‘Chiropractic is safe’ is a statement by Dr Arleen Scholten (see below) and thousands of other chiropractors like her. This sentence seems to be a nice marketing slogan – but sadly it is far removed from reality:
- chiropractic causes mild to moderate adverse effects in about 50% of all patients;
- in addition, it caused many much more serious complications, including deaths.
How many such serious events have occurred is anyone’s guess. The reason for this uncertainty is that there is no monitoring system that would give us this information. About 500 serious complications have been published in the medical literature. But these published cases are just the tip of a much bigger iceberg. We have shown that under-reporting is close to 100%.
This means that the vast majority of these cases remain completely undocumented. Some appear in the popular press, like the one recently published in the DAILY MAIL:
A chiropractor has been arrested on suspicion of manslaughter after a retired bank manager died following treatment for backache.
John Lawler, 80, was undergoing routine treatment at a private clinic when he lost consciousness and appeared to have become paralysed from the shoulders down. He was taken straight to hospital but died the next day as a result of a ‘traumatic spinal cord injury.’
His wife of 55 years, Joan Lawler, 81, was in the chiropractor’s clinic with her husband and witnessed the incident. Police are investigating to establish whether or not criminal negligence was a factor in his death.
Dr Arleen Scholten, 40, the chiropractor who treated Mr Lawler, was arrested by police on suspicion of manslaughter and released pending further inquiries.
Mr Lawler, a former Barclays Bank manager, was an active and healthy grandfather who lived in York. It is understood he was taken ill on his third visit in a week to Chiropractic 1st – a clinic within walking distance of the family home. He was seen by Dr Scholten, a chiropractor and director of the company, on Friday, August 11 and was undergoing treatment on his back when the unexpected and fatal problem occurred.
Mr Lawler was taken to York District Hospital by ambulance before being transferred to Leeds General Infirmary when the seriousness of his condition became clear.
END OF QUOTE
DOCTOR Scholten tells us on her website that we get to help people who suffer from a variety of health issues. Naturally, chiropractic helps traditional neck and back problems, but chiropractic has also produced wonderful results with a variety of organic and systemic problems. Chiropractic is safe.*** Chiropractic is natural. And Chiropractic works!
Doctor Scholten also informs us that our children were all adjusted the day they were born, 2 were homebirths and I continue to check their spines regularly. There is a saying in Chiropractic ‘If the twig is bent so grows the tree’.
Say no more!
(*** my emphasis)
51 Responses to “Chiropractic is safe”… Oh really?
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there is also today’s article on the same subject:
http://www.dailymail.co.uk/health/article-4987014/Got-bad-Read-seeing-chiropractor.html
it seems so.
Am I right in understanding that she remains free to ‘treat’ people while investigations continue?
Always wonderful to see the professors’ name and research in widespread publication.
Its interesting that in many areas of the US, Blue Cross (selling Medicare supplemental insurance) have TV ads of a rotation-lumbar-manipulation (delivered by a DC) and a loud ‘crack’ with the “actor” letting out an ‘ahhh’.
The voice-over says ‘and Chiropractic is covered’.
So Blue Cross is not only ‘promoting’ that their 65+ y/o insured try Chiropractic-manipulation BUT they will pay for it…apparently willingly.
I believe there are no “good” studies published on manipulation in a 65+ age group(?)
So apparently (like the Chiropractic profession) some insurance companies aren’t necessarily ‘worried’ about ominous side-effects either.
According to Professor of Physiotherapy, Roger Kerry: ‘The question we need to ask is not “is chiropractic dangerous?” but “can we identify patients who are most at risk?”’.
Risk of serious injury or death, lest we forget.
Identify those most at risk? So that practitioners may continue to make money from killing patients at low risk?
Professor Kerry, please shuffle off.
Et tu, Peter Dixon, for ensuring that your clients are “properly assessed” before they are well and truly dispatched.
@ Leigh Jackson
Have you even read the work of Roger Kerry?
What is the point of your question, receptionist?
@ Frank
Roger Kerry has written extensively on the topic of this blog post and for Leigh Jackson to dismiss his point of view by saying “Professor Kerry, please shuffle off” shows a certain lack of respect.
So, i would guess that Leigh Jackson has most likely never read any of Roger Kerry’s work and that’s why I asked the question.
