MD, PhD, FMedSci, FRSB, FRCP, FRCPEd

A team of Swiss and UK chiropractors just published a survey to determine which management options their colleagues would choose in response to several clinical case scenarios. In order to avoid the accusations of citing out of context, or misreporting the findings in other ways, the wording of the following post is close to the original text of the article.

PART ONE

The clinical scenarios refer to treatments which appear not to be successful, not indicated, possibly harmful or where a patient might be suffering from a treatment-induced complication:

Scenario 1. A patient with non-specific low back pain has not improved at all after 4–6 treatments.

Scenario 2. A patient, who has a simple neck problem with no previous long-term problems, has now improved at least 80% and stayed at this level for a couple of weeks.

Scenario 3. A patient returns from the last treatment with a new distal pain (e.g. sciatica when treated only for localized LBP, or brachialgia when treated only for local neck pain).

Scenario 4. An elderly woman complains about immediate chest pain on inspiration after manual treatment directed to her thoracic spine.

It is worth noting that scenario 4 is the most dramatic but it is by far not the worst case scenario; this would have been the case of a patient who develops signs of a stroke after neck manipulation. It is telling, I think, that this possibility has been excluded in the survey.

The following 9 management options were provided:

• I would re-evaluate the patient with a view to establishing a better diagnosis

• I would send the patient for diagnostic imaging

• I would change my treatment approach and use another technique

• I would send the patient for a second opinion to another healthcare professional but keep on monitoring their condition

• I would try a few times more

• I would encourage the patient to continue the treatment until their spine is subluxation-free

• I would stop treatment and monitor the patient regularly

• I would stop the treatment, apologise and report the event to the chiropractic reporting and learning system

• I would stop the treatment, but tell the patient that s/he is welcome to return if they feel the need

To each of these options, the chiropractors could answer by ticking: ‘never’, ‘unlikely’, ‘likely’ and ‘most likely’.

PART TWO

In a second part of the questionnaire the researchers assessed the chiropractors’ general attitude towards safety issues by seeking the level of agreement on a five-point scale, with the responses ‘strongly disagree’, ‘disagree’, ‘neither agree nor disagree’, ‘agree’ and ‘strongly agree’, with 23 statements relating to six different safety dimensions, as follows:

• Teamwork – helping out, relationships, respect, teamwork-emphasis

• Work pressure – rushing, overwork, staff contingent, patient numbers

• Staff training – in response to new processes, on-the-job, appropriateness of tasks

• Process and standardisation – organisation, procedures, workflow, processes

• Communication openness – ideas for improvement, alternative views, asking questions, voicing disagreement

• Patient tracking/follow-up – reminders, documentation, reports, monitoring

260 Swiss and 1258 UK chiropractors were invited to complete the questionnaire. Responses were received from 76% of the Swiss and from 31% of the UK chiropractors. The dismal response rate for UK chiropractors seems to speak volumes.

The results of this survey indicate that both Swiss and UK chiropractors tend to manage clinical scenarios where treatment appears not to be successful, not indicated, possibly harmful or where a serious complication might have occurred, by re-evaluating their care. Stopping treatment and/or incident reporting to a safety incident reporting and learning system were generally found to be unlikely courses of action. The authors believe that this unlikeliness of safety incident reporting is due to a range of recognised barriers, although Swiss and UK chiropractors are positive about local communication and openness which are important tenets for safety incident reporting. The observed positivity towards key aspects of clinic safety indicates a developing safety culture within the Swiss and UK chiropractic professions.

In this context, scenario 4 is the most dramatic and therefore the most relevant scenario -but, as noted above, not a worst case scenario. It suggested a rib fracture as a result of chiropractic manipulation, with osteoporosis as a possible risk factor. The authors state that there is a strong argument for such an incident to be reported because patient injury occurred and because reflection on the detailed circumstances of the case, shared with colleagues, might serve to minimise the risk of such an occurrence happening elsewhere. However, incident reporting was found to be an unlikely option and comments revealed that this may be due to a perceived connection of reporting with guilt and error, as has been identified with other healthcare reporting initiatives, or only warranted in extreme cases.

The survey also showed that 33% of UK and 48% of Swiss chiropractors seem to work alone. In the eyes of the authors, this is limiting opportunities for fostering a safety culture through activities such as teamwork.

The authors draw the following conclusions:

• This study prompted chiropractors to reflect on aspects of clinical risk.

• Swiss and UK chiropractors tend to manage potentially risky clinical scenarios by reevaluating their care and changing their approach

• Safety incident reporting to an online system is currently an unlikely course of action, probably due to previously recognised barriers, although Swiss and UK chiropractors are positive about local communication and openness which are important tenets for safety incident reporting.

