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Chiropractic and Stroke: Evaluation of One Paper

Do not trust the cheering, for those persons would shout as much if you or I were going to be hanged.”
~ Oliver Cromwell

In the blogosphere, the proponents of chiropractic often quote the following paper, with the abstract:

Risk of Vertebrobasilar Stroke and Chiropractic Care
Results of a Population-Based Case-Control and Case-Crossover Study
Spine. 2008 Feb 15;33(4 Suppl):S176-83.
by Cassidy JD, Boyle E, Côté P, He Y, Hogg-Johnson S, Silver FL, Bondy SJ.
(5)

Why be different? Here is the abstract.

STUDY DESIGN: Population-based, case-control and case-crossover study. OBJECTIVE: To investigate associations between chiropractic visits and vertebrobasilar artery (VBA) stroke and to contrast this with primary care physician (PCP) visits and VBA stroke.
SUMMARY OF BACKGROUND DATA: Chiropractic care is popular for neck pain and headache, but may increase the risk for VBA dissection and stroke. Neck pain and headache are common symptoms of VBA dissection, which commonly precedes VBA stroke.
METHODS: Cases included eligible incident VBA strokes admitted to Ontario hospitals from April 1, 1993 to March 31, 2002. Four controls were age and gender matched to each case. Case and control exposures to chiropractors and PCPs were determined from health billing records in the year before the stroke date. In the case-crossover analysis, cases acted as their own controls.
RESULTS: There were 818 VBA strokes hospitalized in a population of more than 100 million person-years. In those aged <45 years, cases were about three times more likely to see a chiropractor or a PCP before their stroke than controls. Results were similar in the case control and case crossover analyses. There was no increased association between chiropractic visits and VBA stroke in those older than 45 years. Positive associations were found between PCP visits and VBA stroke in all age groups. Practitioner visits billed for headache and neck complaints were highly associated with subsequent VBA stroke.
CONCLUSION: VBA stroke is a very rare event in the population. The increased risks of VBA stroke associated with chiropractic and PCP visits is likely due to patients with headache and neck pain from VBA dissection seeking care before their stroke. We found no evidence of excess risk of VBA stroke associated chiropractic care compared to primary care.

Seems impressive, especially the conclusion. Chiropractic is not to blame for VBA strokes. But abstracts are like movie trailers. They give a flavor of the movie, but often leave out many important plot devices and characters. The Dark Knight evidently has a plot line concerning Two Face, but you would not know it from the trailers (9). Writing an abstract is an art, and you have to choose those feature you wish to emphasize in a limited space. But if you want to know the rest of the story (12), you have to actually pull and read the reference. If you were to read this article in its entirety, you would not be so sanguine about the safety of chiropractic.

As best as I can tell, no one bothers to read the whole reference to see what it says. So I did (6). Dr. Hall has covered the issue of stroke and chiropractic nicely in other posts, but I figure if I am going to go to the trouble of reading this stuff, why should I be the only one to suffer? Consider this an extended footnote to Dr. Hall’s posts, if she will be so kind as to humor me.

Does the meat (7) of the article support the abstract? Lets wander through the content instead of the abstract and see.

First they found 818 vertebral artery strokes on the basis of discharge codes.
First problem: discharge codes are not a reliable way to know the real diagnosis (13).

The discharge diagnosis is sometimes a best guess, often not based on the strictest of criteria, and when people compare the real diagnosis based on a chart review to the discharge coded diagnosis, they often have a poor correlation. And, at least in the US, coding is an art to maximize reimbursement, not a method of determining what the patient really had. You have to do chart reviews to know what the patients ‘real’ diagnosis is, and even then, given the vagaries of testing and disease presentation, you often have to go with best bet.

Also, note the patients have the diagnosis of stroke, not the reason for the stroke. For the elderly, where stroke is common, the most common cause of stroke is thrombus, a blood clot forming in an artery that feeds the brain. The second most common cause is emboli, flipping a blood clot to the brain. In the young, where stroke is rare, the cause is more commonly a tear in the vertebral artery, a dissection, which can be precipitated by trauma.

The worry in chiropractic is a stroke CAUSED BY A DISSECTION. Sorry for yelling. Already the study is flawed as we do not know if there were dissections. Stroke may be a surrogate for dissection, but not a good one, especially in the elderly.

I would bet that the diagnosis of stroke is more accurate in younger people. When a young person presents with a stroke or other neurologic symptoms, they get the million dollar work up as they are not supposed to have a stroke, whereas if an obese, elderly, hypertensive, smoking, diabetic presents with transient dizziness or double visions from medications or viral illness, well, they might be labeled as a vertebral artery stroke without undergoing a precise diagnostic work up. So while the number of VBA strokes is likely to be accurate in the young, in the elderly it is possible to over represent the number of strokes.

Also, that was 818 vertebral strokes in 100 million person years, so a VBA stroke is a rare thing. This is important in that if you have a high background of vertebral artery strokes from thrombus or emboli, which is a common cause in the elderly, you will lose the rare dissection. If you want to find a rare event like a dissection as cause of stroke, the elderly may not be the best place to look, as the noise of the thrombo-embolic stokes will overwhelm the effects of the dissection. In the elderly, looking for a dissection based on stroke codes would be like locating your cell phone by listening in a concert hall by calling it while The Who is playing (11).

They compared these 818 strokes to a control group in a case control study.

Case control studies are good for a rare disease and a common exposure and can only establish an association, which is not, I will emphasize, establishing causation.

They compared those that visited a chiropractor with those that visited a family practitioner, over a month’s time to see if it was associated with a vertebral artery stroke. You know their conclusion.

So does the body of the paper support the conclusions of the abstracts? Well, yes and no.

For people over age 45, there was the same association of vertebral artery stroke after a visit to a chiropractor or a primary care practitioner. A stroke mind you. The cause of the stroke was not determined. It would be reasonable to assume that most strokes in the elderly would be due to thrombi or emboli and that the rare event of a dissection, the worry of a chiropractic manipulation of the neck where you tear the artery, might go undiagnosed.

In the over 45 age group, strokes due to chiropractic could be lost in the sea of strokes due to other reasons, and since we do not know if there were a dissection or blood clot as a cause of strokes, it is hard to conclude that there were no extra strokes from chiropractic. The study was not powered to determine the rare event of a chiropractic event against the background to usual stokes in the elderly. The mean age in this study was 63 (11).

Young people should not have any strokes. In the young, vertebral artery dissection is a common cause of a rare event. It is also the worry from chiropractic neck manipulation. If you could find an effect of chiropractic, it would be in the young. And they do. The people who have an increase in stroke are those under age 45. And it is a big association: odds ratios from 3 to 12.

The association is most noticeable in the first 24 hours after seeing a chiropractor. Usually if you rip an artery it is symptomatic right away. Again, we do not know if these people had dissection or not. We only know they had stroke of some sort, within a day after seeing a chiropractor. One would predict that if there were an association between chiropractic and stroke you would most easily find it in the young and the effect would be most noticeable in the first day or so after the chiropractic visit.

And this article confirms this association.

Note the word association. Association is not causation. You would need a prospective study comparing stoke rates from chiropractic patients vs non chiropractic patients to find causality.

But if you are less than 45 and visit a chiropractor, there is a strong association between that visit and a stroke in the next 24 hours.

Table 3 has the smoking gun. The highest odds ratio (14) for a stroke is 12, 4 times any other, in the age less than 45 in the first 24 hours after a visit to a chiropractor. And, to give credit where credit is due, they mention this as a key point in the discussion and, in the introduction, note two other studies that show an association between visiting a chiropractor and having a stroke. The risk of stroke is 5 to 6 times in these studies.

Part of what they do is smear the data by taking it out for a month after a visit, diluting the effect of the first 24 hours after visit.

How do the authors deal with this data?

They emphasize in the abstract, which is all anyone will read, that there were equal strokes after visits to chiropractic and primary care physicians. They do not bother to mention the increased association in the young until you reach the discussion, which most will not read.

They account for this by suggesting that patients with headache and neck pain, symptoms of an incipient vertebral artery stoke, lead people in equal proportion, to seek care from DC and MD

In other words, they had a stroke in progress at the time they sought care.

The codes used by the chiropractic and primary care physicians for the visit, admittedly inaccurate, were by and large NOT vertebral artery stroke symptoms.

“Neck-related chiropractic visits were identified using diagnostic codes: C01–C06, cervical and cervicothoracic subluxation; C13–C15, multiple site subluxation; C30, cervical sprain/strain; C40, cervical neuritis/ neuralgia; C44, arm neuritis/neuralgia; C50, brachial radiculitis; C51, cervical radiculitis; and C60, headache.

For PCP visits, we included community medicine physicians if they submitted ambulatory fee codes to OHIP. Fee codes for group therapy and signing forms were excluded. Headache or neck pain-related PCP visits were identified using the diagnostic codes: ICD-9307, tension headaches; 346, migraine headaches; 722, intervertebral disc disorders; 780, headache, except tension headache and migraine; 729, fibrositis, myositis and muscular rheumatism; and 847, whiplash, sprain/strain and other traumas associated with neck (These codes include other diagnoses, and we list only those relevant to neck pain or headache)”

Compare these to the symptoms for vertebral artery stroke (from E medicine)

“Ipsilateral facial dysesthesia (pain and numbness) – Most common symptom, Dysarthria or hoarseness (cranial nerves [CN] IX and X), Contralateral loss of pain and temperature sensation in the trunk and limbs, Ipsilateral loss of taste (nucleus and tractus solitarius), Hiccups, Vertigo, Nausea and vomiting, Diplopia or oscillopsia (image movement experienced with head motion), Dysphagia (CN IX and X), Disequilibrium, Unilateral hearing loss, headache”

Beside headache, there is no overlap in symptoms of a vertebral artery stroke and reasons in this study for visiting an MD or DC.

To suggest, based on the codes, that they had a stroke in progress is disingenuous at best (17).

That is a hypothesis they came up with to account for the data. Spin, as it were. That hypothesis may be true, but it is not proven by the data. The study was not designed to demonstrate that result. People who do not read the article carefully take this hypothesis, and they call it a plausible hypothesis in the paper, as the conclusion of the data. This unproved hypothesis is emphasized in the abstract as if it were a conclusion from the data. And those that do not read past the abstract repeat it as if it were a valid conclusion from the data.

To repeat: “The increased risks of VBA stroke associated with chiropractic and PCP visits is likely due to patients with headache and neck pain from VBA dissection seeking care before their stroke” is a hypothesis to account for the data, not the conclusion of the data.

It will take another study to prove or disprove that hypothesis.

My read of the paper is different.

My conclusion, from reading the paper in its entirety, rather than the abstract, is that a population that should not have a stroke, the young, has a marked increase association with stroke 24 hours after visiting a chiropractor and that given the rarity of a vertebral artery dissection as a cause of stroke in the elderly, the elderly is not a group that one could easily find an increase in stroke after chiropractor visit.

To quote the paper:

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

Note the word major. I agree it is not a major cause of stroke, at least in the elderly. In the young, the highest odds ratio, 12, for a stroke is in the first 24 hours after visiting a chiropractor is twice what has been found in prior studies. As mentioned above, a case control study cannot determine causality, just association.

Given the number of chiropractor visits and the rarity of vertebral artery tear, chiropractic is probably a rare cause of a rare event.

However, given that chiropractic neck manipulation is worthless magical thinking, ANY stroke is one too many.

Less than a movie trailer, this abstract is more like the Superman covers of my youth, where the cover had only glancing resemblance to the story (16).

Go to the website whatstheharm.net and peruse the chiropractic section. It is striking how many young people had a stroke just after having chiropractic neck manipulation. Of course, these are just anecdotes, and the plural of anecdote is anecdotes not data. But wait. Anecdotes are the prime proof for alt med proponents, since evidence usually proves their pet quackery is a crock. Dr Weil calls anecdotes, “uncontrolled clinical observations.” That’s what whatstheharm has: uncontrolled clinical observations that Weil says should have the same weight as clinical trials (15).

Given three studies that now show an increase in the stroke rates in the young after neck manipulation, I would not let a chiropractor come close to my neck.

In real medicine, it takes less data than this to bring a drug under scrutiny to decide if the benefits are worth the potential risks of a therapy. In my own world of infectious diseases, there have been millions of doses of the antibiotic telithromycin given and only a handful of liver failure and death associated with the antibiotic. I would not prescribe this antibiotic unless I had no other options given the potential risks, albeit very small, and this is for a therapy that actually works.

As a slight tangent with some biologic correlates, it should be pointed out that in a good hanging, the victim should not strangle to death (1).

A good hanging should be set up such that there is a fall just far enough so that the first and second vertebral bodies are separated, breaking the neck and quickly killing the victim. You do not want them to fall too far, as the head may come clean off and that is aesthetically unpleasant. Most people who die these days from hanging do not get a ‘good’ hanging; they suffocate at the end of a rope, a particularly gruesome way to die.

The vertebral artery is often damaged in suicidal hanging (2); “The vertebral artery was shown to be injured quite frequently (rupture, intimal tear, sub-intimal hemorrhage), namely in one quarter of all cases, and indeed in more than half taking into account the perivascular bleeding.” This easy injury is in part due to mechanical reasons “The vertebral arteries appear to be particularly susceptible to injury in trauma of the cervical spine because of their close anatomical relationship to the spine” (3).

A passive hanging (no drop) gives about 686 Newton’s of force around the neck for a 70 kg human. In chiropractic, “the mean force of all manual applications (is) 264 Newton’s and the mean force duration (is) 145 milliseconds (8)”. So a chiropractic neck manipulation, for a short period of time, can provide 38% the force of a hanging. And a bad hanging at that.

Neck injuries are not that frequent because the muscles of the neck prevent injury by preventing sudden, disastrous, movement. If you want to increase the chance of injury from relatively minor trauma, have the person relax. If the muscles are relaxed because the person is not expecting the trauma, the chance of injury goes up. It is why whiplash can occur after minor injuries (4). Chiropractors often have their patients relax just before the coup de grace, I mean manipulation, helping to maximize the chance of injury despite having less force applied to the neck than a noose and gravity.

Given the above, to claim that the VBA occurred before the patient had chiropractic neck manipulation is like saying the hanging victim had a broken neck, but it occurred on the steps up to the scaffold.
———————-

References and Snide Asides

“Hanging is too good for a man who makes puns; he should be drawn and quoted.”
Fred Allen

(1) evidently in the 1600’s the English, when the hung (hanged?) their prisoners had them suffocate and did not tie their legs to that the ghastly death dance would serve as a deterrent.

(2) Forensic Sci Int. 1984 Aug;25(4):265-75.
Injury of the vertebral artery in suicidal hanging.

(3) Neurosurgery. 1991 Dec;29(6):912-5.
Subintimal dissection of the vertebral artery in subluxation of the cervical spine

(4) And faking an injury to get money.

(5) I will relegate the issues of the author to a footnote, since I want to focus on the content of the article, but if one is judged by the company they keep.….http://www.chirowatch.com/Chiro-strokes/gm080120stroke.html.

(6) Caveat: I am not an epidemiologist nor a statistician. I took and dropped statistics each year I was in college. Not that I was bad at math, my undergrad degree was in physics (this is not bragging, well, yes it is)
So we have, at Good Samaritan Hospital, a bunch of real smart residents, a few of them, such as the resident on my service, are trained in epidemiology and such studies.
Since 3 out of 2 Americans do not understand statistics, and I am one of those people, so I asked one of my residents to help explain the article to me.

(7) Or the soy protein for you vegans.

(8) http://www.aetna.com/cpb/medical/data/100_199/0107.html

(9) Written two weeks before the movie released.

(10) The Who. I know they are old, but they did get the record as the worlds loudest band. My son says Motorhead is louder. I don’t know. Let me know what the worlds loudest band is, it you have a moment.

(11) Elderly. Crap. I’m 51 and I’m now calling those in their 50’s elderly. But then I do have my ARUP card, so I can get cranky any time I want for any reason I want. Damn kids and their tattoos/visible underwear/goatee/boom box. In my day, well, my day was the day of the hippie. I suppose I have nothing, really, to complain about. Pop culture of my youth was worse.

(12) Copyright Paul Harvey, all rights reserved. Do not use without express written approval of Major League Baseball

(13) To give the DC their due, they have a complete discussion of the potential drawbacks of the study in the discussion that includes most of the issues I raise here. But, as mentioned, you have to get past the abstract.

(14) The odds ratio compares whether the probability of an event is the same for two groups. An odds ratio of 1 implies that the event is equally likely in both groups. An odds ratio greater than one implies that the event is more likely in a group. An odds ratio less than one implies that the event is less likely in a group.

(15) This is sarcasm.

(16) Superman never married Lois Lane, at least in the 1970′s.

(17) Or talking out your …. Steve wants us to be upscale. Never mind.

___________________________________________________

7/19/08 Addendum

Since the initial post, thanks to the comments, I have come up with an alternative hypothesis to account for the data. Like the authors, it is neither proven nor disproved by the data, but I think has more plausibility than their explanation.

There is a baseline number of VBA strokes in a population. When patients have serious symptoms, they tend to preferentially seek care with MD’s rather than alternative providers. The group patients who sought care from their primary providers were indeed having incipient VBA strokes. It is why they went to the doctor.

The other group, who were not having an incipient VBA stroke (suggested by the codes for chiropractor visits) had neck manipulation and VBA strokes were induced in this population to a the rate equal to or exceeding the rate of the PMD group.

The study could be interperted that visits to a chiropractor for neck manipulation induce strokes at a rate equal to or greater than the control population ie those presenting with stroke.

Again: a hypothesis. It explains the data as well as the authors, and with more plausibility when viewed in the light of anatomy and physical forces to the neck, other uncontrolled clinical observations :), and prior epidemiologic studies of the association for manipulation and stroke.

Posted in: Chiropractic

Leave a Comment (113) ↓

113 thoughts on “Chiropractic and Stroke: Evaluation of One Paper

  1. SIXinternational says:

    Minor correction –

    “Go to the website whatstheharm.com and peruse the chiropractic section.”

    The site you are looking for is whatstheharm.net – specifically http://whatstheharm.net/chiropractic.html – lest people get confused.

  2. Six – thanks, fixed.

  3. Joe says:

    Thanks for that!

    To quote the paper “Our results suggest that the association between chiropractic care and VBA stroke found in previous studies is likely explained by presenting symptoms attributable to vertebral artery dissection.”

    So, why haven’t they figured out that they should not snap the necks of people who present with symptoms (headache, sore neck) of VAD??!!

    I was under the impression that there is at least one more survey suggesting that chiros are blameless in that Spine supplement. So, I wanted to look at the original issue, rather than simply ordering a reprint. Unfortunately, that involves a trek to the big city (Springfield, MA) and the, usual, arduous search for a parking space near the college. Another thing I hoped to see was the “referee” status of the articles. After all, if it is simply conference proceedings, or refereed by chiros, it can easily be dismissed as unreliable.

    The chiros are crowing over this publication in a “reputable” journal; but if the standards are the same as for their quack journals, it doesn’t count. If Spine is usually reliable, what induced them to publish this stuff?

  4. qetzal says:

    Our results suggest that the association between chiropractic care and VBA stroke found in previous studies is likely explained by presenting symptoms attributable to vertebral artery dissection.

    For this to be correct, wouldn’t you also have to postulate that when patients experience these symptoms, they disproportionately seek help from chiropractors rather than PCPs? I know there are a lot of people seeing chiro’s in the US, but are they really 5-12 times more likely to see a chiro for the sudden onset of symptoms related to dissection? That sounds far-fetched to me.

    I suppose an alternate possibility is that chiros don’t recognize the incipient dissection, so the patients are likely to progress to stroke. In contrast, PCPs could be much more likely to make a correct diagnosis and take steps that prevent subsequent stroke.

    That’s not a very chiro-favorable interpretation either.

    Third option is I’m misunderstanding something here. If so, please set me straight.

  5. vinny says:

    Very nice study review. There are other posibilities for why young people might seek out chiropractic rather than medical care to treat their neck symptoms and as you emphasized, correlation is not causation. Nevertheless, based on this review, I would be even more hesitant to recommend chiropractic care to anyone.

  6. qetzal says:

    Oops! Looks like it’s option 3 – my misunderstanding.

    The OR = 12 cited in the post relates to VBA strokes occurring within 1 day of a chiro visit in patients < 45 yr. By comparison, the OR for VBA strokes within 1 day of a PCP visit is 11.2 (Table 4 of the paper).

    So I was wrong to think that strokes were 12-times more likely after chiro than after PCP. In fact, the odds are not detectably different for chiros versus PCPs.

    Dr. Crislip mentioned that in the original post (note to self – read more carefully next time!):

    They emphasize in abstract, which is all anyone will read, that there were equal strokes after visits to chiropractic and primary care physicians. They do not bother to mention the increase association in the young until you reach the discussion, which most will not read.

    But now the point of Dr. Crislip’s second sentence eludes me. Yes, the association increases in the young, but it increases equally for both chiro and PCP visits. As far as I can tell, the authors are completely correct to say their study “found no evidence of excess risk of VBA stroke associated chiropractic care compared to primary care” (my emphasis).

    Of course, the lack of evidence may simply be due to the methodological flaws discussed above. But I no longer see how this paper can reasonably be called one of “three studies that now show an increase in the stroke rates in the young after neck manipulation.”

    Once again, if I’m misunderstanding, I hope someone will set me straight.

  7. DavidCT says:

    Now I have to find a way to convince a good friend that having his neck “cracked” on a fairly regular basis is not a good idea. If that fails perhaps having his wife nag him about beefing up his life insurance will help.

    Some people find these blogs informative. Others already know everything. Thanks for the effort!

  8. overshoot says:

    Everyone has a hot button. Most of us have more than one.

    One of mine is the use of apostrophes in plural nouns by otherwise literate people.

    (Sorry ’bout that — maybe I should have mentioned mercury?)

  9. Spiv says:

    Boom boxes? Dr, I’m afraid your condition is indeed in an advanced state. In the 21st century we get our music from the the infamous “series of tubes.”

    Seriously though, it’s good to see a real breakdown of this study. I’d heard of it, but like so many others I had only seen the abstract and couldn’t help but wonder about the data itself.

  10. pmoran says:

    I have also looked at the study and would add to the concerns. In my country a patient developing symptoms from a VB dissection after neck manipulation (often a gradual process) would almost certainly see be seen by a doctor before being referred to hospital. This would seriously contaminate the PCP figures and it does not seem to be allowed for in the data .

    You would also expect patients with the more obvious symptoms of a stroke (listed by Mark) to preferentially see a PCP rather than a chiropractor.

    As Mark says, the study is not well suited to detecting a rare cause of a rare condition. I expect improving less invasive imaging technology will soon enable the more ready diagnosis of vertebral artery dissection and the situation will become clearer.

  11. Harriet Hall says:

    “the association between chiropractic care and VBA stroke found in previous studies is likely explained by presenting symptoms attributable to vertebral artery dissection”

    There is one thing none of these studies even attempts to refute: the fact that healthy patients with no prior symptoms even vaguely suggestive of stroke have collapsed on the chiropractor’s table with vertebral artery tears. That is the elephant in the room.

    Studies like this are efforts to distract us from what even the chiropractic journals and forums recognize as a small but real danger.

  12. nwtk2007 says:

    500 deaths everyday due to medical mistakes, not just tough cases and complications, but mistakes …… and that is not an elephant in the room? What would that be? About a million elephants compared to this one?

    And small but real is the key, which hopefully will be eliminated as a risk by chiro’s very soon.

  13. Harriet Hall says:

    nwtk2007 said,

    “500 deaths everyday due to medical mistakes”

    Whether or not that is true, it is irrelevant to this discussion. You are trying to divert our attention with the tu quoque logical fallacy.

    “hopefully will be eliminated as a risk by chiro’s very soon.”

    I’ve been attentively watching this issue for several years now, and I haven’t seen any evidence that chiropractic is doing anything to reduce the risk. Maybe a few individual chiros, but the great majority believe in subluxations and do inappropriate manipulations and do not get informed consent. Do you know something I don’t? What chiropractic school or organization has come out with a statement that that type of neck manipulation should be avoided, especially for ridiculous indications like “maintenance” and tailbone pain?

    All I’ve seen from the chiropractic community is defensive posturing and protestations that these disasters are “very rare.” But maybe I’ve missed something. Show us your evidence.

  14. Mark Crislip says:

    “500 deaths everyday due to medical mistakes”

    Of course. Thats what I missed in the paper.

    Its should not be called the tu quoque logical fallacy.

    It should be called the “oh yeah? well you are fat” fallacy.

    It was a poor study. It is used by some as evidence that chiropractic is safe because strokes diagnosed after a visit to a chiropracter were present before the visit.

    The key point of the review is that conclusion is a hypothesis and is not proven from the data in the study and it cannot be used on that basis as evidence that chiro is safe. The study says nothing about the safety of chiro and suggests it is not safe in the young.

