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A Statement on Cervical Manipulation and Dissections

VAD

The American Heart Association and the American Stroke Association recently published in the journal Stroke a thorough analysis of the evidence for an association between cervical manipulative therapy (CMT) and both vertebral artery dissection (VAD) and internal carotid artery dissection (ICAD). The full article is online: “Cervical Arterial Dissections and Association With Cervical Manipulative Therapy: A Statement for Healthcare Professionals From the American Heart Association/American Stroke Association.” For background, an arterial dissection is essentially a tear in the inner lining of the artery. This tear disrupts the normal flow of blood, and also causes platelets to gather at the site of injury. This can result in a blood clot at the site of the dissection. This blood clot can block flow through the artery, or it can break off and lodge downstream, blocking flow at that point. Dissections, therefore, can result in a stroke (a lack of blood flow to a portion of the brain causing damage). There are four arteries in the neck that bring blood from the heart to the brain, two carotid arteries in the front, and two vertebral arteries in the back. A dissection in one or more of these arteries is associated with 2% of all strokes, but with 8-25% of strokes in patients <45 years old. This is mostly because strokes associated with processes like atherosclerosis are much less common in the younger population. Arterial dissections are classified as either spontaneous or traumatic. Trauma can be either severe, such as whiplash injury from a car accident, or subtle, such as from yoga or simply turning one’s neck to look past the shoulder. There is an ongoing controversy as to the relationship between CMT and cervical dissection, either ICAD or VAD. Chiropractors, who are one of the main practitioners of CMT, have generally denied a causal connection, while neurologists have been more cautious. As the reviewers point out, it is now clear, based on several studies, that there is an association between CMT and cervical dissection. What is not clear is if the CMT is causing the cervical dissection. They write:

In summary, a few case-control studies suggest that CMT is associated with CD. These studies did not specifically distinguish whether the CMT included a thrust maneuver or not; the former is typically used with chiropractic manipulation. In the absence of prospective cohort or randomized studies, the current best available evidence suggests that CD, especially VAD, may be of a low incidence but could be a serious complication of CMT. Although these studies suggest an association, it is very difficult to determine causation because patients with VAD commonly present with neck pain, which may not be diagnosed prior to any CMT.

There is one study in particular, the Cassidy study, which is often cited as the evidence that the correlation between dissection and CMT is not causal. Specifically, they found that patients are just as likely to visit a medical practitioner as a chiropractor in the weeks prior to a stroke. Therefore, the authors argue, patients go to the doctor for the neck pain, rather than CMT causing the neck pain through dissection. While the review was otherwise thorough, I was disappointed in their treatment of the Cassidy study. Our own Mark Crislip did a much better job, pointing out the many flaws in the Cassidy study. Specifically, they included older strokes and a longer time frame, both resulting in a statistical dilution of cases where CMT might have caused VAD. When you look only at stroke patients <45 and within 24 hours of having CMT, there is a clear association – about a 5-fold increased risk of VAD. Other information discussed in the review is also illuminating. For example, the ratio of ICAD to VAD in spontaneous dissection is 2:1, but following CMT the ratio is 3:1 in favor of VAD. This can have two interpretations – either CMT causes some VAD, or that patients with VAD are more likely to seek treatment for neck pain than patients with ICAD. Both conditions result in neck pain, but VAD is more posterior so it is not entirely implausible that this difference in symptoms is partly responsible for the increased association between VAD and CMT. They also discuss a possible mechanism. There is no question that CMT stretches the vertebral artery, although in most cases probably not enough to cause dissection. This makes sense, as VAD is a rare complication of CMT (even if we assume that 100% of the association results from CMT causing VAD). In the rare cases of VAD associated with CMT, this may result from aggressive CMT, or from the particular of the patient’s anatomy.

Conclusion

The authors of the new review conclude:

Clinical reports suggest that mechanical forces play a role in a considerable number of CDs, and population controlled studies have found an association of unclear etiology between CMT and VAD stroke in young patients. Although the incidence of CD in CMT patients is probably low, and causality difficult to prove, practitioners should both strongly consider the possibility of CD and inform patients of the statistical association between CD and CMT, prior to performing manipulation of the cervical spine.

This is a typically conservative conclusion, and it’s difficult to fault the authors for being so cautious. I do think they are understating the probability of a causal relationship, however, probably because they were overly influenced by the Cassidy study, which they should not have been given its fatal flaws. That aside, we can state clearly that, although rare, VAD is associated with CMT. There is a very plausible mechanism for injury, and it is clearly known that even mild trauma can cause VAD. Further, there are numerous case reports of young healthy patients developing symptoms of VAD, including stroke, shortly after their CMT, sometimes immediately. It is true that none of this proves a causal connection, because we can’t do randomized trials (although prospective trials would be helpful). But this is true in the same way that we can’t prove smoking causes lung cancer, we only have an association. When we have a clear association with multiples lines of evidence suggesting the most likely causal explanation, and that explanation points to a medical risk, then I think it is reasonable to act on that risk. We recommend that patients do not smoke. We should also recommend that they do not have CMT, especially high cervical manipulation and forceful manipulation. Medicine is a game of risk vs benefit, and so considering the risk is not enough. What is the benefit of CMT for the specific conditions it is used to treat? The evidence for the benefit of CMT is less than the evidence that it causes VAD. A Cochrane review of CMT for neck pain and headache concluded:

Done alone, manipulation and/or mobilization were not beneficial; when compared to one another, neither was superior.

So CMT does not work, but perhaps may have some benefit when added to medical management, and even then it is no better than the gentler mobilization. Therefore, since CMT (if it works at all) is not superior to mobilization, and may involve a rare but serious risk of VAD and stroke, it seems to me it is unethical to perform CMT for neck pain or headache rather than mobilization. It can further be noted that, even if chiropractors are correct in saying that most people with VAD and CMT presented with an existing VAD causing neck pain, that still does not justify CMT. In such a case (someone with a VAD and neck pain) the neck should not be manipulated at all because such manipulation could very plausibly provoke a stroke. Cases of suspected VAD need emergent medical evaluation and treatment. The current review is further evidence that CMT should be eliminated as a medical procedure.

Posted in: Chiropractic, Neuroscience/Mental Health

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135 thoughts on “A Statement on Cervical Manipulation and Dissections

  1. R Miller says:

    In addition, if people are interested in this topic they can read the comment section of Sam Homala’s previous entry: http://www.sciencebasedmedicine.org/upper-neck-manipulation-caveats-for-patients-and-providers/#begincomments

    In the comments, Stephen Perle, who is supposedly one of the big names in ‘scientific’ chiropractic practice, utilizes the Cassidy study to deny a link between CMT and VAD. He dismisses the AHA/ASA piece by posting a youtube video.

    1. R Miller says:

      Homola*, apologies.

  2. ptbise says:

    Steve do you have a reference for this statment:

    “When you look only at stroke patients <45 and within 24 hours of having CMT, there is a clear association – about a 5-fold increased risk of VAD"

    Thanks.

    –Chris

  3. whoa says:

    Making a big deal about almost nothing just because you hate chiropractic.

    1. Lawrence says:

      I didn’t think a “Stroke” was almost nothing….

    2. Harriet Hall says:

      “Making a big deal about almost nothing just because you hate chiropractic.”

      No, considering the best available evidence about neck manipulation regardless of who performs it.

      It is not a matter of “hating chiropractic” but of discouraging ineffective treatments that just might harm patients. Perhaps you are making a “little deal” about “something” just because you love chiropractic.

    3. WilliamLawrenceUtridge says:

      Making a big deal about almost nothing just because you hate chiropractic.

      Look Mary, nobody says you have to read it. But I will point out that numbers like these have caused drugs to be pulled from the market. Vioxx increased the risk of heart attacks from almost nothing to tiny, and it didn’t even kill people (while heart attacks went up, overall deaths did not, compared to other NSAIDS). Meanwhile it is actually a pretty effective painkiller with reduced intestinal adverse effects. Natalizumab, an effective treatment for MS, has caused 31 cases of progressive multifocal leukoencephalopathy with three deaths – but despite this low level of adverse effects, it was pulled for several years.

      Do you think that Vioxx should be returned to the market? Or that natalizumab should be pulled?

      Meanwhile, SMT has relatively few proven benefits, certainly nothing solid, and pretty good evidence of causing strokes. Do you have a double-standard?

  4. weing says:

    “Making a big deal about almost nothing just because you hate chiropractic”
    That wasn’t the point of the article. Please read it. And VAD is not almost nothing.

  5. whoa says:

    There is no evidence that it causes stroke. Some associations.

    You would never see Novella making a big deal about the risks of mainstream treatments, which are often extremely dangerous and harmful.

    The evidence for this is weak and unscientific. And even if there were good evidience (which there isn’t), the risk of stroke would still be extremely small.

    1. Harriet Hall says:

      Novella would make a very big deal about any mainstream treatment that was harmful and had no proven benefit!

    2. R Miller says:

      “There is no evidence that it causes stroke. Some associations.”

      There’s also no direct caustive evidence that smoking causes lung cancer, only associations.

      “You would never see Novella making a big deal about the risks of mainstream treatments, which are often extremely dangerous and harmful.”

      Well, that’s the thing. In neurology the risks are established and openly discussed both in the professoin and with patients. Dr. Novella doesn’t really need to discuss them here because they aren’t controversial in their existence. However, in this case, you have a profession completely denying the existence of a risk at all. The two situations are not the same.

      “The evidence for this is weak and unscientific. And even if there were good evidience (which there isn’t), the risk of stroke would still be extremely small.”

      Take the time to actually explain why. How is the study unscientific? If you consider the evidence of harm weak, then what does that say about the evidence for benefit which is even has even weaker evidence? If there is no benefit, then a non-zero harm (no matter how small) is unacceptable.

    3. WilliamLawrenceUtridge says:

      There is no evidence that it causes stroke. Some associations.

      Lung cancer is only associated with smoking. I hear it’s fun, and apparently harmless. You should try it.

      You would never see Novella making a big deal about the risks of mainstream treatments, which are often extremely dangerous and harmful.

      So what? So chiropractic only has to be intellectually honest about the risks it presents when real medicine has none? Is that your approach to accounting as well, banks should only have to be honest to their customers when hedge funds are properly regulated? Plumbers only have to charge a fair fee for their services when mechanics do?

      The evidence for this is weak and unscientific. And even if there were good evidience (which there isn’t), the risk of stroke would still be extremely small.

      The evidence is imperfect and tentative, but it is also coherent. But the greatest issue is that chiropractors haven’t done enough research, despite more than a century of practice, to compare their interventions to things like usual care, placebo, massage, NSAIDs, rest or really any other intervention. Simply put – chiropractors don’t know if rapidly rotating a head to an extreme of its range of motion is better at resolving pain than simply doing nothing. Don’t you think there is something wrong about that?

      1. whoa says:

        If you mean they haven’t done lots of big expensive placebo-controlled double-blind experiments, maybe they haven’t. That doesn’t mean they have no evidence.

        1. R Miller says:

          It would help your posistion if you were consistent. You stated above that associations cannot be used to establish evidence for risks. Now you state that some evidence of benefit by observational (i.e., assessment of association) studies is satisfactory. Which is it?