• Barriers to the use of safety incident reporting systems need to be addressed in order to encourage wider use of the existing systems.

• A significant proportion of Swiss and UK chiropractors practice in a single-handed environment. We suggest that single-handed practitioners have most to gain from participation in a national safety incident reporting and learning system.

• Female chiropractors appear to be more risk-averse than male chiropractors.

• Positivity towards key aspects of clinic safety indicate a developing safety culture within the Swiss and UK chiropractic professions.

In my view, the findings of this survey are deeply worrying and the interpretation of the authors is not far from an attempt to ‘white-wash’ the results. Like with most investigations of this nature, the results are wide open to selection bias; particularly the dismal UK response rate begs many questions. In all likelihood, reality is much worse than implied by the results of this investigation. And these results clearly show that, even with a fairly dramatic safety incident, chiropractors fail to respond adequately. There is no doubt in my mind: chiropractors put patients at risk.

12 Responses to How chiropractors put patients at risk

  • Professor Ernst wrote: “…Responses were received from 76% of the Swiss and from 31% of the UK chiropractors. The dismal response rate for UK chiropractors seems to speak volumes.”

    There certainly seems to be a pattern with that dismal UK response rate. For example, only around 10% of UK chiropractors responded to a recent General Chiropractic Council survey on patients’ views of chiropractic
    http://edzardernst.com/2013/02/more-dismal-research-of-chiropractic/

    …and only 92 out of 200 UK chiropractors responded to a recent questionnaire on risk-related issues , with only 45% of those respondents indicating that they always discussed the risks of neck manipulation with patients:
    http://www.guardian.co.uk/science/blog/2011/jul/12/chiropractors-ethical-duty-patients-risks?CMP=twt_fd

  • The authors of the survey wrote: “…incident reporting was found to be an unlikely option…”

    And there’s another pattern. There have been two other occasions where incident reporting in the UK has been flagged up as being unsatisfactory (although it’s worth noting that the Scottish Chiropractic Association claims that it has a “robust risk management and reporting system” which it operates and manages even although it doesn’t appear to be public, and there’s no indication if any of the reports it receives are added to the data in the medical literature regarding complications following chiropractic treatment). More details can be found here:
    http://www.ebm-first.com/chiropractic/uk-chiropractic-issues/1888-british-chiropractic-association-members-attitudes-towards-the-chiropractic-reporting-and-learning-system-a-qualitative-study.html

  • “The authors believe that this unlikeliness of safety incident reporting is due to “a range of recognised barriers, although Swiss and UK chiropractors are positive about local communication and openness which are important tenets for safety incident reporting. The observed positivity towards key aspects of clinic safety indicates a developing safety culture within the Swiss and UK chiropractic professions.””

    What is a barrier to safety incident reporting? Not knowing it exists? Refusal to use it? Adherence to a dogmatic belief that chiropractic is safe and therefore doesn’t need safety incident reporting? Colour me curious.

  • No comments sticking up for this. Interesting.

    “Like with most investigations of this nature, the results are wide open to selection bias; particularly the dismal UK response rate begs many questions.”

    Even though it’s a survey, very low when it comes to evidence, surely Chiropractors can offer more participation than this. Is it laziness, or is it a genuine reluctance to participate in research? In Oz, a survey was collected on opinions of chiros on evidence based practice (unsure if released as yet) and it took no more than 10 minutes. How long could this survey have taken?

    “In all likelihood, reality is much worse than implied by the results of this investigation.”

    You can’t really say this with any degree of evidence to support this. This is purely speculative opinion. There is a chance that the chiropractors that didn’t answer were too busy reporting an adverse finding or consulting with their colleagues about a case after stopping care. It’s a stretch I know, but come on Prof, evidence goes both ways. It’s far better to give them an uppercut for not responding than by saying things are worse than indicated.

    • “IN ALL LIKELIHOOD” very clearly indicates that I am speculating here! what are you on about?

      • Matt wrote: “Is it laziness, or is it a genuine reluctance to participate in research?…There is a chance that the chiropractors that didn’t answer were too busy reporting an adverse finding or consulting with their colleagues about a case after stopping care. It’s a stretch I know, but come on Prof, evidence goes both ways. It’s far better to give them an uppercut for not responding than by saying things are worse than indicated.”

        The following is lifted from an article by a chiropractor PhD in the September 2011 issue of the Journal of the Canadian Chiropractic Association:

        Quote
        “Regrettably, research and science are too often viewed as processes that can only constrain, hamper or distort chiropractic…I was recently bewildered when colleagues and chiropractic representatives feared the possible negative consequences of good quality research and of its dissemination within and outside the profession. “
        http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3154060/?tool=pubmed

        Add to that the recent leak which showed that the British Chiropractic Association apparently defends the business interests of its members by controlling what information they can share with the media, public, or patients …
        http://www.zenosblog.com/2013/04/beware-the-spinal-spin/

        and it becomes obvious that Professor Ernst is right on the mark.

