I took a course on “dry needling” aka “Western Medical Acupuncture” a few years ago run by a rheumatologist.  There is some evidence that needling can help with pain relief, particularly from arthritis and for low back pain.  It’s also widely used, particularly in sports medicine, to help with painful muscular “trigger points”.

I recently received a well timed email enquiry about this topic, the reply to which I reproduce below.

Hi Richard, do I have heard that you use acupuncture to help back pain.  How does it work? Peter, Queens Park.

Hi Peter

It’s an exciting time for the use of acupuncture to relieve pain as a molecule which may control how acupuncture relieves pain was pinpointed by US researchers in the last month.

Experiments in mice showed that levels of adenosine – a natural painkiller – increased in tissues near acupuncture sites.

Pain experts said the findings may partly explain how the treatment works.

Adenosine is known to have many roles in the body including regulating sleep and reducing inflammation, the researchers said.

Other research has shown that it becomes active in the skin after an injury to act as a local painkiller.

In the latest study, the researchers were looking at the effects of the molecule in the deeper tissues which acupuncturists target with fine needles.

The team performed a 30-minute acupuncture session at a pressure point in the knee of mice that had discomfort in one paw.

They found that in mice with normal functioning levels of adenosine, acupuncture reduced soreness by two-thirds, as assessed by nerve sensitivity measurements.

In mice specially engineered to lack the receptor for adenosine, acupuncture had no effect.

And during and immediately after an acupuncture treatment, the level of adenosine in the tissues near the needles was 24 times greater than before the treatment, the researchers said.

Then using a drug which extends the effects of adenosine, they found that the benefits of acupuncture lasted three times as long.

The study leader Dr Maiken Nedergaard, a neuroscientist said:

“In this work, we provide information about one physical mechanism through which acupuncture reduces pain in the body,” she added.

Acupuncture is used for a wide range of treatments but on the NHS its use is limited to lower back pain.

Experts pointed out that acupuncture may mediate its effects in a number of different ways.

A spokesman from the British Pain Society said: “We have known for a long time that acupuncture alters the response to pain by modulation of some of the pain pathways in the spinal cord, and also by the release of endorphins.

“It is very interesting that scientists have found an alteration in the tissue levels of adenosine, which helps to explain some of the modulatory effects of acupuncture on pain perception.”

It seems to have come as news to some, but the Vertebral Subluxation Complex (VSC) has been regarded as a historical concept by the BCA and the chiropractic academic institutions for many years.  When I was at the AECC 1989 -93 I was taught it as such.

I’ve reproduced the response from the BCA below regarding the GCC statement but there are some who think that the GCC or the BCA rejecting this concept is the death knell for chiropractic.  Everyone is entitled to their opinion and I respect those who are willing to put their name to one. I just happen to think the opposite.  Not rejecting it would be.

I have been looking into the situation in Denmark, where chiropractors are covered by the health service and have “cultural authority” as specialists in the non-surgical management of spinal healthcare.  Patients with back pain can access a chiropractor directly, without requirement for referral from their GP.

How did they get there?  Well, they took many important and sometimes very difficult steps.  One of the first was that in 1992 the president of the Danish Chiropractic Association (DKF) made a public statement that they were rejecting all historical concepts (subluxation) associated with chiropractic and that chiropractors in Denmark treated musculoskeletal conditions. (Btw, if anyone can get that statement, I would love to see it).

This followed, by accounts I have heard, an extremely emotional SGM where many were making the same arguments as we are hearing now, that without subluxation chiropractic has no identity etc, etc Well, at that SGM they voted to become a profession that treated musculoskeletal problems.

Their identity doesn’t seem to have suffered too much.

I’ll blog later on what other steps they took in Denmark, and how we could learn from them.  But for now I’ll reproduce the definition on chiropractic from their association website:

“A chiropractor is a licensed health care professional dealing with investigation, diagnosis, prevention and treatment of pain conditions and reduced function of the musculoskeletal system.”

