Analysis of Fractures and Dislocations Caused by Chiropractors in South Africa

ANALYSIS OF FRACTURES AND DISLOCATIONS CAUSED BY CHIROPRACTORS IN SOUTH AFRICA

ABSTRACT

Purpose: The purpose of the study was to perform a retrospective analysis of fractures and dislocations caused by chiropractors in South Africa.

Method: An online survey was distributed to the Allied Health Profession Council of South Africa's database, inviting all registered chiropractors to partake in the survey by use of an email. The participants received an information letter, which explained the anonymity and confidentiality, as well as the fact that their participation were voluntary. Participant's consent was automatically recorded by clicking on the link to the survey. The survey consisted of three sections involving the chiropractor demographics, detail regarding the fracture or dislocation and patient information. Once the survey was completed, participants submitted the survey and results were analyzed by the University of Johannesburg's statistics program (STATKON).

Results: The retrospective analysis revealed that South African chiropractors had caused fractures and dislocations. The percentage of chiropractors who had caused a fracture or dislocation was 14% (18 participants) and resulted in full recovery in all case reports. This indicates that the extent of injury was minor and did not cause long term complication. More specifically, 1 fracture occurred in the treatment of every 1382 patients. With regards to dislocations, 1 dislocation occurred in every 8639 patients treated.

95.5% of fractures were found along the ribs. Fractures were caused by spinal manipulative therapy and dislocations were caused by mobilization techniques. Taking note that 80% of the patients had osteoporosis. Also, the majority of patients were over the age of 50 (79.2%). Clinical signs and symptoms were used as diagnostic method by 14 participants (60.9%).

Conclusion: The chiropractic profession should take these findings into consideration when presented with similar cases. Altering the force used during posterior to anterior thoracic manipulation and lumbar side posture manipulation in patients over 50 or rather using mobilizations in such cases, might decrease the risk of fractures and dislocations occurring in the future. The location of fractures and dislocations mainly occurred at the ribs. Therefore, care should be taken when manipulating or mobilizing the ribs, as it is an area susceptible to injury.

A large percentage of practitioners relied on clinical signs and symptoms for diagnosis of fractures and dislocations in this study, reasons which needs to be clarified in further research. Clinical signs and symptoms do not provide a definite diagnosis. This questions whether the fractures and dislocations in this study did actually occur, as most weren't diagnosed with relevant special investigations. One of the reasons could be due to misinterpretation of the question in the survey. The question asked: "How was it diagnosed?". It did not specify when it was diagnosed The participants could have used signs and symptoms as a preliminary diagnosis made in the practice, before sending for further investigations.

Key Words: Fractures, Dislocations, Chiropractic, South Africa

INTRODUCTION

According to numerous studies, minor and major complications do arise from chiropractic manipulation. However, chiropractic manipulation has a very low risk of causing serious harm to the body (Carlesso, et al., 2015; Cohn, 2001; Haldeman and Rubinstein,1992; Herbert et al., 2015; Scott-Crossley, 2015). Major complications like cauda equina syndrome, lumbar disc herniation and vascular complications occur rarely (Carnes et al., 2010, Herbert et al., 2015). Limited research has been completed on specific adverse events of chiropractic treatment, such as fractures and dislocations. A recent survey on the complications of chiropractic treatment in South Africa found that 17.8% of practitioners experienced fractures and 3.7% reported dislocations (Scott-Crossley, 2015). The location of a fracture or dislocation bears great significance to the severity and outcome of the complication.

The survey compiled information regarding the incidence and location of fractures and dislocations occurring as a result of chiropractic treatment in South Africa. Additional information including the diagnosis, pre-existing pathology, patient recovery, specific chiropractic treatment and geographical data was recorded. This study collected data to be able to prevent unnecessary complications in the future.

Chiropractic treatment

Chiropractors focus on the treatment of musculoskeletal disorders by use of spinal or extremity manipulations. Chiropractic treatment may also include a variety of other therapies such as dietary advice, exercise programs, nutritional supplements and manual therapies (Peterson and Bergman, 2011). A manipulation is applied to a joint, using a specific part of the chiropractor's hand, or body, as a contact, followed by a low amplitude thrust. It is characterized by a crack sound, which is called a cavitation.

Complications of chiropractic treatment

A complication occurs as result of a treatment which is associated with undesirable effects. Chiropractic manipulation has a very low risk of causing serious complications to the body (Carnes, Mars, Froud and Underwood, 2010). Minor to moderate complications can be expected in almost half of patients after the first manual treatment according to Carnes Mars, Froud and Underwood (2010).

Review of fractures and dislocations caused by chiropractors

Fractures and dislocations are possible complications of chiropractic treatment and very little research is available on this topic. A recent survey on complications caused by chiropractic treatment in South

Africa found that fractures and dislocations occurred. According to the survey,17.8% of respondents experienced fractures and 3.7% experienced dislocations on at least one occasion during treatment (Scott-Crossley, 2015). This revealed that fractures and dislocations were a relatively prevalent complication to treatment, however little is known regarding details such as the location, pre-existing pathology, patient profile and demographics as well as practitioner profile and demographics. For this reason this follow up study has been performed.

Cervical fractures caused by chiropractors

International studies have identified cervical spine fractures as a possible complication to manipulative therapy. The first report of a cervical fracture was in 1925, which included an anterior dislocation of the atlas and a fracture of the odontoid process after chiropractic treatment (Blaine,1925).

The literature available on cervical fractures caused by chiropractors is limited. This could be due to the rare incidence of cervical fractures caused by chiropractors or it may be under reported. The literature reports can be termed as "near misses". Cervical fractures were avoided before the commencement of treatment, as seen in the following cases.

Fractures can be diagnosed by use of diagnostic imaging before spinal manipulative therapy is applied, as emphasized in the following case study. Consecutive chiropractic manipulations are used for the treatment of neck pain. A woman with a history of osteoporotic fractures and alcohol abuse, presented with neck pain to a chiropractor after excessive flexion and extension of her neck. Her pain increased in intensity after a few treatments and she was sent for radiographic imaging, which revealed multiple fractures of the dens, C6 and C7 vertebrae. The chiropractic manipulation could have worsened the fractures but it is not necessarily the cause of the fractures. This study highlights the importance of diagnostic imaging before treatment of patients. (Ea, Weber, Yon and Liote, 2004).

A study by Regelink and de Zoete (2001), emphasized the importance of identifying signs and symptoms of fractures and using radiographic imaging for diagnosis in practice. A patient presented with neck pain, after a fall from a rooftop, to a chiropractor's office with no abnormalities on their radiographic films. The chiropractor requested the patient to retake the radiographs and found a Jefferson fracture. Jefferson fracture consists of two fractures in the anterior and posterior arch of the atlas resulting from an axial force (Lam and Kapetanakis, 2012).

Thoracic fractures caused by chiropractors

According to Darbert, Freeman and Weis (1970). The thoracic spine had the largest amount of minor adverse events from chiropractic manipulation in relation to other regions of the body. Adverse events in the thoracic spine include costovertebral and costotransverse joint sprains, intercostal muscle tears, transverse process fractures and rib fractures (Peterson and Bergmann, 2011). Approximately 75-90% of all spinal fractures are found in the thoracic and lumbar spine. The thoracolumbar junction is mostly effected. These result from either low force applied to an osteoporotic spine or high force injury associated with spinal cord injury. The thoracic spine injuries can be divided anatomically into thoracic (T1-T9) or thoracolumbar (T10-L2) injuries. The thoracolumbar junction consists of the union between the rigid thoracic spine and the more mobile lumbar spine (Baliga and Ahmed, 2016).

Thoracic fractures caused by chiropractors present with a similar phenomenon as seen in cervical fractures. As mentioned above, the literature reports can be termed as "near misses". Thoracic fractures were avoided before the commencement of treatment, as seen in the following case.

A very interesting article by Nguyen, Carmichael, Scott Bainbridge and Kozak in 2006, found a 24 year old healthy male complaining to a chiropractor of interscapular and sternal pain while drilling with arms above the head, pain was exacerbated by breathing. He received two treatments including spinal manipulation, interferential current stimulation and cryotherapy which worsened the pain. He was sent for an X-ray, which detected no abnormalities. A Computed Tomogragraphy (CT) scan was taken thereafter and revealed a first rib fracture on the right hand side. Therefore a fracture can't be ruled out by X-ray radiology alone. When pain increases with treatment it should be a warning sign for practitioners to investigate further using multiple diagnostic tests.

Previous research has reported adverse events in the thoracic region due to spinal manipulative therapy. A compression fracture of the ninth thoracic vertebra occurred after spinal manipulation was performed by a physiotherapist in 1985 (Austin, 1985).

Thoracic fractures have been reported as a complication to manipulation in younger age groups. According to Wilson, Greiner and Duma (2012), a three week old baby with suspected colic, obtained a posterior rib fracture following a chiropractic treatment.

Lumbar fractures caused by chiropractors

A recent article (Herbert et al. 2015) reviewed serious adverse events and spinal manipulative therapy of the low back. Seven cases reported fractures in the lumbar spine. Lumbar vertebrae compression fracture of L2 resulted from manipulation causing near total paraplegia. An alarming contributing factor, which was not initially picked up by the chiropractor, was an adenocarcinoma with spinal metastasis.

Haldeman and Rubinstein (1992) reported 3 cases of lumbar fractures. The first case reported L5 compression fracture with the patient experiencing multiple falls prior to treatment. Prior trauma could have damaged the spine and increased the risk of a fracture. The second case found multiple compression fractures in the thoracic and lumbar spine. This patient presented with multiple medical conditions including osteoporosis and previous fractures. The third case reported a L3 compression fracture. This patient suffered with severe osteoporosis and was on long term prednisone medication which influences the structure of the bone. Hansis et al. (2004) presented a case where an L4 compression fracture occurred after treatment. Osteoporosis was a possible contributing factor.

Lumbar compression fracture and vertebral body fracture of L3 vertebra have been reported in Canada, due to suspected forceful manipulation technique (Livingston, 1968, Livingston, 1971) as well as the presence of prostate carcinoma with spinal metastasis. It should be noted that a carcinoma is a contra- indication to spinal manipulative therapy.

All the literature above lacked key information such as description of manipulation technique and explanation of complications experienced, necessary for a more accurate estimation of complications associated with lumbar spinal manipulative therapy. It appears that the majority of fractures in the lumbar spine are compression fractures, involving the vertebrae of the thoracolumbar junction (T12-L1). Compression fractures are caused by forces directed along the long axis of the spine with the spine in the forward flexed position. Resulting in a wedge shaped vertebra, commonly without any neurological complications.

Contra-indications to spinal manipulation therapy

Contra-indications to spinal manipulation include trauma, instability, neurological symptoms, atherosclerosis, vertebrobasilar symptoms, aneurysm, cancer, healing fractures, ligament sprains, degenerative joint disease, osteoporosis, diabetes mellitus, spondylolysthesis, congenital anomalies, clotting disorders, alzheimers and inflammatory disease (Espositi and Philipson, 2005).

Predisposing risk factors of fractures

Risk factors of fractures include previous fragility fracture, postmenopausal women, aging, obesity, low dietary calcium intake, vitamin D deficiency, excessive alcohol consumption, smoking, family history of fracture, corticosteroid medication, medical conditions(such as diabetes and HIV infection), certain medications and inflammatory disorders(such as rheumatoid arthritis) (Bickley, 2013).