    Is it dangerous? biologic and physical plausibility, suggestive epidemiologic studies and numerous uncontrolled clinical observations. makes me nervous.

  15. DLC says:

    In my less-skeptical youth, I saw a chiropractor for lower back pain.
    The fact is, my big stomach had much more to do with my lower back pain than any amount of fictional subluxations or bad energy or whatever the woo is nowadays.
    Fortunately for me, I survived the experience, poorer but wiser.
    I lost weight and most of my back problems also disappeared.
    unfortunately, in the intervening two decades I gained the weight back, and now have back problems again. But, I hope you will excuse me if I attempt to lose weight instead of seeing a chiropractor, this time.

  16. pook says:

    Interesting article below. I believe one of the skeptics here voiced his support for the manmade global warming theory. Seems like we are not to be blamed after all and the weather is in God’s hands.

    http://www.dailytech.com/article.aspx?newsid=12403

  17. nwtk2007 says:

    Harriet, I like that, the “tu quoque logical fallacy”

    You are exactly right.

    That is exactly the point.

  18. qetzal says:

    Mark Crislip wrote:

    The study says nothing about the safety of chiro…

    I agree with that. Or at least, it merely says chiro is not so wildly unsafe that they could detect it with their insensitive analysis.

    …and suggests it is not safe in the young.

    I still don’t see this part. The OR for VBA stroke within 1 day of a chiro visit was not different than the OR for VBA stroke within 1 day of a PCP visit. Chiro was no more likely to be associated with stroke than was a visit to the PCP. I saw nothing else in the paper to suggest that chiro caused VBA stroke.

    Please understand – I’m not arguing that chiro is not a cause of stroke. I’m only questioning your interpretation of this specific paper.

    If I’m missing something here, I’d much appreciate your pointing it out. Thanks!

  19. Harriet Hall says:

    nwtk2007 said,

    “Harriet, I like that, the “tu quoque logical fallacy” You are exactly right. That is exactly the point.”

    I think you missed the point. In case you don’t know what tu quoque means, I’ll explain. A is accused of murdering one person. He defends himself by saying, “Well, B murdered two people.” That may be true, but it in no way diiminishes A’s crime. You try A for murder. B may need to be tried for murder too, but his crime has no bearing on A’s case.

    In some cases it is abundantly clear that chiropractic neck manipulation was the direct cause of a stroke.

    I’m still waiting for your evidence that those manipulations are justified. If there is no benefit compared to other, safer treatments, why keep doing them?

    I’m still waiting for your evidence that the chiropractic community is taking any measures to reduce the risk.

  20. Mark Crislip says:

    I added this to the initial post as well
    7/19/8 Addendum

    Since the initial post, thanks to the comments, I have come up with an alternative hypothesis to account for the data.  Like the authors, it is neither proven nor disproved by the data, but I think has more plausibility than their explanation.

    There is a baseline number of VBA strokes in a population.  When patients have serious symptoms, they tend to preferentially seek care with MD’s rather than alternative providers. The group patients who sought care from their primary providers were indeed having incipient VBA strokes. It is why they went to the doctor.

    The other group, who were not having an incipient VBA stroke (suggested by the codes for chiropractor visits) had neck manipulation and VBA strokes were induced in this population to a the rate equal to or exceeding the rate of the PMD group.

    The study could be interperted that visits to a chiropractor for neck manipulation induce strokes at a rate equal to or greater than the control population ie those presenting with stroke.

    Again: a hypothesis. It explains the data as well as the authors, and with more plausibility when viewed in the light of anatomy and physical forces to the neck, other uncontrolled clinical observations :), and prior epidemiologic studies of the association for manipulation and stroke.

  21. nwtk2007 says:

    Harriett – “I think you missed the point. In case you don’t know what tu quoque means, I’ll explain. A is accused of murdering one person. He defends himself by saying, “Well, B murdered two people.” That may be true, but it in no way diiminishes A’s crime. You try A for murder. B may need to be tried for murder too, but his crime has no bearing on A’s case.”

    No, I got it. Except in this case A is accused of murdering one person, but B is actually guilty of murdering 500 everyday. A stands only accused at this point.

  22. Harriet Hall says:

    nwtk2007,

    It sounds to me like you didn’t get it at all. “You’re guilty too” is not a valid argument, whether it’s 2 or 2000.

  23. Blue Wode says:

    The latest on this topic from Neck911:
    http://tinyurl.com/6jln32

  24. nwtk2007 says:

    Harriett says – “It sounds to me like you didn’t get it at all. “You’re guilty too” is not a valid argument, whether it’s 2 or 2000.”

    In this case it’s more like 150,000. Per year.

    In the debate world of argument fallacies, you are correct, but in the real world, the world of reality, it is valid. Absolutely valid.

  25. weing says:

    nwtk2007,
    I’m skeptical of your numbers.

  26. nwtk2007 says:

    Weing – “I’m skeptical of your numbers.

    Not my numbers. Check out the following link,

    http://www.ahrq.gov/qual/errback.htm

    Also, search “medical mistakes” or “medical errors” on you tube and you’ll find a video done by an MD in New York. In his works the equivalent of a jumbo jet crash everyday.

  27. weing says:

    Do you mean you trust MDs? If I were you I wouldn’t trust him. Sounds downright dangerous to me.

  28. Harriet Hall says:

    I said “You’re guilty too” is not a valid argument, whether it’s 2 or 2000.”

    nwtk replied “In this case it’s more like 150,000. Per year. In the debate world of argument fallacies, you are correct, but in the real world, the world of reality, it is valid. Absolutely valid.”

    nwtk, you still don’t get it. Let’s start over and see if you are capable of understanding. We were talking about injuries due to chiropractic. Whatever number of injuries are due to MDs, it has no bearing whatsoever on the question we were discussing.

    It seems you want to raise a totally different subject: whether MDs do more harm than chiropractors. I asked you to read my article “Death by Medicine” which raises some of the fallacies in accusing MDs of those deaths. It is ludicrous to compare a chiropractic-induced stroke in a healthy young person to a terminal cancer patient whose life is prolonged by modern medicine but who eventually dies because a risky last-ditch treatment effort fails. The absolute rate of errors in either case should be balanced against the good that is done: only the risk/benefit ratio is significant.

    You are trying to justify the harm done by chiropractors by implying patients would have been harmed more if they had seen MDs. If you want us to take you seriously, what you need to do is provide evidence that a patient with any given symptom or lack of symptoms will have a better outcome seeing a chiropractor than seeing an MD. I know of no such evidence.

  29. nwtk2007 says:

    Harriett – “It is ludicrous to compare a chiropractic-induced stroke in a healthy young person to a terminal cancer patient whose life is prolonged by modern medicine but who eventually dies because a risky last-ditch treatment effort fails. The absolute rate of errors in either case should be balanced against the good that is done: only the risk/benefit ratio is significant.”

    Are you so biased and blind in your beliefs that you don’t see the difference in what you are siting here and a medical mistake?

    There is clear deliniation between cases like the terminal cancer patient and medical mistakes that kill people an estimated 500 times per day. And you know that Harriet. That is why in the real world it is significant to accusations of risk in chiropractic. You cannot be a part of a group that kills 500 everyday by mistakes (incompetence) and go throwing stones at chiropractic for it’s fractional risk.

    Chiropractic needs to take a hard look at the risks of cervical manipulation, but if that is so, then medicine needs to take a much, much harder look at their level of mistakes. The harm to the public is gargantuan compaired to harm from chiropractic.

  30. Harriet Hall says:

    ARRGH!!
    CAN SOMEONE PLEASE EXPLAIN TU QUOQUE TO NWTK2007?!!

    He still doesn’t understand that tu quoque is a logical fallacy, that he can’t defend chiropractic by attacking medicine. And he still doesn’t understand the fallacy of measuring harm without putting it into a risk/benefit ratio. He just doesn’t get it.

    Apparently he can’t read, either, because he says there are 150,000 deaths a year from medical errors and cites a source that estimates 44,000 to 98,000.

  31. nwtk2007 says:

    If you go to the following link, this Dr says it is the equivalent to a jumbo jet crashing everyday, about 500/day.

    At that rate it is about 182,000 per year.

    And don’t think I am defending chiro, I am accusing medicine. I am pointing out to the self righteous chirobashers who use the risk of manipulation as the basis of their attack, that they are the pot calling the kettle black.

    It is interesting that anti Alt’s and anti-chiro’s can scoff at the low risk of chiro manipulation in the face of what the medical community does thru their idiot mistakes on a day to day basis.

    I know what you’re saying with the logical fallacy crap, but you need to be aware, and I am sure you are but just won’t admit it, your risk/benefit ratio does not apply to mistakes, it applies to risk of the procedure. Risks of a procedure needed based upon EBM is not the same as mistakenly killing someone by doing the wrong thing, reading a chart wrong, being ignorant of drug interactions, etc.

  32. Fifi says:

    nwtk – What group of chiropractors do you represent? You made the claim in another thread that you represent a group of chiropractors who don’t believe what most chiropractors believe and what is taught at your Alma Mater. Clearly you don’t belong to or represent the small collection of chiropractors who practice EB chiro since they acknowledge the risks of arterial tearing and stroke that accompanies neck manipulations. So which group ARE you here representing? And what do you believe and base your practice upon if it’s not EB nor what your Alma Mater teaches (and most chiropractors believe)?

  33. Joe says:

    nwtk2007 on 23 Jul 2008 at 3:05 pm wrote “And don’t think I am defending chiro, I am accusing medicine.”

    That just emphasizes your ignorance (which I cited on the post in which you fantasized about me). The topic is a serious problem with chiropracty, problems in medicine are irrelevant. Your inability to defend chiro is significant, and noted.

  34. Calli Arcale says:

    Well, then here’s a question for you, ntwk. Why are you wasting space attacking medicine in a thread about the perils of chiropractic, if it is not to divert attention away from the perils of chiropractice?

    In case you hadn’t noticed, this blog is about ALL medical screwups, whether they are promoted by MDs or people who consider themselves “alternate”. There are other posts which pertain to the sort of thing you’re talking about. Yet rather than post your attacks there, you post them here. Interesting. It is possible you are innocently offtopic, but it is difficult for readers to avoid the conclusion that this is deliberate on your part, and that you are less interested in the truth than you are in denigrating “mainstream medicine”.

    If you wish to change people’s impression of you, I recommend trying to avoid drawing threads off topic to discuss your pet topic of the horrors of modern medicine, especially when you do this so vociferously that it makes it difficult to carry on the original discussion. But that’s up to you.

    Meanwhile, I think I can explain what Harriet Hall was telling you. Errors will occur in any medical field, whether it’s oncology or chiropractic. (There should not be a dichotomy between medicine and alternative medicine. I am adamant about that. The only ones who want such a split are the ones who want special treatment for “alternative” medicine, and no medicine should be exempt from the regulation. There’s too much potential for harm, and too much temptation for the unprincipled.) But the errors are far more likely to have fatal consequences when one is treating terminally ill cancer patients than when one is treating healthy adults. This does not excuse mistakes in any field. But it does predict a skew in the results that is not the result of MDs and DOs being more incompetent than alternative medical practitioners. It is merely the result of the stakes being so much higher on one side than the other. This may be a type of selection bias.

    Another problem, more difficult to quantify, is the fact that while hospital records are regulated very tightly, the same is not true of many alternative medical practitioners, in part because of wildly varying standards from state to state, and the lack of consistent reporting streams for alternative medicine. This alone predicts that more errors will be reported for “mainstream medicine” than for things like chiropractic. This would be reporting bias. It’s hard to quantify this bias, since it would involve knowing how much is not reported when all you have to go on is the reports themselves.

  35. Fifi says:

    nwtk2007 on 23 Jul 2008 at 3:05 pm wrote “And don’t think I am defending chiro, I am accusing medicine.”

    Well at least nwtk is admitting that what he does ISN’T medicine and may even be diametrically opposed and be anti-medicine* ;-)

    *I guess the motto for anti-medicine would have to be “First do some harm…then they have to come back for more “cure”!”

  36. nwtk2007 says:

    FiFi – “Clearly you don’t belong to or represent the small collection of chiropractors who practice EB chiro since they acknowledge the risks of arterial tearing and stroke that accompanies neck manipulations. ”

    nwtk2007 said this, just a few posts ago,

    “Chiropractic needs to take a hard look at the risks of cervical manipulation,”

    followed by,

    “but if that is so, then medicine needs to take a much, much harder look at their level of mistakes.”

    This is called perspective. If you can’t see that, then your biases have truly blinded you.

    Off topic? Not when brought up as a matter of perspective.

