Kinsinger Letter - chiropractic at University of Alberta
J. William Kinsinger, M.D.
3126 S. Boulevard #245
Edmond, OK 73013
405-990-2745
kinsingerb AT ol.com
Paul Hagler, PhD
Professor & Associate Dean, Graduate Studies and Research
Faculty of Rehabilitation Medicine
3-50 Corbett Hall, Edmonton
Alberta, Canada, T6G2G4Office (780) 492-9674
E-mail: paul.hagler AT ualberta.ca
And
Robert Sydenham B.Sc. D.P.T. F.C.A.M.T.
207, 11520-100 Avenue
Edmonton, Alberta
T5K 0J7
bsydenham AT shawbiz.ca
Office 780-482-7428
SENT BY E-MAIL AND BY LETTER POST.
November 11, 2005
Dear Dr. Hagler:
Nothing in this letter is meant to question the sincerity, competence or integrity of any member of your Faculty. I know from past experiences that too often Universities become involved in an issue in which all the information has not been considered. This was the experience at York University and recently at Florida State University. I wish to provide some information, ask critical questions and suggest reasonable solutions.
My name is Dr. William Kinsinger. I am a Board certified anesthesiologist practicing in the State of Oklahoma. I am part of a large world-wide group of academics, physicians, members of the legal community, and of the general public who are extremely concerned about the practice of chiropractic and in particular the tragedy of stroke and death due to chiropractic highest neck manipulation.
We closely monitor claims made by chiropractors and became aware that the University of Alberta is soliciting practitioner referrals in order to do a study on “chiropractic manipulation”. We then became aware of an exchange of correspondence between yourself and physical therapist Robert Sydenham.
We also note that the current website of the Canadian Chiropractic Association, under the heading of “University Chairs of Chiropractic” refers to Dr. Kawchuk. (SEE REFERENCE ONE). We understand there is no chiropractic chair at the University of Alberta so perhaps you should have the Canadian Chiropractic Association clarify this.
We expressed our concern to Mr. Sydenham and he suggested we address them to you directly. We are in the process of determining who in the scientific and ethics community we should address our concern to. We have asked Mr. Sydenham to provide us with the names of the members of the ethics committee as well as those in the medical community.
Our group is very concerned about University academic integrity. Last year we were involved in a successful campaign to stop Florida State University from accepting a school of chiropractic. A paper I wrote on that subject is called “Preserving Academic Scientific Excellence at Florida State University”. May I suggest that officials at the University of Alberta should read this paper? I will gladly make it available. I can send the text without the documents as an e-mail attachment or a full copy by mail as may be requested.
Our concern is public information and safety. In that regard your Canadian newspaper, The National Post, published an editorial comment I wrote in support of the decision of the Government of Ontario to stop all government support of chiropractic. You will note that my first concern was safety not fiscal. (SEE REFERENCE FIVE)
ACADEMIC FREEDOM AND ACADEMIC EXCELLENCE
In your letter of October 19, 2005, to Mr. Sydenham, you state that “it may come as a surprise to you but universities are founded on the principle of academic freedom”. This reminds me of the arguments put forward by the chiropractors during the Florida State University debate; “we can teach whatever we want”. Our argument was that academic freedom does not include teaching non-scientific courses and awarding the students with a doctorate degree. I might add that if this comment was made to me I would find it rather insulting.
May I suggest that the foremost issue of concern for any University is its academic integrity? The name of the University should not be used in any way directly or indirectly by others to support non-scientific claims.
Academic integrity was the very reason why York University in Toronto, along with the Universities of Victoria, Ottawa and indeed Calgary when an informal approach was made to them, to deny any question of a school of chiropractic affiliated with a university. This was also the reason why Nobel Laureates and others combined to defeat a similar recent effort by chiropractors at Florida State University. My colleagues and I were very proud to work directly with these esteemed scientists.
If you wish to preserve the academic integrity of the University you must be sure you are not endorsing “chiropractic”
CONFUSING SCIENTIFIC MANUAL THERAPY WITH CHIROPRACTIC PHILOSOPHY
I understand that you define this as a study to “understand the cause of mechanical back pain”. There is no mention about neck manipulation. There is no mention about the fact that “chiropractic manipulation” will be used. This is only divulged in your letter to Mr. Sydenham. Just as various medications differ, there are fundamental differences between chiropractic manipulation and scientific manual therapy. Is the ethics committee aware that those being solicited were not informed as to the therapy to be used?
You cannot define “chiropractic manipulation” to suit your own purposes. “Chiropractic manipulation” is defined by all the chiropractic schools, all their licensing bodies, including Alberta, and all their professional associations in the same manner, that is, maintaining health and treating disease by treating “chiropractic vertebral subluxations”. Clearly this is a false philosophical belief system and scientific medicine and basic anatomy have rejected this for over 100 years. (SEE REFERENCE TWO).
I would invite you to go on the website on the Alberta College of Chiropractors (http://www.albertachiro.com/). I could write a book about what is claimed but let me suggest you click on the section “Just For Kids”. Do you feel that a regulatory body, there to protect the public should ask children to examine their own parents?
“Did you know that when a baby is growing inside its Mommy the very first things that grow are the brain, then the spinal cord and the spinal nerves? They are so important that they have to come first before anything else - before your heart or your lungs or even your arms and legs! “
“What do you think happens to your organs when your have bad posture and your spine is not straight? The nerves don't communicate properly with those organs, and then they can't work properly. So what can you do to make sure your spine and nerves can communicate with your organs? You stand up straight. Don't let your spine guys slouch.
