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

spinal manipulation

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As parts of Australia are going back into lock-down because of the increasingly high COVID-19 infection rates, the Chiropractic Board of Australia (CBA) has issued a statement on chiropractors’ claims regarding immunity:

The Board is particularly concerned that during the ongoing COVID-19 pandemic there are claims in advertising that suggest spinal adjustments and/or manipulation can boost or improve general immunity or the immune system.

There is insufficient acceptable evidence to support such claims in advertising. Acceptable evidence mostly encompasses empirical data from formal research or systematic studies, in the form of peer-reviewed publications. Information about what constitutes acceptable evidence for advertising can be found in the Advertising resources section of the Ahpra website.

Advertising that there is a relationship between manual therapy (e.g. spinal adjustments and/or manipulation) and achieving general wellness or boosting or improving immunity contravenes the National Law and the Guidelines for advertising regulated health services.

Although many claims do not directly reference spinal adjustments and/or manipulation preventing or protecting from COVID-19, there is currently greater awareness of immunity issues and the public is seeking information on ways to prevent or protect themselves from the disease. Consequently, there is a greater risk that claims about spinal adjustments and/or manipulation boosting or improving general immunity may be interpreted to be claims about boosting or improving immunity to COVID-19.

Making claims in advertising that spinal adjustments and/or manipulation can boost or improve general immunity or the immune system is likely to result in regulatory action being taken by the Board.

__________________________________

“… IS LIKELY TO RESULT IN REGULATORY ACTION …”???

Come on, pull the other one!

Bogus claims have been made by chiropractors since ages.

Bogus claims are what chiropractors thrive on.

Without them, they would go bust.

Every now and then some regulator makes some noises reminding chiropractors that bogus claims are bogus. But have they EVER taken any action?

Have they ever even INTENDED to take action?

I doubt it.

In fact, statements of this nature seem to be the chiropractic way of sanctioning false claims. The somewhat paradoxical way this works is as follows: chiropractors make bogus claims all the time; we all got so much used to them that hardly anyone bats an eyelash. But every now and then the bogus nature of the claims become noticeable to the wider public – like now with COVID-19 – and some people or organisations take offence. This is clearly not good for the chiro-business or image. Therefore, the professional chiro organisations step in by issuing a statement – like the one above – condemning the claims and threatening action. All the chiros know, of course, what this is about and change absolutely nothing. The desired effect is guaranteed: chiros can carry on as before, but the image is saved and the business can continue.

I very much doubt that, in the coming weeks, the CBA will do much about the many Australian chiropractors who will continue to mislead the public about COVID-19 or any other issues.

Nice window dressing perhaps, but no substance at all.

If you disagree with my view, please send me the details of any decisive regulatory action which the CBA took regarding immunity claims, and I will delete this post.

Some chiropractors seem too uninformed, stupid or greedy to stop claiming that spinal manipulation boosts the immune system. In the current situation, this is not just annoying, it is positively dangerous.

Here is a fine example of such a person; he is even so convinced of his views that he felt like giving an interview:

How can/does chiropractic care improve your immune system? What happens to our bodies physiologically when we get chiropractic adjustments?

Chiropractic care addresses the vertebral subluxation. This occurs when a vertebra becomes misaligned. This misalignment can result in irritation to the spinal nerve roots, which exit the spinal cord.

When a spinal nerve root is irritated, it stresses the nervous system — thus the potential to weaken the immune system. When we evaluate the spine for these subluxations and identify a misalignment, chiropractors can adjust the spine to alleviate the irritation to the spinal nerve root. This in turn helps to remove the stress from the nervous system.

If people have problems with their immune systems, can chiropractic care help make them better?

Chiropractic care is not a panacea for disease. Its main role is to remove the interference on the nervous system. The three main stresses on the nervous system are thoughts, traumas, and toxins. These are mainly caused by poor lifestyle choices.

Negative thoughts and self-doubt, physical trauma, and environmental toxins all affect the body in ways that stress the nervous system, thus weakening the immune response. Chiropractic care can address the entire nervous system by not only creating a physiological change, but also inducing a reduction of stress, which results in emotional regulation.

