NICE

Margaret McCartney

Yes, because evidence is the only way medicine gets better. Yes, because people have sometimes died, or had risky procedures, or endured more suffering, because of the application of opinion-based, fashion-set meandering through all the medical interventions that imagination has to offer. Yes, because time, money and effort is wasted when people are given non evidence based treatments by healthcare practitioners.

Nevertheless, the careers section of the British Medical Journal website devotes some uncritical space to careers advice about osteopathy. The doctor describing his decision to pursue a qualification in the discipline – he now combines medicine with osteopathy – says that since the UK National Institute for Health and Clinical Excellence recommend it, it should be done.

But this isn’t, I don’t think, good enough: mainly because the evidence for treating back pain, which is the specific Nice recommendation he refers to, is complicated by the fact that the great bulk of back pain will get better no matter what doctors do or don’t do.

More importantly, a systematic review of systematic reviews of spinal manipulation a review of systematic  suggests that  ”Collectively these data do not demonstrate that spinal manipulation is an effective intervention for any condition. Given the possibility of adverse effects, this review does not suggest that spinal manipulation is a recommendable treatment.”

There remains the concept that doing more in medicine is always better. In truth, doing can be far more evidence based.

By Margaret McCartney

Simon Singh, as mentioned before, was in the High Court last week facing the British Chiropractic Association over an article he wrote for the Guardian (which is no longer available to read on their website.)

In court, the Judge held that the phrase Singh used –  ”happily promotes bogus treatments”  – was capable of bearing the meaning that the BCA was being knowingly dishonest in using treatments (in the article, Singh was referring to the treatment of certain childrens ailments) they knew to be ineffective. The BCA sued for libel over this claim, and in court it was held that Singh would either need to defend, settle or appeal regarding the meaning of his article.

It goes without saying I am disappointed about this. The best way to have a discussion about evidence is transparantly, preferably unthreateningly, and in the public domain. Much of this has been done, quietly, already. For example, the Cochrane Collaboration -an international organisation which searches for evidence on healthcare interventions, assesses it for quality and disseminates its results – has examined some evidence on chiropractic, and other reviews are ongoing:

For example, one review of manipulation and mobilisation for neck pain found that :  

This review of 33 trials did not favour manipulation or mobilisation done alone or in combination with various other physical medicine agents. It was unclear if manipulation and mobilisation performed in combination were beneficial, but when compared to one another, neither was superior.”

Or there’s a review of the evidence for using chiropractic to treat asthma which concludes :

“There is not enough evidence from trials to show whether any of these therapies can improve asthma symptoms.”

 Some large studies suggest some benefit, for example the UK Beam Trial, which looked at the effectiveness of exercise and manipulation for back pain. But there are, I think, also valid criticisms of this trial – for example, the high drop-out rate, and the indices used to measure improvement. 

Thus, we can say that there is some evidence for chiropractic in certain situations. What I am unclear about it whether it is any better than the combination of exercise, physiotherapy and pain relief I will commonly advise. Moreover, a Cochrane review from 1994 concludes that, “There is no evidence that spinal manipulative therapy is superior to other standard treatments for patients with acute or chronic low-back pain.”

However, yesterday NICE recommended chiropractic treatment for low back pain, as well as acupuncture “needling” (there is a column coming up about this, but briefly: we know that sham and even needle-free acupuncture is as good an intervention as full acupuncture.)

To make it clear, I am no more “against” chiropractic than I am for or against any other kind of medical intervention. The judgement about using or recommending something should be about; the chances of it working, its potential to harm, the cost-effectiveness of the intervention, and how a patient feels about using it. This means using evidence and assessing it for fairness.

You may also be interested in the judgement the ASA made recently about a chiropracter’s clinic . So what is “bogus”? And how are consumers to be helped to sort this out?

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Margaret McCartney is a Glasgow-based GP and FT Weekend columnist. She started writing for the Life and Arts section in 2005 and moved to the magazine in 2008. She also has her own blog: www.margaretmccartney.com/blog

Clive Cookson has been a science journalist for the whole of his working life. He joined the FT in 1987. Clive, the FT's science editor, picks out the research that everyone should know about. He also discusses key policy issues, from R&D funding to science education.

Andrew Jack is pharmaceuticals correspondent, covering the industry and public health issues. He has been a journalist with the FT for 19 years, based in London, Paris and Moscow

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