As a scientist I am sure you will recognize that the first paragraph is genetic nonsense and the second that the heart, lungs, GI tract and brain function improperly due to “slouching” is to be polite, neurological quackery.
“Chiropractic manipulation” often involves a high velocity low amplitude thrust and when done in a position of extension and rotation on the neck is dangerous. This in fact has been banned by physical therapists. In addition some types of low back chiropractic manipulation have been directly associated with paralysis due to cauda equina syndrome. How aware of this are the physicians you solicited?
Furthermore, the most essential concept in chiropractic manipulation is highest neck manipulation. The first chiropractic “adjustment” done by Palmer was of the highest neck and had nothing to do with low back pain but was supposedly done to cure deafness. Canadian authors Paul Benedetti and Wayne MacPhail published an excellent book on this called “Spin Doctors: ISBN 1-55002-406-X.
So the first question is, how can the University of Alberta do a study on scientific manual therapy when your letter dated October 19, 2005 defines what is being done as a study on “chiropractic manipulation”. As well you state “A chiropractor was chosen due to the scientific questions that were posed in the study”.
If that was the concern then surely a physical therapist and not a chiropractor should have been chosen. If a chiropractor is chosen, and you appear to have one who is highly qualified and has achieved academic excellence, then the first task of the University is to make it clear that the chiropractor involved and the University of Alberta do not support in any way directly or indirectly “chiropractic manipulation”. So may I suggest you have started out on both wrong feet?
RAND AND CHIROPRACTIC
In the United States this issue of chiropractors trying to say that manipulation studies support chiropractic has also arisen. To help achieve the distinction between scientific manual therapy and chiropractic philosophy, Dr. Paul Shekelle of RAND issued a public statement that he obliged the American Chiropractic Association to publish.
It makes clear that all the claims made by chiropractors that RAND was supporting chiropractic manipulation were misleading and that in fact his work was specific to spinal manipulation and had nothing to do with chiropractic. (SEE REFERENCE THREE).
In that regard, I do want to congratulate the physical therapy community in Canada for developing and supporting the Orthopractic guidelines (http://www.orthopractic.org/). These
make clear the essential differences between scientific manual therapy and chiropractic philosophy.
OTHER ALBERTA UNIVERSITY BACK DOOR SUPPORT
You have to ask yourself if you are being used to promote chiropractic. This was the position the University of Calgary recently found itself in at the Inquest into the death of 45 year old Lana Dale Lewis of Toronto. In order to claim that chiropractic neck manipulation was safe Herzog from the University of Calgary was called to testify. His study done in Alberta in 2002 was done on 80-99 year old cadavers with a chiropractor gently moving the head through a limited range of motion.
The first problem with this study was that the subjects were already dead. The best the “study” could prove is that dead people can’t have a stroke and die twice due to a chiropractic neck manipulation. The second problem is the subjects were 45-50 years beyond the risk group we see most strokes in, young women less than 45 years of age. .
The best criticism of this study was stated by another chiropractor, Christopher Good of New York Chiropractic College. As chiropractor Good points out, Herzog himself clearly states that his study was done on cadavers and “we cannot interpolate these results into a living system” (JMPT June 2003. Pa. 338-340). Furthermore, the place that Herzog did his testing in the neck, the distal CO-1 and C-6 was the wrong place in the neck to test. Good states, “The most important section that can be measured is the C1-2 section, especially at the C-2 foramen.”
Chiropractor Good goes further by pointing out that Herzog never tested “the most forceful manipulation of all and maybe one of the most common used by practitioners”. He goes on to say that until this is tested “we are simply deluding ourselves and misleading others”.
So the best and most often quoted study on the risk of neck manipulation was done on 80-90 year old dead people based on a type of neck manipulation chiropractors almost never use and at a place in the neck where the pathology does not usually occur.
Needless to say this testimony was torn apart and in the end the Jury did indeed conclude that Lana Dale Lewis died directly as a result of a chiropractic highest neck manipulation
Any University endorsement of “chiropractic manipulation” is an automatic endorsement of chiropractic highest neck manipulation. Sixty years of scientific literature point out the strokes and deaths caused needlessly by this. http://www.neck911usa.com/.
TREATING BACK PAIN BY NECK MANIPULATION
To put this in a Canadian concept, one should read the report on the Inquest into the death of 20 year old Laurie Jean Mathiason of Saskatoon Saskatchewan. Like the great majority of cases we have seen, Laurie had low back pain, in fact tailbone pain and yet her neck was manipulated, in fact over 100 times before she died. The fact remains that many chiropractors believe they can treat low back pain by neck manipulation (75% of patients
with low back pain) and the University of Alberta will be indirectly if not directly endorsing this belief.
THE SOLICITATION LETTER TO PHYSICAL THERAPIST AND MDs and CHIROPRACTORS.
I have additional concerns about the solicitation letter sent to “rehabilitation practitioners” They certainly should be aware that the lead investigator is a chiropractor and that the research is being described as one on “chiropractic manipulation”.
In Canada the Canadian Medical Protection Association has stated some clear legal opinions on this subject. Certainly referring physicians should be aware of this (SEE REFERENCE FOUR). Certainly this is a prime consideration for the Ethics Committee to review.
In addition, Canadian Neurologists from across Canada as well as the Chiefs of Pediatrics of Canadian Hospitals have expressed a clear opinion on the issue of “chiropractic manipulation”.
