MISUSE OF THE LITERATURE BY MEDICAL AUTHORS IN DISCUSSING SPINAL MANIPULATIVE THERAPY INJURY

Misuse of the Literature by Medical Authors
in Discussing Spinal Manipulative Therapy Injury
This section is compiled by Frank M. Painter, D.C.
Send all comments or additions to: Frankp@chiro.org

This article is reprinted with the permission of National College of Chiropractic and JMPT. Our special thanks to Editor, Dr. Dana Lawrence, D.C. for permission to reproduce this article exclusively at Chiro.Org

FROM: J Manipulative Physiol Ther 1995 (May); 18 (4): 203–210 ~ FULL TEXT

Terrett AG

School of Chiropractic and Osteopathy,
Faculty of Biomedical and Health Sciences,
RMIT University,
Bundoora, Australia.

You may also want to review Adrian Wenban's related article:

Inappropriate Use of the Title Chiropractor and Term Chiropractic Manipulation
in the Peer-reviewed Biomedical Literature
Chiropractic & Osteopathy 2006 (Aug 22); 14 (1): 16

OBJECTIVE: This study was conducted to determine how the words chiropractic and chiropractor have been used in publications in relation to the reporting of complications from cervical spinal manipulation therapy (SMT).

STUDY DESIGN: The study method was to collect recent publications relating to spinal manipulation iatrogenesis which mentioned the words chiropractic and/or chiropractor and then determine the actual professional training of the practitioner involved.

METHOD: The training of the practitioner in each report was determined by one of three means: surveying previous publications, surveying subsequent publications and/or by writing to the author(s) of ten recent publications which had used the words chiropractic and/or chiropractor.

RESULTS: This study reveals that the words chiropractic and chiropractor commonly appear in the literature to describe SMT, or practitioner of SMT, in association with iatrogenic complications, regardless of the presence or absence of professional training of the practitioner involved.

There are more articles like this @ our
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CONCLUSION: The words chiropractic and chiropractor have been incorrectly used in numerous publications dealing with SMT injury by medical authors, respected medical journals and medical organizations. In many cases, this is not accidental; the authors had access to original reports that identified the practitioner involved as a non–chiropractor. The true incidence of such reporting cannot be determined. Such reporting adversely affects the reader's opinion of chiropractic and chiropractors.

From the Full-Text Article:

INTRODUCTION

Among the health professions, chiropractic has an impressive safety record for its 99–yr existence [1, 2]. Chiropractors in Australia are aware that complications can occur after spinal manipulation therapy (SMT), and, as responsible professionals, they have investigated and instituted procedures to minimize their occurrence [2–19]. In fact "the incidence and mechanisms are better reported in the chiropractic literature than elsewhere" [20].

METHODS

This paper presents cases from the medical literature and popular press in which medical authors have incorrectly reported the facts regarding manipulation injuries of the cervical spine. The method of investigation was to study recent publications which reported cervical spine manipulation accidents. In those that used the words "chiropractor" or "chiropractic," attempts were made in each reported case to determine the profession to which the practitioner belonged. This was done by referring to previous or subsequent publications or by trying to contact the actual author of ten recent English language publications (six of whom replied). This investigation reveals that many cases of complication after manipulation described in the medical literature as "chiropractic complications" are found to, be, on closer inspection, either
(a) medical misrepresentation of the literature (Examples 1–24);

(b) inaccurate reporting by medical authors (Examples 25–36) or

(c) inaccurate reporting by medicolegal journalists (Examples 37–40).

RESULTS

A. Medical Misrepresentation of the Literature

Several authors (Examples 1–24) have blatantly misrepresented the literature. The original case reports cited either do not identify or do clearly indicate that the practitioner is not a chiropractor. However, in these cases, the medical author chooses to quote them as examples of "chiropractic" injury.

In 1992, the Australian Medical Association (AMA) produced a document titled Chiropractic in Australia [21] which contained, as an appendix, an annotated list titled "Complications of Chiropractic Manipulation." Evaluation of the references reveals cases of misrepresentation of the literature (Examples 1–3, and see discussion).
Example 1. The AMA document [21] refers to an article by Putman and Wu about a case of tracheal rupture following SMT [22]. The original article indicates that the "chiropractor" in this case was, in fact, a blind, unlicensed masseur at a local health club.

Example 2. The AMA document [21] reports as a complication of chiropractic manipulation the article by Murthy and Naidu [23] of an aneurysm of the internal carotid artery. Reading the actual publication reveals that the "chiropractor" in this case was a barber in India.

