Consent or Submission? The Practice of Consent within UK Chiropractic

What are the risks of manual treatment of the spine? A scoping review for clinicians

Background

Communicating to patients the risks of manual treatment to the spine is an important, but challenging element of informed consent. This scoping review aimed to characterise and summarise the available literature on risks and to describe implications for clinical practice and research.

Method

A methodological framework for scoping reviews was followed. Systematic searches were conducted during June 2017. The quantity, nature and sources of literature were described. Findings of included studies were narratively summarised, highlighting key clinical points.

Results

Two hundred and fifty articles were included. Cases of serious adverse events were reported. Observational studies, randomised studies and systematic reviews were also identified, reporting both benign and serious adverse events.Benign adverse events were reported to occur commonly in adults and children. Predictive factors for risk are unclear, but for neck pain patients might include higher levels of neck disability or cervical manipulation. In neck pain patients benign adverse events may result in poorer short term, but not long term outcomes.Serious adverse event incidence estimates ranged from 1 per 2 million manipulations to 13 per 10,000 patients. Cases are reported in adults and children, including spinal or neurological problems as well as cervical arterial strokes. Case-control studies indicate some association, in the under 45 years age group, between manual interventions and cervical arterial stroke, however it is unclear whether this is causal. Elderly patients have no greater risk of traumatic injury compared with visiting a medical practitioner for neuro-musculoskeletal problems, however some underlying conditions may increase risk.

Conclusion

Existing literature indicates that benign adverse events following manual treatments to the spine are common, while serious adverse events are rare. The incidence and causal relationships with serious adverse events are challenging to establish, with gaps in the literature and inherent methodological limitations of studies. Clinicians should ensure that patients are informed of risks during the consent process. Since serious adverse events could result from pre-existing pathologies, assessment for signs or symptoms of these is important. Clinicians may also contribute to furthering understanding by utilising patient safety incident reporting and learning systems where adverse events have occurred.

UK Chiropractic: Regulated but Unruly

Since 1994 chiropractic has been regulated by statute in the UK. Despite this air of respectability, a range of important problems continue to bedevil this profession. Professional organizations of chiropractic and their members make numerous claims which are not supported by sound evidence. Many chiropractors adhere to concepts which fly in the face of science and most seem to regularly violate important principles of ethical behaviour. The advice chiropractors give to their clients is often dangerously misleading. If chiropractic in the UK is to grow into an established health care profession, the General Chiropractic Council and its members should comply with the accepted standards of today's health care.

Withdrawal rates as a consequence of disclosure of risk associated with manipulation of the cervical spine

Background

The risk associated with cervical manipulation is controversial. Research in this area is widely variable but as yet the risk is not easily quantifiable. This presents a problem when informing the patient of risks when seeking consent and information may be withheld due to the fear of patient withdrawal from care. As yet, there is a lack of research into the frequency of risk disclosure and consequent withdrawal from manipulative treatment as a result. This study seeks to investigate the reality of this and to obtain insight into the attitudes of chiropractors towards informed consent and disclosure.

Methods

Questionnaires were posted to 200 UK chiropractors randomly selected from the register of the General Chiropractic Council.

Results

A response rate of 46% (n = 92) was achieved. Thirty-three per cent (n = 30) respondents were female and the mean number of years in practice was 10. Eighty-eight per cent considered explanation of the risks associated with any recommended treatment important when obtaining informed consent. However, only 45% indicated they always discuss this with patients in need of cervical manipulation. When asked whether they believed discussing the possibility of a serious adverse reaction to cervical manipulation could increase patient anxiety to the extent there was a strong possibility the patient would refuse treatment, 46% said they believed this could happen. Nonetheless, 80% said they believed they had a moral/ethical obligation to disclose risk associated with cervical manipulation despite these concerns. The estimated number of withdrawals throughout respondents' time in practice was estimated at 1 patient withdrawal for every 2 years in practice.

Conclusion

The withdrawal rate from cervical manipulation as a direct consequence of the disclosure of associated serious risks appears unfounded. However, notwithstanding legal obligations, reluctance to disclose risk due to fear of increasing patient anxiety still remains, despite acknowledgement of moral and ethical responsibility.

