Articles by JCS

Response to Sun

Response to British Fake News: "Chiropractors are hiding a deadly secret"

 

 Chicken Little Journalism British Style

Chicken Little (or Henny Penny in the UK) is a children’s story about a hysterical belief that disaster is imminent. We see this on occasion when a medical Chicken Little cries, “Chiropractors are bad, Chiropractors cause strokes.” (yada, yada, yada).

Part of the problem with this Chicken Little journalism is the mainstream media never gives the fair and balanced response to this issue from the chiropractors’ point of view. Instead, such journalists fabricate fake news stating, “The sky may be falling, but there’s no scientific proof, but still be afraid that it might!”

Such fear-based news has two aims: 1) to grab the viewer's attention with the teaser; and 2) to persuade the viewer that the solution for reducing the fear is in the news story—in this case, to not use chiropractors.


The success of fear-based news relies on presenting dramatic anecdotes in place of scientific evidence, promoting isolated events as trends, depicting categories of people as dangerous and replacing optimism with fatalistic thinking, evident Down Under in the attack on pediatric chiropractic in a victim-less non-crime.[1]


Once again we witness another example of Chicken Little journalism in the UK with “Chiropractors are hiding a deadly secret” by Miles Goslett (October 25, 2017). Sadly, Mr. Goslett has an ax to grind with his one-sided article citing known medical trolls, Edzard  Ernst and Simon Singh. Yellow journalism may be more descriptive of his Chicken Little article since he failed to offer a fair and balanced approach.

For example, Goslett quoted the discredited Ersnt when he wrote “More than half of patients treated by chiropractors suffer side-effects and at least 26 in the UK are feared to have died, a Sun investigation reveals.”

What this Chicken Little failed to mention is the 26 deaths occurred over 76 years. Ernst noted in his 2010 article, “Deaths after Chiropractic: A Review of Published Cases” that “Twenty-six fatalities were published since 1934 in 23 articles.”[2]

Considering 26 deaths over 76 years equates to 0.34 deaths per year (one-third of a person!), instead of sounding an alarm to scare people, Ernst 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 The Dartmouth Institute for Health Policy and Clinical Practice:

“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]

These figures show spine surgery for neck[4] and back pain[5] accounts for 2,300 serious side effects/deaths per 1 million encounters. NSAIDs/aspirin[6] and prescription opioid pain[7] medications account for 207 serious side effects/deaths per million. Combining these stats, overall 2,507 people per million are seriously injured or died from medical spine treatments. Again, the rate of serious side-effects/deaths from manipulation is only 1 in 5.85 million adjustments.[8]

Considering American chiropractors treated 33 million patients in 2014,[9] this equates to 5 or 6 serious or fatal events annually. In comparison, when medical spine care providers see an equivalent 33 million patients, this equates to 82,731 serious events or deaths annually.

This is equivalent to Chicken Little screaming in the barnyard “the sky is falling” while the barn is on fire.

Indeed, it’s obvious who’s hurting more patients, begging the question: why is this overall medical iatrogenesis (physician-induced mistakes) rarely reported in the media?

In fact, the rate of adverse events associated with chiropractic care is less than having a stroke while in a hair salon or a dentist’s chair,[10] or being hit by lightning (one in 600,000).[11] 

Yet, when was the last time you’ve read about anyone dying after back surgery or in a dentist’s chair after administration of presurgical anesthetic medication[12]  or suffering a Beauty Parlor Stroke Syndrome? I can answer that question: Never!

Goslett also wrote more fake news:

“In 2016, Playboy model Katie May, 34, suffered a stroke and died hours after a session in Los Angeles. The coroner said her death was a direct result of a neck adjustment which tore a major artery to her brain.”

His comment is simply not true as experts now claim.

The unfortunate accidental death of Katie May was clearly misrepresented by many in the media. Instead of presenting her death as a rare accident as the experts explained, many in the media seemed hell-bent to character assassinate her chiropractor and thereby defame the reputation of an entire profession based on one rare accident.

This distressing situation revealed how many journalists ignored extremely important facts that were mischaracterized or omitted altogether in their fake news reports that only added to the media assault on the entire chiropractic profession.