‘Roger Kerry has written extensively on the topic of this blog
blog posts are not what I would call evidence.
@ Edzard,
Would you consider this evidence?
http://www.ifompt.org/site/ifompt/IFOMPT%20Examination%20cervical%20spine%20doc%20September%202012%20definitive.pdf
IT’S A CONSENSUS DOCUMENT
@ AN Other
I do not respect Kerry.
I condemn his comment to the Daily Mail, which begs the question.
His question assumes that only those with a known high risk of stroke need be worried about the risk of cervical manipulation. His question assumes that chiropractic does not cause stroke to anyone else, or else the possibility that it may do is not worth considering. The evidence, to the best of my knowledge, is consistent with the possibility that chiropractic can cause stroke via arterial dissection.
His comment is deplorable, IMO.
Kerry stated that the question is not whether chiropractic is dangerous, but whether we can identify patients who are most at risk.
The question for all patients is whether chiropractic is worth risking their lives for.
Peter Dixon, President of the Royal College of Chiropractors, states “We abide by a strict code of practice that demands all patients are properly assessed. Patient safety is at the forefront of all we do.”
Ref http://www.dailymail.co.uk/health/article-4987014/Got-bad-Read-seeing-chiropractor.html “
However, patients cannot be properly assessed when chiropractors have no reliable methods to screen for all patients who might be predisposed to suffering a vertebrobasilar artery dissection after neck manipulation. For example:
QUOTE
“Some chiropractors advocate “screening tests” with the hope of detecting individuals prone to stroke due to neck manipulation [22-24]. These tests, which include holding the head and neck in positions of rotation to see whether the patient gets dizzy, are not reliable, partly because manipulation can rotate the neck further than can be done with the tests. Listening over the neck arteries with a stethoscope to detect a murmur, for example, has not been proven reliable, though patients that have one should be referred to a physician. Vascular function tests in which the patient’s head is briefly held in the positions used during cervical manipulation are also not reliable as a screen for high-risk patients because a thrust that further stretches the vertebral artery could still damage the vessel wall.” In a chapter in the leading chiropractic textbook, Terrett and a colleague have stated:
Even after performing the relevant case history, physical examination, and vertebrobasilar function tests, accidents may still occur. There is no conclusive, foolproof screening procedure to eliminate patients at risk. Most victims are young, without [bony] or vascular pathology, and do not present with vertebrobasilar symptoms. The screening procedures described cannot detect those patients in whom [manipulation] may cause an injury. They give a false sense of security to the practitioner [25].”
Ref: https://www.quackwatch.org/01QuackeryRelatedTopics/chirostroke.html
QUOTE
“We [also] do not accept that the existing data on risks, imperfect though it is, is uninformative. The fact that not all studies have shown an effect in the over 45’s most likely reflects the other causes of these events in that population clouding the picture. Indeed finding the association in a group who would not normally be expected to experience such an event (i.e. <45 yrs) arguably makes the association more convincing. While attempts to develop screening procedures is commendable, given that the association between manipulation and VAD/stroke is found in this group who are less likely to present with key vascular risk factors, it seems unlikely that screening will achieve its goal satisfactorily. Reid and colleagues point out that in one survey [3], 45% of these events may have been preventable, which still leaves a rather uncomfortable 55% that may not have been. Indeed acceptance of Cassidy and colleagues argument, that there are patients receiving cervical manipulation who present with a pre-existing dissection, only further illustrates that screening is far short of being effective… In the end, it remains our opinion that cervical spinal manipulation is unnecessary and inadvisable given the other options available.”
Ref: http://www.bmj.com/content/344/bmj.e3679/rr/591678
And it’s not just neck injuries. A draft document on revalidation, which was commissioned in the recent past by the General Chiropractic Council (in order to provide an analysis of the risks and benefits of chiropractic), showed, in section 5.72, the British Chiropractic Association admitting that its members had caused rib fracture injuries in patients:
https://web.archive DOT .org/web/20120503062817/http://www.gcc-uk.org/files/page_file/C-170210-04a.pdf
It has been highlighted previously that reports of deaths after chiropractic treatment are "about three times the number of deaths from trovafloxacin, an excellent antibiotic abandoned in the U.S. as too dangerous”
https://sciencebasedmedicine.org/compare-and-contrast/
…but they’re probably far higher than that given that U.S. chiropractors don’t have to report complications or deaths due to this loophole:
http://www.ebm-first.com/chiropractic/risks/1842-letter-from-britt-harwe-president-chiropractic-stroke-awareness-group-csag.html
Meanwhile, the only chiropractic adverse event reporting system in the world continues to be worse than useless:
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
In essence, believe at your own peril that chiropractic is safe.