Is there any particular research that gives evidence on how chiropractic care can improve your immune system?  

Three past studies suggest that manipulation consistently reduced the production of pro-inflammatory mediators associated with tissue damage and pain from articular structures. Two studies provide evidence that manipulation consistently reduced the production of pro-inflammatory mediators associated with tissue damage and pain from articular structures.

Two studies provide evidence that manipulation may induce and enhance production of the immunoregulatory cytokine IL-2 and the production of immunoglobulins as well.

There are a multitude of clinical studies demonstrating the effects of stress on the body and the correlation between stress and immune function. More double blind, randomized clinical trials need to be conducted on the direct relationship between spinal subluxation and the effect on the immune system. In private practice, we observe the impact that adjusting the spine has on overall wellness and its undeniable effect on boosting the body’s ability to adapt to stress and improve your immune system.

Is there anything else about the physiology of how chiropractic care impacts the immune system that you think is important for readers to know?

Our health is our wealth. Taking responsibility for our wellbeing and being preventative affords the body the best possible chance of protecting itself from illness and disease.

Chiropractic care is rooted in the fundamentals that our negative thoughts, traumas, and toxins can lead to disease. By properly evaluating every patient and addressing their physical and emotional challenges, we as a profession can be the leaders of preventative care and restore health naturally and effectively.

On the one hand this is embarrassing, as it exposes almost everything that is wrong with chiropractic. On the other hand, it is informative, as it demonstrates how deeply some chiropractors are entrenched in platitudes, half-truths and blatant lies. The inevitable question is: do these chiropractors really believe this nonsense, or do they merely promote it because it is good for business?

Whatever the answer may be, one thing is fairly obvious: the ones who are being harmed by such drivel are the patients who lack sufficient critical thinking abilities to look through it. They pay not just with their money, but also with their health.

SO, PLEASE LEARN TO THINK CRITICALLY, FOLKS!

As mentioned before, the US ‘Agency for Healthcare Research and Quality (AHRQ) have published a most comprehensive review update entitled ‘Noninvasive Nonpharmacological Treatment for Chronic Pain‘. It followed the AHRQ Methods Guide for Effectiveness and Comparative Effectiveness. The conditions included were:

  • Chronic low back pain
  • Chronic neck pain
  • Osteoarthritis (knee, hip, hand)
  • Fibromyalgia
  • Chronic tension headache

 

Here are the main findings related to spinal manipulation:

LOW BACK PAIN

  • Spinal manipulation was associated with small improvements compared with sham manipulation, usual care, an attention control, or a placebo intervention in short-term (3 trials) and intermediate-term (3 trials) function (strength of evidence : low). There was no difference between spinal manipulation versus sham manipulation, usual care, an attention control, or a placebo intervention in short-term pain (3 trials), but manipulation was associated with a small improvement compared with controls on intermediate-term pain (3 trials) (SOE: low for short term, moderate for intermediate term).

CHRONIC TENSION HEADACHE

  • Spinal manipulation therapy was associated with small improvements in function and moderate improvements in pain compared with usual care over the short term in one trial (: low). Approximately a quarter of the patients had comorbid migraine.

HARMS

It was noted that many trails failed to report on adverse effects (AEs). Non- serious AEs reported included mild to moderate increase in pain, local discomfort and tiredness (2 RCTs).

___________________

Hardly impressive, is it?

Yet, some chiropractors treating chronic pain claim they practice Evidence-based medicine. This review seems to disclose this claim as bogus. What chiropractors do practice on virtually all patients is spinal manipulation which generates more harm than it produces benefit.

Please note yet again that:

  • many chiro trials fail to mention AEs (thus violating research ethics),
  • clinical trials are always too small to give a reliable impression about safety,
  • no post-marketing surveillance exists in chiropractic,
  • we thus have to rely mostly on case reports and similar articles,
  • and the collective evidence from such reports shows quite clearly that spinal manipulations are not safe,
  • chiropractors tend to deny all of the above,
  • this is because they have a monumental conflict of interest.

