Trick or Treatment (26 page)

Unfortunately, manipulating the cervical region is a common practice among chiropractors, because it was promoted by B. J. Palmer as the most powerful chiropractic ‘cure-all’. Chiropractors have been oblivious to the damage that they might have been causing, because there is often a delay between the vertebral dis section and the blockage of blood to the brain. Hence, the link between chiropractic therapy and strokes went unnoticed for decades. Recently, however, cases have been identified where manipulating the cervical region has certainly been the cause of vertebral dissection.

One of the most clear-cut cases highlighting the dangers of spinal manipulation concerns Laurie Mathiason, a twenty-year-old Canadian, who visited a chiropractor twenty-one times between July 1997 and February 1998 in order to relieve her low back pain. On each occasion the chiropractor manipulated her cervical vertebrae, but after her penultimate visit she complained of pain and stiffness in her neck. That evening she became clumsy, dropping ashtrays and plates at the restaurant where she worked, so she returned to the chiropractor the next day.

As the chiropractor manipulated her neck once again, Laurie began to cry, her eyes started to roll, she foamed at the mouth, her body began to convulse and she turned blue. She was rushed to hospital, slipped into a coma and died three days later.

The sudden and unusual nature of Laurie’s death led to an inquest, with the aims of establishing the circumstances of her death and preventing similar tragedies in the future. After four days of evidence, it seemed that the penultimate chiropractic treatment had almost certainly damaged Laurie’s vertebral artery, which caused a blood clot in one of the arteries supplying her brain and led to the relatively mild effects she felt that evening. The final treatment then dislodged the blood clot, which subsequently travelled to Laurie’s brain and killed her.

The coroner’s jury attributed Laurie’s death to ‘traumatic rupture of the left vertebral artery’, and the coroner declared: ‘So at this point, the public knows that Laurie died of a ruptured vertebral artery, which occurred in association with a chiropractic manipulation of the neck.’ The jury also suggested a series of measures aimed at minimizing the risks to patients, which initially seemed to be well received by the senior figures in the chiropractic community. Unfortunately, this positive reaction from chiropractors rapidly evaporated, as they failed to implement the recommendations of the inquest and began to deny responsibility for Laurie’s death.

Two days after the inquest ended, Paul Carey, president of the Canadian Chiropractic Protective Association, boldly stated on CBC Radio: ‘The jury members did not make a direct relationship to the chiropractic adjustment.’ Just a few weeks later, a press release from the Canadian Chiropractic Association claimed: ‘The jury did not make a finding that chiropractic treatment was the cause of this tragedy.’ These statements were followed by chiropractic newspapers, newsletters, leaflets and advertisements that seemed to contradict the findings of the inquest, which only added to the grief felt by the Mathiason family. Laurie’s mother, Sharon Mathiason, was openly critical when these pronouncements appeared:

The case of Laurie Mathiason is certainly not unique. Indeed, in Canada alone there have been several other young women, such as Dora Labonte, Lana Dale Lewis and Pierrette Parisien, who have died soon after receiving chiropractic manipulation of the neck. These high-profile cases have made headlines and generated major discussions about the safety of chiropractic manipulation, but the key question is whether these tragedies are freak accidents, perhaps involving patients who were already vulnerable to strokes, or whether they are the tip of an iceberg, hinting at a widespread risk for all patients.

There have been several attempts to assess the level of risk associated with chiropractic neck manipulation, and the one that is most often quoted by chiropractors is a study entitled
The Appropriateness of Manipulation and Mobilization of the Cervical Spine
. Conducted in 1996, it estimated that the number of strokes, cord compressions, fractures and large blood clots was 1.46 per million neck manipulations. This is a remarkably small risk, essentially one in a million, but it is misleadingly low for two reasons. First, experts suspect that the vast majority of incidents go unreported and unrecognized, so most incidents could not have been included in the study. Second, a patient may receive more than ten treatments for a particular condition, thus increasing the risk by a factor of more than ten.

Other surveys have suggested higher risks, and perhaps the most significant study was published by Canadian researchers in 2001, concluding that the risk of artery damage is one incident per 100,000 individuals receiving chiropractic neck manipulation. They compared patients who had suffered damage to their vertebral arteries with control groups with no history of stroke. The results showed that patients under forty-five years of age who had suffered torn arteries were five times more likely to have visited a chiropractor in the week prior to the damage being recognized than healthy individuals of a similar age. This implies that chiropractic treatment can increase the risk of damaged arteries by a factor of five.

One of us, Professor Ernst, has repeatedly reviewed the literature on the risks of spinal manipulation. To date, about 700 cases of serious complications have been documented in these publications. This should be a major concern for health officials, particularly as under-reporting will mean that the actual number of cases is much higher. Indeed, if spinal manipulation were a drug with such serious and widespread adverse effects and so little demonstrable benefit, then it would almost certainly have been taken off the market by now.

The risk of torn arteries caused by chiropractors, and the dire consequences of such damage, raises three serious criticisms of the chiropractic profession. First, it is surprising that the exact risk associated with spinal manipulation is so poorly understood. Chiropractors seem to have no system for recording and monitoring the damage that they may inadvertently cause, and therefore they seem to be avoiding any attempt to assess the safety of their profession. This problem was highlighted in 2001, when a team of researchers, including Edzard Ernst, asked members of the Association of British Neurologists to report cases of neurological complications referred to them that had occurred within twenty-four hours of neck manipulation. They identified thirty-five cases, which included nine strokes, over the course of one year. Ernst and his colleagues were shocked to find that none of these cases had hitherto attracted any attention, inasmuch as they had not been reported in the medical literature or anywhere else.