I note that the man who tragically died following chiropractic treatment suffered an injury that paralysed him from the shoulders down. Here are some quadriplegia reports related to chiropractic which have been documented in the medical literature:
http://edzardernst.com/2013/08/another-wheelchair-filled-with-the-help-of-a-chiropractor/#comment-42493
and here
https://www.ncbi.nlm.nih.gov/pubmed/23878767
https://www.ncbi.nlm.nih.gov/pubmed/19854314
https://www.ncbi.nlm.nih.gov/pubmed/1735825
https://www.ncbi.nlm.nih.gov/pubmed/13518952
@ Blue Wode
As an editor of an anti-quackery website, why do you tweet a link to an article in the Daily Mail by a Dr, who suggests it is reasonable to try acupuncture and there is very little likelihood of harm from acupuncture.
@ AN Other
I corrected her on the same day the article was published:
https://twitter.com/Blue_Wode/status/911900484583219200
At least she got it completely accurate about chiropractic:
http://www.dailymail.co.uk/health/article-4913138/amp/Why-d-never-send-patients-chiropractor.html
@ Blue wode
But your most recent tweet of the article is not followed by your correction.
@ AN Other
Here you go https://twitter.com/Blue_Wode/status/920643647598727168
Now, do you have any worthwhile comments to make about the topic of this blog?
@ Blue Wode
What do you think of this?
http://www.ifompt.org/site/ifompt/IFOMPT%20Examination%20cervical%20spine%20doc%20September%202012%20definitive.pdf
https://www.sciencedirect.com/science/article/abs/pii/S1052305716304347
Yes…side effects to chiropractic treatment occur…deaths?…this is a very rare possibility but what are the relative risks of manipulation relative to other types of care?
Most of the deaths associated with chiropractic care are not cause-effect…not in the least.
In the current case, this man had CPLL syndrome (mostly seen in the Asian poplulation)…impossible to DDX without radiographs which most, well-trained doctors would miss! The chiropractor used a drop/extension technique commonly used in older patients with the activator…this caused a fracture of the PLL and subsequent ischemia to the upper cervical cord…from direct pressure and bleeding.
Rare, unfortunate and unforseen…as far as the treatment is concerned in my professional opinion.
Adverse effects from treatment are well-documented and are contained on the Canadian consent forms…yes we are trained to do our own screening before treatment is provided including radiographs and other diagnostics.
Do you order them for every patient over the age of 70 regardless of presentation? Of course not…this patient had lingering leg pain from stenosis so it may have been a good idea to acquire radiographs of the cervical spine before treatment.
In this case…the chiropractor didn’t feel that it was warranted…However….perhaps now she may think differently.
Let’s stop this non-sense and look at the bigger picture.
the bigger picture is the risk/benefit balance – and for chiro, it is not positive.
Buzz Kulick,
Most well-trained doctors wouldn’t have manipulated this man’s spine. In any case, most well-trained doctos know that they are not radiologists and leave the business of reading x-rays to the specialists.
There is not a very big Asian population in York, or the North of England generally. The Coroner stated that the prevalence was 10% in elderly men, and as he did not qualify this I would interpret it as referring to a demographic that consisted mainly of white caucasians. I don’t know what his sources were, however.
Within medical practice adverse events (including deaths) are routinely reported regardless of whether they thought to be caused by the treatment in question. Since this is not the case in chiropractic care, where are the data to justify this assertion?
Who are you asking? I don’t understand what you are getting at with this question.
This poor gentleman died at the hands of somebody who fraudulently misrepresented herself to him as a doctor (and still does so on her web site), performed an unsafe manipulation on him without his consent which caused a serious injury, then went well beyond her area of expertise to act in ways that worsened his injury, and finally lied to the emergency services, as a result of which he did not receive the appropriate further care. Your verdict is that this was rare, unfortunate and unforeseen. To me it seems reckless.
