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Dynamic Chiropractic – May 1, 2014, Vol. 32, Issue 09

We Get Letters & E-Mail

Shouldn't the Pentagon Know More About Chiropractic Care?

Dear Editor:

I just finished reading the excellent book Keys to An Amazing Life: Secrets of the Cervical Spine, by Kenneth Hansraj, MD.

After reading it, I began thinking about the death of a colorful American some 68 years ago, and whether or not any chiropractor had noted an observation about his death in a chiropractic light.

Shortly after World War II, Gen. George Patton was a passenger in a car involved in a minor collision. The supposedly tough soldier should have exited this with absolutely no effects; but it apparently broke his neck and a few days later, he died.

Every picture I have seen of Gen. Patton shows a ramrod-straight spine. There was absolutely no normal curvature in his cervical spine, and his head was always tilted somewhat down.

Did he have stenosis of the cervical spine? Retrolordosis at C4-6? Strained facets? Weakened, compromised cervical ligaments? Already-thinned discs? Could the occiput have been in an excessive subluxated position? Was it the atlas subluxation? The axis?

We know that for the last several years of Gen. Patton's life, he was constantly bothered by sinus problems and colds. Were these cervical subluxations impeding the nerve supply to his immune system in his neck?

I would like to hear an opinion from the followers of Drs. Sweat, Gonstead, Pierce, etc., on this possibility. But more importantly as far as this hypothesis goes: Does the chiropractic profession have an obligation to inform the Pentagon that it should warn drill instructors not to force new recruits to maintain ramrod postures – as this may cause future spinal / health problems?

Frederick Vlietstra, DC
Middletown, N.Y.

Office Flow: Have You Reviewed the Patient Experience Lately?

Dear Editor:

We moved our clinic to a new location a couple of years ago and really focused on the best possible flow of the office space for our patients – starting with checking in a patient and updating their health forms, to our therapist doing vitals; to doctors treating and then the therapist performing laser, stim, etc., after seeing the doctor; to finally checking out the patient.

Flow makes a big difference, so if you haven't evaluated the flow in your office in awhile, I recommend having someone on your team be a patient and have your staff walk them through all the steps, so you can really see what your patients are experiencing from the moment they walk into your clinic.

Carol Steingreaber,
Cedar Rapids, Iowa

Editor's note: The preceding letter was submitted online as commentary on our recent poll question, "When was the last time you reviewed office layout / design to ensure it maximizes the patient experience?"

Let's Stop Confusing the Public About Chiropractic

Dear Editor:

Regarding Dr. Jeff Tucker's "Chiropractic Trends: What's Ahead (Part 2)" [published in the Feb. 1, 2014 issue], Dr. Tucker is both lamenting public confusion about chiropractors and encouraging chiropractors to cause as much confusion as possible. Chiropractic began as a specialization. It consisted of adjusting the spine to correct vertebral subluxations. The "craziness" that has caused confusion for the public is the very thing Dr. Tucker suggests. How could chiropractors practicing the "specialization" list he offers give the public an understanding of chiropractic?

In my experience, the patient comes to the chiropractor seeking a "good" adjustment. That is what they want. It is the chiropractor who wants to offer a myriad of choices, thus confusing the public.

If correction of vertebral subluxations by adjustments of the spine was practiced by all chiropractors, there would be specialization, focus, branding and no more confusion. It's as simple as that.

Judy Keim Ross, DC
Goshen, Ind.

Editor's note: The following letter is a response to orthopedic surgeon Steven Zeitzew's letter in the April 15 issue. Dr. Zeitzew critiqued Dr. Rosner's "NSAID: 'Nuff Said About the Issue of Toxicity" (Oct. 1, 2013 DC).

Cutting Down the Cherry Tree

Dear Editor:

Dr. Zeitzew's concern about issues "missed" in my recent article on NSAIDs toxicity is extremely well-taken when it comes to the question of risk-benefit ratios, as that topic alone occupies the centerpiece of all informed-consent issues, whether in clinical practice or in research. That said, there is little question that the effectiveness of NSAIDs as a COX-2 inhibitor is well-established; indeed, that particular application had been classified (along with spinal manipulation) as the most effective in the management of acute low back pain as far back as 1992 by what was then the Agency for Health Care Policy and Research.

