A cautionary note about calls to crack down on chiropractic

A few weeks ago, Health Minister Nicola Roxon received a submission calling on the Government to close a chiropractic paediatric clinic run by RMIT University in Melbourne, and raising concerns about the use of chiropractic in babies and children.

The submission was from Loretta Marron, a regular contributor to Crikey/Croakey, cancer survivor and a former Australian Skeptic of the Year who advocates against unproven and disproven alternative therapies.

As I reported in the BMJ at the time, the science writer Simon Singh and the complementary medicines expert Professor Edzard Enrst have lent their weight to Marron’s campaign, as have several prominent Australian medical and scientific experts.

However, another Croakey contributor, Jon Wardle, argues below that there are many benefits to keeping chiropractic training within the university sector. Rather than tarring the entire field with one brush, critics would do better to pursue the minority who are charlatans, he says.

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Will taking chiropractic training out of universities really protect patients?

Jon Wardle writes:

Recently a submission to the health minister recommending the closure has made news both nationally and internationally in an effort to force RMIT University to close down its paediatric chiropractic training clinic.

Although the submission initially suggests it is a request to only close down the paediatric clinic at RMIT University, as it promotes the use of unproven and harmful remedies targeting pregnant women and children, it goes further to suggest removal of chiropractic training from the university sector altogether.

The submission says “[i]t is high time that universities returned to their core principles and dropped pseudoscientific courses which lead to attacks on vaccination and the promotion of expensive, useless and potentially harmful treatments”.

In addition to RMIT University, the submission also suggests courses at Macquarie University and Murdoch University should also be investigated.

But would removing these courses and clinics from the university sector really be in the public interest?

A university chiropractic course is comprehensive, usually lasting five years. The RMIT course has twice the amount of conventional anatomy, physiology and health sciences units as it does units specific to chiropractic practice.

But even the chiropractic units have a substantial conventional health science element to them as well.

That’s a lot of ‘real’ science for what the submission calls a ‘pseudoscientific’ course. Students are even taught clinical research skills to evaluate evidence.

The reason for this is because although chiropractors may have their own philosophy on healing, they must also work within the conventional health model.

This high level of conventional training also means that practitioners can recognise the limitations of their therapies, be made aware of serious conditions that require referral, can recognise ‘red flag’ situations, and of course can also better assess treatment risk – and therefore minimise these risks – when delivering their treatments.

What’s more, this increase in standards has been a direct result of moving chiropractic training into the university sector. In fact the federal government’s 1977 Webb report recommended regulation of the profession and inclusion in the university sector specifically to increase these standards.

This is important because the simple fact is Australian’s have a right to choose their health provider as they wish. To deny patients this right would be construed as anti-competitive.

The fact is one in six Australians do choose a chiropractor – and they will continue to see them regardless of where their clinical training comes from.

Having this training in a university setting rather than the private sector (or from within the profession itself) provides for better and safer practitioners.

Whilst the evidence base for chiropractic in children is low, this does not necessarily mean that such treatments should be automatically denied.

Some children may respond well to chiropractic – whether it is due to specific or non-specific effects.

Some of these may be children who have not responded to more ‘evidence-based’ medicine (which, after all, does not actually work for everyone). Where should these children go then?

And of course whilst the submission primarily made reference to the inappropriateness of chiropractors treating non-musculoskeletal conditions in these populations, some children will require musculo-skeletal treatment, though admittedly the evidence for this area is also lacking (for both positive and negative trials).

Even if the practitioner does refer, it may be their duty of care to provide an attempted treatment within the initial consultation if it does not pose undue risk. To do nothing may simply not be appropriate. After all, it could be weeks before the referral appointment can be made.

Although it shouldn’t be first-line treatment, there is a case for chiropractic to at least be another option for child treatment.

Chiropractic has come a long way since the days of ‘vertebral subluxation’ being seen as the only source of illness. Not every modern chiropractic treatment focuses on manipulation.

Chiropractors learn far more gross anatomy and as much physiology as most health professions. Most chiropractors work in conjunction with other health professions, and often expand their treatments to include massage, physical therapy, dietary and lifestyle advice and some medicines.

They generally focus on musculoskeletal conditions, though like any other health profession in Australia are not limited to these conditions.

Nor is spinal manipulation a therapy that is limited to chiropractors. It is also taught to and practised by osteopaths, Chinese medicine practitioners, ‘musculo-skeletal therapists’ and naturopaths on the complementary side of the practitioner fence, and physiotherapists and medical practitioners on the other conventional side (the venerable Professor John Murtagh has even written a book on the topic).

Patients will continue to utilise these services. The most important thing is that chiropractors are made aware of their limitations and refer when appropriate. University training clinics are the ideal places to learn such skills.