    And I will also point out, the risk of arterial dissection is still not clear and is rare enough to be debated. The harm from medical mistakes is not debatable. It is fact. Once again, perspective.

    The evidence of risk of stroke related to manipulation of the cervical spine is still only a very slight correlation, not a causation, to put it in the EBM terms. If I were to promote any benefit from say, vit C, and it were supported by as much evidence as stroke and manipulation, the regular posters on this forum would crucify me and call it anecdotal at best and that it was placebo effect.

    Apply the same standards of EBM to stroke with manipulation and that is all you have.

  37. nwtk2007 says:

    #####*I guess the motto for anti-medicine would have to be “First do some harm…then they have to come back for more “cure”!”#####

    I think the best pro-medicine motto would be “Let’s try to make fewer than 500 deadly mistakes per day.”

    I know, too off topic. I will not mention it again, unless provoked.

  38. Harriet Hall says:

    nwtk2007,

    When a healthy asymptomatic young woman has her neck manipulated for a useless indication, collapses on the table, and is found to have tears in both vertebral arteries, you don’t just have a correlation or an anecdote, you have a smoking gun. Whatever the statistical studies show, there are at least some strokes that are obviously due to neck manipulation. To deny that is like saying the knife didn’t cut the man, he was going to bleed anyway.

  39. Harriet Hall says:

    nwtk2007 said,

    “I think the best pro-medicine motto would be “Let’s try to make fewer than 500 deadly mistakes per day.””

    That’s essentially what medicine does – tries to identify errors and find ways to reduce them. Do you have any idea how many articles there are in the medical literature adressing those problems? Evaluating programs to see how much they reduce errors? The very error statistics you cite are estiimates of the “establishment” itself. If chiropractic had some something similar, I’d have more respect for it. Instead of addressing the stroke issue and renouncing maintenance adjustments of the neck, they have gone into defensive denial.

  40. nwtk2007 says:

    I hear what you’re saying and I totally agree.

  41. Versus says:

    The American Chiropractic Association sent the Cassidy article along with the rest of this issue of Spine (which dealt mostly with neck pain) to over 16,000 U.S. neurologists, at about $12 per mailing. I do wish that the Science-Based Medicine blog authors would use their collective clout and urge the American College of Neurologists to issue a reponse, either in Spine or in one of their journals, pointing out the flaws in this study, as aptly summarized by Dr. Crislip. A sort of “thanks but no thanks,” if you will. Interestingly, I don’t think any of the Spine articles supported the use of cervical manipulation for neck pain, but I have not had a chance to look at all of them. They certainly didn’t support the use of cervical manipulation for treatment of allergies, asthma, painful periods, earaches, colic, and the other conditions chiropractors claim they can improve by reducing cervical “subluxations” with manipulation. (As Dr. Hall correctly points out, if there’s no benefit, why try it?) It’s all very well to dissect this study in a blog, but a “counter-article” would be even better.

  42. EBC says:

    Well let us not forget that the intention of a chiropractor is to help people suffering from spinal disorders. In doing so the treatment of choice is spinal manipulation. I think the ignorance on this blog, and in society in general, perpetuates the animosity, hatred, and cruelty I read towards chiropractors. I mean the logical and mechanisms behind a spinal manipulative treatment is easy to understand and is never intended to harm anyone. A chiropractors job is to find areas in the spine which have lost their normal range of motion. Older chiros called these areas “subluxations”, now they are referred to as “hypomobile spinal articulations”. These stiff spinal joints are often responsible for neck and back pain. The only way to restore movement to these areas is by a gentle procedure called spinal manipulation. The forces involved are very gentle. The rational behind the treatment is to reduce the scar tissue in the facet capsule that is causing the loss of motion. The spinal manipulation procedure also stimulates propriocepters (motion detectors in the joints) which facilitate multifidus core muscle activity. This is important because weak inhibited core muscles predispose a person to spinal injury. Another fact is chiropractors are the best trained spine doctors (second to neurosurgeons & some orthopaedic surgeons) who are taught to screen patients for serious pathology or other contraindications for treatment. Unfortunately a handful of DC’s missed a handful of stroke cases as the study outlined. MD’s are not perfect either! I had a patient come in to my office who had just been to her MD & the MD told her she had a pinched nerve in her neck and then prescribed her the usual NSAIDS, and muscle relaxers. Well due to persistent symptoms she came in to my office and in about 5 minutes I realized she was in the middle of a ischemic stoke. So she was sent to the hospital and treated (But wait I’m suppose to be a quack chiro who just “cracks” peoples necks with no exam or thought process!?!?). Other people claim that chiros twist people’s necks around and have directly caused the dissection. Well in a cervical spinal manipulation treatment the neck is NOT rotated! It’s a lateral flexion move and the gentle force is specific to one vertebrae. Also considering there are about 3 million cervical adjustments done EVERY week day (this is per day) I would say cervical adjustments are extremely safe. A local chiropractic school here in San Jose, called Palmer West, has NEVER had any type of injuries associated with spinal manipulation in the past 30 years and these are students who are still learning how to do spinal manipulation! Oh and by the way, only a very small percentage of DC’s (maybe 5%) still claim that pressure on nerves can cause organ dysfunction; so that’s a weak argument that does not apply to the majority.

  43. nwtk2007 says:

    That was a pretty good summary of what I have been telling these guys for weeks now.

    But them not being chiropractors, I guess they know better.

    5% might be about right also because I know of none who treat or claim to treat organ dysfunction with manipulation.

    One response you will most definitely get here is the “tu quoque” cry. By pointing out the MD case they will inevitably say “What has that got to do with chiropractic?” and “They’re bad so it’s OK for me to be bad is not a defense of chiropractic.”

    By pointing out this stuff here, we are essentially casting pearls to the swine, but it is fun and helps me to think through and clarify what I do on a daily basis.

  44. Harriet Hall says:

    Nice try, EBC, but “intentions” and anecdotes and opinions and unsupported claims don’t trump Dr. Crislip’s trenchant analysis of a flawed study. You have a very rosy view of chiropractic that doesn’t match the reality we see.

    You haven’t demonstrated that there is any “ignorance” on this blog, and any animosity you may perceive is directed at pseudoscience and poor science, and certainly not at chiropractors who have critical thinking skills and use them to limit their practice appropriately.

    nwtk2007,
    5% might be about right, or it might about wrong. Instead of throwing out guesses, how about citing some actual statistics? How about some pearls of science for a change?

  45. nwtk2007 says:

    How about some admission that chiropractors and chiropractic isn’t what this blog and others anti-chiro say it is.

    EBC is totally correct in what he says about what chiro’s do these days. Very few try to treat anything more than musculoskeletal problems. Most treat neck and back pain, some do more with extremities, other’s specialize in atheletic problems and injuries, and many, like myself, treat injuries to the neck, back, shoulders, knees, etc.

    You say “chiropractors who have critical thinking skills” implying that many don’t. What an ad hominem bias and what a copy of what other bloggers here have said before you ever thought to say it. Your medical profession is filled with “dr’s” who couldn’t critically think their way out of a paper bag because all they can do is recite. Most write scripts and that is about it. The one’s that do more are the ones we work with.

    Your refusal to admit the truth is also evidence of your bias, which you claim you have none of, since you are so precisely accurate about what science is. Obviously, only you know what true science is. Please.

    What you have here is snob science. Your nose scrapes the very cieling of true respectability in the science world.

  46. Blue Wode says:

    nwtk2007 wrote: “EBC is totally correct in what he says about what chiro’s do these days. Very few try to treat anything more than musculoskeletal problems.”

    Can you produce good evidence in support of that claim?

    It doesn’t seem to be compatible with research that was conducted in 2003 which revealed that 89.8% of North American chiropractors felt that spinal manipulation should not be limited to musculoskeletal conditions. [McDonald W, Durkin K, Iseman S, et al W. How Chiropractors Think and Practice: The Survey of North American Chiropractors. Institute for Social Research, Ohio Northern University]

    It also seems to be at odds with a survey which was carried out by the World Federation of Chiropractic (WFC) in 2004 which gave the following percentages for chiropractors who thought that the phrases below described the chiropractic profession “perfectly” or “almost perfectly”:

    Quote:

    “Management of vertebral subluxation and its impact on general health”

    - 65% of chiropractors said that the general public should perceive chiropractic that way

    “Management of vertebral subluxation”

    - 56% of chiropractors said that the public should perceive chiropractic that way

    http://tinyurl.com/4thm9w (See page 30)
    [WFC Consultation on Identity: Quantitative Research Findings, December 7th, 2004]

    BTW, for anyone who isn’t aware of how chiropractors practice in the UK (where the scope of chiropractic isn’t defined by law), here is what a recent survey revealed:

    Quote:

    “Overall, mechanical conditions of the musculoskeletal system were felt to be treated effectively by chiropractic intervention and there was 100% agreement that it was beneficial in treating mechanical dysfunctions of the spine. Non-musculoskeletal conditions in adults, including asthma (64%), gastro-intestinal complaints (61%) and pre-menstrual syndrome (PMS) (70%), were considered conditions that can benefit from chiropractic management. Opinions on the treatment of osteoporosis (43%), obesity (26%), hypertension (42%) and infertility (30%) were less conclusive. Childhood musculoskeletal and muscular conditions, infantile colic, otitis media and asthma were perceived to benefit from chiropractic intervention by more than 50% of the respondents.

    -snip-

    Traditional chiropractic beliefs (chiropractic philosophy) were deemed important by 76% of the respondents and 63% considered subluxation to be central to chiropractic intervention.”

    http://tinyurl.com/599vfs
    [Aranka Pollentier and Jennifer M. Langworthy, The scope of chiropractic practice: A survey of chiropractors in the UK, Clinical Chiropractic, Volume 10, Issue 3, September 2007, Pages 147-155.]

    Returning to the main topic of this thread, it’s worth noting a report in this week’s news that a chiropractor in New Zealand has been advised to apologise to a *33-year-old* woman patient who suffered a stroke after he treated her:
    http://www.nzherald.co.nz/nz/news/article.cfm?c_id=1&objectid=10532931

  47. Joe says:

    EBC does not like the term subluxation, many other chiros are embarrassed by it as well. Therefore by 1998 they were using more than 300 synonyms for it http://www.dynamicchiropractic.com/mpacms/dc/article.php?id=37512

    What do the high priests of this cult have to say about subluxations? The Association of Chiropractic Colleges (2008): http://www.chirocolleges.org/paradigm_scopet.html “Chiropractic is Concerned with the preservation and restoration of health, and focuses particular attention on the subluxation.”

    What does the ordinary chiro think? “How chiropractors think and practice” William P. McDonald et al “Seminars in Integrative Medicine” 2004 V.2 #3 92-98: The text says 89% of chiropractors believe in subluxations, and this is a survey by a chiropractor. Also, according to the abstract http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B75KC-4F1H9GS-5&_user=10&_rdoc=1&_fmt=&_orig=search&_sort=d&view=c&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=754fe88415cd702aa52be6484f7005b8 “ >75% of the respondents empirically find that the adjustment of the vertebral subluxation complex usually elicits improvements in select visceral ailments.”

    EBC, the bottom line is- it does not matter what you call it, it still does not exist.

    The McDonald survey found nine out of ten believe in subluxations, three in four think they can treat visceral illness, one in five are straight (adjust the spine regardless of the problem). My local paper carries an ad for a chiro offering a deeply discounted, introductory exam; including taking an x-ray (without any reason for doing so). Yet, the chiros that post here want us to believe they cannot find those quacks with two hands and a flashlight? It strains credulity.

    I see Blue Wode has already cited the McDonald survey; but I had something to add.

  48. nwtk2007 says:

    You are not presenting anything new here and you are greatly exaggerating the content.

    I’ll not even bother with further explanation as it will fall on deaf ears except to say that it is typical of the anti-chiro group to twist info regarding chiropractic.

    There is nothing contradictory in those studies sited and what I have said about how chiropractors I know work.

    The fact is that you want chiro’s to make claims of treating medical conditions so you can bash their credibility. It is the essence of what you need to do what you love to do, bash chiropractic.

    I treat injuries but at the same time I see changes for the better in many of the conditions sited in those studies. I don’t treat those conditions but I see the effects. To deny it would be to deny my own eyes.

    How those changes occur is a topic for debate and research, which in some cases has happened and in others is happening and in others has not happened.

    You can keep trying but no matter how you twist the content of surveys or exaggerate their meaning, it will not change anything.

  49. Harriet Hall says:

    “I’ll not even bother with further explanation as it will fall on deaf ears ”

    Translation: I don’t have any evidence to counter the evidence you’ve presented.