SUGGESTIONS
I will not go into many of the comments made in your letter. Rather I would prefer to make a few suggestions as to how this issue can be resolved. In doing so I must state that your own personal and professional interests as well as those of the University of Alberta are all secondary to the public interest. No one in the public must be misled in any way as to what the University of Alberta is endorsing. Indeed we intend to advise some of our many stroke victims living in Alberta of this debate and they may wish to be heard before the ethics committee.
One: The study should be redefined as one of manual therapy and not “chiropractic”
Two: Greg Kawchuk should address a public letter to the Canadian Chiropractic Association and the Alberta College of Chiropractors stating clearly, as Dr. Shekelle did, that this project does not in any way support “chiropractic”. All references to that effect should be removed from sites of the Canadian Chiropractic Association and others.
Three: This issue should be returned to the ethics committee and interested parties should be invited to address their concerns.
Four: Physicians who may have referred patients should be advised of the legal ramifications as stated by their own professional organization. I already understand that an Alberta physician is considering a complaint against your faculty to be made to the Alberta College of Physicians and Surgeons that physicians were not informed this was a “chiropractic” study.
Five: It would appear that it is the physical therapy profession and not the chiropractic profession that has made the greatest effort to provide safe and scientific manual therapy. Certainly the physical therapy profession should be front and center in any study. This does not mean that a chiropractor can never be involved. I believe very strongly that any
chiropractor who is not doing “chiropractic manipulation” and is not allowing their name to be used to imply endorsement for chiropractic could be involved.
On behalf of my colleagues I thank you for reading this rather long letter and I trust we can move on together in the best interest of the public we all serve.
Sincerely,
J. William Kinsinger M.D.
c.c. Please distribute to members of the ethics committee
Bob Haennel PhD Chair, Physical Therapy2-50F, Corbett Hall, Edmonton, Alberta, Canada, T6G 2G4Bob.Haennel AT ualberta.ca
Fax: 1-780-492-4429
ASSOCIATE DEAN David Magee PhDProfessor, Physical Therapy3-50C, Corbett Hall, Edmonton, Alberta, Canada, T6G 2G4david.magee AT ualberta.caFax: 1-780-492-4429
Dr. Albert M. Cook
Dean, Faculty of Rehabilitation Medicine3-48 Corbett HallFaculty of Rehabilitation MedicineThe University of AlbertaEdmonton, AB T6G 2G4
Al.Cook AT ualberta.ca Fax: (780) 492-1626
Dr. Tom Marrie
Dean, Faculty of Medicine
University of Alberta
Edmonton, Alberta
Tom.marrie AT ualberta.ca
Fax: 1-780-492-7303
Greg Kawchuk
3-50 Corbett Hall
University of Alberta
Edmonton, Alberta, Canada T6G 2G4
Fax: 1-780-492-1626
Robert Sydenham and for
Distribution to the members of the
Ethics Committee and other interested
Parties in the physical therapy profession.
This letter is not confidential and may be made public.
REFERENCE ONE
University Chairs in Chiropractic [Top]The chiropractic profession has also established a university Research Chair program jointly funded with CIHR. Dr. Greg Kawchuk was the first member of the profession to be awarded a university-based Chiropractic Research Chair. He was subsequently awarded a Canada Research Chair at the University of Edmonton, one of the federal government’s highest research awards. (www.ccachiro.org)
REFERENCE TWO
Chiropractic is defined by all the schools of chiropractic, by all the chiropractic associations and by all the licensing bodies as treating chiropractic “vertebral subluxations” and thereby maintaining health and treating illness. The basic concepts are:
1. The vertebral bones are out of alignment, i.e. they have subluxations.
2. This is especially true of the two top vertebrae, the atlas and the axis and the occipital atlas joint.
3. Chiropractors claim they can make their diagnosis using just their fingers.
4. From this they can then determine which organs in the body are diseased and they can state what the disease is. This includes the brain, heart, lungs, abdominal and reproductive organs, all our senses touch, visual, hearing, our immune system, our blood and all the cranial nerves. They don’t need blood tests or X rays, just their fingers.
5. They contend they can manipulate this subluxation and both maintain and restore health or “wellness” to the entire body. The “adjustment” may be a simple turning of the head as with an infant or a high velocity low amplitude manipulation as with an adult.
REFERENCE THREE
STATEMENT OF DR. PAUL SHEKELLE OF RAND
American Chiropractic Association Journal of Chiropractic/July 1993
“Through RAND’s process of monitoring the popular media, we have become aware of numerous instances where our results have been seriously misrepresented by chiropractors writing for their local newspapers or writing letters to the editor. RAND
vigorously defend the integrity of its work and we have had to write letters to these same newspapers pointedly correcting the misrepresentations.”
Claim: The RAND study showed that chiropractic is the most effective treatment for low back pain”
Clarification: RAND’s results were about spinal manipulation, not chiropractic, and dealt with appropriateness, which is a measure of net benefits and harm. Comparative efficacy of chiropractic and other treatments was NOT explicitly dealt with.
Claim: The RAND study showed that chiropractic is the most cost-effective form of treatment for low back pain:
Clarification Again, the RAND’s results are specific to spinal manipulation and cost was specifically excluded from our analysis.
Claim: The RAND study showed that patients with low-back pain should first seek care from a doctor of chiropractic.
Clarification: No mention is made from whom patients should seek care in our work.
Claim: The RAND study shows that chiropractic is the best form of care for many musculoskeletal conditions.