Possible contributing factors for lumbar compression fractures caused by manipulation included osteoporosis in various studies (Haldeman and Rubinstein, 1992; Hansis et al, 2004; Herbert et al. 2015). Other contributing factors according to Herbert et al. 2015 was found in two reported cases of lumbar fractures, which included adenocarcinoma and prostate carcinoma with spinal metastasis. Previous trauma and long term prednisone use was also possible contributing factors to lumbar fractures.

Diagnosis of a fracture or dislocation

Clinical assessment (history taking) of a patient with a fracture will reveal severe localized pain over a bone, which is aggravated by movement as well as swelling, deformity and limited movement. A history of trauma is common in both fractures and dislocations, but may occur without trauma in those with a pre-existing pathology such as osteoporosis and osteopenia (Walker, Colledge, Ralston and Penman, 2014).

X-ray radiography is used to accurately identify fractures or dislocations. A fracture line may be seen on an X-ray merely 5 days after the fracture had occurred (Yochum and Rowe, 2004). Other signs to look out for on X-ray include identification of bone displacement, loss of cortex continuity and vertebral endplate erosion(when referring to the vertebra)(Walker, Colledge, Ralston and Penman, 2014).

Relevance of the location of a fracture or dislocation

The region of the injury bares great significance to the classification of the severity of the complication. For example, a rib fracture would be considered less serious than a fracture of the dense. Similarly in the case of dislocations.

Patients with isolated rib fractures could resume normal activity within 41 days (Kerr-Valentic, Arthur, Mullins, Pearson and Mayberry, 2003). The exception to the rule of rib fractures begin considered less serious would be when the first rib is involved. First rib fractures are associated with severe injury and has a high mortality rate (Lin, Chuang, Hsu, Tailor and Lee, 2015). Fortunately, the first rib is situated deeply below the clavicle and is highly protected (Lin, Chuang, Hsu, Tailor and Lee, 2015). Only one article in literature reported a first rib fracture after spinal manipulative therapy (Nguyen, Carmichael, Scott Bainbridge and Kozak, 2006), indicating that first rib fractures are not commonly associated with chiropractic treatment.

Other possible influences of fractures and dislocations caused by chiropractors

Pre-existing pathologies

Manipulation of the spine should be avoided if a pre-existing pathology like malignancy of the spine is present, as it may cause pathological vertebral fractures (Austin, 1985: 1114) and other major complications (Peterson and Bergman, 2011: 106). Other pathologies that are contra-indicated to spinal manipulation include vertebrobasilar insufficiency, aneurysm, current fracture, severe sprains, osteoarthritis, osteoporosis, blood clotting disorders, space-occupying lesion, malingering and diabetic neuropathy. New research conducted regarding complications of chiropractic treatment should include more detailed information about the pre-existing condition of the patient, to provide more accurate information (Herbert et al, 2015).

Osteoporosis is the most common bone disorder in the world and causes over 9 million fractures per year. This disorder is highly prevalent in people over the age of 50 (Yu and Wang, 2016). This condition causes low bone mass which weakens the structure of bone. Patients with osteoporosis have an increased risk of bone fractures due to the increased bone fragility. A third of woman will experience an osteoporotic fracture in their lifetime. Osteoporosis presents as an asymptomatic condition until a fracture occurs. The diagnosis of osteoporosis is under reported according to Hoiberg, Rubin, Hermann, Brixen and Abrahamsen (2016). Osteoporotic fractures are most commonly found in the spine and is contra-indicated to spinal manipulative therapy (Espositi and Philipson, 2005).

Treatment type

Chiropractic treatment consists of a large range of different procedures and techniques. The primary treatment used by chiropractors is Spinal Manipulative Therapy (SMT). Generally complications of spinal manipulative therapy are due to incorrect diagnosis or improper technique. By modifying the manipulation in certain conditions, instability and pathological fractures can be avoided (Peterson and Bergmann, 2011).

Spinal manipulative therapy can cause harm to the thoracic region of the body, if a high amount of thoracolumbar rotation and a large direct force is used when the patient is in a side posture position. The risk of damage is increased when the patient has a pre-existing pathology or small body size (Peterson and Bergmann, 2011).

A recent study compiled essential characteristics of correct tecnique during lumbar spine side posture manipulation. The patient position entailed localizing a specific segment, appropriate chiropractic table height, patient relaxation and sufficient rolling of the patient's trunk towards the chiropractor. In order to deliver the best possible technique, the chiropractor should keep their centre of gravity as close as

13 possible to the localized segment, hold stable forearm contact, use body and legs while shifting weight downwards and deliver a high-velocity low-amplitude thrust (O'Donnell, Smith, Abzug and Kulig, 2016).

MATERIALS AND METHODS An online survey was used to collect relevant information from chiropractors in South Africa.

Participant Recruitment

The Allied Health Professions Council of South Africa (AHPCSA) were involved in the participant recruitment of the survey by sending emails on behalf of research to their databases. Emails were sent to the AHPCSA's database, which invited the registered members to participate in the study.

Methodology

The participants received an information letter (Appendix B), which was part of the original email (Appendix A), which explained the anonymity and confidentiality, as well as the fact that their participation was voluntary. The participants were informed in the information letter that once they had submitted the survey, their data could not be removed from the results due to the anonymity of the answers. Participant's consent was automatically recorded by clicking on the link to the survey (Appendix C).

Survey Outline

The first section of the survey consisted of a compilation of questions related to the chiropractor's demographics including the amount of years the chiropractor has been working, age, gender and geographical information.

The second section of the survey consisted of detailed information regarding the frequency, location, diagnosis and cause of a potential fracture and or dislocation.

The third section of the survey consisted of patient information including age, gender, pre-existing condition and outcome of the condition caused. The second and third section of the survey was repeated for every fracture and dislocation reported, to enable answering of these sections for each specific occurrence of a fracture or dislocation. Refer to Appendix C for survey outline.