The bigger picture is that systems need to be put in place to prevent this happening again.
I should add that an important role of a medical practitioner is to be on the alert for rare conditions and rare complications. Although individually they are rare, there are a lot of them, and if they are not considered they will never be diagnosed. To my mind “unforseen” (your spelling, not mine) goes hand-in-hand with “inadequately trained”. And in my experience of chiropractors that generally means missing the spinal tumour because they only know how to look for subluxations (which as we all know are bulges in the wallet which need to be relieved).
One would need to see if chiropractors miss pathology at a higher rate than medical doctors, of course, taking into account they are following clinical guidelines.
A baby died during a Craniosacral Manipulation by a “Craniosacral Therapist” in the Netherlands.
I watched my osteopathic teacher “D.O” during my training to become an European Osteopathic Manipulater (so called “Osteopath”) teaching us “Osteopathy in the Cranial Field” as he did such bendings on babies forcing them to stay in a folded and bend position similar like that as reported in the case below. He did this to “release tension” from “too much bending back” in babies. (Bending back is normal in babies as long as there are no neurological or infectious diseases which definitely might need medical intervention but never ever “Craniosacral Osteopathy” or “Craniosacral Therapy).
This teacher of Craniosacral Osteopathy was educated in the 1980th by Harald Magoun D.O. and later on by J. Jealous D.O. (Biodynamics in Osteopathy) showing such techniques to us.
So such things might happen by scholars of such craniosacral osteopathic trainers.
On the other hand old chiropractor’s Atlas therapy still persists and the German physician Dr. Biedermann renamed it into KISS syndrom.
Acvording to his opinion of KISS problems like dyslexia dyscalculation ADD or ADHS and functional digestion dysorders in babies are caused by a so called “Atlas problem”.
The same is told by craniosacral osteopaths or therapists anf that such disorders could be treated regalarly by “Craniosacral Osteopathy”.
Here is the article of German’s physiotherapists magazine showing the backround of a baby’s death by Craniosacral Manipulation:
https://crafta.org/artikel/art19.pdf
I still do not understand why anyone would want to train as a chiropractor and not as an osteopath.
How does an intending student choose which ‘profession’?
And come to that, why an osteopath or chiropractor and not physiotherapist.
I take it intending students of osteopathy or chiropractic do not want to be (or are not capable of being) a medical practitioner or nurse – but what is it they do want which is not satisfied by the modern physiotherapy profession – which includes massage and manipulation?
Is the answer simply ‘Faith in (just slightly different) anachronistic concepts which have no foundation in reality’?
And Blue Wode quotes a Daily Mail article which refers to a chiropractor as being a ‘doctor’. Is this deliberately misleading on the part of chiropractors who use the title ‘Dr’? And is that not fraud?
Are they not sufficiently proud of their profession not to style themselves as ‘Ch John Smith’ (for ‘Chiropractor John Smith’)?
On the subject of the title ‘Dr’, I see that the chiropractor who was arrested on suspicion of manslaughter was calling herself ‘Dr. Arleen Scholten’ on her website on 29th September this year:
https://web.archive.org/web/20170929010544/http://www.chiropractic1st.co.uk/ *
Yet today on her website, she has styled herself as Arleen Scholten D.C. (Doctor of Chiropractic)
http://www.chiropractic1st.co.uk/
That must mean that she wasn’t up to speed with the General Chiropractic Council’s advice on titles at the time she treated the patient who sustained the catastrophic injury and who died shortly thereafter. Scroll down here:
https://www.gcc-uk.org/registration/information-for-chiropractors-who-are-on-the-register/guidance-for-registrants-using-their-registered-name-and-the-gcc-registration-number.aspx
@Blue
The GCC page about the use of the Dr-title has moved. I found it here: https://www.gcc-uk.org/i-am-a-chiropractor/guidance/using-your-registered-name-and-gcc-reg-no-use-of-dr-title
The text:
@ Björn Geir
Thank you. (NB. The GCC unveiled its new website at the end of October and much of its previous content now seems to require more effort to locate.)
Hopefully, when the GCC reopens Mrs Scholten’s case, they will include her failure to make clear that she was a Doctor of Chiropractic. BTW, in my comment above, I wrote that ‘Dr. Arleen Scholten’ was published on her website on 29th September ‘this year’. It should, of course, have been 2017:
https://web.archive.org/web/20170929010544/http://www.chiropractic1st.co.uk/
I would suspect that those that do not qualify for admission to a Chiropractic school is 0%.