Clarification: We dealt only with low-back pain and our results cannot be extrapolated to any other condition”
REFERENCE FOUR
April 14, 1997, Canadian Medical Protective Association to Dr. Marvin Levant, Calgary, Alberta.
PHYSICIAN REFERRALS
“Another situation of potential liability is when a physician refers the patient to another health professional. Some jurisprudence suggests that the physician has an obligation to satisfy himself or herself that the other professional is competent. In these circumstances, it is suggested that once the physician has informed himself of the other professional’s credentials and general competence, there can be no liability.”(C.M.P.A.)
LIABILITY OF THE CHIEF OF THE MEDICAL STAFF OF A HOSPITAL
In the context of hospitals, however, statues like the Public Hospitals Act of Ontario provide that the head of a department of the chief of the medical staff can be made responsible by the by-laws of the hospital, to advise the medical advisory committee of the hospital with respect to the quality or medical diagnosis, care and treatment provided to patients.
“A physician occupying one of these positions could therefore have an obligation to report concerns about the care provided by a chiropractor who holds a position on the medical staff of the hospital”.
PHYSICIAN KNOWLDEGE OF PATIENT RISK
“There is no obligation on physicians to report negligent or incompetent chiropractors to health authorities. In the situation however, where it was apparent to the radiologist that the patient will not receive adequate treatment from a chiropractor, or that the chiropractor has made a mistake in the diagnosis of his condition, a court might be sympathetic to a plaintiff’s argument that the radiologist had a duty to report the situation to the patient or to the patient’s family physician” (C.M.P.A.)
FORSEEABLE RISKS
“Courts however, may be receptive to a plaintiff’s argument that in certain circumstances, where injury to the patient was foreseeable, the radiologist had the duty to advise the patient, or the patient’s family physician, of the diagnosis”.
COMPETANT CARE
“We recommend that in instances when, in the radiologist opinion, the patient would not receive adequate treatment from a chiropractor, for the condition diagnosed by the radiologist, that the patient and the family physician be informed of the diagnosis and advised that the condition should be followed by the appropriate physician"” (C.M.P.A.)
LIABILITY OF THOSE WHO EMPLOY A CHIROPRACTOR
“There are certain exceptions to the general rule that the physician is not responsible for the care provided by other health care professionals. When the other health care professional is employed by the physician, for instance, the physician could be held vicariously liable for the actions of that other health care professional”.
REFERENCE FIVE
The editorial article published in the National Post, Canada.
Deadly quacks: Neurologists have long protested the practice of 'highest neck manipulation,' which in some cases has resulted in lethal strokes
J. William Kinsinger
Thursday, February 17, 2005
Ontario's decision to remove chiropractic care from its roster of publicly-funded health care services has been painted in the press as a purely budgetary choice. In fact, the government's decision was justified on both medical and ethical grounds. For the good of Canadians' health, one can only hope that other provinces follow suit.
Chiropractors are not "doctors," they do not train in any hospital and their medical teachings have been rejected by many universities. Chiropractic treatment is based on the philosophical -- not scientific -- idea that spinal manipulation can treat just about any illness, including asthma, hypertension in adults, and autism in children and ear infections in babies.
The Ontario Chiropractic Association has marketed this idea well, instructing parents to bring newborn babies to chiropractors "as soon after birth as possible," and issuing alarming statements saying that "our children deserve to be treated naturally, not with dangerous chemical drugs and unproven surgeries."
Such specious rhetoric has proven effective. Over the past 10 years, more than $100-million has been billed by Ontario chiropractors to treat infants and children, using spinal manipulation, for everything from newborn colic to bed-wetting. It has even been presented as an alternative to immunization.
Thankfully, the medical community has moved to debunk such claims. In 1994 and again in 1998, the Chiefs of Pediatrics of Canadian Hospitals rightly stated that spinal manipulation of infants and children is "ineffective and useless." Accordingly, they called on provincial governments to stop paying for the treatment.
Neurologists, meanwhile, have long protested the chiropractic practice of "highest neck manipulation," used frequently on people who have no neck pain whatsoever. Although coroner's inquests have found that highest neck manipulation can cause lethal strokes, chiropractors have persisted, claiming that strokes and death occur only rarely.
In fact, such outcomes are not rare, and case reports detailing strokes have been published in numerous respectable medical journals over the past 60 years. Two further reports appeared in 2004 alone. One can only wonder why Ontario waited so long to cut payment for such procedures.
Ontario chiropractors have also been marketing "maintenance care" as a means to sell their services, and have billed for hundreds of millions of dollars by performing spinal manipulation on people who are perfectly well. Wisely, the Center for Medicare and Medicaid Services in the United States recently delisted all such claims.
Ontario's decision to delist chiropractic services ought to be permanent. And Alberta, Manitoba and Saskatchewan, which still cover the cost of chiropractic treatment, should follow its lead.
Unfortunately, some opposition politicians are making an issue of Ontario's decision. The province's Conservative leader, John Tory, wrote in the Post last December that a "visit to a chiropractor costs less than one to a family doctor or an orthopedic surgeon." This is a narrow view: Whether a service is cheap or not matters little if the benefit is dubious and the attendant risks considerable.
Chiropractors misleadingly market themselves as mainstream health care professionals, offer help to those who do not need it and endanger patients by promising results they have neither the training nor the ability to deliver. Ontario has not only saved money by delisting chiropractic services -- it has saved lives as well.