Ethical Considerations

The Higher Degrees Committee and the Academic Ethics Committee provided authorization for the study prior to the release of the survey (Appendix D). Due to the sensitivity and possible litigious nature

of the data collected, complete anonymity of the participant was guaranteed. This anonymity eliminated any possible litigation. The answers were not traceable back to the participant. With the assurance of the anonymity, the participant was requested to honestly answer the questions, so as to provide accurate data for this study. The accuracy of the data was imperative so that the chiropractic treatments which may have caused complications, could be correctly identified, and possibly altered in future treatment regimes. This may assist in enhancing the professional and public image of the chiropractic profession, and may reduce the risk of malpractice for the practitioner in future. Plagiarism did not occur in this dissertation and was proved by a turnitin report (Appendix D).

RESULTS Biographic characteristics of the sample population

Duration of years in practice

The largest group of participants had been in practice for 1-5 years, which was 33.3% (43 participants) of the sample. The second largest group had been in practice for 11-15 years, which was 20.2% of the sample or 26 participants. The third largest group had been in practice for 6-10 years, which was 17.8% of the sample or 23 participants. Only 14.7% of participants or 19 participants had been in practice for more than 15 years and 14% or 18 participants were in practice for less than one year.

Age distribution

The majority of the participants were between the ages of 24-30 and consisted of 44 participants (34.1% of entire sample of participants). The second largest group were between the ages of 38-45 years of age and consisted of 36 participants (27.9% of participants). The 31-37 year age group only had one participant less than the second largest group and made up 27.1% of the participants. From the 46-50 years age group the participants numbers decreased dramatically in relation to the largest age groups. Only five participants were between the ages of 46-50 years of age (3.9% of participants). The 51-55 and 56-59 year age groups both had only one participant (combined contributing 1.6%). The 60-65 year age group had 3 participants, making up 2.3% of participants. Then the last group which was the participants older than 65 had four participants (3.1% of participants).

There is a strong positive association between age and the number of years in practice which is to be expected.

Gender distribution

The gender distribution was almost equally shared between the two genders. There were 52.7% males (68 male participants) and 47.3% females (61 females participants).

Provincial distribution (n=125)

The pie chart in Figure 4.4 included 125 participants valid data. The majority of participants were from Gauteng and had 73 participants (58.4%). KwaZulu-Natal followed second with 21 participants (16.8%). Western Cape had 20 participants (16%). Only 7 participants (5.6%) practiced in the Eastern Cape. The North West Province and the Free State had 2 participants (1.6% respectfully).

Incidence of fractures and dislocations

The percentage of chiropractors who had caused a fracture or dislocation was 14% (18 participants). The remainder of the total sample, which consisted of 111 participants had, to their knowledge, never caused a fracture or dislocation. The 18 participants reported 25 fractures and 4 dislocations in total. The discrepancy in the numbers is because some practitioners caused more than one fracture or dislocation.

Percentage of participants causing a fracture, dislocation or both (n=18)

The majority of participants had only caused fractures (14 participants), contributing to 77.8% of the group. Only 3 participants (16.7%) had caused dislocations and 1 participant (5.6%) had caused both a fracture and a dislocation. The frequency of each is discussed under heading 4.7.1.

Cause of the fracture or dislocation (n=24)

The majority of fractures and dislocations were caused by spinal manipulative therapy (83.3%, 20 participants). Mobilization caused 12.5% (3 participants) of the fractures and dislocations. One participant (0.42%) reported an external factor whereby a pen found in a patient's pocket acted as a fulcrum and caused a costal cartilage dislocation.

Fractures

Frequency of fractures (n=16)

The majority of the group had caused a fracture once (56.3%, 9 participants), 31.3% (5 participants) caused a fracture twice and 12.5% (2 participants) caused a fracture three times. Resulting in 25 fractures in total.

Location of fractures (n=22)

95.5% of fractures were found at the ribs. The majority of the group (68.2%, 15 participants) had caused a fracture of the rib and did not specify the exact location of the rib involved. The level of the rib fractured was stated by some participants, which included a 3rd, 4th, 5th, 8th (was reported twice) and 9th rib fracture. Almost a third (27.3%, 6 participants) had caused a fracture at the angle of the rib. Only 4.54% (1 participant) had caused a fracture of the transverse process of C4 vertebrae.

Description of manipulation technique involved in the cause of rib fractures (n=19)

Posterior to anterior manipulation of the thoracic spine had caused a 57.9% (11 cases) of rib fractures. Lumbar side posture manipulation caused 26.3% (5 cases) of rib fractures. Crossed bilateral body drop caused 10.5% (2 cases) and bilateral transverse thenar manipulation caused 5.3% (1 case) of rib fractures.

Description of manipulation technique involved in the cause of transverse process of C4 vertebra

Only one participant caused a fracture of the transverse process of C4 using a rotary cervical manipulation.

Dislocations

Frequency and location of dislocations

Three participants caused a dislocation (n=3). Only one participant indicated the frequency and location of the dislocations. This participant caused a dislocation twice and indicated the location of both were found at the costal cartilage of the ribs. A total of 4 dislocations occurred.

Description of technique involved in the cause of dislocations (n=3)

Posterior to anterior rib mobilization caused 66.7% (2 participants) of dislocations and anterior thoracic mobilization caused 33.3% (1 participant) of dislocations.

Diagnosis of the fracture or dislocation (n=23)

Interestingly history taking (60.9%, 14 participants) was the primary method of diagnosis for fractures and dislocations.This indicates that purely signs and symptoms of fractures and dislocations were used for diagnosis. A third of the group (30.4%%, 7 participants) had used X-ray radiography and 4.3% (1 participant) used MRI (Magnetic Resonance Imaging).

Patient information

Age of the patient (n=24)

The leading group was the 51-60 years age group contributing to 37.5% (9 patients) of patients. The second largest group was the 61-70 years age group (29.2%, 7 patients). The 41-50 years and 71-80 years age groups both contributed 12.5% (3 patients) respectively. The smallest group involved was the 31-40 year age group (8.3%, 2 patients).