Example 3. The AMA document [21] refers to the article by Dunne et a1. [24]. This iatrogenic consequence of manipulation therapy is ascribed to a chiropractor, despite the article's clear description of the practitioner as a naturopath. Further investigation of Statements and Sworn Saiths at the Coroner's Inquest [25] reveals that the naturopath, the deceased's wife, a work colleague, and his boss all declared that the deceased had told them that the medical practitioner had manipulated his neck and aggravated his pain two days before the onset of the stroke.
The work colleague's statement reported that the patient described the medical practitioner's manipulation as " ... putting a hand on his chin, and hand on his head and twisting his head around and also side to side."
In their report of the case, Dunne et al, [24] implicated the Naturopath (who denied having manipulated the patient's neck), without any mention of the medical practitioner (see Coroner's Inquest [25]). The AMA document [21] does not mention this case in relation to medical or naturopathic practitioners, but lists it as a "complication of chiropractic manipulation."

Example 4. Another type of misrepresentation of the literature that could create a misperception by the reader about chiropractic and chiropractors was published by Winer [26], who wrote (emphasis added):
Some 430 cerebrovascular catastrophes following cervical manipulation have been reported in the English-speaking literature. The majority of these tragedies have been caused by chiropractors. This is not a political statement; it is a statement of fact.
If the word catastrophe, in the context of Winer's citation [26], means either death, tetraplegia or residual neurological deficit, then up to that time (December 1992), based on material available to the author, only 78 cases suffered such sequelae ((see Discussion section). Table 1 lists the 78 cases of "catastrophe" reported in the English language according to the practitioner involved (see Discussion section).

Frisoni and Anzola [27] incorrectly ascribe at least nine cases (Examples 5–13) to chiropractic manipulation although the original author reports that the practitioner was not a chiropractor, or does not describe the professional background of the practitioner.

Example 5. Frisoni and Anzola report a case of Smith and Estridge [28] as "Female 48 years old, chiropractic manipulation." The practitioner in this case was, in fact, an osteopath.

Example 6. Frisoni and Anzola report a case of Ford and Clark [29] as "Male 37 years old, chiropractic manipulation." The 'practitioner' in this case was the man's wife.

Example 7. The case of Lyness and Wagman [30] was reported as "Female 20 years old, chiropractic manipulation." The practitioner in this case was an osteopath.

Example 8–10. The three cases of Mueller and Sahs [31] are described [27] as "Female 43 years old, chiropractic manipulation," "Female 28 years old, chiropractic manipulation" and "Male 38 years old, chiropractic manipulation." Careful reading of this paper reveals that the authors did not describe the professional identity of any of the practitioners involved.

Example 11–12. The cases reported by Schmitt [32] were tabulated [27] as "Female 35 years old, chiropractic manipulation" and "Male 51 years old, chiropractic manipulation." The original paper reports a heilpraktiker (German health practitioner) in the first case and a medical practitioner in the second case.

Example 13. Frisoni and Anzola [27] reported the case of Dunne et a1. [24] as "Male 43 years old, chiropractic manipulation." This example has already been described as Example 3. The actual article [24] states that a naturopath was the practitioner involved. Sworn statements at the Coroner's Inquest stated that a medical practitioner had manipulated the neck. But Frisoni and Anzola, as did the AMA previously [21], chose to list this as an injury from "chiropractic manipulation."

Example 14. Povlsen et al. [33] are also guilty of the same type of mis-reporting. They refer to the case of Lyness et al. [30] as being caused by chiropractic cervical manipulation, whereas the practitioner was, in fact, an osteopath.

Example 15. Povlsen et a1. [33] refer to the case of Khurana et a1. [34] as a case of the "locked-in" syndrome after chiropractic cervical manipulation, although Khurana et a1. do not mention chiropractic or chiropractors in the publication.

Example 16. Phillips et al, [35] also reported incorrectly that the case of Dunne et a1. [24] was due to chiropractic manipulation. This example has already been described in Examples 3 and 13.

Example 17. Phillips et a1. [35] also quote incorrectly the cases described in the paper by Mas et a1. [36] as examples of "dissections of the cervico cerebral arteries" because of "cervical chiropractic manipulation." Mas et a1. did not describe the professional group to which any of the practitioners belonged.

Example 18–24. The Medical Journal of Australia [37] provides further examples of medical misuse of the literature. In this paper, references 1 and 2 are listed as "previously reported cases of stroke resulting from chiropractic neck manipulation"; and references 2–6 are listed as " ... cases of chiropractic-manipulation-induced stroke."

Of the 11 cases ascribed to chiropractors in this article, investigation revealed that at least 7 instances (Examples 18–24), did not involve a chiropractor at all. The practitioners in each of the five references quoted [37] to illustrate cases of "chiropractic-manipulation-induced-stroke" were:
Example 18 [24] – Medical practitioner or Naturopath (see Examples 3, 13, 16).

