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Letter to the Editor, The New York Times, regarding Jane Brody article of April 3, 2001

Anthony L. Rosner, Ph.D.
April 9, 2001

Publisher's Note

References

Editorial Offices
New York Times
229 West 43 Street
New York, NY 10036-3959

To the Editor:

Jane Brody's recent article ["When Simple Actions Ravage Arteries," 04/03/01] is an unfortunate and careless portrayal of a healthcare intervention which was specifically designed to avoid the more serious and often irreversible sequelae of the more invasive tools of orthodox medicine: drugs and surgery. Emphasizing the body's own capacity to heal, chiropractic management of patients is based upon the diagnosis, treatment and prevention of disorders of the musculoskeletal system and how they are reflected upon general health through the nervous system.

While Ms. Brody points out that chiropractic spinal manipulation is "but one possible cause" of the dissections which, in turn, account for only 2% of all nonhermorrhagic strokes, the reader of her article is bombarded with the indelible impressions that chiropractic is by definition associated with the "sudden, abrupt neck movement or extreme neck position [which] can cause an arterial dissection in a susceptible person." Progressing from two anecdotes of patients who experienced fatal vertebral artery events shortly after manipulative therapy, Brody creates a disturbing innuendo throughout the article which portrays chiropractic treatment only in the most destructive terms.

This entire article represents a disturbing assault upon the factual information which documents both chiropractic and the incidence of vertebral artery dissections. There are at least three elements which seriously undercut Brody's portrayal of chiropractic:

1. Chain of dubious source material: Ms. Brody proclaims that chiropractic spinal manipulation is "estimated to cause stroke in as many as one in 20,000 patients." This seemingly forbidding statistic is solely based upon a review of spontaneous dissection of the carotid and vertebral arteries recently published in The New England Journal of Medicine by Walter Schievink.1 What Brody does not point out is that this paper does not offer primary research data or even a systematic review of the literature.

In its 2,200 word length, the Schievink article devotes no more than 13 words [about half of 1 percent] in citing the possible risk estimate of spinal manipulation--and it gets it wrong. With no primary data of its own to support its claims, it misquotes an earlier study by stating that "as many as 1 in 20,000 spinal manipulations causes a stroke."1 To Schievink's detriment, the earlier report by Vickers [which itself provides no primary data but merely estimates], suggests that severe adverse events range from 1 in 20,000 patients undergoing cervical manipulation to 1 million procedures."2

This arbitrary and capricious chain of information in presumably peer-reviewed scientific journals borders upon the ludicrous. It is a perfect example of the children's game of "telephone" in which an unconfirmed message becomes mutated as it is passed from person to person without confirmation, amply demonstrating a pleiomorphism of fact and rumor. It is an affirmation of a theory of Mark Twain, who once suggested that "lies go halfway around the world before truth puts on its boots." In any event, this exceedingly tentative information is given far too much credibility in Ms. Brody's article.

2. More definitive estimates of incidence of vertebral dissections: Risks are inherent in every medical procedure or lifestyle activity that we encounter. In terms of interventions of the spine, chiropractic has been shown to be many orders of magnitude safer than either medication or surgery. Assuming that each patient receives an average of 10 manipulations in treatment, death rates following cervical manipulation calculate to anywhere between 1/100-1/400 the rates seen in the use of NSAIDs for the same condition.3,4 Death rates from lumbar spine operations have been reported to be 300 times higher than the rate produced by cerebrovascular accidents in spinal manipulation;5,6 for cervical surgeries, recent death rates have been estimated to be 700-fold greater.5 As Rome has pointed out,7 risks for "virtually all" medical procedures ranging from the taking of blood samples,8 use of vitamins,9 drugs,10 "natural" medications,10 and vaccinations11 are routinely accepted by the public as a matter of course. Elsewhere, it has been demonstrated that no less than 18 everyday activities have actually been associated with vascular accidents but are decidedly nonmanipulative.12 Why should chiropractic have been singled out as having a conspicuously alarming risk?

By way of contrast, the risk of fatal stroke following cervical manipulation has been assessed in an exhaustive systematic literature review of many sources to be 3 per 10 million manipulations,13 or about 0.00025%.3 This is actually less than the mortality rate from stroke in the general population, reported in 1992-93 to be 0.00057%.14

3. Undetermined identification of caregiver or precipitating event: Have all the cases of arterial dissection alluded to by Brody actually follow manipulation by a licensed chiropractor? There is no validation of this fact in the studies reported. The actual number of iatrogenic complications specifically ascribed to chiropractic has been shown to be significantly overestimated due to the fact that the practitioner actually involved is in many cases a nonchiropractor. Rather, a major portion of these accidents have occurred at the hands of an individual with inadequate professional training but incorrectly represented in the medical literature as a chiropractor. This particular revelation is alarming in that it suggests that for many years chiropractors have been overrepresented [possibly in a systematic manner] in the literature as having precipitated vertebral dissections and stroke.15

