Articles by JCS

Piling On Chiropractic

Coincidence or Collusion?

Piling on Chiropractic

Is it just me or do you find it odd that now eleven articles (increasing daily) have appeared within days of each other on the same issue—the safety of chiropractic?

Is this just a coincidental “piling on” or actual collusion—a planned effort by the insidious AMA agents of misinformation to plant fear in the public’s mind? How many more will there be when other news organizations pile on all reciting the same bias material?

      Recall that columnist Ann Landers was among many journalists who colluded with the AMA’s agents, so it’s not unreasonable to think this insidious relationship continues “behind the scenes” as directed by the evil AMA.



        This is just too unlikely to pass off as coincidental or serendipitous on such an obscure topic. Indeed, considering the gigantic issues facing healthcare in America, such as the huge costs, unnecessary surgeries, medical mistakes, opioid addiction, and the battle over Obamacare, comparatively speaking, the issue of strokes after manipulation is a small one, which makes me wonder why they bother to revive an issue that has already been resolved and affects so few?

         Apparently it's time to play Bash the Chiropractors once again in the media.

I know some people may think I am embellishing the media’s treatment of chiropractic care. I've been called the Malcolm X of chiropractic for my "aggressive" position to push back against this medical slander. There are some chiro-cynics who feel our problems are "self-inflicted" and there's no media interest in our profession. Our right wingers in the National Association of Chiropractic Medicine want to abandon chiropractic principles and merge with the medical profession. Others like myself just want a fair chance to compete on a level playing field, but that is unlikely.

       The mere fact of the infrequency of good articles about chiropractic care in this epidemic of back pain is shocking considering the money involved, the new supportive research, and the call for reform in medical spine care.

Indeed, chiropractic is Missing in the Media, except when it is attacked. It seems the only time this profession is mentioned occurs when there is a negative issue, such as insurance fraud, sex abuse, or, once again, the reviving of the stroke issue. When was the last time we read an article about the millions of patients we help without drugs, shots, or surgery? When was the last time the media covered the supportive research? Or when the scientists bashed the outdated disc theory as "irrelevant incidentalomas"?

Instead of these important issues, we see the resurgence of critical articles from the medical professionals that chiropractors may cause strokes or paralysis. The medical-media remains convinced to once again try this case in the court of pubic opinion with more salacious articles supported by weak evidence.

After the Lana Lewis lawsuit in Canada brought international media attention to her death from a stroke weeks after being manipulated by her chiropractor who was found not negligent in this case, researchers have brought to light many interesting facts about spinal manipulative therapy (SMT) and stroke that remain unknown because the media refuses to explain these facts to the public.

Dr. Adrian Upton, Head of the Department of Neurology at McMaster Health Sciences Centre testified at the inquest into the death of Lana Lewis that, based on all of the evidence he has reviewed, Ms. Lewis died of a stroke caused by advanced atherosclerosis. During examination, he stated that a chiropractic neck adjustment she received not long before her stroke was at best “a remote possibility at the bottom of the list of probabilities” for causation. Ms. Lewis was extremely hypertensive, off her meds, and a heavy tobacco smoker at the time of her death—as Dr. Upton put it, “she was a time bomb ready to explode.”

The revitalizing of the stroke issue began in 2010 study from England, “Deaths After Chiropractic: A Review Of Published Cases,” by Edzard Ernst of the Medical School at the University of Exeter, that again raised the level of fear over chiropractic care when he noted that “Twenty-six fatalities were published since 1934 in 23 articles.”[1]

Considering this covers 76 years and equates to 0.34 deaths per year, instead of sounding an alarm to scare people as Ernst attempted, he should have praised chiropractic care for its obvious safety since this is an extremely low rate in comparison with equivalent medical methods for the same diagnostic condition.

Ernst’s paper drew quick criticism from leading medical and chiropractic scholars. According to SM Perle, S French, and M Haas:

Ernst ignored the evidence against a causal relation between spinal manipulation and death. Instead, he went boldly along a path of fear mongering and propaganda that we expect was predetermined to establish the dangers of CSM (cervical spinal manipulation).[2]

Another review from The Dartmouth Institute for Health Policy and Clinical Practice was equally critical:

Three deaths were reported during the last 10 years of the study, so for that most recent time period, the absolute risk could be estimated to be 3/10 per 100 million, or three deaths for every billion chiropractic encounters…This rate is so low that it cannot possibly be considered significant…An interesting flip side to the research question might be: by undergoing a course of chiropractic spinal manipulation, how many patients were able to avoid death by avoiding complications of surgical intervention?[3]

Despite the push back to Ernst’s article as inflammatory and baseless, just the mention in the media continues to scare the public about cervical spinal manipulations, which is exactly the goal of political medicine to soil chiropractors’ image in this war.