An international team of students of chiropractic have published a paper protesting against those chiropractors and chiropractic organisations that claim their treatments boost the immune system and thus protect the public from the corona-virus infection. Here their abstract:

Background

The 2019 coronavirus pandemic is a current global health crisis. Many chiropractic institutions, associations, and researchers have stepped up at a time of need. However, a subset of the chiropractic profession has claimed that spinal manipulative therapy (SMT) is clinically effective in improving one’s immunity, despite the lack of supporting scientific evidence. These unsubstantiated claims contradict official public health policy reflecting poorly on the profession. The aim of this commentary is to provide our perspective on the claims regarding SMT and clinically relevant immunity enhancement, drawing attention to the damaging ramifications these claims might have on our profession’s reputation.

Main text

The World Federation of Chiropractic released a rapid review demonstrating the lack of clinically relevant evidence regarding SMT and immunity enhancement. The current claims contradicting this review carry significant potential risk to patients. Furthermore, as a result of these misleading claims, significant media attention and public critiques of the profession are being made. We believe inaction by regulatory bodies will lead to confusion among the public and other healthcare providers, unfortunately damaging the profession’s reputation. The resulting effect on the reputation of the profession is greatly concerning to us, as students.

Conclusion

It is our hope that all regulatory bodies will protect the public by taking appropriate action against chiropractors making unfounded claims contradicting public health policy. We believe it is the responsibility of all stakeholders in the chiropractic profession to ensure this is carried out and the standard of care is raised. We call on current chiropractors to ensure a viable profession exists moving forward.

In the paper, the authors also state that significant reputational damage can follow when unfounded claims are made that undermine public health policy… We call for a strong stance to be taken against these unsubstantiated claims and do not condone this unacceptable behaviour. As students, we are worried for the profession’s reputation and call on current chiropractors to ensure we have a viable profession moving forward. 

BRAVO!!!

Now that the students have realised that the immunity claim is bogus, it would be only a small step to realise that so many other claims chiropractors make on a daily basis are false as well. There may be a difference in terms of severity, but there is none in terms of principle. As responsible healthcare professional to be, the student must rebel against ALL false claims made in their name.

So, will these students and other like-minded chiropractors please not stop here. I urge them to have a serious look at the claims their profession makes. Subsequently, they ought to take the ethically appropriate action.

And what might that be?

I see two possibilities:

  1. Get rid of the abundance of lies that dominate chiropractic.
  2. Find a different, more honest profession.

The UK university at Teesside has announced its plan to offer a chiropractic degree. The course will be hosted by its School of Health and Life Sciences and the Department of Allied Health Professions. The designated course leader, Daniel Moore, explains:

“The benefit for us when we developed this curriculum from a blank canvas was not only exciting, but it granted an opportunity for us to do things in a slightly different way.  The placement model is something I feel we may see more of in the future because the benefit it gives students is significant from a confidence point of view, and provides interaction with both the profession and patients from the first semester.  We also could create our modules from scratch giving us the ability to build context into historically quite fixed modular content whilst staying mapped to the education standards.  We also give all students iPads from the start of their degree which will allow us to collaborate and communicate in a really unique and beneficial way throughout the course.”

“I have always been interested in knowledge transfer, and how as individuals we learn and how we develop ourselves.  Part of my draw to being a chiropractor was my wanting to help people become the best version of themselves.  So it isn’t a great leap to the higher educational world where my goal now is similar, facilitating and leading people towards being the best chiropractor they can be.  They can then move into the profession and make a positive impact themselves.  I feel I can make a positive difference to the profession here, and that is important to me.”

“My goal in my mind is clear.  To create chiropractors that are safe, competent and confident, to go into practice and add value to the chiropractic profession.  I also hope I can create students that are excited to graduate and practice chiropractic, I feel we have a lot to offer as chiropractors and students should be excited about that opportunity.”

“I am from the North East of England, so have an affinity to this region.  I am passionate about chiropractic and think my history, since being a student shows my willingness to represent that.  I was a student member of the NMSK faculty of the College of Medicine as well as being on WIOC Student Council for 4 years.  I then moved into practice where I took on delivery of CPD events for the RCC, qualified as an FA Medical Tutor, I was also involved in writing initial material for the RCC’s online Quality Standards offering, and have been involved in multiple British Masters Athletics Medical Team events with a great group of people over the years.  I am a dad, to two wonderful boys and a husband to Elaine (also a chiropractor and BCA member).  I keep myself fit, and race Cross Country Mountain Bikes and Cyclocross to a national level and plan on competing at the World Masters Championships this August all things being well. Now I lead the chiropractic course at Teesside and I am planning my PhD, I couldn’t be more excited about the opportunities that lay ahead.”

Allow me to add a few points and ask a few questions:

  1. Mr Moore wants to ‘create chiropractors that are safe, competent and confident’. How about creating therapists who are effective in curing or alleviating disease or symptoms? Has he perhaps realised that, in chiropractic, this is not possible? Do his peers at Teesside know that chiropractic does not generate more good than harm?
  2. I am fascinated to learn that Mr Moore is now planning to do his PhD. Should a higher degree not have been a precondition to becoming a course leader in academia?
  3. As far as I can see, Mr Moore has never published a single paper in the peer-reviewed literature. Should a track record in research not have been a precondition to becoming a course leader in academia?
  4. Does the University of Teesside know that even the most proper (and I fear the course does not even appear to be proper) teaching of nonsense must result in nonsense?
  5. Have they taken leave of their senses at Teesside university?

DD Palmer, the founder of chiropractic, famously claimed that 95% of all diseases are caused by subluxations of the spine and the rest by subluxations of other joints. He said and stated this theory in different forms not once but dozens of times, and it thus quickly became the mantra of chiropractic. When it was noted that subluxation, as imagined by Palmer and his son BJ, did not exist, chiropractors found themselves with a considerable amount of egg on their faces.

Ever since, they have tried to cover up the blemish, some by repeatedly re-defining subluxation, others by claiming that they do not believe in Palmer’s theory anyway. The issue was and is fiercely fought over even threatened to break up the profession. At present, we are being told incessantly that large chunks of the profession are reformed, have come to terms with their profession’s foundation in a fictional concept, and have now abandoned subluxation altogether.

Critics, in turn, are quick to point out that, if that is so, chiropractors lack a ‘raison d’être’. The best chiropractors of this persuasion could do, they say, is to re-train as physiotherapists who also use spinal manipulation but without the nonsensical chiropractic ‘philosophy’.

While this debate is ongoing and shows no sign of subsiding, it is relevant, of course, to ask what proportions of the chiropractic profession belongs to which persuasion. This paper evaluated the issue of the professional identity within the profession of chiropractic based on the literature from 2000 to 2019. Initially 562 articles were sourced, of which 24 met the criteria for review.

The review confirmed three previously stated professional identity subgroups:

  • a vitalistic approach pro subluxation,
  • a approach contra subluxation,
  • a centrist or mixed view.

Whilst these three main chiropractic identity sub-types exist, the terminology used to describe them differs. Research aimed at categorising the chiropractic profession identity into exclusive sub-types found that at least 20% of chiropractors have an exclusive vertebral subluxation focus. However, deeper exploration of the literature shows that vertebral subluxation is an important practice consideration for up to 70% of chiropractors.

The review also found that practising chiropractors consider themselves to be primary care or primary contact practitioners with a broad scope of practice across a number of patient groups not limited to musculoskeletal management.

So, if I understand these findings correctly, they confirm that chiropractors like to see themselves as physicians who are able to treat most conditions that present themselves in primary care. At the same time, their majority considers that vertebral subluxation is an important practice consideration. This clearly suggests they are likely to treat most conditions by adjusting spinal subluxations. In turn, this implies that DD Palmer’s dictum, ‘95% of all conditions are caused by subluxations of the spine’, is still adhered to by about 70% of all chiropractors.

If this is so, the best advice I can give to the general public is this: if you have a health problem, the last person you should consult is a chiropractor.

