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EDITORIALS: E Ernst and W J J Assendelft Chiropractic for low back pain BMJ 1998; 317: 160 [Full text]

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Chiropractic for Low Back Pain

Roy M Love   (20 July 1998)

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Robert A King   (21 July 1998)

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Lynn Whitaker   (22 July 1998)

more good than harm

Charles Pfeifle   (23 July 1998)

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Christopher Davis   (24 July 1998)

Low back pain and beneficial effect of chiropractic.

Klaas J Postma   (24 July 1998)

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Michael Pedigo   (4 August 1998)

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Alan Breen   (4 August 1998)

Chiropractic

L G F Giles   (4 August 1998)

Chiropractic for low back pain

A Scott Lakernick   (18 August 1998)

Take a closer look at the evidence for safety

Neil Osborne   (18 August 1998)

Mobilisation and manipulation are vastly different

Garland D Glenn   (11 September 1998)

JUST A JOURNALISTIC ARTICLE

Michele Spangaro   (21 December 1998)

Confusing a Profession with a Treatment Modality Again

Gregory T Wright   (20 July 1999)

Chiropractic for Low Back Pain 20 July 1998
Roy M Love, Imed past pres of Pa Chiro Assoc. Nittany Valley Chiropractic Send response to journal: Re: Chiropractic for Low Back Pain	I find Ernts and Assendelft's article both interesting and incongruent. Failing to referrence Meade's and Koes work comparing chiropractic to physical therapy and traditional medicine for low back pain pubished in BMJ and showing chiropractic's superiority in effectiveness and long term benefit is perplexing. To fail to mention that medically accepted forms of treatment ie. physical therapy modalities and prescriptions like muscle relaxants and injections have shown no valid research basis for therapy is irresponsible literature research review. If the authors find chiropractic treatment for low back pain lacking validity according to research basis I would like to know what they think is supported as effective for the treatment of low back pain. Lastly let us remember that the choropractic profession did most of their research on validity on a self funded basis where the medical profession and physical therapy profession with federally funded grants available did nothing to investigate the validity of their practices. In final comment, few medical procedures have a one in one million complication rate. I wonder if physicians warn their patients of the much greater risk of a female smoking patients sustaining a stroke from taking some forms of birth control medications. Since the US Agency for Health Care Policy and Research came to their conclusions regarding efficacy of treatments for acute low back pain there seems to be a great deal of interest in reexamining spinal manipulation's effectiveness. I think these authors should not throw stones if they live in glass houses.
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Robert A King Send response to journal: Re: this article	Thank you for your editorial in the most recent edition of BMJ. We are unsure of many things, particularly medical care and the use of pharmaceuticals in treating various illnesses. Not only should we continue to question chiropractic, osteopathic or medical intervention; perhaps we should seek to find a way to prevent the 106,000 deaths from prescription medications each year (U.S. stats). I would also be very curious to know the cost of more than 2 million adverse reactions to prescription drugs in the U.S alone, each year. And certainly I am an avid proponent of research, and would be happy to support continued research on the 85% of medical treatments that are unproven. Your article helps to raise questions, particualry the more serious ones. Thank you.
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Lynn Whitaker Send response to journal: Re: this article	It is a pity that the authors of the leading article on the role of chiropractic in low back pain1 appear to be so ignorant about chiropractic in the United Kingdom. The serious reservations they express about safety should not have been made without an adequate understanding of the field. One third of all chiropractors in Britain are trained in the McTimoney school (identifiable by the letters AMCA, MMCA or FMCA). McTimoney chiropractors assess patients on the basis of history and examination: they do not use radiographs and cannot be accused of exposing their patients unnecessarily to radiation. The risks of (rare) complications of treatment quoted in the article apply only to high velocity manipulation techniques - the 'bone crunching' of popular conception. McTimoney chiropractors do not practise these; they use a highly specific and accurate technique (toggle-recoil) for mobilising joints which involves negligible force. They are trained to identify and exclude the relatively few patients with contraindications to this treatment during history taking and examination. Lastly, McTimoney chiropractors recognise the skills of doctors and are trained to communicate and work with medical practitioners. There is nothing in their training to instill negative attitudes towards immunisation. A leading article on the effectiveness or otherwise of the medical management of back pain would not refer generically to treatment with 'pharmaceuticals' - the authors would specify exactly which drugs were under discussion and evaluate their respective beneficial and deleterious effects. Given the heterogenous nature of the chiropractic profession, it is similarly important that researchers and authors distinguish between different modalities of 'chiropractic'. Yours sincerely Lynn Whitaker BA RGN (student McTimoney chiropractor - corresponding author) Phil Whitaker MA MRCGP (non-principal GP) 1. Ernst E, Assendelft WJJ. Chiropractic for low back pain. BMJ 1998;317:160
