LEADER 195

Back “Osteoporosis should be regarded Br J Sports Med: first published as 10.1136/bjsm.37.3.195 on 1 June 2003. Downloaded from ...... as a contraindication for ”

Chiropractic spinal manipulation for A special case is the patient suffering from osteoporotic . About 4% of back pain all back pain originates from osteoporosis,11 a figure that increases E Ernst with age, particularly in women. Plain ...... radiography, as often used by most chiropractors, is unhelpful in diagnosing The effectiveness of chiropractic spinal manipulation for back mild to moderate osteoporosis (or most pain is uncertain other causes of back pain). Its use as a diagnostic tool in mechanical back pain is limited because “it does not pro- ports medicine clinicians with var- If the documented benefit from a treat- vide adequate clinically relevant ment is uncertain, any (even a relatively 11 ied training include mobilisa- findings”. Osteoporosis should be re- small) risk can weigh heavily. Spinal Stion and manipulation among their garded as a contraindication for chiro- manipulation, especially the chiropractic therapeutic skills. Examples include chi- practic spinal manipulation. Yet, in prac- variety which often uses relatively high ropractors, physiotherapists, and osteo- tice, no reliable diagnostic methods are forces (up to about 500 N),6 is far from paths, not to mention the doctors and available to chiropractors for identifying risk-free. About half of all patients will massage therapists who treat various osteoporosis, and no threshold values experience transient, mild to moderate joint pathologies. Although athletes have been determined for people at rarely have osteoporosis, the broad field problems, mostly local pain, after treatment.7 Dramatic complications have risk. of sports medicine includes the use of The Code of Practice of the General exercise therapies and treatment of the also been noted with some degree of regularity.8 They mostly relate to cerebrov- Chiropractic Council determines that musculoskeletal system in people of all “before instituting any examination or ages. Therefore this leader focuses on the ascular accidents after upper spinal manipulation. Risk factors are not identi- treatment, a chiropractor shall ensure role of chiropractic . that informed consent . . .has been Back pain sufferers from more than 60 fiable, which means that everyone receiv- 1 ing chiropractic treatment is at risk. given . . . Informed consent means con- countries consult chiropractors. A book- sent that is given by a person who has let by the British Chiropractic Associ- Estimates of that risk (by chiroprac- tors) vary from 1 in 400 000 to 1 in about been supplied with all the necessary rel- ation boldly states that “95% of back 12 9 evant information”. This opens a range pain is mechanical in origin, and can be 4 million manipulations. But under- reporting can be as large as 100%,10 a fact of important questions. What infor- treated by a chiropractor in a primary mation do patients find necessary and care setting”.2 Yet there are many who that renders the above estimates nonsen- 8 relevant? Are patients routinely in- doubt such promotional statements. A sical. In a recent case-control study, 582 cases of vertebrobasilar accidents were formed about the evidence on effective- recent, perhaps more sober, assessment ness and safety of chiropractic spinal matched with healthy controls. Patients http://bjsm.bmj.com/ of the data reads differently: “43 ran- under 45 years of age who had experi- manipulations? Are they fairly advised domised trials of spinal manipulation for enced a vertebrobasilar accident were five about other treatment options? Are they treatment of acute, subacute and chronic times more likely than controls to have told about the dubious value of radio- have been published. 30 visited a chiropractor in the preceding graphs? Are they told that osteoporosis favoured manipulation over the com- week, and five times more likely to have is a contraindication? The sooner the parison treatment in at least a subgroup made more than three visits for cervical chiropractic profession addresses these of patients and the other 13 found no 3 treatment in the preceding month. There issues the better for their patients. significant differences”. However, these were no significant associations for older In conclusion, the proven benefit of trials used mostly non-chiropractic spi- patients. For every 100 000 chiropractic chiropractic spinal manipulation is far on September 24, 2021 by guest. Protected copyright. nal manipulation. The only systematic patients below the age of 45 years, less certain than chiropractors tend to review of exclusively chiropractic spinal approximately 1.3 cases of vertebrobasilar admit and its risks are not negligible. manipulation concluded that “the avail- accidents attributable to that treatment This is true for back pain in general able RCTs provided no convincing evi- would be observed within one week of and for osteoporotic back pain in par- dence of the effectiveness of chiropractic 4 treatment. These data indicate that the ticular. for acute or chronic low back pain”. incidence of serious complications has Br J Sports Med 2003;37:195–196 Since the publication of this article, the previously been underestimated. emerging trial data have not tended to be Serious complications occur mostly ...... encouraging. The effectiveness of chiro- with upper spinal manipulation. However, practic spinal manipulation for back pain chiropractors view the spine as a func- Author’s affiliation is thus at best uncertain. More specifi- tional entity, thus often manipulating the E Ernst, Peninsula Medical School, cally, for osteoporotic back pain no trial Complementary Medicine, Universities of spine at levels at which “subluxations” are Plymouth and Exeter, 25 Victoria Park Road, data are available at present. Similarly it detected regardless of the location of pain. Exeter EX2 4NT, UK is unclear whether this approach is In other words, patients with low back Correspondence to: Professor Ernst; superior to other treatments used for this pain often also receive upper spinal 5 [email protected] back pain. These statements are true manipulation for treatment. One could regardless of the many national guide- furthermore argue that manipulation is REFERENCES lines that seem to suggest the opposite. much safer than other treatment options 1 Dagenais S, Haldeman S. Chiropractic. such as non-steroidal anti-inflammatory Primary Care Clinical Office Practice “Risk factors are not identifiable, drugs.1 This may well be true, but one 2002;29:419–37. which means that everyone needs to point out that the risk-benefit 2 British Chiropractic Association. Chiropractic...a helping hand for you and receiving chiropractic treatment is relation, not the absolute risks, must your patients. London: British Chiropractic at risk” inform therapeutic discussions. Association, 2000.