The ‘Corona-Virus Quackery Club’ (CVQC) is enjoying a fast-growing membership. As mentioned in previous posts, it consists of:

homeopaths,

colloidal silver crooks,

TCM practitioners,

orthomolecular quacks,

Unani-salesmen.

Chiropractors have been keen to join since weeks. They have a long tradition of claiming that their ‘adjustments’ boost the immune system, and therefore it was to be expected that they also jump on the corona-bandwagon.

Some chiropractors seem to believe that the corona-virus pandemic is a fine business opportunity or, as one put it, the perfect opportunity to have a heart to heart with patients about their immune and nervous systems! Remember, if germs automatically caused disease, the human race wouldn’t be around to debate the issue. Many forget that Louis Pasteur, the father of the germ theory recanted his belief. On his deathbed he observed, “It’s the soil, not the seed.” In other words, without the right environment, germs can do little harm.

Chiropractors and other health care workers are at greater risk due to patient or client interactions and are encouraged to take extra precautions when it comes to cleaning and disinfecting surfaces and skin or close contact.

“Every chiropractic practice has been touched by coronavirus [fears],” says Bill Esteb, DC, who has created and is circulating a coronavirus and chiropractic guide on how to avoid contracting the virus.

“We wanted to create a tool that chiropractors could use as a conversation springboard. Chiropractors need to remind their patients that germs don’t automatically cause disease. And that ‘catching’ the coronavirus, or anything else, requires a hospitable environment.”

The only way to catch anything, says Esteb, is to become a hospitable host. Flipping the message, Esteb in his coronavirus and chiropractic guide says here is “How to Catch the Coronavirus”:

  • Eat a Poor Diet — Make sure your body lacks the vitamins, minerals, enzymes and micronutrients needed to keep itself in good repair.
  • Avoid Adequate Rest — Stay up late and use sugar, tobacco, coffee and energy drinks as needed.
  • Become Dehydrated — Reduce the effectiveness of your natural defense mechanisms by shunning adequate water.
  • Stop Exercising — Reduce the efficiency of your lymphatic system, which requires movement to circulate this important germ-fighting fluid.
  • Think Negative Thoughts — Worry that you’ll be a victim. Closely monitor news reports about outbreaks, fearing the advancing pandemic.
  • Rarely Wash Your Hands — Use your dirty hands and fingers to rub your eyes, pick your nose or wipe your lips.
  • Skip Your Chiropractic Adjustments — Handicap your nervous system, the master system that controls your entire body. Wait until symptoms are clearly present.

“Following these suggestions is the way to become a suitable host for any number of germs or microbes,” Esteb says. “The tongue-in-check approach keeps the subject light. It stimulates more instructive patient conversations. It helps reduce appointment cancellations.

“Most people have an inappropriate fear of germs. And while this poster and patient handout won’t eliminate it, use it to explore the value of ongoing chiropractic care as a preventive strategy.”

——–

The Internet is full with messages of this type. Here is just one example: The best defense for the Corona Virus is to be healthy when you are exposed to the virus. Get adjusted to boost your immune system. Check out this video blog on what you can do to be healthy and prepare your body to fight off the corona virus.

——–

Perhaps the worst excesses can be found on Twitter:

James Langford 
@JamesLangford15·

Did you know that a properly aligned body supports and activates our immune system. During this time of concern from the corona virus, making sure your body is healthy is the best way to combat this illness. #health #immunesystem
Oxford Chiropractic
@OxfordChiropra1·

Scared of the corona virus? Practice a little preventative care like mama always used to tell you and get your spine adjusted!!! It’s boosts your immune by 200%!!!!! Why aren’t we talking… instagram.com/p/B9pjMqdATmBn
——–
So, considering this concerted effort, I am happy to announce that, from today, my friends the chiros are official members of the CVQC.
CONGRATULATIONS GUYS!
PS
Whether Boris Johnson will be allowed in, depends on future announcements; so far, his chances are not bad.