J. William Kinsinger is an American physician, and a member of a professional group monitoring government support for alternative medicine.© National Post 2005
3126 S. Boulevard #245
Edmond, OK 73013
405-990-2745
kinsingerb AT ol.com
Paul Hagler, PhD
Professor & Associate Dean, Graduate Studies and Research
Faculty of Rehabilitation Medicine
3-50 Corbett Hall, Edmonton
Alberta, Canada, T6G2G4Office (780) 492-9674
E-mail: paul.hagler AT ualberta.ca
And
Robert Sydenham B.Sc. D.P.T. F.C.A.M.T.
207, 11520-100 Avenue
Edmonton, Alberta
T5K 0J7
bsydenham AT shawbiz.ca
Office 780-482-7428
SENT BY E-MAIL AND BY LETTER POST.
November 11, 2005
Dear Dr. Hagler:
Nothing in this letter is meant to question the sincerity, competence or integrity of any member of your Faculty. I know from past experiences that too often Universities become involved in an issue in which all the information has not been considered. This was the experience at York University and recently at Florida State University. I wish to provide some information, ask critical questions and suggest reasonable solutions.
My name is Dr. William Kinsinger. I am a Board certified anesthesiologist practicing in the State of Oklahoma. I am part of a large world-wide group of academics, physicians, members of the legal community, and of the general public who are extremely concerned about the practice of chiropractic and in particular the tragedy of stroke and death due to chiropractic highest neck manipulation.
We closely monitor claims made by chiropractors and became aware that the University of Alberta is soliciting practitioner referrals in order to do a study on “chiropractic manipulation”. We then became aware of an exchange of correspondence between yourself and physical therapist Robert Sydenham.
We also note that the current website of the Canadian Chiropractic Association, under the heading of “University Chairs of Chiropractic” refers to Dr. Kawchuk. (SEE REFERENCE ONE). We understand there is no chiropractic chair at the University of Alberta so perhaps you should have the Canadian Chiropractic Association clarify this.
We expressed our concern to Mr. Sydenham and he suggested we address them to you directly. We are in the process of determining who in the scientific and ethics community we should address our concern to. We have asked Mr. Sydenham to provide us with the names of the members of the ethics committee as well as those in the medical community.
Our group is very concerned about University academic integrity. Last year we were involved in a successful campaign to stop Florida State University from accepting a school of chiropractic. A paper I wrote on that subject is called “Preserving Academic Scientific Excellence at Florida State University”. May I suggest that officials at the University of Alberta should read this paper? I will gladly make it available. I can send the text without the documents as an e-mail attachment or a full copy by mail as may be requested.
Our concern is public information and safety. In that regard your Canadian newspaper, The National Post, published an editorial comment I wrote in support of the decision of the Government of Ontario to stop all government support of chiropractic. You will note that my first concern was safety not fiscal. (SEE REFERENCE FIVE)
ACADEMIC FREEDOM AND ACADEMIC EXCELLENCE
In your letter of October 19, 2005, to Mr. Sydenham, you state that “it may come as a surprise to you but universities are founded on the principle of academic freedom”. This reminds me of the arguments put forward by the chiropractors during the Florida State University debate; “we can teach whatever we want”. Our argument was that academic freedom does not include teaching non-scientific courses and awarding the students with a doctorate degree. I might add that if this comment was made to me I would find it rather insulting.
May I suggest that the foremost issue of concern for any University is its academic integrity? The name of the University should not be used in any way directly or indirectly by others to support non-scientific claims.
Academic integrity was the very reason why York University in Toronto, along with the Universities of Victoria, Ottawa and indeed Calgary when an informal approach was made to them, to deny any question of a school of chiropractic affiliated with a university. This was also the reason why Nobel Laureates and others combined to defeat a similar recent effort by chiropractors at Florida State University. My colleagues and I were very proud to work directly with these esteemed scientists.
If you wish to preserve the academic integrity of the University you must be sure you are not endorsing “chiropractic”
CONFUSING SCIENTIFIC MANUAL THERAPY WITH CHIROPRACTIC PHILOSOPHY
I understand that you define this as a study to “understand the cause of mechanical back pain”. There is no mention about neck manipulation. There is no mention about the fact that “chiropractic manipulation” will be used. This is only divulged in your letter to Mr. Sydenham. Just as various medications differ, there are fundamental differences between chiropractic manipulation and scientific manual therapy. Is the ethics committee aware that those being solicited were not informed as to the therapy to be used?
You cannot define “chiropractic manipulation” to suit your own purposes. “Chiropractic manipulation” is defined by all the chiropractic schools, all their licensing bodies, including Alberta, and all their professional associations in the same manner, that is, maintaining health and treating disease by treating “chiropractic vertebral subluxations”. Clearly this is a false philosophical belief system and scientific medicine and basic anatomy have rejected this for over 100 years. (SEE REFERENCE TWO).
I would invite you to go on the website on the Alberta College of Chiropractors (http://www.albertachiro.com/). I could write a book about what is claimed but let me suggest you click on the section “Just For Kids”. Do you feel that a regulatory body, there to protect the public should ask children to examine their own parents?
“Did you know that when a baby is growing inside its Mommy the very first things that grow are the brain, then the spinal cord and the spinal nerves? They are so important that they have to come first before anything else - before your heart or your lungs or even your arms and legs! “
“What do you think happens to your organs when your have bad posture and your spine is not straight? The nerves don't communicate properly with those organs, and then they can't work properly. So what can you do to make sure your spine and nerves can communicate with your organs? You stand up straight. Don't let your spine guys slouch.
