Australian Spinal Research Foundation: it’s time to drop the pretence

The Australian Spinal Research Foundation (ASRF) has just released their Annual Report detailing financial activity for 2012-2013. Net revenue for this period was $1,697,097. The amount of money spent or allocated to research grants was $52,029. This amounts to 3.07% of all monies generated by the Australian Spinal RESEARCH Foundation (emphasis mine). Conversely, $605,956 was spent on salaries or wages during this same period.

This seems somewhat disproportionate. So, in this post The Rogue Chiropractor will look deep into the history of ASRF revenue and research grant expenditure. The ASRF annual reports can be found freely online here.

Table 1: Summary of ASRF research project funding relative to revenue and expenses

Financial Year

Revenue

Spend on Research grants

Percentage of Revenue spent on grants

Wages & Salaries

Percentage of Revenue spent on Wages & Salaries

Operating Profit/(Loss)

2012-2013 1,697,097 52,029 3.07% 605,956 35.71% 97,373
2011-2012 1,615,773 50,212 3.11% 540,425 33.45% (16,577)
2010-2011 1,622,725 167,356 10.31% 525,342 32.37% 72,379
2009-2010 1,367,874 32,463 2.37% 464,471 33.96% 55,516
2008-2009 1,033,502 126,501 12.24% 407,117 39.39% 493,018
2007-2008 1,357,343 54,268 4.00% 378,209 27.86% 451,679
2006-2007 1,101,033 89,752 8.15% 304,876 27.69% 169,404
2005-2006 1,076,631 141,324 13.13% 216,955 20.15% 303,171
2004-2005 647,904 37,710 5.82% 204,842 31.62% 250,271
2003-2004 1,028,298 90,300 8.78% 214,680 20.88% 281,230
2002-2003 682,809 18,139 2.66% 190,965 27.97% 74,375
2001-2002 754,939 21,238 2.81% 156,310 20.70% 211,761
2000-2001 641,046 57,559 8.98% 151,167 23.58% 149,128
TOTAL 12,929,877 886,822 6.86% 4,361,315 33.73% 2,592,728

The ASRF started in 1976 and is considered a well-established not-for-profit organisation. Over the past 13 years the ASRF has grossed an impressive $12.9M largely through spizzed-up promotion of subluxation theories. Only 6.9% of all revenue ends up eventuating in the ASRF’s primary function which is research grant activity. Of interest, 33.7% of income is spent on wages and salaries.

Let us now examine the R&D spending of other organisations that promote research and development in healthcare. In 2012, that big pharma evil corporation Pfizer reported revenue of $58,986 million ($58.986 billion) in 2012. Their R&D expenses in this period was $7,870 million ($7.870 billion). This equates to 13.34% of revenue being spent on research and development. Compare that with 2011 where revenues were $67,425 million and R&D expenditure was $9,112 million (13.5% of revenues), 2010 revenues were $67.057 million and R&D expenditure was $9,392 (14% of revenues).

On the surface it would be simple to say, “Pfizer earns more money from drug sales so they can spend more money on their research and development”. This may well be true, they do earn more money from drug sales than chiropractors could ever hope to see from treating their patients. They have an interest to maintain their profits, so they will then of course spend more money on their research and development. But why should they have a higher percentage of revenue raised spent on R&D? That is an interesting question.

In stark contrast the Physiotherapy Research Fund (PRF) earns substantially less income (Table 2). In 2012 the PRF grossed $189,281 which was an astounding $1.4M less than the ASRF. However, it was still able to provide the Australian Physiotherapy Profession with twice (183%) as much research grant funding.

Table 2: Summary of PRF research project funding relative to revenue and expenses

Year end Dec 31

Revenue

Spend on Research Grants

Percentage of Revenue Spent on Research Grants

Administration

Percentage of Revenue spent on Administration

Operating Profit/(Loss)

2012 189,281 92,028 48.62% 4,029 2.13% 93,224
2011 115,063 45,153 39.24% 3,483 3.03% 21,909
2010 125,094 106,135 84.84% 3,049 2.44% 14,110

There are two differences that are as obvious as the nose on one’s face. The first, is the much higher percentage of revenues that are spent on research grants. The second is the low administration cost, the only comparable figure to salaries/wages category in the ASRF financial statements.