The objective of this analysis was to evaluate the impact of chiropractic utilization upon use of prescription opioids among patients with spinal pain. The researchers employed a retrospective cohort design for analysis of health claims data from three contiguous US states for the years 2012-2017.

They included adults aged 18-84 years enrolled in a health plan and with office visits to a primary care physician or chiropractor for spinal pain. Two cohorts of subjects were thus identified:

  1. patients who received both primary care and chiropractic care,
  2. Patients who received primary care but not chiropractic care.

The total number of subjects was 101,221. Overall, between 1.55 and 2.03 times more nonrecipients of chiropractic care filled an opioid prescription, as compared with recipients.

The authors concluded that patients with spinal pain who saw a chiropractor had half the risk of filling an opioid prescription. Among those who saw a chiropractor within 30 days of diagnosis, the reduction in risk was greater as compared with those with their first visit after the acute phase.

Similar findings have been reported before and we have discussed them on this blog (see here, here and here). As before, one has to ask: WHAT DO THEY ACTUALLY MEAN?

The short answer is NOTHING MUCH! And certainly not what many chiros make of them.

They do not suggest that chiropractic care is a substitute for opioids in the management of spinal pain.

Why?

There are several reasons. Perhaps the most important ones are that such analyses lack any clinical outcome data, and that comparing one mistake (opioid-overuse) whith what might be another (chiropractic care) is a wrong apporoach. Imagine a scenario where half to the patients had received, in addition to their usual care, the services of:

  • a paranormal healer,
  • a crystal therapist,
  • a shaman,
  • or a homeopath.

Nobody would be surprised to see a very similar result, particularly if all of these practitioners were in the habit of discouraging their patients from using conventional drugs. Or imagine a scenario where half of all patients suffering from spinal pain are entered into an environment where they receive no treatment at all. Who would not expect that this regimen does not dramatically reduce the risk of filling an opioid prescription? But would that indicate that zero treatment is a good solution for managing spinal pain?

The thing is this:

  • If you want to reduce opioid use, you need to prescribe less opioids (for instance, by re-educating doctors to do as they have been told in med school and curb over-prescribing).
  • If you discourage patients to use opioids (as many other healthcare professionals would), many will not use opioids.
  • If you want to know whether chiropractic is effective in managing spinal pain, you need to conduct a well-designed clinical trial.

Or, to put it simply:

CORRELATION IS NOT CAUSATION!

 

During my almost 30 years of research into so-called alternative medicine (SCAM), I have published many papers which must have been severe disappointments to those who advocate SCAM or earn their living through it. Many SCAM proponents thus reacted with open hostility. Others tried to find flaws in those articles which they found most upsetting with a view of discrediting my work. The 2012 article entitled ‘A Replication of the Study ‘Adverse Effects of Spinal Manipulation: A Systematic Review‘ by the Australian chiropractor, Peter Tuchin, seems to be an example of the latter phenomenon (used recently by Jens Behnke in an attempt to defame me).

Here is the abstract of the Tuchin paper:

Objective: To assess the significance of adverse events after spinal manipulation therapy (SMT) by replicating and critically reviewing a paper commonly cited when reviewing adverse events of SMT as reported by Ernst (J Roy Soc Med 100:330-338, 2007).

Method: Replication of a 2007 Ernst paper to compare the details recorded in this paper to the original source material. Specific items that were assessed included the time lapse between treatment and the adverse event, and the recording of other significant risk factors such as diabetes, hyperhomocysteinemia, use of oral contraceptive pill, any history of hypertension, atherosclerosis and migraine.

Results: The review of the 32 papers discussed by Ernst found numerous errors or inconsistencies from the original case reports and case series. These errors included alteration of the age or sex of the patient, and omission or misrepresentation of the long term response of the patient to the adverse event. Other errors included incorrectly assigning spinal manipulation therapy (SMT) as chiropractic treatment when it had been reported in the original paper as delivered by a non-chiropractic provider (e.g. Physician).The original case reports often omitted to record the time lapse between treatment and the adverse event, and other significant clinical or risk factors. The country of origin of the original paper was also overlooked, which is significant as chiropractic is not legislated in many countries. In 21 of the cases reported by Ernst to be chiropractic treatment, 11 were from countries where chiropractic is not legislated.

