Like so many malformed and demented images at a carnival side show, complete with barkers and calliope music, national media presentations in just the past month have attempted to generate public hysteria over what has been described as the "perils" of chiropractic. The venue that chose the term "perils" elected to do so by plastering headlines that were larger than those run by the New York Times last September to describe the terrorist attacks in New York and Washington.2 This was followed, in short order by [i] an alarmist broadcast on Joan Hamburg's "Medical Minute" on WOR radio in the New York metropolitan area that created the impression that a visit to a chiropractor could turn out to be a lethal experience;3 [ii] a posting on Time magazine's website by the senior editor that not only made a mockery of the author's scientific credentials (chief science writer for Time, managing editor of Discover, and recipient of the Richard Leaky award from the American Association for the Advancement of Science, top journalism awards from the AMA and the American College of Allergy and Immunology), but of anything remotely connected with systematic information retrieval. In terms of objective news reporting, Edward R. Murrow and Howard K. Smith would be spinning in their graves.
Following the screaming headlines, Brad Evenson's article in the National Post put forth the statement from "60 leading Canadian neurologists" that neck manipulations "cause strokes and crippling injury with alarming frequency." For openers, a major clue that this statement was politically motivated was that it almost triumphantly proclaimed that it was being dispatched on the fourth anniversary of a single chiropractic patient who died after a neck manipulation in Saskatoon. The article insisted that the prevailing estimation of frequency of stroke - one per million neck manipulations (actually, substantially less5,6) - produces 200 strokes per year, or as many as one in 5,000 manipulations. Much of this data is based upon a study by John Norris, one of the chief signatories of the aforementioned communiqué to the Canadian neurologists.
To its credit, the Norris study correctly suggested that a variety of neck movements could precipitate vertebrobasilar artery events,7 in keeping with a large and compelling body of literature. However, spinal manipulation can be shown to represent but a tiny fraction of these precipitating movements, and is almost impossible to identify with any regularity as the predominating cause of an arterial dissection. The author did give his prejudices away by stating, "There is no doubt that chiropractic neck manipulation can result in the dissection of the carotid or vertebral arteries leading to stroke," with no support from either the data in his paper or the literature cited.7 His letter of response to criticisms only appeared to make matters worse, for it refused to disclose any details supporting his contention that manipulation of the cervical spine was associated with 27 percent of the strokes observed in 50 cases per year. Worse, Norris flaunted his prejudice by stating, "The research question is not whether neck manipulation can result in dissection of a cervical artery, for it surely can..." (italics mine).8 So can stargazing; yoga; hair-washing; driving a vehicle; archery; wrestling; emergency resuscitation; rap dancing; sleeping; swimming; and tai chi - at frequencies at or above those that can be attributed to spinal manipulation.5,9,10
By far the most offensive and pathological article was Leon Jaroff's, which graced the Time website (www.time.com). From its leading sentence ("Chiropractors have been taking their lumps lately"), to its headline ("Back Off, Chiropractors!"), to its profusion of pejorative terminology used to describe chiropractic ("bewildering variety of weird practices ... sillier ... troublesome ... bizarre"), it is not too difficult to assume that the article would have as many good things to say about chiropractic as Amnesty International would have found words to support the Holocaust. It began by quoting the Canadian neurologists again - this time at a meeting of the American Stroke Association in Texas - stating that 156 cases of stroke were analyzed, and that "nearly 40 percent of them had apparently resulted from chiropractic neck manipulation."4 Again, the obvious questions are: What was the instrument used to capture the incidence of arterial dissections? Within what time period following the precipitating factor were vertebral artery dissections noted? How many of these were transient? What was the number of cervical manipulations performed? What was the technique employed? Given the fact that vertebral basilar artery accidents are often attributed to manipulators falsely represented as fully licensed and trained chiropractors,11 who were the individuals performing the manipulations?
But Jaroff doesn't stop there. Farther down in his column, he claims that "doctors find many of the other claims and practices of chiropractic questionable, if not downright objectionable."4 What doctors are we referring to here, anyway? Neurologists? Physical therapists? Physiatrists? He suggests that the problem lies within their vast differences in methods of treatments without a uniform criterion for identifying a subluxation. It seems to me that the man is unaware of a few disparities on the medical side, such as: [i] over a sevenfold difference in the rate of back surgeries performed, depending upon which part of the United States you are referring to;12 [ii] over 70 times the variation in the usage rates of medication for attention deficit disorder given to public school children in neighboring towns in Virginia;13 or [iii] opposing treatment recommendations for prostate cancer, depending upon whether the attending physician is a urologist or radiation oncologist.14
In my book, "bizarre" and "objectionable" would include the death rates due to medication side effects estimated by the Institute of Medicine to range from 230,000-280,000 per year,15 while those caused by NSAIDs (such as ibuprofen) are reported to approach an annual toll of 16,00016 - dwarfing any estimate of chiropractic facilities by several orders of magnitude that could ever be served up by crusading neurologists, the scientific literature, or whatever.
