' Association. N Z Med J. 2008;121(1281):99–101.

11. The Canadian Chiropractic Association. Chiropractic Health Care Commission – Manitoba.

http://www.ccachiro.org/client/cca/cca.nsf/web/A667B070372C0BCA85256D3600559607?O

penDocument Accessed 21 January 2009.

12. Cooper RA, Laud P, Craig L, Dietrich CL. Current and Projected Workforce of Nonphysician

Clinicians JAMA. 1998;280:788–794.

Page 19: Complaint to Chiropractic Board of Australia about Barham Chiropractic …€¦ · In May 2010 the General Chiropractic Counc il, the statutory regulatory body for chiropractors in

NZMJ 9 April 2010, Vol 123 No 1312; ISSN 1175 8716 Page 43

URL: http://www.nzma.org.nz/journal/123-1312/4054/ ©NZMA

13. Assendelft WJJ, Morton SC, Yu EI, et al. Spinal manipulative therapy for low-back pain.

Cochrane Database of Systematic Reviews 2004, Issue 1. Art. No.: CD000447. DOI:

10.1002/14651858.CD000447.pub2.

14. Hondras MA, Linde K, Jones AP. Manual therapy for asthma. Cochrane Database of

Systematic Reviews 2005, Issue 2. Art. No.: CD001002. DOI:

10.1002/14651858.CD001002.pub2.

15. Husereau D, Clifford T, Aker P, et al. Spinal manipulation for infantile colic. Canadian

Coordinating Office for Health Technology Assessment 2003; (Technology report no 42).

16. Sawyer CE, Evans RL, Boline PD, et al. A feasibility study of chiropractic spinal

manipulation versus sham spinal manipulation for chronic otitis media with effusion in

children. J Manip Phsiol Ther 1999;22(5):292–267.

17. Fernandez-de-Las-Penas C, Alonso-Blanco C, Cuadroado ML. Are manual therapies effective

in reducing pain from tension-type headache?: A systematic review. Clin J Pain.

2006;22(3):278–285.

18. Gross A, Hoving JL, Haines T, et al. Manipulation and mobilisation for mechanical neck

disorders. Cochrane Database of Systematic Reviews 2004, Issue 1. Art. No.: CD004249.

DOI: 10.1002/14651858.CD004249.pub2.

19. Ernst E. Chiropractic spinal manipulation for whiplash injury? A systematic review of

controlled clinical trials. FACT. 2009;2:85–86.

20. Wardwell W. History and evolution of a new profession. St. Louis, MO. Mosby-Yearbook;

1992.

21. DeVocht JW. History and overview of theories and methods of chiropractic: a counterpoint.

Clin Orthop Relat Res. 2006;444:243–249.

22. Martin SC. The only truly scientific method of healing. Chiropractic and American Science

1895-1990.1994;85:207–227.

23. Homola S. Bonesetting, chiropractic and cultism. Panama City, FL: Critique Books; 1963.

24. Palmer BJ. Chiropractic proofs. Davenport, Iowa; 1903.

25. Pedersen P. A survey of chiropractic practice in Europe. Europ J Chiropractic. 1994;42:3–28.

26. Wilson FJH. A survey of chiropractors in the United Kingdom. Eur J Chiropract.

2003;50:185–198.

27. Pollentier A, Langworthy JM. The scope of chiropractic practice: a survey of chiropractors in

the UK. Clin Chiropractic. 2007;10:147–155.

28. Chiropractic News Digest 2003, June 11, http://www.chirobase.org/18CND/03/03-02.html

Accessed 3 December 2008.

29. McDonald W, Durkin K, Iseman S, et al. How Chiropractors Think and Practice. Ada, OH;

Institute for Social; Research, Ohio University; 2003.

30. American Chiropractic Association. About chiropractic.

http://www.amerchiro.org/level2_css.cfm?t1id=13&t2id=61 Accessed 3 December 2008.

31. Redwood D. Chiropractic. In Micozzi MS, ed. Fundamentals of complementary and

integrative medicine. (3rd Edition). St Louis: Elsevier; 2006.

32. Gay RE. Chiropractic. In Yuan CS, Bibber EJ, Brent AB. eds. Textbook of complementary

and alternative medicine. 2nd ed. Abingdon: Informa Healthcare; 2006.

33. Wiles MR. Visceral disorders related to the spine. In: Gatterman MI, ed. Chiropractic

management of spine-related disorders. Baltimore: Williams & Wilkins; 1990;379–96.

34. Swenson RS. Clinical investigation of reflex function. In: Haldeman S. ed. The modern

developments in the principles and practice of chiropractic. 2nd ed. rev. Norwalk, CT:

Appleton Century Crofts. 1992;105–14.

35. Ernst E. Adverse effects of spinal manipulation: a systematic review. J R Soc Med.

2007;100:330–8.

36. Rubinstein SM, Leboeff-Yde C, Knol DL, et al. Predictors of adverse events following

chiropractic care for patients with neck pain. J Manip Phys Ther. 2008;31:94–103.

Page 20: Complaint to Chiropractic Board of Australia about Barham Chiropractic …€¦ · In May 2010 the General Chiropractic Counc il, the statutory regulatory body for chiropractors in

NZMJ 9 April 2010, Vol 123 No 1312; ISSN 1175 8716 Page 44

URL: http://www.nzma.org.nz/journal/123-1312/4054/ ©NZMA

37. Benedetti P, MacPhail W. Spin doctors: The chiropractic industry under examination.

Toronto, Ontario: Dundurn Press; 2002.

38. Helmreich RL (2000). On error management: lessons from aviation. BMJ 2000;320: 781–785.

39. General Chiropractic Council. Consulting the profession: A survey of UK chiropractors.

http://www.gcc-uk.org/files/link_file/ConsultTheProfession.pdf Accessed 1 December 2008.

40. General Chiropractic Council. Code of Practice and Standard of Proficiency. http://www.gcc-

uk.org/files/link_file/COPSOP_8Dec05.pdf Accessed 1 December 2008.

41. Fisher F. Medical ethics today: its practice and philosophy. London, England: British Medical

Association; 1993.

42. Ernst E, Cohen M. Informed consent in complementary and alternative medicine. Arch Intern

Med. 2001;161:2288–92.

43. Schmidt K, Ernst E. Letter to the Editor: Are asthma sufferers at risk when consulting

chiropractors over the Internet? Respiratory Med. 2003;97:104–5.

44. Schmidt K, Ernst E. MMR vaccination advice over the Internet. Vaccine. 2003;21:1044–7.