    “I see the effects. To deny it would be to deny my own eyes.”

    Translation: forget science; testimonial evidence a la 1600 is good enough for me.

    And for the record, my comments about respecting people with critical thinking skills was in no way ad hominem nor an attack on the intelligence of chiropractors. It applies to everyone, not just to chiropractors. There are plenty of medical doctors and PhDs who lack critical thinking skills, and I point out errors wherever I see them.

    You claim we love to bash chiropractic. I claim we hate to see unsupported claims anywhere. We love science and reason.

    Edzard Ernst, the world’s first professor of complementary medicine, has spent 15 years looking for scientific evidence to support alternative medicine. His conclusion about chiropractic: “Chiropractors, on the other hand, might compete with physiotherapists in terms of treating some back problems, but all their other claims are beyond belief and can carry a range of significant risks.” If you fully understand why he came to that conclusion, perhaps you can show him where you think he went wrong.

  50. Joe says:

    nwtk2007 on 21 Sep 2008 at 11:18 am wrote “… you are greatly exaggerating the content.

    “… it is typical of the anti-chiro group to twist info regarding chiropractic.”

    You have some explaining to do.

    I cited your educational association saying the subluxation is the core of chiropracty. How is that exaggerated or twisted? I cited a survey by a chiro showing that 9 in 10 chiros believe in subluxation, I did not even ask how many more would agree if their pet names for subluxation were included. How is that exaggerated or twisted?

    Good advice in a debate is “Never ask a question whose answer is not known to you.” And I know the answers to the questions I posed- What I wrote is factual and neither exaggerated nor twisted. NWTK would just like them to be, because s/he has no contravening data.

    It seems that nwtk would like to leave open the possibility that the bizarre claims of chiro may be valid:

    nwtk2007 on 21 Sep 2008 at 11:18 am wrote “How those changes occur is a topic for debate and research, which in some cases has happened and in others is happening and in others has not happened.”

    Great! Cite the cases where reliable research has “happened” and been shown to support any chiro claim. That’s what we await.

  51. nwtk2007 says:

    Joe, you’ve proven you will comment and criticize research without even reading it. You are the classic of this blog and yet you ask for evidence.

    I am still waiting for the scads of evidence that manipulation causes strokes other than a couple of “studies”, and, as you put it, anecdotal stories and claims.

    You have presented nothing but mis-interpreted survey hog wash which doesn’t begin to give the conclusions you would say they do.

    Try again.

    I am in the practice and what I have said is the way it is, despite what associations and surveys seem to indicate to you.

    You are not there. You don’t know.

  52. Harriet Hall says:

    nwtk2007′s next to the last comment amounted to “I don’t have any evidence but evidence doesn’t matter”

    His last comment amounts to “Trust me, I’m a chiropractor.”

  53. nwtk2007 says:

    No it doesn’t.

  54. EBC says:

    Joe do you believe in scar tissue? Do you understand the physiology of injury?

    A vertebrae that has lost it’s normal range of motion is considered by some chiropractors as a “vertebral subluxation”. The term that I use, so I don’t confuse medical physicians that are reading my reports and/or SOAP notes, is a hypomobile (loss of normal motion) spinal articulation.

    I’m not embarrassed by the “subluxation” term, I’m just more specifically describing what it is that I’m treating. A hypomobile spinal articulation is tender to palpation and is hypomobile to motion palpation. So this is not a believe system here Joe…it’s fact!

    The irony of this argument, as it relaties to the subluxation causing nerve interference which then may possibly cause dysfuntion in the body, is that today’s chiropractors from the best chiropractic college in the world (Palmer West) are taught in our second quarter of neurophysiology class, that it is IMPOSSIBLE for any dysfunction to happen in the body due to nerve interference. The instructor who teaches this class did a great paper that you can look up on Pubmed explaining the impossible relationship; “Somatic dysfunction and the phenomenon of visceral disease simulation: a probable explanation for the apparent effectiveness of somatic therapy in patients presumed to be suffering from true visceral disease”, by Nansel,D.

    If our organs needed the brain to function then people paralyzed from the neck down would never survive. Even though the father of medicine, Hippocrates, was the first to suggest “look to the spine as a cause of disease”, we now know disease is much more complex and is caused by a variety of factors.

  55. Joe says:

    EBC on 22 Sep 2008 at 5:10 pm wrote “… Do you understand the physiology of injury?”

    Do you?

    EBC on 22 Sep 2008 at 5:10 pm wrote “A vertebrae that has lost it’s normal range of motion is considered by some chiropractors as a “vertebral subluxation”. The term that I use, … is a hypomobile (loss of normal motion) spinal articulation.”

    How else can I explain this- it does not matter what you call it.

    EBC on 22 Sep 2008 at 5:10 pm wrote “The irony of this … ”

    Is that you admit that “… it is IMPOSSIBLE for any dysfunction to happen in the body due to nerve interference.” And then you cite an article in an unreliable, chiro magazine (JMPT), that purports to support the notion that chiro can still, somehow, be effective for visceral diseases. Archie Bunker (1970s TV show- “All in the Family”) would say “We need more of that kind of convoluted thinking.”

    Why argue? Just cite high-quality evidence for your therapeutic claims. Life does not get any easier than that, unless you lack the evidence; which you do.

  56. nwtk2007 says:

    Joe – “Is that you admit that “… it is IMPOSSIBLE for any dysfunction to happen in the body due to nerve interference.” And then you cite an article in an unreliable, chiro magazine (JMPT), that purports to support the notion that chiro can still, somehow, be effective for visceral diseases.”

    EBC did not admit anything. He said they were taught that.

    And of course, any article in JMPT is not going to be read by you Joe but you certainly will comment on it.

    You twist words better than any attorney could hope to do.

    What a ….

  57. EBC says:

    The point I was trying to make was to explain how chiropractors are not taught that nerve pressure causes disease.

    The doctor that wrote that article Joe is a neurophysiologist and an instructor at Palmer West College of Chiropractic.

    He is the first to let prospective chiropractors know that the “subluxation nerve pressure model” is invalid. Even if there was abnormal pressure on the sympathetic nerves there would not be dysfunction in the distal end organ because our organs are hormonally controlled for the most part.

    Therefore calling the stiff areas in the spine a “subluxation” would NOT be the same as a “hypomobile spinal articulation”, because a “subluxation” would suggest a neurological interference pattern, in which I am not claiming with a stiff spinal segment.

    The only neurological problem you would have with a hypomobile spinal articulation would be lack proprioceptive
    stimulation. The core muscles (multifidus muscle) depend on movement from the spine to function properly. Loss of zygopophyseal motion causes inhibition of the multifidus muscle.

    Joe is adamant about me finding a double blinded study which will prove the existence of a hypomobile vertebral segment. After a brief Pubmed search I did find one:

    Bunketorp Käll L., 2008. Assessment of motion in the cervico-thoracic spine in patients with subacute whiplash-associated disorders. J Rehabil Med.40(6):418-25.

    I will continue searching to find a high quality study to prove the existence of a stiff spinal joint. I think one of the only objective tests would be a motion xray, but then interpretation of spinal motion may be subjective as well.

    A consistent clinical finding I have discovered though is tenderness at the area of hypomobility in the spine. Immediately after a spinal manipulation treatment the area is considerably less tender and the segmental and overall range of motion improves.

    Plus 90% of the time the patient feels immediate improvement.

    Also I will be happy to give you some great research that’s not from JMPT which shows that spinal manipulation is superior to other forms of treatment for most cases of neck and back pain.
    When spinal manipulation is combined with multifidus core muscle strengthening exercises this combo is the best possible treatment one can do to treat and manage back pain.

    So Joe please explain to me how an NSAID or muscle relaxant is is helping someone with neck or back pain?

    Last time I checked NSAIDS interfere with healing, increase your risk of gastrointestinal disease, and increase your chance of stroke by 400%!

    This “natural” medical approach to spinal problems is the most ludicrous of them all!

  58. Joe says:

    EBC on 22 Sep 2008 at 9:24 pm wrote “The [chiropractor] that wrote that article Joe is a neurophysiologist and an instructor at Palmer West College of Chiropractic.”

    That does not matter, if he had good, reliable information he should have published it in a good, reliable journal.

    Although I no longer look at such magazines, even the title suggests that it is nonsense “… : a probable explanation for the apparent effectiveness of somatic therapy in patients presumed to be suffering from true visceral disease” See the weasel words ‘probable’ and ‘apparent.’ What is needed is a clinical demonstration that such an association exists (and that chiro can influence that relationship).

    EBC wrote “Joe is adamant about me finding a double blinded study which will prove the existence of a hypomobile vertebral segment. After a brief Pubmed search I did find one: Bunketorp …”

    First, you should look-up what is meant by double-blinded (that article is not). Then you should note that the paper is not about chiropractic, and does not support chiropractic.

    EBC wrote “A consistent clinical finding I have discovered …”

    Publish your discovery in a good journal! One is left to wonder why an effective process went unnoticed and is not standard practice.

    Let me help you with your research: Ernst, E. “Journal of Pain and Symptom Management” Volume 35, Issue 5, May 2008, Pages 544-562. It is behind a pay-wall OnLine.

  59. Joe says:

    EBC wrote “Joe is adamant about me finding a double blinded study which will prove the existence of a hypomobile vertebral segment.”

    Sorry, I mis-read. I don’t want to know if a hypomobile … exists. Subluxations exist, chiros just don’t treat them. Sorry if I was not clear that I don’t care what you call the object of your attention. I want reliable, clinical evidence of the effectiveness of chiro.

  60. nwtk2007 says:

    Joe – “First, you should look-up what is meant by double-blinded (that article is not). Then you should note that the paper is not about chiropractic, and does not support chiropractic.”

    Duh, Joe. That was the whole point; to suggest that what had been interpreted by some to be “cure” for visceral conditions, was not and might actually be misdiagnosed musculoskeletal conditions which mimic some visceral conditions.

    Still not reading.

    I could not find the Ernst article you suggested, not that you had actually read it, but did come across one, abstract only, -

    “Spinal manipulation (SM) is a popular form of treatment of back and neck pain, as well as of other conditions. Uncertainty exists as to its safety. The aim of this systematic review was to summarize the data of all prospective investigations into the safety of SM. Five independent literature searches were carried out to identify all such studies. Data were extracted and validated according to pre-defined criteria. Five investigations met the inclusion criteria. The most valid studies suggest that about half of all patients will experience adverse events after chiropractic SM. These events are usually mild and transient. No reliable data exist about the incidence of serious adverse events. These data indicate that mild and transient adverse events seem to be frequent. Serious adverse events are probably rare but their incidence can only be estimated at present. Further prospective investigations are needed to define their incidence more closely.”

    Particularly, “No reliable data exist about the incidence of serious adverse events.”

    and, “Serious adverse events are probably rare but their incidence can only be estimated at present.”

    Now, where are those double blind studies supporting your and other’s premise that chiropractic manipulation causes strokes. Show me some reliable, scientific evidence, as you would say Joe.

  61. Blue Wode says:

    Nwtk2007 wrote in response to Joe: “I could not find the Ernst article you suggested…but did come across one, abstract only”

    That one abstract only that you came across was published in 2001 [Ernst, E. Prospective investigations into the safety of spinal manipulation, J Pain Symptom Management 2001 Mar;21(3):238-42].

    In 2007, Ernst had a systematic review of adverse effects of spinal manipulation published in the Journal of the Royal Society of Medicine. Here are a couple of snippets from it:

    Quote:

    “Many authors have voiced doubt about the safety of spinal manipulation. A particular concern is stroke after upper spinal manipulation. The systematic review by Ernst and Stevinson, published in 2002, summarized safety data available up to 2001.6 Since then, an abundance of new evidence has emerged. The aim of this article is therefore to identify adverse effects of spinal manipulation published since 2001.

    -snip-

    The effectiveness of spinal manipulation for most indications is less than convincing. A risk-benefit evaluation is therefore unlikely to generate positive results: with uncertain effectiveness and finite risks, the balance cannot be positive.”

    This part, in particular, appears to address Nwtk2007’s concerns:

    Quote:

    “The chiropractic profession tends to downplay the risks: ‘chiropractic services are safe’;60 ‘the healthy vertebral artery is not at risk from properly performed chiropractic manipulative procedures.’61 Others argue that ‘the occurrence of cerebrovascular accidents in the chiropractic population is 0.000008%’,62 that causality is not proven or even unlikely,61,63-66 that other interventions are more risky (see below),67 that the mechanical forces employed for spinal manipulation are too low to cause injury,68 or that there is a ploy from the medical establishment to sideline chiropractors.69-71 In the light of the evidence summarized above, such attitudes do not seem to be in the best interest of patients.