In terms of actual precipitating events as well as caregivers, there is considerable controversy. Many of the reported instances of cerebrovascular accidents attributed to chiropractic occurred more than 1 hour after manipulative therapy, measured in days16 or weeks.17 Because the incidence of death from vertebral basilar artery incidents associated with nonchiropractic events appears to be considerably higher than that brought on by cervical manipulation,7 the most plausible model of strokes brought on by arterial dissection which needs to be heeded by Ms. Brody is that such events are cumulative rather than traumatic events, culminating years of turning the head and possibly extending the spine as well. Most if not all of the chiropractic incidents described probably represent movements of the artery in a select and high-risk group of patients which most likely would have occurred [or possibly did occur] during some everyday activity. The challenge for chiropractors and medical practitioners alike is to be able to identify such high-risk patients in advance of their experiencing any number of lifestyle activities, in which spinal manipulation plays only an extremely limited role.

In the spirit of the distinguished journalism for which the New York Times has been repeatedly recognized, I hope that this additional information becomes available to your readership, as well as becoming an integral part of Jane Brody's future writings about chiropractic healthcare.

Sincerely yours,

Anthony L. Rosner, Ph.D.
Director of Education and Research
Foundation for Chiropractic Education and Research


PUBLISHER'S NOTE:

The article referenced herein was written by Jane E. Brody and published in the New York Times on April 3, 2001. Entitled "When Simple Actions Ravage Arteries," the article first describes a man who suffers from dissection of the carotid artery following water skiing. The article goes on to describe two women who suffered from artery dissection following cervical spinal manipulation, and then attempts to discuss the likelihood of stroke following manipulation. The full article may be purchased at www.nytimes.com.

 


REFERENCES:

1Schievink WI. Spontaneous dissection of the carotid and vertebral arteries. New England Journal of Medicine 2001; 344(12): 898-906.

2Vickers A, Zollman C. ABC of complementary medicine: The manipulative therapies: Osteopathy and chiropractic. British Medical Journal 1999; 319: 1176-1179.

3Dabbs V, Lauretti W. A risk assessment of cervical manipulation vs NSAIDS for the treatment of neck pain. Journal of Manipulative and Physiological Therapeutics 1995; 18(8): 530-536.

4Gabriel SE, Jaakkimainen L, Bombardier C. Risk of serious gastrointestinal complications related to the use of nonsteroidal anti-inflammatory drugs: A meta-analysis. Annals of Internal Medicine 1991; 115: 787- 796.

5Deyo RA, Cherkin DC, Loesser JD, Bigos SJ, Ciol MA. Morbidity and mortality in association with operations on the lumbar spine. Journal of Bone and Joint Surgery 1992; 74A: 536-543.

6Boullet R. Treatment of sciatica: A comparative survey of the complications of surgical treatment and nucleolysis with chymopapain. Clinical Orthopedics 1990; 251: 144-152.

7Rome PL. Perspective: An overview of comparative considerations of cerebrovascular accidents. Chiropractic Journal of Australia 1999; 29(3): 87-102.

8Horowitz SH. Peripheral nerve injury and causalgia secondary to routine venipuncture. Neurology 1994; 44: 962-964.

9Caswell A [ed]. MIMS Annual, Australian edition, 22nd edition. St. Leonards, New South Wales: MediMedia Publishing, 1998.

10Anonymous. Readers' Q & A. Australian Medicine 1998; October 5:18.

11Burgess MA, McIntyre PB, Heath TC. Rethinking contraindications to vaccination. Medical Journal of Australia 1998; 168: 476-477.

12Terrett AGL. Vertebral stroke following manipulation. West Des Moines, IA: National Chiropractic Mutual Insurance Company, 1996.

13Hurwitz EL, Aker PD, Adams AH, Meeker WC, Shekelle PG. Manipulation and mobilization of the cervical spine: A systematic review of the literature. Spine 1996; 21(15): 1746-1760.

14Myler L. A risk assessment of cervical manipulation vs. NSAIDs for the treatment of neck pain. Journal of Manipulative and Physiological Therapeutics 1996; 19(5): 357.

15Terrett 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.

16Terrett AGJ. Current concepts in vertebrobasilar complications following spinal manipulation. West Des Moines, IA: NCMIC Group Inc., 2001.

17Bin Saeed A, Shuaib A, Al-Sulaiti G, Emery G. Vertebral artery dissection: Warning symptoms, clinical features and prognosis in 26 patients. Canadian Journal of Neurological Sciences 2000; 27: 292-296.



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