More Bedwetting Bogosity*

I was pretty surprised to find that many Chiropractors claim to treat bedwetting (nocturnal enuresis) in children.  They often cite studies published in their own ‘academic’ journal to back up this claim.  After finding that even these studies do not really support the chiropractic treatment of this condition, I wondered how Chiropractors justify offering this treatment: so I decided to contact an un-scientifically chosen^** sample of chiropractic clinics, pointing out the weakness of the evidence and asking them to consider correcting any errors in the way that they were representing it.   I also wanted to see how open they would be to the idea of including good conventional advice on their websites, as a service to their customers. 

So far, most have not replied.  Of those who have been gracious enough to reply, one chiropractor has promised a detailed response soon.  Another argued that their claims are about Chiropractors using non-chiropractic interventions, but then made a defence based on clinical experience with spinal ‘adjustment’.  One clinic has apparently “noted” my comments. 

My enquiries used the basic template shown below, adjusted to reflect the specific claims or content of the websites: 

I am curious why your website says that Chiropractic can [insert specific claim about bedwetting].  Are you aware that a Cochrane Review in 2005 called the evidence for this “weak”; that no positive trials have been reported outside the Chiropractic literature; and that two negative trials and a negative review have been published by The Journal of Manipulative and Physiological Therapeutics? 

Given the evidence currently available don’t you think that you should remove this claim for your website? 

Wouldn’t it help your prospective customers if you provided links to the very helpful NHS Choices website or the children’s health charity ERIC (Education and Resources for Improving Childhood Continence)? 

[References and links provided]

So, who have I contacted and what response have I had?  

Milton Keynes based Isis, (Cached URL) do provide some good advice on their website.  They mention credible likely causes and go on to discuss management strategies, the use of alarms and medical options.  Finally, a link is provided to the ERIC website.  This is all good.  It’s probably deals with this issue better than any other chiropractic website I’ve seen. 

Unfortunately, they do claim that chiropractic treatment works for nocturnal enuresis, at least to some degree: 

 “[…] early trauma to the lower back and sacrum may be the major reason why bedwetting in some patients stops when the spine is adjusted by a chiropractor.”  

This is supported by the same inaccurate summary of cherry-picked research I had first spotted being used by Walsall Chiropractic Health Clinic: three articles from The Journal of Manipulative and Physiological Therapeutics (a chiropractic journal).  Both of the articles that reported trials were of poor quality and the outcomes did not support the clinical use of chiropractic (Leboeuf et al, 1991; Reed et al, 1994).  The summary makes them appear to endorse spinal manipulation for this condition. 

I am sure that this is being used in good faith but this really needs correcting.  Unfortunately, they have yet to respond to my enquiry. 

Next, I emailed the ChiroPlus Chiropractic Clinic (Cached URL) in Newark.  Their website says:

“At ChiroPlus we have a particular interest in family health. The areas where Chiropractic may be able to help include: 

Pregnancy related back pain

Pubic symphysis disorder (PSD)

Post natal spinal check for mother & baby

Colic and Bed wetting

Recurrent ear infections

Constant crying in babies

Lack of sleep in babies”

At least they say they may be able to help, rather than making a more confident assertion.  However, the website does not provide any evidence to support these (relatively) modest claims; neither have they replied to my enquiry. 

Barnes Chiropractic Healthcare (Cached URL) similarly offers no evidence on their website to support their less modest assertion that: 

“[…] childhood illnesses and conditions such as asthma and bedwetting, are problems that can cause misery for children, parents and siblings, but which can be dealt with in an effective and gentle way with cranial and chiropractic treatment […].”

They have not replied either.

The Tayside Chiropractic and Wellness Clinic (Cached URL) state that: 

“Chiropractic is safe during pregnancy and for babies and children. Chiropractic treatment can sometimes help with colic, chronic ear infections and bed wetting in children”

 They offer no evidence.  However, I have had an interim reply from one of the Chiropractors:

 “I would […] be interested to hear how you found my website and what your qualifications are?

 I hope that you notice that it says chiropractic can sometimes help with…. because sometimes it does.  I am not claiming anything nor am I making promises.

 In fact I find that adjusting the lumbar spine sometimes helps with urinary incontinence is adults too.

If someone called up for that problem specifically in a child we would usually offer them a spinal screen.  This is a complimentary visit and we would discuss any other concerns.

I will look into your research when I get a chance next week.”

First, I do note the use of the word “sometimes”.  It makes the claims made by the Tayside Clinic less bold than some.  Perhaps this indicates a better awareness of the evidence.  I hope so; and look forward to seeing what they make of the references I provided. 

