A debate that for years has raged behind the closed doors of chiropractic associations was brought to the attention of the broader public recently when citizens who suffered debilitating strokes after being treated with spinal manipulation by chiropractors pushed regulators in Hartford to require that practitioners inform their patients of the risk.
The Connecticut State Board of Chiropractic Examiners held two public hearings on January 5 and 6 to consider a declaratory ruling that would mandate informed consent regarding stroke. Another hearing was held this Tuesday, and one more is scheduled for Friday. If the board passes the regulation, Connecticut will be the first state in the U.S. to have such a requirement.
The chiropractic trade associations in the state oppose the proposed measure for two major reasons. First, they believe that a mandate of this type would “single out” chiropractic over other medical procedures. Second, they deny the causal relationship between neck manipulation and increased risk of stroke.
A closer inspection reveals that neither of these arguments has a strong foundation in facts.
At the hearings, Matthew N. Pagano, a Winsted chiropractor and representative of the Connecticut Chiropractic Association, told Rick Green of the Hartford Courant that the measure was redundant, since all doctors in the state are already required to inform their patients about the risks of treatment.
According to the article, which appeared on January 5, “Pagano said that limiting informed consent to a single type of treatment would mean patients would actually learn less about their overall health care.”
Chiropractors are indeed being “singled out” in this particular instance. The problem is that informed consent is not at all limited to only a single type of treatment in the medical field; their procedures are hardly the only ones that have ever been questioned. Consider Yaz. Or Prozac. Or MRI and X-ray technologies. Or cancer screenings.
Pagano’s argument may be meant to imply that manipulations performed by other practitioners (such as osteopathic physicians) can also lead to stroke. If so, however, it doesn’t exempt chiropractors from responsibility. In medicine, being scrutinized doesn’t make you a martyr – it makes you accountable. Rather than decreasing awareness, a warning would expand it.
Right now, many chiropractors voluntarily inform their customers about the risk of stroke. But some – including, apparently, the trade associations – do not believe that a real threat exists. That’s where their second argument comes in, and where the facts become extremely muddy.
In an interview for FOX 61 News during the hearings, Pagano claimed that “the latest epidemiological evidence that we have shows that there’s no cause and effect relationship between stroke and chiropractic adjustment.”
Pagano goes a bit too far in this assessment. Studies over the past twenty years have in fact shown at least a slight association between neck manipulation and strokes, particularly in younger people. A well-established mechanism supports this hypothesis: two sensitive arteries run through holes in the neck vertebrae that can easily be damaged when twisted. Blood clots from this area are known to cause strokes.
More troubling, however, is the dearth of reliable data on strokes related to spinal manipulation. Dr. Stephen Barrett, vice-president of the National Council Against Health Fraud, a scientific advisor to the American Council on Science and Health, and creator of Quackwatch, an online database on pseudoscience in medicine, enumerates the challenges in his page on the subject.
“Speculations exist that the risk of a serious complication due to neck manipulation are somewhere between one in 40,000 and one in 10 million manipulations,” he says. “No one really knows, however, because (a) there has been little systematic study of its frequency; (b) the largest malpractice insurers won’t reveal how many cases they know about; and (c) a large majority of cases that medical doctors see are not reported in scientific journals.”
Some of the literature that does exist to plays down any association, either through faulty experimental designs or by trying to “explain away” the study’s own data.
This is in part an effect of the nature of chiropractic itself. The basis for the profession, a concept known as spinal subluxation (partial dislocation), was invented in 1895 by Daniel David Palmer. Palmer believed that the function of spinal nerves could be disrupted by minor misalignments in the surrounding bones, and that this in turn interfered with the body’s overall health. He speculated that these were responsible for “95 percent of all disease.”
None of this has been borne out by scientific research, and it has been the single most divisive issue within the chiropractic community, which has yet even to provide a demonstrable definition for what constitutes a subluxation. Today, the profession runs the gamut: from “reforms” who restrict their practices to what can often be top-notch physical therapy (especially for short-term relief of neck and back pain), to hard-liners and faith healers who continue to promote Palmer’s defunct ideas and actively decry science-based medicine.
Therein lays the rub. Strokes might be rare. But a large number, perhaps even a majority, of spinal manipulations are not justified by scientific evidence. When weighed in this light, even the remote danger of a debilitating – and not infrequently deadly – stroke should give consumers pause.
It should give the State Board of Chiropractic Examiners pause as well. Those who wish to see chiropractic legitimized should welcome the chance to be held to the same standards as all other scientifically validated treatments – they should accept the facts, disclose the risk, and follow up with rigorous research to refine their knowledge. If they don’t, chiropractors may undercut their own relevancy and slip farther into the world of woo.
To read stories about people who’ve been hurt by chiropractic, go to what’stheharm.net/chiropractic.