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Letters to the Editor
Please e-mail letters for publication to Dr Kamran Abbasi [kamran.abbasi@rsm.ac.uk].
Letters should be no longer than 300 words and preference will be given to letters
responding to articles published in the JRSM. Our aim is to publish letters quickly. Not
all correspondence will be acknowledged.
Adverse effects of spinal manipulation
As a UK-wide statutory regulator, the General Chiropractic
Council (GCC) has a duty to act in the public interest. The
GCC sets standards of chiropractic education, training,
conduct and practice. The GCC also has a duty to promote
chiropractic so that its contribution to the health of the
nation is understood and recognized. Two points
.The GCC requires all chiropractors to explain to
patients the risks and benefits of the chiropractic
management of their condition to enable appropriate
consent to be obtained;
.While acknowledging that every human activity carries
some risk, the GCC’s core message to the public is that
‘chiropractic management of musculoskeletal disorders is safe,
evidence-based and effective in terms of outcomes and cost’.
Having carefully considered Professor Ernst’s study, the
GCC has seen nothing that changes this.
1
The GCC is deeply concerned that a study whose
conclusions cannot be justified by the research papers reviewed,
has been presented as ‘scientific rigour’ (JRSM 2007;100:330–
338). This is liable to lead to yet more public confusion when
confronted with yet another research scare story. This does not
serve the interests of the public or those of researchers who are
dedicated to improving the public’s health.
Competing interests
PD is the Chairman of the GCC.
Peter Dixon
Email: p.barton-hanson@gcc-uk.org
REFERENCE
1Ernst E. Adverse effects of spinal manipulation: a systematic review. JR
Soc Med 2007;100:330–8
I am astounded that the Journal has seen fit to publish Edzard
Ernst’s latest offering (JRSM 2007:100:330–338)
1
—
especially following critical comment of his last paper
published herein (JRSM 2006;99:192–196).
2
Professor Ernst calls this a systematic review, yet it is
not. While it is a personal review of the literature, it does
not fulfill the criteria for a systematic review which
principally assesses the methodological quality of previous
studies according to pre-determined criteria and bases its
conclusions on the level of evidence presented. This latest
contribution is based on low-quality research and is riddled
with misquotes and errors.
Whether Professor Ernst likes it or not, the major body of
published evidence points to manipulation being a safe and
effective tool in a chiropractor’s armamentarium. Instead, he
focuses on negligible risk elements of care and ‘puffs them up’
out of all proportion—effectively claiming causality where
none exists. He even suggests that minor, common side-
effects of chiropractic are sufficient to call into question the
sagacity of chiropractic care being provided. This is as
nonsensical as suggesting that injections should not be given
because they cause localized inflammation and ‘hurt’ patients
for a short period—or even more silly, to suggest that those
with fractures should not have them cast as that process causes
itching and muscular atrophy.
One can only conclude that Professor Ernst not only has a
problem with chiropractic, but that this is sufficient to cloud
his judgment and create illogical ‘findings’ from nothing.
Competing interests
BJL is the President of the British
Chiropractic Association.
Barry J Lewis
Email: bcapresident@btinternet.com
REFERENCES
1Ernst E. Adverse effects of spinal manipulation: a systematic review. JR
Soc Med 2007;100:330–8
2Ernst E, Canter P H. A systematic review of systematic reviews of spinal
manipulation. J R Soc Med 2006;99:192–6
If one is to draw any conclusions from the recent article by
Ernst (JRSM 2007;100:330–338),
1
two assumptions must
be made:
(1) That Ernst’s reviews are not without their limitations;
(2) That correlation and causal effect are the same thing
with respect to serious adverse effects.
Having done this, we learn that spinal manipulation may
or may not help and that the incidence of serious adverse
effects is unknown because not enough have been reported.