In addressing neck pain, ample evidence has recently accumulated in systematic reviews,2-4 randomized controlled trials,5-8 prospective9 and retrospective10 studies to demonstrate substantial validated benefits resulting from cervical manipulation. In fact, one such study clearly stated that "although our findings need to be confirmed in subsequent randomized studies for definitive risk-benefit assessment, the preliminary data shows that the benefits of upper cervical chiropractic care may outweigh the risks."9

On the subject of risk, Dr. Zeitzew has unfortunately ventured into an area that may be a gross misrepresentation. His citation of the NEJM's estimate "of as many as 1 in 20,000 spinal manipulations causing stroke" is taken from a paper11 that contained no supporting data of any kind, but rather cited a previous paper that likewise presented no supporting data. Instead, it contained an extended statement that failed to be carried forward in its entirety. That quotation reads: "Adverse events range from 1 in 20,000 patients undergoing cervical manipulation to 1 million procedures."12 (Italics mine)

So, there are two major problems here: (1) Dr. Zeitzew freely substituted the word stroke for adverse event; and (2) He truncated the upper bound of figures from the original quotation.

If it is actual data that we need to correct this misconception, we need only to turn to a wealth of studies which demonstrate that the occurrence of major complications, regardless of the region of the spine manipulated, has generally been shown to be less than one per million.13-15 Even transient, minor side effects have been estimated to occur at 1 per 120,000 cervical manipulations.16

These figures pale by an absurdly large number of orders of magnitude when compared to the 10,000-20,000 fatalities and multiple organ systems adversely affected by NSAIDs,17-25 as I indicated previously.

To summarize, the risks of spinal manipulation, while existent, are most likely far less problematical than what one is led to believe from the implications of Dr. Zeitzew's letter. In striking contrast, for example, is the conclusion of a similar review of the research literature taken from the Physician's Guide to Alternative Medicine: "One of the myths about chiropractic is that spinal manipulation, especially cervical, is actually dangerous."26

The other side of the coin is that, in virtually all of the papers which have attempted to quantify the risk of cervical manipulations, none has described the benefits. And as far as the cost-effectiveness issue is concerned, an ample number of publications have demonstrated to substantial extent the savings realized from chiropractic care,27-29 especially when comparisons to medical care for neck and back pain are taken into consideration.30

So, Dr. Zeitzew's concerns about the need to provide meaningful risk-benefit ratios and cost-effectiveness data may have in fact come home to roost. Put another way, rather than having cherry-picked studies, as Dr. Zeitzew has suggested, I may have attempted to follow George Washington's example by cutting down the cherry tree – or at least some of its branches.

Anthony Rosner, PhD, LLD (hon), LLC
Brookline, Mass.