Given that ASRF money largely comes from donations from chiropractors (as members), from events for chiropractors (such as Dynamic Growth Congress) or from product endorsements, the scale of monies available it always going to be smaller, and as such, it is imperative that money is spent wisely and on research projects that are clinically relevant.

In 2008, Dr Martin Harvey, then a governor of the ASRF, reported in an article that appeared in The Australian Chiropractor (the CAA publication) that in 2001 ASRF resolved to “changing the procedure of assessment for research grants to include a panel of practicing chiropractors and expressly including terms that relate to subluxation and wellness in the priorities that grant applicants are asked to address.” Indeed, it is listed on the ASRF research website:

  • Priority 1 – Clinical research that investigates the impact of chiropractic care on human function, global well being and quality of life
  • Priority 2 – Basic science research that investigates the vertebral subluxation theory and the chiropractic adjustment

It is now 2013 and we must ask ourselves the question – are we any closer to being able to prove the existence of the vertebral subluxation complex and the effects they have on health? Twelve years on and we are still no closer to being able to accurately define a valid and reliable method of identifying one. Should the spizzed-up CAA board throw millions of dollars of their membership’s money at subluxation research based upon the advice of this floundering research foundation?

In 2013 the grant rounds focused on funding research that investigates the hypothesis that chiropractic care facilitates a greater level of health, enhanced quality of life and human performance. On the surface this looks fantastic – finally there will be research to test whether chiropractic actually makes a difference on overall health, rather than making claims without evidence to substantiate such claims. But the research itself is going to be limited – it automatically precludes chiropractic researchers who have moved beyond the VSC paradigm.

The answer is simple – it is time to remove the reference to the vertebral subluxation complex in the priorities for research. This would promote inclusiveness among an already divided chiropractic community, allowing for research into the benefits of chiropractic care free from the shackles of the VSC but still providing an avenue for those researchers who may be able to objectively demonstrate clinical effect of VSC (or absence of).

Or, perhaps the ASRF needs a name change – Australian Subluxation Marketing Fund, so that chiropractors who have moved on from the vertebral subluxation complex can easily identify that this might not be where they want to direct their donations and those that want to contribute to VSC research can do so.

Yours in chiropractic,

The Rouge Chiropractor…

Chiropractic Board of Australia – have they shown some claw?

Last week, on Wednesday 8th August, the Chiropractic Board of Australia announced :

The Chiropractic Board of Australia is cracking down on chiropractors who step outside their primary role as healthcare practitioners and provide treatment that puts the public at risk.

To protect public safety, the Board has:

  • ordered practitioners to remove all anti-vaccination material from their websites and clinics 
  • removed several courses from the list of approved CPD programs, and 
  • introduced random audits of practitioner compliance with the Board’s registration standards.

The CBA (not to be confused with the financial institution with the same acronym) should be commended for this little baby step into restoring some credibility to the reputation of chiropractors who would dearly love to be seen as evidence based healthcare practitioners. Practitioners working with doctors, physios, OTs, EPs, using best available evidence, sound clinical judgement based on plausible science and their patient’s needs and desires. Practitioners who have been crying out silently for the board to show some muscle on this issue.

It is long overdue, in this “writer’s” opinion. Many would say that the CBA had their hand forced by the episode of Catalyst on Thursday 11th July which was embarrassing to say the least. This is an issue that has been building for years.

Up until June 2012, chiropractors made up the largest professional membership of anti vaccine group “Australian Vaccination Network”. The list of professional members at this time can be found at the Diluted Thinking page here. There are chiropractors and chiropractic websites that espouse vaccine “information” on their websites which are able to be viewed by a public, claiming to offer an informed choice. From Wynyard Chiropractic to Arnold Chiropractic (Chatswood) to Perth Hills Chiropractor (which links directly to Vaccination Decisions, a website that displays all the hallmarks of being an anti vaccination webpage), Align Chiropractic , Maximum Health Chiropractic in Mackay, Liberty Chiropractic & Central Coast Balance Centre to name a few.