This is clearly a case for more research to be done to define
the extent to which under-reporting, bias and even
conspiracy theories contribute to their real incidence—
but to continue to ignore evidence of the effectiveness of
spinal manipulation, as outlined in previous letters to the
LETTERS
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JOURNAL OF THE ROYAL SOCIETY OF MEDICINE Volume 100 October 2007
Journal (JRSM 2006;99:277–278),
2–4
in order to repeat the
mantra that ‘it doesn’t work and it’ll probably harm you’ is
bad science that does no-one any good. Might I suggest that
a way ahead, in the UK at least, is for Ernst and/or the
JRSM to speak to regulatory bodies such as the General
Chiropractic Council
4
or the General Osteopathic Council
5
before publication? This is an efficient way to learn about
current research in the professions, to realize that that
systems are in place for adverse event reporting and to
recognize that some popular generalizations about the
activities of chiropractors and osteopaths are inaccurate.
Lighting the touch-paper of ‘an eclectic and combustible
mix’, to quote the Editor (JRSM 2007;100:299), may attract
attentiontotheJournal, but one wonders at what price?
Competing interests
IJ is a Fellow of both the RSM and
the College of Chiropractors.
Ian Johnson
McTimoney College of Chiropractic, Kimber Road, Oxon OX14 1BZ, UK
Email:Ijohnson@mctimoney-college.ac.uk
REFERENCES
1Ernst E. Adverse effects of spinal manipulation: a systematic review. JR
Soc Med 2007;100:330–8
2Breen A, Vogel S, Pincus T, et al. Systematic review of spinal
manipulation: A balanced review of evidence? J R Soc Med 2006;99:277
3Byfield D, McCarthy P. Systematic review of spinal manipulation: Flaws
in the review J R Soc Med 2006;99:277–78
4Lewis BJ, Carruthers G. Systematic review of spinal manipulation: A
biased report. J R Soc Med 2006;99:278
5General Chiropractic Council. www.gcc-uk.org
6General Osteopathic Council. www.osteopathy.org.uk
The National Council for Osteopathic Research (NCOR)
welcomes Professor Ernst’s interesting paper
1
concerning
safety and spinal manipulation (JRSM 2007;100:330–338).
This is a topic taken very seriously by all osteopaths.
Unfortunately, the term ‘adverse event’ does have
negative connotations and wasn’t clearly defined; minor
increases in soreness are an anticipated treatment response
experienced by many patients following examination and
treatment when provocation tests are used routinely to
reach an accurate diagnosis. A serious adverse event could
be viewed more accurately as a reaction requiring urgent
medical intervention.
Spinal manipulation is described as being of ‘unproven
effectiveness’ compared with non-steroidal anti-inflamma-
tories (NSAIDs) but, unfortunately, some more recent
high-quality work seems to have been overlooked.
2,3
While
it is true that spinal manipulation is not currently subject to
post-marketing surveillance, osteopaths are developing a
standardized data collection tool, through NCOR, to gather
long-term prospective data concerning all responses to
osteopathic treatment.
Risks associated with spinal manipulation are not a new
phenomenon to osteopaths. Pre-manipulative screening is
routinely used, although this is not without difficulties;
recent work published in the International Journal of
Osteopathic Medicine reviewed the literature to highlight risk
factors for spinal manipulation.
4
Osteopaths are currently funding a series of research
proposals, through the General Osteopathic Council,
investigating safety related to osteopathic treatment (call
announced 20 February 2007). This information will allow
osteopaths to fulfil the mandatory requirement of obtaining
informed consent prior to examination and treatment.
5
The
areas of current investigation include:
.Adverse events associated with physical interventions in
osteopathy and relevant manual therapies;
.Communicating risk and obtaining consent in osteo-
pathic practice;
.Insurance claim trends and patient complaints to the
profession’s regulator;
.Investigating osteopaths’ attitudes to managing and
assessing risk in clinical settings and patients’
experiences and responses to osteopathic treatment.
Patient safety remains of paramount importance to
practising osteopaths.