In the case of Katie May, she initially tweeted to her friends her neck pain began at a photo session when the photographer asked her to hold a provocative pose for a long time that involved arching her back and leaning her neck to the side, almost immediately causing pain that Ms. May thought was simply a “pinched nerve” as she later tweeted to her fans.

 Initially mistakenly reported by TMZ she had a “brutal fall”[13] at the photo shoot, Ms. May told her friends that she “just held a pose and kinked her neck.” After a few days of self-care at home, she later she sought chiropractic care, which is a common scenario from a hyper-extended neck injury occurs causing the stroke before the spinal adjustment is rendered.[14]

Ms. May tweeted that her neck still hurt afterwards, unaware her pain was actually due to a tear in her carotid artery. When her pain did not subside after three visits to a chiropractor near her apartment in West Hollywood, she sought help at a local hospital when she progressively felt worse with dizziness, headache, numbness and slurred speech — all signs of a stroke.

The Los Angeles County Coroner’s office attributed her death to “neck manipulation” but gave no “operating theory” of her demise. Suddenly his opinion began a perfect storm of misinformation that went viral overnight to categorically condemn chiropractic.

Although the vast majority of news articles on this Katie May incident at best were incomplete, many also bordered on fake news laden with misinformation, important omissions or inflammatory comments, such as we now see in The Sun article by Goslett.

Researchers also agree vertebral arteries can experience a tear or dissection from seemingly harmless movements — from sneezing, painting a ceiling or having hair washed in a salon — that involve turning or extending the neck in an awkward position or holding it for a lengthy time in a strained position as was the situation in the Katie May case when she posed with her head extended backwards for a prolong period of time.[15]

Perhaps the most unbiased article came from the Pittsburgh Post-Gazette, “Medical Examiner Says Neck Manipulation Killed Internet Phenom,” written by Sean D. Hamill on October 23, 2016. Despite the inflammatory “gotcha” headline, the bulk of the article contained fair and balanced comments from both MDs and chiropractors who have studied such injuries.

“It’s a chicken and egg question,” said Dr. Gerard Clum, a chiropractor-educator for 42 years. “Was the chiropractor the cause of it or merely associated with it?”

According to Michael Schneider, DC, PhD, associate professor in the University of Pittsburgh department of physical therapy and a practicing chiropractor, “My educated opinion was that she probably had a small dissection in the [modeling] pose.”

Penn State neurologist Robert Harbaugh said from the evidence in the case he believes “the chiropractor got caught in the middle” and was unlikely to have caused the original tear. “And if [the chiropractor] had dislodged [the pre-existing] clot, her neurological symptoms would have happened immediately,” he said, rather than progressing slowly over the day.

Dr. Harbaugh, director of the Penn State Institute of the Neurosciences, was lead author of the most recent large scale review, “Systematic Review and Meta-analysis of Chiropractic Care and Cervical Artery Dissection: No Evidence for Causation:”[16]

Our analysis shows a small association between chiropractic neck manipulation and cervical artery dissection. This relationship may be explained by the high risk of bias and confounding in the available studies, and in particular by the known association of neck pain with CAD and with chiropractic manipulation. There is no convincing evidence to support a causal link between chiropractic manipulation and CAD. Belief in a causal link may have significant negative consequences such as numerous episodes of litigation.”

 “I think the data is overwhelming that there’s a very low risk” of dissection from neck manipulation, said Dr. Harbaugh, who was also a co-author on the AHA’s Stroke Council report, “Cervical Arterial Dissections and Association With Cervical Manipulative Therapy[17] that suggested there was an association between stroke and neck manipulation.

“To date, no study has found causality,” said Keith Overland, a chiropractor for 35 years who is a past president of the American Chiropractic Association. “I don’t see indicting a particular procedure that’s done millions of times a year without complications.” [18]

If the L.A. County Coroner had done his homework, he would have understood the mechanism of injury in similar cases suggests the stroke began with the initial injury — in this case, a prolonged pose with her neck in the extended position — and not from the chiropractor’s adjustment.

