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The chiropractic war with reality rages on…

Regular readers will know that I have had a bit to say in the past about the way the chiropractic profession is run in Australia. I have refrained thus far from posting about the latest controversy, but I feel compelled to comment again now.

The cudgels were taken up again back on 29 September, when Amy Corderoy and Julia Medew published an article in the Fairfax press detailing the story of an infant who had been taken to Monash Medical Centre in Melbourne with an apparent serious injury to the upper spine. The medical slang term for the type of injury is a “hangman’s fracture” as it was commonly seen in those who died at the end of a noose if the job was properly done. It can also occur in situations where the head is forcibly extended (chin up) and a lengthening force is applied along the neck, such as an unrestrained head hitting a car dash, or your chin hitting a table violently if you fell forwards. The Fairfax article also detailed evidence from Reasonable Hank, a blogger who had been observing discussions on a Facebook list for chiropractors and noticed several of them boasting about surreptitiously treating patients in public hospitals, including newborns. The screenshots published on Reasonable Hank’s blog post can be viewed here.

It’s fair to say the Chiropractors' Association of Australia (CAA) went into crisis management mode. They issued a demand for a retraction of the story on the grounds that the report generated by the Chiropractic Board of Australia’s investigation had found that

“In fact no finding was made that any treatment performed by the Chiropractor caused a fracture as alleged.”

“It remains the case that not a single serious adverse event has been recorded in the medical literature (world-wide) involving a qualified Chiropractor treating a child since 1992.”

I’ve heard this line from CAA officials before. I pointed out this case to the CAA Board member who I first heard make this claim. It details a case of suspected child abuse of an infant with fractured ribs. The parents were cleared and the fractures attributed to the use of an Activator instrument (“the stick that clicks”) by a chiropractor who had treated the baby. To avoid the risk of misquoting, I’ll give you his response verbatim:

“Occam’s razor would suggest another, far more common cause of such an injury, no matter how nice the parents may have seemed to the hospital social workers.”

Nice. Since it is clearly impossible for a chiropractor to injure a child, the logical conclusion is child abuse, no matter what the experienced social workers and paediatricians who actually did the investigation thought. Classy.

But back to the CAA’s response to this latest report of a serious injury. In their initial response to the article, CAA President Laurie Tassell told Medical Observer magazine:

“The official report made it quite clear that the chiropractor did not cause the injury but unless AHPRA releases the report we can’t use those findings.”

But it didn’t stop him going on to tell everybody that it showed there was no fracture, hangman’s or otherwise.

The next blow to CAA’s PR effort came on October 3 when, in the wake of Medew and Corderoy’s article, Queensland MP and former GP Dr Alex Douglas announced he would lobby for legislative changes to prevent chiropractors treating children unless adequate evidence of safety and efficacy was found.

Somehow, a copy of the AHPRA report, with names redacted, was obtained by Labour MP Jo-Ann Miller, the Shadow Minister for Health in Queensland. It was tabled in the Queensland parliament with a short speech and thus became a publicly available document. This was accompanied by a co-ordinated damage control effort including a favourable report in the Australian, which gave them the reassuring headline they no doubt wanted and which has been widely quoted on chiropractors' social media. Newscorp journalist Andrew Fraser must have been secretly delighted at the prospect of giving his Fairfax colleagues a bit of a poke in the eye by having such a neat story handed to him. Certainly it emboldened CAA President Laurie Tassell, who trumpeted to Medical Observer that there were:

“no features on any images to confirm there has been a fracture, with no oedema of the bone, cleft or surrounding tissues”.

“The child did not have a fracture as alleged; [the child] had a congenital condition known as congenital spondylosis and the chiropractor could not and did not cause any injury to the child.”

Before I discuss the relevance of this new finding, it might pay to reflect for a second on the extraordinary situation of a professional association’s spin program benefiting from the leaking to a politician of a confidential investigation. The circumstances of the chain of events which occurred are now in the public domain, under parliamentary privilege. Such reports are highly sensitive, and are kept strictly confidential for very good reasons. In this case, both the child involved and the father of the child have a rare congenital spinal condition. This, plus other details in the leaked report could easily identify them. Experts and witnesses must be confident that they can speak freely and give frank opinions to the regulator without fear of leaks. Future investigations will be compromised if there is a legitimate concern on the part of expert witnesses that their opinions will become part of a media circus. A spokesperson for AHPRA told Medical Observer:

“As a regulator, the board is not able to breach the law or confidentiality requirements by releasing information that is not public.”

This leak represents a massive governance failure on the part of the CBA, and for the sake of the integrity of future investigations cannot be without consequences for those involved.

Sadly for the CAA’s efforts, the release of the report has not so much been a bullet in the foot as a landmine which has taken both their legs off.

