Media Bias and Chiropractic Sensationalism and Misinformation: Furthering the Agenda of a Medical Monopoly Introduction Unfortunately there is an apparent persistent reporting bias in the media concerning Chiropractic, especially pertaining to stroke. The following scientific research is presented, along with the corresponding references for transparency and clarity, in response to a recent W-Five report. This thinly-veiled attack purports to be fair and balanced, but consisted almost entirely of hysterical misrepresentations, sensationalism and outright falsification. This essay begins with an analysis of the (mis)information presented by W-Five, a comparison of relative risk of manipulation, followed by a summary of the actual science behind stroke and the risk of neck manipulation, and finally an analysis of common stroke risk factors.
PART 1: Misrepresenting and Falsifying Data; Academic and Scientific Irresponsibility The Fraud of W-Five and Edmonton Neurologist Dr. Brad Stewart Dr. Stewart was recently interviewed on W-Five concerning the risk of Cervical Spinal Manipulation (Neck Adjustment). He is heard quoting statistics (1 in 20,000) from the prestigious ʻNew England Journal of Medicine (NEJM)ʼ. Unfortunately, Dr. Stewart, intentionally or otherwise, dubiously misrepresents this data as scientifically derived information. Upon review of the actual source (the article itself), it is readily apparent that these statistics are completely unfounded and non-scientific. The article in question was not investigative scientific research at all, but rather a review article, which is not research but merely one authorʼs attempt to summarize findings concerning a given topic. This dubious reference is further compounded by the fact that the main topic of the article is not Chiropractic or neck manipulation at all, but rather spontaneous causes of stroke. Neck manipulation is briefly mentioned by a mere quotation from another source, so now we have a quote of a quote (much like the childhood game “telephone” in which the message at the end of the line is a far cry from the original). So, what is the source of the original quote? This other source is an article published in the British Medical Journal (BMJ). Again, this second article is not a scientific investigation, but rather another author opinion-based review article. The direct quote from this article in relation to neck adjustments states: “Estimates of such severe adverse events vary widely, ranging from 1 in 20 000 patients undergoing cervical manipulation to 1 per million procedures. The question arises; how and why can W-Five and an Edmonton Neurologist cherry-pick certain data, yet choose to ignore related data not only from the same article, but from the same paragraph?! Furthermore, the following quote is taken directly from the same article: “There is considerable evidence from randomized controlled trials of the effectiveness of spinal manipulation for back and neck pain. “ Therefore, Dr. Stewartʼs claims that there is no scientific data to support the use of Chiropractic adjustments for neck pain are refuted in the very article which he is found referencing (inaccurately) for stroke risk. Sadly, it gets even worse. The following quote is taken directly from the NEJM article, contained in the same paragraph as Dr. Stewartʼs reference: “However, generalized connective tissue disorders have been identified in one fourth of patients with such dissections (in relation to Cervical Manipulation), and the initial symptoms of vertebral-artery dissection commonly mimic the musculoskeletal neck pain for which people go to chiropractors.”
History Repeating- the Persistence of Misinformation and the Media Perhaps the producers of W-Five are suffering from a creative drought of originality? Perhaps they are too lazy to fact-check? The very same subject, quoting the very same dubious research ahs been reported by the respected scientific writer Jane Brody for the New York Times over seven years ago (in April 2001). Brody already falsely stated that chiropractic spinal manipulation is "estimated to cause stroke in as many as 1 in 20.000 patients.” Her documentation for this statement was again the paper by Wouter Schievink, the very same paper quoted by Dr. Stewart. As in Jane Brody's article, and as noted above, there were no data in Schievink's paper to support such a statement. Instead, as noted, the author quoted the article by Andrew Vickers 2 years earlier in the British Medical Journal. As mentioned, Vickers likewise failed to provide any data to support this contention but rather provided only the declaration: "Ad-
verse events range from 1 in 20.000 patients undergoing cervical manipulation to 1 million procedures”. Through this entire trail of some of the most trusted medical journals, therefore, there is nothing more than the authorsʼ opinions to support this rather drastic contention regarding stroke estimates attributable to spinal manipulation. Worse, the lowest frequency stated by the original author has been completely suppressed in citations in the subsequent scientific and popular literature. Only the suggested figure, which is 50-fold greater than the lower boundary, ever appears to have been carried forward and mentioned.