Competing interests
AM is Chair of the NCOR.
Professor Ann Moore, Chair, and members of the
National Council for Osteopathic Research
Email: C.A.Fawkes@brighton.ac.uk
REFERENCES
1Ernst E. Adverse effects of spinal manipulation: a systematic review. JR
Soc Med 2007;100:330–338
2Licciardone JC, Brimhall AK, King LN. Osteopathic manipulative
treatment for low back pain: a systematic review and meta-analysis of
randomised controlled trials. BMC Musculoskeletal disorders 2005;6:43
3Bronfort G, Nilsson N, Haas M, et al. Non-invasive physical treatments
for chronic recurrent headache. Cochrane Database of Systematic Reviews
2004;3:CD001878
4Gibbons P, Tehan P. HVLA thrust techniques: what are the risks? Int J
Osteopath Med 2006;9:4–12
5General Osteopathic Council. Fitness to Practise Guidelines. London: May 2005
As no vertebral joint ever moves in isolation, and as
variations in movement are common between different
vertebral levels and between left and right, clinical
identification of ‘normal range’ remains a dream. So,
therefore, must ‘normal integrity’.
1
Spinal manipulation is commonly used by osteopaths,
not occasionally.
The declared therapeutic aim in chiropractic is to
restore normal vertebral alignment. This is questionable, as
no vertebra is bilaterally symmetrical and no two vertebrae
are identical, so that clinical identification of misalignment
is scientifically unsound.
1
What we may feel is differences in
knobbliness—due to asymmetry, misalignment, or both.
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JOURNAL OF THE ROYAL SOCIETY OF MEDICINE Volume 100 October 2007
One of the reasons why chiropractors show predomi-
nance in manipulation is their frequent prescription of a
course of a dozen sessions. Clinical resolution is common
after a single manipulation, while non-resolution after three
is an indication for a therapeutic re-think.
2
This must distort
the validity of Ernst’s findings (JRSM 2007;100:330–338).
3
Over forty years of manipulative practice, I failed to
help many patients, but, after thousands of manipulations, I
am aware of only two instances of causing harm, both the
direct outcome of the patient failing to answer my questions
honestly, thus hiding a contraindication. The contra-
indications to vertebral manipulation are clearly set out
and are of greater importance than manual skills.
4,5
To Ernst’s final sentence I would but comment on the
enormous number of patients who seek spinal manipulation for
the very good reason that they find it commonly helps. Should
the medical profession not take a more positive attitude?
Competing interests
None declared
John K Paterson
Email: j.paterson275@btinternet.com
REFERENCES
1Paterson JK. Musculoskeletal Medicine in Clinical Practice. London:
Springer-Verlag, 2006
2Paterson JK. A survey of musculoskeletal problems in general practice.
Manuelle Medizin 1987;3:40–8
3Ernst E. Adverse effects of spinal manipulation: a systematic review. JR
Soc Med 2007;100:330–338
4Burn L, Paterson JK Musculoskeletal Medicine, the Spine. London: Kluwer
Academic Publishers, 1990
5Burn L. A Manual of Medical Manipulation. London: Kluwer Academic
Publishers, 1994
Professor Ernst has published a so-called ‘systematic’
review
1
of adverse events following spinal manipulation
based on low quality evidence including, for the most part,
case reports (JRSM 2007;100:330–338). The whole point of
systematic reviews is to get away from an author’s often
strong prior beliefs and opinions, and instead present an
impartial and even-handed review of the evidence. Essential
ingredients are that the evidence is critically appraised and
the recommendations based firmly on the quality of the
evidence presented. In this case, all of the evidence was
included indiscriminately and the findings of a causal link
between spinal manipulation and adverse events based on
unsupportive low-level evidence. Moreover, Professor Ernst
makes a judgement on this apparent causation as either
‘certain’, ‘likely’ or ‘possible’. There are no criteria presented
in this paper for how such judgements were made.
