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Chiropractic and Stroke

I wonder how many people have heard that chiropractic neck adjustments can cause strokes. It isn’t exactly common knowledge. One organization is trying to raise public awareness through signs on the side of city buses (Injured by a Chiropractor? Call this number) and through TV commercials. I had never heard about this phenomenon myself until a few years ago, when I heard it mentioned on an episode of Alan Alda’s Scientific American Frontiers. I questioned his accuracy, but I quickly found confirmation in the medical literature.

A typical case was that of 24 year old Kristi Bedenbaugh who saw her chiropractor for sinus headaches. During a neck manipulation she suffered a brain stem stroke and she died three days later. Autopsy revealed that the manipulation had split the inside walls of both of her vertebral arteries, causing the walls to balloon and block the blood supply to the lower part of her brain. Additional studies concluded that blood clots had formed on the days the manipulation took place. The chiropractor later paid a $1000 fine.

The two vertebral arteries run straight up the back of the neck passing through holes in the sides of each neck vertebra. When the head
turns, the “tethered” artery is drastically kinked: null

Because of this kinking, it is particularly susceptible to injury. Even a simple thing like extending the neck back over the basin for hair washing at the beauty salon has been known to cause a stroke. The artery is elastic, but with hardening of the arteries, with cholesterol plaques, with trauma (like automobile accidents) or simply with rapid stretching, the delicate lining of the artery can tear. It is easy to imagine how a rapid, forceful thrust by a chiropractor could cause damage.

Sometimes the damage is immediate and the patient collapses on the chiropractor’s table. Sometimes mild symptoms start immediately and progress after the patient leaves the chiropractor’s office. Sometimes the tear is a small one and it clots over; then days later the clot breaks loose, travels to the brain and causes a delayed stroke. By this time, the patient may not connect his sudden collapse to the previous visit to the chiropractor.

Chiropractors are well aware of the risk. They discuss it in their journals and online forums. They have tried to find ways to screen patients for high risk, but there is no reliable way to do so. Strokes are a major reason for chiropractic malpractice insurance payouts – 9% of claims paid by the major chiropractic insurer in 2002, the only year for which I was able to find statistics. Some chiropractors are now asking patients to sign an informed consent form before manipulations. If asked, most chiropractors downplay the risk, saying it occurs in less than one in a million manipulations. Many (perhaps most) chiropractors do not mention the risk at all.

Most alarming: some chiropractors perform these neck adjustments with no warning and without permission. I met a woman who still walks with a limp and has other residual impairments from a chiropractic stroke. She went to her chiropractor for a shoulder problem and thought he was going to massage her shoulder muscles. She did not want him to manipulate her neck, did not give him permission, and didn’t realize what he was doing until he suddenly twisted her neck. She collapsed on the table and nearly died.

How often can a stroke be attributed to neck manipulation? We really don’t know. Estimates have varied from one in ten million manipulations to one in 40,000. I should clarify that only one specific type of stroke, basilar stroke, has been linked to chiropractic. It has been estimated that about 20% of all basilar strokes are due to spinal manipulations. This would work out to about 1300 a year in the U.S. But we just don’t know, because it has not been properly studied. Carotid artery strokes have also been reported after chiropractic treatments. Chiropractors do not follow up on every patient. Patients who have delayed strokes may never see their chiropractor again, so chiropractors would naturally tend to underestimate the risk. Many of these diagnoses are missed because the vertebral arteries are not typically examined on autopsy.

One study of patients under the age of 45 who had this kind of stroke showed that they were 5 times more likely to have visited a chiropractor in the preceding week than control patients. In the past, neurologists treating stroke patients simply did not ask patients about chiropractic; and when they started asking, they started finding. There have been deaths. There have been court cases. In 2002, a group of Canadian neurologists issued a statement of concern to the public, recommending vigilance, education, informed consent, and other measures to protect the public. Awareness is rising, and injured patients have formed organizations in the US, Canada, and the UK both for support and for litigation.