Continuing on his wrecking expedition, Jaroff opines: "Even more troublesome, all too many chiropractors urge their patients to eschew such widely-accepted health measures as immunization and fluoridation and to be suspicious of anything medical. Are these guys for real?" I will grant that the immunization question remains a topic of controversy, but I have seen precious little, if anything, on fluoridation. And where's the evidence that chiropractors are driving their patients to be "suspicious of anything medical?" If anything should cause one to be suspicious of anything medical, it would be Jaroff's commentary!
Finally, Jaroff jumped all over a recent JMPT article that found fault with patient brochures from practitioners and chiropractic national organizations, gleefully declaring that the conclusions published were "damning." Let's see. The actual conclusion, as I read it, states: "A sampling of patient literature...suggests that a significant segment of 'official chiropractic' in Canada and the United States publishes uncritical and scientifically unvalidated claims for the chiropractic healing art."17 Damning indeed. Have we forgotten the word "critical?" I recall that only 15 percent of medical procedures have been reported to be validated by any scientific data,18 and that only one percent has been considered to be worthwhile.19
What is truly amazing is how Jaroff delved into a journal almost never quoted in the national media to ferret out this single article (more a commentary than a traditional scientific study) to discredit chiropractic. He clearly walked right by the vast majority of other published studies in that same journal, which unfortunately have not received the media attention they should, yet for over a quarter of a century have indicated that chiropractic treatments not only match the medical alternatives for treating such diverse conditions as back pain;20 carpal tunnel syndrome;21 cervicogenic, migraine and tension-type headache;22-25 dysmenorrhea;26 premenstrual syndrome;27 infantile colic;28 enuresis;29 and even ear infections,30 but do so for longer durations after treatment and without the common, injurious or even fatal side of medications.
With this buckshot condemnation of everything chiropractic, Jaroff seems clearly driven to discredit it by any means possible. There is more tarring with the brush here than in anything I've seen since the Three Stooges last attempted to paint each other. Until these fearmongering agents of the media can appreciate the simple fact that randomized clinical trials offer support for the efficacy of chiropractic treatment, not only for managing back pain, but for headaches, carpal tunnel syndrome, infantile colic and bedwetting problems, and can share this information with their deserving audience, they are trashing their primary responsibility for giving the public truly meaningful medical advice on treatment options, the centerpiece of which should quite simply be the risk-to-benefit ratio.
Needless to say, I have spent much of the past month responding in detail to each of these charades in what we used to call "journalism." The public, which is entitled to the best health care information at hand, clearly is the loser here. On the other hand, they may take solace in that - contrary to popular opinion - vaudeville is not dead, and Mr. Jones' Looney Tunes live on in the pages and the broadcasts of our free press.
To quote one of Chuck Jones' favorite characters, "Th-th-th-that's all, folks!" Or, perhaps we should be taking the issue directly to our Canadian neurologists and asking each, point-blank: "What's up, doc?"
- Bill Caroll Show, CFRB 1010 radio, February 6, 2002, posted on the internet.
- Evenson B. National Post February 7, 2002.
- Hamburg J. Medical Minute, WOR AM 710 radio, February 22, 2002.
- Jaroff L. Back off, chiropractors! TIME.com, February 27, 2002.
- Hurwitz EL, Aker PD, Adams AH, Meeker WC, Shekelle PG. Manipulation and mobilization of the cervical spine: A systematic review of the literature. Spine 21(15):1746-1760.
- Haldeman S, Carey P, Townsend M, Papadopoulos C. Arterial dissections following cervical manipulation: The chiropractic experience. Canadian Medical Association Journal 2001;165(7): 905-906.
- Norris JW, Beletsky V, Nadareishvilli ZG, Canadian Stroke Consortium. Canadian Medical Association Journal 2000;163(1):38-40.
- Norris JW. Cervical manipulation: How risky is it? Letters to the editor. Canadian Medical Association Journal 2001;164(6):752.