Some chiropractors see this as an issue of freedom of speech. Others see it as offering their patients information to allow them to make an informed choice when considering all aspects of vaccination. A few see it is a weak move from the board as seeking approval from the AMA and “Big Pharma” and see it as another nail in the coffin for chiropractic in the long term in Australia.

What it is, is a recognition that delivery of vaccines is not within the scope of practice of chiropractors and that giving false or misleading advice to patients in our care is not acceptable. If a chiropractor is going to give any advice about vaccination it really shouldn’t be anything more than “speak to your GP” and “avoid the AVN”.

Listen here to CBA chairman Phillip Donato OAM chat with Adam Spencer on ABC 702 Sydney regarding the chiropractic board’s decision.

The board should also be commended for removing anti-vaccination courses from the list of approved CPD courses as well. Concerns over this were raised about this in March by Amy Corderoy in the Sydney Morning Herald in this article.

Next on the list for the CBA has to be the countless websites that offer treatment (instead of conventional medicine) for conditions such as ADHD, allergies, asthma, autism, bed wetting, colic, reflux in the face of either a paucity of evidence of spinal manipulative therapy in these conditions or an abundance of evidence showing a no effect.

Survey – Chiropractors and Evidence Based Practice

Good morning. I would just like to conduct a brief survey of the readership. It is based around evidence based/informed practice, clinical decision making and whether chiropractors feel pressured to apply methods that conflict with their evidence based beliefs.

I realise that one of the limitations of this survey is that I have no way of determining if it is chiropractors who are responding and if they are answering truthfully.

All the best.

Review – ABC Catalyst

Hello,

I have found myself rather busy in the last few days, and laid up with a virus. Like many chiropractors, medical doctors, parents and interested observers I watched Catalyst on Thursday night. As I have been feeling a little off colour, Adelaide chiropractor Tom Condon kindly offered to deliver his take on the program. I welcome your comments below.

A critical review of Catalyst’s report into all things Chiropractic, by Dr Tom Condon.

Catalyst’s report into chiropractic on Thursday 11/7/13 certainly gathered a lot of attention on social media sites but is all the criticism warranted? Let’s examine further.

Dr Maryanne Demasi
“Now, most people go to the chiropractor for back pain, and, despite its surging popularity, its proven benefit is fairly limited. A review of spinal manipulation showed that it could alleviate lower back pain, but it was no more effective than heat therapy, or even a good massage.”

This statement made at the beginning of the report is misleading in several ways. Back pain is the most common complaint relating to time off work and one of the most common presenting complaints to the GP office, it is a big deal. Whilst it is true that Cochrane reviews have found spinal manipulation for acute low back pain to be on par with therapies such as heat or massage, it is also on par or superior to certain physio therapeutics, surgical outcomes, exercise/rehab measures. To put it simply all these interventions seem better than placebo but there is no stand out therapy. In this commentators opinion, this is due to the fact that back pain is a symptom of multiple disorders which respond differently to different therapies. So equally, it would be appropriate to report that spinal manipulation is also one of the most efficacious interventions for low back pain and this would not be wrong either. It appears, however Catalyst sought to marginalise our role.

Various points on treating kids with chiropractic.
Mostly these points were on the ball.
Reviews by Bronfort, Cochrane and guidelines by COCA all suggest that chiropractic has no proven benefit in most of these childhood illnesses. That being said many kids also have musculoskeletal problems for which until the evidence emerges would be said to mirror the adult population regarding efficacy and as such a therapeutic trial of treatment with informed consent for this population may be appropriate.

Subluxation theory, static and interference
I agree whole heartedly – evidence does not support these claims and they often do not pass biological plausibility. I particularly liked the points regarding adolescent scoliosis and spinal stimulators. If the chiropractic profession wants to cling to subluxation theory (unlike in Britain where it has been accepted that there is no evidence to suggest subluxations cause disease) then the onus is on them to demonstrate it beyond reasonable doubt. It is not the responsibility of the medical or scientific community to prove that it is not testable, effective or reproducible. It is also not satisfactory to say that it works, I’ve seen it work. Chiropractors cling to the same standard of proof when it comes to vertebral artery dissection, so there cannot be a double standard when it comes to subluxation.