Examples 19–21 [27] – Medical practitioner, Physiotherapist, Physiotherapist.

Examples 22–24 [38–40] – Self, Self, Self.

Example 19–21 are further discussed as "inaccurate reports" (Examples 26–28).

Table I. Cerebrovascular manipulative "catastrophes" reported in the English language (1934–1992) (not including cases of complete recovery, almost complete recovery, unknown outcome, and anecdotal cases).

Outcome | | Tetraplegia Residual "locked-in" neurologic Manipulator Death syndrome deficit" Total Chiropractor/ 13 3 34 50 chiropractic Osteopath 2 2 4 8 Medical 3 4 7 practitioner Physiotherapist 3 3 Wife 1 1 Self 1 1 Barber 1 1 Unnamed 1 6 7 Total 20 5 53 78

a Residual neurological deficit ranged from minor to severe disability. In many cases, the status of the patient was given only while they were in the hospital. Cases of minor injury may have totally recovered two months later and had no neurological deficit.

b How many of the early cases of manipulative injury were incorrectly attributed to chiropractors or chiropractic is not known, and is most likely impossible to determine.

B. Inaccurate Reporting by Medical Authors

The examples described so far illustrate cases in which medical authors blatantly misquote the literature. The net effect is to create a misleading impression of chiropractic. Some cases of misleading reporting are not so obvious (Examples 25–36). In these, the original publication does attribute the injury to a chiropractor or to chiropractic, but personal communication with the author reveals a different scenario.
Example 25. The word "chiropractic" appears in the title and in six other places in a small case report by Carmody et al. [41]. As reported by Cashley in the Lancet [42], personal communication between him and Hutchinson, a co-author of the Carmody paper (Letter, 6 May 1988), revealed that the practitioner involved was not a qualified chiropractor. Carmody et al. was also cited as reference 27 in the AMA's Appendix [21] as an example of "complications of chiropractic manipulation."

Example 26–28. Frisoni and Anzola [27] published a paper documenting three cases of previously unreported chiropractic-induced stroke. Correspondence regarding the educational background of the practitioner elicited this response from Dr. Anzola (Letter, 15 March 1993):

"To answer your main question, in our three cases the chiropractor was a GP in one case and a physiotherapist in the remaining two."

Example 29. Tak-Wing Chen and Sien-Tsong Chen [43], in a report published both in Chinese and in English abstract describe their case as "Brainstem Stroke Induced by Chiropractic Neck Manipulation." Personal correspondence with Dr. Sien-Tsong Chen revealed that in this case the "chiropractor" was a Kung Fu practitioner.

Example 30. Mas et al. [44] describe a 35–yr-old woman who consulted a chiropractor. In the ensuing discussion, these authors relate chiropractic manipulations to the subsequent pathology. Personal correspondence with Professor Mas (Letter, 1 June 1993) reveals that he is 'not sure of the professional background of the practitioner involved.

Example 31–34. Hamann et al. [45] published a short, five-paragraph paper on four cases of "cervicocephalic artery dissections due to chiropractic manipulations" in which the word "chiropractic" appears eight times. One sentence reads " ... and our patients had been treated by experienced chiropractors" (emphasis added).

The four cases [45] are interesting when one realizes that:

The techniques described do not appear to be typical of those taught in chiropractic colleges (three involved axial traction);

There are only 21 qualified chiropractors in Germany (most manipulations are performed by medical practitioners or heilpraktikers); and

There is only one qualified chiropractor who practices within a hundred miles of the hospital of the University of Saarland. [42, 46].

Hamann wrote a second paper [47] where he corrected the errors in his first paper [45] relating to the educational background of the practitioners involved. He wrote:
"The chiropractors in our series (one is a lay practitioner, the others are orthopaedic and internal medical specialists) ... ".

Example 35. A 39–yr-old male died the day after neck manipulation by an osteopath in Sydney. The postmortem examination incorrectly attributed the cause to a cerebellopontine infarction after bilateral dissection of the vertebral arteries with propagation of thrombus into the basilar artery after chiropractic manipulation [12–13]. The pathology is not contested, but the arbitrarily introduced reference to chiropractic is.

Example 36. A 38–yr-old woman had her cervical spine manipulated by an osteopath for relief of headaches [48]. After treatment, she developed visual disturbance, slurred speech, left-sided weakness and drowsiness.

Although the St. John's Ambulance officer's report, the Emergency Department Record, and the clinical notes taken on admission all noted that she had been manipulated by an osteopath, the medical registrar's report incorrectly listed the diagnosis as "chiropractor stroke." The outpatient record and the hospital's final diagnosis on discharge incorrectly gave the diagnosis as "chiropractic stroke."