more good than harm 23 July 1998
Charles Pfeifle private chiropractic practice Send response to journal: Re: more good than harm	That the authors would like to cast some doubt on all the positive publicity that chiropractic has been receiving recently, is understandable. That they question that, especially in English speaking countries, the results of Manual Therapy studies are used to defend chiropractic is correct. That they contend that the definite proof of chiropractic is not in yet, can be supported. Assuming then, that it does not work, then any risk, be it minute, would be too much. But to imply that the results of the studies on manipulations that have been done (more than on any other treatment for low back pain) are not at least seemingly effective is ludicrous. That more research is necessary is a cliché last sentence in all studies, especially systematic reviews, and can be accepted as a truth. In the meantime, we must run with this ball. The issue of risk is almost a non-issue. The risk is negligible. (The frequent mild and short reactions to a treatment can be regarded as innocent, and not relevant to these arguments.) That we should be concerned with risks, and try to reduce them even more, is obvious. To use this as an argument against chiropractic, in the light of medical risk in general, is hypocritical. (At a minimum, the forth leading cause of deaths in the US is related to adverse reactions to medicine!) To quote one of the authors, "Although complications of spinal manipulations have not yet been studied in prospective surveys, the incidence of serious complications is generally considered to be low", and "Cauda Equina Syndrome, as a result of spinal manipulation, can be assumed to be rare, ...."(1). As for the allegation of overuse of x-rays, a useful comparison is a recent study in the Journal of Manipulative and Physiological Therapeutics(2), showing that chiropractors refer less often for MRI than other disciplines, and seem to be better at referring those patients who have some form of pathology. We are curious as to the cited article yet to be published on these professed excesses. The question of cost-effectiveness has certainly not been satisfactorily answered, but if the benefit of the doubt goes to the side with significantly more studies showing cost-effective ness, than those showing none, then chiropractic wins that one at the time being. Two new additions have recently been added(3,4). The use of the argument "the negative attitude of some chiropractors towards immunisation" is almost insulting. That some chiropractors (and probably as many other medical profession als) commit adultery certainly does not mean that the vast majority practice or condone this activity. As a matter of fact, there has been controversy on immunisation for years; it is not just the domain of chiropractors. To question the validity of any treatment is the position of a scientist. Unfortunately, there are not enough good studies on chiropractic. This is being worked on at many centres throughout the world. Only recently has there been any money available outside of the profession for these endeavours. That this much research has been done so far, completely dependent on donations from the profession, is a credit to that profession. They certainly deserve additional support in the future. Charles Pfeifle Oosterhout, The Netherlands 1. Assendelft WJJ, Bouter LM, Knipschild PG. Complications of spinal manipulation - a comprehensive review of the literature. J Fam Pract 1996; 42:475-480. 2. Kilmer SE, Chiropractic utilization of lumbar magnetic resonance imaging: how accurate are we compared with other specialties? J Manipulative Physiol Ther 1998; 21:173-176. 3. Manga P., Angus D., Enhanced chiropractic coverage under OHIP as a means of reducing health care costs, attaining better health outcomes and achieving equitable access to health services. Ottawa, Canada 1998. 4. Scheurmier N, Breen AC. A pilot study of the purchase of manipulation services for acute low back pain in the United Kingdom. J Manipulative Physiol Ther 21(1)14-18.
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Christopher Davis Send response to journal: Re: this article	Editor, Is fairness outmoded, I asked myself, as I read Ernst and Assendelft's article1? They assert that "cervical manipulations are burdened with severe adverse reactions...", yet a 1996 RAND Corporation report2 surveying "The Appropriateness of Manipulation and Mobilization of the Cervical Spine" found that serious complications from manipulation occur with a frequency of one in one million treatments and that mortality is three in 10 million treatments. Moreover this refers to all manipulations, not just those carried out by Chiropractors. But, the iatrogenic burden of NSAIDs ingestion is, arguably, orders of magnitude greater, with serious GI events occurring at a rate of one in a thousand. Severe neurological complications from cervical spine surgery run at nearly 16 in every thousand cases with associated mortality being about seven per thousand cases. I shall leave debate about the effectiveness of Chiropractic in the treatment of low back pain to my betters but I think it only reasonable to remind readers of two articles published in this journal in 19903 and 19954 reporting the results of an MRC trial, and its follow up of the same cohort, the authors of which concluded that "at three years the results confirm the findings of the earlier report that ........ those treated by chiropractic derive more benefit and long term satisfaction than those treated by hospitals." Were Ernst and Assendelft to write their article again substituting any one of hundreds of 'classical' medical or surgical interventions, for chiropractic and low back pain, they could cast a similar shadow over many well-known, accepted and effective therapies which would be judged ineffective and unsafe using the scales they have employed to weigh the case of chiropractic! Christopher Davis OBE Consultant in Pharmaceutical Medicine and Applied Physiology Og House Ogbourne St George Marlborough Wiltshire SN8 1TF 1 Ernst E, Assendelft WJJ. Chiropractic for low back pain. BMJ 1998;7152:160. 2 Coulter et al. The Appropriateness of Manipulation and Mobilization of the Cervical Spine. RAND Document No MR-781-CR 1996 Santa Monica, California. 3 Meade et al. Low back pain of mechanical origin: Randomized comparison of chiropractic and hospital outpatients treatment. BMJ 1990;300:1431-7. 4 Meade et al. Randomized comparison of chiropractic and hospital and outpatient treatments: results from extended follow-up. BMJ 1995;311:349-351.
Low back pain and beneficial effect of chiropractic. 24 July 1998
Klaas J Postma, medical examiner Back Diagnosis and Treatment Advisory Workers' Compensation Board, British Columbia, Canada Send response to journal: Re: Low back pain and beneficial effect of chiropractic.	Having dealt with chronic low back pain patients in a multi-disciplinary Chronic Pain Program for nearly twenty years and currently assessing complex low back pain problems, this leads me to make the following observations: First of all, it is my strong conviction that most low back pain symptoms, persisting for longer than three or four weeks, are either on the basis of a medical underlying condition, or due to lumbar disc related pathology and NOT due to so-called "musculo-ligamentous injury"! Premature Adolescent Discogenic Disease is but one example. However, regardless of the underlying pathology, there are two reasons why chiropractic may improve low back pain patients. Firstly, to have daily "treatments" means for the patients to get out of bed, get dressed and get to the office and back. In other words, they engage in some physical activity, which is many times better than lying on the couch or on the floor, taking narcotic analgesics! Secondly, the chiropractor literally puts his or her hands on the patient's back instead of only talking and advising from the other side of the desk! The patient, quite appropriately, translates this into a sense of caring and compassion, which has an enormous placebo effect! Klaas J. Postma MD
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Michael Pedigo, President American Chiropractic Association Send response to journal: Re: this article	To the Editor: If you would like information on chiropractic's track record for treating low-back pain, perhaps you should ask the 20 million patients who will visit doctors of chiropractic this year alone. Patient satisfaction with chiropractic care has consistently rated higher than traditional medical care for low-back pain. A significant recent study found that "compared to those who sought care from medical doctors, those who sought care from chiropractors were more likely to feel that treatment was helpful, more likely to be satisfied with their care, and less likely to seek care from another provider for that same episode of pain." [Spine, Carey et al. (1996)] A study published in the July 1, 1998 issue of the Annals of Internal Medicine shows that chiropractic treatment is appropriate for low-back pain in a considerable number of cases. The study by the Rand Corporation found that 46 percent of a sample of low-back pain patients received appropriate care from doctors of chiropractic — an appropriateness rating similar to that of common medical procedures. In addition, chiropractic is one of the safest forms of treatment available today. According to a study by the Rand Corporation, a serious adverse reaction from cervical manipulation occurs once in 1 million manipulations. [Spine, Hurwitz et al. (1996)]. Complication rates for manipulation of the lumbar region of the spine are even lower, with odds of a serious reaction occurring in one in 100 million manipulations. [Annals of Internal Medicine, Shekelle et al, (1992)]. When compared to the number of illnesses and deaths that will occur this year from the appropriate use of prescription and over-the-counter drugs, the number of serious complications from chiropractic treatment is extremely low. A study published in the April 15, 1998 issue of the Journal of the American Medical Association found that more than 2 million Americans become seriously ill every year from reactions to correctly-prescribed drugs and 106,000 die from those side effects. My profession, like every other health care profession, is by no means beyond reproach. I agree that more and better chiropractic research is required. More and better medical research is required as well. It is my hope that the chiropractic and medical professions will continue to work together in this regard. Our patients will be the ultimate beneficiaries. Sincerely, Michael D. Pedigo, D.C. President American Chiropractic Association
