Chiropractic Manipulation vs Manipulation Under Anesthesia

I read a very interesting article by Gardner et al¹ in the April 2013 issue: “Man, 57, With Dyspnea After Chiropractic Manipulation” (Grand Rounds. 2013;23[4]:23,24,27,28). In the article, a patient with ankylosing spondylitis underwent chiropractic manipulation for 10 years, and subsequently received serial manipulations under anesthesia (MUA) during which the patient sustained thoracic spine fractures and a hemothorax.

What concerned me about this particular article are the generalizations and conclusions made. The title itself is very deceptive in its implication that chiropractic manipulation caused the fractures and hemothorax. Within the article, the authors write “the patient, who had a history of ankylosing spondylitis, had been receiving weekly therapy from a chiropractor for about 10 years.” Although the article does not specifically detail what types of modalities were used for these 10 years, presumably the main modality was spinal manipulation. Following this treatment, the patient received serial manipulations under anesthesia, presumably from the same chiropractor, following which the patient experienced his subsequent dyspnea.

The authors fail to identify that MUA has been around for more than 60 years and was developed by osteopathic physicians.² Therefore, MUA is not a chiropractic procedure as the authors suggest, but a mainstream medical procedure that specifically trained and credentialed chiropractors can perform. MUA procedures are standardized, no matter what type of clinician is performing them. This insinuation by the authors suggests either an agenda with this communication, or a lack of knowledge and training in this procedure.

As an example, they write “In the chiropractic literature, between 3% and 10% of patients are estimated to be candidates for MUA.” They then reference this statement using a 1973 article from the Journal of the American Osteopathic Association, which was not authored by a chiropractic physician (see reference 14 in the article).

The authors also cite the most extensive safety review of MUA,³ which reported a complication rate of 0.7%. To say that the literature supporting MUA for various indications is “largely anecdotal” is disingenuous, since there have been several textbooks,^4,5 textbook chapters,^6,7 reviews,³ and guidelines⁸ developed on the use and appropriateness of MUA. For this particular patient, it is likely that he was not, nor should have been, a candidate for MUA in the first place, as evidenced by published indications and contraindications.^3-8 However, this is not a problem with the procedure itself, but a practitioner error in the patient selection process.

The authors devoted the majority of the article to discussion of the utilization and safety of chiropractic manipulation. In this particular patient’s case, chiropractic care was utilized for more than 10 years without incident prior to the MUA being performed. Therefore, the entire discussion section of this article is totally irrelevant from the main point of the communication. The discussion section references only chiropractic manipulation in the typical clinical setting. The authors should have stayed focused on the safety concerns of MUA only. To the objective reader, this looks as if the authors are taking advantage of this platform to further a specific opinion on chiropractic manipulation. This is exemplified by the authors’ assertion that “the clinicians who treated the case patient find it curious that the reported rate of adverse events following this procedure is so low, but they suspect an element of reporting bias in the chiropractic literature.” This is purely a speculative statement, and one that does not belong in the scientific, peer-reviewed literature.

Notwithstanding the authors’ opinions on chiropractic manipulation, the entire study design of this paper limits any possible conclusions. There is no mention of the patient’s bone density status before or after MUA and no discussion of his apparent severe thoracic kyphosis, which also could have accounted for the patient’s fractures.

There are multiple possibilities as to the cause of this fracture, and the authors are making assumptions based purely on timing of diagnosis. In conclusion, this article likely should not have been accepted for publication given the erroneous citations, incorrect descriptions, irrelevant discussion, and a conclusion drawn from pure speculation and inadequate study design. In my opinion, this article lowers the perceived objectivity and quality of this biomedical journal, and may only serve to slant the opinions of readers who likely have minimal experience with chiropractic physicians, chiropractic medicine, or manipulation under anesthesia.
Mark W. Morningstar, DC, PhD
Grand Blanc, MI

The Authors’ Reply
We read with great interest the letter to the editor regarding our case report. We appreciate the author taking the time to make insightful comments. Our replies to his comments and concerns are as follows:

1. The author of the letter is concerned that the title of the article is somewhat misleading. We do concur with this, and would note that the original title of this case report that we submitted to the journal was “Unstable Thoracic Spine Fracture and Massive Hemothorax After Chiropractic Manipulation Under Anesthesia.” The journal itself requested that we change it to fit the format of their case reports.

