FROM:
Chiropractic & Osteopathy 2006 (Aug 22); 14 (1): 16 ~ FULL TEXT
You may also want to read this Editorial Comment by the author.
You may also want to review Terrett's original article “Misuse of the Literature by Medical Authors in Discussing Spinal Manipulative Therapy Injury”
Adrian B Wenban, B.Sc., B.App.Sc., M.Med.Sc.
BACKGROUND: The misuse of the title chiropractor and term chiropractic manipulation, in relation to injury associated with cervical spine manipulation, have previously been reported in the peer-reviewed literature. The objectives of this study were to - 1) Prospectively monitor the peer-reviewed literature for papers reporting an association between chiropractic, or chiropractic manipulation, and injury; 2) Contact lead authors of papers that report such an association in order to determine the basis upon which the title chiropractor and/or term chiropractic manipulation was used; 3) Document the outcome of submission of letters to the editors of journals wherein the title chiropractor, and/or term chiropractic manipulation, had been misused and resulted in the over-reporting of chiropractic induced injury.
METHODS: One electronic database (PubMed) was monitored prospectively, via monthly PubMed searches, during a 12 month period (June 2003 to May 2004). Once relevant papers were located, they were reviewed. If the qualifications and/or profession of the care provider/s were not apparent, an attempt was made to confirm them via direct e-mail communication with the principal researcher of each respective paper. A letter was then sent to the editor of each involved journal.
RESULTS: A total of twenty four different cases, spread across six separate publications, were located via the monthly PubMed searches. All twenty four cases took place in one of two European countries. The six publications consisted of four case reports, each containing one patient, one case series, involving twenty relevant cases, and a secondary report that pertained to one of the four case reports. In each of the six publications the authors suggest the care provider was a chiropractor and that each patient received chiropractic manipulation of the cervical spine prior to developing symptoms suggestive of traumatic injury. Regarding two of the four case reports contact with the principal researcher revealed that the care provider was not a chiropractor, as defined by the World Federation of Chiropractic. The authors of the other two case reports did not respond to my communications. Regarding the case series, which involved twenty relevant cases, the principal researcher conceded that the term chiropractor had been inappropriately used and that his case series did not relate to chiropractors who had undergone appropriate formal training. The author of the secondary report, a British Medical Journal editor, conceded that he had misused the title chiropractor. Letters to editors were accepted and published by all four journals to which they were sent. To date one of the four journals has published a correction.
CONCLUSIONS: The results of this year-long prospective review suggests that the words chiropractor and chiropractic manipulation are often used inappropriately by European biomedical researchers when reporting apparent associations between cervical spine manipulation and symptoms suggestive of traumatic injury. Furthermore, in those cases reported here, the spurious use of terminology seems to have passed through the peer-review process without correction. Additionally, these findings provide further preliminary evidence, beyond that already provided by Terrett, that the inappropriate use of the title chiropractor and term chiropractic manipulation may be a significant source of over-reporting of the link between the care provided by chiropractors and injury. Finally, editors of peer-reviewed journals were amenable to publishing letters to editors, and to a lesser extent corrections, when authors had inappropriately used the title chiropractor and/or term chiropractic manipulation.
From the Full-Text Article:
Discussion
As already mentioned, Terrett [6] has carried out a study
with the objective of determining how the words chiropractic
and chiropractor have been used in publications
reporting complications from cervical SMT. Furthermore,
he pointed out that in countries without chiropractic registration
it can be difficult to determine the educational
and professional background of the provider of care that
has been associated with harm. Terrett revealed that errors
regarding terminology and professional identity have
been documented, in one or more cases, in India, Ireland,
Italy, Taiwan, France, and Germany. The results of the
present study suggest that errors regarding terminology
and professional identity are still taking place in Germany
[9,13], and that Spain [12] and England [14] can now also
be added to that list.
Terrett's review [6] revealed that many cases of complication
after manipulation described in the medical literature
as "chiropractic complications" are found to be, on closer
inspection, either
(a) medical misrepresentation of the literature;
(b) inaccurate reporting by medical authors; or
(c) inaccurate reporting by medico-legal journalists.
Reflecting upon the present study in light of Terrett's classification,
we find that two case studies [9,12], and one
case series [13] are examples of inaccurate reporting by
medical authors and that the secondary report, published
in an English medical journal [14], that briefly summarised
the findings from one of the above mentioned case
reports [9], was in part the result of inaccurate reporting
by the involved BMJ editor, and is therefore an example of
medical misrepresentation of the literature.
It is important for research attempting to document associations
between the care provided by chiropractors and
harm, and/or benefits, to realize that chiropractic is a profession
and not just a procedure. That such is the case is
reflected in WHO Guidelines on Basic Training and Safety
in Chiropractic [22];
'Chiropractic – A health profession concerned with the
diagnosis, treatment and prevention of disorders of the
musculoskeletal system, and the effects of these disorders
on the nervous system and general health.'
Furthermore, membership in the chiropractic profession
is predicated on detailed globally agreed upon educational
standards. The European Council on Chiropractic
Education (ECCE) is an international autonomous organization
established by the chiropractic profession in
Europe to accredit and re-accredit institutions providing
undergraduate chiropractic education and training. The
principal goal of the ECCE is to assure the quality of chiropractic
undergraduate education and training against a
set of educational Standards. It is the only chiropractic
educational accreditation agency serving Europe that is a
member of the Council on Chiropractic Education International
(CCEI), and that is recognized by the profession
and the other Councils on Chiropractic Education around
the world. Through its membership with CCEI, the ECCE
adheres to the CCEI Model Standards that include educational
criteria and accreditation procedures. Such adherence
indicates essential equivalence of the educational
standards of all CCEI member agencies and, thereby, the
competency of individuals graduating from institutions
accredited by ECCE and all member Councils on Chiropractic
Education [23].
