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.
Rapid Response:
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.
Competing interests: No competing interests