2. We would respectfully disagree that manipulation under anesthesia (MUA) is a “mainstream medical procedure.”As allopathic clinicians, we acknowledge our error and failure to differentiate between osteopathic physicians and chiropractic care in the discussion. We certainly have no agenda with this communication. The patient mentioned in the case report specifically asked that we not make any negative remarks about his chiropractor and chiropractic care in general, as he had a good relationship with his chiropractor. We also had no reason to defame the individual chiropractor or chiropractic care in general.

3. The specific case in our report involves manipulation under anesthesia, but the same type of complication could happen with any procedure under sedation, performed by any type of clinician. As is stated in the letter, “For this particular patient, it is likely that this patient was not, nor should have been, a candidate for MUA in the first place, as evidenced by published indications and contraindications.” We agree.

4. We do not think that the single paragraph we devoted to general chiropractic manipulation renders our entire discussion section irrelevant. The bulk of our discussion does center on MUA, and we stand by our review of the literature on this subject. Details were abbreviated and discussion limited due to the nature of a case report.

5. As this is a case report, there is really no “study design” to speak of.The hemothorax and spine fracture were temporally associated with MUA. The symptoms began immediately after introduction of the procedure, and there were no other events that had any relation to the symptoms and eventual findings. There was no other obvious cause.

Again, we thank the author of this letter for taking the time to comment on our report, and we appreciate being given the opportunity to respond.
Scott C. Gardner, PA-C, MMSc, DFAAPA, Sarah D. Majercik, MD, MBA, FACS, Don VanBoerum, MD, FACS, John R. Macfarlane, MD

References
1. Gardner SC, Majercik SD, VanBoerum D, Macfarlane JR. Man, 57, with dyspnea after chiropractic manipulation (Grand Rounds). Clinician Reviews. 2013;23(4):23,24,27,28.

2. Siehl D, Bradford WG. Manipulation of the low back under general anesthesia. J Am Osteopath Assoc. 1952;52:239-242.

3. Kohlbeck FJ, Haldeman S. Medication-assisted spinal manipulation. Spine J. 2002;2:288-302.

4. Gordon RC, ed. Manipulation Under Anesthesia: Concepts in Theory and Application. Boca Raton, FL: CRC Press; 2005.

5. Savitz MH, Chiu JC, Yeung AT. Practice of Minimally Invasive Spinal Technique: Special Millennium Edition. AAMISMS Education, LLC; 2000.

6. Gordon RC, Rogers A, West DT, et al. Manipulation under anesthesia: an anthology of past, present, and future use. In: Weiner RS, ed. Pain Management: A Practical Guide for Clinicians. 6th ed. Boca Raton, FL: CRC Press; 2002.

7. Dagenais S, Mayer J, Haldeman S. Medicine-assisted manipulation therapy. In: Dagenais S, Haldeman S, eds. Evidence-Based Management of Low Back Pain. St. Louis, MO: Mosby, Inc; 2012:248-257.

8. Tain L, Gunderson C, Cremata E, et al; Committee for Manipulation Under Anesthesia. Recommendations to the Industrial Medical Council Work Group of California for manipulation under anesthesia use for injured workers. Sacramento: Industrial Medical Council; 2003.

I read a very interesting article by Gardner et al¹ in the April 2013 issue: “Man, 57, With Dyspnea After Chiropractic Manipulation” (Grand Rounds. 2013;23[4]:23,24,27,28). In the article, a patient with ankylosing spondylitis underwent chiropractic manipulation for 10 years, and subsequently received serial manipulations under anesthesia (MUA) during which the patient sustained thoracic spine fractures and a hemothorax.

What concerned me about this particular article are the generalizations and conclusions made. The title itself is very deceptive in its implication that chiropractic manipulation caused the fractures and hemothorax. Within the article, the authors write “the patient, who had a history of ankylosing spondylitis, had been receiving weekly therapy from a chiropractor for about 10 years.” Although the article does not specifically detail what types of modalities were used for these 10 years, presumably the main modality was spinal manipulation. Following this treatment, the patient received serial manipulations under anesthesia, presumably from the same chiropractor, following which the patient experienced his subsequent dyspnea.

The authors fail to identify that MUA has been around for more than 60 years and was developed by osteopathic physicians.² Therefore, MUA is not a chiropractic procedure as the authors suggest, but a mainstream medical procedure that specifically trained and credentialed chiropractors can perform. MUA procedures are standardized, no matter what type of clinician is performing them. This insinuation by the authors suggests either an agenda with this communication, or a lack of knowledge and training in this procedure.

