Characterization of side effects sustained by chiropractic students during their undergraduate training in technique class at a chiropractic college: a preliminary retrospective study

To the Editor:

I found the paper by Macanuel et al. to be quite shocking with its liberal use of the term “injuries” throughout the document. Not only is the term injury used quite frequently throughout this paper, but it appears that the authors have used this term interchangeably with other terms such as “side effects” and “unpleasant reactions.”¹ The term “side effects” is used in the title, methods and conclusion sections of this paper. However, the introduction and results of this document, report injuries quite extensively. The authors report that the students were instructed to self-report any “unpleasant reactions”.

In the Webster’s dictionary, “injury” is defined as “harm or damage”. Whereas, an “adverse effect” is an “unfavorable response”.²

Several authors have reported unpleasant reactions following chiropractic spinal manipulative therapy to all spinal regions.^3,4,5 Patient symptoms following a treatment procedure should not be misinterpreted as an injury. For example, many cases of post-SMT transient dizziness, faintness, and tingling, may be nothing more than hyperventilation brought about by patient anxiety subsequent to the treatment.⁶

In clinical practice, it is important to differentiate between “normal” and “abnormal” reactions to treatment. This must be interpreted by the treating practitioner. However, it appears that the authors of this paper have failed miserably in differentiating between the terms side effects and injuries. The most common symptoms after manipulation are related to innocuous physiological reactions or short-term local discomfort.⁷ These are usually self-limiting events that usually resolve within 24 hours. This is similar to muscle soreness after a workout. Herzog quotes Senstad’s articles about mild reactions. Herzog however, also talks about serious consideration for potential damage to the vertebral or carotid arteries during cervical spine procedures and that such “injuries” can lead to paralysis, permanent disability, or death. He makes a clear distinction between mild reaction and injury and damage.

There are many authors who reserve the term “injury or damage” in cases where there is a measurable impairment or permanent or serious damage as a result of an accident.^8,9,10

In Dr. Scott Haldeman’s textbook, he appears to provide a more clear distinction between the terms “accidents” and “reactions”.¹¹ Haldeman defines “accidents” as “serious impairments, permanent or fatal, resulting from SMT and incidents as “consequences of SMT which are noticeable by their seriousness or their long duration”. Conversely, he defines “reactions” as “consequences of SMT, which are slight and short-lived”. He also differentiates reactions to spinal adjustments as either being normal and expected to occur after a successful manipulation, or as an adverse reaction resulting from certain factors. He further differentiates reactions into “functional reactions” for example, perspiration over the trunk and axillae after manipulation; or a painful reaction post-manipulation due to muscular aches and pains. These muscular aches and pains are usually short-lived, and do not demonstrate any residual impairment.

I am also concerned about the recommendations made by the authors: “It may be prudent for teaching faculty to caution second year students to be more wary of injuring each other and ...” In lieu of my concern of the author’s liberal use of the term “injury”, this recommendation appears to be inappropriate and may be a form of fear mongering. In the rehabilitation field, it is common knowledge that “hurt” does not equal “harm”. Many health practitioners educate their patients and teach them the difference between hurt versus harm. For example, the Quebec Task Force reports that most incidents of WAD are self-limited, and that the key message to the WAD patient is that “pain is not harmful, is usually short-lived, and is controllable.”¹²

Some authors also refer to the misuse of the literature by medical authors in discussing spinal manipulative therapy injury.^13,14 Both Drs. Carey and Terrett have reported medical biases in cases where the region of the spine was not even manipulated or the treatment was not administered by a chiropractor. Macanuel et al. in this paper, report an unusual case of injury to a third year student, who experienced the following symptoms: stiffness to the neck, nausea, cramping, fatigue, dizziness, vomiting, headache, and vertigo, following side posture manipulation directed at the thoracolumbar junction. This exemplifies my point, that this adverse reaction should not have been termed an injury, as causality would not likely be proven in this particular case. It may have been a functional or physiological response, however, it should not have been termed an injury.

I applaud the authors for attempting to characterize side effects sustained by chiropractic students during their undergraduate training. This seems logical, as chiropractic students presumably are novice manipulators at this stage. However, their liberal use of the term “injury” undermines their efforts. This is not a case where researchers are under attack for their publication of perhaps controversial topics, such as reported in “The Messenger Under Attack – Intimidation of Researchers by Special Interest Groups”.¹⁵ Authors such as Senstad and Leboeuf-Yde have reported common and uncommon reactions to spinal manipulative therapy more appropriately, by not misconstruing the two terms “adverse reaction” and “injury”. People report symptoms of back pain, neck pain and headaches arising insidiously or from their activities of normal living. We cannot automatically assume that approximately 20–30% of the population have sustained “injuries” on a daily basis, i.e., point prevalence of neck pain and back pain.^16,17 Common sense must also prevail.

Unfortunately, the authors have failed to provide this clear distinction and have regrettably termed any symptoms post-manipulation as an injury. Perhaps they would like to explain their purpose in doing so and provide the reader with clarification on this paper and in future endeavors.