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• Authors' Reply: chiropractic spinal manipulation for back pain
  E Ernst
  Published on: 18 December 2003
• Observations concerning chiropractic spinal manipulation for back pain a reply
  Peter W. McCarthy
  Published on: 6 November 2003
• The "war" on chiropractors
  Alan C Breen
  Published on: 6 August 2003

• Published on: 18 December 2003

  Authors' Reply: chiropractic spinal manipulation for back pain

  • E Ernst, Director
  • Other Contributors:
    • Sran MM

  Dear Editor

  McCarthy, Byfield [1] and Breen [2] make a number of comments which require a brief reply. I wrote the article on this specific subject because I was invited to do so by the British Journal of Sports Medicine. All three correspondents seem to oppose my "long track record" of writing about adverse effects of spinal manipulation. I do this simply because it is my job. I try to apply the rules of science to al...

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  Dear Editor

  McCarthy, Byfield [1] and Breen [2] make a number of comments which require a brief reply. I wrote the article on this specific subject because I was invited to do so by the British Journal of Sports Medicine. All three correspondents seem to oppose my "long track record" of writing about adverse effects of spinal manipulation. I do this simply because it is my job. I try to apply the rules of science to all areas of complementary medicine. To exclude therapeutic safety from this strategy would be unforgivable. I have certainly published more on the adverse effects of herbal medicine than on spinal manipulation. To assume that I have singled out spinal manipulation is therefore pure fantasy.

  I disagree with McCarthy and Byfield about their assumption that the safety of cervical manipulation is not directly related to osteoporosis and back pain. Contrary to these authors, I also think that “a comprehensive case history” is not a specific and sensitive diagnostic tool for osteoporosis. However, I do agree with McCarthy and Byfield that many adverse effects of manipulation go unreported. In our own case series under-reporting was precisely 100%.[3] Finally, I am not aware that "the chiropractic profession has sought to engage [me] in constructive dialogue for at least 5 years".

  I believe Breen [2] is wrong in stating that 2the majority of systematic reviews" do not agree with my article. We have recently evaluated all reviews of spinal manipulation for back pain published in the last 10 years.[4] Sixteen reviews met our inclusion criteria; 9 reached a positive and 7 a negative conclusion about the effectiveness of spinal manipulation. An overall positive conclusion was most significantly associated with low methodological quality of the review and first authorship by a chiropractor or osteopath.

  In summary, I feel that my article was as evidence-based as it could be given its brevity while the comments of McCarthy, Byfield and Breen seem to bear the hallmarks of an emotional ad hominem attack.

  References

  (1) McCarthy PW and Byfield DC. Observations concerning chiropractic spinal manipulation for back pain a reply [electronic response to Ernst and Sran Chiropractic spinal manipulation for back pain - Commentary] bjsports.com 2003http://bjsm.bmjjournals.com/cgi/eletters/37/3/195#38

  (2) Breen AC. The "war" on chiropractors [electronic response to Ernst and Sran Chiropractic spinal manipulation for back pain - Commentary] bjsports.com 2003http://bjsm.bmjjournals.com/cgi/eletters/37/3/195#38

  (3) Stevinson C, Honan W, Cooke B, Ernst E. Neurological complications of cervical spine manipulation. J Roy Soc Med 2001; 94: 107-10.

  (4) Canter PH, Ernst E. Sources of bias in reviews of spinal manipulation for back pain. Submitted 2003.

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  Conflict of Interest:
  None declared.

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• Published on: 6 November 2003

  Observations concerning chiropractic spinal manipulation for back pain a reply

  • Peter W. McCarthy, Lecturer
  • Other Contributors:
    • David C. Byfield.

  Dear Editor

  We found the leader by Professor Ernst (Br J Sports Med 2003;37:195-196) to be rather disjointed, out of date and potentially misleading. This is particularly evident in the initial paragraph. The author begins by generally addressing sports medicine clinicians, including those who are trained in mobilisation and manipulation, namely osteopaths, physiotherapists and chiropractors and a...

