In the last issue of The Week in Chiropractic (March 4, 2002)

An op-ed piece in TIME.com, written by Leon Jaroff, was discussed. 
Anthony

L. Rosner, Ph.D., FCER's Director of Research, sent the following 
response

to Mr. Jaroff. For a copy of the complete article by Dr. Rosner (with

references), please e-mail a request to FCERedit@aol.com.



Dear Mr. Jaroff:



Once in a while a truly ill-conceived, misleading, ignorant and 
offensive

article taints what the reader hopes to be an informative press. I 
regret

to have come to the conclusion that your recent submission, "Back 
Off,

Chiropractors!" fits every one of those criteria. I am dismayed that 
a

person of your background and stature has failed one of the primary 
tenets

of research, which is of course to conduct a thorough review of 
available

information which has actually appeared in the refereed scientific

literature for the past 20 years. The article I have enclosed for 
your

reference which just appeared in the Annals of Internal Medicine is 
one of

many summaries of the current evidence which your article has 
chosen to

ignore. To begin, you will notice that not all neurologists would 
share

the opinions you have drawn upon so liberally in your article-as 
one of

the authors of the enclosed reprint is in fact a leading neurologist 
who

for decades has published articles in the peer-reviewed journals 
offering

data in support of many of the basic tenets of chiropractic theory.



I would first like to acquaint you with some of the basic 
information

regarding chiropractic and then discuss some of the most troubling 
aspects

of your article. In the interests of both objective reporting and the

sharing of credible information in an open press, I hope that you 
will be

able to respond appropriately to this material.



General Comments:



Chiropractic is recognized and licensed in every state and province 
in

North America, as well as in 76 nations representing the European, 
Asian,

Latin American, Caribbean, Eastern Mediterranean, and Pacific 
domains.2

The increasing acceptance of chiropractic as a legitimate health 
care

profession has occurred in part through the increasing emphasis on

research by professional organizations and the colleges with 
funding by

outside agencies. It also stems from the accrediting and review of

educational curricula at chiropractic colleges around the world, 16 
of

which are accredited in the United States by the Council for 
Chiropractic

Education (CCE). The CCE has had accrediting agency status with 
the U.S.

Department of Education since 1974 and with the Council on 
Postsecondary

Accreditation since 1976. The minimum content of hours required 
for CCE

accreditation is 4,200 and ranges from 4,400 to 5,220 hours at 
colleges

nationwide. In fact, the didactic basic science and clinical science 
hours

among chiropractic colleges around the United States compares 
extremely

closely with the corresponding averages obtained from medical 
schools

nationwide.



With over 65,000 licensed practitioners in the United States, 
chiropractic

has taken its place as the foremost profession through which 
spinal

manipulations have been administered-largely in the treatment of 
back pain

but increasingly for other disorders such as neck pain; headache;

cumulative trauma disorders in the extremities; infantile colic; 
enuresis;

otitis media; asthma; and GI dysfunctions (these will be cited 
below).

Indeed, it has been estimated that the total number of chiropractic 
office

visits nationwide each year is 250 million, with 94% of all spinal

manipulations administered by chiropractors.



What may not as well-known as it should is that the practice of

chiropractic includes a complete physical examination and 
establishing a

diagnosis. The aim is to establish biomechanical and neurological

integrity through an assortment of noninvasive measures, many 
(but not

all) of which are manual. These would include manipulation, 
mobilization,

soft-tissue and non-force techniques, exercise and rehabilitation, 
and

occasionally such educational programs as nutritional counseling 
or

wellness care.



With regards to back pain, the efficacy of these procedures has 
been

reviewed repeatedly by carefully structured guidelines, developed 
both

within the profession and by multidisciplinary panels representing 
the

U.S. and no less than 10 other countries worldwide. According to 
Meeker

and Haldeman, 73 randomized clinical trials comparing spinal 
manipulation

with either placebos or other treatments in the management of 
back pain

have been published in the scientific literature-almost all within 
the

past 20 years. Meta-analyses addressing acute low-back pain have 
also

appeared in the literature, supporting the appropriateness of spinal

manipulation in managing acute low-back pain. According to a 
systematic

review by van Tulder, 



"There is limited evidence that manipulation is more effective 
than a

placebo treatment."



Although contradictory results did not allow van Tulder to compare

manipulation to other physiotherapeutic applications, there was no 
such

uncertainty regarding chronic low-back pain. Here van Tulder 
unequivocally

states that



"There is strong evidence that manipulation is more effective than 
a

placebo treatment.... There is moderate evidence that manipulation 
is more

effective for chronic LBP than usual care by the general 
practitioner,

bed-rest, analgesics, and massage."