The coroner also should have known any association between manipulation and stroke is coincidental — a situation where the patient was already in the midst of a dissection or stroke and just so happened to have seen a chiropractor for neck pain or headaches during that time frame.[19]

Aneesh Singhal, MD, vice chair of the department of neurology at Massachusetts General Hospital, reported experts aren’t entirely sure why some people may suffer a dissection from neck trauma and not others. “It’s a chance issue. However, it’s possible that people who eventually get a dissection have some structural abnormalities of the wall of the artery.”[20] The use of oral contraceptives has also been associated with arterial dissection.[21]

Who’s Hurting Whom?

Rather than dwelling on accidental anecdotes, researchers have studied the rates of iatrogenic injuries caused by medical doctors.

The British Medical Journal (BMJ) has been at the forefront reporting medical iatrogenesis, an issue conveniently ignored by Goslett, Ernst and Singh. 

In 2016 the BMJ revealed medical care is the third-leading cause of death in the United States in the range of 251,000 per year (that the authors admit is a conservative estimate) that equates to nearly 700 deaths per day due to medical mistakes. I assume these stats are also appropriate and proportional in the UK.

Nor did these medical trolls sound an alarm about patient safety in 2013 when the BMJ published on its website, Clinical Evidence, What conclusions has Clinical Evidence drawn about what works, what doesn't based on randomised controlled trial evidence? suggesting 2,000 of 3,000 standard medical treatments were ineffective, unproven or too dangerous to use.


Nor did the Chicken Little trolls warn the public about the rash of back surgeries. Spinal Fusion Surgeries Questioned, an article published by the Medical Journal of Australia InSight newsletter on April 26, 2016, that spoke of the urgent need to stop the tsunami of back surgeries:

“Spinal fusion surgeries for chronic low back pain are on the rise, despite the lack of research to back their efficacy, and experts are now calling for tighter guidelines, including a waiting period.”

Dr. Richard Williams, orthopaedic surgeon and spokesperson for the Royal Australasian College of Surgeons, told MJA InSight that a key regulation called for a waiting period of 12 months before a spinal fusion surgery was performed, noting "Most patients will recover after these 12 months” without any surgery.

If Goslett, Ernst and Singh were keen on protecting the public about medical methods that mislead and misrepresent the benefits to patients, why have they not spoken about this back surgery scam? Or about the opioid abuse, addiction and deaths caused by “pill mills” and pain management clinics that dispense narcotics like Halloween candy?

Medical Groups Laud Chiropractors

Obviously this fake news article by Goslett was aimed to mislead and frighten patients about chiropractic care when, in reality, the chiropractic care has now been lauded among the most effective treatments for acute and chronic low back pain by numerous American medical groups.

The poor results from medical spine care—drugs, shots, surgery—led numerous governmental agencies to examine the opioid crisis and came to important policy changes that included the use of chiropractic care—spinal manipulative therapy—in the treatment of both acute and chronic LBP.

·        The updated American College of Physicians guidelines for treating nonradicular LBP with nondrug, nonsurgical conservative care were published on Feb. 14, 2017, in the Annals of Internal Medicine:

The American College of Physicians (ACP) recommends in an evidence-based clinical practice guideline that physicians and patients should treat acute or subacute LBP with non-drug therapies such as superficial heat, massage, acupuncture, or spinal manipulation.

·        A similar JAMA study appeared on April 11, 2017, Association of Spinal Manipulative Therapy With Clinical Benefit and Harm for Acute Low Back Pain Systematic Review and Meta-analysis, also recommending SMT before medical spine care.

Findings:  In this systematic review and meta-analysis of 26 randomized clinical trials, spinal manipulative therapy was associated with statistically significant benefits in both pain and function, of on average modest magnitude, at up to 6 weeks.

Consumer Reports published two positive articles soon after the ACP and JAMA guidelines were released:

·        Stop Back Pain Without Drugs by Sally Wadyka, Consumer Reports, February 14, 2017:

For the first time, the American College of Physicians is advising treating back pain with nondrug measures like tai chi, yoga, chiropractic, and massage before resorting to over-the-counter or prescription pain relievers. 

·        Spinal Manipulation Can Ease Your Aching Back by Teresa Carr, Consumer Reports, April 11, 2017:

A new analysis finds that the hands-on technique works as well as pain drugs and is safer, too.

When you wrench your back, your first impulse may be to rummage through the medicine cabinet for an over-the-counter pain drug or even ask your doctor to prescribe a strong opioid painkiller such as Percocet or Vicodin. But an analysis published April 11 in the Journal of the American Medical Association finds that spinal manipulation can ease your backache and get you moving again without the risk of medication side effects.