    It is, of course, important to present any risk-benefit assessment fairly and in the context of similar evaluations of alternative therapeutic options. One such option is drug therapy. The drugs in question—non-steroidal anti-inflammatory drugs (NSAIDs)—cause considerable problems, for example gastrointestinal and cardiovascular complications.72,73 Thus spinal manipulation could be preferable to drug therapy. But there are problems with this line of argument: the efficacy of NSAIDs is undoubted but that of spinal manipulation is not, and moreover, the adverse effects of NSAIDs are subject to post-marketing surveillance while those of spinal manipulation are not. Thus we are certain about the risks and benefits of the former and uncertain about those of the latter. Finally, it should be mentioned that other therapeutic options (e.g. exercise therapy or massage) have not been associated with significant risks at all.”

    Full text here:
    http://jrsm.rsmjournals.com/cgi/content/full/100/7/330

    Re the abstract of the 2008 Ernst article (‘Chiropractic: A critical evaluation’) which Joe cited and Nwtk2007 couldn’t find, here it is:

    Quote:

    “Chiropractic was defined by D.D. Palmer as “a science of healing without drugs.” About 60,000 chiropractors currently practice in North America, and, worldwide, billions are spent each year for their services. This article attempts to critically evaluate chiropractic.

    The specific topics include the history of chiropractic; the internal conflicts within the profession; the concepts of chiropractic, particularly those of subluxation and spinal manipulation; chiropractic practice and research; and the efficacy, safety, and cost of chiropractic. A narrative review of selected articles from the published chiropractic literature was performed. For the assessment of efficacy, safety, and cost, the evaluation relied on previously published systematic reviews.

    Chiropractic is rooted in mystical concepts. This led to an internal conflict within the chiropractic profession, which continues today. Currently, there are two types of chiropractors: those religiously adhering to the gospel of its founding fathers and those open to change.

    The core concepts of chiropractic, subluxation and spinal manipulation, are not based on sound science. Back and neck pain are the domains of chiropractic but many chiropractors treat conditions other than musculoskeletal problems. With the possible exception of back pain, chiropractic spinal manipulation has not been shown to be effective for any medical condition.

    Manipulation is associated with frequent mild adverse effects and with serious complications of unknown incidence. Its cost-effectiveness has not been demonstrated beyond reasonable doubt. The concepts of chiropractic are not based on solid science and its therapeutic value has not been demonstrated beyond reasonable doubt.”

    http://www.citeulike.org/user/dbs/article/3199975

  62. nwtk2007 says:

    This is just more dribble.

    -”Since then, an abundance of new evidence has emerged. The aim of this article is therefore to identify adverse effects of spinal manipulation published since 2001. ”

    Let’s see this new evidence.

    -”The effectiveness of spinal manipulation for most indications is less than convincing. A risk-benefit evaluation is therefore unlikely to generate positive results: with uncertain effectiveness and finite risks, the balance cannot be positive.”

    For some, the benefits will never be recognized and despite available studies and research to the contrary, anti-chiro scoffers continue to deny the benefits. Many times dismissing a paper or study without even reading it as evidenced by their comments and “responses”.

    And what is this obssession with chiropractic history? We are in the now and chiro’s do not reflect even much of the “chiro leadership” at present. This is a changing field and for many of us it has already changed.

    It is much the same in medicine and it changes as well. A few months ago the AMA issued a statement that they were naive enough to assume that lowering cholesterol would reduce plaqueing in coronary arteries and thus they supported the use of cholesterol lowering drugs. Do you think all MD’s feel that this is true? Do you think they all agree with this. Does the AMA represent the entire professions position on this subject?

    Quoting chiro history or statements from college and trade union philosophy doesn’t change anything. It’s a waste of time.

  63. EBC says:

    I agree with nwtk2007 that clinging to the history of how chiropractic started is a waste of time.

    Blue Wod did a great job demonstrating how the chiropractic profession is not unified and we all have mixed opinions.

    Therefore chiropractors who are trying to be more objective and who base their treatment plans on the evidence, should be appreciated and encouraged to keep it up.

    Unfortunately it seems though that one is doomed by association. With all the effort it takes just to get a patient in the door mostly because of people (MD’s, media, general public) slandering our profession, I have thought of just giving up. The only thing that does keep me going are the results I get with my patients. When I experience eliminating someone’s headaches they have had for 20 years, or squashing a chronic back problem so a guy can play golf again, this is what fuels my passion.

    I did my due diligence and found some evidence pertaining to the effectiveness of spinal manipulation for Joe:

    -snip-

    Waddel, MD et al. Clinical guidelines for the Management of Acute Low Back Pain. Royal College of General Practitioners 1996:15.

    The authors stated that there were 36 RCTs of spinal manipulation (SM) for lower back pain (LBP). 19 report positive results & 5 more positive results in subgroups. There is very little evidence available on SM in patients with nerve root pain. With in the first 6 weeks of acute or recurrent LBP, SM provides better short-term improvement in pain, activity levels & patient satisfaction than other treatments.

    Recommendations: Consider SM within the first 6 weeks of onset.

    -snip-

    Bronfort, Hass, et al. Efficacy of SM & mobilization for LBP & neck pain: A systematic review & best evidence synthesis. The Spine Journal 2004; 4:335-356.

    A review of 43 RCT’s on treatment efficacy of SM & mobilization (MO) for the management of LBP and neck pain using stringent methodological criteria isolating treatment effect of SM & MO. RCTs in English, Danish, Swedish, Norweigan & Dutch thru 2002 using patient oriented outcomes (pain, disablility, global improvement, & recovery time).

    Results: Acute LBP: Moderate evidence SM provides more short-term pain relief than MO & detuned diathermy, limited evidence of faster recovery than a commonly used physical therapy treatment strategy. Chronic LBP: Moderate evidence SM’s effect is similar to an efficacious Rx NSAID. SM/MO is effective in the short term compared to placebo & general practitioner care, and in the long term compared to physical therapy. Limited to moderate evidence that SM is better than PT & home back exercise in both the short and long term.

    Conclusions: Data synthesis suggests that recommendations can be made with some confidence regarding the use of spinal manipulation &/or manual therapy as a viable option for the treatment of both LBP & neck pain.

    After you guys rip this blog apart, turn my words around, and accuse me of being a crystal swinging faith healer…I will be happy to show studies about how well spinal manipulation works in conjunction with exercise; specifically core strengthening.

  64. Blue Wode says:

    EBC wrote on 23 Sep 2008 at 9:43 pm: “I did my due diligence and found some evidence pertaining to the effectiveness of spinal manipulation for Joe…..Waddel, MD et al. Clinical guidelines for the Management of Acute Low Back Pain. Royal College of General Practitioners 1996:15.”

    FYI, the Royal College of General Practitioners withdrew those guidelines three years ago because they were out of date. It has yet to produce new guidelines. See page 2 here:
    http://www.gcc-uk.org/files/link_file/GCC_news_15.pdf

    In their place, many UK chiropractors are pushing a set of European guidelines which briefly mention considering spinal manipulation for the management of acute non-specific low back pain:

    Quote:

    “We do not know for which subgroup of patients spinal manipulation is most effective. Future studies should focus on identifying these subgroups. Spinal manipulation should be provided by professionals with competent skills. Risk of serious complication after spinal manipulation is low (estimated risk: cauda equina syndrome <1 in 1 000 000).[55] Current guidelines contraindicate manipulation in people with severe or progressive neurological deficit.

    Recommendation T7
    Consider (referral for) spinal manipulation for patients who are failing to return to normal activities.”

    See pages 26-27 here:
    http://www.backpaineurope.org/web/files/WG1_Guidelines.pdf

    However, it’s worth noting the following comments on official guidelines for back pain which were made by Professor Edzard Ernst after he’d presented the findings of four Cochrane reviews which had all demonstrated an overwhelming lack of evidence for chiropractic:

    Quote:

    “Chiropractors argue that their approach must be safe and effective, not least because the official guidelines on the treatment of back pain recommend using chiropractic. However, this is true only for some, but by no means all, countries. Secondly, guidelines are well known to be influenced by the people who serve on the panel that develops them. Cochrane reviews, on the other hand, are generally considered to be objective and rigorous. Writing about the importance of systematic reviews for health care in the Lancet, Sir Ian Chalmers stated, ‘I challenge decision makers within those spheres who continue to frustrate efforts to promote this form of research to come out from behind their closed doors and defend their attitudes and policies in public. There is now plenty of evidence to show how patients are suffering unnecessarily as a result of their persuasive influence.’

    The Value of Chiropractic
    http://www.medicinescomplete.com/journals/fact/current/fact1002a02t01.htm

    On 23 Sep 2008 at 9:43 pm EBC cited the following study as having “some evidence pertaining to the effectiveness of spinal manipulation”: Bronfort, Hass, et al. Efficacy of SM & mobilization for LBP & neck pain: A systematic review & best evidence synthesis. The Spine Journal 2004; 4:335-356.

    Here’s what Edzard Ernst had to say about that study in a systematic review of systematic reviews of spinal manipulation which he co-authored with Peter Canter in 2006:

    Quote:

    “Three systematic reviews were related to SM for neck pain10-12 of which one reached a positive [Bronfort, et al]10 overall conclusion and this was the same review which reached a positive conclusion regarding back pain. The most authoritative of the three reviews12 stated that SM/mobilization is effective only when combined with other interventions such as exercise and as a sole treatment for neck pain, it is not of demonstrable effectiveness.

    -snip-

    It is perhaps relevant to note that all three of the overtly positive recommendations for SM in the indications back pain,10 neck pain10 and headache13 originate from the same chiropractor [Bronfort]. Ernst and/or Canter, the present authors, conducted three of the systematic reviews included8,11,16 and all three reviews reached negative conclusions about the effectiveness of spinal manipulation. However, these systematic reviews were themselves carried out in a rigorous and systematic fashion and we therefore do not believe that their inclusion represents a source of any additional bias.”

    http://jrsm.rsmjournals.com/cgi/content/full/99/4/192

    EBC wrote on 23 Sep 2008 at 9:43 pm “…chiropractors who are trying to be more objective and who base their treatment plans on the evidence, should be appreciated and encouraged to keep it up”.

    But with an increasingly slim evidence base on which to base such treatment plans, will these (few) chiropractors be able to earn a decent living in the long run?

  65. Joe says:

    EBC wrote on 23 Sep 2008 at 9:43 pm “…chiropractors who are trying to be more objective and who base their treatment plans on the evidence, should be appreciated and encouraged to keep it up.”

    Maybe; but, how do you know you are basing your treatments on reliable evidence? Working, as one must, with the lowest common denominator- you don’t learn it in chiro school. I don’t trust self-taught practitioners. If they had the moxie, they would (mostly) not have gone to chiro school in the first place. Therefore, attending a “rational” chiro is gambling; which is something I am loathe to do with mere money, let alone- my health.

    Put another way, the statistical surveys (I have cited) are against you. Why should anyone take a chance with chiro when massagers and PTs are equally effective for the one thing (SMT for acute low back pain which chiros do equally well), without the chiro’s delusions of grandeur?

    Massagers and PTs do not reliably cause strokes in neck “adjustments” such as we see with chiro.

    I agree with Blue Wode; If you truly work within limited, proven efficacy- how can you make a living? While back pain is common, most people in your trade make money from useless maintenance treatments and “therapy” for visceral illness. Do you defend their business? What should be done about them?

  66. nwtk2007 says:

    Joe – “Why should anyone take a chance with chiro when massagers and PTs are equally effective for the one thing (SMT for acute low back pain which chiros do equally well),”

    Utter B$. You like evidence, show it.

    I am still waiting for all the “evidence” that chiropractic causes strokes in the first place. Put it ALL on the table here. And please, READ it before you site it.

    You see, the nice thing about you anti-chiro’s is that you continue to show that there is no evidence against the chiropractic profession. Using your own standard for “scientific evidence” you just can’t hurt the profession.

    I still say you guys are the best witnesses for the chiropractic defense in the Nette case.

  67. nwtk2007 says:

    Blocking me again. Too funny.

  68. nwtk2007 says:

    Like I have said, I am still waiting for your “evidence” that manipulation by chiropractors causes strokes.

    Using your own standard of “evidence”, you just don’t have any.

  69. nwtk2007 says:

    Keep on blocking. I am just asking for your evidence that manipulation causes stroke.

    You know, the subject of this blog?

