One of the many issues that needs addressing about chiropractic is its safety. On this blog, we have had dozens of posts and debates on this topic. Today, I want to try and summarise them by providing a fictitious dialogue between a critic and a chiropractor.
Here we go:
Critic (CR): It seems to me that most of the chiros I talk to are convinced that their hallmark therapy, spinal manipulation, is risk-free.
Chiro (CH): Hallmark therapy? Not true! Osteopaths, physios, doctors they all use spinal manipulation.
CR: I know, but name me a profession that employs it more regularly than you chiros.
CH: In any case, it is as good as risk-free; nothing is totally devoid of risk, but chiropractic spinal manipulation (CSMT) is generally very safe, because we are better trained at it than the others.
CR: Do you say that because you believe it or because you know it?
CH: I know it.
CR: That means you have the evidence to prove it?
CH: Yes, of course. Over the years, I have treated over a thousand patients and never heard of any problems.
CR: Without a monitoring system of adverse events that occur after chiropractic spinal manipulation, this is pretty meaningless.
CH: Monitoring systems do not establish causality.
CR: No, but they are a start and can tell you whether there is a problem that requires looking into.
CH: Let me remind you please that the question of safety is foremost an issue for conventional medicine; this is why a monitoring system is useful for drugs. We actually do not need one, because CSMT is safe.
CR: Are you sure?
CR: The much-cited paper by Dabbs and Lauretti is out-dated, poor quality, and heavily biased. It provides no sound basis for an evidence-based judgement on the relative risks of cervical manipulation and NSAIDs. The notion that cervical manipulations are safer than NSAIDs is therefore not based on reliable data. Thus, it is misleading and irresponsible to repeat this claim. Is there not a better comparison for supporting your point?
CH: Not as far as I know. But you can trust our collective experience: CSMT is safe!
CR: Don’t you think that the issue is too important to rely purely on experience? Your collective experience can be very misleading, you know.
CH: Then tell me why chiros pay only a fraction of the insurance premium compared to doctors.
CR: Yes, that is the argument many chiros love. But it also is a very poor one: doctors treat patients who are often very ill, while chiros treat mostly sore backs. Don’t you think that explains a lot about the difference in insurance premiums?
CH: Perhaps, but if you claim CSMT to be harmful, how about you supporting your claim with evidence?
CR: Sure, the best is to review systematically all prospective studies on the topic; and if you do this, the conclusion is that data from prospective studies suggest that minor, transient adverse events occur in approximately half of all patients receiving spinal manipulation. The most common serious adverse events are vertebrobasilar accidents, disk herniation, and cauda equina syndrome. Estimates of the incidence of serious complications range from 1 per 2 million manipulations to 1 per 400,000. Given the popularity of spinal manipulation, its safety requires rigorous investigation.
CH: I bet these are studies done by people who are against chiropractic.
CR: No, actually the primary studies were all done by chiropractors.
CH: Minor transient problems! These are merely what we expect; things often need to get worse before they get better.
CR: Imagine that a drug company claims such BS about the side-effects of a new drug.
CH: But that’s different!
CR: In what way?
CH: Big Pharma is only out to make money.
CR: And chiros?
CH: That’s different too.
CR: What about the serious adverse events like vertebrobasilar accidents, disk herniation, and cauda equina syndrome? Are you going to deny they exist?
CH: Some of those serious complications, while rare, are conditions that existed prior to CSMT being performed with the practitioner missing it upon initial examination.
CR: How do you know?
CH: I know this from experience.
CR: I already told you that experience is unreliable.
CH: Then show me the evidence that I am wrong.
CR: No, you have to come up with the evidence; the burden of proof is evidently on your shoulders.
CH: Whatever! As long as there is no good evidence, I cannot accept that serious complications are a real problem.
CR: That’s just fine: you say “as long as there is no good evidence…” and, at the same time, you prevent good evidence from emerging by preventing a decent AE monitoring system.
CH: I always knew that one cannot have a reasonable discussion with you. I consider that I have won this debate; this issue is now closed.