Indeed, 0.34 deaths after chiropractic care is not an epidemic considering 14,800 people will die this year from Oxycotin alone. Where is the same media attention to this serious issue?

Certainly the deaths from SMT does not rise to the level of the medical War on Cancer, the War on Heart Disease or Obesity, but it is the on-going War on Chiropractic that never ends.

Moreover, this again appears to be a case of “citation laundering”  of facts that are passed on as “perceived wisdom” by newscasters where they quote one another or parrot medical incendiary comments, which seems to be this sudden condemnation of chiropractors without a serious look at the supportive research.

Indeed, David Cassidy’s article, Should we abandon cervical spine manipulation for mechanical neck pain? No.”  in support of manipulation was virtually ignored by the media hell-bent on slamming chiropractors’ reputations as dangerous. “Don’t confuse us with the facts” seems to be the media’s motto.
             Now that the message of chiropractic adjustments causing strokes has entered the public's mind via the media, how do we stop this misinformation? Where is our counteroffensive from the ACA or the F4CP?

 What I also find troubling is the reply by the ACA’s president, Keith Overland, who was put into a difficult position. He failed to quote the miniscule rates of serious complications after CMT that would have blown this argument out of the water. Instead, his response was: "’Yes, people had strokes, but they were most likely going to suffer the stroke regardless of the provider they chose,’ said Overland.”

Doesn’t this sound like an admission of guilt instead of a strong push back to these nonsensical attacks?

I daresay the ACA needs a full time PR spokesperson who is articulate concerning the latest research. Dr. KO is a politician, not a statistician, and he shouldn’t be placed in this situation to recall research studies when his mind is full of political issues as it should be, not research studies.

Perhaps next time Dr. KO can refer this type of attack journalism to someone who has the facts, such as Tony Rosner, Jay Triano, David Cassidy, Lou Sportelli, or even yours truly. Indeed, my book is filled with this research to prove our position.

Here are just a few studies that KO should have cited:

  • A study by Anthony Rosner, PhD, comparing medical procedures to chiropractic care concerning strokes flipped this coin to mention patients need to be warned of the dangers of medical procedures rather than chiropractic care. As he suggests, “The statistics really begin to spin one's head.”[4]  Using a baseline figure of one per one million as an estimate of stroke incidence attributed to cervical manipulations, one finds a:
    • two times greater risk of dying from transfusing one unit of blood;[5]
    • 100 times greater risk of dying from general anesthesia;[6]
    • 160-400 times greater risk of dying from use of NSAIDs;[7]
    • 700 times greater risk of dying from lumbar spinal surgery;[8]
    • 1000-10,000 times greater risk of dying from traditional gall bladder surgery;[9]
    • 10,000 times greater risk of serious harm from medical mistakes in hospitals.[10]

Obviously these medical risks are unknown by the public and unmentioned by the media, yet the same medical professionals who criticized chiropractors forget to mention these facts (a case of “professional amnesia” as Dr. Rosner suggests) of the remote danger of manipulation or the fact that patients who seek medical care are equally susceptible, if not more so, to medical mistakes and iatrogenic problems.

  • According to research by Alan Terret et al., the rate of iatrogenic problems associated with spinal manipulative therapy as rendered by doctors of chiropractic is only 1 in 5.85 million cases, which is less than the chance of stroke in a hair salon or being hit by lightning (one in 600,000).[11] It equated to one occurrence in 48 chiropractic careers.[12]
  • In 2006, Jay Triano, DC, PhD, wrote about the stroke issue in his publication, Current Concepts in Spinal Manipulation and Cervical Arterial Incidents, that included 675 references and a comprehensive discussion of cervical artery injury and manipulation. He also came to the sobering conclusion that chiropractic is very safe:
    • The increased risk of death resulting from NSAID use is 1,500 times greater than the risk of tetraplegia following cervical SMT.
    • On analysis, SMT as delivered by chiropractors is one of the most conservative, least invasive and safest of procedures in the provision of health care services. 
    • The risks of SMT pale when compared to known medical risks.  Chiropractors, by their training and skill in SMT and special emphasis on the spine, are the best positioned to deliver this mode of health care to the public.
    • Conclusion: VBA stroke is a very rare event in the population. The increased risks of VBA stroke associated with chiropractic and PCP visits is likely due to patients with headache and neck pain from VBA dissection seeking care before their stroke. We found no evidence of excess risk of VBA stroke associated chiropractic care compared to primary care. [13]

Dr. KO might have put this into perspective with medical mistakes, such as the study of iatrogenic deaths from medical care that are staggering. Barbara Starfield, MD, MPH, of the Johns Hopkins School of Hygiene and Public Health, reported that medical care is now the third-leading cause of death in the U.S., causing 225,000 preventable deaths every year. [14] And this study is now 12 years old and these numbers have probably more than doubled!