“BCA Statement on Vertebral Subluxation Complex

The BCA welcomes today’s statement from the General Chiropractic Council (GCC) on Vertebral Subluxation Complex, which appears here http://www.gcc-uk.org/files/page_file/guidance_on_claims_for_VSC_May_2010.pdf

As a responsible organisation, the BCA understands the need to ensure that the public is properly informed about the evidence base for chiropractic treatment so that it is able to make informed choices about the care it receives. For many years, the BCA has not supported the concept of the Vertebral Subluxation Complex in the light of the absence of evidence supporting claims made it can be the cause of disease and serious illness. It also notes that no provider of UK undergraduate chiropractic education teaches Vertebral Subluxation Complex theory in the context of modern healthcare delivery.

The BCA supports and encourages the inclusion of chiropractic in mainstream healthcare provision in the UK. To facilitate the integration of chiropractic, unsubstantiated historical concepts and ambiguous terminology must be discarded in favour of an emphasis on delivering an evidence-based care model that is easily understood by other members of the healthcare team.

The BCA reminds members of their obligations under the GCC Code of Practice and Standard of Proficiency. In ensuring compliance, they should refrain from making any reference to Vertebral Subluxation Complex in media to which their patients or the general public may have access. This advice has no bearing on scope of practice, which is not defined in the Chiropractors Act, but all chiropractors are required to adopt the practice of a reasonable and competent chiropractor.

Chiropractors are the leaders in non-surgical spinal healthcare. There is strong evidence to support the inclusion of chiropractic in musculoskeletal healthcare initiatives, most recently contained in the NICE Guidelines http://guidance.nice.org.uk/CG88 Chiropractors have specific expertise in the assessment, treatment and management of spinal and joint pain syndromes, and are well placed to deliver cost-effective services within the mainstream UK healthcare framework.

Notes to the above statement:

The issue from which this advice stems is that a member of the public has requested information from the GCC about its view on the strength of the research evidence supporting the contention that the VSC is the cause of disease, many health conditions and in some cases, premature death.

The enquiry was made in the context that outcome 4(a) in the current version of the GCC’s Criteria for Recognition of Degrees in Chiropractic, requires that students must “understand the history, theory and principles of chiropractic in a contemporary context” is accompanied by guidance that includes reference to “vertebral subluxation-centred models”.

/Continued….

-2-

The GCC’s Education Committee sought observations on the following from the three recognised UK providers of undergraduate chiropractic degree programmes (AECC, MCC and WIOC): -

• How the chiropractic vertebral subluxation complex is covered in the detailed curriculum; and
• What relevant research they draw from.

The detailed responses from each of the institutions can be read in the paper which was considered by the GCC at its meeting on 12 May 2010

http://www.gcc-uk.org/files/page_file/C-120510-11.pdf

The GCC’s Education Committee provided the following advice to the GCC which it accepted at its meeting on 12 May 2010 : -

• The chiropractic vertebral subluxation complex is taught only as an historical concept.
• There is no clinical research base to support the belief that it is the cause of disease or health concerns.

The GCC did consult all of the professional associations and the College of Chiropractors prior to its meeting, and has had further dialogue with representatives at the end of last week.  This guidance relates to marketing materials and websites and is not an attempt to define the scope of chiropractic practice.

The GCC’s Guidance is as follows:-

The chiropractic Vertebral Subluxation Concept is an historical concept but it remains a theoretical model.  It is not supported by any clinical research evidence that would allow claims to be made that it is the cause of disease or health concerns.  Chiropractors are reminded that they must make sure their own beliefs and values do not prejudice the patient’s care – GCC Code of Practice Section 8.3.  They must provide evidence based care which is clinical practice that incorporates the best available evidence from research, the preferences of the patient and the expertise of practitioners including the individual chiropractor her/himself – GCC Standard of Proficiency Section A2.3 and the Glossary refer.  Any advertised claims for chiropractic care must be based only on best research of the highest standard – GCC Guidance on Advertising – issued March 2010 refers.