As an example, they write “In the chiropractic literature, between 3% and 10% of patients are estimated to be candidates for MUA.” They then reference this statement using a 1973 article from the Journal of the American Osteopathic Association, which was not authored by a chiropractic physician (see reference 14 in the article).

The authors also cite the most extensive safety review of MUA,³ which reported a complication rate of 0.7%. To say that the literature supporting MUA for various indications is “largely anecdotal” is disingenuous, since there have been several textbooks,^4,5 textbook chapters,^6,7 reviews,³ and guidelines⁸ developed on the use and appropriateness of MUA. For this particular patient, it is likely that he was not, nor should have been, a candidate for MUA in the first place, as evidenced by published indications and contraindications.^3-8 However, this is not a problem with the procedure itself, but a practitioner error in the patient selection process.

The authors devoted the majority of the article to discussion of the utilization and safety of chiropractic manipulation. In this particular patient’s case, chiropractic care was utilized for more than 10 years without incident prior to the MUA being performed. Therefore, the entire discussion section of this article is totally irrelevant from the main point of the communication. The discussion section references only chiropractic manipulation in the typical clinical setting. The authors should have stayed focused on the safety concerns of MUA only. To the objective reader, this looks as if the authors are taking advantage of this platform to further a specific opinion on chiropractic manipulation. This is exemplified by the authors’ assertion that “the clinicians who treated the case patient find it curious that the reported rate of adverse events following this procedure is so low, but they suspect an element of reporting bias in the chiropractic literature.” This is purely a speculative statement, and one that does not belong in the scientific, peer-reviewed literature.

Notwithstanding the authors’ opinions on chiropractic manipulation, the entire study design of this paper limits any possible conclusions. There is no mention of the patient’s bone density status before or after MUA and no discussion of his apparent severe thoracic kyphosis, which also could have accounted for the patient’s fractures.

There are multiple possibilities as to the cause of this fracture, and the authors are making assumptions based purely on timing of diagnosis. In conclusion, this article likely should not have been accepted for publication given the erroneous citations, incorrect descriptions, irrelevant discussion, and a conclusion drawn from pure speculation and inadequate study design. In my opinion, this article lowers the perceived objectivity and quality of this biomedical journal, and may only serve to slant the opinions of readers who likely have minimal experience with chiropractic physicians, chiropractic medicine, or manipulation under anesthesia.
Mark W. Morningstar, DC, PhD
Grand Blanc, MI

The Authors’ Reply
We read with great interest the letter to the editor regarding our case report. We appreciate the author taking the time to make insightful comments. Our replies to his comments and concerns are as follows:

1. The author of the letter is concerned that the title of the article is somewhat misleading. We do concur with this, and would note that the original title of this case report that we submitted to the journal was “Unstable Thoracic Spine Fracture and Massive Hemothorax After Chiropractic Manipulation Under Anesthesia.” The journal itself requested that we change it to fit the format of their case reports.

2. We would respectfully disagree that manipulation under anesthesia (MUA) is a “mainstream medical procedure.”As allopathic clinicians, we acknowledge our error and failure to differentiate between osteopathic physicians and chiropractic care in the discussion. We certainly have no agenda with this communication. The patient mentioned in the case report specifically asked that we not make any negative remarks about his chiropractor and chiropractic care in general, as he had a good relationship with his chiropractor. We also had no reason to defame the individual chiropractor or chiropractic care in general.

3. The specific case in our report involves manipulation under anesthesia, but the same type of complication could happen with any procedure under sedation, performed by any type of clinician. As is stated in the letter, “For this particular patient, it is likely that this patient was not, nor should have been, a candidate for MUA in the first place, as evidenced by published indications and contraindications.” We agree.

4. We do not think that the single paragraph we devoted to general chiropractic manipulation renders our entire discussion section irrelevant. The bulk of our discussion does center on MUA, and we stand by our review of the literature on this subject. Details were abbreviated and discussion limited due to the nature of a case report.

5. As this is a case report, there is really no “study design” to speak of.The hemothorax and spine fracture were temporally associated with MUA. The symptoms began immediately after introduction of the procedure, and there were no other events that had any relation to the symptoms and eventual findings. There was no other obvious cause.

Again, we thank the author of this letter for taking the time to comment on our report, and we appreciate being given the opportunity to respond.
Scott C. Gardner, PA-C, MMSc, DFAAPA, Sarah D. Majercik, MD, MBA, FACS, Don VanBoerum, MD, FACS, John R. Macfarlane, MD

References
1. Gardner SC, Majercik SD, VanBoerum D, Macfarlane JR. Man, 57, with dyspnea after chiropractic manipulation (Grand Rounds). Clinician Reviews. 2013;23(4):23,24,27,28.