They get to pretend (at least to the 6% that utilize them) they are actually doctors
Since most are likely entrepreneurs, egotistical, independent and religiously imbued at-heart they can control their own income and professional “parameters” via fraud tactics.
Richard, their goal is to con the public into thinking they are equivalent to physicians in training and expertise, which is blatantly false. They are inferior to Physical Therapists who offer legitimate musculo-skeletal treatments and rehab without the bogus claims of Chiros of fixing and preventing M-S spinal issues as well as numerous other totally unrelated ailments with their magic manipulations, machines, vitamins, herbs and other nonsense.
You can earn muvh more money by odteopathy or chriropravtic than by physiotherapy in Germany.
The German health system shortened the income for physiotherapists after the breakdown of The German Democratic Republic. There was no longer a need for a competition of both western and eastern social systems.
A German Higher Court in his decision in 2014 followed the opinion that oldfashioned iatromechanistic and vitalistic “osteopathy” in Germay (including craniosacral and visceral manipulation) is ESSENTIALLY pseudoscientific and partially ESOTERIC. There seems to be a need for esoretic explanations and approaches in phystiotherapy ad well.
Here is the court’s decision:.
https://openjur.de/u/897943.html
AN Other asked me: “What do you think of this?
http://www.ifompt.org/site/ifompt/IFOMPT%20Examination%20cervical%20spine%20doc%20September%202012%20definitive.pdf ”
As Professor Ernst has already commented above, “IT’S A CONSENSUS DOCUMENT”.
It is apparent from the current medical literature (adverse event case reports v. scientific evidence of effectiveness) that the risks of neck manipulation outweigh the perceived benefits. Until there is better data, the precautionary principle applies: https://en.wikipedia.org/wiki/Precautionary_principle
@ Blue Wode
No original thoughts of your own.
The document is a clinical reasoning framework to provide guidance for the assessment of patients for the likelihood of stroke in advance of cervical manipulation.
This document seems to suggest the opposite of your quote from https://www.quackwatch.org/01QuackeryRelatedTopics/chirostroke.html
@ AN Other
Why shouldn’t I be on the same page as Professor Ernst?
IMO, while there is still a need for the Precautionary Principle to be applied, the IFOMPT document is pretty irrelevant. Time and money would be better spent on setting up adverse event reporting systems.
interesting to see that both chiros in this practice have changed their titles from ‘Dr’ to ‘DC’
a bit late, but…
Update:
http://www.yorkpress.co.uk/news/16362400.no-charges-after-man-80-dies-following-visit-to-chiropractor-clinic/
Shocking, IMO.
@BW. Which part of that article did you find shocking?
DrDale wrote: “@BW. Which part of that article did you find shocking?”
This part:
QUOTE
“John Lawler lost consciousness during treatment at Chiropractic 1st…As part of the investigation, detectives have consulted expert witnesses including an independent chiropractor”
Firstly, Mr Lawler ‘lost consciousness’ after having *walked* into the clinic, received manipulative treatment, and suffered a traumatic spinal cord injury *on the table*:
http://www.dailymail.co.uk/news/article-4982286/Woman-arrested-manslaughter-man-80-dies.html
With regard to an independent chiropractor expert witness, one of the General Chiropractic Council’s expert witnesses recently brushed off my complaint about this raw milk related article
https://www.express.co.uk/life-style/life/663130/doctor-advises-stop-drinking-milk-but-is-this-safe
with “it’s consistent with a body of reasonable chiropractic opinion”. NB. Opinion, not evidence!
Also, on p.13 of the General Chiropractic Council’s Fitness to Practice Report 2007, its expert witness claimed that “subluxations are commonplace to the point of universality in patients”
Ref. http://www.ebm-first.com/chiropractic/uk-chiropractic-issues/1214-gccs-expert-witness-claims-subluxations-are-commonplace-to-the-point-of-universality-in-patients.html
For more, see the #SinghBCA hashtag on Twitter from yesterday.
So you’re shocked because after a year long investigation and consulting with experts the police didn’t have enough evidence to file charges?
Dr Dale wrote: “So you’re shocked because after a year long investigation and consulting with experts the police didn’t have enough evidence to file charges?”