Specific Concerns:



The opportunism in your article is hard to disguise. The 
consistently

derogatory language used to describe chiropractic ("bewildering...

weird... troublesome... damning... bizarre") can only be taken to 
reveal

the overriding sentiments of the author and does little to 
enlighten. Your

communication comes on the heels of a sensationalist banner 
headline

(printed in type larger than that used by the New York Times that 
gave the

first descriptions of the September 11 terrorist attacks in New 
York and

Washington) which warned of the "perils" of chiropractic in the 
Canadian

National Post, based primarily upon two highly flawed studies by

neurologists which were at odds with the vast preponderance of 
literature

appearing in the scientific journals. It delves into a journal almost

never quoted previously in the national media in order to ferret out 
an

article which was critical of the language used in some patient 
brochures

from some chiropractic organizations - conspicuously omitting any

reference to the vast majority of other published studies in that 
very

same journal which for over a quarter of a century have indicated 
that

chiropractic treatments not only match the medical alternatives 
for

treating such diverse conditions as back pain, carpal tunnel 
syndrome,

cervicogenic, migraine and tension-type headache, dysmenorrhea,

premenstrual syndrome, infantile colic, enuresis, and even ear 
infections,

but do so for longer durations after treatment and without the 
common,

injurious or even fatal side of medications.



These "side effects" need to be scrutinized more closely:



- A review of over half a dozen peer-reviewed published scientific 
papers

puts the risk of cerebrovascular accidents (including stroke) 
associated

with spinal manipulation at anywhere from 1 per 400,000 to 1 per 
5.85M

cervical manipulations, the latter figure representing the most 
rigorously

derived frequency. On the other hand, the risk of deaths from the 
use of

such medicines as nonsteroidal antiinflammatory agents (NSAIDs) 
or from

surgery to treat many of the same conditions as those managed by

chiropractors is 400 to 700 times greater; yet warnings pertaining 
to the

use of these particular options do not seem to have been mentioned 
by your

commentary.



- Death rates due to medication side effects have been estimated 
by the

Institute of Medicine to range from 230,000-280,000 per year. 
Those caused

by commonly used NSAIDs (such as ibuprofen) have been reported to 
approach

an annual rate of 16,000-dwarfing any estimates of chiropractic 
fatalities

by several orders of magnitude.



- As many as 68 everyday activities have been shown to disrupt 
cerebral

circulation, 18 of which have actually been associated with 
vascular

accidents but are decidedly non-manipulative. Such activities 
would

include childbirth; interventions by surgeons or anesthetists 
during

surgery; calisthenics; yoga; turning the head while driving a 
vehicle,

undergoing x-rays, or treating a bleeding nose; star gazing; 
swimming; rap

dancing; and beauty parlor events.



- Experiments with arterial models at the University of Calgary 
have shown

that peak elongations of the vertebral artery during neck 
manipulations

are at most 11% of the elongations that would be seen at the 
arterial

failure limits; in fact, these elongations are consistently lower 
than

those seen during routine diagnostic tests.



- The common musculoskeletal conditions routinely diagnosed and 
treated by

chiropractors were shown in one study to have eluded first-year 
medical

orthopedic residents, who failed a validated competency 
examination.



The chiropractic profession remains deeply concerned about and is 
actively

researching the occurrences of any cerebrovascular accidents ever 
to occur

with manipulations, which remains an event rarer than most 
activities in

daily life. What is already becoming more and more apparent is 
that

vertebral artery failures need to be regarded as the result of 
cumulative

events such as those I have mentioned above rather than simply the 
recent

visits to the chiropractor as maintained by the study which you 
mentioned.

The only constructive alternative would be to continue to pursue

productive research, hopefully with cooperation between the 
chiropractic

and medical professions.



That goal is obviously discouraged by your commentary. The facts 
that

randomized clinical trials support both the efficacy and safety of

chiropractic treatment not only for managing back pain but for 
headaches,

carpal tunnel syndrome, infantile colic and bedwetting problems as 
well

should be shared with your audience as well if they are to be given 
truly

meaningful medical advice on treatment options, the centerpiece 
of which

should quite simply be the risk-to-benefit ratio. Guidelines of no 
less

than 11 nations have recognized the effectiveness of chiropractic 
as a

viable treatment option for millions of patients. Until this type of

information can be freely shared with your audience as well, they 
are

being seriously misled by the one-sided presentation on your Web 
site.



As the Director of Research in a National Foundation which for over 
50

years has supported research and postgraduate support in areas 
pertaining

to chiropractic healthcare, I am horrified by the grossly 
misleading

impression that your recent Web site commentary has created. 
Because your

audience should be entitled to the best available healthcare 
information,

I hope that it will be possible for you to incorporate the issues I 
have

raised in another of your commentaries in the near future.