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Article

May 1999 • Volume 22 • Number 4

Commentary
Chiropractic: More good than harm or vice versa?

Anthony L. Rosner, PhD [MEDLINE LOOKUP]

Sections

Introduction
Strength of Medical Evidence
The Relationship Between Chiropractic and Manipulation
Direct Risk to the Patient
The Use of Radiographs
Attitudes Toward Immunizations
Cost-Effectiveness
References
Publishing and Reprint Information

Introduction

TOP

In marked contrast to a recent flurry of studies documenting increasingly positive consumer attitudes toward alternative medicine in general ^1–9 and chiropractic in particular, ^8,10–12 a signed editorial appeared recently in The British Medical Journal that speculated that chiropractic may be hazardous to one's health. The authors, Edzard Ernst and Willem Assendelft,¹³ concluded from the vantage points of (1) strength of evidence, (2) safety, and (3) cost-effectiveness, that presumed advantages of chiropractic over other forms of health care intervention for the treatment of low back pain were insufficiently established to be accepted; in fact, they suggested that more evidence may exist to the contrary. In their estimation, chiropractic may do more harm than good.¹³

This editorial misinterprets or omits critical information in at least 6 separate areas, creating a negative impression of the efforts of the world's third largest health profession in managing back pain. Chiropractic, involving more than 60,000 practitioners worldwide, has for more than a century distinguished itself as a noninvasive, conservative, and drugless approach to health care that has gained most of its recognition through the management of low back pain. Thus it is surprising to find that Ernst and Assendelft¹³ conclude that “it is uncertain whether chiropractic does more good than harm” after multidisciplinary panels from at least 2 countries ^14,15 have concluded, after a systematic review of the evidence shown in the peer-reviewed literature, that manipulation is one of two best-documented and efficacious approaches to the treatment of low back pain—the other being the use of analgesics and nonsteroidal anti-inflammatory drugs (NSAIDs).

The 6 areas that have received inadequate attention in the editorial and that must be addressed are (1) strength of medical evidence; (2) the relationship between chiropractic and spinal manipulation; (3) direct risk to the patient; (4) the use of radiographs; (5) attitudes toward immunization; and (6) relative costs. These will all be revisited in some detail here.

Strength of medical evidence

TOP

A recent review of 8 randomized controlled trials restricted to chiropractic manipulation has formed the nucleus of Ernst and Assendelft's¹³ argument that meaningful outcome data for chiropractic in the management of low back pain are lacking. That particular review suggested that, largely because of small sample sizes, incomplete tracking of different outcome measures, failure to include blind or naive patients, and loss to follow-up, the results could not be statistically pooled or deemed clinically significant. However, in an accompanying article, at least one of the editorial authors (Assendelft) clearly demonstrates that most of these trials bore positive results and that “there certainly are indications that manipulation may be effective in some subgroups of patients.”¹⁶ Furthermore, the vast differences that exist among sham procedures described in randomized clinical trials involving chiropractic ^17,18 suggest that far too little is understood at this time with regard to what precisely is identified as the active component in chiropractic adjustments; thus criticisms regarding the lack of differentiation between experimental and control groups (as opposed to significant departures each group may show from baseline values during the course of treatment) may be premature. At the very least, it seems fatuous to fault the lack of patient blinding in which it is virtually impossible to either mask or precisely identify what it is the chiropractor is actually doing.

Taking a broader perspective, one has to question the validity of randomized clinical trials as the sole source of information regarding meaningful patient outcomes. First, it is important to recall that only 15% of medical procedures have been found to be supported by any literature references at all,¹⁹ only 1% of which is deemed to be scientifically rigorous.²⁰ Second, it is easy to forget that sound clinical observations in the doctor's office remain the cornerstone on which all experimental approaches, including randomized clinical trials (RCTs), are based. In the world of clinical treatment, erroneous judgments are as much the product of improper generalizations of RCTs (which by their definition take place within a highly restricted setting) than of the quality of the RCTs themselves. Indeed, the entire structure of evidence-based medicine is put into perspective by no less an authority than David Sackett, who argues: “External clinical evidence can inform, but never replace, individual clinical expertise, and it is this expertise that decides whether the external evidence applies to the individual patient at all, and, if so, how it should be integrated into a clinical decision.”²¹