  70. Blue Wode says:

    On 27 Sep 2008 at 8.23pm, in response to Joe asking “Why should anyone take a chance with chiro when massagers and PTs are equally effective for the one thing (SMT for acute low back pain which chiros do equally well), without the chiro’s delusions of grandeur? Massagers and PTs do not reliably cause strokes in neck “adjustments” such as we see with chiro”, nwtk2007 wrote “…You like evidence, show it”.

    It has been shown that the vast majority of injuries resulting from manipulation to the cervical spine are caused by chiropractors. See fig. 2 here:
    http://www.ptjournal.org/cgi/content/full/79/1/50

    In addition to that, it has already been established that the profession of the manipulator is irrelevant to the effectiveness of treatment:

    Quote:

    “A systematic review of spinal manipulation concluded that there is no evidence that high-velocity spinal manipulation is more effective than low-velocity spinal mobilisation, or that the profession of the manipulator affects the effectiveness of treatment.”

    See the discussion section here (p.1643):
    http://www.acatoday.org/pdf/Lancet_Acute_Back_Pain_Nov.07.pdf

    On 27 Sep 2008 at 8.23pm nwtk2007 wrote: “I am still waiting for all the “evidence” that chiropractic causes strokes in the first place. Put it ALL on the table here. And please, READ it before you site it.”

    You’ll find that the Nettes’ Statement of Claim covers much of what you ask for in paragraphs 87-155. In particular, I would draw your attention to paragraph 146 on page 55 because it illustrates how most chiropractors – and their regulators – seem to find it acceptable to rely on anecdotal or weak evidence where it supports chiropractic treatment, but where similar, or more robust evidence [e.g. the Laurie Jean Mathiason and Lana Dale Lewis cases] suggests that serious complications (e.g. stroke) can result from chiropractic treatment, they are quick to dismiss it:

    Quote:

    “Incredibly, and, acting in bad faith, the College [Alberta College and Association of Chiropractors] attacked the new and surprisingly high number of vascular accidents associated with chiropractic services that were published medical literature and reported in the media by demanding a level of evidence it has never demanded of itself. It maintained that the causal link between strokes and chiropractic adjustment remained unproven.”

    http://www.casewatch.org/mal/nette/claim.pdf

  71. nwtk2007 says:

    Once again, you prove my point. If the EBM bloggers here applied their accepted level of what they consider to be good scientific evidence to this issue, they would say that there is none.

    This has been demonstrated time and again even to the point of seeing them reject accepted science only because it is accepted by those they consider to be pseudoscience promoters. And that is too funny.

    If you look at what you are presenting objectively, without your anti-chiro bias and in the same way you seem to project what good scientific evidence is, then you would reject it also.

    Again I say, tally it up here, step by step, one study after another, no anecdotal evidence or “case studies”. True evidence as this blog puts it and lets see if it weighs in.

    It simply isn’t there.

  72. Joe says:

    Adverse effects of spinal manipulation JRSM 2007 Ernst

    http://jrsm.rsmjournals.com/cgi/reprint/100/7/330?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&author1=ernst%252C+edzard&searchid=1&FIRSTINDEX=0&resourcetype=HWCIT

    “Results The searches identified 32 case reports, four case series, two prospective series, three case-control studies and three surveys. In case reports or case series, more than 200 patients were suspected to have been seriously harmed. The most common serious adverse effects were due to vertebral artery dissections. The two prospective reports suggested that relatively mild adverse effects occur in 30% to 61% of all patients. The case-control studies suggested a causal relationship between spinal manipulation and the adverse effect. The survey data indicated that even serious adverse effects are rarely reported in the medical literature.

    “Conclusions Spinal manipulation, particularly when performed on the upper spine, is frequently associated with mild to moderate adverse effects. It can also result in serious complications such as vertebral artery dissection followed by stroke. Currently, the incidence of such events is not known. In the interest of patient safety we should reconsider our policy towards the routine use of spinal manipulation.”

  73. pmoran says:

    But the strongest evidence was and still is the anecdotal — a usually young patient has their neck manipulated and immediately gets neurological symptoms that they did not have before. Such cases are rare but too regular to ignore. The chiropractic profession has at times itself accepted the risk of stroke and even offered advice as to how to avoid strroke.

    No, we don’t have stronger evidence in the sense of large scale prospective controlled trials, and we never will. Most would regard it as unethical to perform such studies, while we lack strong reasons for performing spinal manipulation for any condition.

    The situation is exactly comparable to limitations upon the use of some drugs because of anecdotal reports of serious side effects. By normal medical standards spinal manipulation would be limited to fully informed patients as a late resort for disabling conditions when there is nothing else to try.

  74. Harriet Hall says:

    Please note: pmoran was talking about neck manipulation when he said “By normal medical standards spinal manipulation would be limited to fully informed patients as a late resort for disabling conditions when there is nothing else to try.”

    His remarks don’t apply to lower back manipulations. There is no evidence that spinal manipulation of the lower back causes strokes and there is evidence that it is as effective as other treatment options for short-term treatment of certain types of low back pain.

  75. Joe says:

    pmoran,

    Strokes are rare-enough that a definitive connection to chiro may never be established. However, bilateral VAD seems inextricably linked- to the extent that Ms. Nette’s doctor suspected chiro when he saw her.

    As I recall, a nineteenth century pathologist noticed that when people, died after exhibiting a certain set of symptoms, they had burst appendices. He recommended appendectomy for those cases, and it seemed effective. That is not high-quality evidence; but it is bloody obvious. When a doctor sees a situation and has a strong, accurate notion that it was due to chiro, it tells us something. The literature suggesting the link is vast.

    Note, some chiros say that VAD was pending in people who have stiff necks and/or headaches; yet they don’t realize that such people should not receive their neck-snap.

    pmoran writes “By normal medical standards spinal manipulation would be limited to fully informed patients as a late resort for disabling conditions when there is nothing else to try.” Chiros are unable to provide reliable evidence that the neck snap is better than any safer form of therapy for any condition. Thus, the notion of informed consent is moot.

    One must be careful of terminology here. Chiros like to claim they do “adjustments;” whereas they like to adopt the safety claims of health professionals (e.g., PTs) who provide safer “mobilizations.” The PT article cited by Blue Wode demonstrates the superiority of PT manipulations. In his video http://ph-ms.ouhsc.edu/ah/rehab/kinsinger.wmv Dr. Kinsinger makes the points that PTs are better because they are more selective about providing neck manipulation and more skilled at it. Ms. Nette was in excellent health when she went for her “routine maintenance” by the chiro, what possible justification could there have been for him to snap her neck?

  76. Paul says:

    Mark,
    In your article you state “Beside headache, there is no overlap in symptoms of a vertebral artery stroke and reasons in this study for visiting an MD or DC”. You further state “The codes used by the chiropractic and primary care physicians for the visit, admittedly inaccurate, were by and large NOT vertebral artery stroke symptoms”.

    There is evidence that neck pain and headache preceed a vertebral artery stroke. The symptoms you list in your article would be someone in the midst of a stroke. Symptoms preceeding the stroke would be different.

    In “Vertebral Artery Dissection: Warning Symptoms, Clinical Features and Prognosis in 26 Patients” from the Canadian Journal of Neurological Sciences (2000; 27: 292-296) they found that early symptoms of a VBA stroke are “headache and/or neck pain followed by vertigo or unilateral facial paresthesia is an important warning sign that may precede onset of stroke by several days”.

    They also state that “Headache and neck pain were also an important warning sign before the onset of stroke. This was reported by 53% of the patients, one day to two weeks before the onset of their stroke. Some of the patients had sought medical advice for these early signs”.

    I think it is reasonable for Cassidy et al. to use the diagnostic codes they did. I would think that neck pain and headache would be a valid reason for subjects to seek chiropractic treatment which would support their conclusions. I look forward to responses.

  77. Joe says:

    Paul on 30 Sep 2008 at 10:43 pm wrote “There is evidence that neck pain and headache preceed a vertebral artery stroke.

    “… They also state that “Headache and neck pain were also an important warning sign before the onset of stroke.” …

    “I would think that neck pain and headache would be a valid reason for subjects to seek chiropractic treatment …”

    Wouldn’t the fact that headache and neck pain can indicate a pending stroke be a reason for chiros not to apply the ol’ neck snap (in addition to the fact that it doesn’t do anything that cannot be done more safely)?

    Why do you think headache and neck pain are valid reasons to go to chiros? Their unique contribution to therapy of said symptoms leaves some customers seriously dead. Even asymptomatic customers are killed by these procedures.

  78. nwtk2007 says:

    Joe, how many were killed by chiropractic vs medical mistakes, not to mention just ibuprofen this year?

    Given the unique deadliness of medicines like ibuprofen and the risks of mistakes being made, why would neck pain and headaches be a valid reason for seeking medical help?

    Try to be objective with your answer and provide numbers and evidence to back up your claim.

  79. Joe says:

    nwtk,

    The question before us is the danger of the, thoroughly unnecessary, chiro neck-snap. If you want to hold forth on another topic (e.g., ibuprofen), start your own blog.

    Again, I invite you to provide reliable evidence that the neck-snap has benefits that outweigh the risk. We showed you our evidence against that, it is only fair to show us yours.

    Moreover, perhaps you could provide evidence that chiros should snap necks of people who have, pro-dromal (CVA), neck pain and/or headaches. In addition, why do it to someone who has no such symptoms (as in the Nette case)?

  80. nwtk2007 says:

    Joe,

    I have in the past provided evidence that cervical manipulation is at least AS effective as some meds for HA’s, one in particular, elavil and the treatment for migrain HA’s. I have provided evidence for manipulation being beneficial for NP also, again, that it is as effective as some meds. I you will remember, you commented on it and dismissed it without bothering to read it.

    It was very clear that you didn’t and I won’t waste any further time presenting evidence to you.

    As to manipulating people who have S/S that might be a stroke in the making, there are clear and easy steps to determine that and it then becomes clear that the patient is not or is possibly having a stroke.

    As to Ms Nette, I don’t think you really know what her S/S were or why she went to the chiro in the first place. She had apparently been treated by the chiro for years and I would guess with good success due to the continued patronage by Ms Nette. If she is the type to have been “brain washed” or fooled into going, then I would suspect that her account of what happened to her to be even more suspect.

    And why not consider the risks of meds such as ibuprofen when discussing the stroke and chiro issue? What does medicine have to hide here? The data is clear about the risks of ibuprofen that is for sure. The data on the risk of cervical manipulation is sketchy at best. I have read the evidence presented here and it doesn’t stand up to the EBM standard so proudly presented here.

    Your question and comment, “Why do you think headache and neck pain are valid reasons to go to chiros? Their unique contribution to therapy of said symptoms leaves some customers seriously dead.” is strenuously biased at best and illicits a response such as mine. The risks of ibuprofen alone byfar outweigh the risk of cervical manipulation.

  81. Paul says:

    Joe,
    I would agree that medication for neck pain and headaches is a separate issue but it is related. I think both manual treatment and medication need to show a benefit in light of the risk. That is why studies like Cassidy et al. are important. They found no additional risk of VBA following chiropractic care.

    When we look at manual therapies manipulation or mobilization with exercise has strong evidence of benefit in the long term for mechanical neck disorder and neck disorder with headache (Gross et al., 2007). VBA stroke is a rare event and can be preceeded by neck pain and headache. Neck pain is prevalent in the general population. Neck pain is a disabling condition with a course marked by periods of remission and exacerbations (Côté, Cassidy, Carroll & Kristman, 2004). I think there is reasonable evidence to consider chiropractic treatment as an option for headaches and neck pain. OTOH, it might be reasonable for chiropractors to start with gentler treatments as the risk of minor adverse symptoms is higher with manipulation.
    I would suggest reading through the Task Force on Neck Pain and Its Associated Disorders (Spine, 2008)

  82. Joe says:

    Paul on 01 Oct 2008 at 7:02 pm wrote “That is why studies like Cassidy et al. are important. They found no additional risk of VBA following chiropractic care.”

    You seem to have missed Dr. Crislip’s point- the data do not support that conclusion.

    As for the “Task Force on Neck Pain and Its Associated Disorders (Spine, 2008).” Spine is a repository for inferior papers (such as Cassidy’s), which is mostly what chiropractor’s produce. I see you mention another paper by Cassidy (2004); his “research” is amateurish now, it was not better then. Furthermore, if you want to be taken seriously- you have to give proper citations to literature.

    nwtk2007 on 01 Oct 2008 at 6:58 pm wrote “I have provided evidence for manipulation being beneficial for NP also, again, that it is as effective as some meds. [You] will remember, you commented on it and dismissed it without bothering to read it.”