PART 2: Safety Double-Standards Relative Risk- Scientific Comparison of Chiropractic to Commonly used Pharmaceuticals and Treatment The bulk of the scientific literature establishes the presumed risk of cerebrovascular accidents (including stroke) associated with spinal manipulation at anywhere from 1 per 400,000 to 1 per 5.5 million cervical manipulations, the latter figure representing the most scientifically rigorous derived frequency to date. On the other hand, the risk of deaths from the use of medicines such as nonsteroidal anti-inflammatory 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 are often ignored in both common medical treatment and the media. Death rates due to medication side effects have been estimated by the Institute of Medicine to range from 230,000 to 280,000 per year . Those caused by commonly used Non-Steroidal Anti-Inflammatory Drugs (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. Medications such as ibuprofen are available over-the-counter, and are taken regularly by patients with little or no thought or mention of risk, no investigative reports, nor the need to sign a strongly-worded consent form that Chiropractors are forced to have patients sign. Best estimates of hospitalization and death (amongst patients taking NSAIDs) from gastrointestinal ulcers and bleeding are 40,000 per million (4%) and 4,000 per million (.4%) respectively. In the US this amounts to 32,000 hospitalizations per annum and 3,200 deaths. As noted by the Canadian Medical Association; “The estimated level of risk (of stroke as a result of cervical manipulation) is smaller than that associated with many commonly used diagnostic tests or prescription drugs”. The press coverage dedicated to the safety concerns of Chiropractic neck manipulations is disproportionate to that received by commonly utilized treatments in the medical field, especially considering the admittedly superior safety record of manipulation. Thus, an evident media reporting bias exists and persists.
PART 3: The Actual Science of Stroke Risk and Chiropractic Extensive (and the most recent) research performed in 2008 at the University of Toronto by the Medical Community published in an exclusive peer-reviewed scientific journal demonstrated the following information: • There were 818 VBA strokes hospitalized in a population of more than 100 million person-years. • In those aged <45 years, cases were about three times more likely to see a Chiropractor or a Medical Doctor before their stroke than controls (i.e. those with stroke symptoms likely to seek care for the associated head and neck pain). • There was no increased association between chiropractic visits and VBA stroke in those older than 45 years. • Positive associations were found between Medical Doctor visits and VBA stroke in all age groups. • Practitioner visits billed for headache and neck complaints were highly associated with subsequent VBA stroke. The Conclusions Drawn from this Study are: • VBA stroke is a very rare event in the population. • The increased risks of VBA stroke associated with chiropractic and Medical Doctor visits is likely due to patients with headache and neck pain from VBA dissection seeking care
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before their stroke (headache and neck pain being common symptoms of a stroke in progress, not yet identified as such). There is no evidence of excess risk of VBA stroke associated chiropractic care compared to primary care (Medical Doctor visits).
A recent epidemiological study has analyzed stroke rates in two Canadian provinces while comparing Chiropractic usage in the same provinces. This was done to examine and determine any possible association between stroke and Chiropractic. Should Chiropractic have an association with stroke, one would expect that the province with higher Chiropractic usage would have concurrent increases in stroke rates. However, the study has found that: • The incidence of VBA strokes was similar in both provinces, while chiropractic utilization was 10 times higher in Saskatchewan vs. Ontario during the same time period. • There was a decrease in chiropractic utilization in Ontario and fairly constant utilization in Saskatchewan around the time of a drastic increase in the incidence of VBA stroke. This studyʼs strongest finding is that the incidence of VBA stroke was not correspondingly higher in Saskatchewan as compared to Ontario during the study period, even though the rate of chiropractic utilization was 10 times higher in Saskatchewan. If cervical manipulation were a primary cause of VBA stroke, there should have been a corresponding increase in the incidence of the condition in the population in which the rate of manipulation was higher. Another scientific study demonstrated that: • Spinal Manipulation (neck adjustments) resulted in strains sustained internally by the Vertebral (Cervical) Artery that were similar to those experienced during typical range of motion (such as turning the head). These strains were almost an order of magnitude lower than those required to mechanically disrupt the artery. • As a result, it has been concluded that under normal circumstances, a single, typical (highvelocity/low-amplitude) SMT thrust is very unlikely to tear or otherwise mechanically disrupt the artery. Approximately 10% of Americans consult Chiropractors, with about 250 million patient visits per year. Further studies have demonstrated that the risk of stroke with spinal manipulation is 1 in 3.8-5.8 million.