  • I apologise and retract the last comment.

  • Having read this paper and some of the references quoted I am quite surprised at your very negative comments.

    Firstly, surely it should be applauded that chiropractors have at least established an incident reporting system. It may not be a perfect system but they are looking to address the issues and are clearly happy to openly publish and address the limitations of their system and approach. I understand that other manual therapy professions such as osteopaths and physiotherapists do not have any such systems.

    Secondly, on reading the cited references, it is clear that under reporting and reluctance to report “incidents” is a common theme amongst most, if not all, health care professions. Why would you expect chiropractors to be any different?

    Thirdly, a response rate of 30% for a questionnaire is actually quite respectable, I know that when we have conducted surveys amongst UK GPs response rates were very much lower than this.

    I feel that in your desperation to say negative comments about chiropractors you are missing important issues. I stated that I was surprised by your comments, but having looked at your tweets maybe I should not be.

    No offence is intended but I suggest that I more grown up approach is needed by all.

    • andy wrote: “…on reading the cited references, it is clear that under reporting and reluctance to report “incidents” is a common theme amongst most, if not all, health care professions. Why would you expect chiropractors to be any different?”

      Because the science is now showing us that it is almost certain that the benefits of chiropractic treatment are outweighed by its risks. It follows, therefore, that chiropractors won’t want any further proof of that or they could be waving goodbye to their livelihoods. See here:
      http://edzardernst.com/2013/04/time-to-re-write-the-guidelines-on-spinal-manipulation-for-acute-low-back-pain/

      It’s also worth noting that, with regard to chiropractic spinal manipulation for low back pain (for which, until recently, there has been some weak evidence), the subluxation-based pseudoscientific beliefs of chiropractors appear to be overlooked when guidelines are being developed. For example:

      Quote
      “Chiropractors view the spine as an entity. Where they diagnose ‘subluxations’, they will normally manipulate and ‘adjust’ them (11). And ‘subluxations’ will be diagnosed in the upper spine, even if the patient suffers from back pain. Thus many, if not most back pain patients receive upper spinal manipulations. It follows that the risks of this treatment should be included in any adequate risk assessment.”

      Ref: Spinal manipulation for the early management of persistent non-specific low back pain — a critique of the recent NICE guidelines, Edzard Ernst, Int J Clin Pract (18th August 2009). Reference (11) is Ernst E. Chiropractic: a critical evaluation. J Pain Sympt Man 2008; 35: 544–62. Page 6 of the paper mentions a report that indicates that only 11% of all cervical manipulations are “appropriate” and gives the reference Coulter I, Hurwitz E, Adams A, et al. The appropriateness of manipulation and mobilization of the cervical spine. Santa Monica, CA: RAND, 1996:18e43.

      So, chiropractors *are* different from other healthcare professions. In the UK, they were regulated prematurely, and, as they continue to be mired in an enormous amount of quackery, window-dressing gambits appear to be all they have these days as they desperately attempt to maintain an air of legitimacy.

  • This is an eye-opening article. Very interesting and informative. Thank you so much for sharing this. Keep up the good work!

  • I find this study and article very interesting but also not surprising. I successfully sued a prominent UK Chiropractor for clinical and medical negligence following treatments by him.

    What puzzled me after my claim was settled was that whilst the GCC seemed to have a transparent process for documenting complaints brought to it about it’s members there seemed to be no method for the public to know if a UK ‘Dr’ of Chiropractic has been found guilty or admitted negligence (my case was settled when barristers got involved ‘out of court’ presumably to avoid public court records being created). Since my legal battle I have spoken to a number of people whom also felt they were left in a worst state than prior to the treatment but assumed they were one off or to blame rather than perhaps being a victim as I was of bad practice. There are good and bad people in all professions but I’m sure that others would like to know if their therapist has a good track record. Frankly I wouldn’t buy a book, fridge or car these days without looking at some reviews but for something as hands on and critical to wellness there is nothing similar. – no reviews, audits or star rating (would you eat in a place only had two stars on the door for food hygiene?). Actions speak louder than words yes but only if we actually get to hear if those actions are good or BAD – when I hear that “benefits of chiropractic treatment are outweighed by its risks”, that suggests that the ‘few’ who are left worse off represent an acceptable margin of error. Some may be happy with this/any level of risk but at least give them the information to make an informed choice by documenting errors of judgment/actions and establishing patterns of failure by individuals. Please don’t reply with a smoke screen and screams of ‘compensation culture’ as the only people who profited out of my misfortune were the lawyers and my Dr of Chiropractic continues to practice today without a blemish on reputation or record.

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