The report in fact DOES confirm that the imaging showed a fracture. Without getting too heavily into technicalities, the congenital condition the baby had makes it harder to exclude a hangman’s fracture than usual, as the piece of bone which fractures is replaced by cartilage and immature bone which doesn’t image well. Nevertheless, Paragraph 33 of the report notes that “initial radiology opinion was that (redacted) had suffered a bilateral fracture of the posterior arch of the axis vertebra”. These initial reports and even what type of scan it was are never referred to again. A repeat CT done a couple of months down the track, and quoted at length in Paragraph 33 was reported as showing the spondylolysis but no obvious fracture.

Another CT done nearly six months after the child first went to hospital seems damning. The report of the CT concludes:

Evidence of some healing involving the left C2 pedicle defect suggesting a likely previous underlying trauma/fracture superimposed on a developmental spondylolysis

So in fact, the scenario appears to be that the injury was initially diagnosed as a bilateral fracture, which was hard to see on the next scan, but clearly evident as an asymmetrical area of new bone formation with the appearance of a healing fracture. In anticipation of indignant protests in the comments section, I would hasten to add that normal development of a child’s spine is very hard to mistake for a healing fracture if you have an experienced eye. Monash Medical Centre is a major teaching and research hospital with no shortage of highly skilled radiologists. I am intrigued to know what the scan was that the child initially had. It may have been an MRI, or another CT, but it is mentioned once, then not again.

Later paragraphs of the report are puzzling in their logic. Paragraph 61 admits that the “low force techniques” supposedly used by the chiropractor would provide biomechanical forces which may be exceeded by or matched by forces produced by normal handling.

If this is so, why bother doing them? Perhaps we are all paediatric chiropractors, fixing subluxations inadvertently every time we cuddle our kids or change their nappy.

The rest of Paragraph 61 is simply incredible. The expert chiropractor writing the report suggests that:

because of inability to completely rule out any other occurence during the period 25-27 January it is difficult to link without reasonable doubt the examination and treatment provided by (redacted) and (redacted)’s loss of head control. Temporal relationship does not automatically confirm cause and effect.

See what they did there? Just because the child lost the ability to control its head movements after a chiropractic neck treatment, don’t assume that the two are related. It was clearly those parents again, probably chucking the kid around at an Australia Day barbie, seems to be the message. Cases of hangman’s fracture due to child abuse are referred to in several places within the body of the report. More innocent peoples' reputations get pushed under a bus in pursuit of keeping the “no-harm” myth intact.

So on that form I am drawn to the unsavoury conclusion that if your child gets injured having chiropractic treatment, there seems a fair chance you as a parent might get accused of injuring your own child if you complain.

Andrew McNamara, the CEO of CAA, put his point of view as simply as possible on Twitter.

This is what doubling down looks like

CAA has also put out a couple of Member Updates, reassuring their members that “an internationally renowned medical radiologist has examined the material (x-rays, CT Scans, MRIs) and confirms that there are ‘no features on any images to confirm there has been a fracture, with no edema of the bone, cleft or surrounding tissues’”. This radiologist has not been named, and according to a Medical Observer interview with Tassell, this is because of “regrettable fear of retribution”. Now I know that the Big Pharma cabal of which I am regularly accused of being a part is powerful, but are we ruthless and cold-blooded enough to force an overseas radiologist of considerable eminence into witness protection? Just because he read a few x-rays in a way we didn’t like? And anyway, Monash Medical Centre has its own Professor of Radiology, plus a fleet of Associate Professors so why get some anonymous, terrified foreigner when you could just ask any of these equally capable hometown imaging boffins?

As things stand now, we have CAA categorically stating in a Members' Update that:

  1. The child did not have a fracture as alleged
  2. The child had a congenital condition known as Congenital Spondylolysis
  3. The Chiropractor could not and did not cause any injury to the child.

Of these statements, I would say the first seems highly questionable given the AHPRA report and perhaps other facts of the case not contained or mentioned at length in it. The second is uncontroversial, and nobody disagrees with it. If you believe the third statement, you require a better explanation to be found for such a serious injury. The suggestion from the AHPRA expert is that the parents were responsible, either accidentally or deliberately. This is at odds with the conclusions of the treating team at Monash. One wonders what Dr Pappas and his team saw in this case that convinced them to go ahead with a report to the Chiropractic Board. I doubt Pappas or any other time-poor public hospital clinician would start a process like this for laughs, or even because they hate chiropractors. Still less because they are “camp followers” of the AMA as Tassell has remarked. If you believe the President and CEO of CAA, this is an unprovoked malicious attack on the credibility of the chiropractic profession by shadowy powers strong enough to meaningfully retaliate against an eminent overseas radiologist. This is a point of view they seem prepared to seek help from politicians and journalists to defend.

There never was a baby with a broken neck. 2+2=5. Ignorance is strength. And we’ve always been at war with Eastasia, didn’t you know?