Is your back in safe hands? (Filed: 23/03/2006)

http://www.telegraph.co.uk/health/main.jhtml?view=DETAILS&grid=P8&xml...

Cured by a crunch

An expert has claimed that spinal manipulation can be dangerous. Judith Woods assesses the risks

Every day an estimated 80,000 people visit an osteopath and a further 50,000 seek out a chiropractor to alleviate their back pain. So what are they to make of a damning indictment of those who practice these therapies by Britain's leading expert in complementary medicine?

	Chiropractors and osteopaths deal mainly with headache and back and neck pain

Should they continue to pay fees of up to £60 an hour to have their backs ''cracked'', their joints pulled apart or their muscles teased out? Or should they dose up on painkillers instead?

Chiropractors and osteopaths use spinal manipulation and massage techniques to treat the misalignment of vertebrae and other bones. Now, Edzard Ernst, professor of complementary medicine at the University of Exeter's Peninsula Medical School, says that the benefits of such techniques are ineffective at best and at worst, seriously damaging.

In his report, published this week in the Journal of the Royal Society of Medicine, Prof Ernst analysed 16 reviews of research into spinal manipulation between 2000 and 2005. He concluded that the evidence does not confirm that it is an effective treatment for a range of conditions. He also said that the risk of mild adverse effects such as headaches and serious, though rare, complications such as stroke, means spinal manipulation should not be recommended at all.

No surprise then that the professor's findings have been roundly rejected by chiropractors and osteopaths alike, who have criticised both the methodology of his research and his conclusions, and accused him of waging a campaign against practitioners.

"This report is misleading," says David Byfield, head of the Welsh Institute of Chiropractic at the University of Glamorgan. "Ernst has said spinal manipulation is not effective for an aggregate of diverse conditions, and for some reason he has included back pain alongside infant colic, allergies and asthma.

"Very few of our patients come to us with infant colic. They come with headaches and back and neck pain, for which spinal manipulation can be very effective."

Byfield, who is a member of the General Chiropractic Council, which has 2,200 qualified chiropractors on its register, says that patients shouldn't feel deterred from seeking treatment for back pain on the basis of the new report.

"People come to us on personal recommendation and word of mouth, not because of reviews in medical journals," he says. "The bottom line is that they are interested in results."

There is certainly a demand for the skills of these practitioners. Back pain has become something of a modern epidemic in our desk-bound, sedentary society, with 80 per cent of adults experiencing it at some time or another, and a third of the population suffering from it regularly. Many GPs can offer sufferers little more than pain relief, which has led to great demand for complementary therapists who typically charge anything from £30 to £60 for a session.

Chiropractic and osteopathy are broadly similar in approach. Both manipulate the spine and associated joints, massaging muscles and using movement to improve flexibility.

Broadly speaking, chiropractors place most emphasis on the spine, using manipulation and massage and they tend to apply high-velocity thrusts as part of their technique.

Osteopaths generally work across the whole body, regarding it as a single, functional unit. They concentrate more on soft tissues and stretching, using manual therapy and may suggest exercises to promote posture correction.

Where a chiropractor might use spine X-rays to help with diagnosis, an osteopath will look at overall postural balance and palpate tendons, ligaments and muscles. Either might employ spinal manipulation or ''back crunching'', to free up joints that have become compressed.

"Osteopaths have never claimed that spinal manipulation is the panacea for all ills," says Matthew Cousins, former president of the British Osteopathy Association.

"But it is one treatment we offer as part of a whole spectrum of treatments that are effective for musculoskeletal conditions. There are around 5,000 osteopaths in this country who undergo an extensive, four-year training and are a closely regulated profession with very high standards.

"When a new patient comes to us, we take a detailed medical history. Professor Ernst's report makes us sound like we give people a quick chat, a crack to the back and send them on their way."

Like osteopaths, chiropractors undergo four years of training, and must complete a programme of further education every year in order to be allowed to stay on the register of the General Chiropractic Council. Any chiropractor who is not on the register is practising illegally.

Similarly, under the Osteopaths Act 1993, it is an offence for anyone to describe themselves as an osteopath, either expressly or by implication, unless they are registered. People are advised never to visit a chiropractor or osteopath without first checking their credentials - and with good reason.

In 2002, Angelo Valente, a former fish and chip shop owner from Fife in Scotland, was found to be breaking the law by falsely claiming to be an osteopath and taking money to treat back problems, in a ''surgery'' he set up next door to a branch of his fish and chip business.

His treatment involved smearing baby oil on patients' backs and pummelling them, causing in some cases, severe pain and bruising.

While patients must be protected from unqualified ''quacks'', Prof Ernst argues that it is the registration of osteopaths and chiropractors that has led to people becoming too accepting of these therapies, assuming they are risk-free when this is not the case.

For example, according to a 2003 study by neurologists at the University of California, chiropractic manipulation can cause vertebral artery dissection - the tearing of an artery leading to the brain. The doctors concluded that chiropractic treatment raised the risk of stroke, regardless of underlying factors.

Dr Wade Smith, professor of neurology at the university, did concede however that millions of chiropractic treatments were carried out each year, making the risk of stroke quite low.

Professor Alan Breen, head of the Anglo-European College of Chiropractic in Britain, insists there is no connection between the treatment and stroke. "To put it simply, it is a coincidence that stroke occurred in the individuals studied. There are dozens of reported cases of dissection and stroke following completely normal activities such as walking, housework, tennis, swimming, coughing, sneezing and yoga."

Frances Denoon, a former insurance negotiator, might disagree. She suffered a stroke following a visit to a registered chiropractor in Bristol in 1998. She described a "gut-wrenching 'crack' " as the practitioner manipulated her neck, followed by dizziness, nausea and a loss of vision. She was rushed to hospital and underwent life-saving brain surgery.

Ms Dunoon was unable to sue the chiropractor because there was no evidence he had been negligent in his treatment. She has, however, set up a website - www.chirovictims.org.uk - for ''victims'' of complementary therapies, who want to share their stories.

Whatever the real or perceived risks, for many people with back problems, osteopathy and chiropractic offer a way of alleviating and managing debilitating pain. So why don't studies reflect this?

Because osteopaths and chiropractors tailor their treatment to individual patients, it is difficult to conduct accurate clinical trials, as no two individuals are the same, says Robert Lever, professor at the European School of Osteopathy in Kent.

"Researchers are looking in the wrong place for evidence. If they spent a little time at a busy practice they would see the evidence."