Gender distribution of the patient (n=23)

The gender distribution of the patients were 60.9% (14 patients) females and 39.1% (9 patients) males.

Pre-existing condition of the patient (n=10)

Osteoporosis were found in 80% of patients (8 patients) that experienced a fracture or dislocation. Diabetes mellitus and recent heart bypass surgery were found in 10% (1 participant) of patients respectively.

Patient recovery after a fracture or dislocation (n=16)

All participants reported that patients experienced full recovery, with no disability.

Case description summary

In order to simplify the data from the study, summaries of each case of a fracture and dislocation has been described in table format (4.12.1 Table presenting cases of fractures and dislocations in females), (4.12.2 Table presenting cases of fractures and dislocations in males).

Perspective of results

The average years that participants have been in practice, according to the results, were approximately 7.7 years. Table 4.13 was used to calculate the weighted average (1002/129). According to Kane and Forte (2007), chiropractors treat an average of 102 patients per week. If it is assumed that chiropractors work 44 weeks per year and treat 102 patients per week for 7.7 years, then the total amount of patients treated would be 34558. According to results of the survey, a total of 25 fractures and 4 dislocations occurred. Thus, 25 fractures occurred in the treatment of 34558 patients. More specifically 1 fracture occurred in the treatment of every 1 382 patients. With regards to dislocations, 4 occurred in the treatment of 34 558 patients or rather 1 dislocation occurred in every 8639 patients treated. This calculation refers to one complete chiropractic treatment regime which may include multiple manipulations.

DISCUSSION

Incidence of fractures and dislocations

The percentage of chiropractors who had caused a fracture or dislocation was 14% (18 participants) of the sample population. The remainder of the population (111 participants) had never caused a fracture or dislocation. The 18 participants reported 25 fractures and 4 dislocations.

A recent survey on the complications of chiropractic treatment in South Africa found that 17.8% of chiropractors experienced fractures and 3.7% reported dislocations (Scott-Crossley, 2015). When comparing the results with Scott-Crossley's (2015) research, the percentage of fractures had a 5.4% lower incidence and a 1.4% lower incidence of dislocations. The variation in percentage could be due to the larger sample group (197 participants) in Scott-Crossley's study in comparison to the 129 participants forming this sample population. The larger the population size, the smaller the possibility of a sampling error (Brink, van der Walt and van Rensburg, 2012). In future research survey's should increase the size of the population sample, to provide an improved representation of the total population. This could be achieved by providing incentives to chiropractors to partake in the survey. For example: chiropractors could be offered CPD (Continuing Professional Development) points once they have completed the survey.

Cause of the fracture or dislocation

All fractures were caused by spinal manipulative therapy. Dislocations were caused by mobilization and one participant reported that a pen was found in a patient's pocket which acted as a fulcrum and caused costal cartilage dislocation. The description of techniques used are described under heading 5.6.4 and heading 5.7.2

The higher incidence of adverse events caused by manipulation when compared to mobilization, could be due to the different method of application between the two techniques. Manipulation is a high velocity, low amplitude thrust applied to a localized area of the body. Mobilization is a low velocity passive movement that is applied within the patient's range of motion. Consequently, both techniques produce positive outcomes such as connective tissue lengthening, analgesia, motor, sympathetic, neurophysiological and mechanical effects (Gross et al. 2010). But a manipulation is applied using a larger force at a higher speed than a mobilization, which can explain the higher incidence of adverse events caused by manipulation. When comparing manipulation to mobilization, the one technique

cannot be declared superior to another because there is very little comparative studies found in literature (Gross et al. 2010).

Frequency of fractures

The majority of the target population had caused a fracture once (56.3%), 31.3% of the group caused a fracture twice and 12.5% caused a fracture three times.

A recent study by Scott-Crossley (2015), reported the frequency of fractures experienced by chiropractors in South Africa. The majority of respondents that had caused a fracture (60.6% or 20 chiropractors) had only experienced this on one occasion. The second largest group had experienced this complication 2-3 times (25.7% or 9 chiropractors) followed by occurrences taking place more than 5 times (8.6% or 3 chiropractors). One chiropractor (2.9%) indicated that fractures had occurred 4-5 times. The variation in percentage results could be due to the larger sample group of 197 participants in Scott-Crossley's study, as mentioned above (heading 5.3).

Scott-Crossley's (2015) research was the only study providing the frequency of fractures caused by chiropractors. This leaves a vacancy within literature related to this topic. It would be beneficial to repeat a similar study in other countries, to contribute to the limited research available and to identify further association to fractures that may differ from results in South Africa.

Location of fractures

The majority of the target group (68.2%, 15 participants) had caused a fracture of the rib and did not specify the exact location of the rib. Almost a third (27.3%, 6 participants) had caused a fracture at the angle of the rib. Therefore 95.5% of fractures were found at the ribs. Only 4.54% (1 participant) had caused a fracture of the transverse process of C4 vertebrae.

From existing literature it can be seen that approximately 75-90% of all spinal fractures are found in the thoracic and lumbar spine. The thoracolumbar junction is mostly effected. These result from either low force applied to an osteoporotic spine or high force injury associated with spinal cord injury. The thoracic spine movement has less movement than the rest of the spine, because it is attached to the ribs forming the ribcage (Levangie and Norkin, 2011).

Rib fractures are primarily caused by large forces delivered to the chest (Kessel et al. 2014). A research study by Stemper, Hallman and Peterson (2011), measured the amount of chest compression produced by thoracic manipulation delivered by chiropractors. The severity of chest compression depth was classified according the Abbreviated Injury Scale. Scale 1 level injury indicated minor chest

20 deformity such as a single rib fracture. The study found that chiropractic manipulation resulted in a minimal risk of minor chest deformity (Scale 1 level injury). Hence, a manipulation, even when the chiropractor used their largest force possible, was not commonly associated with patient injury. Nonetheless, the larger the force, the higher the risk of injury. The study also noted that other factors may influence the chest resistance such as age, gender and degeneration of the spine (Kessel et al. 2014). The rib cage of the paediatric age group is described as higher in elasticity and flexibility and requires higher amount of force to cause a fracture than in the adult population (Kessel et al. 2014).

