Content provided in partnership with

Health Care Industry

Commentary in Response to JVSR Article

Journal of the American Chiropractic Association, Dec 2004 by McGregor, Marion, Triano, John J, Adams, Alan, Lawrence, Dana

Eighty-One Patients with Multiple Sclerosis and Parkinson's Disease Undergoing Upper Cervical Chiropractic Care to Correct Vertebral Subluxation: A Retrospective Analysis

Erin L Elster, DC. J Vertebr Sublux Res 2004 Aug 2; pp. 1-9.

Most Popular Articles in Health: Fuel your workout: exercisers who eat before they work out have more energy ...; Soothe a dry, itchy scalp: 5 easy expert solutions; Cocktails and calories: Beer, wine and liquor calories can really add up. ...; The sour truth about apple cider vinegar - evaluation of therapeutic use; The, six best supplements you've never heard of: these secret weapons can ...; More »

We are always interested in discovering ways to help more patients and determining what we may contribute to the health of any patient. Dr. Elster should be congratulated on her energy and willingness to seek evidence related to her beliefs and preferred hypotheses of care for patients through chiropractic. This retrospective case series, however, resulting from a significant effort by a private practice clinician, suffers extensively from over-reaching hypotheses, bias, and misrepresentation. The design and methodology of the study are technically inadequate to answer the posed questions.The author's statement of results is internally inconsistent with the methods used and at cross-purposes with some of the explicit comments made. Altogether, instead of fostering credibility for the profession and support for the clinical work she proposes, this work is more likely to raise concerns based on the absence of appropriate rigor and objectivity.

Dr. Elster writes that among her purposes are I) "to examine the role of head and neck trauma as a contributing factor to the onset of Multiple Sclerosis (MS) and Parkinson's disease (PD)" and 2) "...to investigate the potential for improving and arresting MS and PD through the correction of trauma-induced upper cervical injury." Unfortunately, the methodology will not allow her to approach an answer to either of these objectives. The serious flaw in reasoning is that either question could be addressed without the use of a control group.This work is technically a retrospective case series with no control. It is abundantly clear that this report could never be used to examine for "contributing" factors toward any diagnosis, as she has nothing to compare it against.

That the author should be aware of the necessity of a control group is evident from the reference to studies in her literature review that are categorized as "retrospective case-controlled studies" (emphasis added). Unfortunately, after consulting the listed references reported by the author, we found that the references have been misrepresented with respect to their actual content and the reported study observations. An excellent example of this is the difference between the types of trauma discussed in Bower et al.'s article (reference 1) and the type of trauma discussed by Elster. In their abstract, Bower and colleagues clearly state that "subjects who experienced a mild head trauma with only amnesia had no increased risk [of PD]; however, subjects who experienced a mild head trauma with loss of consciousness or a more severe head trauma had an OR [odds ratio] of I 1.0..." (p. 1610). In contrast, Dr. Elster fails to quantify or qualify the injuries in her patient sample, simply listing a history of trauma. Without documenting or discussing the level of severity or length of time between the purported trauma and/or the occurrence of any given head injury, it becomes impossible to consider relationship to the reported diagnoses of MS or PD.

The author attempts to excuse her failure to include a control group by stating,"This paper does not purport to be a controlled research study, but rather serves to provide a foundation for future research." It is somewhat of a contradiction, therefore, that in the conclusion the author states: "These results indicate a causal link between trauma, upper cervical injury, and disease onset for both MS and PD." Clearly, no such causal link can be derived from these data and by the author's own admission that the appropriate controlled research necessary for such a conclusion has not been conducted here.

It is similarly inappropriate not to include criteria and documentation confirming the diagnoses.The reader is left to take at face value the word of the author that these cases are legitimate patients with the disease described. Considering the other serious mistakes evident in the manuscript, there is no reason to support such an assumption. Such criteria, using valid and standard clinical assessment measures, would also allow an objective determination of outcome of care. The measures chosen by Dr. Elster, on the other hand, not only fail to be gold standards but are themselves controversial at best and irrelevant at worst.

With respect to the author's contention that her purpose includes investigating "the potential for improving and arresting MS and PD through the correction of trauma-induced upper cervical injury," the methodology of the effort is so strongly inconsistent with the objective that it simply cannot be taken seriously. First, there is no real information regarding patient severity or improvement. Rather, the single (unblinded) clinician responsible for patient care has apparently made a judgment regarding improvement based on discussion with the patient. The setting has a substantial opportunity for bias, even if unintended. Patients are known to alter their expression of perceived changes in symptoms on the basis of their relationship with the doctor. They will report greater response to treatment when discussing it with the treating doctor than they will report to a third uninvolved party. No effort was made to deal with this well-known phenomenon. Moreover, there is no effort to deal with the well-known natural history of these two disorders. Information regarding the length of follow-up was not provided. Symptoms of both conditions, but especially MS, have a tendency to ebb and flow quite naturally.

Health Care Industry

Commentary in Response to JVSR Article

Journal of the American Chiropractic Association, Dec 2004 by McGregor, Marion, Triano, John J, Adams, Alan, Lawrence, Dana

Find Research Guides for:

Find Featured Titles for: Arts

Most Popular Articles in Health

Most Popular Publications in Health