Any members referring to the VSC on their websites, are recommended to review the context of the wording used as a matter of urgency to ensure compliance with the GCC’s Code of Practice and Standard of Proficiency and thus prevent the possibility of a complaint being made to the GCC about the use of the terminology.

Please contact BCA Head Office if you require any clarification.

Richard Brown DC, LL.M, FCC, FBCA, FEAC

President, British Chiropractic Association                                       24^th May 2010″

I discussed the difference between osteopaths and chiropractors here. Eddie Izzard does it hilariously here amongst other great observations.

In my London clinic I work alongside a very well known Spinal Surgeon.  I asked  him about his continued use of facet joint infiltrations (where steroid and local anesthetic is injected into the spinal joints) despite the lack evidence for efficacy and the NICE guidelines recommending against it’s use.

For those who are unaware, the NICE guidelines of May 2009 recommended against the use of these injections.  This caused an outcry from in particular pain specialists, who use these all the time for the treatment for some types of low back pain and who feel they are effective.

His answer was interesting.  He sees patients every week who he, through his experience, identifies as those who he thinks will improve with these injections.  He explains to the patients the evidence, risks and benefits and why he thinks in their case it is the right treatment to administer.  Patients rightly trust this very experienced and excellent surgeon and give him consent to go ahead with a treatment he recommends.

This type of encounter often occurs in a healthcare setting, and demonstrates that although evidence must guide our thinking, there may be times where experience and patient choice can outweigh that.

This is a (slightly abridged for the blog) letter that was published in “Contact” magazine in May last year before I decided to stand for this years BCA council.

“Dear Editor

Recent and ongoing events surrounding the Simon Singh trial and the resulting omnibus complaints to the GCC have, and will continue to, damage the reputation of the BCA and chiropractic in the UK.  Whether it is fair or not does not matter, nor does it matter now whether the legal action should have been taken.  It’s now time to look to the future, because if ever there was a crossroads for the profession in the UK, this is it.

I believe there is only one way BCA can minimise and start to repair this damage, and that’s by being bold and leading chiropractic in the UK into the mainstream.  The BCA has held itself up as the “gold standard” for chiropractic and supported evidence based care.  It should now take a much stronger stance, endorsing only evidence based care.  The BCA should insist that its members practice this way, and that its members must not make any claims that treatment helps conditions that are not supported by such evidence.

This would be a very strong message for promotional purposes and I believe would be applauded by some of those who are now turning against us.  Of course the BCA should endorse research into other conditions which chiropractic could help, but for which the case remains unproven.

We should state clearly that we are experts in spinal care.  The market for it is out there and NICE have just recommended we help provide care on the NHS.  If we have a clear message about what we do, we are in a great position to take advantage of the opportunity that is waiting to be grasped.  If we confuse ourselves, the public and the medical community with a “broad church” approach, we will not only be unable to take this opportunity, but the profession will flounder and face many more difficulties.  This has happened in other countries who chose this approach like the USA, Canada and Sweden.

In Denmark and Norway by contrast, where associations have taken the stance I suggest, the result has been accelerated inclusion in their national health services and acceptance by the public as experts in the field.  There has been no loss of identity, quite the opposite, it has been strengthened.  It is no coincidence that, in Denmark particularly, the best research into other conditions that spinal manipulation may help such as colic and asthma has taken place.

There will be fear that some members will leave the BCA and join other associations who will support chiropractors who treat subluxations to affect organic disorders.  Let them leave and let the BCA and it’s registered chiropractors be the “gold standard”.

This reform needs to occur immediately, and if it does, there can be a silver lining to the cloud that is currently threatening our future.

Richard Hollis”

I had an interesting and productive meeting with some osteopathic researchers yesterday.  One thing that came up was misconceptions in both professsions about the other.

They said that osteopaths viewed chiropractors as more “alternative”.  They were a little surprised when I said that chiropractor’s hold that view of osteopaths.