·        Even the almighty Joint Commission  promoted chiropractors from the ranks of the medical zombies (recall the Joint led the boycott of DCs leading to the Wilk v. AMA trial) with its Revisions to pain management effective January 1, 2015:

Both pharmacologic and nonpharmacologic strategies have a role in the management of pain. The following examples are not exhaustive, but strategies may include the following:

Nonpharmacologic strategies: physical modalities (for example, acupuncture therapy, chiropractic therapy, osteopathic manipulative treatment, massage therapy, and physical therapy), relaxation therapy, and cognitive behavioral therapy.

Increasingly chiropractors are considered the best portal for primary spine care providers as the Optum report concluded:

In 2013, the Optum Health internal analysis of LBP treatments determined the best track to take for cost efficiency begins with a patient consulting a chiropractor first. When a chiropractor was the first provider, treatments were “well-aligned with clinical evidence; the least fragmentation of care; low rates of imaging, injections, and prescription medications; and low total episode cost when manipulation is introduced within the first 10-days of the episode.”

Using chiropractors as the first point of contact also greatly reduced the likelihood of spine surgery:

       If The Sun newspaper has an ounce of professional integrity, I urge the editor to print this article in full to counteract the blatant fake news by Goslett. A public apology would also be appropriate for the damage he caused on the reputations of the thousands of British chiropractors helping patients with their spinal problems.

 

 



[1] If It Bleeds, It Leads: Understanding Fear-Based Media, Managing depression requires you to mind your media intake, by Deborah Serani Psy.D. Psychology Today, Post published on Jun 07, 2011

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

[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] Marquez-Lara A, Nandyala SV, Hassanzadeh H, Noureldin M, Sankaranarayanan S, Singh K: Sentinel Events in Cervical Spine Surgery. Spine 2014 Jan 29 [Epub ahead of print],   http://www.ncbi.nlm.nih.gov/pubmed/24480955

[5] Smith, JS et al. Rates and causes of mortality associated with spine surgery based on 108,419 procedures: a review of the Scoliosis Research Society Morbidity and Mortality Database. Spine 2012, Nov 1;37(23):1975-82

[6] Lanas A et al. A nationwide study of mortality associated with hospital admission due to severe gastrointestinal events and those associated with nonsteroidal anti-inflammatory drug use. Am J Gastroenterology 2005, Aug;100(8):1685-93.

[7] Email to American Chiropractic Association from Division of Unintentional Injury Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, April 29, 2014.

[8] Haldeman S, Carey P, Townsend M, Papadopoulos C: Arterial dissections following cervical manipulation: the chiropractic experience. CMAJ 2001;165:905.

[9] http://www.gallup.com/poll/184910/majority-say-chiropractic-works-neck-back-pain.aspx

[10] Management of Medical Emergencies in the Dental Office: Conditions in Each Country, the Extent of Treatment by the Dentist, Anesth Prog. 2006 Spring; 53(1): 20–24.

doi:  10.2344/0003-3006(2006)53[20:MOMEIT]2.0.CO;2

[11] Allan G.J. Terrett, Current Concepts in Vertebrobasilar Complications Following Spinal Manipulation (West Des Moines, IA:  NCMIC Group Inc., 2001).

[12] https://www.ncbi.nlm.nih.gov/pubmed/7182526

[13] Katie May Stroke Triggered By Brutal Photo Shoot Fall http://www.tmz.com/2016/02/05/model-katie-may-stroke-fall-photo-shoot/

[14] Sean D. Hamill, Medical examiner says neck manipulation killed Internet phenom, Pittsburgh Post-Gazette, Oct. 23, 2016

[15] https://www.ncbi.nlm.nih.gov/pubmed/21739395

[16] https://www.ncbi.nlm.nih.gov/pubmed/27014532

[17] http://stroke.ahajournals.org/content/45/10/3155.full

[18] Sean D. Hamill, Medical examiner says neck manipulation killed Internet phenom, Pittsburgh Post-Gazette, Oct. 23, 2016

[19] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2271108/

[20] http://www.self.com/story/katie-may-stroke-chiropractor

[21] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2647091/



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