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We found the leader by Professor Ernst (Br J Sports Med 2003;37:195-196) to be rather disjointed, out of date and potentially misleading.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.

Dear Editor

There are a number of interesting points raised by this case report, as well as some fundamental and misleading errors.

I would be very interested to know what the authors actually mean by the term “shin splints”

They state that “Exercise-induced compartment syndrome is the least common” (cause of lower leg pain). Perhaps exercise-induced acute compartment syndromes are very rare, but certainly not chronics. It is debatable as to whether CCS (Chronic Compartment Syndrome) or MTSS (Medial Tibial Stress Syndrome)is the most common cause of exercise-induced lower leg pain, and it is impossible to prove either way. However CCS is at least 100 times more common in athletes than either venous diseases or obliterative arterial diseases. This is supported by both common sense and the literature. For example, in the April 2004 issue of the Journal, Cunningham & Spears maintain that CCS is the most common form of leg pain in athletes

EICS is a misleading term because it does not distinguish between Chronic and Acute, which is a very important difference in terms of possible sequelae and urgency of treatment. CCS is better, exercise is implicit in the name as, unlike acutes, which can have many causes, there is no other cause of a CCS.

Why was the Superficial posterior compartment decompressed, when it was clearly shown by the pressure tests to be completely normal?

The most common causes of acute compartment syndrome must certainly include tibial fractures and crush injuries, but muscle ruptures and blood diseases are extremely rare causes. External compression and burns are far more common. But are these facts really relevant in a paper about CCS.

Bilateral involvement is much more common than unilateral (as per Detmer (5) 82/94 patients), it is not just an occassional finding as implied here.

Fascial defects have only ever been reported in the Anterior compartment, so are not relevent to Deep Posterior compartments.

Many of the surgical techniques, e.g. fibulectomy are only ever used in acute cases, so mentioning them here is purely padding.

The reference to a 20% decrease in strength of the compartment following surgery (Mozan & Keagy) is misleading. This is an isolated paper on frog’s legs. There is no in-vivo evidence to suggest any long- term detrimental effects of surgery for CCS, although several investigations have been undertaken.

Taken together these points would give the inexperienced reader a rather false and misleading picture of the incidence, diagnosis and treatment of a Chronic Compartment Syndrome.

Dear Editor

I read with great interest the recently published study by Shave et al.[1] in the February, 2004 issue of the British Journal of Sports Medicine. The authors found that exercise training in hypoxic environment did not affect cardiac systolic and diastolic functions. However, it is known that the characteristics of the study population (broad age range, aerobic exercise capacity) may cause significantly different diastolic Doppler parameters in subjects.

Furthermore, I believe that exercise duration is important for cardiac functions and fatigue as much as exercise distance. It should be also explained how the authors found lower E wave velocity, while higher cardiac stroke volume and output in hypoxic group before exercise.

On the other hand, Bailey et al. [2] reported that the stimulus of intermittent normobaric hypoxia invoked an additive cardioprotective effect. Although anticipated, they found a decreased power output for a given submaximal heart rate during hypoxic training because of an increased sympathoadrenerjik drive and that the hypoxic inspirate did not influence the submaximal heart rate and power output relationship.

It has been explained that the prevailing arterial hypoxemia would decrease absolute training intensity and subsequent oxygen flux and thus mask the potentially synergistic effects of hypoxic training [3]. The authors proposed that physiological adaptation to intermittent hypoxemia could have upregulated vascular reactivity, in particular, if the hypoxic stimulus was of sufficient magnitude to induce morphological changes in the endothelium.

I also believe that increased cardiovascular functional adaptations to regular exercise in athletes [4] in normobaric normoxic conditions are prevent cardiovascular injury and fatigue in hypoxic environment.

References

(1). Shave RE, Dawson E, Whyte G, George K, Gaze D, Collinson P. Effect of prolonged exercise in a hypoxic environment on cardiac function and cardiac troponin T. Br J Sports Med 2004;38:86-8.

(2). Bailey DM, Davies B, Baker J. Training in hypoxia: modulation of metabolic and cardiovascular risk factors in men. Med Sci Sports Exerc 2000;32:1058-66.

(3). Levine BD, Stray-Gundersen J. Living high-training low: effect of moderate-altitude acclimatization with low-altitude training in performance. J Appl Physiol 1997;83:102-12.

(4). Kasikcioglu E, Kayserilioglu A, Oflaz H, Akhan H. Aortic distensibility and left ventricular diastolic functions in endurance athletes. Int J Sports Med 2004;25 (In press)

Dear Editor,

This a very interesting, but curious,paper.The novel theory presented, enhanced the CNS as the more important center regulatory of exercise fatigue, resembles all the research that occupied the minds of clinical and experimental neuroscience people in regard of pain.

Pain is a reality, an alarm signal. Of course there are many pain syndromes as diseases by thereselfes, as migraine, cluster headache, trigeminal neuralgia, thalamic pain post-stroke, etc., and very important pain due to other diseases, especially in cancer patients.

Nothing new about the typical pain neurosurgery, as cingullectomy, to give a better quality of life in terminal oncology people: they continue to refer pain, but without the limbic system information as these stimulus is a nociceptive one, the suffering disappear – they points and describe pain when questioned, but this symptom don’t cause any distress: the emotional aspect of this form of sensibility was removed.

In another example, people with trigeminal neuralgia can survive many years with good control of the pain with carbamazepine and perhaps (after more controlled studies and evidence-based guidelines) gabapentin.However, the total control of the disease is based in an anatomical question, the vascular loop around the trigeminal pathway, and the definitive treatment is the surgery, first performed by Janetta, from Pittsburgh, many years ago.

After these considerations, the theory explained could reach a danger level: fatigue is a periphery nociceptive sensation, an alarm signal. Techniques to reduces or control the CNS role are, in thesis, something like doping: the athlete could perform better marks, however could be present a potential risk of damage in the muscles, bones, peripheral nerves and even in central nervous structures.

The whole thing resembles a different way of Pavlov’s conditioning methods, with a plausible cause of disease risk to people in good health.