It was difficult to compare the location findings, as there were no similar studies done before. An assumption could be made that larger than normal forces were applied during the manipulation, to patients with pre-existing conditions causing the ribs to fracture.

Description of manipulation technique involved in the cause of rib fractures

Posterior to anterior manipulation of the spine involves a quick thrust to various processes of the thoracic spine in the posterior to anterior direction (Gudavalli, 2014). Lumbar side posture manipulation requires the patient to be placed in a side lying position. Thereafter the hip and knee is flexed and brought across the midline of the body. The pelvis stays perpendicular to the chiropractic table. The manipulation is applied with a combination of a high velocity thrust through the contact hand, arm and shoulder and a body drop motion of the body (Gudavalli, 2014).

Spinal manipulation is a skill that requires years of experience. The time period necessary to become a skilled chiropractor can not be clearly specified. All that can be said, is that the more quantitive feedback is given during practice of manipulations, the quicker a student will learn proper technique (Descarreaux and Dugas, 2010). Spinal manipulatiion has significantly various outcomes on each patient. This could be due to patient's health state or variation in the force applied by each chiropractor during chiropractic manipulation (Perle and Kawchuk, 2005).

Description of manipulation technique involved in the cause of transverse process of C4 vertebra

Only one participant caused a transverse process of C4 vertebra fracture. They used a rotary cervical manipulation. Rotary cervical manipulation can be delivered by using a pad of thumb contact or an index finger contact on a localized area of the neck. The manipulation uses a traction force coupled with lateral flexion and quick rotation movement (Kirk, Lawrence and Valva, 1998). The risk of damage during chiropractic treatment is increased when the patient has a pre-existing pathology or small body size (Peterson and Bergmann, 2011). The literature available on cervical fractures caused by

chiropractors is limited. This could be due to the rare incidence of cervical fractures caused by chiropractors or it may be that cervical fractures are under reported. The first report of a cervical fracture, as a possible complication to manipulative therapy, was in 1925 (Blaine, 1925).

Frequency and location of dislocations

Three participant caused dislocations (n=3). Only one participant indicated the frequency and location of the dislocations. The dislocation occurred twice and both were found at the costal cartilage of the ribs.

A recent study by Scott-Crossley (2015), reported the frequency of dislocations experienced by chiropractors in South Africa. 50% of the respondents reported dislocation occurring once and the other half reported dislocations occurring 2-3 times. This study did not describe the location of the dislocation.

Description of technique involved in the cause of dislocations

Posterior to anterior rib mobilization caused 66.7% (2 cases) of dislocations and anterior thoracic mobilization caused 33.3% (1 case) of dislocations (n=3). A mobilization is defined as sustained gliding or oscillations applied to a joint or body region. Rib mobilizations are used when rib motion is decreased on physical examination. An anterior thoracic mobilization can be characterized as a posterior to anterior movement. Therefore 66.7% indicated that a posterior to anterior mobilizations was used when causing a dislocation but they did not specify which mobilization technique was used. Only 33.3% specified the technique, indicating that an anterior thoracic mobilization was used. During an anterior thoracic mobilization the patient lies supine with arms crossed over their chests. The practitioner uses a fist contact over the rib head and rolls the patient over the contact hand inducing rotation and lateral flexion forces. (Vizniak,2012). These forces may cause damage to the body when too large force is used or if the patient has a pre-existing pathology (Peterson and Bergmann, 2011).

Diagnosis of the fracture or dislocation

The large percentage of practitioners (60.9%) that relied on clinical signs and symptoms (history taking) for diagnosis of fractures and dislocations in this study, needs to be clarified. Clinical signs and symptoms do not provide a definite diagnosis. This questions whether the fractures and dislocations in this study actually occurred, as most weren't diagnosed with relevant special investigations. The information is not reliable and makes it difficult to come to an accurate conclusion. Multiple studies have highlighted the importance of diagnostic imaging with treatment of patients (Ea et al., 2004, Regelink and de Zoete, 2001, Nguyen et al., 2006), but still the majority of practitioners chose not to send for

diagnostic investigation. The reasoning behind this decision made by practitioners provides an opportunity for future research.

One of the reasons could be due to misinterpretation of the question in the survey. The question asked: "How was it diagnosed?". It did not specify when it was diagnosed The participants could have answered that it was diagnosed by signs and symptoms, because it could have been a preliminary diagnosis made in the practice, before sending for further investigations. Another reason for delaying immediate diagnostic imaging, could be due to the fact that a fracture line may be seen on an X-ray merely 5 days after the fracture had occurred (Yochum and Rowe, 2004).

A third of the group (30.4%) had used X-ray radiography for diagnosis. Radiography is commonly used to identify fractures or dislocations (Yochum and Rowe, 2004). Also interestingly, according to Mattox, Reckelhoff, Welk. and Kettner (2014) almost half of rib fractures may be missed on radiographic imaging. Therefore an accurate diagnosis of a fracture or dislocation cannot be verified using radiography alone.

In this study 4.3% (1 participant) used an MRI (Magnetic Resonance Imaging) for diagnosis. MRI is used primarily for analysis of soft tissue damage, as well as detection of disc, ligament, muscle and prevertebral soft tissue injury (Yochum and Rowe, 2004). Therefore, the practitioner might have referred the patient to a specialist, in suspicion of damage to structures involved.

Patient information

Age of the patient

The majority of patients were between the ages of 51-70 years. The risk of bone fractures increases with age (Bickley, 2013), which may explain why most patients were over the age of 50. Osteoporosisis the most common bone disorderin the world and causes over 9 million fractures per year.This disorder is highly prevalent in people over the age of 50 (Yu and Wang, 2016), which would explain why fractures and dislocations were found mainly in patients over the age of 50.