C. Inaccurate Reports by Medicolegal Journalists

Examples 37–40 suggest a bias against chiropractors by some newspaper reporters in the popular press, which gives an incorrect and negative impression of chiropractic.
Example 37. In 1992, a newspaper [49] reported the death of a well-known Australian: "Theatrical entrepreneur Frank Baden-Powell died of a heart attack yesterday in Sydney, aged 61, during a visit to a chiropractor". Investigation revealed that he died in a medical manipulator's office as a result of an anaphylactic reaction to "scoline" (succinylcholine), an intravenous, ultra-short-acting depolarizing neuromuscular blocking agent (muscle relaxant).

Example 38. In the Metro Digest section of the Los Angeles Times [50], a headline inaccurately read "Patient wins $750,000 for chiropractic mistake." This case, Saltzberg v. Hawkins [51], involved Dr. Jeffrey Hawkins, a board-certified pediatrician in general medical practice [52, 53].

Example 39. At an inquest in Sydney, a forensic pathologist opined that neck manipulation by a Perth chiropractor had injured a 36–yr old woman's right vertebral artery, causing a dissecting aneurysm at the C3–4 vertebral level with subsequent embolus formation; the aneurysm embolized to the left middle cerebral artery 4 days later while she was swimming. (Note the interesting anatomy: the vertebral arteries do not flow into the middle cerebral artery.)

The press reported, "A chiropractor who treated a champion hockey player for a pinched nerve may have triggered her death just four days later" [54]. The word "chiropractor" is mentioned twice in this article, the word "chiropractic" is mentioned three times and the chiropractor is named three times.

The inquest was resumed in Perth [55], and the Coroner, after hearing the evidence, found that the fatal middle cerebral artery thrombus had probably arisen from the left carotid artery (which does supply the middle cerebral artery). The chiropractor was subsequently cleared of all responsibility [56–57].

Example 40. There was recent report in Sydney [58] of the "locked-in" syndrome after treatment by a "chiropractor." This involved a well-known radio announcer and was reported by at least ten major city newspapers [59–68]. The patient was fortunate to have survived this particular complication but was left with a neurological deficit that prevented him from continuing in his previous employment.

The practitioner involved is a registered osteopath in the State of New South Wales (Letter, M. Walsh, Registrar NSW Chiropractors and Osteopaths Registration Board, 19 Sep 1994); during the court case he was referred to as an osteopath [58]; he was previously referred to in relation to this case as an osteopath [69]; in the Sydney Yellow pages telephone book he is listed as an osteopath [70].

In the nation's major newspapers, however, he was reported to be a chiropractor [59–68]. Table 2 lists how many times the words "chiropractor" and "chiropractic" incorrectly appeared, in these articles.

Table 2. The number of times the terms chiropractic and chiropractor were used incorrectly in ten major newspapers [59–68] in a recent injury involving an osteopath
Reference Number 59 60 61 62 63 64 65 66 67 68 Chiropractor 1 2 2 1 1 1 ---------------------------------------------------------------------------------- Chiropractic 1 1 1 1 1 1 1

The Age newspaper [71] published a 4.8 X 3.3 centimeter (about 2 in X 1.5 in) "clarification" 2 days later, on page 6, pointing out that the Chiropractor's Association of Australia had advised them that the practitioner involved was an osteopath. The next day, on page 2, a review of the week's articles [72] again stated that the practitioner was a chiropractor.

Table 3 summarizes the 30 examples presented in this paper in which reports described cases of "chiropractic" complications, but subsequent research revealed that the "chiropractor" was not really a chiropractor.