It’s a shame that there is a level of suspicion evident in the reply.  My qualifications are neither here nor there: either my reading of the literature is justifiable or it is not. 

I have had a more extensive dialogue with a representative of the Stanmore Chiropractic Clinic. (Cached URL) 

“Many thanks for taking time and interest in my website.  I took the time to read the piece titled Chiropractic: a bogus^* treatment for bedwetting? but I found it a shame that a man with your obvious intelligence feels the need to use the term “bogus”.  It is a term that could be easily be misconstrued as was evident by the fact that the term needed to be further clarified.  If you want to analyse the research and state your findings then I am sure that no Chiropractor would mind.  What I do mind are articles that are headed in a way that could infer deception.

I was indeed aware of the websites that you alluded to. 

As to whether I should remove the claim about bed wetting from my website… the answer is no.  My website in fact states that “some of the conditions that CHIROPRACTORS can help with” not ChiropractIC.  You appear to not understand that Chiropractors do more than just manipulate joints of the spine.   As a Chiropractor I will use all the best methods to help my patients.  If a child is brought to my clinic for bed wetting some my indeed have work done to their spine, but some may also be told about the alarm clock method and given advice. It depends on the case and the findings on the examination.

As a clinician we are taught to use evidence based methods and this includes RCT’s [sic] as well as the full spectrum of evidence based medicine.  This also includes reading case reports and our own experience in practice.  I have treated a few patients with bed-wetting.  One case that comes to mind is a young girl who was previously dry at night for a number of years but began to wet the bed again out of the blue.  In this case she was given an adjustment to her lumbar spine and was once again dry from that night onwards.  As this is my clinical experience it would be incorrect to state to patients that we can’t help with this condition.  However, unfortunately I feel that even if I wrote this in a case report and published it, people in your position are unlikely to be swayed from their opinions. 

I am always interested to hear viewpoints from the public and I thank you for your comments.”

The reply makes some interesting points.  First, it’s nice that they took the time to look me up and read what I have written.  I hope they will drop by and leave a comment on the blog, as there are a few contentious points raised in the reply^***.  

I do think their complaint about my use of the word bogus^*, is well, bogus^*: it is a perfectly cromulent word.  Maybe it’s only Chiropractors and English High Court judges who take it to mean a deliberate deception.  I certainly don’t and I think I made that excruciatingly clear in my post. 

The distinction drawn between Chiropractors and chiropractic has certain logic to it.  I am glad that this Chiropractor is able to “use all the best methods to help” their patients.  It’s a shame that after having their cake they try to eat it. 

“I have treated a few patients with bed-wetting […] As this is my clinical experience it would be incorrect to state to patients that we can’t help with this condition”

This amounts to a claim that chiropractic manipulation, not just Chiropractors, can help.   Of course, without good trial data they cannot say if that it was the spinal adjustment that helped: perhaps the condition would have resolved itself in due course; perhaps it was an expectation that manipulation would help that did the trick; or maybe it was the attention the child received from a sympathetic and caring authority figure.  Maybe it was a combination of these.  Without trial data, who knows?  

The reply really misses the point of RCTs.  Clinical experience is, of course, a vital part of medicine but it is subject to the usual human biases: preferential recall of ‘successes’ (confirmation bias); inferring that the treatment caused any improvement, because improvement followed the treatment (post hoc ergo propter hoc); attributing improvement to the specific treatment rather than observer and subject expectancy effects; to name a few.  Whilst RCTs seek to minimise these sources of bias; clinical experience cannot.  Therefore clinical experience can mislead.  Using it as the rationale for treatment can only really be justified in the absence of trial data; and if the likely benefits outweigh any risks.

However, in this case there is trial data.  It has it flaws; but it does show that there is no good reason to offer chiropractic treatment for this condition.  To prefer personal experience over this evidence is to stand logic on its head.

It’s also odd that the Chiropractor seems to think that a single published case study should change my mind.  Again, this demonstrates a lack of understanding of the biases present in observation and the expectation effects present during treatment.  

Someone with a good medical education shouldn’t expect that a single published case study, or a series of them, would change anyone’s mind. For that matter a single positive RCT shouldn’t change anyone’s mind either. 

There are many reasons why positive trials might appear in the literature, aside from the specific effect of the intervention.  For instance, there is a false positive rate generated by the conventional approach to testing statistical significance.  This is augmented by testing hypotheses with low plausibility (Ioannidis, 2005).  Then again, apparently positive trials are more likely to be published (publication bias).  Finally, when assessing therapies that involve a clinician touching a patient it is difficult to design a meaningful ‘placebo’ treatment and then blind patients as well as clinicians to who is getting the real treatment and who is not. (And yet PubMed does not contain a single positive trial for chiropractic treatment of nocturnal enuresis in children!) 