        2. Andrey Pavlov says:

          Boring repetitive troll is boring and repetitive. And amazingly dense, considering how many times we here have pointed out that basically the entire raison d’etre of SBM vs EBM is to say that there is too much emphasis on RCTs and too little on basic sciences and other forms of evidence.

        3. WilliamLawrenceUtridge says:

          If you mean they haven’t done lots of big expensive placebo-controlled double-blind experiments, maybe they haven’t. That doesn’t mean they have no evidence.

          One doesn’t need a lot of money to conduct a randomized, placebo-controlled trial of whether cervical manipulation is superior to stretching, or gentle massage, or doing nothing. So even if one doesn’t have the money to enroll tens of thousands of patients to determine if there is genuinely an increased risk of CAD, one could at least conduct a couple of trials to see which treatments work for neck pain, which work best, and from there pick the one with the greatest effectiveness and the least even theoretical risks.

          But chiropractors haven’t done this.

          And they bash drug companies for being greedy and dishonest…

    4. Thor says:

      All I can say is “whoa”, ie. hold your horses. What’s your vested interest in promoting chiropractic? Wouldn’t you want to base your beliefs on as many real things and as few false things as possible? What ulterior motive could you have, except that questioning this would potentially open the flood gates to any number of beliefs that could use reexamining.

      1. whoa says:

        I know that the theory of chiropractic is similar to the theory of yoga. I know that yoga is valid and I know that it works because of decades of daily experience. I don’t need a big double-blind placebo controlled experiment to convince me.

        I realize that you “skeptics” don’t believe your own experiences, thoughts or perceptions, unless they are verified by Big Science.

        However, I am not a worshiper of authority, and I do trust my own experiences.

        I know that my own perceptions are not infallible, so I always check and verify, and compare my experiences to other people’s experiences. We seldom arrive at absolute answers, but we can be pretty darn sure of some things.

        It is ironic that you label yourselves skeptics and independent thinkers, when actually you are just as authoritarian and cult-like as fundamentalist religious believers. They have absolute faith in the bible, while you have absolute faith in the mainstream scientific authorities.

        1. JD says:

          I realize that you “skeptics” don’t believe your own experiences, thoughts or perceptions, unless they are verified by Big Science.

          I must have missed the swing beyond “Big Agro” and “Big Pharma” to the ever so broad “Big Science.” I am left wondering what constitutes “Little Science.” Maybe the Health Ranger’s “Lab” or some guy doing PCR in his basement? That’s a useful comment, I am enlightened.

          It is ironic that you label yourselves skeptics and independent thinkers, when actually you are just as authoritarian and cult-like as fundamentalist religious believers. They have absolute faith in the bible, while you have absolute faith in the mainstream scientific authorities.

          So, the individual defending chiropractic is claiming that striving for treatments with well-defined risks and benefits which are supported by sound research constitutes a “true believer.” You’re hypocrisy is truly laughable.

          It seems that you’re vendetta against all things science is calling for our return as a society to a period when blood-letting was viewed as a reasonable treatment modality. Maybe that can be the next claim, chiropractic (or whatever form of woo you choose to defend) treats the “bad humors.” This is likely more reasonable than whatever nonsense biological rationale is currently offered.

        2. Sawyer says:

          I realize that you “skeptics” don’t believe your own experiences, thoughts or perceptions, unless they are verified by Big Science

          Contrary to what you may have learned, putting the word “Big” in front of an idea, industry, or institution doesn’t constitute an actual argument. It may work on Youtube comments but it doesn’t work here. Of course you’ve never had a productive discussion with anyone here, so I encourage you to keep using this tactic.

          Scientists and philosophers have been working hard for about 400 years to integrate personal experiences and thoughts into well-controlled, objective experiments. This is literally the driving force to modern science and everything we understand about the universe. The fact that you don’t think skeptics are able to combine personal experience with carefully designed trials is a sign of your own arrogance and ignorance, not ours.

        3. Frederick says:

          Yoga is exercise, that’s good Science, exercise has being demonstrate as good for a long time now, good SBM doctors will advise you to do exercise , There’s nothing “alternative” in yoga, except when they fall in the spiritual guru stuff, But you can just ignore it. Also Stretching is good for you, ( of course to the limit, you can to go far with any movement and hurt yourself). Whatever some alternate medicine hypothesis is believed to as why yoga is good, it is probably not the real “why”. Dancing is also good for you, it is exercise too, nobody is calming that dancing is a alternative medicine. And since the theory of Chiropractic has being demonstrated false many times over, and that the guy who invented it, pull it out of his butt, never really tested it, there’s no reason now, with Fmri, cat scan and x-rays, to keep believing it. Be hey, suited yourself, live in you fantasy world, but don’t try to make us buy that they have good “evidence”, because they don’t.

        4. weing says:

          “They have absolute faith in the bible, while you have absolute faith in the mainstream scientific authorities.”

          No. It’s faith in the scientific method.

          1. whoa says:

            I have faith in the scientific method. But I don’t have to wait until my informal experiments are verified by big expensive double-blind placebo-controled studies. If I did, I would probably have to wait forever.

            For one thing, it’s easy to control with placebos when the treatment is a pill, difficult or impossible for many other treatments.

            For another thing, some authority somewhere has to decide what gets funding. The authorities are human beings and therefore just as likely as anyone to be biased.

            And furthermore, even in an ideal system (which our scientific estatblishment most certainly is not), time and money are limited. If I want to know if yoga is better for health than dancing, for example, I might have to wait decades for a formal study. It is easier and quicker to find out for myself.

            1. KayMarie says:

              Sigh, no one says you can’t do anything at all until a RCT proves it.

              If your n of one shows it works for you and there is no evidence it is harming you (with all placebo caveats in place and you aren’t spending money you don’t have on it or avoiding your MD and all other treatments to keep doing your n of one) then do it.

              The point of all the RCT is you cannot generalize from an n of one to the whole population, or usually even determine mechanism of action or much of anything else that most people try to extrapolate from their personal experience.

              Even with RCT you will still have to do the n of one to see if yoga is better than dancing for you because population statistics mean nothing at the level of the individual. If yoga is 95% better that doesn’t mean for each individual it is 95% better. It is better for 95 out of 100 people. If you are one of the 5 that dancing is better for, then dance like nobody’s watching, even if for most of your neighbors they will get 100% of the benefit difference from the yoga.

              1. whoa says:

                You are misinformed about statistics — my informal experiments do NOT have an N of one.

                If I experiment with yoga every day over a period of decades, the N is in the thousands. This is known as a “within-subject” N.

                But yes, yoga might only work for me and not anyone else, based only on my personal experiments. HOWEVER, many people, over thousands of years, have experimented with yoga.

                So I combine my large number of personal experiences with the very large number of other people’s experience, and wind up with an enormous N.

                No, the experiments are not double-blinded or placebo-controlled. Therefore the “skeptics” won’t believe it no matter what.

              2. KayMarie says:

                The plural of anecdote is not data.

                10 million n of one experiments (each day of your life, each person who ever did it) still does not add up to a controlled experiment where we can actually determine mechanisms and causation.

                And again, no one is saying that if it works for you stop it. Just scientifically you need to be careful to distinguish that which you want to believe to be true, from what we have reliable data on.

                Your personal experience is not the same as anthers, even if you can both agree that yoga is good for you and you can both agree some experience from doing it might have a similar interpretation. I mean my red isn’t the same as your red isn’t the same as someone eles’s red. if something that simple cannot be experienced the same exact precise way, why assume something much more complex must be.

                No one is saying you shouldn’t do yoga, no one is saying that many people seem to get some benefit from yoga. Scientifically some of the claimed health benefits seem plausible based on the sorts of things you can falsify. But relaxation, exercise, stretching, etc as best as we can tell work the same way in all people.

                If you like it, and you wanna do it, go for it. Science blesses you my child to do whatever exercise, meditation, stretching, relaxation, works for you.

                But scientifically we don’t prove causation for that which we cannot study scientifically. It is like asking a priest to pray to God to tell me if faction 1, 2, 3, or 4 is going to be the one to light up the cell in a particular assay and trusting it much more than the objective data. Well God told the priest it was 2, so even though 3 changed colors we will ignore that and proceed with fraction 2.

                Do you need science to prove that which it cannot study or know or agree it has to be scientific? I certainly don’t demand the reverse of religious or philosophical beliefs.

              3. KayMarie says:

                ” not the same as anthers”

                anothers, not a plant part.

              4. whoa says:

                KayMarie,

                Maybe someday someone will get funding to compare yoga to other forms of exercise or relaxation. Even then, you can’t be sure based on only one study.

                What our mainstream scientific establishment comes down to is funding. And allocation of funding is determined by many things, including bias and having the right friends. Yes, maybe scientific importance fits in there somehwere, but don’t assume it’s the biggest factor.

                We don’t have to be led like sheep by the mainstream scientific authorities, like so many at this blog seem to be.

                There is value in mainstream scientific research, but it can’t be your only resource. You must have some faith in yourself and in humanity, even though we know our perceptions are never perfect.

                The organized “skeptics” have no faith at all in human experience, unless it is santioned by the big authorities.

                They scornfully dismiss all personal anecdotes — even if the same anecdote is told by millions.

                And they scornfully dismiss all the findings of alternative science.

                Essentially, they scornfully dismiss anything that does not fit their 19th century materialist worldview.

                The scientific method and current mainstream establishment science are NOT the same things. Very far from it. The scientific method doesn’t care about philosophical or ideological biases. It does NOT say that any theory involving life energy must be false, and therefore must not even be tested, for example.

              5. KayMarie says:

                They scornfully dismiss all personal anecdotes — even if the same anecdote is told by millions.

                Well the same can be said from the true believers. How many never get whatever mystical experience you say happens but are discounted. If the magic didn’t work for you than something is wrong with you. It can’t ever be that the magic is just make believe.

                And yes, human beings doing human endeavors have human failings. One of the advantages of the scientific method is that eventually the science changes the establishment.

                And science doesn’t pretend to be able to study that which cannot possibly be measured. We can’t measure your enlightenment, and don’t pretend to.

                Like I said, I won’t ask whatever is running up and down your spine to tell me about my experimental results if you stop asking science to measure that which is not falsifiable or measurable by anything other than whatever interpretation your neurons put on your experience. I’m sure some of those things we will never be able to measure and will always and forever be matters of faith, not data.

              6. weing says:

                “The scientific method ……. does NOT say that any theory involving life energy must be false, and therefore must not even be tested, for example.”
                Of course it doesn’t. Have you never heard of ATP and mitochondria?

              7. Andrey Pavlov says:

                So I combine my large number of personal experiences with the very large number of other people’s experience, and wind up with an enormous N.

                Ah yes, the old statistical mistake that even some legitimate researchers make. Sorry woah, but stats DONT work that way. You CANNOT take a million n=1 trials and make a single trial of n=1,000,000.

                Perhaps this is where you are failing in your understanding of how the scientific method actually works.

                Anyways, point being that you are flat out and 100% wrong in your understanding of stats on this point.

              8. Andrey Pavlov says:

                There is value in mainstream scientific research, but it can’t be your only resource. You must have some faith in yourself and in humanity, even though we know our perceptions are never perfect.