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Alan Breen, Research Director Send response to journal: Re: this article	EDITOR, The Editorial, "Chiropractic for low back pain - we don't know whether it does more good than harm"1, seems to have been written more in a spirit of professional aversion than one of critical doubt. This impression is conditioned by previous commentaries by these authors in the popular press2 and the biomedical literature3-6. The question is why? There is substantial scientific evidence that the manipulation that chiropractors (and indeed osteopaths and some physiotherapists) do for back pain is both effective and safe. This evidence has been reviewed by multidisciplinary panels of experts in both the UK and USA7-8 , resulting in the production of two national clinical practice guidelines for acute back pain which totally disagree with these authors. The only randomised controlled trial of overall chiropractic management for back pain9-10, in contrast to manipulation alone, is not mentioned in this Editorial, yet this trial (included erroneously by one of these authors in 199111 in a review of manipulation trials) was ranked as high quality, was positive in its evidence for chiropractic management and yet was subsequently condemned as seriously flawed by him in a separate paper6. This Editorial is equally contradictory. No one would dispute the need to research further the evidence for the effectiveness, cost-effectiveness and safety of manipulation and associated treatment approaches. The Medical Research Council is currently supporting a large randomised trial in this area by a multidisciplinary research team led by the Department of Health Sciences and Clinical Evaluation at the University of York. Many other studies are in progress. Nevertheless, the current UK National Clinical Practice Guideline Evidence Review states: "Within the first 6 weeks of acute or recurrent low back pain, manipulation provides better short-term improvement in pain and activity levels and higher patient satisfaction than the treatments to which it has been compared." and "The risks of manipulation for low back pain are very low, provided patients are selected and assessed properly and it is carried out by a trained therapist or practitioner" 7. Both the Chiropractors and Osteopaths Acts and their General Councils will provide these assurances for the public, however, there is no certainty in science. Those who demand certain proof of things are already prejudiced against them. Alan Breen, Research Director Anglo-European College of Chiropractic, Bournemouth BH5 2DF 1. Ernst E, Assendelft WJJ. Chiropractic for low back pain - we don't know whether it does more good than harm. British Medical Journal 1998;317:160. (18 July) 2. Ernst E. Hidden truths behind healing hands. The Independent 1998, June 2. 3. Ernst E. Beyond reasonable doubt. New Scientist 1998 April 18:49. 4. Ernst E. Cervical manipulation - is it really safe? Internal Journal of Risk & Safety in Medicine 1994;145-49. 5. Ernst E. Bitter pills of nature: safety issues in complementary medicine. Pain 1995;60:237-38. 6. Assendelft WJJ, Bouter LM, Kessels AGJ. Effectiveness of chiropractic and physiotherapy in the treatment of low back pain: a critical discussion of the British Randomised Clinical Trial. Journal of Manipulative and Physiological Therapeutics 1991;14(5):281-86. 7. Waddell G, Feder G, McIntosh A, Lewis M, Hutchinson A. Clinical guidelines for the management of acute low back pain: clinical guidelines and evidence review. London: Royal College of General Practitioners, 1996. 8. Agency for Health Care Policy Research. Management guidelines for acute back pain. Washington DC: US Department of Health and Human Services, 1994. 9. Meade TW, Dyer S, Browne W, Townsend J, Frank AO. Low back pain of mechanical origin: randomised comparison of chiropractic and hospital outpatient treatment. British Medical Journal 1990;300(6737):1431-37. (June) 10. Meade TW, Dyer S, Browne W, Frank AO. Randomised comparison of chiropractic and hospital outpatient management for low back pain: results from extended follow-up. British Medical Journal 1995;311:349-51. (November) 11. Koes BW, Assendelft WJJ, van der Heijden GJMG, Bouter LM, Knipschild PG. Spinal manipulation and mobilisation for back and neck pain: a blinded review. British Medical Journal 1991;303:1298-1302. (November)
Chiropractic 4 August 1998
L G F Giles, Director, Spinal Pain Unit Townsville General Hospital Send response to journal: Re: Chiropractic	The Editor, Editorials "Chiropractic for Low Back Pain" BMJ 1998; 317:160-160 (18 July) This Editorial is titled "Chiropractic for Low Back Pain" but Ernst and Assendelft refer to cervical manipulations, potential overuse of radiographs by chiropractors and a negative attitude of some chiropractors to immunisation. Therefore, one must assume that a buckshot approach aimed fairly and squarely at chiropractic has been taken as topics unrelated to the title of the Editorial have clearly been included. The apparent attempt to define chiropractic intervention in the Editorial's opening paragraph is incorrect, stating that, for example, chiropractic is used in the "hope of correcting vertebral disc displacements ......" and in the hope of correcting "spinal misalignment". Properly qualified chiropractors do not hope to correct "vertebral disc displacements", by manipulating