However, RMIT does have a duty to explore evidence in this area – it certainly goes without saying that RMIT University really should get its act together in developing a research program at its chiropractic school. Though it also goes without saying that this has been a problem in clinical training courses across the professions.

This professional division exists between chiropractic ‘purists’ who believe that all disease is sourced in the spine, and those who are more integrative in outlook. ‘Purists’ are now well in the minority – though it is admittedly a vocal one – and their numbers have been diminishing further as chiropractic training has moved into universities.

Taking training out of the university sector will only support this fringe group, not stop it.

In is arguments the submission focuses on this ‘old’ chiropractic, suggesting that ‘chiropractors say’ that 80% of all health problems are caused by spinal problems. Whilst this is true for a segment of the chiropractic professions, chiropractic internationally is bitterly divided, and this isn’t a representative view of the whole profession.

Additionally, concerns about the impact of chiropractic on public health measures such as vaccination aren’t necessarily supported by the evidence in this area.

It is true that some chiropractors do advise against vaccination, but most chiropractors don’t. Canadian studies have even found that two-thirds of chiropractors have vaccinated their own children, though no data exists for Australian chiropractors (though it should be noted that the Canadian profession is in fact less ‘mainstream’ than the Australian one).

It is also true that international studies also show that children who see a chiropractor are less likely to receive full immunisation. And they show this pretty consistently.

However, implying that such data means that chiropractors are automatically advising patients not to use vaccines amounts to classic attribution error – mixing causality with correlation.

Other factors are at least equally as likely. For example, families who see chiropractors are probably less likely to vaccinate anyway, as parents with an ‘alternative medicine orientation’ are more likely to reject vaccination – regardless of what their healthcare provider says.

This error also informs the submission’s focus on the Australian Vaccination Network – a group that is not run by health professionals of any persuasion. The 120 chiropractic members of this organisation, who the submission focuses on, equates to less than 3% of Australia’s 4387 nationally registered chiropractors, and are most likely from the fringe of the profession.

Rejection of vaccination amongst chiropractors usually relates to original chiropractic philosophy, which saw all disease linked to the spine and vaccines interfering with healing. Such outdated views are disappearing, and are the minority of the profession.

In fact, by having courses in the university sector, students are exposed to positive information on public health measures such as vaccination. In fact, international studies demonstrate that anti-vaccination rates of CAM practitioners are directly related to conventional health science levels in courses, and that most anti-vaccination ‘education’ in chiropractic comes from outside the formal training sector.

There are clear risks to therapies used by chiropractic – particularly spinal manipulation. This is why the profession is regulated and minimum standards of training are imposed. In fact Chiropractic Boards in Australia receive far more complaints about spinal manipulation by unregistered practitioners than do about chiropractors.

There are other risks as well – notably financial exploitations through over-servicing. However, this does constitute a breach under the national registration scheme legislation (as does misleading advertising), and regulatory arrangements are in place to discipline such practitioners.

There are undeniably a lot of charlatans in the field, and the submission is right to criticise them. However, the 50 New South Wales practitioner websites she uses to illustrate what ‘chiropractors say’ represent well under 5% of practitioners in that state.

Tarring the whole profession with the same brush as its ‘lowest level’ does little to recognise the complexities and breadth that exist in the profession. The issue is one that is grey, not black and white. Failing to view the world as such is dogmatic and, dare I say, quite unscientific (and skeptics really should know better).

Additionally, to say that RMIT is responsible for the actions of students once they graduate draws an incredibly long bow. Universities simply aren’t in control of their alumni once they graduate.

For the same reason St Mary’s Hospital Medical School (now Imperial College Medical School) shouldn’t be punished for the claims of Andrew Wakefield – which have done far more damage to vaccination rates than a few rogue chiropractors.

If the authors of such submissions are truly interested in public safety rather than initiating a crusade against a specific health profession, their time would be better spent highlighting the actions of specific practitioners to the appropriate regulatory authorities.

Such mechanisms and safeguards already exist, not only in practitioner regulatory arrangements but also other pieces of legislation, such as that enacted by the Australian Competition and Consumer Commission against misleading allergy treatment claims.

With Australia having one of the highest public levels of support for complementary and alternative therapies in the developed world, it would be a very brave minister or vice-Chancellor that closed down an established course with no real benefit to the public for doing so.

However, taking away the very thing that has progressed chiropractic beyond outdated philosophy to a modern health profession could have serious ramifications for the public.

• Mr Jon Wardle is a naturopath, complementary medicines researcher at the University of Queensland School of Population Health, and a director of the Network of Researchers in the Public Health of Complementary and Alternative Medicine