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 vaccinations [11] 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 days [16]
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 (Oct 30); 319 (7218): 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 (Oct); 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.
Perspectives: An Overview of Comparative Considerations of Cerebrovascular Accidents
Chiropractic
Chiropractic Journal of Australia 1999 (Mar); 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.
13
Hurwitz EL, Aker PO, Adams AH, Meeker WC, Shekelle PG.
Manipulation and Mobilization of the Cervical Spine: A Systematic Review of the Literature
Spine (Phila Pa 1976) 1996 (Aug 1); 21 (15): 1746–1760
14Myler L.
A Risk Assessment of Cervical Manipulation vs. NSAIDs for the Treatment of Neck Pain
J Manipulative Physiol Ther 1995 (Oct); 18 (8): 530–536
15Terrett AGJ.
Misuse of the Literature by Medical Authors in Discussing Spinal Manipulative Therapy Injury
Journal
of Manipulative and Physiological Therapeutics 1995 (May); 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.
Bin Saeed A, Shuaib A, Al Sulaiti G, Emery D.
Vertebral Artery Dissection: Warning Symptoms, Clinical Features and Prognosis in 26 Patients
Canadian Journal of Neurological Sciences 2000 (Nov); 27 (4): 292–296
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