    “Manipulation” as applied by a heath professional can be useful, that is highlighted by Blue Wode and Dr. Kinsinger. It is the chiro “adjustment” that is dangerous. Chiros are schizophrenic about that- on one hand, they point to the safety of “manipulation,” on the other hand, they claim (without proof) their “adjustments” are superior.

    It seems your feelings are hurt that I did not look at some papers you cited. I cannot recall what they were; but, I usually refuse to examine articles in bogus sources (e.g., chiropractic or AltMed magazines). Such papers are a waste of my time. Moreover, I am not capable of providing the sophisticated level of analysis that Dr. Crislip applied to the article in question here. Publications (fallible as they may be) in high-quality medical journals give me more confidence because they have already passed the scrutiny of health professionals.

    So, if you have any high-quality support for your claims- please show us.

  83. nwtk2007 says:

    Joe – “As for the “Task Force on Neck Pain and Its Associated Disorders (Spine, 2008).” Spine is a repository for inferior papers”

    and

    Joe – “I usually refuse to examine articles in bogus sources (e.g., chiropractic or AltMed magazines). Such papers are a waste of my time.”

    Very typical, but you’ve made my point. If you won’t read the research, then you can’t discuss why it’s no good and a “waste of your time”.

    Joe – “I am not capable of providing the sophisticated level of analysis”

    That much is obvious, and without so much as reading it, you never will. You don’t hurt my feelings Joe, quite the contrary. I find you quite typical a great many of the EBM elite. I commend your “religiosity” and your “belief” in such a helpful and risky (500 deaths a day due to errors alone, 3000 deaths a year due to ibuprofen alone, ….. ) “belief system”.

  84. Paul says:

    Joe,
    Let me get this straight, when Dr Crislip writes an article on a non-peer reviewed website it is high on your evidence list, when Cassidy et al. published in a peer-reviewed medical journal it is amateurish. I would consider that an ad hominin attach on Dr Cassidy et al. There were a number of highly published authors on that paper. Bondy for example was an author on the Rothwell et al. paper on chiropractic and stroke in Ontario. Dr Crislip has reviewed the article by Cassidy et al., and a few on this forum have pointed out some concerns. It is great Dr. Crislip has turned his time and energy to this topic.

    My feeling are not hurt that you didn’t look up the references (as you claim). I can tell you didn’t read them as none of them were from “chiropractic or Altmed magazines” as you speculate. They were from the Journal of Rheumatology, Pain and Spine.
    Joe, can we keep this debate to the scientific literature. You cite Dr Kinsinger, has he published on this topic in a peer-reviewed medical journal? I am not familiar with any articles written by him on topic and I could not find any articles published by him on an author search.

  85. Joe says:

    Paul, I recently cited Kinsinger’s video:

    Joe on 29 Sep 2008 at 6:20 am wrote “In his video http://ph-ms.ouhsc.edu/ah/rehab/kinsinger.wmv Dr. Kinsinger makes the points that PTs are better because they are more selective about providing neck manipulation and more skilled at it. Ms. Nette was in excellent health when she went for her “routine maintenance” by the chiro, what possible justification could there have been for him to snap her neck?”

    As for the quality of this blog, the authors are well-known and reliable. If you think the posts are wrong (as is often found in Spine), just write critiques.

    When chiros complain that Dr. Barrett (www.chirobase.org) is so mean I invite them to choose some articles and show how they are wrong- they never come back.

    Please, instead of arguing, give proper literature citations.

  86. nwtk2007 says:

    You ask for literature but freely admit that you don’t and won’t read it.

    What a joke.

    Have you been baptized into this church?

    As to Dr Kinsinger, that is the same song and dance from all PT’s, no offense. They will also claim to be better at diagnosis than orthos. It is always the same with all the ones I have worked with.

    The fact is that most do practically no manipulation or mobilization so their claim at being better comes from no practice and no experience. It is just a claim.

    Citing Mr Kinsingers video amounts to nothing. It is not research and nothing but opinion.

    And I am sure the people who have had bad and fatal reactions to just ibuprofen alone ( not to mention the thousands of others) where in perfectly good health prior to their injuries, which out number alleged chiro injuries thousands to one.

  87. Harriet Hall says:

    nwtk2007 still doesn’t understand that an attack on ibuprofen is not a defense of chiropractic. Ibuprofen has proven risks and proven benefits; so does spinal manipulation. Why not give patients the most accurate information available about the risks and benefits of all options and let them make an informed decision?

    What about patients who have no pain, have no reason to take ibuprofen, and are injured by a “maintenance” adjustment for which there is no indication and no chance of benefit? I have just heard from another patient whose vertebral artery was torn by a chiropractor, who had NO preexisting condition whatsoever, and who had never even heard that there was any concern about the possibility of stroke from neck manipulation.

  88. Joe says:

    nwtk2007 on 02 Oct 2008 at 8:58 am wrote “You ask for literature but freely admit that you don’t and won’t read it.”

    Can you say “Straw Man?” Sure you can. I said I won’t bother with quack magazines. If you cite something in JAMA I will look at it, and if it is a single “case report” I will know it is inadequate. If it looks thorough (to me), I will leave it to experts for further evaluation. Publication in a refereed journal is only near the beginning of life for an idea.

    Of course PTs do less manipulation because few patients need it; moreover, nobody needs to have their neck snapped (excuse me, “adjusted”). Chiros only have “adjustment,” so almost every customer “needs” it. Blue Wode cited the study that shows PTs are better at it than chiros. Your claim that chiros are more experienced ignores the fact that most of what they do is unnecessary. Similarly, a highly experienced astrologer is still useless.

    Dr. Kinsinger’s opinions are well-informed. Instead of whining, tell us where you think he is demonstrably wrong.

  89. nwtk2007 says:

    Harriett,

    I love medicine and it’s benefits to both me and my family when needed. But I don’t take ibuprofen and I don’t encourage my friends to either. I also don’t allow it for my kids.

    The info about ibuprofen is offered only as a comparison of risks of treatment for neck pain and headache. If you think the risk of ibuprofen is neglegable and not a concern then you use it, but be honest about the risks please.

    As to the person you heard from who had a vertebral artery torn, how do you know and how do you know it was due to manipulation? What is their medical history and why did the go to a chiro in the first place? Are they a smoker? Are they old, female, male? Do they have hypertension, diabetes? Is there a reasonable chance that the chiro could have foreseen it coming in the patients exam findings, medical history? Did the chiro perform an adequate exam or history? Have you seen the patient’s PCP records? Has the patient ever made the same complaints to the PCP prior to going to the chiro? Did you even think about any of this before you thru up this onfo onto the blog? Does anybody? Do we ever hear the whole story and get to see the facts of the case other than “hearing from someone who had their vertebral artery damaged by a chiro manipulation”?

    Is this an anecdotal story with the very same merrit you give other anecdotal stories on your blog here? Is there more here than just correlation giving rise to causation?

    Is the chiro being investigated? Are they going to try to have the chiro desicplined? Are they going to report the chiro to the licensing authority of the chiro? Are they going to sue the chiro for malpractice?

    The republicans say the economy is ruined by the democrats and the democrats say the opposite.

    Let’s get some details out on this and really look at it. If the chiro is the cause then I will see it just as you might.

  90. Harriet Hall says:

    There is a difference between an anecdote and a smoking gun. When an asymptomatic healthy young person feels something tear as a chiropractor manipulates her neck and promptly develops symptoms of a stroke, causation is about as clear as it gets. Denying that would be like a surgeon denying that the clamp left in the patient’s belly got there during her recent surgery.

    Most chiropractors accept that stroke is a possible complication of neck manipulation, albeit a rare one. It is discussed in the chiropractic literature, they talk about how they could reduce the risk, many chiropractors offer informed consent, and the chiropractic insurance companies pay claims for it. There have been lawsuits; chiropractors have been disciplined. Why are you still denying it?

    And how dare you imply that I am not honest about the risks of ibuprofen!?

  91. nwtk2007 says:

    How dare I?

    Please.

    One injury (alleged) in a million is a smoking gun, but 3000 deaths a year is not.

    Right.

    So this person felt a tear? Do you think there are receptors in the vertebral artery that would yield that sensation? How long of a tear do you think would be needed to get that sensation of feeling a tear? How long of a tear to bring on the real S/S of a vertebral artery tear/stroke? If the “tear” were that big as to be felt as a “tear”, do you think the person would be in a position to relate it to you verbally?

    Do you just take the patients word for it that there was a tear in the vertebral artery? Is there any supporting imaging?

    I am not denying it. I am just not believing every story and accusation that the chiro caused the stroke. It IS a case of causation vs correlation.

    And I do dare to imply that you are not fully honest about the risks of ibuprofen. How many reactions to drugs that you prescribed are you aware of? None? Right.

    Are they still being prescribed? Is a risky drug like ibuprofen still OTC? Could any one under the sun pick some up and take all they want in their ignorance? Would they have the least clue that the stomach problems they are having could possibly be related to the OTC ibuprofen they have been taking three and four of at a time, two to three times a day?

    Can everyone read those tiny directions? Can everyone read? Can everyone read english?

  92. Paul says:

    Joe,
    I could give you the full citations if you are interested in reading the full text of the articles. You should be able to medline the author and year and find the citation yourself.

    OTOH, if you insist that Spine is not a high quality peer reviewed medical journal, we have little to debate. It is very difficult to debate broad generalizations about the quality of the journal. If you have specific problems with say the Côté, Cassidy, Carroll & Kristman, 2004 (Pain, 29, 1648-54), you could be more specific about any methodological issues.

    I cannot continue to debate you (not argue) when you cite websites. Dr. Kingsinger’s views are his own, unless we are appealing to him as an authority figure. Lets keep this a debate and cite the primary peer reviewed literature.

    Dr. Hall,
    Your posts have a lot of good points. I agree, there is not much evidence for asymptomatic treatment in the medical or chiropractic literature. The one paper I cited by Cote et. al., Pain, 2004, shows the recurrent disabiling nature of neck pain. There may be many patients who respond well to neck manipulation, they know they do, and they continue to seek care. Other treatments may have had limited results (yes even ibuprofen with its rare but devastating side effects). I also think informed consent is a good idea.

  93. Joe says:

    Paul on 02 Oct 2008 at 3:19 pm wrote “Côté, Cassidy, Carroll & Kristman, 2004 (Pain, 29, 1648-54)”

    I tracked-down the paper. http://www.ncbi.nlm.nih.gov/pubmed/15561381?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum What do you think it has to do with chiro treatments and stroke??

    Seriously- the inability of your ilk to cite reliable evidence, or relevant evidence, is really wearing on me.

  94. Harriet Hall says:

    nwtk2007 said,

    “How many reactions to drugs that you prescribed are you aware of? None? Right.”

    This is beneath contempt.

    I am reminded of why I cut off the discussion with nwtk2007 last time, and I’m doing so again.

  95. nwtk2007 says:

    Well that is one way of avoiding any further clarification of this patient who you heard from who had a vetebral artery tear after chiropractic manipulation.

    Running away is beneath contempt, not my challenging you on your alleged “patient” and their “vertebral artery tear”.

    Forgive me for not immediately appologizing for the entire chiropractic community when stories like this are published on blogs.

  96. Harriet Hall says:

    Discontinuing an unproductive discussion with an unworthy opponent is a far cry from running away.

    Nwtk2007 apparently can’t even understand that what was beneath contempt was his ridiculous accusation that I deny adverse reactions to drugs.

    Readers can judge where to direct their contempt.

  97. nwtk2007 says:

    Fine.

    Then I will just assume you made the story up or all you have is a “patient” who “says” they suffered a vertebral artery tear at the hands of a chiropractor, and, that you should not have brought it up in the first place because you don’t know anything more about the “case”.

    So in summary of this thread on chiropractic and stroke, there is little, if any, good evidence that chiropractic causes stroke, a lot of anecdotal, non-EBM style evidence purported to be smoking guns even in the face of deadly drug reactions which actually kill, “quickdrawing” of the smoking gun only to quickly holster it and withdraw from the topic.

    OK

  98. pmoran says:

    Nwtk2007, it is absurd for you to demand absolute EBM standards of proof for the (highly plausible) risks of neck manipulation, when so little of the use of that procedure within chiropractic is justified by systematic evidence or plausibility at all.

    Spelt out: if you want to justify common chiropractic practices with flimsy anecdotal material then you must surely accept the force of the well-documented anecdotal and retrospective data that is available in relation to stroke.

    Chiropractic’s critics will only shut up when we observe chiropractors behaving in a rational manner. and not exposing patients to risk, or at minimum potential risk, unnecessarily.

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