As I’m sure many of you are aware, on 25 Feb 2010 a report entitled ‘Effectiveness of manual therapies: the UK evidence report’ was published. The report was commissioned by the General Chiropractic Council (GCC) in June 2009 and Prof Bronfort and his team started work on it in the same month. The cost of the report to the GCC was $20,000, which seems really quite reasonable (particularly as it’s $$$ and not £££). It was intended to provide a clear statement on the level of evidence to support certain claims made by many chiropractors in the UK.
Blogger Zeno covers this in more detail here: Zeno’s Blog: Talking the talk
The report, associated tables and commentaries can be found here http://www.gcc-uk.org/page.cfm?page_id=1396 along with the GCC’s guidance on advertising claims.
A copy of the report can be downloaded (bottom of page) here: http://www.chiroandosteo.com/content/18/1/3 along with a summary of the Background, Methods, Results and Conclusions.
I was particularly interested in reading the reports findings regarding colic and asthma as well as a range of other non-musculoskeletal conditions that often appear on chiropractors websites.
Having read the report and its conclusions it is clear that those who have been questioning colic claims over the past couple of years, have been totally justified in being openly sceptical of these claims. The report clearly states that there is no evidence to support them. Actually it goes a little further and states there is ‘Moderate Negative’ evidence for spinal manipulation as a treatment option for both colic and asthma based on the best quality evidence currently available.
However, having had a quick read of the report, it seemed to me (a complete layman) there were a few things that were not as clear as they could be, so perhaps the GCC would be willing to answer a few questions. I will say now that the GCC were very good in providing prompt replies, often answering within a couple of hours, even when outside of normal office hours.
I found some of the answers quite interesting and some of the information was certainly not ‘clear’ from reading the report. The GCC had already told me they were in the process of updating their Patient Information Leaflet and had taken advice from CAP Copy Advice Team on the matter. The new leaflet is now available on their website.
However, I wanted to know exactly what the GCC thought was acceptable to claim and would they be issuing any direct advertising advice to its members regarding what can, or more importantly, what cannot now be published on websites. Their response was:
The GCC’s guidance to the profession mirrors that of the Committee of Advertising Practice Copy Advice Team ie that any claims for chiropractic must be based on best research of the highest quality. This will almost certainly mean randomised controlled trials that produce high or moderate quality positive evidence.
This reply was given on more that one occasion, and they did emphasis that ‘best research of the highest quality’ and RCT’s producing ‘high or moderate quality positive evidence’ were now the required standard on which any claims must be based. However the GCC seem reluctant to take the next obvious step and issue some direct, unambiguous advice that would help remove any posibility of further complaints being submitted.
Not all the findings are totally clear and could be open to individual interpretation. The report lists three categories of ‘Inconclusive’ evidence, so where does that leave claims for conditions in these categories. From a chiropractors perspective the most beneficial on would be the ‘Inconclusive, but favourable evidence’. Clearly this falls outside the standards set earlier for high or moderate, positive evidence and the report clearly says “Does not support any public claims regarding effectiveness”, although some of the other wording does seem to allow them a get out clause of “Advise patients that this is a treatment option in the absence of an effective alternative” How many chiropractors will actually turn paying customers away and suggest an effective alternative.
I did push them a little further to see it they were willing to issue any specific advice to chiropractors, even if just for those conditions classed as ‘Inconclusive’. The response was to restate their above comments, but interestingly they also added:
I hope you will appreciate that the Council must be careful not to prejudice the consideration by the statutory Investigating Committee of a significant number of current complaints about the content of chiropractors’ websites.
Now correct me if I’ve got the wrong end of the stick, but they’ve just issued a report that says there is no reliable evidence to support asthma or colic. Doesn’t that automatically go some way to influencing the outcome of a number of the complaints!
Those of you who have read the report will see that it lists the findings of 26 conditions, split between three areas (musculoskeletal, headache, non-musculoskeletal), but there seem to be a number of conditions like ADHD, Breastfeeding and Dyslexia (and others) that are missing from the report. They certainly don’t appear on every chiropractors website, but they’re not uncommon.
I asked the GCC what their view was on these conditions and the others not listed in the report. The reply was quite interesting and not something I’d seen mentioned in the report or elsewhere (if I’m wrong, please let me know!). It seems that the initial remit of the report was to investigate every condition listed on any website where the GCC were in receipt of a complaint.
Thank you for your further communication. I think it will be helpful for me to clarify that Professor Bronfort was asked to consider every condition, sign and symptom that was mentioned on any of the websites in respect of which the GCC has received complaints. This included ADHD, difficulties with breastfeeding and dyslexia. Where any condition does not appear in the report, this is because no relevant randomised controlled trials were identified.
Obviously this will help the GCC’s Investigating Committee clear up many of the complaints it still has on its books!
Importantly for chiropractors (and sceptics) it is quite clear on the fact that if a condition was NOT included in the report, it is because there’s NO relevant evidence (RCTs) to support that claim. These conditions must therefore fall well below the required level of evidence needed to make any public claims.
The GCC were also kind enough to provide a list of all the conditions and symptoms that the review was initially asked to consider. It is less of a list and more of a breakdown of conditions listed by website where a complaint has been received. All references to the website and details of the complaint had been removed.
The list of conditions (as supplied) can be found here: ‘conditions ‘ list supplied XXXXXXXX 10 March 10-REDACTED ( Can anybody turn this into a proper list? )
So this all seems to suggest that the only conditions chiropractors can openly advertise (at present) are those actually listed in the report as having the high or moderate levels of positive evidence. These are the only conditions where it is stated chiropractors can say “Supports public favourable claims regarding effectiveness” and “advise patients that this is an effective treatment choice”
I also think it’s safe to assume that this report would never have been commissioned at all if it hadn’t been for the high number of complaints submitted to the GCC and the pressure that has put on the chiropractic profession. With the release of this report the GCC have now set the standard it expects the profession to follow, now it’s up to their members to reach that standard …..
…….. So will chiropractors be willing to accept the report and take down any remaining unsupported claims !