Of course, the absence of high-quality evidence is not to
say there is no risk associated with spinal manipulation:
there are safety issues with all interventions. What we need
to know is the nature and the size of those risks. In the UK,
there are estimated to be well over two million cervical
spine manipulations by chiropractors each year.
2
Given the
number of cervical spine manipulations done worldwide it
is likely, even if under-reporting is as high as Professor
Ernst suggests, that the level of risk of a serious adverse
event is extremely low. To turn Professor Ernst’s point on
under-reporting and publication bias around, could it be
that journals of medicine are unlikely to publish findings
which might be considered ‘positive’? Good evidence on
safety is of paramount importance; what we have here is
poor quality evidence and unsubstantiated claims masquer-
ading as a systematic review.
Competing interests
None declared.
Jennifer Bolton and Haymo Thiel
Anglo-European College of Chiropractic, Bournemouth BH5 2DF
Email: jbolton@aecc.ac.uk
REFERENCES
1Ernst E. Adverse effects of spinal manipulation: a systematic review. JR
Soc Med 2007;100:330–8
2Thiel H, Bolton J. Estimate of the number of treatment visits involving
cervical spine manipulation carried out by members of the British and
Scottish Chiropractic Associations over a one-year period. Clin
Chiropractic 2004;7:163–7
I have with interest read Professor Ernst’s article entitled
‘Adverse effects of spinal manipulation: a systematic review’
in the July issue of this Journal (JRSM 2007;100:330–338).
Professor Ernst goes through the published side effects of
spinal manipulation, which is fine and which has been done at
least in 20 other papers already. However, when discussing
side effects, an essential part is to consider how often the
treatment in question is administered; unfortunately,
Professor Ernst seems to have forgotten this essential part.
In Denmark, where I reside, chiropractic patients are
reimbursed by the Health Service, and we therefore have
reasonably accurate data. The last data I am aware of show
that just chiropractors (add to this physiotherapists and
manual medicine practitioners) treat some 350,000 patients
per year—out of a population of only 5 million. Including
physiotherapists and other practitioners of chiropractic,
probably 10% of the total population are treated every year.
Compared to this Professor Ernst’s figures for side
effects are minimal and without any impact—remember
that 1 in 10,000 patients die of simple general anaesthesia. I
find Professor Ernst’s conclusion wildly overstated: the
paper is embarrassing seen with international eyes.
Competing interests
None declared.
Professor Niels Grunnet-Nilsson
Faculty of Health Science, University of Southern Denmark
niels.grunnet.nilsson@gmail.com
REFERENCE
1Ernst E. Adverse effects of spinal manipulation: a systematic review. J
Roy Soc Med 2007;100:330–8
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JOURNAL OF THE ROYAL SOCIETY OF MEDICINE Volume 100 October 2007
Author’s response
I am impressed by the flurry of interest in my systematic review
(JRSM 2007:100:330–338).
1
The commentators make several
general and some specific points which deserve an answer.
General comments
Generally, the letter writers seem to think I should ‘take a
more positive attitude’. Reviewing the risks of therapeutic
interventions may look negative to those who make a living out
of using them. However, in truth it is motivated by our desire
to render our future health care safer. The commentators, I
think, confuse ‘negative’ with ‘critical’, and I should point out
that an uncritical scientist is a contradiction in terms.
Another general theme of these letters is the claim that I
‘indiscriminately’ used ‘low-level evidence’. Systematic
reviews on safety issues always have to rely heavily on case
reports, many of which lack sufficient detail and thus
conclusiveness. Yet when case-reports accumulate (in the
case of chiropractic about 700 incidents have been
published), they can send an important signal. To ignore
it because of the low-level argument would quite simply be
irresponsible. Moreover, I did, of course, report high-level
evidence where this was available; the problem here is that
such evidence is scarce and fails to confirm the view that
spinal manipulations are low-risk.