Table 3. Classification of practitioners involved in 30 cases of manipulative iatrogenesis incorrectly attributed to chiropractors
Example (Reference) Actual practitioner A. Medical misrepresentation of the literature ------------------------------------------------- 1 (21, 22) Blind Masseur ----------------------------------------------- 2 (21, 23) Indian Barber ----------------------------------------------- 3 (21, 24, 25) Medical or Naturopath ----------------------------------------------- 4 (26, 27) ----------------------------------------------- 5 (27, 28) Osteopath ----------------------------------------------- 6 (27, 29) Wife ----------------------------------------------- 7 (27, 30) Osteopath ----------------------------------------------- 8 (27, 31) Unknown ----------------------------------------------- 9 (27, 31) Unknown ----------------------------------------------- 10 (27, 31) Unknown ----------------------------------------------- 11 (27, 32) Heilpraktiker ----------------------------------------------- 12 (27, 32) Medical ----------------------------------------------- 13, 3 (27, 24) Medical or Naturopath ----------------------------------------------- 14, 7 (33, 30) Osteopath ----------------------------------------------- 15 (33, 34) ----------------------------------------------- 16, 3 (35, 24) Medical or Naturopath ----------------------------------------------- 17 (35, 36) Unknown ----------------------------------------------- 18, 3 (37, 24) Medical or Naturopath ----------------------------------------------- 19 (37, 27) Medical ----------------------------------------------- 20 (37, 27) Physiotherapist ----------------------------------------------- 21 (37, 27) Physiotherapist ----------------------------------------------- 22 (37, 38) Self ----------------------------------------------- 23 (37, 39) Self ----------------------------------------------- 24 (37, 40) Sel ----------------------------------------------- B. Inaccurate reporting by medical authors ------------------------------------------------- 25 (41,42) Unknown ----------------------------------------------- 26, 19 (27) Medical ----------------------------------------------- 27, 20 (27) Physiotherapist ----------------------------------------------- 28, 21 (27) Physiotherapist ----------------------------------------------- 29 (43) Kung-Fu practitioner ----------------------------------------------- 30 (44) Unknown ----------------------------------------------- 31 (45,47) Lay practitioner ----------------------------------------------- 32 (45,47) Medical ----------------------------------------------- 33 (45,47) Medical ----------------------------------------------- 34 (45,47) Medical ----------------------------------------------- 35 (12, 13) Osteopath ----------------------------------------------- 36 (48) Osteopath ----------------------------------------------- C. Inaccurate reporting by medicolegal journalists ------------------------------------------------- 37 (49) Medical ----------------------------------------------- 38 (50-53) Medical ----------------------------------------------- 39 (54-57) ----------------------------------------------- 40 (58-68) Osteopath -----------------------------------------------
* 40 examples, minus 7 that are duplications of earlier examples,
minus examples 4, 15 and 39 equals 30 cases.

DISCUSSION

Review of publications and of court, hospital, medical, ambulance and autopsy records dealing with manipulative iatrogenesis, collected over the last 17 yr. at RMIT University, reveal 535 cases of vertebrobasilar injury after cervical spine manipulation reported or alluded to in the English, French, German, Scandinavian and Chinese literature (1934–1994). Of these, 494 were published in the English language; 375 of these, however, were anecdotal or produced no convincing evidence, leaving a total of 119 actual reported cases in the English language.

Regarding Winer's claims, I challenge anybody to find "430 cerebrovascular catastrophes after cervical manipulation ... reported in the English-speaking literature" [26]. As of December 1992, only 78 cases could be classified as catastrophes (see Table 1). Winer arrives at this large figure by quoting Robertson [73], as he quoted his paper previously [74].

The Robertson article actually states:
In a recent survey of the Stroke Council of the American Heart Association, 360 heretofore unreported cases of extracranial injury were collected. Two thirds were vertebral arterial injury, one third carotid artery injury, and most were confirmed by arteriography [73].
This does not represent "reported" cases. It was the result of an "audience poll" at the meeting that fails dismally to meet accepted data collection methods. This statement has been previously criticized [75] as the survey yielded "360 cases of who-knows-what?"

Since then, Robertson has not produced any case study of manipulation-induced vertebrobasilar injury to support his statement. In the Abstracts of the subsequent meetings, sponsored by the Stroke Council of the American Heart Association, [76] no mention is made of patients injured by manual therapy, chiropractic or chiropractors. Careful reading of Robertson's editorial reveals that the words chiropractic and chiropractor are not mentioned, and in the author's rebuttal [77] the word chiropractic is mentioned only once, where Robertson mentions, that he had received letters from individuals and societies on this topic. Robertson does not state professional and/or educational background in any single case or say that the majority of cases were "caused by chiropractors," as stated by Winer [26].

Robertson states that one third of his cases involved carotid artery injury. This seems not to refer to therapeutic neck manipulation because the relationship between manual therapy and the occurrence of reported carotid artery injury' is extremely tenuous at best, having been reported in only four cases of manipulation induced vascular injury. Reportedly, one case involved a chiropractor [78], one involved a medical practitioner [79], one an osteopath [30] and one an Indian barber [23].

Winer makes another error in his article regarding tests for vertebrobasilar insufficiency, where he writes, "these were introduced into Australia by the AAMM, and are now widely practised by all different schools of manipulation [4]".

Winer's reference 4 refers to an article he wrote in 1986 [80] which does not mention anything regarding premanipulative tests for vertebrobasilar ischemia as suggested [26]. As early as 1977, in fact, chiropractors in Australia had lectured to manipulative physiotherapy audiences [3, 5] and written in manipulative physiotherapy texts [6] on the importance of the vertebral artery to cervical manipulation. Premanipulative testing procedures have been taught in chiropractic schools in Australia since 1977; were published and commented upon by Australian chiropractors long before Winer's publication in 1986 [3–11]; and had been published in the chiropractic literature since at least 1972 [81], 14 yr before Winer's article was published.