2. Siehl D, Bradford WG. Manipulation of the low back under general anesthesia. J Am Osteopath Assoc. 1952;52:239-242.

3. Kohlbeck FJ, Haldeman S. Medication-assisted spinal manipulation. Spine J. 2002;2:288-302.

4. Gordon RC, ed. Manipulation Under Anesthesia: Concepts in Theory and Application. Boca Raton, FL: CRC Press; 2005.

5. Savitz MH, Chiu JC, Yeung AT. Practice of Minimally Invasive Spinal Technique: Special Millennium Edition. AAMISMS Education, LLC; 2000.

6. Gordon RC, Rogers A, West DT, et al. Manipulation under anesthesia: an anthology of past, present, and future use. In: Weiner RS, ed. Pain Management: A Practical Guide for Clinicians. 6th ed. Boca Raton, FL: CRC Press; 2002.

7. Dagenais S, Mayer J, Haldeman S. Medicine-assisted manipulation therapy. In: Dagenais S, Haldeman S, eds. Evidence-Based Management of Low Back Pain. St. Louis, MO: Mosby, Inc; 2012:248-257.

8. Tain L, Gunderson C, Cremata E, et al; Committee for Manipulation Under Anesthesia. Recommendations to the Industrial Medical Council Work Group of California for manipulation under anesthesia use for injured workers. Sacramento: Industrial Medical Council; 2003.

I read a very interesting article by Gardner et al¹ in the April 2013 issue: “Man, 57, With Dyspnea After Chiropractic Manipulation” (Grand Rounds. 2013;23[4]:23,24,27,28). In the article, a patient with ankylosing spondylitis underwent chiropractic manipulation for 10 years, and subsequently received serial manipulations under anesthesia (MUA) during which the patient sustained thoracic spine fractures and a hemothorax.

What concerned me about this particular article are the generalizations and conclusions made. The title itself is very deceptive in its implication that chiropractic manipulation caused the fractures and hemothorax. Within the article, the authors write “the patient, who had a history of ankylosing spondylitis, had been receiving weekly therapy from a chiropractor for about 10 years.” Although the article does not specifically detail what types of modalities were used for these 10 years, presumably the main modality was spinal manipulation. Following this treatment, the patient received serial manipulations under anesthesia, presumably from the same chiropractor, following which the patient experienced his subsequent dyspnea.

The authors fail to identify that MUA has been around for more than 60 years and was developed by osteopathic physicians.² Therefore, MUA is not a chiropractic procedure as the authors suggest, but a mainstream medical procedure that specifically trained and credentialed chiropractors can perform. MUA procedures are standardized, no matter what type of clinician is performing them. This insinuation by the authors suggests either an agenda with this communication, or a lack of knowledge and training in this procedure.

As an example, they write “In the chiropractic literature, between 3% and 10% of patients are estimated to be candidates for MUA.” They then reference this statement using a 1973 article from the Journal of the American Osteopathic Association, which was not authored by a chiropractic physician (see reference 14 in the article).

The authors also cite the most extensive safety review of MUA,³ which reported a complication rate of 0.7%. To say that the literature supporting MUA for various indications is “largely anecdotal” is disingenuous, since there have been several textbooks,^4,5 textbook chapters,^6,7 reviews,³ and guidelines⁸ developed on the use and appropriateness of MUA. For this particular patient, it is likely that he was not, nor should have been, a candidate for MUA in the first place, as evidenced by published indications and contraindications.^3-8 However, this is not a problem with the procedure itself, but a practitioner error in the patient selection process.

The authors devoted the majority of the article to discussion of the utilization and safety of chiropractic manipulation. In this particular patient’s case, chiropractic care was utilized for more than 10 years without incident prior to the MUA being performed. Therefore, the entire discussion section of this article is totally irrelevant from the main point of the communication. The discussion section references only chiropractic manipulation in the typical clinical setting. The authors should have stayed focused on the safety concerns of MUA only. To the objective reader, this looks as if the authors are taking advantage of this platform to further a specific opinion on chiropractic manipulation. This is exemplified by the authors’ assertion that “the clinicians who treated the case patient find it curious that the reported rate of adverse events following this procedure is so low, but they suspect an element of reporting bias in the chiropractic literature.” This is purely a speculative statement, and one that does not belong in the scientific, peer-reviewed literature.