                Bollocks. What “other way of knowing” would you propose? All but scientific inquiry have failed.

                They scornfully dismiss all personal anecdotes — even if the same anecdote is told by millions

                Well, duh! Well, maybe not with scorn because a true skeptic understands why so many people can be deluded and fooled, but we certainly do dismess them.

                Let me ask you woah… do you believe that Satya Sai Baba was a living god among men? Do you believe that he performed actual miracles and real magic? No? Well millions of people swore to the same experience and many have even laid down their lives for it.

                History is rife with examples of mass delusions and gullibility. Science fixes that for us. The only thing you are advocating is decided to buck that when it happens to suit whatever you already are inclined to believe is the case anyways. So you can always win – if the science agrees with you great. If not, then you must “trust humanity.” Except when that humanity happens to believe in something that you disagree with already.

                Are you a Muslim? Why not… billions of people are, and they all swear by the same experiences and truths of it.

                Christian? Same thing.

                Satya Sai Baba acolyte?

                Homeopath?

                The list is endless of all the “trust in humanity” that you lack but choose to ignore because it suits your argument.

              9. WilliamLawrenceUtridge says:

                Whoa, what doctor has ever told you to stop doing yoga? What commentor here has ever told you to stop doing yoga? What exactly are you using your personal observations about yoga to support? In another comment thread you were an asshole for recommending someone with CFS-like symptoms see a chiropractor because you hypothesized it was caused by cervical abnormalities (in the absence of evidence), is that still what you’re going for? Or are you arguing that your interlocutors claim only RCT-based observations can be trusted? Because that’s false too, since many have made the analogy to lung cancer. In fact, you support the link between lung cancer and smoking despite the absence of RCT, right?

                You need to express yourself more clearly.

                And allocation of funding is determined by many things, including bias and having the right friends. Yes, maybe scientific importance fits in there somehwere, but don’t assume it’s the biggest factor.

                Allocation of funding from national granting bodies is primarily determined by anonymized peer review actually, as well as historical performance of the lab and investigators. But subject matter expertise, novelty of the hypothesis and how well the hypothesis takes into account existing knowledge is also a large factor. The fact that most peer reviews take place in a committee rather obviates the decision coming down to who you have a beer with every Friday. In fact, most peer review processes involve delcarations of conflict of interest, which can be based on being part of the same lab, or even significant scientific disagreements.

                I don’t think your assessment of the scientific process is accurate, are you sure you went to grad school?

                There is value in mainstream scientific research, but it can’t be your only resource. You must have some faith in yourself and in humanity, even though we know our perceptions are never perfect.

                Sure…depending on what you are talking about. Picking a car colour, picking a car, deciding what to have for dinner, who you marry, what kind of exercise, when to cross the street, who to vote for, should a country go to war – science isn’t really necessary. Medicine? Science necessary.

                The organized “skeptics” have no faith at all in human experience, unless it is santioned by the big authorities. They scornfully dismiss all personal anecdotes — even if the same anecdote is told by millions. And they scornfully dismiss all the findings of alternative science.

                All scientists and skeptics ask for is an even playing field and decision-making commensurate to the degree to which the claims are resource-intensive and alignment with existing knowledge. Why is it incredible to you that dramatic and expensive claims, or claims involving life and death, have proof before they are simply believed?

                Also, if you’ve got a million anecdotes and three million dead people who can’t give you anecdotes, how do you represent the latter? And again, what are we talking about? Medicine? Whether or not you should do yoga? Precision, please.

                The scientific method and current mainstream establishment science are NOT the same things. Very far from it. The scientific method doesn’t care about philosophical or ideological biases. It does NOT say that any theory involving life energy must be false, and therefore must not even be tested, for example.

                Sure, that’s why epistemology isn’t a field and why epistemology of science gets 56,000 hits on pubmed.

                Do you understand the burden of proof? If you want to claim there is a “vital force” or “life energy”, then figure out some way to determine whether it exists. Because current research indicates that you can basically create any organic molecule. Vital energy doesn’t seem to be necessary. While science can’t (and certainly doesn’t despite your pretending) prove that a vital force doesn’t exist, it can note, quite accurately, that current scientific knowledge hasn’t found it to be necessary. Merely because you personally dislike this application of Occam’s Razor doesn’t mean your alternative is a superior hypothesis. Sounds like sour grapes ’cause you want to believe in God or something.

            2. Windriven says:

              @whoa

              “even if the same anecdote is told by millions.”

              There are roughly 1.6 BILLION Muslims in the world. Should I accept that as proof that “There is one true god and his name is Allah”?

              1. whoa says:

                I would accept it as good evidence that they are experiencing some kind of connection with some kind of higher consciousness.

                I would nto accept the pariculars, involving the human-counted number of gods or their human-given names.

                I’m sure you think only the materialist/atheists know the real ultimate Truth. But many millions of us know otherwise.

              2. Harriet Hall says:

                “I would accept it as good evidence that they are experiencing some kind of connection with some kind of higher consciousness.”

                I would accept it as good evidence that they are experiencing something. I would not accept it as evidence that a higher consciousness exists or that they were connecting to it. My best guess is that they are all succumbing to the very human tendency that Paul Kurtz called the transcendental temptation, and that they are blindly accepting the teachings of their culture and succumbing to peer pressure.

              3. weing says:

                “I would accept it as good evidence that they are experiencing some kind of connection with some kind of higher consciousness.”
                Hmm. I think dualism has been pretty much disproven. But even if we accept it as a fact, doesn’t this seem pretty arrogant? How do you know it’s not a connection with some kind of lower consciousness?

              4. Windriven says:

                @weing

                I used to torment my mother with a variation on that theme, that belief in gods was a slacker’s outsourcing of ethics and moral philosophy.

              5. Windriven says:

                @whoa

                “I would nto (not) accept the pariculars (particulars), involving the human-counted number of gods or their human-given names.

                I see. So you figure Mohammed to have been a liar or a delusional but the general gist is okey-dokey.

                “I’m sure you think only the materialist/atheists know the real ultimate Truth. But many millions of us know otherwise.”

                You don’t know “Truth” from the crust around your anus. Neither do you know me or what I think. I accept almost nothing as true. I accept that I exist as true. Beyond that pretty much everything else falls somewhere on a continuum of likelihood.

              6. Earthman says:

                Actually the god worshipped by Muslims is the same God worshipped by Christians and Jews. They are all rooted in Abraham.

              7. Andrey Pavlov says:

                There are roughly 1.6 BILLION Muslims in the world. Should I accept that as proof that “There is one true god and his name is Allah”?

                Ha! Go figure we’d go for the same example independently… and that it would fall completely flat on these trolls.

              8. Windriven says:

                @Earthman

                “Actually the god worshipped by Muslims is the same God worshipped by Christians and Jews. They are all rooted in Abraham.”

                While they are all Abrahamic religions, I have met a couple of Muslims who would happily slit your throat for suggesting theirs is the same god as that of the Jews

              9. WilliamLawrenceUtridge says:

                I would accept it as good evidence that they are experiencing some kind of connection with some kind of higher consciousness.

                What, in the sense of “some pattern of brain activity that is interpreted as connection to something larger”, or actually “I’m talking to a powerful consciousness that can manipulate reality”? Sure, I’ll believe they are having an experience. That’s unremarkable, and can be induced by both TMS and drugs, even in atheists. The existence of this consciousness? Particularly given the ability to induce the experience artifically? No.

                I’m sure you think only the materialist/atheists know the real ultimate Truth. But many millions of us know otherwise.

                Certainly you claim to know, but what you really mean is that you believe, based on basically the same evidence that Diana Napolis uses to justify her persecution by Steven Spielberg and Jennifer Love Hewitt. If there were proof of a deity beyond the mere word of their believers, then everyone would believe, but there’s not.

                Also, many if not most atheists don’t take the strong stance of “there absolutely is no god”. Most, if pressed and educated, will admit that such a stance is untennable. Most, myself included, will say that there is no proof of such a god, no good reason to believe in such a god, and that the morass of mutually-contradictory religions make claims and take actions grossly out of step with the actual reasons they have for believing. I would even conclude that emotionally I firmly believe that there is no god, even as I intellectually acknowledge that this statement cannot be true in any absolute sense.

                You should read Guy Harrison’s http://books.google.ca/books/about/50_Reasons_People_Give_for_Believing_in.html?id=hGpiPQAACAAJ&redir_esc=y“>50 Reasons People Give for Believing in a God, it might give you a better sense of the arguments not against god but against believing in a god.

            3. Earthman says:

              “It is easier and quicker to find out for myself.”

              That is the short route to self-delusion. That is why scientists do not do that – it is a known route to fallacy.

            4. Earthman says:

              ‘informal experiment’ is an oxymoron. You do not do experiments, you just play with ideas. Proper science is rigorous, and I am not seeing that you know how it should be done. Try reading some Louis Pasteur – who really knew how to design an experiment.

              You will not believe anything that contradicts that which you already believe in. Challenge that as a statement of truth.

            5. Earthman says:

              Seems not possible to comment further below to your further posts so I will do it here.

              You do not seem to know the difference between N and n. Fall flat on your face at the first hurdle. And you think you can design experiments? Sorry if this seems like an ad hominem attack, it is not intended to be in any way. Just exasperated that you criticise in the absence of knowledge.

            6. whoa says:

              “My best guess is that they are all succumbing to the very human tendency that Paul Kurtz called the transcendental temptation, and that they are blindly accepting the teachings of their culture and succumbing to peer pressure.”

              Yes of course Harriet, because YOU know the ultimate truth that there can be no higher levels of consciousness. Most of the world is stupid, except for you enlightened truth-owning atheists. YOU are smart, the rest of us are delusional idiots.

              YOU and your fellow atheists hold the beacon of true and eternal knowledge and wisdom, and it is your mission to save the world from the ignorance of mystical experiences and faith.

              Oh what a horrible world this would be if not for you all-knowing, all-seeing materialists. Yes, you are completely right about everything and there is no reason for you to doubt your infinite wisdom.

              Human nature is dumb as a rock, in desperate need of your benevolent guidance.

              1. Harriet Hall says:

                YOU don’t know how to read. I offered my “best guess.” Please look “guess” up in the dictionary. I do not claim to know the ultimate truth and I will gladly accept that there are higher levels of consciousness when I see some evidence. I don’t have the hubris that you have, that allows you to think you can know the truth without evidence.

              2. R. Miller says:

                I don’t think you’ve ever responded to Dr. Hall with any ounce of honesty in understanding her position. At some point, it stops being a simple misunderstand and becomes blatantly lying.

                Your double standard, which not-so-subtlety creeps into all your posts, is most obviously exposed here. So your personal experience with life is good enough to decide what is true, science be damned – but if someone else does the same thing and comes to a different conclusion, they must be wrong? Many of the comments on this blog are from health professionals, but many are from people who have been hurt by alternative medicine – why do their experiences not count?

              3. KayMarie says:

                Yes of course Harriet, because YOU know the ultimate truth that there can be no higher levels of consciousness. Most of the world is stupid, except for you enlightened truth-owning atheists. YOU are smart, the rest of us are delusional idiots.

                So much for my belief that enlightened people are able to see what is really there rather than the rantings going on inside their monkey minds.