Dr. KO might have mentioned the huge difference in malpractice rates among DCs and MDs. Malpractice insurance companies know which doctors are hurting patients, and the actuaries show that chiropractors have the lowest malpractice rates among all spine practitioners. Chiropractors pay approximately $1,600 annually[15] compared to spine surgeons, who typically derive as much as 62 percent of all of their professional income from performing surgical procedures on the lumbar spine, will pay approximately $71,000 to over $200,000,[16] which clearly suggests the relatively safety of care provided by chiropractors.

          Certainly the media onslaught on chiropractic will not end until we crack the nut with a strong statement, documentary, or news release in our defense. It’s past time to be proactive and go on the offensive rather than stay the defensive waiting for the next attack.

We cannot “make love, not war” as some in our profession wish until the war has ended, and the AMA has no intention to declare peace. As far back as March of 2000 Howard Wolinsky of the Chicago Sun-Times wrote:

The cold war between the Chicago-based American Medical Association and the American Chiropractic Association is heating up again, nearly a decade after the U.S. Supreme Court ordered the groups to bury the scalpel, the Chicago Sun-Times has learned.

In a Feb. 28 letter to the ACA, AMA Chairman D. Ted Lewers said, "It is our understanding that the ACA desires to meet with the leadership of the AMA in order to `focus on those issues we have in common.' However, the AMA has a different view and no desire for such a meeting."[17]

 

It’s past time for chiropractors to go on the offensive with the facts to refute this medical misinformation. After decades of taking cheap shots from the biased media, the tables have turned with the new research supporting our care, its cost-effectiveness, and safety. Now we need to tell the public.

Regards,

JCS

www.chiropractorsforfairjournalism.info

 

Is Spinal Manipulation for Neck Pain Safe?

 

By LARA SALAHI (@BostonLara)

ABC World News with Diane Sawyer

June 8, 2012

Layli Nottingham, 56, of Palmer, Alaska, said whenever she experienced neck pain she would turn to her chiropractor.

That is, until 1994, when a visit to her chiropractor to undergo a routine technique called spinal manipulation only made her pain worse.

"The pain was so excruciating and it was hitting the nerve that went down the right arm," said Nottingham. "I really had no idea what was wrong with me."

Spinal manipulation, a procedure that uses a flow of movement and points along the vertebrae to restore joint motion and realign the spine, is one of the most common treatments for neck pain. Previous studies suggest between 6 percent to 12 percent of Americans undergo spinal manipulation every year.

But the safety and efficacy of the technique has long been debated by medical experts.

Some evidence suggests that spinal manipulation, which is most often used by chiropractors, can offer some benefit to people who have back pain and some musculoskeletal disorders.

The technique varies in level and intensity, depending on the severity of the ailment, said Keith Overland, a chiropractor and president of the American Chiropractic Association.

However, some medical experts question whether spinal manipulation is a safe and effective technique for patients with neck pain.

Two reviews of the evidence by researchers published Thursday in the British Medical Journal add one more weight on the each side for and against spinal manipulation.

In the first review, the authors conclude the technique is "unnecessary and inadvisable." The review cites studies that have suggested an association between spinal manipulation and more intense injuries, including tearing of the artery, and even stroke.

The studies "provide consistent evidence of an association between neurovascular injury and recent exposure to cervical manipulation," according to Neil O'Connell, a lecturer at the center for research in rehabilitation at Brunel University in Uxbridge and his colleagues wrote.

According to Overland, the most common side effect from manipulation is soreness, adding that other more serious side effects are extremely rare.

"Yes, people had strokes, but they were most likely going to suffer the stroke regardless of the provider they chose," said Overland. "It's incumbent upon the doctor to do a proper thorough examination before giving a treatment."

The second study review suggests there are benefits to the technique, especially when used together with other pain relieving methods, such as exercise.

"We say no to abandoning manipulation and yes to more rigorous research on the benefits and harms of this and other common interventions for neck pain," David Cassidy, a professor in the department of epidemiology at the Dalla Lana School of Public Health at the University of Toronto, and his colleagues wrote.