As a scientist I am sure you will recognize that the first paragraph is genetic nonsense and the second that the heart, lungs, GI tract and brain function improperly due to “slouching” is to be polite, neurological quackery.
“Chiropractic manipulation” often involves a high velocity low amplitude thrust and when done in a position of extension and rotation on the neck is dangerous. This in fact has been banned by physical therapists. In addition some types of low back chiropractic manipulation have been directly associated with paralysis due to cauda equina syndrome. How aware of this are the physicians you solicited?
Furthermore, the most essential concept in chiropractic manipulation is highest neck manipulation. The first chiropractic “adjustment” done by Palmer was of the highest neck and had nothing to do with low back pain but was supposedly done to cure deafness. Canadian authors Paul Benedetti and Wayne MacPhail published an excellent book on this called “Spin Doctors: ISBN 1-55002-406-X.
So the first question is, how can the University of Alberta do a study on scientific manual therapy when your letter dated October 19, 2005 defines what is being done as a study on “chiropractic manipulation”. As well you state “A chiropractor was chosen due to the scientific questions that were posed in the study”.
If that was the concern then surely a physical therapist and not a chiropractor should have been chosen. If a chiropractor is chosen, and you appear to have one who is highly qualified and has achieved academic excellence, then the first task of the University is to make it clear that the chiropractor involved and the University of Alberta do not support in any way directly or indirectly “chiropractic manipulation”. So may I suggest you have started out on both wrong feet?
RAND AND CHIROPRACTIC
In the United States this issue of chiropractors trying to say that manipulation studies support chiropractic has also arisen. To help achieve the distinction between scientific manual therapy and chiropractic philosophy, Dr. Paul Shekelle of RAND issued a public statement that he obliged the American Chiropractic Association to publish.
It makes clear that all the claims made by chiropractors that RAND was supporting chiropractic manipulation were misleading and that in fact his work was specific to spinal manipulation and had nothing to do with chiropractic. (SEE REFERENCE THREE).
In that regard, I do want to congratulate the physical therapy community in Canada for developing and supporting the Orthopractic guidelines (http://www.orthopractic.org/). These
make clear the essential differences between scientific manual therapy and chiropractic philosophy.
OTHER ALBERTA UNIVERSITY BACK DOOR SUPPORT
You have to ask yourself if you are being used to promote chiropractic. This was the position the University of Calgary recently found itself in at the Inquest into the death of 45 year old Lana Dale Lewis of Toronto. In order to claim that chiropractic neck manipulation was safe Herzog from the University of Calgary was called to testify. His study done in Alberta in 2002 was done on 80-99 year old cadavers with a chiropractor gently moving the head through a limited range of motion.
The first problem with this study was that the subjects were already dead. The best the “study” could prove is that dead people can’t have a stroke and die twice due to a chiropractic neck manipulation. The second problem is the subjects were 45-50 years beyond the risk group we see most strokes in, young women less than 45 years of age. .
The best criticism of this study was stated by another chiropractor, Christopher Good of New York Chiropractic College. As chiropractor Good points out, Herzog himself clearly states that his study was done on cadavers and “we cannot interpolate these results into a living system” (JMPT June 2003. Pa. 338-340). Furthermore, the place that Herzog did his testing in the neck, the distal CO-1 and C-6 was the wrong place in the neck to test. Good states, “The most important section that can be measured is the C1-2 section, especially at the C-2 foramen.”
Chiropractor Good goes further by pointing out that Herzog never tested “the most forceful manipulation of all and maybe one of the most common used by practitioners”. He goes on to say that until this is tested “we are simply deluding ourselves and misleading others”.
So the best and most often quoted study on the risk of neck manipulation was done on 80-90 year old dead people based on a type of neck manipulation chiropractors almost never use and at a place in the neck where the pathology does not usually occur.
Needless to say this testimony was torn apart and in the end the Jury did indeed conclude that Lana Dale Lewis died directly as a result of a chiropractic highest neck manipulation
Any University endorsement of “chiropractic manipulation” is an automatic endorsement of chiropractic highest neck manipulation. Sixty years of scientific literature point out the strokes and deaths caused needlessly by this. http://www.neck911usa.com/.
TREATING BACK PAIN BY NECK MANIPULATION
To put this in a Canadian concept, one should read the report on the Inquest into the death of 20 year old Laurie Jean Mathiason of Saskatoon Saskatchewan. Like the great majority of cases we have seen, Laurie had low back pain, in fact tailbone pain and yet her neck was manipulated, in fact over 100 times before she died. The fact remains that many chiropractors believe they can treat low back pain by neck manipulation (75% of patients
with low back pain) and the University of Alberta will be indirectly if not directly endorsing this belief.
THE SOLICITATION LETTER TO PHYSICAL THERAPIST AND MDs and CHIROPRACTORS.
I have additional concerns about the solicitation letter sent to “rehabilitation practitioners” They certainly should be aware that the lead investigator is a chiropractor and that the research is being described as one on “chiropractic manipulation”.
In Canada the Canadian Medical Protection Association has stated some clear legal opinions on this subject. Certainly referring physicians should be aware of this (SEE REFERENCE FOUR). Certainly this is a prime consideration for the Ethics Committee to review.
In addition, Canadian Neurologists from across Canada as well as the Chiefs of Pediatrics of Canadian Hospitals have expressed a clear opinion on the issue of “chiropractic manipulation”.