                Thanks for that, I think?

                YOU and your fellow atheists hold the beacon of true and eternal knowledge and wisdom, and it is your mission to save the world from the ignorance of mystical experiences and faith.

                Mystical experiences seem part and parcel of the human experience. I just don’t claim to know the unknowable from mine or claim they come from the supernatural. Or even worse, claim my supernatural must be better than anyone else’s supernatural because all my friends who go to the same building say it must be so. The more I talk to people the more convinced I am of many paths leading to the same place, and they are far more alike they they are different and no single one has all the capital T Truth.

                I’m open to the idea that mystical experiences are merely a biological output, a very interesting one, but may be nothing more than which neurons fire together in what pattern.

                Oh what a horrible world this would be if not for you all-knowing, all-seeing materialists. Yes, you are completely right about everything and there is no reason for you to doubt your infinite wisdom.

                The more I do science the more I doubt the wisdom and trust the independently verifiable objective data.

                Human nature is dumb as a rock, in desperate need of your benevolent guidance.

                Honestly whoa, the only one I see that appears, in my interpretation, to be acting from a place of others need to follow me and worship my Truth and do as I say without question is you.

                Giving into the temptation to end with the quip, “projection much” at the risk of having it thrown back in my face.

              4. Sawyer says:

                Whoa every other comment you post reads like it was intentionally crafted to piss off every single person involved in the discussion. None of your descriptions of Dr. Hall’s worldview, or my worldview, or anyone else’s here has any semblance in reality.

                Has this discussion tactic ever worked for you on this website? Has it worked for you on any website? Has it ever worked when talking about science and medicine to anyone, anywhere, ever?

              5. WilliamLawrenceUtridge says:

                Yes of course Harriet, because YOU know the ultimate truth that there can be no higher levels of consciousness. Most of the world is stupid, except for you enlightened truth-owning atheists. YOU are smart, the rest of us are delusional idiots.

                While it is possible that there could be higher levels of consciousness, there is absolutely no proof of it. You’re basically saying “even though we can explain in broad strokes how the universe, the planet, life and the species found therein came to exist, and how humans can experience a feeling they label ‘god’, really those levels actually exist despite the lack of any evidence.”

                I don’t think I’m smarter than everyone else (some people, sure, but not everyone). But I did have a formative moment when I asked the question “what happens if I remove the concept of god and devil from my view of the world” and reached a profound realization that nothing changed about the world except my interpretation of it. I doubt most religious people have really thought about and tried to remove “god” from their mental space. I doubt most can even do so.

                We both see the same evidence and interpret it differently. The difference being, you are the one making the claim for existence of an unnecessary being and consciousness. I’m not. There is no way to absolutely resolve this issue, but at least I’m not asking you to get up on Sundays, give your money away or regulate your personal life.

                YOU and your fellow atheists hold the beacon of true and eternal knowledge and wisdom, and it is your mission to save the world from the ignorance of mystical experiences and faith.

                Oh what a horrible world this would be if not for you all-knowing, all-seeing materialists. Yes, you are completely right about everything and there is no reason for you to doubt your infinite wisdom.

                Heh, and the religious say atheists are fervent, unpleasant and irrational.

                Straw man – most of sketpicism, of which atheism is a part, starts from the belief that humans are easily led in the wrong direction. It’s actually the opposite of the belief that we are, or that there even is some sort of beacon of ture and eternal knowledge. It’s the somewhat depressing recognition that humans are profoundly fallible and notoriously reluctant to admit their error. For instance, I doubt you will ever acknowledge that you are misrepresenting what atheists believe.

                Human nature is dumb as a rock, in desperate need of your benevolent guidance

                This conversation would go a lot better if you spent less time fistfucking your opinions about what I believe into my mouth.

                Also, even on a purely logical basis your statement doesn’t hold, since the skeptical postion believes that some measure of accuracy and trust can be found in science, which is itself a part of human nature (the desire for accurate information and honest dealing).

            7. whoa says:

              [“I would accept it as good evidence that they are experiencing some kind of connection with some kind of higher consciousness.”
              Hmm. I think dualism has been pretty much disproven. But even if we accept it as a fact, doesn’t this seem pretty arrogant? How do you know it’s not a connection with some kind of lower consciousness?]

              (It would be advisable to get blog software that can deal with recursion. Oh well, materialists … can’t expect them to be logical).

              weing: There has not been any scientific proof one way or another about dualism. But I am not talking about dualism anyway. I am thinking of higher dimensional levels, as described by physics, and alternate universes, or planes of existence, as described by physics.

              The trouble with you biology majors is you never learned anything about 20th century physics.

              1. AdamG says:

                “The first principle is that you must not fool yourself — and you are the easiest person to fool.”
                – Feynman

              2. weing says:

                “The trouble with you biology majors is you never learned anything about 20th century physics.”
                Now you have a doctorate in physics? I only had 2 semesters of physics back in 1970 and a few years of chemistry. I’ve studied enough quantum mechanics through the Teaching Company to know that I don’t understand it. I’ve never heard of any higher planes of existence such as you are talking about described in physics.

              3. n brownlee says:

                The physics of the Marvel Universe.

              4. Andrey Pavlov says:

                You are a blithering idiot woah.

                Dualism is handily disproven.

                Gods are a delusion created by man.

                Gods didn’t get us to the moon. They didn’t quash infectious diseases. They didn’t tell us about quantum mechanics. They didn’t get a probe to rendezvous with an asteroid.

                And you sure as shit don’t know anything about biology or physics.

              5. Sawyer says:

                The trouble with you biology majors is you never learned anything about 20th century physics

                The trouble with trying to pigeonhole an open community like this one is that there are hundreds of us around that have backgrounds in physics, mathematics, or engineering. I’ve never heard a competent physicist rave about how m-theory confirms higher states of consciousness, because they have just as much disdain for pseudoscience as biologists.

                Oh I forgot, I’m excluded from this conversation because I was educated by a “Big Science” university. Clearly we were wasting our time learning about the discoveries of Maxwell, Bohr, and Boltzmann. I must have been brainwashed, and missed out on all the REAL 19th century physics.

              6. MadisonMD says:

                The trouble with you biology majors is you never learned anything about 20th century physics.

                I majored in mathematical physics. “Alternate universes” is a theoretical construct that provides a way to conceive quantum physics in a manner distinct from the Copenhagen interpretation. The theoretical construct is not, in any practical manner “described by physics.” Other universes, while thought provoking, can not be claimed to be any more real than is, say, Schrodinger’s cat. So you are still wrong.

                Scientifically, I think materialism explains natural phenomena quite well. Of course there are areas that remain to be elucidated–namely neuroscience. Economic materialism, on the other hand, is a human ill that can be quelled by multiple means including by religious belief. For the record, I am not an atheist either.

              7. WilliamLawrenceUtridge says:

                weing: There has not been any scientific proof one way or another about dualism. But I am not talking about dualism anyway. I am thinking of higher dimensional levels, as described by physics, and alternate universes, or planes of existence, as described by physics.

                What aspect of quantum physics and hypotheses about a multidimensional universe do you see applying specifically to the issue of consciousnesses that are capable of existing outside of but influencing our dimension, and why do you think that such a consciousness would give a crap about the specific primates on this planet out of billions? And why would the consciousness be able to exert an influence solely on the human brain but nothing else? Merely because other dimensions than our own might exist doesn’t mean that they do (even within physics this idea is far from taken for granted), and the mere existence of other dimensions is merely the first link in a long chain of questions and hypotheses that would ultimately lead to a personal deity. Let me lay them out for you:

                1) There exist multiple dimensions
                2) These dimensions can interact with our own
                3) These dimensions support consciousness
                4) This consciousness(es) is advanced enough to be able to reason
                5) It’s reasoning powers are sufficient to be able to understand human interactions
                6) It is itself capable of perceiving our dimension
                7) It is itself capable of influencing our dimension
                8 ) It cares enough to attempt to influence our dimension
                9) Of the entire universe, it has decided to focus attention on our planet

                OK, great, assuming all of those unproven assumptions are true that’ll get to the point where a consciousness could be “god” here on Earth. Now, assuming you are talking about say, the Christian god, we now have:

                10) It is either incapable of or unwilling to exert any direct influence anywhere except in the Middle East; all other actions must be taken on its behalf by humans who already believe in it
                11) It is either incapable of or unwilling to exert any direct influence at any time in human history except between 3000BC and 30 AD (approximately)
                12) It has strong opinions about human relationships, particularly relations between strictly-categorized genders (but does not acknowledge the existence of those with ambiguous genders) and really cares who we have sex with
                13) It changes its mind (or another entity takes its place, somewhere between 500 BC and 0 AD
                14) It is unable to influence beyond, or restricts its activities solely to those that can be ambiguously interpreted or lack objective prove that can be independently verified
                15) It acts in extremely limited ways to isolated events, bar the occasional dramatic flourish where it ressurects someone from the dead
                16) Rather than exerting a direct influence on all humans either constantly or regularly, it relies on forms of communication available to every single other possible entity, or even merely those humans who wish to portray such an entity (books and spoken word) whose contents are not preserved in a fixed fashion but exhibit changes and drifts depending on who writes them down or memorizes them
                17) The entity wants attention or worship, but doesn’t need it to survive

                Am I missing some? I’m sure I am. The entity I have hypothesized, based on your claims and my knowledge of Christianity, doesn’t sound like something I would want in charge of my life. Doesn’t sound particularly worthy of worship either.

                So if you’re seriously using theories of multidimensionality of modern physics to demonstrate or even support the existence of god, you’ve now got at least nine specific hypotheses to test and prove. 17 if you want Jebus to be in the picture.

                Don’t wave around the theories of physics as if it justified your religious faith. People who do so are contemptible. I’ll respect you more (measured in mustard seeds) if you just admit that your faith is an irrational prejudice and don’t try to justify it by reference to external proof.

            8. whoa says:

              “I will gladly accept that there are higher levels of consciousness when I see some evidence.”

              Ok Harriet, then you can’t really look down on those of us who see that evidence all the time.

              Some do, others don’t. Some people can see colors, others can’t. Some people have a sense of music, others are tone deaf. Some people experience connection with higher levels of consciousness, others don’t.

              One thing is certain — as long as you have a negative attitude about spirituality you will never experience it.

              I actually think spiritual and non-spiritual people should just agree to disagree and leave each other alone. If you don’t like the idea of gods or spirits, fine, people like different things.

              It does bother me when you assume we are ignorant or delusional because we are spiritual. We can see or sense that there is infinitely more behind the scenes. That does not come from ignorance or delusion, or wishful thinking, or peer pressure. We are born that way.

              1. WilliamLawrenceUtridge says:

                Some do, others don’t. Some people can see colors, others can’t. Some people have a sense of music, others are tone deaf. Some people experience connection with higher levels of consciousness, others don’t.

                False comparison, through the use of techonlogy we can independently verify that different colours represent different aspects of the electromagnetic spectrum. It is extremely easy, trivial even, to get the vast majority of people to agree that blue is blue, even if we don’t know if your blue is my red – blue itself can be poven to exist. The same argument can be made of sound, be it infrasonic or suprasonic, or even by a deaf person using a microphone and display screen. Music (or at least the sounds that can be labelled as “music”, I’m listening to Skrillex right now and am questioning if it is actually music) can be independently verified.