Advice offered by practitioners of complementary/ alternative medicine: an important ethical issue

The current popularity of complementary/alternative medicine (CAM) generates many challenges to medical ethics. The one discussed here is the advice offered by CAM practitioners. Using selected examples, the author tries to demonstrate that some of the advice issued through the popular media or provided by acupuncturists, chiropractors, herbalists, homeopaths, pharmacists, and doctors is misleading or dangerous. This, the author argues, can impinge on the main principle of medical ethics: beneficence, nonmaleficence, and autonomy. We should work toward correcting this deplorable situation.

Ethics of complementary medicine: practical issues

Complementary medicine is popular, yet ethical issues are rarely discussed. Misleading information, informed consent, publishing, and confidentiality are discussed in the light of medical ethics. The message that emerges is that, in complementary medicine, ethical issues are neglected and violated on a daily basis.

Chiropractic: a critical evaluation

Chiropractic was defined by D.D. Palmer as "a science of healing without drugs." About 60,000 chiropractors currently practice in North America, and, worldwide, billions are spent each year for their services. This article attempts to critically evaluate chiropractic. The specific topics include the history of chiropractic; the internal conflicts within the profession; the concepts of chiropractic, particularly those of subluxation and spinal manipulation; chiropractic practice and research; and the efficacy, safety, and cost of chiropractic. A narrative review of selected articles from the published chiropractic literature was performed. For the assessment of efficacy, safety, and cost, the evaluation relied on previously published systematic reviews. Chiropractic is rooted in mystical concepts. This led to an internal conflict within the chiropractic profession, which continues today. Currently, there are two types of chiropractors: those religiously adhering to the gospel of its founding fathers and those open to change. The core concepts of chiropractic, subluxation and spinal manipulation, are not based on sound science. Back and neck pain are the domains of chiropractic but many chiropractors treat conditions other than musculoskeletal problems. With the possible exception of back pain, chiropractic spinal manipulation has not been shown to be effective for any medical condition. Manipulation is associated with frequent mild adverse effects and with serious complications of unknown incidence. Its cost-effectiveness has not been demonstrated beyond reasonable doubt. The concepts of chiropractic are not based on solid science and its therapeutic value has not been demonstrated beyond reasonable doubt.

Adverse effects of spinal manipulation: a systematic review

OBJECTIVE

To identify adverse effects of spinal manipulation.

DESIGN

Systematic review of papers published since 2001.

SETTING

Six electronic databases.

MAIN OUTCOME MEASURES

Reports of adverse effects published between January 2001 and June 2006. There were no restrictions according to language of publication or research design of the reports.

RESULTS

The searches identified 32 case reports, four case series, two prospective series, three case-control studies and three surveys. In case reports or case series, more than 200 patients were suspected to have been seriously harmed. The most common serious adverse effects were due to vertebral artery dissections. The two prospective reports suggested that relatively mild adverse effects occur in 30% to 61% of all patients. The case-control studies suggested a causal relationship between spinal manipulation and the adverse effect. The survey data indicated that even serious adverse effects are rarely reported in the medical literature.

CONCLUSIONS

Spinal manipulation, particularly when performed on the upper spine, is frequently associated with mild to moderate adverse effects. It can also result in serious complications such as vertebral artery dissection followed by stroke. Currently, the incidence of such events is not known. In the interest of patient safety we should reconsider our policy towards the routine use of spinal manipulation.

Adverse effects of spinal manipulation: a systematic review

OBJECTIVE

To identify adverse effects of spinal manipulation.

DESIGN

Systematic review of papers published since 2001.

SETTING

Six electronic databases.

MAIN OUTCOME MEASURES

Reports of adverse effects published between January 2001 and June 2006. There were no restrictions according to language of publication or research design of the reports.

RESULTS

The searches identified 32 case reports, four case series, two prospective series, three case-control studies and three surveys. In case reports or case series, more than 200 patients were suspected to have been seriously harmed. The most common serious adverse effects were due to vertebral artery dissections. The two prospective reports suggested that relatively mild adverse effects occur in 30% to 61% of all patients. The case-control studies suggested a causal relationship between spinal manipulation and the adverse effect. The survey data indicated that even serious adverse effects are rarely reported in the medical literature.

CONCLUSIONS

Spinal manipulation, particularly when performed on the upper spine, is frequently associated with mild to moderate adverse effects. It can also result in serious complications such as vertebral artery dissection followed by stroke. Currently, the incidence of such events is not known. In the interest of patient safety we should reconsider our policy towards the routine use of spinal manipulation.