Several commentators criticize me for not discussing the
frequency of serious adverse events and some even provide
data of their own. They must have missed a whole section
of my paper where I do discuss these issues. But let’s look at
their figures: Bolton and Thiel state that there are over
2,000,000 cervical spine manipulations each year. Our UK
survey disclosed 35 serious adverse effects within one year
(JRSM 2001;94:107–110).
2
Under-reporting was 100% in
our series; this renders the calculation of any incidence
impossible, so let’s be optimistic and assume it is only 90%.
One severe adverse effect would thus occur in about 5,700
spinal manipulations. Assuming that, on average, patients
receive about 30 spinal manipulations during the course of a
treatment (three per session, 10 sessions per course), the
figure would indicate that one in about 1,900 patients could
experience a severe adverse effect. Of course, this is back of
the envelope stuff, but it nevertheless might indicate that
the true incidence of adverse events is quite different from
what chiropractors believe.
There seems to be a general consensus amongst the
letter writers that my conclusions were ‘unjustified’. So let
me re-state them: ‘Spinal manipulation, particularly when
performed on the upper spine, is frequently associated with
mild to moderate adverse effects. It can also result in
serious complications such as vertebral artery dissections
followed by stroke. Currently, the incidence of such events
is not known. In the interest of patient safety we should
reconsider our policy towards the routine use of spinal
manipulation.’ To reconsider policy is not to ban! But to
ignore such data would be to fail the public’s interest.
Specific comments
Several commentators make specific comments that cannot
be left unchallenged. The Chairman of the GCC states that
his institution ‘requires all chiropractors to explain to
patients the risks and benefits’ of chiropractic. Langworthy
et al. recently showed that ‘only 23% [of UK chiropractors]
report always discussing serious risk’.
3
Is Dixon implying
that 77% of all UK chiropractors are being summoned
before the GCC’s disciplinary panel?
The President of the BCA accuses me of ‘misquotes and
errors’ and of puffing up evidence ‘out of all proportion’.
Should he not provide evidence for his allegation? He also
asks whether we would ban injections because they cause
inflammation and hurt—to which the answer must be yes,
definitely, if these injections are not demonstrably effective!
Mr Johnson states that ‘systems are in place for adverse
event reporting of spinal manipulation’. Yet the Chair of the
NCOR confirms that ‘spinal manipulation is not currently
subject to post-marketing surveillance’.
Professor Grunnet-Nilsson states that ‘at least 20 other
papers’ have already addressed my topic. Does he mean to say
that we therefore do not need to update our knowledge—
which, of course, was the stated aim of my systematic review?
In conclusion, it is an important and positive move to
keep potential risks of therapeutic interventions under close
scrutiny. It is also good to discuss discrepancies of opinion
openly. In doing so we should, however, abstain from ad
hominem attacks and insults (e.g. ‘Professor Ernst . . . has a
problem with chiropractic’ [Lewis], ‘Professor Ernst has
published a so-called ‘‘systematic review’’ . . . unsub-
stantiated claims masquerading as a systematic review’
[Bolton and Thiel], ‘this . . . paper is embarrassing’ . . .
[Grunnet-Nilsson]). Scientific disputes are productive: mud
battles are not.
Competing interests
None declared.
Edzard Ernst
Complementary Medicine, Peninsula Medical School,
Universities of Exeter & Plymouth, UK
REFERENCES
1Ernst E. Adverse effects of spinal manipulation: a systematic review. JR
Soc Med 2007;100:330–8
2Stevinson C, Honan W, Cooke B, Ernst E. Neurological complications
of cervical spine manipulation. J R Soc Med 2001;94:107–10
3Langworthy JM, le Flemming C. Consent or submission? The practice
of consent within UK chiropractic. J Manipulative Physiol Ther
2005;28:15–24
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JOURNAL OF THE ROYAL SOCIETY OF MEDICINE Volume 100 October 2007