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  Dear Editor

  We found the leader by Professor Ernst (Br J Sports Med 2003;37:195-196) to be rather disjointed, out of date and potentially misleading. This is particularly evident in the initial paragraph. The author begins by generally addressing sports medicine clinicians, including those who are trained in mobilisation and manipulation, namely osteopaths, physiotherapists and chiropractors and abruptly concludes, for no apparent reason, that chiropractic manipulation will be the focus of the remainder of the article. Our question is, "Why single out chiropractic manipulation when similar forms of manipulation are routinely practised by all of the other initially identified professions?".[1] This author has a long track record of reporting the potential adverse reactions specifically related to manipulation performed by chiropractors. Additionally, the author chooses a different forum for each "letter". The current leader appears to be simply rehashing old statements rather than adding new material to the discussion. Each new forum tends to confuse the issue further, as new groups of professionals are brought into the debate without all of the information required to make an informed decision. This type of approach requires the chiropractic profession to continually respond in a more defensive fashion. This undermines co-operative research efforts and thwarts any attempt at productive interprofessional debate.

  Chiropractic manipulation is singled out, even though Assendelft et al,[2] concluded the minimum effectiveness of spinal manipulation irrespective of the provider was not superior to other treatments for back pain. Such results can also be interpreted as manipulation being at least equivalent to other available treatments. This would naturally increase the number of therapeutic options available for the management of a complex clinical condition. Under these circumstances, clinical utilisation and decision making should always take into account patient centred factors such as side effects and patient satisfaction. Professor Ernst clearly has reservations regarding the United Kingdom's current national clinical practice guideline and evidence review. This states that: "Within the first 6 weeks of acute or recurrent low back pain, manipulation provides better short-term improvement in pain and activity levels and higher patient satisfaction than the treatments to which it has been compared" and "the risks of manipulation for low back pain are very low, provided patients are selected and assessed properly and it is carried out by a trained therapist or practitioner [3] "; i.e., chiropractors, manipulating physiotherapists and osteopaths.

  With respect to the forces applied during a manipulation, the paper quoted by Professor Ernst could appear misleading. The loads reported for manipulation by Triano and Schultz [4] do not take into account the surface area of contact and the dissipation of the forces by the local tissues. This would reduce and dissipate the forces over a wider area. Professor Ernst also misleads the reader by suggesting that these loads are inordinately high when in fact, as pointed out by Triano and Schultz [4] "estimates of the loads transmitted were consistent with those observed in common tasks requiring lifting and twisting movements". Furthermore, researchers in this area would freely admit that it has been poorly researched until more recently [5] with chiropractic manipulative forces being the most extensively studied of all the professions mentioned. Professor Ernst also appeared to be unaware of the recent publication by the UK BEAM group.[1] This group, while formulating their methodology concluded that chiropractic, osteopathic and physiotherapeutic manipulation had more similarities than differences: this would be expected to incorporate the potential risks as well as the potential benefits.

  With respect to the statement that "dramatic complications have been noted with some degree of regularity" Professor Ernst abruptly switches the argument to cervical manipulation. This statement apparently refers to the potential yet unproven association made between stroke and cervical spine manipulation. Although this is out of direct context with the theme of the leader, namely osteoporosis and back pain, it would suggest there have been many incidences and that the manipulation was a causative factor in the production of vertebrobasilar artery accidents. There is experimental evidence which would argue to the contrary.[6] However, in the relative absence of direct evidence there exists an alternative, yet equally plausible hypothesis for this association: namely, that those people who already have problems with their vertebrobasilar artery (dissection or plaque) develop symptoms, which would lead them to seek out a chiropractor for treatment. This is made more evident in a society where chiropractic is more commonly available, such as Canada and USA. Such problems in diagnosing a patient in this situation are not unique to chiropractic. A recent case report in the Lancet [7] presented details of a patient with acute onset neck pain attending a hospital based emergency department. This patient was given analgesics and discharged. She returned (24 hours later) with more advanced symptoms suggestive of an acute anterior spinal artery syndrome. It is interesting to note that chiropractic manipulation had been ruled out, as had rapid head movement and head trauma, however, no mention of ruling out visits to other practitioners of manipulation was made. Although this is only one isolated report, it is probable that there are many such incidences that go unreported in all health care professions.