the spine, as is implied. It would be stupid to contemplate manipulating the spine for disc displacement by which the authors presumably mean extruded disc material. "Spinal misalignment" can be corrected by using an appropriate shoe-raise when leg length inequality and pelvic obliquity are the cause of the postural scoliosis (or spinal misalignment) (Giles and Taylor 1981; Giles 1984). Ernst and Assendelft have selectively cited the literature. For example, they cite two Journal of Manipulative and Physiological Therapeutics papers (references 4 and 13) written by Assendelft et al (1996) and Assendelft and Bouter (1993). Why was the important paper by Terrett (1995), in which he clearly cites misuse of the literature by medical authors in discussing spinal manipulative therapy injury, selectively excluded when the Editorial raises the issue of "cervical manipulations are burdened with severe adverse reactions such as vertebrobasilar accidents and paralyses due to fractures"? The only reference to this topic is by Assendelft et al 1996 (reference 5). Ernst and Assendelft apparently saw it as appropriate that Ernst's paper "Chiropractors' use of X-rays" should be included (reference 8), as well as Ernst's paper which apparently refers to "negative attitude of some chiropractors towards immunisation" (reference 9). Normally, scientific documents at least reflect the topic under discussion in the title and, in my opinion, the Editorial's title is misleading. Furthermore, from a scientific point of view, it would be more appropriate to use references other than a preponderance of one's own to make a particular point, and not to omit any pertinent reference such as Terrett's (1995). Finally, I have often wondered how the BMJ Editorial Board published the paper "Spinal Manipulation and Mobilisation for Back and Neck Pain: a blinded Review" by Koes, Assendelft, Vander Heijden, Bouter and Knipschild (1991) when the authors made the following statement under Introduction: "Manipulation involves a high velocity thrust to a joint beyond its restricted range of movement. Mobilisation uses low velocity passive movements within or at the limit of joint range", citing Ottenbacher and Di Fabio (1985). Koes et al (1991) then stated "throughout this article we will use manipulation to cover both manipulation and mobilisation" - a preposterous statement for anyone purporting to know anything about manipulation or mobilisation! Assendelft WJJ, Bouter LM, Knipschild PG. Complications of spinal manipulation - a comprehensive review of the literature. J Fam Pract 1996; 42: 475-480. Assendelft WJJ, Bouter LM. Does the goose really lay golden eggs? A methological review of workmen's compensation studies. J Manipulative Physiol Ther 1993; 16: 161-168. Assendelft WJJ, Koes BW, Van der Heijden GJMG, Bouter LM. The effectiveness of chiropractic for treatment of low back pain: an update and attempt at statistical pooling. J Manipulative Physiol Ther 1996; 19: 499-507 Ernst E. Chiropractors' use of X-rays. Br J Radiol (in press). Ernst E. The attitude against immunisation within some branches of complementary medicine. Eur J Pediatr 1997; 156: 513-515. Giles LGF, Taylor JR. Low back pain associated with leg length inequality. Spine 1981; 6: 510-521. Giles LGF. Letter to the Editor. Spine 1984; 9: 842. Koes BW, Assendelft WJJ, vander Heijden GJMG, Bouter LM, Knipschild PG. Spinal manipulation and mobilisation for back and neck pain: a blinded review. BMJ 1991; 303; 1298-1303. Ottenbacher K, De Fabio RP. Efficacy of spinal manipulation/mobilisation therapy; a meta-analysis. Spine 1985; 10-833-837. Terrett AGJ. Misuse of the literature by medical authors in discussing spinal manipulative therapy injury. J Manipulative Physiol Ther 1995; 18: 203-210.
Chiropractic for low back pain 18 August 1998
A Scott Lakernick, Chiropractic Neurologist Family Chiropractic Wellness Center Send response to journal: Re: Chiropractic for low back pain	It is truly unfortunate that the authors apparently never interviewed a single Chiropractor or Chiropractic patient before rendering their propaganda laden opinions. First, I for one feel that if the risk factors involved in a cervical manipulation is factually one in one million, then this procedure must be valid. I do not know of any medical procedure which enjoys a similarly low risk factor (eg spinal surgery, lumbar epidural blocks, etc) Second, to generalize that all chiropractors feel adverse to medical procedures, citing immunization as the example, is ridiculous. We are all doctors seeking the best possible result for our patients. I sincerely hope that these authors are not insinuating that we would believe otherwise. Third, the use of cervical spinal manipulation to relieve nociception in all areas of the spine is well documented. As we stimulate joint mechanoreceptors in the intervertebral articulations, a cortical response will initiate feedback through reticulo spinal formations and will serve to inhibit nociception. I believe more homework is necessary before an opinion article like this one is published. The British Medical Journal should set higher standards for their publications. Please keep in mind that all research in the Chiropractic profession is self funded without federal grant money. If the medical profession is truly interested in cooperation amongst the healing arts, then they should act accordingly.
Take a closer look at the evidence for safety 18 August 1998
