MD, PhD, FMedSci, FRSB, FRCP, FRCPEd.

On their website, the UK ‘ROYAL COLLEGE OF CHIROPRACTORS (RCC) published a short statement regarding the safety of chiropractic. Here it is in full:

Experiencing mild or moderate adverse effects after manual therapy, such as soreness or stiffness, is relatively common, affecting up to 50% of patients. However, such ‘benign effects’ are a normal outcome and are not unique to chiropractic care.

Cases of serious adverse events, including spinal or neurological problems and strokes caused by damage to arteries in the neck, have been associated with spinal manipulation. Such events are rare with estimates ranging from 1 per 2 million manipulations to 13 per 10,000 patients; furthermore, due to the nature of the underlying evidence in relation to such events (case reports, retrospective surveys and case-control studies), it is very difficult to confirm causation (Swait and Finch, 2017).

For example, while an association between stroke caused by vertebral artery damage or ‘dissection’ (VAD) and chiropractor visits has been reported in a few case-control studies, the risk of stoke has been found to be similar after seeing a primary care physician (medical doctor). Because patients with VAD commonly present with neck pain, it is possible they seek therapy for this symptom from a range of practitioners, including chiropractors, and that the VAD has occurred spontaneously, or from some other cause, beforehand (Biller et al, 2014). This highlights the importance of ensuring careful screening for known neck artery stroke risk factors, or signs or symptoms that there is an ongoing problem, is performed prior to manual treatment of patients (Swait and Finch, 2017). Chiropractors are well trained to do this on a routine basis, and to urgently refer patients if necessary.

END OF QUOTE

The statement reads well but it might not be entirely free from conflicts of interest. Yet, in the name of accuracy, completeness and truthfulness, I take the liberty of making a few slight alterations. Here is my revised version:

Experiencing mild or moderate adverse effects after chiropractic spinal manipulations, such as pain or stiffness (usually lasting 1-3 days and strong enough to impair patients’ quality of life), is very common. In fact, it affects around 50% of all patients. 

Cases of serious adverse events, including spinal or neurological problems and strokes often caused by damage to arteries in the neck, have been reported after spinal manipulation. Such events are probably not frequent (several hundred are on record including about 100 fatalities).  But, as we have never established proper surveillance systems, nobody can tell how often they occur. Furthermore, due to our reluctance of introducing such surveillance, some of us are able to question causality.

An association between stroke caused by vertebral artery damage or ‘dissection’ (VAD) and chiropractic spinal manipulation has been reported in about 20 independent investigations. Yet one much-criticised case-control study found the risk of stoke to be similar after seeing a primary care physician (medical doctor). Because patients with VAD commonly have neck pain, it is possible they seek therapy for this symptom from chiropractors, and that the VAD has occurred spontaneously, or from some other cause, beforehand (Biller et al, 2014). Ensuring careful screening for known neck artery stroke risk factors, or signs that there is an ongoing problem would therefore be important (Swait and Finch, 2017). Sadly, no reliable screening tests exist, and neck pain (the symptom that might be indicative of VAD) continues to be one of the conditions most frequently treated by chiropractors.

I do not expect the RCC to adopt my improved version. In case I am wrong, let me state this: I am entirely free of conflicts of interest and will not charge a fee for my revision. In the interest of advancing public health, I herewith offer it for free.

5 Responses to Royal College of Chiropractors: please allow me to revise your statement on safety?

  • “Mechanical disorders cause 90% of neck pain episodes.

    Diagnostic radiographic or laboratory tests are not necessary during the initial evaluation of patients with probable mechanical neck pain. These tests, however, are indicated for patients whose history and physical findings suggest persistent compression of the spinal cord or nerve roots or raise the possibility of neck pain as a component of an underlying systemic disease.”

    CURRENT Diagnosis & Treatment: Rheumatology, 3e
    Chapter 9. Approach to the Patient with Neck Pain
    David Borenstein, MD

  • @EE
    “Experiencing mild or moderate adverse effects after manual therapy, such as soreness or stiffness, is relatively common, affecting up to 50% of patients”.
    That is more accurate in comparison to your revision as studies show similar results of temporary stiffness or soreness for physio AND chiro.
    But hay lets just make it exclusively about chiropractic.
    “But, as we have never established proper surveillance systems, nobody can tell how often they occur”.
    Perhaps in the interest of ACCURACY you should have said:
    “But as there are no proper surveillance systems for chiropractic, osteopathy, physiotherapy, general practitioners, acupuncture, medical acupuncturists etc, nobody can tell how often adverse events occur for any of them”.
    But hay lets just make it exclusively about chiropractic.
    Such a system was proposed here in Australia years ago where adverse event information would be accurately collected within hospital emergency departments (free from medical bias or assumptions) and referred to the relevant registration board for investigation. It was supported by chiropractors but “fizzled” (to quote a medical specialist involved) due to resistance from doctors. Shock horror.
    But hay lets make it all exclusively about chiropractors.
    “I am entirely free of conflicts of interest”.
    Pray tell Prof Ernst who is the chiropractic researcher who “knows a thing or two about adverse effects of spinal manipulation” and who you have “always thought highly” (to quote you)? Yet you ignore Charlotte LeBoeuf-Yde’s work until you could take issue with one line in a BLOG then you did a hatchet blog.
    This would indicate that you are not entirely free from conflict of interest or bias.
    Are you therefore free of conflicts of interest or bias?
    You demand evidence yet ignore the researchers providing it.

    • ” studies show similar results of temporary stiffness or soreness for physio AND chiro.”
      links please!
      in any case, the article is about chiro, not physio.
      ““But as there are no proper surveillance systems for chiropractic, osteopathy, physiotherapy, general practitioners, acupuncture, medical acupuncturists etc, nobody can tell how often adverse events occur for any of them”.”
      no, the article is about chiro, not physio.
      ““fizzled” (to quote a medical specialist involved) due to resistance from doctors. Shock horror”
      no evidence for that, as far as I can see;
      “Pray tell Prof Ernst who is the chiropractic researcher who “knows a thing or two about adverse effects of spinal manipulation” and who you have “always thought highly” (to quote you)? Yet you ignore Charlotte LeBoeuf-Yde’s work until you could take issue with one line in a BLOG then you did a hatchet blog.”
      you are talking utter nonsense.
      “This would indicate that you are not entirely free from conflict of interest or bias.”
      in your dreams!

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