Notwithstanding the authors’ opinions on chiropractic manipulation, the entire study design of this paper limits any possible conclusions. There is no mention of the patient’s bone density status before or after MUA and no discussion of his apparent severe thoracic kyphosis, which also could have accounted for the patient’s fractures.

There are multiple possibilities as to the cause of this fracture, and the authors are making assumptions based purely on timing of diagnosis. In conclusion, this article likely should not have been accepted for publication given the erroneous citations, incorrect descriptions, irrelevant discussion, and a conclusion drawn from pure speculation and inadequate study design. In my opinion, this article lowers the perceived objectivity and quality of this biomedical journal, and may only serve to slant the opinions of readers who likely have minimal experience with chiropractic physicians, chiropractic medicine, or manipulation under anesthesia.
Mark W. Morningstar, DC, PhD
Grand Blanc, MI

The Authors’ Reply
We read with great interest the letter to the editor regarding our case report. We appreciate the author taking the time to make insightful comments. Our replies to his comments and concerns are as follows:

1. The author of the letter is concerned that the title of the article is somewhat misleading. We do concur with this, and would note that the original title of this case report that we submitted to the journal was “Unstable Thoracic Spine Fracture and Massive Hemothorax After Chiropractic Manipulation Under Anesthesia.” The journal itself requested that we change it to fit the format of their case reports.

2. We would respectfully disagree that manipulation under anesthesia (MUA) is a “mainstream medical procedure.”As allopathic clinicians, we acknowledge our error and failure to differentiate between osteopathic physicians and chiropractic care in the discussion. We certainly have no agenda with this communication. The patient mentioned in the case report specifically asked that we not make any negative remarks about his chiropractor and chiropractic care in general, as he had a good relationship with his chiropractor. We also had no reason to defame the individual chiropractor or chiropractic care in general.

3. The specific case in our report involves manipulation under anesthesia, but the same type of complication could happen with any procedure under sedation, performed by any type of clinician. As is stated in the letter, “For this particular patient, it is likely that this patient was not, nor should have been, a candidate for MUA in the first place, as evidenced by published indications and contraindications.” We agree.

4. We do not think that the single paragraph we devoted to general chiropractic manipulation renders our entire discussion section irrelevant. The bulk of our discussion does center on MUA, and we stand by our review of the literature on this subject. Details were abbreviated and discussion limited due to the nature of a case report.

5. As this is a case report, there is really no “study design” to speak of.The hemothorax and spine fracture were temporally associated with MUA. The symptoms began immediately after introduction of the procedure, and there were no other events that had any relation to the symptoms and eventual findings. There was no other obvious cause.

Again, we thank the author of this letter for taking the time to comment on our report, and we appreciate being given the opportunity to respond.
Scott C. Gardner, PA-C, MMSc, DFAAPA, Sarah D. Majercik, MD, MBA, FACS, Don VanBoerum, MD, FACS, John R. Macfarlane, MD

References
1. Gardner SC, Majercik SD, VanBoerum D, Macfarlane JR. Man, 57, with dyspnea after chiropractic manipulation (Grand Rounds). Clinician Reviews. 2013;23(4):23,24,27,28.

2. Siehl D, Bradford WG. Manipulation of the low back under general anesthesia. J Am Osteopath Assoc. 1952;52:239-242.

3. Kohlbeck FJ, Haldeman S. Medication-assisted spinal manipulation. Spine J. 2002;2:288-302.

4. Gordon RC, ed. Manipulation Under Anesthesia: Concepts in Theory and Application. Boca Raton, FL: CRC Press; 2005.

5. Savitz MH, Chiu JC, Yeung AT. Practice of Minimally Invasive Spinal Technique: Special Millennium Edition. AAMISMS Education, LLC; 2000.

6. Gordon RC, Rogers A, West DT, et al. Manipulation under anesthesia: an anthology of past, present, and future use. In: Weiner RS, ed. Pain Management: A Practical Guide for Clinicians. 6th ed. Boca Raton, FL: CRC Press; 2002.

7. Dagenais S, Mayer J, Haldeman S. Medicine-assisted manipulation therapy. In: Dagenais S, Haldeman S, eds. Evidence-Based Management of Low Back Pain. St. Louis, MO: Mosby, Inc; 2012:248-257.

8. Tain L, Gunderson C, Cremata E, et al; Committee for Manipulation Under Anesthesia. Recommendations to the Industrial Medical Council Work Group of California for manipulation under anesthesia use for injured workers. Sacramento: Industrial Medical Council; 2003.