The approach of the chiropractic profession stands in stark contrast to the conventional medical establishment, which rigorously assesses the safety of drugs before they are made publicly available. Even when a drug is available for prescription, doctors are encouraged to continue to monitor and report any adverse incidents in order to identify any rare side-effects. In Britain, this programme of ongoing vigilance is called the Yellow Card Scheme and it is administered by the Medical Healthcare Products Regulatory Agency (MHRA). This and other methods are the reasons why we learn about hitherto unknown risks and why we can, if risks emerge, withdraw a drug. Nothing remotely similar exists in the world of chiropractic.

The second criticism of chiropractors is that they often fail to warn patients of the potential risks of their treatment. A study published by chiropractors in 2005 assessed the consent policy among 150 randomly selected chiropractors in the United Kingdom, and it revealed that only 23 per cent always discussed serious risks with their patients before treatment. This contravenes the requirements of the Department of Health in the UK: ‘Before you examine, treat or care for competent adult patients you must obtain their consent…Patients need sufficient information before they can decide whether to give their consent: for example information about the benefits and risks of the proposed treatment, and alternative treatments.’ It also falls short of the Code of Practice of the British General Chiropractic Council: ‘Before instituting any examination or treatment, a chiropractor shall ensure that informed consent to such treatment or examination has been given. Failure to obtain informed consent may lead to criminal or civil proceedings.’

The third criticism is that chiropractors continue to offer treatments for non-musculoskeletal conditions, even though spinal manipulation can have no impact on these conditions. This is an issue of concern that has already been raised, but it becomes even more problematic if we bear in mind the two previous criticisms. Not only is spinal manipulation useless in terms of treating, for example, asthma, but it also carries a potentially deadly risk and patients are not always informed of this.

Earlier in this chapter we offered some words of caution to patients who might be considering seeing a chiropractor, but we would like to add to this advice in light of the serious risks that we have now outlined. For example, we have stated that chiropractic therapy can sometimes help with back problems, and therefore short-term treatment from a mixer chiropractor can be helpful, but we have also stated that chiropractors tend to be no better than conventional physiotherapists at treating such conditions. Hence, because physiotherapeutic exercise is a much safer treatment than chiropractic manipulation, we would strongly recommend the former rather than the latter as the first choice.

Another treatment option, which we would also recommend ahead of chiropractic therapy, is
osteopathy
. The origins of osteopathy are similar to those of chiropractic therapy, inasmuch as both emerged in North America at the end of the nineteenth century as the result of discoveries made by charismatic mavericks. In the case of osteopathy, the founder was Andrew Taylor Still. He believed that manipulating bones in general, not just the spine, improved blood flow and enhanced the nervous system. Moreover, he argued that manipulating bones could enable the body to heal every possible illness!

Although the traditional ambitions of both chiropractic therapy and osteopathy – manipulating the spine or bones in general can cure everything – are equally bizarre and misguided, we would advise the latter rather than the former for several reasons. First, osteopaths have largely shed the more bizarre beliefs and claims from their early days and are today more solidly grounded in science. Second, they usually employ gentler techniques which cause fewer adverse side-effects. Third, they use fewer X-rays and are less likely to employ untested diagnostic methods. Fourth, they generally do focus on conditions relating to the spine and the musculoskeletal system, leaving other diseases to other specialists. Importantly, however,
cranial osteopathy
is not a treatment that we would recommend as there is no evidence at all that it works. Both osteopathy and cranial osteopathy are explained in more detail in the appendix.

If you do still decide to visit a chiropractor, despite all our concerns and warnings, then we would very strongly recommend that you start your consultation by confirming that your chiropractor will not be manipulating your neck. Even if your problem relates to your lower back, it is still worth stressing that your neck should not be touched, as many chiropractors will manipulate the neck without informed consent in order to address a whole range of conditions. Indeed, Laurie Mathiason, who died in 1998, was having her neck manipulated even though she was concerned about a pain in her lower back.

Finally, before ending this section on the risks of chiropractic therapy, it is important to stress that all the concerns that have been raised also apply to the treatment of children. Many parents feel that they are acting in their children’s best interests by taking them to see a chiropractor, but they should be aware that they are exposing them to the hazards of X-rays, temporary adverse reactions, spinal injuries and even stroke. In fact, the dangers to children are particularly worrying, because children’s bones continue growing right to the end of their teenage years, so a chiropractor would be manipulating an immature spine.

As with adults, many chiropractors are willing to treat children for wholly inappropriate conditions, such as asthma, bedwetting, clumsiness, ear infections, gastric problems, hyperactivity, immune-system problems, learning disorders and respiratory problems. Chiropractors will claim to be able to treat such conditions, but we know that the evidence does not suggest that spinal manipulation can offer any benefit. Prompted by these sorts of unfounded claims, the journalists Paul Benedetti and Wayne MacPhail have investigated the issues surrounding children and chiropractic therapy, and they included their findings in
Spin Doctors: The Chiropractic Industry Under Examination
. They focused their attention on their native Canada, where virtually all chiropractors deal with children, and where a significant fraction of parents seek out chiropractic treatment for their offspring. Indeed, according to a survey conducted in 2004 in Toronto, 31 per cent of children had been treated by a chiropractor.

To find out what happens to children who visit a chiropractor, Benedetti and MacPhail arranged for a colleague to accompany an eleven-year-old-girl, known as Judy, to visit five chiropractors in the Toronto area in 2001. Judy was also examined by Dr John Wedge, an experienced paediatric orthopaedic surgeon at Toronto’s Hospital for Sick Children, who confirmed that she was ‘a perfectly healthy girl’. The goal was to find out if the chiropractors would agree with Dr Wedge’s conclusion.