• DOI:10.1111/J.1742-1241.2010.02568.X
• Corpus ID: 72845939

Response to critiques of deaths after chiropractic

@article{Ernst2011ResponseTC,
  title={Response to critiques of deaths after chiropractic},
  author={Edzard Ernst},
  journal={International Journal of Clinical Practice},
  year={2011},
  volume={65}
}

• E. Ernst
• Published 1 January 2011
• Medicine
• International Journal of Clinical Practice

To the Editor: These interesting comments merit a short response. Wenban and Bennett are correct in stating that RCTs are insufficient tools for studying adverse effects (AEs). The main reason is that, for rare AEs, one requires sample sizes much larger than those of the average RCT. Specifically for manual therapies, it has recently been noted that about half of all published RCTs fail to report AEs completely (1), an overt omission and violation of research ethics that is likely to distort the published evidence on AEs in favour of chiropractic. Wenban and Bennett state that the death reported by Schmitt in a German article (2) was caused by a German Heilpraktiker. The event happened in the 1970s when, for all intents and purposes, German Heilpraktiker was the equivalent of UK chiropractors (e.g. no statutory regulation or mandatory training). The death reported by Mas (3) was, as far as I can see, correctly reproduced in my article; I could not reasonably be expected to know of the ‘personal correspondence’ that Wenban and Bennett cite. I also believe that I reported Dziewas’s initial publication (4) correctly, and I was unaware of any subsequent correspondence. I am sorry for these misunderstandings, but would insist that the absolute number (e.g. 26 as I assumed or 23 as Wenban and Bennett think) is almost irrelevant. The crucial message of my review is that ‘numerous deaths have occurred after chiropractic manipulations’ (5), and this is not being disputed. Whedon et al. find it difficult to understand ‘what was done’ and think that my review failed to meet PRISMA guidelines. As a member of the team that developed the PRISMA guidelines, I can assure Whedon et al. that they were designed for reviews of efficacy studies rather than case reports. To the best of my knowledge, no guideline for case reports exists, and my attempts to initiate such a document have, so far, not been successful. Whedon et al. also state that chiropractors cause most AEs because they perform most manipulations, a notion that I acknowledge and support in the discussion of my review (5). Finally, the authors criticise me for not evaluating the potential benefits of chiropractic. This detail was not the subject of my review. I do, however, refer to such evaluations and should add that a report recently commissioned by the General Chiropractic Council (6) did not support many of the outlandish claims made by many chiropractors across the world (7). Perle et al. criticise me for including cases not published in the medical literature. These cases were, however, merely added for completeness and not included in my total number of 26 cases reported in my review. Perle et al. mention several articles that I did not cite. Admittedly, there are hundreds that I had to ignore, mostly because they were of no or only limited relevance to my summary of fatalities after chiropractic. As already mentioned above, I also did not evaluate the potential benefits of chiropractic because this was not the focus of my review. I do, however, strongly reject the allegation of selective reporting. Poelsma and Owen comment that I failed to include 36 further deaths after chiropractic reported by Cassidy et al. These cases had to be excluded because they did not provide any information about individual cases, which was a precondition for inclusion into my review, as I tried to explain in the methods section of my article. Poelsma and Owen also claim that Cassidy’s study is the ‘most exhaustive investigation ever performed into the subject’. I beg to differ: first, the article was not on the topic of fatalities after chiropractic, and secondly, it has been repeatedly criticised for being seriously, perhaps even fatally, flawed e.g. (8). The ‘inconvenient truth’ might thus turn out to be a ‘convenient untruth’. Finally, Dohos and Tragiannidis show that all this is not abstract, bloodless number crunching. Chiropractic continues to be associated with deaths, and hundreds of non-fatal but serious AEs are on record. To date, no system is in place to monitor such cases. Under-reporting is therefore almost certainly huge. These authors state that ‘the risks of chiropractic neck manipulations by far outweigh their benefits’. I am inclined to agree. Sincerely, Prof. E. Ernst