                As for your final point – a similar conclusion can be reached. We can all agree that experiences of such a consciousness can exist. What that means is what we are arguing about. You say it proves that Jebus is real, I say it proves that a specific pattern of neural activity is present. I can at least independently verify that the pattern of activity is occurring. You can’t do the same.

                One thing is certain — as long as you have a negative attitude about spirituality you will never experience it.

                Hah, define spirituality. I can enjoy my friends, my family, sex, food, music, the beauty of the world and even religious paintings (I’m a big Caravaggio fan). I’ve had experiences you could define as “spiritual” (unexpectedly and irrationally enjoyable moments). I’ve connected to things larger than me (the skeptical movement, the universe as a whole) in ways that could be seen as “spiritual”. And again, your mere experience only proves that you had that experience – not that your experience validates the existence of anything beyond itself. Like Descartes, all you can prove is existence, you can’t move beyond that point.

                It does bother me when you assume we are ignorant or delusional because we are spiritual.

                I don’t think you are ignorant or delusional, I think you are arrogant in assuming your experience and reasoning are more valid than anyone else’s and that you can ignore the evidence because of them. Your spirituality is irrelevant, it’s your arguments that are terrible (and often fallacious, you are particularly fond of straw men, making statements about other people’s beliefs that are obviously inaccurate).

                We can see or sense that there is infinitely more behind the scenes. That does not come from ignorance or delusion, or wishful thinking, or peer pressure. We are born that way.

                You may be able to sense such things – but how do you know you are accurately perceiving the world? How do you know it’s not internal electrical activity to the brain? How do you know it has implications beyond the edge of your skin? It’s not ignorance or delusion that is the source of our disagreement – it’s interpretation. From sensations that we have all had (who hasn’t had the feeling of someone standing next to them, only to find it wasn’t true?) you posit the existence of an entire world of hypothetical entities. Specific ones too, linked to the beliefs of a group of bronze age, geographically limited sheep herders.

                I completely agree that we are “born this way”, but by “this way” we mean different things. You mean, I presume, “born capable of believing in a god that exists”. I mean “capable of fooling ourselves into beliefs that have no proof behind them.

              2. Sean Duggan says:

                @WLU:
                Interestingly enough, we’ve managed to scientifically prove that the color of “magenta” doesn’t exist. Instead, it’s the result of a short-circuit in the brain.

              3. whoa says:

                “From sensations that we have all had you posit the existence of an entire world of hypothetical entities. Specific ones too, linked to the beliefs of a group of bronze age, geographically limited sheep herders.”

                Well that shows how extremely ignorant you are. I was talking about spirituality, and you assume I was talking about the mythology of a particular culture. As if only one religion has ever existed on earth.

              4. AdamG says:

                I was talking about spirituality, and you assume I was talking about the mythology of a particular culture.

                lol way to completely dodge basically every point raised by WLU. Gotten around to defining “spirituality” yet? As a PhD in Cognitive Psychology you should know the importance of clearly defining your terms…

              5. Windriven says:

                @whoa

                “I was talking about spirituality, and you assume I was talking about the mythology”

                Are you arguing that spirits are not mythological, that they are actual? Specifically which spirit(s) are you talking about spirituality-wise?

              6. Andrey Pavlov says:

                As if only one religion has ever existed on earth.

                The fact that so many exist prove that all of them are BS. Unless you are whoa in which case it proves… whatever the hell he wants it to prove.

              7. WilliamLawrenceUtridge says:

                Well that shows how extremely ignorant you are. I was talking about spirituality, and you assume I was talking about the mythology of a particular culture. As if only one religion has ever existed on earth.

                Fine, specific which religion you think is right and I’ll adjust my statements. For now it applies only to Christianity, do you note any error in my reasoning vis-a-vis Christianity?

                Also, you make this point as if it somehow validated your arguments about spirituality being anything but a neurological hiccup, when it does quite the opposite. Unless you are saying “spirituality is just a neural hiccup that has no implications beyond human consciousness”. Which basically is the same as saying all religions are nonsense.

                Is that what you’re saying?

                But please, go back to trying to use science to prove that religion, any of them, is true. I’m waiting, and I’ll do a bit of research to address the specific one that you think is right. Maybe start a new comments thread at the bottom of the page, don’t worry – I’ll see it.

            9. WilliamLawrenceUtridge says:

              I have faith in the scientific method. But I don’t have to wait until my informal experiments are verified by big expensive double-blind placebo-controled studies.

              Fortunately for yoga, you don’t have to. We already know gentle exercise is good for you, irrespective the form.

              For one thing, it’s easy to control with placebos when the treatment is a pill, difficult or impossible for many other treatments.

              True, sometimes you have to get creative. Other times, you just have to compare it to no treatment. Or in the case of yoga, something similarly gentle like pilates, or nonspecific stretching, even just walking.

              For another thing, some authority somewhere has to decide what gets funding. The authorities are human beings and therefore just as likely as anyone to be biased

              There are over 2,700 results for “yoga” on pubmed. And further – funding by the NIH or other funding bodies (in fact – most funding bodies) is done by peer review committee, not “some guy with authority”. And what bias, exactly, is being expressed here? I don’t think anyone here is claiming yoga is bad for you (cervical manipulation, a bit more so).

              And all you’re really doing is saying “anyone who disagrees with me is biased”. Which is horribly lazy on your part.

              And furthermore, even in an ideal system (which our scientific estatblishment most certainly is not), time and money are limited.

              No duh, that’s why peer review committees are used to allocate grant funding.

              If I want to know if yoga is better for health than dancing, for example, I might have to wait decades for a formal study. It is easier and quicker to find out for myself.

              Why do you need to know if yoga is better than dancing? It’s the rare doctor who would discourage you from doing either, and I think most here would say whatever you can do regularly over the long term is fine.

              I’m not even sure what windmill you are tilting at – that doctors discourage exercise? That doctors discourage yoga? Don’t comment while angry or drunk or angry because you are drunk?

        5. Thor says:

          Exactly as I thought. Thanks for answering my questions.

          I’ve been doing yoga since I was 15 (see Frederick’s comment).
          I’ve seen chiropractic close and upfront throughout my career.
          I speak with experience. That’ not a good analogy.

          You don’t know me – I don’t worship authority.

          Your last paragraph is laughable in its misrepresentation (talk about a false comparison).

        6. WilliamLawrenceUtridge says:

          Yoga is also replete with nonsense and not actually as safe as it is sold as being.

          How do you know your decades of daily experience are not systematically distorting your conclusions? By doing yoga you aren’t doing tai chi, or even just daily walking. How do you know walking isn’t better for you, with less risk of avulsed bone or damaged hips from moving the joint past a safe range of motion?

          I realize that you “skeptics” don’t believe your own experiences, thoughts or perceptions, unless they are verified by Big Science.

          Meanwhile you are credulous enough to believe that your beliefs have some sort of inherent, unquestionable accuracy. The history of human thought and indeed science itself demonstrates that humans aren’t particularly good at reasoning to appreciate empirical truths beyond those that are immediate, replicable, and limited in size to something within an order of magnitude of their own body.

          I know that my own perceptions are not infallible, so I always check and verify, and compare my experiences to other people’s experiences.

          See, that’s funny, because you went on a long rant on another thread about how reliable your experiences are and how cognitive fallacies aren’t actually a thing, based on your experience as a graduate student in psychology. Further, if you associate only with a certain type of person with comparable experiences, if you discount and ignore the experiences of people who disagree with you (which you appear to do), then all you’re doing is ensuring a biased sample of other people’s experiences, almost custom-designed to confirm your existing prejudices.

          We seldom arrive at absolute answers, but we can be pretty darn sure of some things

          The things we can be “pretty darn sure of” are quite limited. Causal relationships linked closely in time and distance. Objects scaled roughly between a grain of sand and a building. Distances from about one milimeter to one kilometer. The history of human knowledge before the advent of careful empirical testing was one of erroneous conclusions based on flawed reasoning and unfounded assumptions that rested unchallenged for thousands of years. Even the things you would think we would be good at – human relationships – aren’t particularly trustworthy, as witnessed by the discovery of unexpected paternity, historical betrayals, paranoia and conspiracy. I’m reading a lot on the Roman emperors and it’s a sad litany of actual betrayal, false betrayal, imputed betrayal that never happened and persecution of former friends. In the absence of some sort of oversight and systematic inquiry, humans aren’t much good at anything beyond surviving immediate dangers that are readily visible to themselves.

          It is ironic that you label yourselves skeptics and independent thinkers, when actually you are just as authoritarian and cult-like as fundamentalist religious believers. They have absolute faith in the bible, while you have absolute faith in the mainstream scientific authorities.

          What is ironic is that you make this claim because we don’t believe your pronouncements ex cathedra. My recall is that your posts tend to be long on pronouncements and short on references – going even further as to insist that the scientific literature was wrong based on your experiences and thus could be ignored when inconvenient to you.

        7. simba says:

          The bottom line is that Whoa’s personal experiences invalidate the personal experiences of all others because he or she is a special snowflake.

          So science is wrong if and when it contradicts Whoa’s personal experiences. Other people’s personal experiences make them nasty little skeptics who aren’t open minded, so long as they contradict Whoa’s personal experiences- if they confirm them then they’re the proof of their truth. If Whoa hasn’t had psychogenic pain or illness, then no-one could have, and those people who think they are in serious pain really are just neurotic and need a hobby.

          It’s basically just your bog standard narcissistic dismissal of others and of anything that contradicts Whoa’s world view. It also explains why Whoa consistently mischaracterizes other people’s positions- they seem to be literally incapable of understanding any position that is not their own, or of comprehending disagreement.

          But no, because we have the ability to see nuance (i.e. something more complicated than ‘neurotics vs REAL physical illness’, ‘yoga is magikul and better than any other exercise because of LIFE ENERGY because I say so’), and understand viewpoints that aren’t Whoa’s, we are the closed-minded skeptics.

          I don’t understand why I don’t get to claim that walking the dog is a very special form of exercise that cures ailments and that invokes a special healing energy. After all, I’ve experienced transcendental calmness while doing that for years, as well as occasionally getting in primal scream therapy (“don’t you dare roll in that!”). It certainly helped me more than yoga- does that mean I get to claim it’s definitely better than yoga because of my thousands of n=1 personal experiences?

          1. n brownlee says:

            Most excellent comment, Simba. Truth, wit, and grace.

          2. Thor says:

            Ditto n brownlee! More please from you, simba.

          3. WilliamLawrenceUtridge says:

            Currently mashing imaginary like button.

  6. M. Driscoll says:

    However, in this case, you have a profession completely denying the existence of any risk at all”

    This is the furthest thing from the truth as every licensed chiropractor has every new patient sign an informed consent. This informed consent sheet is required by law to include the possible risks of CMT, of which, stroke is mentioned. Not only that, we are required by law to offer the patient 3 alternative options to treatment if they’re not comfortable with or do not want to continue the procedure.
    If you’re scared of having your neck ADJUSTED by a trained, competent, licensed chiropractic physician I feel sorry for you. There are a myriad of different ways to ADJUST the neck (and every other joint in the body) that are extremely low-force, involve no twisting, bending, or torquing of the individual, and result in no “pop” or “snap” cavitation. Educate yourself about a profession before you try to demonize it, I thought the “witch hunt” days of the AMA after the chiropractic profession were over.