SUGGESTIONS
I will not go into many of the comments made in your letter. Rather I would prefer to make a few suggestions as to how this issue can be resolved. In doing so I must state that your own personal and professional interests as well as those of the University of Alberta are all secondary to the public interest. No one in the public must be misled in any way as to what the University of Alberta is endorsing. Indeed we intend to advise some of our many stroke victims living in Alberta of this debate and they may wish to be heard before the ethics committee.
One: The study should be redefined as one of manual therapy and not “chiropractic”
Two: Greg Kawchuk should address a public letter to the Canadian Chiropractic Association and the Alberta College of Chiropractors stating clearly, as Dr. Shekelle did, that this project does not in any way support “chiropractic”. All references to that effect should be removed from sites of the Canadian Chiropractic Association and others.
Three: This issue should be returned to the ethics committee and interested parties should be invited to address their concerns.
Four: Physicians who may have referred patients should be advised of the legal ramifications as stated by their own professional organization. I already understand that an Alberta physician is considering a complaint against your faculty to be made to the Alberta College of Physicians and Surgeons that physicians were not informed this was a “chiropractic” study.
Five: It would appear that it is the physical therapy profession and not the chiropractic profession that has made the greatest effort to provide safe and scientific manual therapy. Certainly the physical therapy profession should be front and center in any study. This does not mean that a chiropractor can never be involved. I believe very strongly that any
chiropractor who is not doing “chiropractic manipulation” and is not allowing their name to be used to imply endorsement for chiropractic could be involved.
On behalf of my colleagues I thank you for reading this rather long letter and I trust we can move on together in the best interest of the public we all serve.
Sincerely,
J. William Kinsinger M.D.
c.c. Please distribute to members of the ethics committee
Bob Haennel PhD Chair, Physical Therapy2-50F, Corbett Hall, Edmonton, Alberta, Canada, T6G 2G4Bob.Haennel AT ualberta.ca
Fax: 1-780-492-4429
ASSOCIATE DEAN David Magee PhDProfessor, Physical Therapy3-50C, Corbett Hall, Edmonton, Alberta, Canada, T6G 2G4david.magee AT ualberta.caFax: 1-780-492-4429
Dr. Albert M. Cook
Dean, Faculty of Rehabilitation Medicine3-48 Corbett HallFaculty of Rehabilitation MedicineThe University of AlbertaEdmonton, AB T6G 2G4
Al.Cook AT ualberta.ca Fax: (780) 492-1626
Dr. Tom Marrie
Dean, Faculty of Medicine
University of Alberta
Edmonton, Alberta
Tom.marrie AT ualberta.ca
Fax: 1-780-492-7303
Greg Kawchuk
3-50 Corbett Hall
University of Alberta
Edmonton, Alberta, Canada T6G 2G4
Fax: 1-780-492-1626
Robert Sydenham and for
Distribution to the members of the
Ethics Committee and other interested
Parties in the physical therapy profession.
This letter is not confidential and may be made public.
REFERENCE ONE
University Chairs in Chiropractic [Top]The chiropractic profession has also established a university Research Chair program jointly funded with CIHR. Dr. Greg Kawchuk was the first member of the profession to be awarded a university-based Chiropractic Research Chair. He was subsequently awarded a Canada Research Chair at the University of Edmonton, one of the federal government’s highest research awards. (www.ccachiro.org)
REFERENCE TWO
Chiropractic is defined by all the schools of chiropractic, by all the chiropractic associations and by all the licensing bodies as treating chiropractic “vertebral subluxations” and thereby maintaining health and treating illness. The basic concepts are:
1. The vertebral bones are out of alignment, i.e. they have subluxations.
2. This is especially true of the two top vertebrae, the atlas and the axis and the occipital atlas joint.
3. Chiropractors claim they can make their diagnosis using just their fingers.
4. From this they can then determine which organs in the body are diseased and they can state what the disease is. This includes the brain, heart, lungs, abdominal and reproductive organs, all our senses touch, visual, hearing, our immune system, our blood and all the cranial nerves. They don’t need blood tests or X rays, just their fingers.
5. They contend they can manipulate this subluxation and both maintain and restore health or “wellness” to the entire body. The “adjustment” may be a simple turning of the head as with an infant or a high velocity low amplitude manipulation as with an adult.
REFERENCE THREE
STATEMENT OF DR. PAUL SHEKELLE OF RAND
American Chiropractic Association Journal of Chiropractic/July 1993
“Through RAND’s process of monitoring the popular media, we have become aware of numerous instances where our results have been seriously misrepresented by chiropractors writing for their local newspapers or writing letters to the editor. RAND
vigorously defend the integrity of its work and we have had to write letters to these same newspapers pointedly correcting the misrepresentations.”
Claim: The RAND study showed that chiropractic is the most effective treatment for low back pain”
Clarification: RAND’s results were about spinal manipulation, not chiropractic, and dealt with appropriateness, which is a measure of net benefits and harm. Comparative efficacy of chiropractic and other treatments was NOT explicitly dealt with.
Claim: The RAND study showed that chiropractic is the most cost-effective form of treatment for low back pain:
Clarification Again, the RAND’s results are specific to spinal manipulation and cost was specifically excluded from our analysis.
Claim: The RAND study showed that patients with low-back pain should first seek care from a doctor of chiropractic.
Clarification: No mention is made from whom patients should seek care in our work.
Claim: The RAND study shows that chiropractic is the best form of care for many musculoskeletal conditions.