PART 4: The Reality of Stroke- the “Silent Killer” Stroke is a leading cause of death and disability worldwide. In the United States, for example, there are an annual estimated 731 000 strokes and 4 million stroke survivors. • Spontaneous Dissections The annual incidence of spontaneous VADʼs (strokes) in hospital settings has been estimated to occur at the rate of 1 to 1.5 per 100,000 patients. Spontaneous dissections of the carotid and vertebral arteries affect all age groups, including children, but there is a distinct peak in the fifth decade of life. The annual incidence of spontaneous vertebral-artery dissection can be estimated at 1 per 100,000 to 1.5 per 100,000. • Homocysteine Direct correlations of elevated plasma homocysteine levels with the occurrence of spontaneous cervical artery dissections have been demonstrated. A significant number of clues all point toward the disruption of the structure of collagen and elastin in the arterial wall: In the majority of skin biopsies taken from patients with cervical arterial dissections, irregular collagen fibrils and elastic fiber fragmentations have been found . A growing body of evidence suggests that the inherent fragility of the arterial wall of the cerebrovascular system rather than any trauma associated with maneuvers by the attending physician is the major culprit regarding arterial dissections. Finally, spontaneous dissections appear to correlate with the fragility of the arterial wall, which may be attributable to inborn errors of metabolism that might be detectable by means of a homocysteine assay. • Genetic Factors
Patients with a spontaneous dissection of the carotid or vertebral artery are thought to have an underlying structural defect of the arterial wall, although the exact type of arteriopathy remains elusive in most cases. Having a family history of stroke, heart attack or TIA is considered a risk factor for stroke. • Environmental Factors A history of a minor precipitating event is frequently elicited in patients with a spontaneous dissection of the carotid or vertebral artery. Colorful terms are often given to these occurrences, such as “bottoms- up dissection” and "beauty-parlor stroke.” Other precipitating events associated stroke include completely normal neck movements, such as practicing yoga, painting a ceiling, coughing, vomiting, sneezing, and other factors such as the receipt of anesthesia, and the act of resuscitation. A growing body of evidence suggests that the inherent fragility of the arterial wall of the cerebrovascular system rather than any trauma associated with maneuvers by the attending physician is the major culprit regarding arterial dissections. An appreciable body of literature exists to demonstrate that a wide variety of common lifestyle activities have been associated with cerebral ischemia or even CVAs (strokes) but are decidedly nonmanipulative. By way of illustration, one very recent investigation has described beauty parlor stroke syndrome and salon sink radiculopathy, confirmed by both symptoms and blood flow velocities in the bilateral vertebral and carotid arteries as measured by a diagnostic ultrasound instrument. Thus, it would appear that the tearing of the arterial wall in a dissection is both cumulative and spontaneous: cumulative in that repeated, low-grade insults to the artery would most likely be required to yield a dissection; and spontaneous in that these more minor impositions appear to be by dint of any number of self-imposed maneuvers as well as any by a practitioner, making it extremely difficult if not impossible to distinguish between them. • Lifestyle and Other Factors Many lifestyle factors are implicated in the development of stroke. These include: • Being age 55 or older • High blood pressure (hypertension)— a systolic blood pressure of 140 millimetres of mercury (mm Hg) or higher, or a diastolic pressure of 90 mm Hg or higher • High cholesterol — a total cholesterol level of 200 milligrams per deciliter (mg/dL), or 5.2 mmol/L, or higher • Cigarette smoking • Diabetes • Obesity — a body mass index of 30 or higher • Cardiovascular disease, including heart failure, a heart defect, heart infection, or abnormal heart rhythm • Previous stroke or TIA • High levels of homocysteine, an amino acid, in your blood (as noted above) • Use of birth control pills or other hormone therapy • Other factors that can increase your risk of stroke include heavy or binge drinking and the use of illicit drugs such as cocaine Therefore, the plethora risk factors of stroke are complex, dynamic, interdependent and thus difficult to assess. Furthermore, an appreciable percentage of strokes are the result of spontaneous dissections, or normal common activities of daily living, and thus not typically attributable to any identifiable risk factors. Thus, strokes can occur at random and in individuals with no risk factors. These vascular events can occur in the population completely independent of chiropractic visits.
Conclusion Perhaps those in the media do not understand the polar contrast of opinion and science. Perhaps presenting unfounded claims in a sensationalized and dramatic fashion will generate increased viewership. However, a Medical Doctor and Neurologist no less, should know better. Therefore, one must question the motives and/or competence of a man (Dr. Stewart) who so willingly and blindly accepts unscientific and dubious information, and is so strong in his uninformed conviction that he is willing to stake his reputation on national television.
Furthermore, W-Five at best makes vague reference to, and at worst completely ignores the plethora of more recent and rigorous scientific data so readily available in the scientific literature (some of which has been presented in this essay). W-Five presents a sensationalized one-sided argument whilst completely ignoring facts, which is irresponsible and dishonest. The number of patients suffering a stroke following a visit to their medical doctor, tantamount to Chiropractic, has no mention on W-Five. What dangerous procedure is being performed in medical clinics across Canada that accounts for this increased risk? Furthermore, the plethora of scientific literature on the effectiveness of spinal manipulation for a host of neck conditions has no mention. Conversely, unfounded claims suggesting a lack of science supporting chiropractic manipulation is provided, ironically and hypocritically, without any supporting science (aside from a vague reference to the New England Journal of Medicine, which as noted through actual investigation, is in actuality is a misquote, misrepresentation and entirely based upon an unscientific opinion). Canadians deserve better than this. Fortunately, the vast body of actual scientific data supports the safe use of cervical manipulation (neck adjustments). One can only hope for vindication; that science, and not dogma, prevails.