Finally, one must not underestimate the value of patient satisfaction in treatment, because this aspect has been shown to directly affect patient compliance (and thus inherent quality) regarding a particular mode of health care delivery.²² From an extensive variety of viewpoints of patients with lowback pain, those under the care of chiropractors, compared with allopathic medical providers, have expressed 2 to 3 times the levels of satisfaction with their treatments. ^23,24 Paradigms involving the patient as the center of all clinical decision-making have recently been shown to be highly effective in contemporary health management and have been observed to form the basis of traditional chiropractic care. ^25,26

The relationship between chiropractic and manipulation

TOP

Returning to the examination of outcomes in randomized trials involving chiropractic, the fact remains that from the 25 randomized controlled trials reviewed in a meta-analysis by Shekelle et al,²⁷ there is a statistically significant positive outcome for groups undergoing spinal manipulation in the resolution of acute low back pain. Furthermore, in this study, no less than 94% of the manipulations were delivered by chiropractors.²⁷ With more than 100 different chiropractic techniques having been described,²⁸ the distinction between spinal manipulation and chiropractic adjustment may be incompletely defined at this writing. Thus to differentiate clinical trials involving spinal manipulation and chiropractic adjustment and suggest the latter to be ineffective, as implied by Ernst and Assendelft,¹³ is misleading. We simply need further research to differentiate each type of manipulation in terms of both efficacy and effectiveness—but the incompleteness of evidence provided thus far fails to justify Ernst and Assendelft's¹³ questioning the very rationale for performing the intervention in the first place.

Direct risk to the patient

TOP

The implication from Ernst and Assendelft's¹³ editorial is that chiropractic manipulation represents a significant risk to the patient and that, in light of the perceived poor quality of evidence presented in the literature in its behalf, it may not be worth pursuing. In fact, the type and strength of evidence discussed above would appear to paint a considerably different picture of spinal manipulation than that presented in the editorial. In terms of risk, the editorial omits four crucial pieces of information:

More precise estimates of serious complications from cervical manipulations have recently been estimated to be 6 per 10 million manipulations, with fatal occurrences estimated at the rate of 3 per 10 million manipulations.²⁹ This rate pales in comparison to NSAID-related gastropathies resulting in death; assuming that each patient receives an average of 10 manipulations in treatment, death rates after cervical manipulations calculate to anywhere between 1/100 to 1/400, the rates seen in the use of NSAIDs for the same condition. ^30,31 It is also far below the risk of death from such voluntary and everyday activities as power boating, pregnancy, taking contraceptive pills, or automobile driving.³² One would imagine that we have lost our perspective on the entire issue of benefit-to-risk ratios here.
Risks of surgery to the spine have been ignored. The selective information presented in the editorial fails to account for the fact that death rates for lumbar spine operations have been reported to be 300 times higher than the rate produced by cerebrovascular accidents in spinal manipulation ^33,34; for cervical surgeries, recent death rates have been estimated to be 700-fold greater.³³
With the recent association of cerebrovascular accidents with rotational maneuvers applied to the upper neck, ^35,36 accident rates produced by spinal manipulations in this region may now be anticipated to decrease. The accident rate in using medications (decidedly non-chiropractic), on the other hand, has recently been shown to have increased in the 10 years ending in 1993, rising 2.5-fold for hospital inpatients and jumping 8.5-fold for outpatients.³⁷
The actual number of iatrogenic complications specifically ascribed to chiropractic has been shown in the literature to be significantly overestimated, because of the fact that the practitioner actually involved is in many cases a nonchiropractor. Rather, a major portion of these accidents has occurred at the hands of a practitioner with inadequate professional training but incorrectly represented in the medical literature as a chiropractor.³⁸

The use of radiographs

TOP

The risk of “potential overuse of radiographs” alluded to in the editorial is based solely on a commentary published by one of the authors (Ernst³⁹). More definitive information on the use of radiographs by chiropractors has been provided by a set of guidelines that have been in place for the profession for more than 5 years⁴⁰ and verified with appropriate red flags by multidisciplinary agencies of both the US and British governments. ^14,15 Such safety measures as gonadal shielding and filtration systems have long been introduced and advocated by the chiropractic community. ^41–44 In fact, one of the most exhaustive texts on radiology currently in use by all physicians has been authored by chiropractors.⁴⁵

What Assendelft and Ernst¹³ have overlooked is the fact that since the 1970s Medicare has mandated that chiropractors must order radiographs to receive reimbursement for their patients. Allopathic doctors face no such requirement. After years of legislative efforts, the chiropractic community has finally succeeded in reversing that requirement, beginning in the year 2000.

Attitudes toward immunizations

TOP

There is no doubt that a minority of the chiropractic profession harbor antiimmunization sentiments,⁴⁶ as suggested by the editorial. However, most chiropractors have been officially represented by a policy statement from the American Chiropractic Association insisting that spinal manipulation is not a substitute for routine vaccination.⁴⁷ Studies in the leading chiropractic research journals clearly recognize the enormous body of scientific evidence that has been produced in support of immunization as a safe and cost-effective means of preventing a variety of infectious diseases in all age groups worldwide.⁴⁶

Cost-effectiveness

TOP

Conflicting with the conclusions drawn by Ernst and Assendelft,¹³ the preponderance of studies drawn from both workmen's compensation data and insurance records have found chiropractic to be distinctly advantageous in the treatment of musculoskeletal disorders. ^48–51 In contrast, the two studies that have generated the editorial's assertions came to the opposite conclusion, suggesting that chiropractic services are more, rather than less, expensive for medical treatments for back conditions. ^24,52 However, these two particular studies are fraught with weaknesses that have been addressed in detail.⁵³ Specifically, (1) the effects of severity of illness are virtually ignored; (2) the degree of recovery does not receive adequate attention; (3) matching of services with provider type may be irregular; (4) compliance has been disregarded; (5) types of medications and their side effects are not specified; (6) medical expenses are capped by managed care whereas those of chiropractors are allowed to seek free market levels; (7) episodes are poorly defined or contained; and, as is unfortunately true with many cost-effectiveness studies, (8) indirect costs have been ignored.

The cost advantages for chiropractic for matched conditions appear to be so dramatic that a leading Canadian economist has concluded that doubling the use of chiropractic services from 10% to 20% may realize savings as much as $770 million in direct costs and $3.8 billion in indirect costs.⁵⁴ Furthermore, in no cost studies to date have either iatrogenic or legal burdens been calculated, which one would expect should be heavily advantageous for chiropractic health management.

Finally, one needs to be cognizant of the fact that episodes of low back pain as assessed by medical practitioners (and certainly by both Shekelle et al⁵² and Carey et al,²⁴ as explained above) appear to have been short-changed. Rather than fully resolving spontaneously within 1 month, as commonly believed, the vast majority of back pain sufferers continue to report symptoms after 1 year of follow-up. Rather than presenting as an acute condition, back pain has been redefined as “a chronic problem with an untidy pattern of grumbling symptoms and periods of relative freedom from pain and disability interspersed with acute episodes, exacerbations, and recurrences”.⁵⁵ The implication from this study is that medical practitioners have failed to communicate effectively with their patients concerning the nature of their ailment. Chiropractic management would appear to be the alternative of choice, doing more good than harm rather than vice versa as suggested by Ernst and Assendelft.¹³

From the vantage point of all 6 of the previous arguments, the views expressed by Ernst and Assendelft¹³ appear to be significantly compromised. Perhaps the most concise and revealing insight has been offered by the recent report on the status of chiropractic from the Agency for Health Care and Policy Research:

[A] recent evidence-based review of conservative and surgical interventions for acute back pain failed to identify any interventions supported by multiple high-quality scientific studies. Thus despite the poor quality of many of the studies evaluating its effectiveness, there is as much or more evidence for the effectiveness of spinal manipulation as for other non-surgical treatments for back pain. At present, however, comparative data for these largely low-risk (manipulative) therapies (in relation to surgery) are not available [italics mine].⁵⁶

The awareness of the authors of the editorial of this major government report was sadly lacking, as it was for many of the references cited in this reply. One would hope that, in light of all the findings discussed above, that a far more equitable assessment of chiropractic services could be reached and shared by the readership of this short-sighted editorial.