Nottingham had a herniated disc, but at the time, she and her chiropractor didn't know it. Three months after her visit with the chiropractor, an orthopedic surgeon and neurosurgeon diagnosed her condition and recommended physical therapy. Nottingham said if she'd known how serious her condition was, she would've sought help from an orthopedic specialist sooner.

"There is a time and place and certain conditions when chiropractors would be helpful," said Nottigham, adding that she didn't think her chiropractor caused the problem. "I have not seen one since."

According to Dr. Cain Dimon, physician director of the center for pain medicine at William Beaumont Hospitals in Royal Oak, Mich., spinal manipulation may be appropriate only after patients receive a full physical exam to detect the problem and undergo other types of treatments to relieve the pain first.

"I certainly don't dismiss chiropractic manipulation," said Dimon. "It can certainly help in some cases lower pain."

Overland said it's unlikely that a chiropractor would perform a spinal manipulation without first knowing the exact cause of pain.

"If a person has a herniated disc, this would've been diagnosed, said Overland. "Usually chiropractors do a full orthopedic and neurologic examination."

In fact, there are some cases where manipulation may exacerbate the pain, said Dimon.

 For some experts, the problem with spinal manipulation is that it is has become an overpromising treatment for conditions outside the physiological realm of the technique. For years, chiropractors have faced criticism for claiming their practices work to cure a wide variety of ailments, including asthma and cancer.

"It's hard for me to understand physiologically how that would work," said Dimon, who cautioned against undergoing treatments without a physician recommendation.

According to Overland, the lingering controversy over spinal manipulation has less to do with the data concerning its safety or efficacy, and more to do with the resounding consensus by many conventional medical doctors spanning decades that suggests chiropractors are not an equal part of the medical community.

"There's still a lot of residual bias against the profession," said Overland. "Yes, there's risk of every medical procedure, but we need to move away from health in a bottle."

The medical community should place a larger emphasis on understanding chiropractic techniques, he said.

"What's lacking is really good research is how spinal manipulation is helping other types of chronic conditions," said Overland.

 



[1] E Ernst “Deaths After Chiropractic: A Review Of Published Cases,” Int J Clin Pract, 64/8 (July 2010):1162–1165

[2] SM Perle, S French, and M Haas, “Critique of Review of  Deaths after Chiropractic, 4” Letters to editor, The International Journal of Clinical Practice, 65/1 (January 2011):102-106.

[3] JM Whedon, GM Bove, MA Davis, “Critique of review of deaths after chiropractic, 5” Letter to editor, The International Journal of Clinical Practice, 65/1 (January 2011):102-106.

[4] A Rosner, “Evidence or Eminence-Based Medicine? Leveling the Playing Field Instead of the Patient,” Dynamic Chiropractic  20/25 (November 30, 2002) 

[5] J Paling www.healthcare speaker.com, 2000.

[6] Paling, ibid.

[7] V Dabbs, W Lauretti. “A Risk Assessment Of Cervical Manipulation Vs NSAIDs For The Treatment Of Neck Pain,” Journal of Manipulative and Physiological Therapeutics 18/8 (1995):530-536.

[8] RA Deyo, DC Cherkin, JD Loesser, SJ Bigos, MA Ciol, “Morbidity and Mortality In Association With Operations On The Lumbar Spine: The Influence Of Age, Diagnosis, And Procedure,” Journal of Bone and Joint Surgery Am 74/4 (1992):536-543.

[9] Paling, ibid.

[10] Paling, ibid.

[11] G Bronfort, M Haas, R Evans, G Kawchuk, and S Dagenais, “Evidence-informed Management of Chronic Low Back Pain with Spinal Manipulation and Mobilization,” Spine 8/1 (January-February 2008):213-25.

[12] AGJ Terret, “Current Concepts in Vertebrobasilar Complications Following Spinal Manipulation,” NCMIC Group Inc, West Des Moines, Iowa, (2001)

[13] John J. Triano, Current Concepts in Spinal Manipulation and Cervical Arterial Incidents by (Jan 1, 2006)

[14] B Starfield, “Is US Health Really the Best in the World?” JAMA 284/4 (July 26, 2000):483-485.

[15] National Chiropractic Mutual Insurance Company rate (2009)

[16] The Burton Report, “Why Spine Care is at High Risk for Medical-Legal Suits,” www.burtonreport.com/infforensic/MedMalSpCommonCause.htm

[17] Howard Wolinsky, “AMA snubs overture from chiropractors,” Chicago Sun-Times, March 24, 2000

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