    Where are all the testimonials of real-life patients who have received life-changing results from CMT? If you’re proposing that you offer a middle -of-the-road unbiased opinion and want only scientific facts to rule the day, surely you should include some of these results.

    The fact of the matter is the chiropractic profession would love to work hand in hand with the medical profession and work together to achieve the best patient results possible, but we really don’t care if you simply can’t advise that anyone be treated with CMT because the people will continue to seek us out anyways as they have for over a century (in the US) even when we were being thrown in jail for practicing medicine without a license.
    Because chiropractic removes interference and allows the body to heal itself

    1. Harriet Hall says:

      “Where are all the testimonials of real-life patients who have received life-changing results from CMT?”

      I don’t know. Anyway, testimonials aren’t worth much, since they can be found for every quack treatment and snake oil. Where are all the scientific studies showing that patients have had life-changing results from CMT? Why do studies show it is ineffective?

      “chiropractic removes interference”

      Where is the evidence that this is true? What interference?

    2. R Miller says:

      “Where are all the testimonials of real-life patients who have received life-changing results from CMT? If you’re proposing that you offer a middle -of-the-road unbiased opinion and want only scientific facts to rule the day, surely you should include some of these results. ”

      This is a discussion of the evidence. Testimonials are not evidence.

      “Because chiropractic removes interference and allows the body to heal itself”

      Please provide evidence for this statement.

    3. Thor says:

      Though not a chiropractor, I’ve had an inside view of it for over a quarter century. I’m not on a witch-hunt trying to “demonize” the profession, just assessing as honestly and realistically as possible, ie. basing my view on an ever-expanding body of evidence-based information. You may have waaay too much invested in chiropractic (time, money, belief, perhaps career) that it is simply asking too much of yourself to reflect objectively. This is completely understandable, but I say go for the challenge.

    4. R Miller says:

      “This is the furthest thing from the truth as every licensed chiropractor has every new patient sign an informed consent. This informed consent sheet is required by law to include the possible risks of CMT, of which, stroke is mentioned. Not only that, we are required by law to offer the patient 3 alternative options to treatment if they’re not comfortable with or do not want to continue the procedure.”

      First, I suspect you are confusing what may be your state law or a board-related request with a national law. You used the qualifer “every”, I am interested how you are confident that your statement truly applies to every chiropractor. Is there a national law or regulation you can show me? To my knowledge, these informed consent laws pop-up state to state, and are often viciously attacked by chiropractic professional organiation.

      Second, this study from 2007 suggests that informed consent is not satisfactory in explaining the risks to patients on chiropractic practices:

      http://www.ncbi.nlm.nih.gov/pubmed/?term=17693332

      It is from 2007, so you are welcome to provided updates (with evidence, please!) that things have changed in the past years. However, I’m inclinded to agree with study because informed consents don’t work that well in medicine either – it’s kind of like me trying to say that I don’t need to counsel to a patient on medication because it’s in the tiny print somewhere with their prescription. They are largely there to help with legal issues. It remains the responsbility of the health care provider to actually go over the benefits of treatment, risks of treatment, and risks of non-treatment with patients.

    5. tgobbi says:

      M. Driscoll: “The fact of the matter is the chiropractic profession would love to work hand in hand with the medical profession and work together to achieve the best patient results possible…”

      That’s a risible comment, M. Driscoll, for numerous reasons. Here’s one: if you really wanted to cooperate with proper doctors you’d stop objecting to vaccinations, which over 50% of you do. And that’s just the tip of the iceberg of flagrant infractions against science and reason that you’re guilty of.

      You don’t want to work with legitimate medical practitioners; you want them to buy into your dealing in mysticism and the occult.

    6. Peter S says:

      “There are a myriad of different ways to ADJUST the neck (and every other joint in the body) that are extremely low-force, involve no twisting, bending, or torquing of the individual, and result in no “pop” or “snap” cavitation.”

      Are you referring to the device called an activator? Is there any actual evidence it does anything, other than the usual placebo oh I feel great testimonials? I must have had ten sessions or more of having my neck “adjusted” with an activator and noticed nothing.

      1. Frederick says:

        This post is going to be totally absurd, But I can’t resist it.

        I like they way his languages sound like he is treating a Cyborgs or a Androids.

        - Hello mister engineer, I’m coming for my monthly maintenance.

        - Good, sit right there Xb-2113. I’ll go get my activator to Adjust your neck joints, They are a little bit off calibration.

        - Affirmative, Also, Mister engineer, my main automated repair system is getting interferences, cutting its efficacy by 35.6 %

        - Huum, Must by coming from you central CPU systems or sensory unit, the EM Shielding must require some reinforcement, reducing the capacity of your body to repair itself. Ok then I’ll check on that too.
        ( sound of tool buzzing, and sparks)

        Yeah Techno babble!

    7. Jann Bellamy says:

      Informed consent is governed by state law and there is no national standard. It would be interesting to see where you got the idea that “3 alternative options to treatment” must be offered. Alternatives to the treatment under consideration would be governed by the patient’s condition and the risks and benefits of each treatment. That calculation would change over time as new evidence of safety and effectiveness as to any particular treatment became available. Your statement makes me think that misinformation about the requirements of informed consent are being disseminated to chiropractors.
      I don’t speak for the medical profession but I think part of the problem with chiropractors “work[ing] hand in hand” with MDs is contained in your last sentence. As long as you espouse the pseudo-scientific notion that “chiropractic removes interference and allows the body to heal itself” working with MDs is a non-starter.

    8. WilliamLawrenceUtridge says:

      Educate yourself about a profession before you try to demonize it, I thought the “witch hunt” days of the AMA after the chiropractic profession were over.You’ll notice that SBM is unaffiliated with the AMA.

      Where are all the testimonials of real-life patients who have received life-changing results from CMT?

      Where are the testimonials of patients who died of a stroke due to CMT?

      And that’s why testimonials are worthless – you never hear the ones where people died.

      Also – basic question. What is superior, over a timeframe of about a week: manipualtion, gentle stretching, gentle range of motion exercises, or doing nothing. Can you point me to the chiropractic literature that supports manipulation as the safest and most effective of these interventions?

      And that’s not even addressing the frank lunatics who think they can cure cancer by cracking your spine. Or the chiropractors who recommend (and sell!) vitamins and homeopathy. Or the chiropractors who oppose vaccination. Or the chiropractors who justify their practice by reference to medical errors.

      The fact of the matter is the chiropractic profession would love to work hand in hand with the medical profession and work together to achieve the best patient results possible

      Well gosh, sounds like you should do what real medical professionals do when they want to be respected and have their methods adopted – conduct high-quality research demonstrating the effectiveness of your interventions and superiority over other treatments, including placebo and no-treatment groups.

      If you want to play with the big kids, you have to prove that you can run as fast as they can.

      Because chiropractic removes interference and allows the body to heal itself

      Oh jebus, you are one of the chiropractors who seriously think that spinal manipulation can help beyond mere musculoskeletal complaints? Then you’re an idiot.

    9. PMoran says:

      “There are a myriad of different ways to ADJUST the neck (and every other joint in the body) that are extremely low-force, involve no twisting, bending, or torquing of the individual, and result in no “pop” or “snap” cavitation.”

      Unfortunately for this argument, the less you actually do to the neck, the less likely is any therapeutic effect over placebo and non-specific influences.

      It has been difficult enough to demonstrate the superiority of any intervention over any other with any form of treatment of neck pain, which suggests that none of them do anything much.

      1. Windriven says:

        Peter, Is there good evidence that doing more to the neck results in a more significant effect? I am not aware of convincing evidence that chiropractic has meaningful and demonstrable benefit for any indication other than LBP.

        1. Windriven says:

          That should have read … A more significant therapeutic effect.

        2. MadisonMD says:

          Is there good evidence that doing more to the neck results in a more significant effect?

          Peter is saying no, there isn’t. If there were a therapeutic effect, you might expect dose-response such that larger manipulations have greater therapeutic effects than smaller ones. His last paragraph suggests that there is no such dose-response.

        3. PMoran says:

          That’s sort of my point, W. With neck pain we are starting from an even lower baseline of likely effect.

          The evidence for SMT having benefit over placebo for most patients with LBP is fragile enough, given small benefits in the studies and the difficulties of truly blinding such studies.

  7. Thor says:

    The one-two punch on chiropractic of Homola’s and Novella’s posts, just a week apart, isn’t due to lack of material, but emphasizes how important this issue is for the SBM community. And how seriously it is taken. I think chiropractic as a whole (with the possible exceptions of a small minority of practitioners), is one of the most pernicious of all the CAM modalities (not only because of direct harm, but because of rampantly perpetuating anti- and pseudoscience to an “unknowing” public). It is certainly on a par with acupuncture, TCM and naturopathy. Thankfully, it is being held under the loupe by experts in the field, generating understanding for other professional and laypersons.
    It may be old hat to some, or overkill to others, but the message can’t be stated enough.

  8. Frederick says:

    Good article, Funny thing, Today, while working, I was listening to older SGU episode, I’m in 2012 right now ( I finished 2013 2 week ago lol), On episode 361, ( June 16th 2012) you spoke about that same topic. I was wondering if there was any update on that lately, I guess there’s now.

    For what ailment does the Chiro use this manipulation? Neck pain related to headache?
    Because I have a friend who has bad headaches lately, ( He can’t sleep and can’t do a lot of stuff) seem to be related to neck pain, and He saw he’s doctors couple of time for that, but not that much result, saw a Physical therapist 7-8 times, it worked for short term, he said he used florinal, not much success. someone said he should try Maxalt.
    So, he istired and people told him to go see a chiro. one of my friend’s wife is a Chiro. Peoples told him to go see her because she’s good, and some said that she is softer and other chiro ( she doe’s “crack”). But Of course I’m skeptical that it will work really, He his also a little skeptical, He said that he as been to a chiro couple of time for other problem but it did not work, but he rationalize it but saying “but some are good and bad like in all jobs”. So He is going to see her.

    So I wonder what options does someone like him has?
    I have not commented on his status, Because peoples love that chiro, ( she a friend of many of those peoples, including me), But i want to see if I can send him to a proper doctor, I know there’s some “headache” clinic some where around here, with neurologist and different kind of doctors. I don’t know if He can go there. Now that i’ve read that those manipulations have risks, yes small, but no benefit, I feel Like I should give him some science based advice in a private message, I will probably send him some link to SBM and Neurologica Blog.

  9. Kiran says:

    I think when you cite that Cochrane review in your blog post you need to be completely clear about what it said.
    According to the cochrane report that you cite “There was strong evidence of benefit favoring multimodal care (mobilization and/or manipulation plus exercise) over a waiting list control for pain reduction [pooled standardized mean differences -0.85 (95% CI: -1.20 to -0.50)], improvement in function [pooled SMD -0.57 (95% CI: -0.94 to -0.21)] and global perceived effect [standardized mean differences -2.73 (95% CI: -3.30 to -2.16)] for subacute/chronic mechanical neck disorders with or without headache.”