Conclusion: The number of errors or omissions in the 2007 Ernst paper, reduce the validity of the study and the reported conclusions. The omissions of potential risk factors and the timeline between the adverse event and SMT could be significant confounding factors. Greater care is also needed to distinguish between chiropractors and other health practitioners when reviewing the application of SMT and related adverse effects.

The author of this ‘replication study’ claims to have identified several errors in my 2007 review of adverse effects of spinal manipulation. Here is the abstract of my article:

Objective: To identify adverse effects of spinal manipulation.

Design: Systematic review of papers published since 2001.

Setting: Six electronic databases.

Main outcome measures: Reports of adverse effects published between January 2001 and June 2006. There were no restrictions according to language of publication or research design of the reports.

Results: The searches identified 32 case reports, four case series, two prospective series, three case-control studies and three surveys. In case reports or case series, more than 200 patients were suspected to have been seriously harmed. The most common serious adverse effects were due to vertebral artery dissections. The two prospective reports suggested that relatively mild adverse effects occur in 30% to 61% of all patients. The case-control studies suggested a causal relationship between spinal manipulation and the adverse effect. The survey data indicated that even serious adverse effects are rarely reported in the medical literature.

Conclusions: Spinal manipulation, particularly when performed on the upper spine, is frequently associated with mild to moderate adverse effects. It can also result in serious complications such as vertebral artery dissection followed by stroke. Currently, the incidence of such events is not known. In the interest of patient safety we should reconsider our policy towards the routine use of spinal manipulation.

In my view, there are several things that are strange here:

  1. Tuchin published his paper 5 years after mine.
  2. He did not publish it in the same journal as my original, but in an obscure chiro journal that hardly any non-chiropractor would ever read.
  3. Tuchin never contacted me and never alerted me to his publication.
  4. The journal that Tuchin chose was not Medline-listed in 2012; consequently, I never got to know about the Tuchin article in a timely fashion. (Therefore, I did never respond to it.)
  5. A ‘replication study’ is a study that repeats the methodology of a previous study.
  6. Tuchin’s paper is therefore NOT a replication study. Firstly, mine was a review and not a study. Secondly, and crucially, Tuchin never repeated my methodology but used an entirely different one.

But arguably, these points are trivial. They should not distract from the fact that I might have made mistakes. So, let’s look at the substance of Tuchin’s claim, namely that I made errors or omissions in my review.

As to ‘omissions’, one could argue that a review such as mine will always have to omit some details in order to generate a concise summary. The only way to not omit any details is to re-publish all the primary papers in one large volume. Yet, this can hardly be the purpose of a systematic review.

As to the ‘errors’, it seems that the ages and sex of three patients were wrong (I have not checked this against the primary publications but, for the moment, I believe Tuchin). This is, of course, lamentable and – even though I have no idea whether the errors happened at the data extraction phase, during the typing, the revising, or the publishing of the paper – it is entirely my responsibility. I also seem to have mistaken a non-chiropractor for a chiropractor. This too is regrettable but, as the review was about spinal manipulation and not about chiropractic, the error is perhaps not so grave.

Be that as it may, these errors are unquestionably not good, and I can only apologise for them. If Tuchin had dealt with them in the usual way – by publishing in a timely fashion a ‘letter to the editor’ of the JRSM – I could have easily corrected them for everyone to see.

But I think there is a more important point to be made here:

Tuchin concludes his paper stating that it is unwise to make conclusions regarding causality from any case study or multiple case studies. The number of errors or omissions in the 2007 Ernst paper significantly limit any reported conclusions. I believe that both sentences are unjustified. The safety of any intervention in routine use has to be examined on the basis of published case studies. This is particularly true for chiropractic where no post-marketing surveillance similar to that for drugs exists.

