To the Editor:
The review article by Ernst
1
did your readers a great disservice by failing to offer an unbiased evaluation of the chiropractic profession. Instead, Ernst departs from solid science—the very thing he accuses the chiropractic community of doing—and bases his analysis on an arbitrary series of seemingly random topics that paint an incomplete picture.Although Ernst places considerable emphasis on historical events and quotes associated with the evolution of chiropractic, he neglects to mention recent developments in chiropractic licensure, continuing education and a number of other topics that are relevant for the reader to understand not only the current state of the chiropractic profession, but also its future direction. Ernst's citations of quotes more than a century old indicate that he had no intention of presenting a modern picture of chiropractic. He has instead, chosen to linger in the past.
I can appreciate Ernst's decision to discuss research relevant to chiropractic and spinal manipulation, which is, of course, the most common therapeutic procedure performed by doctors of chiropractic. However, I have serious concerns about the sampling of literature used, as well as the obvious omission of data favorable to chiropractic.
To cite just a few specific examples:
Table 3. Systematic Reviews of (Chiropractic) Spinal Manipulation. Table 3 includes only the most recent study associated with each condition. By doing so, the presumption is made that only the most recent study is worth reporting. For example, by including Assendelft et al.
2
as the accepted meta-analysis for the evaluation of spinal manipulation for low back pain, Ernst excluded Anderson's study of 23 randomized controlled trials (RCT) in which spinal manipulative therapy was compared with other therapies, rather than true no-treatment placebos. Spinal manipulation consistently proved more effective in the treatment of low back pain than any of the comparative interventions.3
Safety of Chiropractic and the Risk of Serious Vascular Accidents. A 2008 study by Cassidy et al.
4
finds there is no evidence of excess risk of vertebrobasilar artery (VBA) stroke following chiropractic spinal manipulation. In the study, researchers noted that patients are no more likely to suffer a stroke following chiropractic treatment than they would after visiting their family doctor's office.The Canadian team looked at nine years of data in Ontario, and found that only 818 patients with a VBA stroke were reported among a population of some 11.5 million people. Unlike a previous study in 2001 that investigated the relationship between chiropractic visits and vertebral artery stroke, researchers in this study also studied visits to family doctors that preceded this kind of stroke. The study's authors noted that any observed association between a VBA stroke and chiropractic manipulation is likely due to patients with an undiagnosed vertebral artery dissection seeking care for neck pain and headache before their stroke.
Moreover, a research paper published in 2001 in the Canadian Medical Association Journal found there is only a one-in-5.85-million risk that a chiropractic neck adjustment will be associated with a subsequent cervical artery dissection and stroke.
5
This is significantly less than the estimates of 1:500,000-1 million cervical manipulations calculated from surveys of neurologists.6
, 7
, 8
To properly assess the risks of chiropractic treatment, it must be compared against the risks of other treatments for similar conditions. Some of the most common treatments for musculoskeletal pain—including prescription and over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDs)—carry risks significantly greater than those of chiropractic manipulation. For instance, a study from the New England Journal of Medicine estimated that at least 16,500 NSAID-related deaths occur among patients with rheumatoid arthritis or osteoarthritis every year in the United States.
9
Furthermore, according to a study from the American Journal of Gastroenterology, approximately one-third of all hospitalizations and deaths related to gastrointestinal bleeding can be attributed to the use of aspirin or NSAID painkillers like ibuprofen.10
Chiropractic Care and Cost-Effectiveness. The cost-effectiveness of chiropractic has been documented in several studies. Most recently, Haas et al. concluded that chiropractic and medical care have comparable costs for treating low back pain, with chiropractic producing better outcomes.
11
In MGT of America, a national research firm, conducted a study that reviewed the current scientific literature on the cost-effectiveness of chiropractic care in workers' compensation in the state of Florida. The data revealed that substantial cost savings—as high as 60%—can be measured for health care and disability when chiropractic care is applied to low back and other musculoskeletal injuries.
Studies by Manga
12
, 13
and Stano and Smith14
, 15
, 16
stand out as the foremost efforts in demonstrating the cost-effectiveness of chiropractic care. Manga's study for the provincial government of Ontario, Canada, concluded that doubling the use of chiropractic services from 10% to 20% could realize savings of as much as $770 million annually in direct costs and $3.8 billion in indirect costs. Stano concluded from an extensive review of insurance records that mean total costs were $1,000 for each medical episode and $493 per chiropractic episode.16
Ernst has made no attempt to present a balanced evaluation of the chiropractic profession, and thus his conclusions should not be generally accepted.
References
- Chiropractic: a critical evaluation.J Pain Symptom Manage. 2008; 35: 544-562
- Spinal manipulative therapy for low back pain.Cochrane Database Syst Rev. 2004; 1 (CD000447)
- A meta-analysis of clinical trials of spinal manipulation.J Manipulative Physiol Ther. 1992; 15: 181-194
- Risk of vertebrobasilar stroke and chiropractic care: results of a population-based, case-control and case-crossover study.Spine. 2008; 33: S176-S183
- Arterial dissections following cervical manipulation: the chiropractic experience.CMAJ. 2001; 165: 905-906
- Neurologic complications following chiropractic manipulation. A survey of California neurologists.Neurology. 1995; 45: 1213-1215
- Sudden neck movement and cervical artery dissection.CMAJ. 2000; 163: 38-40
- Stroke after chiropractic manipulation, a “small but significant risk” study finds.Am Heart Assoc News. 1994; 19: 1-3
- Gastrointestinal toxicity of nonsteroidal anti-inflammatory drugs.N Engl J Med. 1999; 340: 1888-1899
- A nationwide study of mortality associated with hospital admission due to severe gastrointestinal events and those associated with nonsteroidal anti-inflammatory drug use.Am J Gastroenterol. 2005; 100: 1685-1693
- Relative cost and effectiveness of medical and chiropractic care for acute and chronic low back pain.J Manipulative Physiol Ther. 2005; 28: 555-563
- The effectiveness and cost-effectiveness of chiropractic management of low-back pain.Kenilworth, Richmond Hill, Ontario1993
- Enhanced chiropractic coverage under OHIP as a means for reducing health care costs, at obtaining better health outcomes and achieving equitable access to health services.Report to the Ontario Ministry of Health, Ontario, Canada1998
- Chiropractic and medical costs of low back care.Med Care. 1996; 34: 191-204
- Costs and recurrences of chiropractic and medical episodes of low back care.J Manipulative Physiol Ther. 1997; 20: 5-12
- The economic role of chiropractic: further analysis of relative insurance costs for low back care.J Neuromusculoskelet Syst. 1995; 3: 139-144
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