Neil Osborne, Senior Clinical Tutor Anglo-Europran College of Chiropractic Send response to journal: Re: Take a closer look at the evidence for safety	In July of 1998 Ernst and Assendelft presented an article in the British Medical Journal entitled “Chiropractic for low back pain: We don’t know whether it does more good than harm” (1). Although well respected researchers and valued contributors in the contemporary push towards ‘evidence-based practice’, it appears that their strive for objectivity has lead to a biased and ill-informed piece of work, that highlights many of the issues against which the antagonists of ‘evidence-based practice’ warn. The authors address matters of effectiveness and cost-effectiveness, but that which is most unhelpful and destructive is their presentation of safety issues. Whilst correctly stating that cervical manipulation carries a risk of stroke to the posterior circulation they fail to put this statement into context. This risk is, thankfully, very small and is estimated at approximately 1 per 1 million cervical manipulations (2,3). A level of risk described by Calman, in 1996, as “negligible” (4). To further place this level of risk in context, a possible alternative to cervical spine manipulation is cervical spine neurosurgery, which carries an estimated paralysis rate of 15,600 per million and a mortality rate of 6,900 per million (5,6). Perhaps a more realistic comparison is with non-steroidal anti-inflammatory drugs (NSAID’s), often prescribed for conditions amenable to spinal manipulative therapy. In 1995 Dabbs and Lauretti (7) reviewed the literature to compare the risk of severe complication from NSAID’s with cervical manipulation, concluding that “cervical manipulation for neck pain is much safer than the use of NSAID’s, by as much as an estimated factor of several hundred times”. Coulter et al (5) estimate that serious complications of NSAID’s, such as gastric perforation and haemorrhage, to be in the region of 1000 per million patients. In England and Wales the gastric bleed incidence for the over sixty population is suggested to be in the region of 1 in 1000 (8) with a very significant correlation between hospitalisation for a serious gastric event and pre-existing use of NSAID. Furthermore, Ernst and Assendelft (1) ascribe all stroke incidents - or Vertebro Basilar Accidents (VBA) - as complications of ‘chiropractic’. Indeed, closer scrutiny of their cited reference (3), detailing the 165 post-manipulative VBA’s reported world-wide between 1947 and 1993, shows that only 92 (55%) were performed by chiropractors the remainder by medical manipulators, osteopaths, physiotherapists, barbers, self manipulation etc. Given that chiropractors, world-wide, probably administer the majority of manipulations - at least 94% in the USA (9) - these statistics would seem to support chiropractic’s brand of manipulation, not condemn it. Furthermore, in 1995 Terrett (9) contacted the patients or original authors of many of such case studies and discovered some gross misrepresentations. He cites 30 cases that were attributed to ‘chiropractic’ in the literature but were in fact administered by other members of the manipulative disciplines, the patients themselves, their wives, barbers and even a Kung Fu instructor. Ernst and Assendelft also claim that fractures are a complication of spinal manipulation (1). Again, this is in part true, but the title of their article again implicates chiropractors alone. The study they cite describes 56 serious complications (other than VBA) from 1925 to 1993, world-wide, of which 31 are fractures, dislocations or involve compression of the myelum. 14 of these are at the hands of chiropractors, the remainder, at the hands of others. Of these 14 cases, 8 demonstrated pre-existing bone disease that would necessarily weaken the bone, such as prostatic metastasis, Pagets etc. No information was available on the remaining 6 cases. It is little wonder that chiropractors place so much emphasis on identifying the non-manipulable lesion through history, examination and x-ray as necessary, in both their training and practice. To have 14 such reported cases in 68 years, only 6 of which were in the last 20 years, world-wide, is frankly anecdotal - and hardly warrants the title of their paper “.. we don’t know whether it (chiropractic) does more good than harm”. With respect to effectiveness and cost-effectiveness, probably the most comprehensive report has been conducted by professor Pran Manga, a Canadian economist who, produced two exhaustive reports (10,11). He looked at international evidence from the UK, USA and Canada and concluded that “there would be highly significant cost savings if more management of low-back pain was transferred from physicians to chiropractors. Evidence from Canada and other countries suggests potential savings of hundreds of millions annually”. Professor Manga was also asked to comment on the study that Ernst and Assendelft cite to demonstrate a lack of chiropractic cost- effectiveness (12). He suggests that this is one of only two studies that do not show better cost-effectiveness of chiropractic care and that “both of these are by medical researchers not economists” and “ have significant design problems that render their conclusions unreliable” (13). Many of Professor Manga’s conclusions on effectiveness are supported by the UK’s Royal College of General Practitioners (RCGP) who, after a thorough analysis of the appropriate literature, produced guidelines for the management of acute low back pain, and openly support the use of chiropractic and other manipulative disciplines (14). In 