Here’s what would change my mind though: if the distribution of results from large good quality trials was clearly pointing to a positive effect and the size of the effect was clinically significant. 

I do wonder what would change this Chiropractor’s mind.  Finally, in the absence of good quality positive evidence should this sort of treatment for bedwetting even be offered?  In my judgement the answer is no. 

Still, at least this clinic didn’t provide the common misleading interpretation of the research evidence. 

Neither did the Capital Chiropractic Clinic of Edinburgh (Cached URL).  However, their website makes some fairly bold claims: 

Kids Chiropractic Care 

Are you tired of constantly being woken up through the night by the sound of your baby or child crying? 

You’ve fed them, you’ve changed their nappy, they don’t want their bottle and they still won’t stop crying? 

Do you think that there might be something else causing your child to cry and be unsettled?

If your child is suffering from excessive crying, colic, restlessness, attention problems, bed wetting, unhappiness, excessive vomiting and eating problems then we may be able to help. 

Chiropractic care for babies and infants is fast becoming one of the most popular forms of health care for parents and children. Although still fairly new in the UK, chiropractic care for children is extremely well known and recognized in other places around the world such as the United States, Australia, Canada and Scandinavia, where the chiropractor is the first place of choice for babies who are suffering from one of the above symptoms. Parents in the UK are now starting to realize how this gentle, non invasive, non medical approach to their Childs heath care cannot only greatly benefit the child but also the parents.

And in their FAQ (Cached URL):

Is chiropractic safe for children?

Again [Ed: the previous paragraphs call it “absolutely 100% safe” for babies], yes absolutely! The human body is constantly changing during the first 20 years of life. Often these pains are described by some people as growing pains. Chiropractic is very safe and effective for children and adolescents. 

I was surprised to see claims of absolute, 100%, safety.  No activity in life is 100% safe.  So along with my standard query I added: 

“[…] Leboeuf et al (1991) reported two adverse reactions in their trail: headache and stiff neck and acute pain in lumbar spine.  Now, you might take the view that a rate of adverse reactions of between 1.1% and 1.7% is not very high; but neither is it zero and neither do your claims of absolute safety seem credible in the light of this work. 

Given the evidence currently available don’t you think that you should remove this claim for your website?” 

So far, I’ve not had a reply [Reply received 3^rd June 2009.^****]. 

Martineau Chiropractic (Cached URL) says on their website: 

“Chiropractic treatment is suitable for all ages from the new born to the very elderly. Chiropractors are trained to adapt their techniques so as to be able to deliver safe effective treatment for all. Many parents bring their babies and children to chiropractors for conditions such as infantile colic, glue ear and bed wetting where research has shown chiropractic to be an effective treatment. Many times conditions which have been put down to growing pains, are in reality a result of some spinal malfunction which responds well to chiropractic care.”

Of course, research has not shown, “chiropractic to be an effective treatment” for bedwetting.  On the contrary, as we have seen, the Cochrane Review charitably called the evidence “weak” (Glazener et al, 2005).  I’ve not had a reply from these Chiropractors either. 

Finally, back to where I started: the Walsall Chiropractic Health Clinic.  They had responded to an initial enquiry, but I thought that I would just help them out a little by pointing out the problems with the way their website handles the research evidence. 

Thank you for your prompt and courteous reply.  Having a science background, I do try and look carefully at any medical intervention that might be suggested for me or a family member.  These days it is a lot easier thanks to the internet: The Cochrane Library, NHS Choices are PubMed are very accessible. 

I do note that your reply seems more cautious than your website.  Having done some more research on this topic I would like to ask you to consider amending the information on your website; specifically the description of research from The Journal of Manipulative and Physiological Therapeutics. 

The first study you list (Reed et al, 1994) is actually negative.  As you note, the authors did find a difference between the treatment and control groups but they say, “The mean pre- to post-treatment change in the wet night frequency for the treatment group compared with the control group did not reach statistical significance (p = 0.067).”  In statistical language this means that there is no good evidence against the (null) hypothesis that there was actually no difference between the wet-night frequencies of the two groups.  In other words the difference is most likely a fluke.  Your summary should really capture the negative (or at the very least, inconclusive) nature of this study. 

Next in your list comes Leboeuf et al (1991).  The authors themselves concluded that, “This result is less favourable than the therapeutic success of other common types of therapy, which have reported “cure” rates well above 50%.”  And, “In the absence of a control group there appears to be no validity in the claim that chiropractic is a treatment of choice for functional nocturnal enuresis.”  If the author’s didn’t view this outcome as a success, shouldn’t you reflect this in your summary? 