Both knowing and having worked with a few osteopaths in the past and currently, in my opinion the professions are almost identical in composition. They both have a majority of practitioners who practice in an evidence informed way treating musculosketetal (MSK) conditions.  There is also a vocal minority who practice in an “alternative medicine” fashion.    The MSK majority in both professions are very similar, and IMO, there are certainly more similarities between myself and some osteopaths than myself and some chiropractors.

“Evidence-based practice (EBP) is an approach to health care wherein health professionals use the best evidence possible, i.e. the most appropriate information available, to make clinical decisions for individual patients. EBP values, enhances and builds on clinical expertise, knowledge of disease mechanisms, and pathophysiology.  It involves complex and conscientious decision-making based not only on the available evidence but also on patient characteristics, situations, and preferences.  It recognizes that health care is individualized and ever changing and involves uncertainties and probabilities.  Ultimately EBP is the formalization of the care process that the best clinicians have practiced for generations”.  Source: McKibbon KA (1998). Evidence based practice. Bulletin of the Medical Library Association 86 (3): 396-401

There are some people who are afraid of evidence based care.  It’s beyond me to explain why.

What’s not to like?  Unless of course the evidence points away from what you would like to believe.    In that case, accept it and move on.

That doesn’t mean that you need bullet proof RCT evidence to treat someone in a particular way.  It does mean that the evidence at least guides you in your thinking.  Anything else makes the treatment “experimental”, and should be conducted as practice based research.

“Evidence-based medicine is not “cook-book” medicine. Because it requires a bottom-up approach that integrates the best external evidence with individual clinical expertise and patient-choice, it cannot result in slavish, cook-book approaches to individual patient care. External clinical evidence can inform, but can never replace, individual clinical expertise, and it is this expertise that decides whether the external evidence applies to the individual patient at all and, if so, how it should be integrated into a clinical decision”. Source: Sackett, D.L. et al. (1996) Evidence based medicine: what it is and what it isn’t. BMJ 312 (7023), 13 January, 71-72

“Good doctors use both individual clinical expertise and the best available external evidence, and neither alone is enough. Without clinical expertise, practice risks becoming tyrannised by evidence, for even excellent external evidence may be inapplicable to or inappropriate for an individual patient. Without current best evidence, practice risks becoming rapidly out of date, to the detriment of patients”. Source:Sackett, D.L. et al. (1996) Evidence based medicine: what it is and what it isn’t. BMJ 312 (7023), 13 January, 71-72)

There is much discussion in both the chiropractic and  medical professions currently about what what constitutes evidence good enough to use in a healthcare setting.

This is not the right way of looking at things, as evidence alone is not enough.Evidence based care, or the term I prefer, evidence informed care, is more than “hard” evidence.  It’s guided by a combination of the best available evidence, clinical judgement or experiance and the preference of the patient.

It’s no secret that I would like chiropractors to completely embrace this concept. That’s one of the reasons I decided to stand for election to the BCA council.

Anyway, I thought I’d share, in a series of postings, some of my favourite quotes from the world of evidence based care, with thanks in particular to Sackett, who’s writings are,  in my view (and most other peoples) , the most important and insightful ever done on this topic.

The first quote is long, but worth reading, and forms the background to the ones that will follow:

“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. By individual clinical expertise we mean the proficiency and judgement that individual clinicians acquire through clinical experience and clinical practice. Increased expertise is reflected in many ways, but especially in more effective and efficient diagnosis and in the more thoughtful identification and compassionate use of individual patients’ predicaments, rights, and preferences in making clinical decisions about their care. By best available external clinical evidence we mean clinically relevant research, often from the basic sciences of medicine, but especially from patient centred clinical research into the accuracy and precision of diagnostic tests (including the clinical examination), the power of prognostic markers, and the efficacy and safety of therapeutic, rehabilitative, and preventive regimens. 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.” Source: Sackett, D.L. et al. (1996) Evidence based medicine: what it is and what it isn’t. BMJ 312 (7023), 13 January, 71-72).

There is interesting discussion on this site, by an osteopathic blogger, about the need for the “manipulative professions” to be evidence based. No argument here with that.