I read a very interesting article by Gardner et al1 in the April 2013 issue: “Man, 57, With Dyspnea After Chiropractic Manipulation” (Grand Rounds. 2013;23:23,24,27,28). In the article, a patient with ankylosing spondylitis underwent chiropractic manipulation for 10 years, and subsequently received serial manipulations under anesthesia (MUA) during which the patient sustained thoracic spine fractures and a hemothorax.
What concerned me about this particular article are the generalizations and conclusions made. The title itself is very deceptive in its implication that chiropractic manipulation caused the fractures and hemothorax. Within the article, the authors write “the patient, who had a history of ankylosing spondylitis, had been receiving weekly therapy from a chiropractor for about 10 years.” Although the article does not specifically detail what types of modalities were used for these 10 years, presumably the main modality was spinal manipulation. Following this treatment, the patient received serial manipulations under anesthesia, presumably from the same chiropractor, following which the patient experienced his subsequent dyspnea.
The authors fail to identify that MUA has been around for more than 60 years and was developed by osteopathic physicians.2 Therefore, MUA is not a chiropractic procedure as the authors suggest, but a mainstream medical procedure that specifically trained and credentialed chiropractors can perform. MUA procedures are standardized, no matter what type of clinician is performing them. This insinuation by the authors suggests either an agenda with this communication, or a lack of knowledge and training in this procedure.
As an example, they write “In the chiropractic literature, between 3% and 10% of patients are estimated to be candidates for MUA.” They then reference this statement using a 1973 article from the Journal of the American Osteopathic Association, which was not authored by a chiropractic physician (see reference 14 in the article).
The authors also cite the most extensive safety review of MUA,3 which reported a complication rate of 0.7%. To say that the literature supporting MUA for various indications is “largely anecdotal” is disingenuous, since there have been several textbooks,4,5 textbook chapters,6,7 reviews,3 and guidelines8 developed on the use and appropriateness of MUA. For this particular patient, it is likely that he was not, nor should have been, a candidate for MUA in the first place, as evidenced by published indications and contraindications.3-8 However, this is not a problem with the procedure itself, but a practitioner error in the patient selection process.
The authors devoted the majority of the article to discussion of the utilization and safety of chiropractic manipulation. In this particular patient’s case, chiropractic care was utilized for more than 10 years without incident prior to the MUA being performed. Therefore, the entire discussion section of this article is totally irrelevant from the main point of the communication. The discussion section references only chiropractic manipulation in the typical clinical setting. The authors should have stayed focused on the safety concerns of MUA only. To the objective reader, this looks as if the authors are taking advantage of this platform to further a specific opinion on chiropractic manipulation. This is exemplified by the authors’ assertion that “the clinicians who treated the case patient find it curious that the reported rate of adverse events following this procedure is so low, but they suspect an element of reporting bias in the chiropractic literature.” This is purely a speculative statement, and one that does not belong in the scientific, peer-reviewed literature.
Notwithstanding the authors’ opinions on chiropractic manipulation, the entire study design of this paper limits any possible conclusions. There is no mention of the patient’s bone density status before or after MUA and no discussion of his apparent severe thoracic kyphosis, which also could have accounted for the patient’s fractures.
There are multiple possibilities as to the cause of this fracture, and the authors are making assumptions based purely on timing of diagnosis. In conclusion, this article likely should not have been accepted for publication given the erroneous citations, incorrect descriptions, irrelevant discussion, and a conclusion drawn from pure speculation and inadequate study design. In my opinion, this article lowers the perceived objectivity and quality of this biomedical journal, and may only serve to slant the opinions of readers who likely have minimal experience with chiropractic physicians, chiropractic medicine, or manipulation under anesthesia.
Mark W. Morningstar, DC, PhD Grand Blanc, MI
The Authors’ Reply
We read with great interest the letter to the editor regarding our case report. We appreciate the author taking the time to make insightful comments. Our replies to his comments and concerns are as follows: