Adverse effects of spinal manipulation - Journal of Rheumatology Correspondence

[Guest guest]

Journal of Rheumatology

April 2004

Hands-on Treatment in Rheumatology

To the Editor:

The editorial by Fitzcharles1 regarding " hands-on " treatments in

rheumatology is timely and balanced. She noted the seemingly low

frequency of side effects of spinal manipulation and wonders whether

this is due to underreporting or the rarity of complications.

We recently surveyed all UK neurologists asking them to note all

neurological adverse effects of spinal manipulation seen within the last

year2. Our response rate was 74% and 35 cases of often serious

complications were reported. None of these had been published in the

medical literature. It follows that, in our case, underreporting was

exactly 100%. I therefore agree with Fitzcharles that (chiropractic)

manipulation (particularly of the upper spine) is associated with

serious complications of unknown frequency. The incidence rates reported

by chiropractors are pure speculation and, in view of huge

underreporting, even nonsensical. The inescapable conclusion is that we

need conclusive incidence figures. Until they are available, caution

seems well advised.

EDZARD ERNST, MD, PhD, FRCP, FRCPEd, Director, Complementary Medicine,

Peninsula Medical School, Universities of Exeter and Plymouth, 25

Park Road, Exeter, EX2 4NT, UK. E-mail: Edzard.Ernst@...

REFERENCES

1. Fitzcharles M-A. Is it time for rheumatologists to rethink the use of

manual therapies? [editorial]. J Rheumatol 2002;29:1117-20.

2. Stevinson C, Honan W, Cooke B, Ernst E. Neurological complications of

cervical spine manipulation. J Roy Soc Med 2001;94:107-10.

Dr. Fitzcharles replies

To the Editor:

The comments of Prof. Ernst are appreciated. Once again caution in the

use of manipulation therapies is advocated. Good medical practice

requires that a physician should be fully aware of risks associated with

a treatment before prescription. We do not currently have accurate

information regarding risks related to " hands-on " or manipulation

therapies. Prof. Ernst and colleagues have recently demonstrated the

high rate of underreporting of neurological events following spinal

manipulation1. This survey of physician habits, which is likely

reflective of usual practice, raises further concerns about the true

frequency of side effects due to any treatment without a formal

monitoring procedure. The literature abounds with anecdote, case

reports, and polls from physicians, none sufficient to give reliable

estimates of risk.

Attempts at systematic review or metaanalysis of manipulation therapies

concede that the quality of clinical trials, mostly examining efficacy,

but also reporting on risks, is generally poor. Risk of harm is clearly

of importance to prescribers. Although a recent metaanalysis reported

that spinal manipulation was no better than other commonly used

treatments for low back pain, advantages or risks associated with

various treatments were not addressed2. In a population-based study

examining the relationship of stroke and chiropractic manipulation, the

rates for chiropractic visits were similar in the preceding year for

both patients and the population controls. However, differences only

emerged when the groups were divided according to age of 45 years, with

younger stroke patients reporting more chiropractic visits3.

Once again there is a strong call for rigorous scientific evidence

before these treatments can be universally endorsed.

MARY-ANN FITZCHARLES, MB, ChB, MRCPUK, FRCPC, Associate Professor of

Medicine, Division of Rheumatology, Montreal General Hospital, McGill

University Health Centre, 1650 Cedar Avenue, Montreal, Quebec H3G 1A4,

Canada

REFERENCES

1. Stevinson C, Honan W, Cooke B, Ernst E. Neurological complications of

cervical spine manipulation. J Roy Soc Med 2001;94:107-10.

2. Assendelft WJJ, Morton SC, Yu EI, Suttorp MJ, Shekelle PG. Spinal

manipulative therapy for low back pain. A meta-analysis of effectiveness

relative to other therapies. Ann Intern Med 2003;138:871-81.

3. Rothwell DM, Bondy SJ, JI. Chiropractic manipulation and

stroke. A population-based case-control study. Stroke 2001;32:1054-9.

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