1990 Meade et al (15) published the results of a randomised trial on the effectiveness of chiropractic compared with hospital out-patient departments in treating low back pain, with very favourable results. Equally favourable were the results at five year follow-up of the same cohort (16). Close inspection of the published literature would suggest statements made by Ernst and Assendelft (1), such as “cervical manipulations are burdened with severe adverse reactions, such as vertebrobasilar accidents and paralyses due to fractures” and “on the basis of the current evidence, it seems uncertain whether chiropractic does more good than harm” to be grossly irresponsible. Clearly, there must be greater care taken when reporting articles that may be unjustly damning to a profession or effective technique. Evidence-based practice is a gold standard towards which we must all progress, but the review of evidence must be accurate, within the context of the clinical discipline to which it relates, and not an isolated ill-informed and theoretical account. After all, whilst I understand that it is mathematically impossible for Bumble Bees to fly, I believe that there is considerable empirical evidence to the contrary. Neil Osborne BSc, DC Senior Clinical Tutor Anglo-European College of Chiropractic, Parkwood Road, Bournemouth. 1 Ernst E, Assendelft W. Chiropractic for low back pain: We don’t know whether it does more good than harm. BMJ 1998; 317:160 2 McGreggor M, Haldeman S, Hohlbeck F. Vertebrobasilar compromise associated with cervical manipulation. Top Clin Chiro 1995; 2(3):63-73 3 Assendelft W, Bouter L, Knipschild PG. Complications of spinal manipulation - a comprehensive review of the literature. J Fam Pract 1996; 42:475-480 4 Calman K. Cancer: science and society and the communication of risk. BMJ 1996:313; 799-802. 5 Coulter ID, Hurwitz EL, Adams AH Meeker WC Hansen DT, Mootz RD, Aker PD, Genovese BJ, Shekelle PG. The appropriateness of manipulation and mobilisation of the cervical spine. RAND 1996. Santa Monica, CA. Document no. MR-781-CR. 6 Thiel H. Chiropractic manipulation of the cervical spine and cerebrovascular injury: A comment. Comp Ther in Medicine. 1994;2:231-232. 7 Dabbs and Lauretti .A risk assessment of cervical manipulation Vs NSAID for the treatment of neck pain. J Manip and Physiol Ther 1995;18:8 530-53 8 Langmann MJ, Weil J, Wainwright P et al. Risks of bleeding peptic ulcer associated with individual NSAID. Lancet 1994, 343 :1075-78. 9 Terrett AG. Misuse of the literature by medical authors in discussing spinal manipulative therapy injury. J Manip and Physiol Ther 1995 18:203-210 10 Manga, Angus.Enhanced chiropractic coverage under OHIP as a means of reducing healthcare costs, attaining better health outcomes and improving the public’s access to cost-effective health services. 1988, University of Ottowa, Ottowa, Canada. 11 Manga, Angus et al (The effectiveness and cost-effectiveness of chiropractic management of low-back pain Pran Manga associates 1993, University of Ottowa, Ottowa, Canada. 12 Carey, Garrett et al The outcomes and costs of care for the acute low back pain among patients seen by primary care practitioners, chiropractors and orthopaedic surgeons. N Eng J Med 1995 333:913-917 13 Chapman Smith .The Chiropractic Report. 1988 12:2 p2 14 Waddell G, Feder G, McIntosh A, Lewis M, Hutchinson A. Low back pain evidence review. 1996 London: Royal College of General Practitioners 15 Meade et al. Low back pain of mechanical origin: Randomised comparison of chiropractic and hospital outpatient treatment BMJ 1990; 300: 1431-7 16 Meade et al Randomised comparison of chiropractic and hospital outpatient treatment: results from extended follow-up. BMJ 1995; 311
Mobilisation and manipulation are vastly different 11 September 1998
Garland D Glenn, private practice Fordingbridge, UK Send response to journal: Re: Mobilisation and manipulation are vastly different	Many of the gross misinterpretations in the article in question have already been addressed, such as efficacy and safety. These topics have so exhaustively been researched that it's time to move on to other uses for the limited funds available in research. The one area which has not been addressed is the comparison of manipulation with mobilisation. In William Kirkaldy-Willis's current edition of the reference work Managing Low Back Pain, not only is there a comparison made between the two, manipulation is shown to be significantly more effective. Perhaps the most important point in this, though, is that the authors do not themselves know the difference. Neurologically mobilisation and manipulation are vastly different. Lower back conditions, such as we are discusing here, are primarily reflexogenic activities. Mobilisation fires muscle spindle fibers which increase the frequency of firing of the target muscle while manipulation fires Golgi tendon organs causing a resetting of the gain and resting length of the target muscle. This is not only different; this is critical. It also explains why manipulation is so much more effective than anything utilised to date. To not understand this difference and claim to treat spinal conditions is an inexcusable ignorance of the basic neurophysiology of the very thing you are claiming to be an expert in. It is disappointing that such a well respected journal would publish such an article.
JUST A JOURNALISTIC ARTICLE 21 December 1998