The conclusions based on such evidence can, of course, never be firm, but they provide valuable signals that can prompt more rigorous investigations in the interest of patient safety. In view of such considerations, my own conclusions in my 2007 paper were, I think, correct and are NOT invalidated by my relatively trivial mistakes: spinal manipulation, particularly when performed on the upper spine, has repeatedly been associated with serious adverse events. Currently the incidence of such events is unknown. Adherence to informed consent, which currently seems less than rigorous, should therefore be mandatory to all therapists using this treatment. Considering that spinal manipulation is used mostly for self-limiting conditions and that its effectiveness is not well established, we should adopt a cautious attitude towards using it in routine health care. 

And my conclusions in the abstract have now, I believe, become established wisdom. They are thus even less in jeopardy through my calamitous lapsus or Tuchin’s ‘replication study’: Spinal manipulation, particularly when performed on the upper spine, is frequently associated with mild to moderate adverse effects. It can also result in serious complications such as vertebral artery dissection followed by stroke. Currently, the incidence of such events is not known. In the interest of patient safety we should reconsider our policy towards the routine use of spinal manipulation. 

 

 

A team of chiropractic researchers conducted a review of the safety of spinal manipulative therapy (SMT) in children under 10 years. They aimed to:

1) describe adverse events;

2) report the incidence of adverse events;

3) determine whether SMT increases the risk of adverse events compared to other interventions.

They searched MEDLINE, CINAHL, and Index to Chiropractic Literature from January 1, 1990 to August 1, 2019. Eligible studies were case reports/series, cohort studies and randomized controlled trials. Studies of high and acceptable methodological quality were included.

Most adverse events are mild (e.g., increased crying, soreness). One case report describes a severe adverse event (rib fracture in a 21-day-old) and another an indirect harm in a 4-month-old. The incidence of mild adverse events ranges from 0.3% (95% CI: 0.06, 1.82) to 22.22% (95% CI: 6.32, 54.74). Whether SMT increases the risk of adverse events in children is unknown.

The authors concluded that the risk of moderate and severe adverse events is unknown in children treated with SMT. It is unclear whether SMT increases the risk of adverse events in children < 10 years.

Thanks to their ingenious methodology, the authors managed to miss 11 of the 13 studies included in the review by Vohra et al which reported 9 serious adverse events and 20 cases of delayed diagnosis associated with SMT. Another review reported 15 serious adverse events and 775 mild to moderate adverse events following manual therapy. As far as I can see, the authors of the new review make just one reasonable point:

We recommend the implementation of a population-based active surveillance program to measure the incidence of severe and serious adverse events following SMT treatment in this population.

In the absence of such a surveillance system, any incidence figures are not just guess-work but also a depiction of the tip of a much bigger iceberg. So, why do the authors of this review not make this point clearly and powerfully? Why does the review read mostly like an attempt to white-wash a thorny subject? Why do they not provide a breakdown of the adverse events according to profession? The answer to these questions can be found at the very end of the paper:

This study was supported by the College of Chiropractors of British Columbia to Ontario Tech University. The College of Chiropractors of British Columbia was not involved in the design, conduct or interpretation of the research that informed the research. This research was undertaken, in part, thanks to funding from the Canada Research Chairs program to Pierre Côté who holds the Canada Research Chair in Disability Prevention and Rehabilitation at Ontario Tech University, and from the Canadian Chiropractic Research Foundation to Carol Cancelliere who holds a Research Chair in Knowledge Translation in the Faculty of Health Sciences at Ontario Tech University.

This study was supported by the College of Chiropractors of British Columbia to Ontario Tech University. The College of Chiropractors of British Columbia was not involved in the design, conduct or interpretation of the research that informed the research. This research was undertaken, in part, thanks to funding from the Canada Research Chairs program to Pierre Côté who holds the Canada Research Chair in Disability Prevention and Rehabilitation at Ontario Tech University, and funding from the Canadian Chiropractic Research Foundation to Carol Cancelliere who holds a Research Chair in Knowledge Translation in the Faculty of Health Sciences at Ontario Tech University.

I have often felt that chiropractic is similar to a cult. An investigation by cult members into the dealings of a cult is not the most productive of concepts, I guess.

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