    The actual conclusion was: “Mobilization and/or manipulation when used with exercise are beneficial for persistent mechanical neck disorders with or without headache. Done alone, manipulation and/or mobilization were not beneficial; when compared to one another, neither was superior.”
    SO The Cochrane review conclusion says that cervical manipulation and mobilisation in conjunction with exercise are BENEFICIAL.
    On top of that, you’ve stated that “It is true that none of this proves a causal connection, because we can’t do randomized trials (although prospective trials would be helpful). But this is true in the same way that we can’t prove smoking causes lung cancer, we only have an association.”
    Well ofcourse we haven’t proven that smoking causes lung cancer we only know that it increases the risk of cancer and we can say this because of the data size, population variety and the weight of the evidence in support of the risk factor increase.
    Comparing a neck manipulation to lung cancer like you have in your post is like comparing the risks for open heart surgery and the risk of having stitches on your left elbow.
    I’m not FOR chiropractic neck manipulation, I’m for strong evidence and against exaggeration/misinterpretation of inconclusive or narrow spectrum data.

    1. whoa says:

      He sure did exaggerate and distort and misinterpret the evidence.

      And smoking is not a valid analogy. Lung cancer is very common, smoking is very common, and the associations clearly imply causality.

      And there have been enough animal studies on smoking to know that it does cause cancer.

      I have no opinion on CMT, specifically. I do not like to see political claims pretending to be scientific.

      1. MadisonMD says:

        And there have been enough animal studies on smoking to know that it does cause cancer.

        And there have been enough animal studies on wrenching necks to know it does cause death. Oh and human studies showing lethality with vertebral artery dissection too.

      2. WilliamLawrenceUtridge says:

        And smoking is not a valid analogy. Lung cancer is very common, smoking is very common, and the associations clearly imply causality.

        Meanwhile CAD is very uncommon, but even more so among those who don’t visit chiropractors. Almost as if, in rare cases, chiropractic adjustments caused CAD in a small number of patients.

        And of course, your comment does not address the second pillar buttressing the argument against CMT – the lack of demonstration of superior efficacy compared to even, say, doing nothing.

        And for that matter – having visited a chiropractor for years I will point out that cervical adjustments don’t necessarily improve neck function and pain. Nearly every time I left the chiropractor I had a mild headache. Upon questioning, my chiropractor at the time said it was “the blood vessels expanding and the nerves being freed after impingement”. Hopefully it wasn’t a stroke.

        1. brewandferment says:

          Yeah, I’ve been wondering about some of that. I too got suck(er)ed into the world of chiroquactic in my teens and twenties, but fortunately after I was on my own budget constraints pretty much kept me from going too regularly. I would still go from time to time if I got back pain issues. The beginning of the end was when I’d gotten a tightness in my upper back that made full lung expansion painful. Previously I’d gotten immediate and welcome relief from an “as needed” chiro adjustment–it was something I’d woken up with and clearly felt muscular/positional in nature. But this time it came to a peak late on a Fri afternoon and the soonest I could get an appt with the chiro was Tues. Rather than face a miserable weekend, I chugged a substantial dose (800 mg) of ibuprofen before bed mostly to get some sleep. Next morning problem had resolved!

          And then awhile later I’d had lower back pain and was seen by a substitute. There was a cervical adjustment and the next morning I started getting a migraine aura, something I’d not had since my teens. Fortunately it resolved (I might have slugged down some ibuprofen but don’t remember) within an hour or so and that was the last time I ever set foot in a chiro office.

          But here’s the thing: now early into my 50′s I get creaky sensations when I turn my neck, and every so often it feels like a muscle has snagged something that takes some head and neck wiggling to free the snagged feeling. And this week I rode a roller coaster which has given me a rather stiff, slightly painful neck. Some of this could all just be age of course but I can’t escape a nagging suspicion that the chiro could have made it occur or at least worsened what would have occurred due to aging.

          I also have stray thoughts of suing the chiro my mom took me too during my teens…oh, wait, he died at 79 of cancer…so much for chiro removing interference and all that trash.

          1. WilliamLawrenceUtridge says:

            One thing I forgot to mention is my contemporary approach to back and neck pain. I don’t do anything, and it seems to go away in a couple days. I used to get pain next to my spine, which my ex chiro labelled as a displaced rib head, corrected by an adjustment while I was lying on his closed fist. Sore afterwards, but better the next day.

            Had a similar pain about a week ago. Ignored it, and it was better the next day.

            And that is why you need control groups.

    2. Earthman says:

      “when used with exercise”

      is this not a confounding element? Was it the manipulation, or was it the exercise>

      1. Harriet Hall says:

        Either manipulation is not effective, or there is some magic that makes it become effective when patients also use exercise. How might that work?

    3. Earthman says:

      “when used with exercise”

      is this not a confounding element? Was it the manipulation, or was it the exercise?

  10. It is a small risk. Nobody, not even the AHA nor their journal, Stroke, is denying that. (http://stroke.ahajournals.org/content/early/2014/08/07/STR.0000000000000016.full.pdf) How small it is, nobody knows. The killer blow for CMT, for mine, is the lack of proven BENEFIT, and being able to reliably predict what subgroups will benefit to CMT over non manipulative techniques.
    There have been drugs that have had a smaller risk ratio than CMT or a lower association with death than CMT that have had LARGER proven clinical benefit than CMT (and I’m not specifically talking about for neck pain/HA, I am talking about drugs in general, such as antibiotics, anti inflammatory agents, etc), that have been banned for being too risky, with a small risk, even with their benefit).

    Just saying…

    1. WilliamLawrenceUtridge says:

      The killer blow for CMT, for mine, is the lack of proven BENEFIT, and being able to reliably predict what subgroups will benefit to CMT over non manipulative techniques.

      Indeed, that’s the nub for me as well. Yet rather than researching this, chiropractors rely on invective, denial, double-standards and obsolete references to the history of medicine. After Mengele, Tuskeegee and Nothing About Us Without Us there was outrage and the medical discipline changed. Chiropractic has schismed, but still has SMT as a core, barely-validated when-all-you-have-is-a-hammer approach to all disease.

  11. Raph says:

    I am curious what this community’s thoughts on this:

    https://www.youtube.com/watch?v=zCp_KDXet9g&feature=youtu.be

    1. Thor says:

      Please reread Dr. Novella’s conclusion of his post. Those are my thoughts on this.
      Yes, VAD is rare. Still a risk, though. CMT, especially the HVLA maneuver, has questionable benefits.

  12. JFF says:

    American physical therapy association (APTA) and the American Academy of orthopedic manual physical therapists (AAOMPT) response to the AHA.

    http://www.apta.org/Media/Releases/Consumer/2014/8/7/

    1. Thor says:

      I’m puzzled. I wasn’t aware that PTs performed cervical manipulation. Chiropractic wasn’t even mentioned.

      1. WilliamLawrenceUtridge says:

        Now that there is a research base for spinal manipulation, they are starting to – but best practices is one-vertebrae-at-a-time rather than all at once, and only after specific training and supervised practice. My PT told me this a couple months back.

        Though come to think of it, I don’t recall it being specifically cervical.

  13. PMoran says:

    From memory the Cassidy study figures showed that patients were about ten times more likely to see a normal doctor about any headache than a chiropractor. it is also extremely likely that patients would preferentially choose to see a doctor than a chiropractor about a new, unusual, occipital headache, especially if accompanied by neurological symptoms.

    I have not seen such highly likely confounding influences discussed anywhere, and I don’t see how this kind of retrospective study can possibly control for them.

    It is a tragedy that this study has been afforded the weight that it has when there is so much other evidence of a problem. There is no question that if this was a medication with similar problems being reported there would be strong advisories being circulated, if not an actual withdrawal from the marketplace, there being no clear, uniquely useful place for cervical manipulation in medicine.

    At most cervical manipulation should be considered as a late resort in fully informed patients with neck pain not responding to other measures. The only barrier to a more rational approach is the heavy investment of chiropractic in the procedure.

    1. MadisonMD says:

      . it is also extremely likely that patients would preferentially choose to see a doctor than a chiropractor about a new, unusual, occipital headache, especially if accompanied by neurological symptoms.

      Agreed! And moreover, isn’t seeing a doctor a prerequisite for obtaining the diagnosis? i.e. ascertainment required an MD visit (though not always PCP).

      I have not seen such highly likely confounding influences discussed anywhere…

      I tried. First here. Then again here. What I received in reply was Marc Perle’s refutation by anecdote (patients presenting to chiros with neurologic symptoms). He apparently was hoping I would accept it as evidence that the rate of such presentations to PCP and DCs are equal?! Nevertheless, I’m heartened that I independently came to your conclusion, Peter.

    2. nene peterson says:

      PM declares: “….. neck pain not responding to other measures. The only barrier to a more rational approach is the heavy investment of chiropractic in the procedure.”

      What would, IYO, be a “more rational approach” to neck pain that has NOT responded “to other measures”?

      And…..Perhaps you can, for clarity, define just what “the procedure” is?

      Do you assume/presume that all chiropractic “procedures” are HVLA?

      1. PMoran says:

        Sorry, nene, I assumed that it is HVLA that we are talking about, and I was suggesting a compromise position that chiropractors might be more likely to accept.

        Yet it is not clear that any measure that involves distortion of the neck is free of this risk. Steve mentions that “Trauma can be either severe, such as whiplash injury from a car accident, or subtle, such as from yoga or simply turning one’s neck to look past the shoulder.” Chiropractors used to defend their use of cervical manipulation by pointing out that cases occur after visits to the hairdresser (while sometimes also wanting to assert that it couldn’t possibly happen after more forceful cervical manipulations).

        I think it is likely that there are underlying anatomical variants that make some people much more prone to vertebral artery dissection than others, so that even rather brisk mobilisation might occasionally be a triggering event.

      2. Thor says:

        There are several things one can and should do. They belong to all the bodyworkers, somatic practitioners, PTs, osteopaths – not just chiropractors. I think the chiropractic profession places way too much emphasis and importance on the HVLA itself. The adjustment, accompanied by the popping sound, is usually considered the “key” part of the treatment. It’s the big gun. As we all know from SBM: bollocks.

        For pain, one could do various forms of hydrotherapy, either hot, cold or contrasted; gentle, passive ROM/stretching; traction; massage therapy modalities; physical therapy.

  14. Lukas says:

    this article is about chiropraktor manipulation. what about trakction manipulation or osteopaty manipulation in OMT?

  15. Christopher Stuart, DC says:

    I appreciate Dr. Homola’s initiative on formulating a guideline for stroke. I think it’s needed. However, as a colleague of his, I am skeptical of that diagram in his post representing “True Anatomy.”

    http://www.sciencebasedmedicine.org/upper-neck-manipulation-caveats-for-patients-and-providers/#begincomments

    I am suspicious the atlas can rotate that much in relation to the axis. . .it would cause a ligamentous tear. I don’t believe the paraphysiological joint space extends that far.

    Fluoroscopic studies would be valuable in ascertaining how much rotation the average HVLA manipulation incurs upon the atlas.

    But. . .that diagram is “Scary.”