Unfortunately, once a case is incorrectly reported and published, respected authors in prestigious publications will later continue to republish the error unknowingly. The report of Frisoni and Anzola [27] illustrates this point in two instances.

Hamann et al. [45], as well as incorrectly reporting their four cases as being due to chiropractors and chiropractic manipulation (which in fact involved a lay practitioner and three medical specialists), also used the Frizoni and Anzola publication [27] as a reference for their statement that vertebral artery dissections are a complication of chiropractic maneuvers. Personal communication with Dr. Anzola (see Examples 26–28) revealed that their cases were due to a medical practitioner and two physiotherapists.

Chapter 15 in the 1993 Year Book of Neurology and Neurosurgery [82], titled "Chiropractic Manipulation Risks," was a review of the Frisoni and Anzola paper [27] and states, "This study describes 3 new cases and reviews the literature on patients who had vertebrobasilar strokes caused by chiropractic manipulation."

As already described, this paper [27] in fact described three new cases caused by a medical practitioner and two physiotherapists (Examples 26–28), and at least nine of the cases reviewed (Examples 5–13) were not due to chiropractic manipulation at all, but were caused by a wife, a medical practitioner, a heilpraktiker, a medical practitioner or naturopath, and two osteopaths. In three cases the practitioner was unknown.

The report of Dunne et al. [24] is very interesting because the report clearly states that a naturopath was the practitioner involved (Example 3). The Coroner's Inquest suggested that a medical practitioner may have been involved [25]. Neither suggested that a chiropractor was involved at all; yet the AMA document [21] and at least three other medical authors [27, 35, 37] referred to this paper as an example of a complication of "chiropractic" manipulation (Examples 13, 16, 18).

"The AMA document [21] quotes other papers [33, 83–84] from countries without chiropractic registration at that time. It is difficult in such cases to determine the educational and professional background of the person claimed by the AMA to be a chiropractor.

Errors regarding terminology and professional identity in these countries is common. See Examples:
     -------------------------------
     Example     2     (India),
     -------------------------------
     Example    25     (Ireland), 
     -------------------------------
     Examples   26–28  (Italy), 
     -------------------------------
     Example    29     (Taiwan),
     -------------------------------
     Example    30     (France), and
     -------------------------------
     Examples   31–34  (Germany)].
     -------------------------------
CONCLUSION

It is impossible to accurately determine just how often non-chiropractors have been inaccurately reported in the medical literature as chiropractors, because, in many cases, it is not possible to communicate with the original author, who has either died or relocated.

Although medical authors have incorrectly ascribed non-chiropractic cases to chiropractic and/or chiropractors, no example was found in the medical literature where a case of manipulation iatrogenesis involving a chiropractor had been incorrectly ascribed to a medical or other practitioner.

We must not deny the existence of the possibility of injury after manual therapy. All steps should be taken to increase awareness of and minimize injury. Australian chiropractors have written on cervical spine injuries after manipulation therapy and necessary precautions since 1977 [2–19].

The greater number of Cases involving chiropractors (see Table 1) is to be expected because of the much greater number of manipulations performed by chiropractors [In the USA, 94% chiropractic, 4% osteopathy, and 2% medical [85–86]].

It has been clearly demonstrated that the literature of medical organizations, medical authors and respected, peer-reviewed, indexed journals have, on numerous occasions, misrepresented the facts regarding the identity of a practitioner of manual therapy associated with patient injury.

Such biased reporting must influence the perception of chiropractic held by the reader, especially when
cases of death [12–13, 21, 24–25, 27, 29, 32, 35, 37, 44, 49, 54–57];

tetraplegia [27, 30, 33, 40, 58–68] and

neurological deficit [21, 23, 27–28, 31, 37–38, 41, 45, 48, 50–53, 58–68]
are incorrectly reported as having been caused by chiropractic. Because of the unwarranted negative opinion generated in medical readers and the lay public alike, erroneous reporting is likely to result in hesitancy to refer to and underutilization of this important mode of health care delivery.

Is this misrepresentation accidental or is it intentionally mischievous? In many cases, the medical author(s) had access to the original reports, which clearly document the practitioner as a non-chiropractor, yet medical authors cited in this paper still published papers incorrectly implicating chiropractic. If the cases described here can be viewed as "using false representations to obtain unjust advantage or injure another" it qualifies as a definition of fraud. [87].

In the public interest, reduction of incidents and accidents from manual therapy will be better served by a joint effort between knowledgeable chiropractors and medical practitioners than by the use of statements not based on fact.

