COMMENTARY

In Response - Setting the Record Straight on Chiropractic Care

July 02, 2001

Introduction

Dr. Mertz has suggested that my articles on Medscape and Medscape Health be removed because he believes they are outdated and inaccurate, concealing the benefits of chiropractic care and scaring patients away from consulting doctors of chiropractic.

He takes issue with my statement that chiropractic neck manipulation can be dangerous, and he points out that a study by the RAND Corporation has shown that a serious adverse reaction from cervical manipulation occurs only once in 1 million manipulations. This study by RAND, published in 1996, was based on a review of the literature and an estimate of the total number of manipulations performed. Most cases of stroke caused by neck manipulation have not been recognized as such and have not been reported in the literature. New studies have revealed that neck manipulation may be much more dangerous than previously suspected.

A study of actual stroke cases conducted by the Canadian Stroke Consortium and reported in the July 11, 2000, issue of the Canadian Medical Association Journal found that stroke resulting from neck manipulation occurred in 28% of cases of stroke caused by injury to neck (vertebral) arteries, causing as many as 200 strokes a year in Canada. On a per patient basis, as reported in the May 2001 issue of Stroke (a journal of the American Heart Association), the Canadian studies suggest that 1 in every 100,000 chiropractic patients under the age of 45 who receive neck manipulation will suffer a stroke -- far more than the 1 in a million reported by RAND.

Obviously, there is a difference in opinion about the dangers of neck manipulation, and more research needs to be done. But there is no doubt that neck manipulation can be dangerous. And risk outweighs benefit when chiropractors use neck manipulation to correct hypothetical "subluxations" in an effort to "restore and maintain health," as many are doing.

In 1996, the Association of Chiropractic Colleges, represented by 16 North American chiropractic college presidents, reached a consensus and concluded that "Chiropractic is concerned with the preservation and restoration of health, and focuses particular attention on the subluxation." It has been estimated that 30% to 69% of chiropractic patient visits include cervical manipulation (Current Concepts in Vertebrobasilar Complications, 2001). Advocates of the subluxation theory often manipulate the neck of an asymptomatic patient in a misguided effort to maintain health.

While spinal manipulation can be safe and beneficial in the treatment of some types of back pain, it is certainly irresponsible not to warn the public of the dangers of inappropriate neck manipulation.

There are undoubtedly some carefully selected neck-related problems that can benefit from cervical manipulation, but such treatment should never be done routinely or as a preventive measure. Patients should always be informed of the dangers of neck manipulation and be given the choice of first trying a safer treatment, such as massage, traction, or mobilization when such treatment is appropriate. And they should be made aware of the fact that the chiropractic theory suggesting that a subluxation or some other problem in a spinal joint can cause "nerve interference" that can result in disease or ill health is unproven and may be scientifically indefensible, even if it is covered by Medicare.

It is a common defense of chiropractors to counter criticism with statements that medical care and prescription drugs kill or injure millions of Americans each year and that "Virtually all interventions by medical doctors have a complication rate higher than those associated with most commonly used chiropractic interventions." The reason for this difference is obvious. Medical physicians commonly treat severely diseased and injured patients who may die despite use of life-saving treatment methods that may be essential but dangerous. Chiropractors never see such patients. And according to Chiropractic in the United States: Training Practice and Research (1997), only about 7% of the population annually uses chiropractors. I have no doubt that if hospitals and emergency rooms were staffed only with chiropractors, the death rate would skyrocket. Human error in medical care is a problem openly discussed in medical literature and the news media, but this certainly does not lend credence to the chiropractic subluxation theory.

When spinal manipulation is used appropriately in the care of mechanical-type back problems, it is relatively safe, since there are no life-and-death situations requiring drastic intervention. In most cases, if spinal manipulation or "wellness care" (often including the use of such questionable treatment methods as homeopathy or acupuncture) does not help, there is little chance that it will hurt. To compare the safety of chiropractic care to that of medical care that often requires drastic intervention is simply ludicrous. And to say that chiropractors are primary care physicians capable of serving as family physicians is nonsensical.

Some chiropractors earn a diploma in family practice, orthopaedics, neurology, pediatrics, sports injuries, rehabilitation, or nutrition by attending weekend courses. It would be an anachronism to consider a chiropractic specialist who employs a limited treatment method (primarily spinal manipulation) to be equivalent to a medical specialist who has access to unlimited medical treatment methods. A "chiropractic nutritionist" can offer some good advice but can hardly be equated with a registered dietician.

I have no problem with the work of properly limited chiropractors who specialize in the care of neuromusculoskeletal problems when they seek the cooperation of medical specialists, and there are many chiropractors who do a good job treating back pain and related problems. But there are so many chiropractors claiming to "restore and maintain health" by adjusting hypothetical spinal subluxations based on a belief system that it is virtually impossible to suppress criticism of the chiropractic profession, as attempted by Dr. Mertz on behalf of the American Chiropractic Association.

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