Michele Spangaro ITALY Send response to journal: Re: JUST A JOURNALISTIC ARTICLE	I'm not a psychiatrist but I do not think I need to be one to say that the primary motive power producing articles like 'Chiropractic for l.b.p.'must be a feeling of fear. It is interesting to see how part of the scentific world is still unconfortably afraid of the consolidate of Chiropractic in our society. The insubstantial nature of 'Chiropractic for lbp' is quite clear and it has been amply shown by the other comments to the article. The script becomes infact insubstantial been published in a Medical and thus 'Scentific' journal. Mr Ernest's (& co) article would have been almost fine if published in an illustrated magazine where opinions can be red at every other page. 'Chiropractic for lbp' infact wants to make an opinion, it wants to push an opinion, it wants to force an opinion and it seems to hide a sense of fear about the Chiropractic profession. The article infact, does not reveal a healthy sense of scientific criticism: the scientific doubt about something. This is what Cartesius, the scientist and pilosopher, suggested to be the right attitude toward science, the famous 'Cartesian's doubt'. Concerning 'Chirpractic for lbp?, it seems that the authors where not at all moved by a salutary scentific doubt. On the countrary, it looks like they knew in advance what type of opinion they wanted to transfer to the readers, before even start writing the article. This is the exact journalistic method which is profoundly different from the scentific method where we write without having in mind an opinion before all the data have been examined. In this article, insteead, it looks like the bibliography has been searched after the article was actually written, just to support a journalistic opinion. Ernest's (& co) article is not written as a consequence of a sincere scentific doubt about Chiropractic and that's why it shoulden't have been publisched in a Medical Journal.
Confusing a Profession with a Treatment Modality Again 20 July 1999
Gregory T Wright, Team Physician and Trainer, Cape Cod League Baseball Private Practice, Harwich Port, Massachusetts, USA Send response to journal: Re: Confusing a Profession with a Treatment Modality Again	Dear Editor: Here it is almost 2000, and in their editorial, Ernst and Assendelft confound the use of the word "chiropractic" with the chiropractic treatment modality called spinal manipulative therapy (SMT). The word "chiropractic" is derived from the Greek "to practice by hand". It is both an adjective and a noun. Chiropractic, the profession, does include SMT, as the authors state in the first sentence of their editorial. In their second sentence, they appear to confuse the two. By the third paragraph, the two terms are synonymous for these authors, as they equate cervical SMT with chiropractic by asking "Is chiropractic safe?". But clearly, "chiropractic" is not just cervical spine manipulation, or spinal manipulation alone. Chiropractic, i.e., chiropractic treatment, includes SMT, massage techniques such as myofascial release and triggerpoint myotherapy, intersegmental traction (a newer form of cervicothoracic or lumbosacral traction), established physicial therapy modalities such as ultrasonic therapy or electric muscle stimulation. It includes rehabilitative medicine procedures such as exercise, bracing, taping, splinting, casting. Botanical medicines, like those found in the PDR FOR HERBAL MEDICINES, are often prescribed. All of these treatments have already been determined to be safe. So clearly, chiropractic is safe. Further, "chiropractic", as a profession, uses diagnostics that are IDENTICAL to the medical profession. For example, you would be hard pressed to find a chiropractic physician, at least in the U.S. where I live, who would not perform an excellent neurological examination of his or her patients. There is no need for an allopathic medical portal of entry for cervical spine manipulation, as D.C.'s perform neurological screens for this procedure very well, and perhaps more effectively than the average general practitioner. I gather from the authors' editorial that they are positioning themselves for control of entry into the system. No need, thank you. D.C.'s perform thorough physical and orthopedic examinations as well. And because chiropractic physicians assess functional components of injuries and conditions, we offer an important mode of diagnosis that, while similar to occupational medicine, is certainly complementary to allopathic medicine. The authors' concern about "the potential overuse of radiographs" by chiropractic physicians appears to be a calculated scare tactic by them, unless it represents a preference for talking about the Dark Ages of medicine before 1960, now almost 40 years ago. Clearly, chiropractic physicians today are well-educated, and do not overuse radiology as a diagnostic technique, at least any more than conventional medicine does (read: How to boost capital to pay for the emergency room). Hearsay evidence plus the one study mentioned hardly gives one pause for concern. Perhaps the authors might consider joining the current decade, where chiropractic physicians are working in U.S. hospitals, HMO and PPO organizations, where they occupy positions in important government health organizations. In the U.S., they are important members of the U.S. Olympic Team medical staff, and Team Physicians for professional sports teams and individual athletes. If not, then at least they might consider undoing their misrepresentation of the profession of chiropractic as one of its many effective techniques. After all, it's almost 2000. Sincerely, Gregory T. Wright, D.C.