Dr John Reggars
“Chiropractors have relied on anecdotal evidence, and, I think, because of their fervent belief in what they do, that they disregard or put aside the scientific evidence, which shows that it’s either ineffective or inconclusive.”

Strongly agree

“I don’t think the general chiropractor is trained well enough to actually diagnose problems with infants.”

In my own case I agree – although we had decent theoretical education our exposure to paediatric patients was minimal.

Vaccination, Websites and claims
Strongly agree with all points made, we need to stick to a solid base of evidence – not fringe science. Most science can be cherry picked to back up personal opinion, the onus is on the practitioner to source the best evidence and present it as such, not cherry pick what fits in with their argument best. Here is the COCA policy and here is the CAA policy. I quite liked this quote from Dr Steve Hambleton:

“Neutral is not good enough. If the Chiropractic Association takes some time, reads the evidence, they should conclude just like everyone else that there’s a major benefit.”

Safety issues

According to Croke, his statements regarding paediatric safety were misrepresented. He made his feelings known on Catalyst’s facebook page here and can be seen below:

Tony Croke on Catalyst facebook page

Tony Croke on Catalyst facebook page

I think Cunningham’s point that without good systems of reporting then we really don’t know is certainly pertinent (however serious adverse affects rarely can be covered up). It is important to judge chiropractors to the same standard held by other health professionals – all adverse effects are under reported. This begs the question – how effective are reporting systems for other health professions?

The crux of it for me is whether the patient was given informed consent for a complaint that is supported by evidence. Then is the therapy suggested efficacious and safer than other seemingly equivalent therapies. A bench mark this commentator suggests is Ibuprofen (Neurofen) as many patients would not think twice (rightly or wrongly) about taking this medication. Research by Dabbs and von Heymann et al suggests we are safer and more effective generally than this medication.

Certainly chiropractic is not risk free, but no intervention is and we generally have quite a fantastic safety record, recent trials indicate many of the more benign adverse outcomes are related more to natural history than to the intervention itself.

Chiropractic and stroke

Catalyst certainly makes no mention of the odds of stroke following chiropractic (which it is hotly debated within itself), suffice to say it is exceptionally rare. Contrary to the vision of a YouTube clip showing cervical manipulation and Dr. Vagg commenting – “we think it is the force that causes the injury” much recent evidence suggests this not to be the case.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2271108/
http://www.sciencedirect.com/science/article/pii/S1050641112000557
http://www.sciencedirect.com/science/article/pii/S0161475410000849
http://www.sciencedirect.com/science/article/pii/S1356689X10001232

Chiropractic education

Science is constantly evolving; and as such knowledge is constantly being updated and corrected. As with all health sciences there are concrete facts. Facts that will largely stay the same. Then there are areas where there is debate. What is accepted as fact when taught in undergrad may in fact be later shown incorrect during a practitioners career. The purpose of a good education is not merely to imprint knowledge but to teach students how to learn, how to discern fact from fiction and how to apply theoretical science to practical science.

Where I graduated we were not taught subluxation theory, energy flows or anything else that could be construed as marginal science. If Dr. Vagg has specific problems then they need to be raised directly with the universities and education departments – an independent review would be appropriate.

Murdoch University course summary

RMIT course summary 

Macquarie University course summary for undergrad and postgrad component 

CQU Mackay course summary
Chiropractic and government funding
Our medicare spending of 10 Million sounds like a lot until you compare it to other spending in which it is a drop in the ocean. Manual therapy has shown to be cost effective compared to physio therapeutics and general practitioner management.

