President's Report

Peter Werth
Although not widely reported in Australia the findings of the Lewis coronial inquiry has had a significant impact in North America, and in particular Canada. The case involved the death of a patient following a cervical manipulation/adjustment from her chiropractor. Those of you who may be unfamiliar with the case please refer to the article by Dr John Reggars elsewhere in this edition of COCA News and previous articles in COCA News. www.coca.com.au/newsletter/2002/sep0203a.htm. The findings some two years after the commencement of the hearing may have implications for all who practise cervical spinal manipulation world-wide.

The findings of the jury of the death being “accidental” is somewhat equivocal in that it does not necessarily implicate the chiropractor’s treatment as the cause of the stroke which took place five days after undergoing cervical spine manipulation, and quite possibly was due to natural causes (Mrs Lewis had many risk factors for such an event) that caused her stroke. The counter argument in summary is that the manipulation caused a dissection of the vertebral artery that progressively deteriorated over the subsequent days leading to an ischaemic event and the eventual death of Mrs Lewis.

Several key issues regarding the relationship to stroke and manipulation have been brought into focus at this inquiry, and it is beyond the scope of this report to provide a detailed analysis although there are some important messages to come out of the Inquiry. Some of these relate to the seventeen recommendations made by the jury, and others are more generic.

In general terms, the relationship of cervical spine manipulation and vertebrobasilar stroke (VBS), being the most serious and potentially life-threatening complication of treatment that we provide, should be addressed by the chiropractic and osteopathic professions, given that we are the two professions that perform the vast majority of cervical spine manipulation. The incidence of such complications according to the literature is extremely rare. This is especially in comparison to many other medical interventions, including some of the accepted medical treatments for neck pain such as non-steroidal anti-inflammatory drugs (NSAID’s), yet it remains a keystone in the arguments of our protagonists that neck manipulation is dangerous, and that chiropractic and osteopathic treatment is therefore unsafe. Having said that, I can hear many of you reading this and saying, hang on a minute, this type of event is so rare, some would say occurring at the same frequency as so-called spontaneous onset VBS, that it is nearly irrelevant. I would tend to agree except for two vital factors;

1. It remains the most commonly used argument as to the “dangers” of consulting a chiropractor or osteopath. As with most other forms of healthcare intervention there are risks involved and our opponents will continue to focus on this to highlight the danger, as opposed to the potential significant benefits of treatment we provide.
2. It is also one of the principal drivers of the professional indemnity insurance premiums that have been so adversely affected over the past few years.

This brings me back to the recommendations of the Lewis inquiry which were made by the jury hearing the case. Some are more specific to the case or refer to problems associated with the coroner’s office, but the message is clear. There needs to be clarification as to the link, if any, between cervical spine manipulation and VBS. The arguments heard by the jury reveal that the evidence is building showing that it’s not a black or white answer. There are potentially many variables involved in the onset of VBS, with trauma being only one factor. The current evidence would suggest that the forces applied during a manipulative procedure (as shown by cadaveric studies) are not significant enough to damage a vertebral artery. However cadaveric studies have some limitations and the study of arteries with pre-existing disease of various types needs further investigation.

The above just briefly highlights one of many of the issues that have evolved over more recent times, and were highlighted by the inquiry. Other recommendations of the jury focus on matters that have been addressed to a large degree in this country by COCA and other groups providing risk management programs. The issues of proper informed consent and accurate and complete record-keeping have emerged as issues in the enquiry.

I feel that the key message that we in Australia can take away from this case is that the VBS issue is not going to go away in a hurry. Despite ongoing research into the relationship between cervical spine manipulation and VBS, and more effective risk management procedures being adopted, you can be sure that the cervical manipulation and VBS will be on the agenda for some time and will have serious implications with respect to how we treat our patients. The recommendations of the inquiry also include the need for further research to be done in this field. Suggestions were to establish a database on the frequency of complications to manipulative treatment and to improve interprofessional dialogue between the medical and chiropractic/osteopathic professions on how to address this issue.

It requires the chiropractic and osteopathic professions to take the lead on this, or others will potentially dictate the terms and conditions on how we can practice. The Lewis inquiry has had a major impact on the chiropractic profession in Canada with many practitioners reporting a thirty percent reduction in patient visits over recent times, due to the negative publicity associated with the case. We need to be seen as having a proactive stance, addressing what many see as our Achilles heel, and showing to the community at large that we are responsible and professional in our efforts to address this issue by providing the most effective and safest care for our patients. It’s a case of lead or be lead, with the latter option potentially having a significant detrimental effect on the way we conduct our practices.