ACKNOWLEDGEMENTS

I thank Professor Andries Kleynhans and Drs. Thomas Molyneux, Colin Crawford, Peter Bryner and Barbara Polus for suggestions that made this a more readable paper.

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Murthy JMK, Naidu KV.
Aneurysm of the cervical internal carotid artery following chiropractic manipulation.
J Neurol Neu- rosurg Psychiatry 1988; 51: 1237-8

Dunne JW, Conacher GN, Khangure M, Harper CG.
Dissecting aneurysms of the vertebral arteries following cervical manipulation: a case report.
J Neurol Neurosurg Psychiatry 1987; 50: 349-53

McCann DA (Coroner, Perth, Australia)
Findings on inquest. 1 August 1986

Winer C.
Spinal manipulation in current medical practice.
Patient Management 1992; 16: 43-9

Frisoni GB, Anzola GP.
Vertebrobasilar ischaemia after neck motion.
Stroke 1991; 22: 1452-60

Smith RA, Estridge MN.
Neurologic complications of head and neck manipulations.
JAMA 1962; 182: 528-31

Ford FR, Clark D.
Thrombosis of the basilar artery with softenings in the cerebellum and brainstem due to manipulation of the neck.
Bull Johns Hopkins Hosp 1956; 98: 37-42

Lyness SS, Wagman AD.
Neurological deficit following cervical manipulation.
Surg Neurol 1974; 2: 121-4

Mueller S, Sahs AL.
Brainstem dysfunction related to cervical manipulation.
Neurology 1976; 26: 547-60

Schmitt HP.
Manuelle Therapie der Halswirbelsaule.
Zeitschrift fur Allgemeinmedizin 1978; 54: 467-74

Povlsen UJ, Kjaer L, Arlien-Soborg P.
Locked-in syndrome following cervical manipulation.
Acta Neurol Scand 1987; 76: 486-80

Khurana RK, Genut AA, Yannakakis GD.
Locked-in syndrome with recovery.
Ann Neurol 1980; 8: 439-41

Phillips SJ, Maloney WJ, Gray J.
Pure motor stroke due to vertebral artery dissection.
Can J Neurol Sci 1989; 16: 348-51

Mas JL, Bousser MG, Hasboun D, Leplane D.
Extracranial vertebral artery dissections: a review of 13 cases.
Stroke 1987; 18: 1037-47

Johnson DW, Whiting G.
Cervical self manipulation and stroke.
Med J Aust 1993; 158: 290

Cook JW, San stead lK.
Wallenberg's syndrome following self-induced manipulation.
Neurology 1991; 41: 1695-6

Rothrock JF, Hesselink JR, Teacher TM.
Vertebral artery occlusion and stroke from cervical self manipulation.
Neurology 1991; 41: 1696

Schellhas KP, Latchaw RE, Wendling LR, Gold LHA.
Vertebrobasilar injuries following cervical manipulation.
JAMA 1980; 244: 1450-3

Carmody E, Buckley P, Hutchinson M.
Basilar artery occlusion following chiropractic cervical manipulation.
Ir Med J 1987; 80: 259-60

Cashley MAP.
Cervicocephalic artery dissections and chiropractic manipulations.
Lancet 1993; 341: 1213-14

Chen TW, Chen ST.
Brainstem stroke induced by chiropractic neck manipulation: a case report.
Chin Med J 1987; 40: 557-62

Mas JL, Henin D, Bousser MG, Chain F, Hauw JJ.
Dissecting aneurysm of the vertebral artery and cervical manipulation: a case report with autopsy.
Neurology 1989; 39: 512-15

Hamann G, Felber S, Haass A, Strittmatter M, Kujat C, Schimrigk K, Piepgras U.
Cervicocephalic artery dissections due to chiropractic manipulations.
Lancet 1993; 341: 764-5

Bohm 1.
Cervicocephalic artery dissections and chiropractic manipulations.
Lancet 1993; 341: 1214

Hamann G.
Cervicocephalic artery dissections and chiropractic manipulations.
Lancet 1993; 342:114

St. John Ambulance, Aukland. Ambulance officer's report (050990-047-61)
Emergency Department record, Registration/admission record, Clinical notes record,
Letter by the medical registrar, Outpatient record, Patient discharge form.