- Terrett AGL. Vertebral stroke following manipulation. West Des Moines, IA: National Chiropractic Mutual Insurance Company, 1996.
- Rome PL. Perspective: An overview of comparative considerations of cerebrovascular accidents. Chiropractic Journal of Australia 1999;29(3):87-102.
- Terrett AGJ. Misuse of the literature by medical authors in discussing spinal manipulative therapy injury. Journal of Manipulative and Physiological Therapeutics 1995;18(4):203-210.
- Weinberg JE, Cooper MM, eds. The Dartmouth Atlas of Health Care in the United States. Chicago, IL: American Hospital Association Publishers, Inc., 1998.
- LeFever GB, Dawson KV, Morrow AL. The extent of drug therapy for attention deficit-hyperactivity disorder among children in public schools. American Journal of Public Health 1999; 89(9):1359-1364.
- Fowler F, Collins MM, Albertsen PC, Zietman A, Elliott DB, Barry MJ. Comparison of recommendations by urologists and radiation oncologists for treatment of clinically localized prostate cancer. Journal of the American Medical Association 2000;283(24):3217-3222.
- Schuster M, McGlynn E. Brook R. How good is the quality of health care in the United States? Milbank Quarterly 1998;76:517-563.
- Wolfe MM, Lichenstein DR, Singh G. Gastrointestinal toxicity of nonsteroidal antiinflammatory drugs. New England Journal of Medicine 1999;340(24):1888-1899.
- Grod JP, Sikorski D, Keating JC. Unsubstantiated claims in patient brochures from the largest state, provincial, and national chiropractic associations and research agencies. Journal of Manipulatie and Physiological Therapeutics 2001;24(8):514-519.
- Smith R. Where is the wisdom: The poverty of medical evidence. British Medical Journal 1991;303:798-799.
- Rachlis N, Kuschner C. Second Opinion: What's Wrong with Canada's Health Care System and How to Fix It. Toronto: Collins, 1989.
- Giles LGF, Muller R. Chronic spinal pain syndromes: A clinical pilot trial comparing acupuncture, a nonsteroidal anti-inflammatory drug, and spinal manipulation. Journal of Manipulative and Physiological Therapeutics 1999;22(6):376-381.
- Davis PT, Hulbert JR, Kassak KM, Meyer JJ. Comparative efficacy of conservative medical and chiropractic treatments for carpal tunnel syndrome: A randomized clinical trial. Journal of Manipulative and Physiological Therapeutics 1998;21(5):317-326.
- Boline PD, Kassak K, Bronfort G, Nelson C, Anderson AV. Spinal manipulation vs. amitrityline for the treatment of chronic tension-type headache: A randomized clinical trial. Journal of Manipulative and Physiological Therapeutics 1995;18(5):148-154.
- Nilsson N, Christensen HW, Hartvigsen J. The effect of spinal manipulation in the treatment of cervicogenic headache. Journal of Manipulative and Physiological Therapeutics 1997;20(5):326-330.
- Nelson CF, Bronfort G, Evans R, Boline P, Goldsmith C, Anderson AV. The efficacy of spinal manipulation, amiltriptyline, and the combination of both therapies for the prophylaxis of migraine headache. Journal of Manipulative and Physiological Therapeutics 1998;21(8):511-519.
- Bronfort G. Efficacy of spinal manipulation for chronic headache: A systemtic review. Journal of Manipulative and Physiological Therapeutics 2001;24(7):457-466.
- Kokjohn K, Schmid DM, Triano JJ, Brennan PC. The effect of spinal manipulation on pain and prostaglandin levels in women with primary dysmenorrhea. Journal of Manipulative and Physiological Therapeutics 1992;15(5):279-285.
- Walsh MJ, Polus BI. A randomized, placebo-controlled clinical trial on the efficacy of chiropractic therapy on premenstrual syndrome. Journal of Manipulative and Physiological Therapeutics 1999;22(9):582-585.
- Wiberg JMM, Nordsteen J, Nilsson N. The short-term effect of spinal manipulation in the treatment of infantile colic: A randomized controlled trial with a blinded observer. Journal of Manipulative and Physiological Therapeutics 1999;22(8):517-522.
- Reed WR, Beavers S, Reddy SK, Kern G. Chiropractic management of primary nocturnal enuresis. Journal of Manipulative and Physiological Therapeutics 1994;17(9):596-600.
- Froehle RM. Ear infection: A retrospective study examining improvement from chiropractic care and analyzing for influencing factors. Journal of Manipulative and Physiological Therapeutics 1996;19(3):169-177.
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