What about balancing your evidence with the results of published reviews?  For instance, you might consider referring to the review by Kreitz and Aker (1994) which concluded that, “The success of each therapeutic option must, in part, be attributed to the natural history of enuresis, as well as any educational or placebo aspects of treatment. Conditioning therapy utilizing the urine pad alarm may be the most reasonable initial mode of intervention. Spinal manipulative therapy has been shown to possess an efficacy comparable to the natural history.”  

What about referencing the respected Cochrane review (Glazener et al, 2005) which concluded that, “[…] chiropractic may help, but the evidence was weak.” 

I am sure that you will be keen to ensure that the evidence you provide is both balanced and summarised accurately. 

As you reasonably suggest that allopathic options should be exhausted first, why not include a link to the very helpful NHS Choices website or the children’s health charity ERIC (Education and Resources for Improving Childhood Continence). 

Best wishes,

apgaylard

They have replied, with a polite but rather cryptic:

“Many thanks again Mr Gaylard. your comments have been noted and will be the subject of much discussion i am certain.”

Well, I do hope that they at least correct their summary of the research to reflect what the trials actually show (or show me where I have got this wrong.)

So, what to make of this?  Well I am sure that these Chiropractors are sincere and really believe that they can help.  Perhaps this is part of the problem.  It seems to lead some of them to be suspicious of any challenge to their public pronouncements whilst others appear blind to the realities of the evidence.  In my small sample, most didn’t seem to want to engage with serious criticism at all.

This latter point is important.  Failing to engage with criticism is missing an opportunity to learn and, in this case, improve the healthcare services offered to children.  To quote Professor Edzard Ernst, from a recent newspaper article entitled, “Distrust me, I’m a chiropractor”:

“In science, if you disagree with someone, you argue your case and openly debate the facts. This is a vital process. We should all learn from it and, at the end, progress may be made.”

Neither do I think that using weasel words like “may” and “sometimes” let the Chiropractors concerned off the hook.  These still invite the unwary to infer some level of efficacy, which is unsupported by the evidence.  I also wonder whether worried parents looking for help will appreciate the distinctions being made. 

It is a shame that the sincere faith of many Chiropractors in a bogus^* chiropractic treatment may actually turn out to hinder rather than help children suffering from nocturnal enuresis and their families. 

Disclaimer

This does not constitute medical advice.  If you need that please consult a medical doctor.

Notes

* Deliberate deception not implied.  I use the word in its contemporary sense of something that is false in itself, but may be taken in good faith as true by the unwary or uninformed. (See “Knowing bogosity” at the Language Log)

**The Chiropractors contacted were identified using a google search limited to the UK.

***The discussion provided here is based on a response to the Chiropractor’s reply sent on 24^th May 2009.

****Reply discussed in this short post.

References 

Blomerth PR. Functional nocturnal enuresis. Journal Of Manipulative And Physiological Therapeutics. 1994 June;17(5):335–338. Available from: http://view.ncbi.nlm.nih.gov/pubmed/7930968.

Glazener CM, Evans JH, Cheuk DK. Complementary and miscellaneous interventions for nocturnal enuresis in children. Cochrane Database Of Systematic Reviews (Online). 2005;(2). Available from: http://dx.doi.org/10.1002/14651858.CD005230.

Ioannidis JP. Why most published research findings are false. PLoS Med. 2005 August;2(8). Available from: http://dx.doi.org/10.1371/journal.pmed.0020124

Kreitz BG, Aker PD. Nocturnal enuresis: treatment implications for the chiropractor. Journal Of Manipulative And Physiological Therapeutics. 1994 September;17(7):465–473. Available from: http://view.ncbi.nlm.nih.gov/pubmed/7989880.

Leboeuf C, Brown P, Herman A, Leembruggen K, Walton D, Crisp TC. Chiropractic care of children with nocturnal enuresis: a prospective outcome study. Journal Of Manipulative And Physiological Therapeutics. 1991 February;14(2):110–115. Available from: http://view.ncbi.nlm.nih.gov/pubmed/2019820.

Reed WR, Beavers S, Reddy SK, Kern G. Chiropractic management of primary nocturnal enuresis. Journal Of Manipulative And Physiological Therapeutics. 1994;17(9):596–600. Available from: http://view.ncbi.nlm.nih.gov/pubmed/7884329.

Edits

5^th June 2009. Reply from Martineau Chiropractic noted.

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