Precautionary Principle Be Damned

Precautionary Principle Be Damned

The Precautionary principle

states that if an action or policy has a suspected risk of causing harm to the public or to the environment, in the absence of scientific consensus that the action or policy is not harmful, the burden of proof that it is not harmful falls on those taking an action…The principle implies that there is a social responsibility to protect the public from exposure to harm, when scientific investigation has found a plausible risk.

Although not always perfectly applied, the precautionary principle does guide the practice of medicine. Part of the problem in medicine is that interventions are always a balance of risk and benefit, but we are constantly reminded of new, rare and potentially dangerous complications of interventions. And we modify or cease practice as a result.

The pseudo-medical  world tends to completely ignore the Precautionary principle. Harm is virtually always denied and, with the exception of disposable acupuncture needles, no pseudo-medicine has ever admitted potential harm and as a result changed to increase patient safety.

At the forefront of ignoring the Precautionary principle is chiropractic.

Evidently (I say evidently as I cannot access the original without paying), the Harvard Health Publications has an article called Stroke: Diagnosing, Treating, and Recovering From a 'Brain Attack' that includes information from the American Heart Association's 2014 position statement on cervical manipulation and artery dissection.

The AHA article, with 236 references in support, has the following conclusion

Although current biomechanical evidence is insufficient to establish the claim that CMT causes CD, clinical reports suggest that mechanical forces play a role in a considerable number of CDs and most population controlled studies have found an association between CMT and VAD stroke in young patients. Although the incidence of CMT-associated CD in patients who have previously received CMT is not well established, and probably low, practitioners should strongly consider the possibility of CD as a presenting symptom, and patients should be informed of the statistical association between CD and CMT prior to undergoing manipulation of the cervical spine.

The American Chiropractic Association (ACA) took umbrage with Harvard and responded with a letter that has an impressive 4 references to suggest chiropractic manipulation is not associated with stoke. And they use as supporting the safety of chiropractic, the Cassidy study, which the ACA evidently did not read since (from the AHA position paper)

for those <45 years of age, 8 cases (7.8%) had consulted a chiropractor within 7 days of the index date compared with 14 of controls (3.4%). They found an association between chiropractic visits and VA strokes.

Although the Cassidy study rationalized it away.

"We have not ruled out neck manipulation as a potential cause of some VBA strokes. On the other hand, it is unlikely to be a major cause of these rare events. Our results suggest that the association  between chiropractic care and VBA stroke found in previous studies is likely explained by presenting symptoms attributable to vertebral artery dissection."

I always face palm when Chiropractors cite a paper for safety that in fact shows the opposite.

The Harvard report also does not make clear that neck manipulations – referred to as "thrusting neck movements" in the report — are safe when skillfully applied by qualified doctors of chiropractic

But given that

for those aged <45 years showed VBA cases to be 5 times more likely than controls to have visited a chiropractor within 1 week of the VBA (95% CI from bootstrapping, 1.32 to 43.87). Additionally, in the younger age group, cases were 5 times as likely to have had ≥3 visits with a cervical diagnosis in the month before the case's VBA date (95% CI from bootstrapping, 1.34 to 18.57).

It would suggest that it is the skillfully applied manipulations by qualified doctors of chiropractic that are precisely the problem.

The ACA focuses on the risks of NSAIDS ignoring the benefits of NSAIDS and mentioning the

untold numbers of potential patients who could benefit from chiropractic care

Since when is zero an untold number? The risk of chiropractic is not acceptable as it has no proven benefit over safer interventions.

If you are truly have the

goal — to improve the health and wellbeing of the American people

you apply the precautionary principle when the preponderance of data points to patient danger.

Otherwise, change the topic,  ignore most the literature, misquote some of the literature, and precautionary principle be damned.

Points of Interest 09/23/2015
Points of Interest 09/21/2015