The incidence and complications of rib fractures caused by minor trauma, especially in the elderly, have been increasing over the last 30 years This may be explained by the elderly population that is living longer than previous years due to new medical interventions. Another suggested reason includes the increased prevalence of falls in the elderly population (Mattox, Reckelhoff, Welk. and Kettner, 2014).

Gender distribution of the patient

The study found that 60.9% of the patients were females and 39.1% were males. The larger group of women in this study could be due to the higher incidence of women developing osteoporosis once they get older. One in three women and one in five men over 50 years old will develop osteoporosis. Osteoporosis increases the risk of bone fractures (Yu and Wang, 2016).

Pre-existing condition of the patient

Osteoporosis was found in 80% of patients (8 patients). Osteoporosis is a condition causing low bone mass which weakens the structure of bone. Patients with osteoporosis have an increased risk of bone fractures due to the increased bone fragility. A third of woman will experience an osteoporotic fracture in their lifetime. Osteoporosis presents as an asymptomatic condition until a fracture occurs. The diagnosis of osteoporosis is under reported according to Hoiberg, Rubin, Hermann, Brixen and Abrahamsen (2016). Osteoporotic fractures are most commonly found in the spine and is contra- indicated to spinal manipulative therapy (Espositi and Philipson, 2005).

Diabetes mellitus increases the risk of developing a bone fracture (Bickley, 2013), which explains why diabetes melitus was reported in one patient. Recent heart bypass surgery was found in 1 patient. An assumption can be made that heart bypass surgery is not commonly associated with fractures and dislocations, because there is no association between them in available literature.

Patient recovery after a fracture or dislocation

All participants reported that patients experienced full recovery, with no disability. This indicates that the extent of injury was minor and did not cause long term complications

CONCLUSION

A large percentage (60.9%) of practitioners relied on clinical signs and symptoms (history taking) for diagnosis of fractures and dislocations in this study, which needs to be clarified in further research. Clinical signs and symptoms do not provide a definite diagnosis. This questions whether the fractures and dislocations in this study did actually occur, as most weren't diagnosed with relevant special investigations.

The retrospective analysis revealed that South African chiropractors had caused fractures and dislocations. The percentage of chiropractors who had caused a fracture or dislocation was 14% (18 participants) and resulted in full recovery in all case reports. This indicates that the extent of injury was minor and did not cause long term complication, implying that chiropractic treatment is safe with

regards to fractures and dislocations. More specifically, 1 fracture occurred in the treatment of every 1382 patients. With regards to dislocations, 1 dislocation occurred in every 8639 patients treated.

Spinal manipulative therapy caused most of the fractures and dislocations. A remarkable 95.5% of fractures were found along the ribs. Taking note that 80% of the patients had osteoporosis. Also, the majority of patients were over the age of 50. Therefore the chiropractic profession should take these findings into consideration when presented with similar cases. Altering the force used during manipulation of the ribs in patients over 50 or rather using mobilizations in such cases, might decrease the risk of fractures and dislocations occurring in the future.

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FIGURES

More than 15 Less than one years year 15% 14%

11-15 years 20% 1-5 years 33%

6-10 years 18%

Figure 4.2 Pie chart indicating the number of years in practice (n=129)

35,0

30,0

25,0

20,0

15,0

10,0

Percentage of Chiropractors 5,0

0,0 24-30 31-37 38-45 46-50 51-55 56-59 60-65 Older years years years years years years years than 65 years Age of Participants

Figure 4.3 Bar graph indicating the age distribution of the participants

Female 47% Male 53%

Figure 4.4 Pie chart indicating the gender distribution of participants

Gauteng Eastern Cape Free State Western Cape North West KwaZulu-Natal

17% 2%

16% 58%

1% 6%

Figure 4.5 Pie chart containing the percentage of provincial distribution (n=125)

Fractures and dislocations 14%

None 86%

Figure 4. 6 Pie chart indicating the percentage of fractures and dislocation caused by chiropractors in South Africa (n=129)

Both 5%

Dislocations 17%

Fractures 78%

Figure 4. 6.1 Pie chart indicating the percentage of fractures, dislocations or both (n=18)

Other* 4% Mobilization 13%

Manipulation 83%

Figure 4.7 Pie chart presenting the cause of a fracture or dislocation (n=24)

Three times 13%

Twice Once 31% 56%

Figure 4.8.1 Pie chart indicating the frequency of fractures (n=14)

Transverse process of C4 5%

Angle of rib 27%

Rib fracture 68%

4.8.2 Pie chart indicating the location of fractures reported (n=22)

Bilateral transverse thenar 5% Crossed bilateral body drop 11%

Lumbar side Posterior to posture anterior thoracic manipulation manipulation 26% 58%

