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The article by Clare Stevinson and others (March 2000 JRSM, pp. 107-110) demonstrates why research should be undertaken only by those who understand the field they are investigating. Throughout, they trivialize the role of manipulation and quote selectively: an important omission is the review paper by Haldeman1, who as a neurologist and a trained manipulator is well qualified to comment.
Manipulation physicians have been aware of the complications of spinal manipulation therapy for more than five decades2. The real difficulty has been in identifying suspect techniques; more than fifty cervical techniques are commonly used in today's practice. Stevinson et al. refer to a survey of California neurologists. The 91 patients reported in this paper3 did not, as they claim, have neurological defects only after cervical manipulation; this was the number who had defects after manipulation in any area—cervical, thoracic or lumbar. The US authors recognized the weaknesses of their study, including inability to verify responses and lack of information on pre-existing neurological details such as myelopathy, cauda equina syndrome, anticoagulant therapy, etc. In the British study, twenty-four respondents reported remembering 35 cases of serious neurological complication but only 16 of these cases could be remembered in enough detail to give even a scant description. A further case is totally erased from the paper. In only 2 cases is the manipulating profession identified— osteopathy and chiropractic, both professions that one of the authors, Professor Ernst, has confronted in the past.
In my chiropractic clinic I regularly treat patients with serious neurological defects, including absent reflexes; these patients are always referred back to their GP for orthopaedic assessment but many of them resolve before this assessment. At present we are treating a patient who has clear upper motor neuron signs and symptoms; we suspect cervical myelopathy, and with much coaxing she has now consented to return to the hospital. When she does show up at the hospital, will she be remembered by the consultant as a cervical myelopathy who had been treated by a chiropractor or as someone who had been correctly referred back to the GP? Before assuming a causative relationship, any investigator must examine the treating practitioner's case notes.
To gain anything out of a long-term prospective study, Professor Ernst and his colleagues must recruit onto their team manipulative experts from the four main fields. Some of the offending techniques have already been identified and the manipulative schools now avoid teaching rotary techniques that include cervical extension. The Institute for Musculoskeletal Research and Clinical Implementation is planning a multidisciplinary prospective trial using Canadian Stroke Consortium data as a pilot study. I am sure that they would be happy to discuss any future research if the aim was to prevent these mostly avoidable problems.
References
1.Haldeman S, Kohlbeck FJ, McGregor M. Risk factors and precipitating neck movements causing vertebrobasilar artery dissection after cervical trauma and spinal manipulation. Spine 1999;24: 785-94 [DOI] [PubMed] [Google Scholar]
2.Pratt-Thomas HR, Berger KE. Cerebellar and spinal injuries after chiropractic manipulation. JAMA 1947;133: 600-3 [DOI] [PubMed] [Google Scholar]
3.Lee KP, Carlini WG, McCormick GF, Albers GW. Neurological complications following chiropractic manipulation: a survey of Californian neurologists. Neurology 1995;45: 1213-15 [DOI] [PubMed] [Google Scholar]
Several interesting points arise from the welcome paper by Clare Stevinson and colleagues. It is reassuring to be reminded of the rarity of these complications. Of course, all the disasters considered may occur without prior cervical manipulation, so the therapy may not be causal. Similarly, discomfort persisting after cervical manipulation may indicate no more then inefficacy of treatment; it is not necessarily a complication.
No mention is made of the appreciable number of doctors employing this therapy, nor of their training for it. Previous work1 suggests that chiropractic manoeuvres are particularly hazardous. What manipulating doctors, physiotherapists, osteopaths and chiropractors do in practice shows remarkable similarities—although with considerable variation in emphasis on different aspects2. Some techniques are very much better controlled than are others: of greatest significance, the terminal thrust must be of maximal speed and minimal amplitude. Perhaps most important is the dictum of not causing the patient pain on setting him up for manipulation. Contraindications to this therapy have been clearly detailed, and their rigorous observance is mandatory for any practitioner employing spinal manipulative techniques.
In over forty years' practice, I have no recollection of a complication arising from cervical manipulation. It would seem that the disasters are more likely to arise from manipulating the wrong neck than from any inherent danger of cervical manipulation.
References
1.Paterson JK, Burn L. Musculoskeletal Medicine: the Spine. London: Kluwer Academic, 1990
2.Paterson JK. Vertebral Manipulation: a Part of Orthodox Medicine. London: Kluwer Academic, 1995
The points raised in these letters largely echo aspects that have already been discussed in our paper, but certain elements must be addressed to ensure correct interpretation of the data.
Dr Paterson may have read more into our study than is warranted by the data. The association between spinal manipulation (SM) and neurological complications was not assumed to be a causal relationship. Survey data can not provide evidence of causality. We also do not perceive the study results as evidence of ‘the rarity of these complications’ since the survey was not designed to produce incidence data. Dr Paterson concludes that in 40 years of practice he has not seen a single serious complication of SM. The laws of probability mean that, if the actual incidence was 1 per 100 000, he would need to perform 300 000 manipulations to have a 95% chance of seeing a single such case1.
Dr Cashley implies that we do not ‘understand the field’ we are investigating and believes that we trivialize the role of SM. The authors of our paper include a consultant neurologist and two physicians, one of whom has training and experience in SM. Research on manipulative therapies has been a major focus of our department since it was established eight years ago. Nowhere in the article is SM trivialized and papers were cited no more selectively than in any other journal article that is not a systematic review. We are very familiar with Haldeman's work and know him personally. We are, of course, also aware that manipulation practitioners have discussed complications of SM for many years and of the difficulties involved in isolating reliable risk factors. This survey attempted to provide no more than preliminary data for the UK on the existence of neurological complications following SM and suggests that the subject should now be more rigorously investigated. We agree that our planned long-term prospective study would benefit from the involvement of the different professions that practise SM, which is why we have invited the General Osteopathic and Chiropractic Councils and the Chartered Society of Physiotherapists to collaborate on this important project.
References
1.Eypasch E, Lefering R, Kurn CK, Troidl H. Probability of adverse events that have not yet occurred: a statistical reminder. BMJ 1995; 311: 619-20 [DOI] [PMC free article] [PubMed] [Google Scholar]