References

  1. Bigos S, Bowyer O, Braen G, et al. Acute Low Back Pain in Adults. Clinical Practice Guideline No. 14. AHCPR Publication No. 95-0642. Rockville, MD: Agency for Health Care Policy and Research, Public Health Service, U.S. Department of Health and Human Services.,December 1994.
  2. Bronfort G, Haas M, Evans RL, Bouter LM. Efficacy of spinal manipulation and mobilization for low back pain and neck pain: a systematic review and best evidence synthesis. Spine J, 2004;4:335-356.
  3. Gross AR, Hoving JL, Haines TA, et al., Cervical Overview Group. A Cochrane review of manipulation and mobilization for mechanical neck disorders. Spine, 2004;29(14):1541-1548.
  4. Hurwitz EL, Aker PD, Adams AH, et al. Manipulation and mobilization of the cervical spine: a systematic review of the literature. Spine, 1996;21(15):1746-1760.
  5. Palmgren JJ, Sandstrom PJ, Lundqvist FJ, Heikkila H. Improvement after chiropractic care in cervicocephalic kinesthetic sensibility and subjective pain intensity in patients with nontraumatic chronic neck pain. JMPT, 2006;29(2):100-106..
  6. Bronfort G, Evans R, Anderson AV, et al. Spinal manipulation, medication, or home exercise with advice for acute and subacute neck pain: a randomized trial. Ann Rev Int Med, 2012;156(1 Pt 1):1-10.
  7. Saaverdra-Hernandez M, Arroyo-Morales M, Cantarero-Villaneuva I,et al. Short-term effects of spinal thrust joint manipulation with chronic neck pain: a randomized clinical trial. Clin Rehabil, 2013;27(6):504-12.
  8. Dunning JR, Cleland JA, Waldrop MA, et al. Upper cervical and upper thoracic thrust manipulation versus nonthrust mobilization in patients with mechanical neck pain: a multicenter randomized clinical trial. J Ortho Sports Physical Ther, 2012;42(1):5-18.
  9. Eriksen K, Rochester RP, Hurwitz EL. Symptomatic reactions, clinical outcomes and patient satisfaction associated with upper cervical chiropractic care: a prospective, multicenter, cohort study. BMC Musculoskel Disord, 2011;12:219.
  10. Dunn AS, Green BN, Formolo LR, Chicoine DR. Chiropractic management for veterans with neck pain: a retrospective study of clinical outcomes. JMPT, 2011;34(8):533-8.
  11. Schievink WI. Spontaneous dissection of the carotid and vertebral arteries. NEJM, 2001;344(12):898-906.
  12. Vickers A, Zollman C. ABC of complementary medicine: the manipulative therapies: osteopathy and chiropractic. BMJ, 1999;319:1176-9.
  13. Haldeman S, Carey P, Townsend M, Papadopoulos C. Arterial dissections following cervical manipulation: the chiropractic experience. Canadian Med Assoc J, 2001;165(7):905-906.
  14. Hurwitz EL, et al. Op cit.
  15. Dabbs V, Lauretti W. A risk assessment of cervical manipulation vs NSAIDS for the treatment of neck pain. JMPT, 1995;18(8):530-536.
  16. Klougart N, LeBouef-Yde C, Rasmussen LR. Safety in chiropractic practice, part II: treatment in the upper neck and the rate of cerebrovascular incidents. JMPT, 1996;19(9):563-569.
  17. Wolfe MM, Lichtenstein DR, Singh G. Gastrointestinal toxicity of nonsteroidal antiinflammatory drugs. NEJM, 1999;340(24):1888-1899.
  18. Ament PW, Childers RS Prophylaxis and treatment of NSAID-induced gastropathy. Amer Fam Physician, 1997;55(4):1323-1326, 1331-1332.
  19. Simon LS. Osteoarthritis: an overview. Clin Cornerstone, 1999;2(2):26-34.
  20. Fries JF. Assessing and understanding patient risk. Scand J Rheum, 1992;92[Suppl]:21-24.
  21. Armstrong CP, Blower AL. Non-steroidal anti-inflammatory drugs and life-threatening complications of peptic ulceration. Gut, 1987;28:527-532.
  22. Gabriel SE, Jaakkimainen L, Bombardier C. Risk for serious gastrointestinal complications related to the use of nonsteroidal anti-inflammatory drugs: a meta-analysis. Ann Int Med, 1991;115: 787-796.
  23. Carson JL, Willett LR. Toxicity of nonsteroidal anti-inflammatory drugs: an overview of the epidemiological evidence. Drugs, 1993;46[Suppl 1]:243-248.
  24. Carson JL, Strom BL, Soper KA, et al. The association of nonsteroidal anti-inflammatory drugs with upper gastrointestinal tract bleeding. Arch Int Med, 1987;147:85-88.
  25. Page J, Henry D. Consumption of NSAIDS and the development of congestive heart failure in elderly patients. Arch Int Med, 2000;160:777-784.
  26. Milan F. Chiropractic for Low Back Pain. In: Physician's Guide to Alternative Medicine, Volume VII. Atlanta, GA: Thomson American Health Consultants, 2005: p. 310.
  27. Stano M. A comparison of health care costs for chiropractic and medical patients. JMPT, 1993;16:291-299.
  28. Lilliedahl RE, Finch MD, Axene DV, Goertz CM. Cost of care for common back pain conditions initiated with chiropractic doctor vs medical doctor/doctor of osteopathy as first physician: experience of one Tennessee-based general insurer. JMPT, 2010;33(9):640-643.
  29. Folsom BL, Holloway RW. Chiropractic care of Florida workers' compensation claimants: access, costs and administrative outcome trends from 1994 to 1999. Topics Clin Chiro, 2002;9(4):33-53.
  30. Martin BI, Deyo RA, Mirza SK, Turner JA, Comstock BA, Hollingsworth W, Sullivan SD. Expenditures and health status among adults with back and neck problems. JAMA, 2008;299(6):656-664.

Dynamic Chiropractic encourages letters to the editor to discuss issues relevant to the profession and/or to respond to a previously published article. Submission is acknowledgment that your letter may be published in a future issue of the publication. Email to submit your letter; please include your full name, relevant degree(s) obtained, as well as the city and state in which you practice.

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