  With respect to the osteoporotic patient, chiropractors are fully aware of the potential risks involved with the application of manual forces with respect to relative osseous fragility. As a result, osteoporosis has been on the British chiropractors list of relative contraindications for manipulation for years, hence it appears rather surprising that a Professor of complementary therapies would appear to be unaware of this fact. We disagree with the statement by Professor. Ernst, that there is no reliable diagnostic method available to chiropractors. Many chiropractors have alternative methods available to them for determining the potential presence of this condition. None more powerful than a comprehensive case history, which is a fundamental statutory competency. Furthermore, many chiropractors have alternatives to radiographs (DEXA, ultrasound) present in their offices or within a referral service, available for confirmatory objective quantification.

  With respect to Professor Ernst's statement concerning information available to the patient; in Britain it is now necessary (indeed incorporated in the educational infrastructure) to inform all patient of the potential risks (benign and potentially serious) as well as expected therapeutic benefits. This is done under the umbrella term of "evidence based medicine" which has been the subject of both undergraduate and postgraduate education in UK chiropractic for at least 10 years. Patients are advised of all the treatment options, including referral to other practitioners. Furthermore they are informed about the use of Xrays and the limitations of plain film Xray to demonstrate the presence or absence of osteoporosis. They are also informed that osteoporosis is a relative contraindication to manual interventions and what that means to the patient in terms of overall case management.

  So in conclusion the article by Professor Ernst does not appear to be well informed or well researched. It appears to target chiropractic because there is less information available about the other manipulating disciplines. The chiropractic profession has sought to engage Professor Ernst in constructive dialogue for at least 5 years. However, he still appears to have ignored the steps being taken by professions such as chiropractic whose clinical focus is guided by statutory regulation aimed at protecting the patient and raising standards of care and education.

  References

  1. Harvey E, Burton AK, Moffett JK, Breen A; UK BEAM trial team. Spinal manipulation for low-back pain: a treatment package agreed to by the UK chiropractic, osteopathy and physiotherapy professional associations. Man Ther. 2003; 8 (1):46-51.

  2. Assendelft WJ, Morton SC, Yu EI, Suttorp MJ, Shekelle PG. Spinal manipulative therapy for low back pain. A meta-analysis of effectiveness relative to other therapies. Ann Intern Med. 2003; 138 (11):871-81.

  3. Waddell G, Feder G, McIntosh A, Lewis M, Hutchinson A. Clinical guidelines for the management of acute low back pain: clinical guidelines and evidence review. London: Royal College of General Practitioners , 1996.

  4. Triano J, Schultz AB. Loads transmitted during lumbosacral spinal manipulative therapy. Spine 1997;22:1955–64.

  5. Herzog W. Clinical Biomechanics of spinal manipulation. Ed W Herzog. Pub Churchill Livingston, London, 2002

  6. Symons BP, Leonard T, Herzog W. Internal forces sustained by the vertebral artery during spinal manipulative therapy. J Manipulative Physiol Ther. 2002; 25(8):504-10.

  7. Latronico N, Fassini P, Antonini B, Gasparotti R. A pain in the neck. Lancet. 2002; 359 (9313):1206.

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  Conflict of Interest:
  None declared.

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• Published on: 6 August 2003

  The "war" on chiropractors

  • Alan C Breen, Professor of Musculoskeletal Health Care
  • Other Contributors:
    • Anglo-European College of Chiropractic

  Dear Editor

  The Ernst and Sran commentary [1] about 'chiropractic manipulation' is not consistent with the majority of systematic reviews, nor national guidelines. It is, however, highly consistent with the previous and prolific writings of the first author himself on this topic. Surely, the significance of this pattern is an obvious one, and the suggestion that if anyone else but a chiropractor performs a ma...

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  Dear Editor

  The Ernst and Sran commentary [1] about 'chiropractic manipulation' is not consistent with the majority of systematic reviews, nor national guidelines. It is, however, highly consistent with the previous and prolific writings of the first author himself on this topic. Surely, the significance of this pattern is an obvious one, and the suggestion that if anyone else but a chiropractor performs a manipulation, it is likely to be much safer, speaks for itself? The same considerations might be applied to journal editorial practice as well, especially when the affected public may have seriously disabling problems which could be pivotally changed by the correct treatment.

  Reference

  (1) Ernst E and Sran MM. Chiropractic spinal manipulation for back pain • Commentary. Br J Sports Med 2003;37:195-196.

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  Conflict of Interest:
  None declared.

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