Clarification: We dealt only with low-back pain and our results cannot be extrapolated to any other condition”
REFERENCE FOUR
April 14, 1997, Canadian Medical Protective Association to Dr. Marvin Levant, Calgary, Alberta.
PHYSICIAN REFERRALS
“Another situation of potential liability is when a physician refers the patient to another health professional. Some jurisprudence suggests that the physician has an obligation to satisfy himself or herself that the other professional is competent. In these circumstances, it is suggested that once the physician has informed himself of the other professional’s credentials and general competence, there can be no liability.”(C.M.P.A.)
LIABILITY OF THE CHIEF OF THE MEDICAL STAFF OF A HOSPITAL
In the context of hospitals, however, statues like the Public Hospitals Act of Ontario provide that the head of a department of the chief of the medical staff can be made responsible by the by-laws of the hospital, to advise the medical advisory committee of the hospital with respect to the quality or medical diagnosis, care and treatment provided to patients.
“A physician occupying one of these positions could therefore have an obligation to report concerns about the care provided by a chiropractor who holds a position on the medical staff of the hospital”.
PHYSICIAN KNOWLDEGE OF PATIENT RISK
“There is no obligation on physicians to report negligent or incompetent chiropractors to health authorities. In the situation however, where it was apparent to the radiologist that the patient will not receive adequate treatment from a chiropractor, or that the chiropractor has made a mistake in the diagnosis of his condition, a court might be sympathetic to a plaintiff’s argument that the radiologist had a duty to report the situation to the patient or to the patient’s family physician” (C.M.P.A.)
FORSEEABLE RISKS
“Courts however, may be receptive to a plaintiff’s argument that in certain circumstances, where injury to the patient was foreseeable, the radiologist had the duty to advise the patient, or the patient’s family physician, of the diagnosis”.
COMPETANT CARE
“We recommend that in instances when, in the radiologist opinion, the patient would not receive adequate treatment from a chiropractor, for the condition diagnosed by the radiologist, that the patient and the family physician be informed of the diagnosis and advised that the condition should be followed by the appropriate physician"” (C.M.P.A.)
LIABILITY OF THOSE WHO EMPLOY A CHIROPRACTOR
“There are certain exceptions to the general rule that the physician is not responsible for the care provided by other health care professionals. When the other health care professional is employed by the physician, for instance, the physician could be held vicariously liable for the actions of that other health care professional”.
REFERENCE FIVE
The editorial article published in the National Post, Canada.
Deadly quacks: Neurologists have long protested the practice of 'highest neck manipulation,' which in some cases has resulted in lethal strokes
J. William Kinsinger
Thursday, February 17, 2005
Ontario's decision to remove chiropractic care from its roster of publicly-funded health care services has been painted in the press as a purely budgetary choice. In fact, the government's decision was justified on both medical and ethical grounds. For the good of Canadians' health, one can only hope that other provinces follow suit.
Chiropractors are not "doctors," they do not train in any hospital and their medical teachings have been rejected by many universities. Chiropractic treatment is based on the philosophical -- not scientific -- idea that spinal manipulation can treat just about any illness, including asthma, hypertension in adults, and autism in children and ear infections in babies.
The Ontario Chiropractic Association has marketed this idea well, instructing parents to bring newborn babies to chiropractors "as soon after birth as possible," and issuing alarming statements saying that "our children deserve to be treated naturally, not with dangerous chemical drugs and unproven surgeries."
Such specious rhetoric has proven effective. Over the past 10 years, more than $100-million has been billed by Ontario chiropractors to treat infants and children, using spinal manipulation, for everything from newborn colic to bed-wetting. It has even been presented as an alternative to immunization.
Thankfully, the medical community has moved to debunk such claims. In 1994 and again in 1998, the Chiefs of Pediatrics of Canadian Hospitals rightly stated that spinal manipulation of infants and children is "ineffective and useless." Accordingly, they called on provincial governments to stop paying for the treatment.
Neurologists, meanwhile, have long protested the chiropractic practice of "highest neck manipulation," used frequently on people who have no neck pain whatsoever. Although coroner's inquests have found that highest neck manipulation can cause lethal strokes, chiropractors have persisted, claiming that strokes and death occur only rarely.
In fact, such outcomes are not rare, and case reports detailing strokes have been published in numerous respectable medical journals over the past 60 years. Two further reports appeared in 2004 alone. One can only wonder why Ontario waited so long to cut payment for such procedures.
Ontario chiropractors have also been marketing "maintenance care" as a means to sell their services, and have billed for hundreds of millions of dollars by performing spinal manipulation on people who are perfectly well. Wisely, the Center for Medicare and Medicaid Services in the United States recently delisted all such claims.
Ontario's decision to delist chiropractic services ought to be permanent. And Alberta, Manitoba and Saskatchewan, which still cover the cost of chiropractic treatment, should follow its lead.
Unfortunately, some opposition politicians are making an issue of Ontario's decision. The province's Conservative leader, John Tory, wrote in the Post last December that a "visit to a chiropractor costs less than one to a family doctor or an orthopedic surgeon." This is a narrow view: Whether a service is cheap or not matters little if the benefit is dubious and the attendant risks considerable.
Chiropractors misleadingly market themselves as mainstream health care professionals, offer help to those who do not need it and endanger patients by promising results they have neither the training nor the ability to deliver. Ontario has not only saved money by delisting chiropractic services -- it has saved lives as well.
J. William Kinsinger is an American physician, and a member of a professional group monitoring government support for alternative medicine.© National Post 2005
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