Summary

All in all, despite all of the hand wringing from chiropractors across social media platforms and the collective burying of heads in sand with “our patients are voting with their feet” and ” 215,000 patient visits per year tell us we’re doing good”, it wasn’t an altogether bad. In this writer’s opinion, it appeared to end up denigrating chiropractic as a whole, rather than just the areas that needed it the most – the ones peddling nonsense about treating paediatric conditions, the anti-vaccination chiros and those that continue to cling to the outdated and yet to be proven subluxation. The free reign given to John Dwyer was disappointing as his arguments ended up being counter-intuitive: if chiropractic courses are forced from universities and back into the fringes, then patients might be put at increased risk due to lower quality education and the potential for pseudoscience to take a stronger hold in newly qualified chiropractors.

A take home message for this author is that it is incumbent on all evidence based chiropractors to make noise and put themselves up for office bearing positions within the representative bodies. If you don’t wish to avail yourself of that responsibility then vote for the best candidate at association election times. Because if you don’t, and the cranks take charge of the representative bodies, then you will only have yourself to blame.

Discussion – The Right Research – Fundamental to Chiropractic from Illuminate vol 2 2013

Before we settle down into tonight’s episode of Catalyst on the ABC, I want to first of all talk about research. Specifically, chiropractic and research. What got me thinking about this was an article in the Australian Spinal Research Foundation’s magazine Illuminate, which can be found online here. If you scroll down to an article by Martin Harvey (page 13).

It is a discussion on the implications of the decision by Macquarie University to discontinue the chiropractic program due to the course not being “research intensive”. Much has been made by chiropractors of this being a political decision due to influence of the Friends of Science in Medicine and various skeptical groups. The simple fact is that if the chiropractic program had a decent volume output of high quality research, then the program would less likely be in this situation.

In this article, Dr Harvey agrees that a higher volume of research needs to be done. Dr Harvey then discusses the need to do the “right research”. He then quotes surveys by World Foundation of Chiropractic and Dr William McDonald that indicate a majority of chiros agree that chiropractic should be about wellbeing, not treatment of musculo-skeletal pain, and that “the right research is that it aligns with the way the majority of the profession sees chiropractic.”

Am I the only one that sees a problem with this approach? I would have thought that a scientific approach to a health profession would be to be guided by the research, not let the profession dictate what research should be done to suit a particular end. Using this approach could mean that research into a potentially useful therapy or combination of therapies that may achieve better outcomes in patients with back pain (where chiropractic has been shown to have most, if any, effect) may be missed and instead vital research dollars could be wasted on a useless diagnostic technique or a useless intervention for a non-existent entity.

Dr Harvey then outlines the ASRF’s approach:

all projects are assessed by a Research Committee, which has eminent researchers from inside and outside the chiropractic research community. Their primary responsibility is to ensure that the scientific methodology is of the highest standard”

This part is looking promising. Dr Harvey continues:

All projects are also assessed by practicing chiropractors to ensure that the research is not only good science but that it is relevant to chiropractic.”

This is the part that concerns me. Research ideas could effectively be vetoed if chiropractors don’t see it as relevant to chiropractic. In delivering patient care, shouldn’t research be focused towards what is going best inform clinical decision making and therefore best for patients? It should not be important if a group of chiropractors see it as relevant to chiropractic, they should see it as relevant to best patient outcomes.

The article then invites us to visit the research link on the ASRF website and click on “Research” and you can view the research priorities:

Priority 1:
Clinical research that investigates the impact of chiropractic care on human function, global well being and quality of life.

Priority 2:
Basic science research that investigates the vertebral subluxation theory and the chiropractic adjustment.

And this is where they lose me. While ever research into the vertebral subluxation is a defined priority of the ASRF then it is not something that I feel can help practitioners achieve better outcomes for patients of chiropractors. And I feel that should be the end goal.

For viewing interest – Catalyst – ABC1 on Thursday 11/07/2013 at 8:00pm

Apologies it has been nearly three weeks since my opening salvo. Combining chiropractic practice with a family is time consuming enough. Adding to that the research that is required to write a suitably informed blog post (besides coming up with a satisfying first real topic) was more difficult than I had imagined. Nonetheless, we shall proceed.

