Author's Response

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To the Editor:

Few readers of the JPSM would have expected the president of the American Chiropractic Association to approve of my article.¹ He states that it “fails to offer an unbiased evaluation of the chiropractic profession.” Even a glance at the title of my paper reveals that it was not meant to be an unbiased systematic review but that its aim was to critically evaluate. In doing this, I certainly had to go into chiropractic's checkered past and, of course, the picture that emerged was “incomplete.” A complete history of chiropractic would have been way beyond the scope of my article.

Manceaux furthermore states that I “had no intention of presenting a modern picture of chiropractic… [but chose] to linger in the past.” How does he know my intentions? How does he reconcile the following recent quotes from the chiropractic fraternity with “lingering in the past?” “88% of US chiropractors believe that subluxation contributes to over 60% of all visceral ailments”²… “the relationship between cervical manipulation and lesions of the cervical arteries… must be negated”³… “the vaccine acts non-specifically to increase a child's pre-existing chronic disease tendancy.”⁴ How does he explain that, of the 208 references I used for my article, only 15 dated from before 1990? And how would he comment on the fact that virtually all textbooks of chiropractic—new or old—insist that all spinal manipulation is a reasonable treatment for conditions like asthma, infant colic, menstrual pain, etc.?

Manceaux surpasses himself when he suggests that I should have displayed superhuman abilities by seeing into the future. The 2008 study by Cassidy et al. that he seems to be so fond of was, of course, not yet available when my article was accepted for publication!

Manceaux errs when assuming that “to properly assess the risk of chiropractic treatment, it must be compared against the risk of treatments for similar conditions.” Comparing risks of treatments in this way is next to meaningless. What counts are risk-benefit analyses. If chiropractic is not demonstrably effective for a certain condition, it also does not demsonstrably generate more good than harm. If other treatments cause harm, they may still be associated with a positive risk-benefit profile. This is not rocket science but this line of thinking is rarely considered by chiropractors.

After accusing me of lingering in the past and being biased, Manceaux cites “recent” and “current” nonsystematic evaluations mostly from more than 10 years ago to suggest chiropractic is cost effective. More up-to-date and systematic reviews, however, conclude otherwise.⁵

My critical evaluation of chiropractic¹ might have been viewed by chiropractors as “not balanced” but it did not, I think, disclose the overt conflicts of interest the president of the American Chiropractic Association displays in his comments. What reason should I have to mislead health care professionals about chiropractic? And what reasons might he have?

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References 

1. Ernst E. Chiropractic: a critical evaluation. J Pain Symptom Manage. 2008;35:544–562
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2. McDonald W, Durkin K, Iseman S, et al. How chiropractors think and practice. Ada, OH: Institute for Social Research, Ohio University; 2003;
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3. Refisch A, Bischoff P. Manipulation and lesions of the cervical arteries. More than a temporal coincidence?. [in German] Man Med. 2004;42:109–118
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4. Peet PM, Peet J. Chiropractic pediatric and prenatal reference manual. 2nd ed.. South Burlington, VT: Baby Adjustors, Inc.; 2001;
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5. Thompson Coon J, Ernst E. A systematic review of the economic evaluation of complementary and alternative medicine. Perfusion. 2005;18:202–214
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