British Chiropractic Association (BCA) demonstrate what evidence-based medicine isn’t

The British Chiropractic Association (BCA) are currently suing Simon Singh for stating, among other things, that the

British Chiropractic Association claims that their members can help treat children with colic, sleeping and feeding problems, frequent ear infections, asthma and prolonged crying, even though there is not a jot of evidence

The BCA have now – somewhat belated – summarised [PDF] the evidence which they feel relates to the article and the use of chiropractic treatment for various childhood illnesses. Other bloggers are assessing various aspects of this evidence – we’ll consider what might constitute good evidence in this context.

It was interesting to see the BCA quote Sackett et al on “Evidence based medicine [EBM]: what it is and what it isn’t”. They summarise (p. 7) the paper’s conclusion as

Evidence based medicine is about integrating individual clinical expertise and the best external evidence

However, while they might orientate themselves towards EBM, this PDF from the BCA provides a nice example of what EBM isn’t. I actually find myself wondering if it might make a good teaching tool for this reason.

For Sackett et al (p. 71)

Evidence based medicine is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research.

Unfortunately, the BCA’s presentation of research is anything but systematic. For example, they include three papers on the negative effects of NSAIDs (p.7). It is not clear how these papers are relevant to – or appropriate for a systematic account of – the efficacy of chiropractic for the childhood illnesses which Singh discussed. Even if NSAIDs led to quick, painful death, this still would not be relevant to the efficacy of chiropractic for various childhood illnesses.

For Sackett et al (p. 71)

External clinical evidence both invalidates previously accepted diagnostic tests and treatments and replaces them with new ones that are more powerful, more accurate, more efficacious, and safer.

It is, therefore, important that one’s search strategy picks up research which might show that the treatments one offers are ineffective and/or dangerous. Sadly, though, the BCA’s summary of the evidence misses out some important research: for example, Olafsdottir et al’s 100 infant randomised, blinded, placebo controlled clinical trial, which concluded that

Chiropractic spinal manipulation is no more effective than placebo in the treatment of infantile colic

Oddly, though, while failing to mention this 100-subject RCT, the BCA still found space to list, among 29 documents of varying quality:

• Studies on NSAIDs
• A number of studies discussing osteopathic treatments (p. 4, and 7)
• A Letter to the Editor about chiropractic and asthma.

In terms of evidence re chiropractic treatment of infantile diseases, I would have thought that Olafsdottir et al would have been rather more significant.

EBM is clearly imperfect in many ways: for example, if can fail to take into account the issue of prior plausibility. However, the BCA’s approach both fails to be EBM and fails to offer a good alternative. It is highly important that those practising medical treatments – which bring potential risks and benefits – critically assess the evidence for what they do. This can allow better treatment to be provided for patients, and ineffective and/or harmful treatments to be stopped.

I am delighted to see that the BCA is interested in EBM. The next desirable step would be for them to move towards it. They should focus on the systematic assessment of the evidence for the use of chiropractic in various conditions: recommending it only for those where there is good evidence of safety and efficacy.

All the lawyers in the world will not make an ineffective treatment effective, and they will not make a potentially harmful treatment safer. Patients are far more important than lawsuits.

BCA’s plethora of evidence

:

Evidence Matters: British Chiropractic Association and The Plethora of Evidence for Paediatric Asthma

Professor David Colquhoun: British Chiropractic Association produces its plethora of evidence

Gimpy assesses the studies and concludes: The BCA’s Proferred Evidence That Chiropractic Can Help with Ear Infections

Unity of Ministry of Truth: Examining the BCA’S ‘Plethora’ of Evidence

Martin of The Lay Scientist: A Review of The BCA’s Evidence for Chiropractic

AP Gaylard of A canna’ change the laws of physics offers a thoughtful analysis of the studies dealing with bed wetting. They aren’t quite as persuasive as the BCA seems to argue that they are.

Phil Plait of Bad Astronomy has some wry advice for the BCA: Careful, BCA, you might slip a disk!

Chris Kavanagh has the most complete round-up of the history and coverage of the BCA v Simon Singh and the blogosphere reaction.