www.bjsportmed.com 196 LEADER

3 Meeker WC, Haldeman S. Chiropractic: a there is an urgent need to assess the M M Sran Br J Sports Med: first published as 10.1136/bjsm.37.3.195 on 1 June 2003. Downloaded from profession at the crossroads of mainstream safety and efficacy of spinal mobilisation and . Ann Intern Med Bone Health Research Group, University of techniques for osteoporotic back pain. 2002;136:216–27. British Columbia, Vancouver, Canada and 4 Assendelft WJJ, Koes BW, van der Heijden Specifically, there is a need to quantify Osteoporosis Program, Children’s & GJMG, et al. The effectiveness of chiropractic (a) the forces that will fracture the osteo- for treatment of low back pain: an update and Women’s Health Centre of British Columbia, attempt at statistical pooling. Journal of porotic spine in the direction of typical 4500 Oak St, Vancouver, BC V6H 3N1, Manipulation and mobilisation procedures, and (b) the Canada; [email protected] 1996;19:499–507. forces that a clinician applies when 5 Shekelle PG. What role for chiropractic in Br J Sports Med 2003;37:195–196 healthcare? N Engl J Med 1998;339:1074–5. performing spinal . This 6 Triano J, Schultz AB. Loads transmitted research will require close collaboration during lumbosacral spinal manipulation of clinicians with bioengineers. therapy. Spine 1997;22:1955–64. REFERENCES 7 Ernst E. Prospective investigations into the Professor Ernst clearly describes the safety of spinal manipulation. Journal of Pain problems associated with inadequate 1 Gal JM, Herzog W, Kawchuk GN, et al. Forces and relative vertebral movements Symptom Management 2001;21:238–42. measures of bone density by plain radio- 8 Rothwell DM, Bondy SJ, Williams SJ. during SMT to unembalmed post-rigor Chiropractic manipulation and : a graphy, yet this is the conventional cadavers: peculiarities associated with joint population-based case-control study. Stroke method used in chiropractic offices. cavitation. J Manip Physiol Ther 1995;18:4–9. 2001;32:1054–60. Although many clinicians still think of 9 Haldeman S, Kohlbeck FJ, McGregor M. 2 Triano J, Schultz AB. Loads transmitted Unpredictability of cerebrovascular ischemia osteoporosis as a disease of the frail eld- during lumbosacral spinal manipulative associated with cervical spine manipulation. erly, clinical experience in Canada therapy. Spine 1997;22:1955–64. Spine 2002;27:49–55. suggests that many middle aged adults 3 Goodsell M, Lee M, Latimer J. Short-term 10 Stevinson C, Honan W, Cooke B, et al. effects of lumbar posteroanterior mobilization Neurological complications of cervical spine have compromised bone health and are in individuals with low-back pain. J manipulation. J R Soc Med 2001;94:107–10. at high risk of fragility fractures. Dual Manipulative Physiol Ther 2000;23:332–42. 11 Jarvik JG, Deyo RA. Diagnostic evaluation of energy x ray absorptiometry is the 4 Harms MC, Bader DL. Variability of forces low back pain with emphasis on imaging. applied by experienced therapists during Ann Intern Med 2002;137:586–97. optimum diagnostic method for . Clin Biomech 12 General Chiropractic Council. Code of osteoporosis.6 Yet many patients seen in 1997;12:393–9. practice. London: General Chiropractic British Columbia’s provincial Osteoporo- 5 Simmonds MJ, Kumar S, Lechelt E. Use of a Council, 1999. spinal model to quantify the forces and motion sis Program are having chiropractic that occur during therapists’ tests of spinal spinal manipulation despite obvious risk motion. Phys Ther 1995;75:212–22...... factors for osteoporosis. All clinicians, 6 Brown JP, Josse RG. 2002 clinical practice COMMENTARY guidelines for the diagnosis and management not just physicians, need to recognise the of osteoporosis in Canada. Cmaj risk factors for osteoporosis and consider 2002;167:S1–34. the risks and benefits of spinal manipu- 7 Farrell JP, Twomey LT. Acute low back pain. his leader identifies the lack of trial Comparison of two conservative treatment data on the safety and efficacy of lation for these patients. approaches. Med J Aust 1982;1:160–4. spinal manipulation for back pain in Evidence of the therapeutic effects of 8 Sterling M, Jull G, Wright A. Cervical T mobilisation: concurrent effects on pain, people with osteoporosis. Although the spinal mobilisation techniques suggests 3 7–9 sympathetic nervous system activity and motor applied forces in spinal manipulation that they can reduce spinal pain, activity. Man Ther 2001;6:72–81. (high velocity thrust techniques) are stimulate sympathetic nervous system 9 Vicenzino B, Collins D, Benson H, et al.An 12 8–10 8 investigation of the interrelationship between high, the forces applied in spinal mobi- activity, and promote motor activity. http://bjsm.bmj.com/ manipulative therapy-induced hypoalgesia lisation (low velocity techniques), as As patients with osteoporosis and back and sympathoexcitation. J Manipulative commonly used by physiotherapists and pain could potentially benefit from spi- Physiol Ther 1998;21:448–53. osteopaths, are much lower (approxi- nal mobilisation, trials are needed to 10 McGuiness J, Vicenzino B, Wright A. 3–5 Influence of a cervical mobilization technique mate maximum 250 N). As the number examine its safety and efficacy in this on respiratory and cardiovascular function. of people with osteoporosis increases, population. Man Ther 1997;2:216–20. on September 24, 2021 by guest. Protected copyright.

www.bjsportmed.com