Butter B, Jansen A. Frank Baden-Powell:
theatrical giant's last curtain.
The Perth Sunday Times 1992 May 17: 29

The Metro Digest Section of the Los Angeles Times.
8 Nov 1991. (Quoted by reference 52)

Saltzberg v. Hawkins, Los Angeles County Superior Court, Case No. 697925.
Kakita J and Jury. Judgement, 13 November 1991. (Quoted by reference 53)

Anonymous.
MD's cervical manipulation causes woman's stroke.
MPI's Dynamic Chiropractic. 1991 Dee 20: 33

Chapman-Smith D.
Who should manipulate: 1.3 million award against MD.
The Chiropractic Report 1992; 6: 6

Ongaro D.
Medic in death riddle.
Daily Telegraph Mirror (Sydney) 1991 April 25; 5

McCann DA (Coroner).
Findings on Inquiry. Coroner's Court, Perth, Australia, 1 December 1992

Hutton J.
Neck treatment not cause of clot: lawyer.
The West Australian (Perth) 1992 Nov 20: 15

Hutton J. Inquest clears neck therapy.
The West Australian (Perth) 1992 Dec 2: 28

Bell v. Griffiths. Hunter J (Judgement).
Supreme Court, Come mon Law Division, Sydney: 14 Sept 1994

Payout no laughing matter.
Melbourne Herald Sun 1994 Sept 15: 3

Papadopoulos N.
$494,760- but it's no laughing matter.
The Melbourne Age 1994 Sept 15: 1

Radio man gets $490,000.
Sydney Daily Telegraph Mirror 1994 Sept 15: 3

Papadopoulos N. Croaky
DJ gets $1/2 M award.
Sydney Morning Herald 1994 Sept 15: 2

Scott 1.
Damages for neck injury.
The Australian 1994 Sept 15: 7

Radio man's $500,000 pain in the neck.
Adelaide Advertiser 1994 Sept 15: 1-2

Laughing DJ compensated.
Townsville Bulletin 1994 Sept 15: 10

Announcer gets compo.
Brisbane Courier Mail (late city ed.) 1994 Sept 15: 4

$.5 mill payout for radio announcer.
Darwin Northern Territory News 1994 Sept 15: 13

Radio career ruined by chiropractor.
The Hobart Mercury 1994 Sept 15: 5

John Bell:
buried alive.
New Idea 1987 Aug 29: 21

Yellow Pages Australia.
Sydney Yellow Pages L-Z (Telephone Book).
Milsons Point, NSW, Australia: Yellow Pages Australia, 1994: 2040

Clarification.
The Melbourne Age 1994 Sept 17: 6

Mottram M.
The week.
Melbourne Sunday Age 1994 Sept 18:2

Robertson IT.
Neck manipulation as a cause of stroke.
Stroke 1981; 12: 1

Winer C.
Catastrophes following forceful cervical manipulation.
Bull Aust Assoc Musculoskeletal Med 1986; 2: 28-30

Watson NA.
Acute brainstem stroke during neck manipulation.
BMJ 1984; 288: 641

Abstracts of the 7th Joint Meeting on Stroke and Cerebral Circulation.
Stroke 1982; 13: 111-25

Robertson JT.
Author's rebuttal. [Rebuttal to Fraser DM. Neck manipulation as a cause of stroke (Letter).
Stroke 1981; 12: 260] Stroke 1982; 12: 260-1

Beatty R.
Dissecting hematoma of the internal carotid artery following chiropractic cervical manipulation.
J Trauma 1977; 17: 248-9

Braune HJ, Munk MHJ, Huffmann G.
Hirninfarkt irn Stromgebiet der Arteria Cerebri Media nach Chirotherapie der Halswirbelsaule.
Dtsch Med Wochenschr 1991; 116: 1047-50

Winer C.
Bull Aust Assoc Musculoskeletal Med 1986; 2: 10-11

Houle JOE.
Assessing hemodynamics of the vertebrobasilar complex through angiothlipsis.
Digest Chiro Econ 1972 (Sep/Oct): 14-15

Bradley WG.
Chiropractic manipulation risks.
In: Bradley WG, Crowell RM, eds.
The year book of neurology and neurosurgery 1993.
St. Louis: Mosby, 1993: 229

Destee A, Lesoin F, Di Paola F, Warot P.
Intradural herniated cervical disc associated with chiropractic spinal manipulation.
J Neurol Neurosurg Psychiatry 1989; 52: 1113

Grayson MF.
Homer's syndrome after manipulation of the neck.
BMJ 1987; 295: 1381-2

Shekelle PG, Brook RH.
A community based study of the use of chiropractic services.
Am J Public Health 1991; 81: 439-42

Shekelle PG, Adams AH, Chassin MR, Hurwitz EL, Phillips RB, Brook RH.
The Appropriateness of Spinal Manipulation for Low Back Pain:
Project Overview and Literature Review
RAND, Santa Monica, CA. 1991; CCR/FCER Monograph No. R-4025/1

Fraud.
The Standard English Desk Dictionary.
Sydney: Bay Books, 1976: 331

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