4.8.3 Pie chart representing the manipulation technique involved in the cause of rib fractures (n=19)

Anterior thoracic mobilization of ribs 33% P-A Rib mobilizations 67%

4.9.2 Pie chart representing the tecnique involved in the cause of dislocations (n=3)

Other: Not indicated 4% MRI 4%

X-ray 31%

History taking 61%

4.10 Pie chart representing the method of diagnosis (n=23)

31-40 71-80 years: years 13% 8% 41-50 years 12%

61-70 years: 29% 51-60 years: 38%

4.11.1 Pie chart indicating the percentage of the age groups of the patients (n=24)

Male 39%

Female 61%

4.11.2 Pie chart representing the patient gender distribution (n=23)

Recent Diabetes surgery mellitus 10% 10%

Other: Osteoporosis 80%

4.11.3 Pie chart indicating the perecentage of pre-existing conditions of the patients

TABLES

Fracture or Location Diagnosis Description of Age of Pre-existing dislocation manipulation/ patient pathologies mobilization technique Fracture Rib X-ray Lumbar side posture 31-40 Not indicated radiology manipulation years old Fracture Angle of Clinical Posterior to anterior 61-70 Osteoporosis rib signs and thoracic manipulation years old symptoms Fracture Left 4th rib Clinical Posterior to anterior 51-60 Osteoporosis signs and thoracic manipulation years old symptoms Fracture Rib X-ray Anterior thoracic 51-60 Not indicated radiology manipulation years old Fracture Rib X-ray Anterior thoracic 41-50 Not indicated radiology manipulation years old Fracture 9th Rib Clinical Lumbar side posture 61-70 Osteoporosis signs and manipulation years old symptoms Fracture Rib Clinical Crossed bilateral body 51-60 Not indicated signs and drop manipulation years old symptoms Fracture Rib Clinical Rib manipulation 61-70 Not indicated signs and years old symptoms Fracture Rib Not Lumbar side posture 61-70 Osteoporosis indicated manipulation years old Fracture Angle of Clinical Lumbar side posture 61-70 Osteoporosis rib signs and manipulation years old symptoms Fracture Rib X-ray Anterior thoracic 51-60 Not indicated radiology manipulation years old Fracture Right 8th Clinical Posterior to anterior 71-80 Osteoporosis rib signs and thoracic manipulation years old symptoms Fracture Left 3rd rib Clinical Posterior to anterior 71-80 Osteoporosis signs and thoracic manipulation years old symptoms Fracture Angle of Clinical Crossed bilateral body 71-80 Osteoporosis rib signs and drop manipulation years old symptoms 4.12.1 Table presenting cases of fractures and dislocations in females

Fracture or Location Diagnosis Description of Age of Pre-existing dislocation manipulation/ patient pathologies mobilization technique Fracture Rib X-ray Poor manipulation 31-40 Not indicated

radiology technique years Fracture Right 5th X-ray Posterior to anterior 51-60 Not indicated rib radiology hypothenar years old manipulation Fracture Angle of Clinical Combination 61-70 Not indicated rib signs and movement years old symptoms manipulation Fracture Transver MRI Rotary cervical 41-50 Not indicated se Magnetic manipulation years old process Resonance of C4 Imaging Fracture Angle of Clinical Posterior to anterior 51-60 Not indicated rib signs and thoracic manipulation years old symptoms Fracture Rib Clinical Posterior to anterior 51-60 Not indicated signs and thoracic manipulation years old symptoms Fracture 8th rib X-ray Manipulation 41-50 Not indicated radiology years old Dislocation Costal Clinical Posterior to anterior rib 51-60 Recent heart cartilage signs and mobilization* years old bypass surgery of rib symptoms Dislocation Costal Clinical Posterior to anterior rib 51-60 Not indicated cartilage signs and mobilization years old of rib symptoms * Patient had a pen in their pocket which acted as a fulcrum

4.12.2 Table presenting cases of fractures and dislocations in males

Years in Practice Frequency Mid-points Frequency × Mid point Less than 1 year 18 0.5 9 1-5 years 43 3 129 6-10 years 23 8 184 11-15 years 26 13 338 More than 15 years 19 18 342 Total 129 1002

Table 4.13 Table values for calculation of average amount of years of participants in practice

AUTHOR DECLARATION

We wish to confirm that there are no known conflicts of interest associated with this publication and there has been no significant financial support for this work that could have influenced its outcome.

We confirm that the manuscript has been read and approved by all named authors and that there are no other persons who satisfied the criteria for authorship but are not listed. We further confirm that the order of authors listed in the manuscript has been approved by all of us.

We confirm that we have given due consideration to the protection of intellectual property associated with this work and that there are no impediments to publication, including the timing of publication, with respect to intellectual property. In so doing we confirm that we have followed the regulations of our institutions concerning intellectual property.

We further confirm that any aspect of the work covered in this manuscript that has involved either experimental animals or human patients has been conducted with the ethical approval of all relevant bodies and that such approvals are acknowledged within the manuscript.

We understand that the Corresponding Author is the sole contact for the Editorial process (including Editorial Manager and direct communications with the office). He/she is responsible for communicating with the other authors about progress, submissions of revisions and final approval of proofs. We confirm that we have provided a current, correct email address which is accessible by the Corresponding Author and which has been configured to accept email from Dr Charmaine Bester,[email protected]

Signed by all authors as follows:

______Kimon Hendrikz Date:

______Dr Charmaine Bester Date:

Author Agreement

I, Dr Charmaine Bester, the corresponding author, certify that all authors have seen and approved the manuscript being submitted.

The article submitted is the authors' original work, has not received prior publication and is not under consideration for publication elsewhere.

______

Corresponding author:

Dr Charmaine Bester

E-mail Address: [email protected]

Tel: 011 559 6936

Fax: 011 559 6117

Institution: University of Johannesburg

Faculty: Health Sciences

Department: Chiropractic

Address: Department of Chiropractic, University of Johannesburg, P.O. Box 17011, Doornfontein, Johannesburg, 2028, Gauteng, South Africa

100 WORD ABSTRACT

Purpose: The purpose was to perform a retrospective analysis of fractures and dislocations caused by chiropractors in South Africa.

Method: An online survey was distributed via email to the Allied Health Profession Council of South Africa's database, inviting all registered chiropractors to participate. The participants received an information letter, which explained the anonymity, confidentiality and voluntary participation. Consent was recorded by clicking on the link to the survey. The survey consisted of three sections including the chiropractor demographics, fracture or dislocation details and patient information.

Results: The percentage of chiropractors who had caused a fracture or dislocation was 14% (18 participants) and resulted in full recovery in all reports.

Full Title: Analysis of Fractures and Dislocations caused by Chiropractors in South Africa.

8 Word Title: Analysis of Fractures and Dislocations caused by Chiropractors.

Key Words: Fractures, Dislocations, Chiropractic, Manipulation, South Africa .