Yes, because (as I have already implied) at least one of the experts is likely to have been extremely biased and influential.
Interesting, i didn’t think a chiropractor would be that influential to sway a police decision on whether or not to file charges of manslaughter.
DrDale wrote: “Interesting, i didn’t think a chiropractor would be that influential to sway a police decision on whether or not to file charges of manslaughter.”
@ DrDale
If the police investigators were ignorant of evidence-based medicine and relied (in good faith) on the advice of non-evidence-based ‘doctors’ of chiropractic, then in these circumstances it isn’t, in my opinion, that surprising.
BW, I can only assume that the expert chiropractor was questioned to see if gross negligence had occurred within the standards of chiropractic care….as gross negligence (medical) manslaughter was what was being investigated.
DrDale wrote: “I can only assume that the expert chiropractor was questioned to see if gross negligence had occurred within the standards of chiropractic care….as gross negligence (medical) manslaughter was what was being investigated.”
@ DrDale
The point is, can an expert chiropractor be trusted?
In addition to my two examples above, which strongly suggest that they can’t, there’s this letter:
http://www.chirowatch.com/Chiro-strokes/gm080120stroke.html
It tells us about another chiropractic expert witness, a Canadian research chiropractor, David Cassidy, who was apparently sued in Saskatchewan in 1999 by his research assistant for falsifying data. It also informs us that he was one whose work is stated in the New England Journal of Medicine as “all of the study’s authors’ conclusions are completely invalidated by their methods”.
In my opinion, taking the above comments into account, and remembering that Mr Lawler ‘lost consciousness’ after having *walked* into the clinic, received manipulative treatment, and suffered a traumatic spinal cord injury *on the table*, it seems to me that there’s been an intense closing of chiropractor ranks.
Furthermore, let’s not forget that the British Chiropractic Association’s website says that chiropractic treatment “mainly involves safe, often gentle, specific spinal manipulation”:
https://chiropractic-uk.co.uk/chiropractic-care/
Interpreted another way, that could mean that some of the manipulations aren’t safe and/or gentle. Indeed, the British Chiropractic Association has previously admitted that over an 18-month period it received 180 complaints many of which alleged physical injuries. See 5.7 to 5.10 here: https://tinyurl.com/ybsooum8
Given that chiropractors have no reliable adverse event reporting systems, that their studies concerning safety are almost invariably severely flawed, and that their manipulative interventions aren’t any better than safer, cheaper, and more convenient options, we are left with this stark reality:
“…if spinal manipulation were a drug with such serious adverse effects and so little demonstrable benefit, then it would almost certainly have been taken off the market”
https://www.theguardian.com/commentisfree/2008/apr/19/controversiesinscience-health
You have not provided any hard evidence that this expert chiropractor mislead police investigators.
Until those facts surface…
DrDale wrote on Sunday 22 July 2018 at 14:23: “You have not provided any hard evidence that this expert chiropractor mislead police investigators. Until those facts surface… ”
@DrDale
That is true. However, in my opinion, based on the examples I have given above, it is very possible that the police were relying on a chiropractic expert witness of dubious competence.
With regard to the facts surfacing, let’s hope that the report that is now being submitted to HM Coroner (to inform a future inquest on a date to be fixed), will be made public.
Ref: http://www.yorkpress.co.uk/news/16362400.no-charges-after-man-80-dies-following-visit-to-chiropractor-clinic/
Yes, we need specifics in many areas of this case before a judgement can be made.
I think it’s worth noting that when the late Mr Lawler’s ‘traumatic spinal cord injury’ occurred the chiropractor who treated him was stating on her website that “chiropractic is safe” (see Prof. Ernst’s blog piece above). Yet the Royal College of Chiropractors’ Chiropractic Patient Incident Reporting and Learning System, which is a forum for anonymously reporting adverse incidents, near-misses, system-based issues (potential safety incidents), and any other clinical learning incidents that may happen in chiropractic practice, has so far received over 230 reports: https://tinyurl.com/ybrh8kkc
However, as it is known that the system is under-utilised, those reports would appear to be recorded by a small band of responsible chiropractors who use it because they don’t ‘fear of retribution’, aren’t ‘too busy’, or have ‘insufficient clarity on what to report’. See:
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