This week, Catalyst, the excellent science show on ABC1 (formerly known as just the ABC, and in some cases, channel 2), will be broadcasting an episode on chiropractic. From their blurb:

“Most people go to the chiropractor for back pain but now there seems to be a new trend emerging. A growing number of parents are taking their babies and young children to the chiropractor for problems that would normally be treated by a medical doctor – conditions like colic, reflux, asthma and autism. This has not only created a divide within the chiropractic industry, it has outraged the medical profession. 

The science behind some of the founding principles of chiropractic has been brought into question. Dr Maryanne Demasi investigates whether chiropractors are really helping babies or putting their lives at risk.”

This looks like it could be quite provocative at first glance. Dr Demasi has been assuring chiropractors, doctors, and consumers via her twitter feed that the story will examine both sides of the “debate”. Views sought apparently include Tony Croke, vice president of the Chiropractors Association of Australia in Victoria, John Reggars, vice president of the Chiropractic and Osteopathic College of Australia and John Cunningham, spinal orthopaedic surgeon.

If you look at the COCA policy on treatment of children you will see a very clear instruction given to it’s members about their scope of practice and ethical obligations to inform patients and their parents about existing evidence with regard to manual therapy on non-musculoskeletal conditions in children. This blogger could not find such a statement on the CAA website but if anyone would like to direct me to it I would be happy to correct. There is also a stark contrast in the language regarding vaccination policy in the two organisations. Here is the COCA policy and here is the CAA policy. I will let you be the judge about which organisation makes it clearer to their members their obligations when it comes to vaccination.

Personally, this blogger looks forward to the episode. I am in two minds as to whether I will live blog or live tweet the episode ( @RogueChiro ), or simply include a summary and discussion on this blog.

Disclaimer: this blogger is a practicing chiropractor and member of the Chiropractors and Osteopaths College of Australia (COCA). The views expressed above are personal and unless linked directly to the website of the organisations mentioned.

Nb: this article has had minor amendments

Opening salvo.

I’ve been wanting to start a blog about chiropractic for a while. There are a lot of blogs out there on all manner of topics. Some good, some bad, and many lie within the middle ground.

This first post will be unreferenced, somewhat rambling, and a practice run at some of the things that will be spoken about. I have deliberately stolen the title of my first post from the first Quack-cast from Dr Mark Crislip.

When it comes to blogs on chiropractic, I haven’t found too many that would satisfy what I need from a chiropractic blog. Maybe I haven’t been looking hard enough. But the vast majority of websites that discuss evidence based healthcare are not chiropractic blogs – they are medical blogs, science blogs, skeptics blogs. One of the best of these, Science Based Medicine, has had chiropractors and the profession as a whole in it’s sights now for a while. A lot of their criticisms are justified. Chiropractors promoting anti-vaccination quackery, chiropractors promoting treatments for organic diseases with weak or non-existent evidence, chiropractors seeking prescription rights or to be recognised as primary care practitioners. Many of their articles seem designed for readership, but the issues raised there are not unique to North America.

In Australia, chiropractic has been carving out a niche in the healthcare market. Chiropractors have been largely accepted as being experts at treating musculo-skeletal back and neck pain, headaches. Despite the lack of evidence, there are chiropractors that claim that chiropractic will improve patients with conditions such as asthma, colic, dysmenorrhea, otitis media despite the best available evidence, discussed in a systematic review by Bronfort et al into manual therapies showing there to be little supporting evidence. Instead of being able to focus on what chiropractic and spinal manipulative therapy has been SHOWN to be effective for and striving to be the best at that and be respected for that and be a valuable contributor to the health care system, lets make a bunch of outrageous claims and throw in a big medicine and big pharma conspiracy theory while we’re at it.

I will be seeking contributors to this blog in coming weeks/months/years. It is a very basic blog. I will be inviting anyone from chiropractors to physiotherapists, to medical doctors or any allied health professional. Hopefully a few people will even accept the invite.

But for now, it’s time to find something real to write about. For now, it’s off to see some patients.

Here is a cartoon I found in the web. This could have been any of us in our undergrad days…

Image