ECCE Standards specify that the duration of a chiropractic
programme last for at least five full-time academic years
and are based on the following definition and description
of a chiropractor:
'The chiropractor is concerned with the health needs of
the public as a member of the healing arts. He/she gives
particular attention to the relationship of the structural
and neurological aspects of the body in health and disease.
He/she is educated in the basic and clinical sciences
as well as in related health subjects. The purpose of his/
her professional education is to prepare for practice as a
primary care provider. As a portal of entry to the healthcare
system, the chiropractor must be well educated to
diagnose, to care for the human body in health and disease,
and to consult with, or refer to, other healthcare providers'.
[23]
To describe someone as a chiropractor simply because
that person performs SMT, but without knowing that person's
educational background or professional affiliations,
is clearly inappropriate. However, that seems to be the
basis upon which the authors of the six articles of this
review proceeded.
Chiropractors who feel an injustice has been committed
when case reports inappropriately link their profession
with some form of harm might consider the following.
The scientific process is not over with the publication of
an article; it's up to the scientist's or clinician's peers to
review works in journals and critique them with letters to
the editor. If a publication's errors go unchallenged, they
are the fault of the reader as much as the person who submitted
the paper for publication.
The researchers who have published these cases probably
did not have malicious intentions towards chiropractic. I
believe that case studies of 'manipulation induced injury'
readily catch the eye of readers and journal editors alike so
that such papers make for an easy publication. Furthermore,
I get the impression, from my communications
with the principal researchers involved, that they are using
the title 'chiropractor' as if it is synonymous with 'spinal
manipulator' and the term 'chiropractic manipulation' as
if it is synonymous with 'spinal manipulation'.
Unfortunately, the case series by Dziewas et al. [13], which incorrectly suggested that twenty cases of carotid artery dissection (CAD) were caused by qualified chiropractors has been quoted by at least four subsequent publications [24-27]. This is another form of what Terrett [6] termed "inaccurate reporting", wherein the original publication, by Dziewas et al. [13], does attribute the injuries to chiropractors, but personal communication with the author, and subsequent letters to the editor [16,20], revealed a different scenario. This form of inaccurate reporting likely adds significantly to the over-reporting of chiropractic-related injury. In support of the authors of those four subsequent publications it should be noted that all three of the reviews [24-26], and the one commentary [27] were submitted for publication subsequent to
the date when my letter to the editor of the Journal of Neurology [20], and the reply by Dziewas [16], made public the fact that the care providers of the 20 relevant cases they reported on were not qualified chiropractors.
It is noted with dismay that despite all the discussion, via letters to editors, in relation to the inappropriate use of the title chiropractor and term chiropractic manipulation, that a more recently published retrospective survey from Germany [28] used the title, Vertebral artery dissections after chiropractic neck manipulation, despite the fact that only 4/36 (11%) of the cases reportedly involved a care provider identified as a chiropractor. The largest group of providers,
18/36 (50%), linked to injury through their use of SMT, were orthopaedic surgeons. Surely if the title of that paper was going to be associated with one particular profession, or specialty, it should have been orthopaedic surgeons rather than chiropractors. Furthermore, given the propensity for publications from Germany to inappropriately use the title 'chiropractor', it may yet prove to be the case that none of the four chiropractic-related injuries identified by that retrospective review were the result of care provided by qualified chiropractors.
This prospective review suffers from a number of limitations;
• Only one electronic data base (PubMed) was monitored across the 12 month. Had more data bases been included more relevant studies may have been detected,
• The search strategy used for this review was very basic and included only three search terms. A more detailed search strategy and the inclusion of more search terms may have resulted in the detection of more relevant studies,
• The means by which authors of relevant papers were contacted was limited to e-mail. Authors of two of the six relevant papers detected via this review's search strategy did not respond to this author's e-mails. The professional identity of the care providers in those two case studies therefore remains unknown. A more thorough attempt to
communicate with authors of relevant papers, beyond email, may have been more successful in eliciting
responses.
The true incidence of this form of over-reporting, wherein a care provider, whose application of SMT is associated
with an injury, is inappropriately identified as a chiropractor, has not been documented. However, based on the
preliminary findings provided by Terrett's previous work [6] and the present prospective review, further investigation,
aimed towards determining the extent to which the inappropriate use of terminology contributes to the overreporting
of chiropractic induced injury, seems warranted. Further research in this area might also explore whether
the title 'chiropractor' and term 'chiropractic manipulation' are being misused only in relation to harm caused by
non-chiropractors, or if the same misuse is taking place in relation to descriptive studies documenting benefits. That
is to say it might also be informative, in determining whether any bias exists, to look at whether the term and
title are also being inappropriately used in studies documenting some patient benefit due to this type of care
when provided by non-chiropractors.
Moreover it is recommended that authors of future publications, aimed at exploring the link between SMT and
injury, should very clearly define the terminology used and clearly delineate the training and professional identification
of those care providers whose care is subsequently deemed to be in some way associated with injury.
Conclusion
The results of this study suggest that the words 'chiropractor' and 'chiropractic manipulation' are often used inappropriately by European biomedical researchers in relation to the reporting of injuries associated with cervical
spine manipulation. Furthermore, the findings of this year-long prospective review provide further preliminary
evidence, beyond that already provided by Terrett [6], that the inappropriate use of the title 'chiropractor' and term
'chiropractic manipulation' may be a significant source of over-reporting of the link between chiropractic care and
injury. Editors of peer-reviewed scientific journals were amenable to publishing 'letters to editors', and to a lesser
extent 'corrections', pertaining to original research that had inappropriately used the title 'chiropractor' and/or
term 'chiropractic manipulation'.
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