    That said, my suspicion is this is a problem of “technique” in the profession. I remember being adjusted by my colleagues in school and some of them were quite rough. I am not sure the senior clinicians ever imparted to them to back off and they leave for practice with bad habits. I vowed never to perform manipulation the c-spine with significant force. My manipulations are more akin to a Grade 5 mobilization and patients have taken notice of that, who have been to previous DC’s.

    As far as “benefit vs. risk”. . .well, if I am doing a Grade 5 mobilization, does that get the endorsement of the medical community vs. a gentle manipulation? Not sure. I think we are parsing over some milli-newtons of force.

    A few milli-newtons and one procedure is accepted and the other becomes “quackery?”

    I hardly think so.

  16. Daniel says:

    The conclusion of the Stroke article is

    “current biomechanical evidence is insufficient to establish the claim that CMT causes CD”

    In other words, they couldn’t prove anything – and it’s pretty obvious they tried. Don’t you think if they’d found a p <.06 association this would be on the front page of the NY Times?

    The real story here is that they went to such lengths and then wrote about CD, not CMT. That tells you what you need to know.

    1. WilliamLawrenceUtridge says:

      Yes, establishment of cause is going to be difficult. But as said before, what’s really missing is comparative effectiveness research. While not definitive, the evidence is suggestive, and given the severity of the outcome in the absence of definite evidence that CMT is superior to other approaches that lack the possible-to-probable chance of causing CAD, one would think that it is reasonable to conclude the precautionary principle should apply. Or at minimum, work should focus on determining if CMT offers anything massage or even doing nothing does not. But chiorpractors haven’t done such work, despite more than a century of existence.

  17. Tinking_Chiro says:

    The discussion on informd consent is very relevant.
    Risk Management for Chiropractors and Osteopaths. Informed consent
    A Common Law Requirement
    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2051308/?tool=pmcentrez&report=abstract
    RISK MANAGEMENT FOR CHIROPRACTORS AND OSTEOPATHS
    Neck Manipulation & Vertebrobasilar Stroke
    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2051301/?tool=pmcentrez&report=abstract

    The physio’s response here is interesting in regards to Informed consent which we all agree on, it also contains statements that a chiropractic critic would go ballistic over if they were uttered by a chiro.
    http://www.physiospot.com/sponsors/aaompt-responds-to-american-heart-association-cervical-manipulation-paper/

  18. Thinking_Chiro says:

    Typo “Thinking_Chiro”.
    Apologies to myself!

    For those interested there is an upcoming free online course on undrestanding research for health professionals. Starts on the 18th of this month!
    https://www.coursera.org/course/researchforhealth
    Reading and applying the latest research to clinical practice is what its all about!

  19. Thinking_Chiro says:

    The recent posts in regards to informed consent are very relevent. Some interesting articles on the Topic:
    RISK MANAGEMENT FOR CHIROPRACTORS AND OSTEOPATHS
    Neck Manipulation & Vertebrobasilar Stroke
    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2051301/?tool=pmcentrez&report=abstract
    Risk Management for Chiropractors and Osteopaths. Informed consent
    A Common Law Requirement.
    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2051308/?tool=pmcentrez&report=abstract

    The recent reply by AAOMPT:
    http://www.physiospot.com/sponsors/aaompt-responds-to-american-heart-association-cervical-manipulation-paper/
    It discusses informed consent well, it also contains statements that a the chiropractic skeptics would go ballistic over if they were uttered by a chiro!

  20. PB says:

    Few people have mentioned manipulation performed by Osteopathic Physicians. I am a DO med student and we definitely had discussions during our OMM course (and our medical neuroscience course) about the potential vertebral dissection complications/stroke as a result of performing cervical high velocity thrusting incorrectly or on a patient who has risk factors (such as cervical arthritis or known hypercholesterolism). The pathophysiology was described as being either due to too much stretching and/or the pinching of the artery by its bony neighbors right where it flexes and ascends into the skull. This was followed of course by a discussion of typical vertebral artery-based stroke symptoms. Our professors basically told us the biggest risk to the vertebral artery comes from doing high velocity thrusting while having the neck in extension. Of course, a lot of the risk also comes about from exactly WHERE in the cervical spine one is trying to work on – the higher up the higher the risk.

    Of course, the evidence speaks for itself in terms of whether CMT even provides benefit. Like all things painful a lot of the “beneficial effect” is probably placebo based (expectation, therapeutic ritual, etc.). I’d be willing to bet that a massage would help just as much for a lot of neck pain symptoms.

    I don’t know about everyone else, though, but I’m guilty of stretching/popping my neck quite often to relieve strain I get from sitting too long.

    I think i did it a lot more while reading this article, actually. :)

    1. Thor says:

      My comment to you got misplaced to #21.

  21. Thor says:

    Thanks for your input, JB. It’s nice to hear from a future (apparently science-based) DO.
    As you may have gleaned from these pages, there is a distinction in the US between science- and woo-based osteopathic doctors. Most fully support and acknowledge the former and disdain the latter. With chiropractic, it is rare indeed to come across anything other than woo. With osteopathy, that’s not the case. Although the field is littered with off-the-wall purveyors of CAM, most appear to solidly practice science-based medicine, approaching it similarly to MDs but with a slightly different perspective and approach. Impressively, historically the field has made great reforms and progress.
    This is being claimed about chiropractic, but by most accounts isn’t happening as it should.
    Good luck in your studies.

  22. Jess T. Brower, DC says:

    West Virginia Doctor Allegedly Made An Employee Motorboat Her Breasts

    http://gawker.com/west-virigina-doctor-allegedly-made-an-employee-motorbo-1621243985

    Doctor Who Prescribed Drugs for Sex and Cash Gets Hard Time

    http://www.medscape.com/viewarticle/829854

    Doctor Found Guilty of Manslaughter After Overdose Deaths

    http://www.medscape.com/viewarticle/828805

    Top Pain Pill Prescriber in Pennsylvania Lands in Prison

    http://www.medscape.com/viewarticle/814131

    14 Florida Physicians Indicted in ‘Pill Mill’ Bust

    http://www.medscape.com/viewarticle/748811

    Since these stories involve MDs, then all MDs must be bad, and all must agree with these actions. This also must be taught in medical school, specifically how to properly motor boat a pair of breasts. This type of thinking is illogical, and yet continuously spewed out on this site. I get it, I too am very skeptical/critical/spiteful towards my colleagues of who I abhor. You cannot put all DCs in the same basket, just as I cannot imagine writing off all medical practice due to the above. The majority of arguments made here are just plain silly.

    1. MadisonMD says:

      Nobody claimed all DC’s are bad. Nobody claimed all MD’s are good. Nobody even claimed that DC’s are the only profession performing cervical manipulations (although seemingly disproportionate number of DC’s are on record here and elsewhere denying the possibility of causing dissection).

      So, do you have something to say on the actual topic of this post?

    2. Windriven says:

      “Since these stories involve MDs, then all MDs must be bad, and all must agree with these actions.”

      These MDs are bad because their ethics suck, not because of medical science. ALL DCs practicing subluxation-based chiropractic are bad because the foundation of their practice is fraudulent, based on nothing more scientific than the febrile imaginings of a religious zealot.

    3. WilliamLawrenceUtridge says:

      So…chiropractors only have to prove CMT is safe and effective when medical doctors never make any mistakes, never do anything questionable, and never murder people? What a curious approach? Purely out of theoretical interest, could you describe what prevents chiropractors from determining if CMT is safer and more effective than, say, massage?

      Nobody is putting all chiropractors in the same basket. What is being said is that a specific intervention practiced by chiropractors has indications of presenting specific risks while not offering benefits that are superior to interventions that do not present such risk. Nobody is saying “chiropractors want to kill people”, and claiming that we are is actually making stuff up.

      What’s silly about comparative effectiveness reserach by the way?

      1. Windriven says:

        “Nobody is putting all chiropractors in the same basket.”

        I am. All traditional chiropractors who base their practice on subluxation theory. Every. Effing. One.

  23. Jess T. Brower, DC says:

    You are correct MadisonMD, my prior post was more of a rant than an actual helpful or meaningful commentary specific to this post. It was more of a summary of my frustration of several posts on this site pertaining to DCs. Maybe it should have been posted elsewhere or not at all.

    I agree, this is a subject of debate. Both extreme sides of the argument are dug in and not willing to budge, so overall I don’t believe any useful conclusion will be satisfactorily met. I believe the truth and commonality lies somewhere in the middle. I appreciate the case reports, and believe that manipulation has been associated with CVA. I truly believe that cervical manipulation performed in absence of true expectation of measurable outcome and relief of specific complaint that solely refers to MSK pain syndrome of the upper quarter including HA, should not be performed. However, in those situations, I believe it is of benefit to some patient subpopulations, that would otherwise not find relief with any other means. So to denounce or discourage all use of cervical manipulation is also dangerous. My personal belief, personal practice, and personal recommendation to all is that cervical manipulation should not be performed in the presence of a new onset HA for at least 72 hours. That is even barring any other symptoms, which would obviously be cause for concern.

    1. WilliamLawrenceUtridge says:

      Even assuming zero risk of CAD from cervical manipulation, there is still the issue of whether it actually helps. Is it the best approach? Is it even better over the long term than simple watchful waiting?

      Until you can answer questions of effectiveness, even discussions of safety are kinda pointless.

  24. Stephen S. Rodrigues, MD says:

    “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. ”

    You advise is your personal opinion.

    I would want expand the concept and use imaginative or rational thinking outside the narrow topic into the real world. What about comparing CD with MVA whiplash, in football, soccer, and CP resuscitation w intubations which are all manipulate the neck.

    That would be a good scientific experiment and much more practical without the CAM biased attitude.

    1. WilliamLawrenceUtridge says:

      You advise is your personal opinion.

      Did you miss the part where Dr. Novella was discussing a consensus statement from an expert body there genius? Do you even read when you post your vague nonsense?

      I would want expand the concept and use imaginative or rational thinking outside the narrow topic into the real world. What about comparing CD with MVA whiplash, in football, soccer, and CP resuscitation w intubations which are all manipulate the neck.

      What, imaginative thinking like…visualizing the rotation of the neck to the extremes reached through chiropractic manipulation? Drawing upon the existing literature? Conducting case-controlled studies?

      Meanwhile your suggestions seem rather stupid and inapt. Chiropractic manipulation involves a powerful rotation. Whiplash, tackles, intubations, these involve extremes of extension.

      Are you sure you went to medical school?

      That would be a good scientific experiment and much more practical without the CAM biased attitude.

      That’s not a scientific experiment there genius. An experiment would involve manipulation, comparative groups. You are proposing observational studies.

      Also, all science-based medicine and skeptics in general ask for is a level playing field – don’t deliver and in particular charge for an intervention without ensuring it is effective and safe first. Why do you consider that an unreasonable demand?

  25. j says:

    Hi there,
    your quote “Done alone, manipulation and/or mobilization were not beneficial; when compared to one another, neither was superior.”
    Is that not from an old cochrane review that has since been updated with different conclusions here?
    http://summaries.cochrane.org/CD004249/BACK_manipulation-and-mobilisation-for-mechanical-neck-disorders
    Thanks

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