Defensive chiropractors have tried to counteract the growing body of evidence with studies like this one, which concluded that “SMT [Spinal Manipulation Therapy] resulted in strains to the VA [Vertebral Artery] that were almost an order of magnitude lower than the strains required to mechanically disrupt it. We conclude that under normal circumstances, a single typical (high-velocity/low amplitude) SMT thrust is very unlikely to mechanically disrupt the VA.” That’s certainly true. It is unlikely. Under normal circumstances. But it does happen.

They tell us that the stroke would have happened anyway. Maybe. We don’t have any way of knowing. But when the patient collapses immediately after the neck is twisted, I think we can say the stroke wouldn’t have happened at that time without the manipulation. Given a choice of sooner or later, later is good.

They tell us that other treatments for neck pain, like NSAIDs, also carry dangers. Patients have developed bleeding ulcers and died from taking aspirin. That’s very true, but they are invoking the logical fallacy known as tu quoque: just because something else is dangerous too, that doesn’t make neck manipulation any less dangerous. And comparing the dangers of two treatments doesn’t mean there aren’t other options that are safer than either of them.

Until really good studies are done, we simply don’t know the magnitude of the risk; but we are reasonably confident there is a risk. Now, let’s measure that risk against the benefits. Some chiropractors are doing neck adjustments on 90% of their patients for everything from ear infections to low back pain. There are lots of testimonials, but no POEMS (patient-oriented evidence that matters) and no evidence of any long-term benefit or any advantage over other treatments. The only thing neck manipulations have been shown to help with is mechanical neck pain, and a recent Cochrane review did not find that manipulation was any better than simple mobilization treatments. If there is no benefit, isn’t any degree of risk too much?

There are plenty of other options for treating mechanical neck pain for those who prefer not to take pain pills. The cervical spine can be gently mobilized with physical therapy methods that have not been linked to stroke. Heat, massage, tincture of time, exercises and other measures may offer symptomatic relief with no associated risks.

“Don’t ever let a chiropractor touch your neck “is the safest advice; but we can’t expect everyone to accept it. Some patients have had good experiences with neck manipulations and will continue to ask for them. We can’t presume to dictate to others. If someone judges that there is a one in a million risk of a stroke and is willing to take that risk, he has every right to do so. I think people have the right to engage in risky behaviors like skydiving and smoking cigarettes. I just think they deserve to know there is a risk, and to have some idea how much of a risk it is. I suspect the general public doesn’t know the facts about neck manipulation.

I wonder if Laurie Jean Mathiason knew neck manipulations could cause strokes. This 20 year old girl had a tailbone injury and sought out a chiropractor who manipulated her neck. Yes, her neck – to fix her tailbone! She fell into a coma and died three days later. Her visit to the chiropractor might qualify her for a Darwin Award. In my opinion, it qualifies as a tragedy and a crime.

For more information and links see: http://www.quackwatch.org/01QuackeryRelatedTopics/chirostroke.html

Posted in: Chiropractic

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324 thoughts on “Chiropractic and Stroke

  1. peterte says:

    I like the blog but, as someone who spent many happy minutes skydiving, I think putting it next to smoking is a little unfair.

    Yes, it’s risky but the risks are immediate and obvious and most if not all taking part are aware of them – there are always exceptions. Smokers as I understand it, don’t feel the risk because it’s potentially years away and I wonder how many appreciate the many ways smoking can kill them?

    The skydiving industry, at least here in the UK, is pretty good at preparing people for their first jump. I don’t think the tobacco industry has a similar approach – who reads wrappers?

    Other than that, keep up the good work :*)

  2. richunger says:

    I’ve never been to a chiropractor, but I’m always cracking my neck. Is there a consensus in the medical community about whether I’m in danger of doing this to myself?

  3. Harriet Hall says:

    I don’t think there’s any consensus because I don’t think the issue has been addressed. I don’t think cracking your own neck is comparable to the high-velocity/low amplitude chiropractic techniques that have been most associated with damage. But on the other hand, since simple things like tipping the head back for a shampoo, painting ceilings, or turning the neck to look behind the car have been known to precipitate a stroke, maybe there is a slight risk. Especially if you have susceptible arteries, which is something you would have no way of knowing.

    One commenter on Wiki-Answers said, “All depends on how you crack them. Cracking your back by stretching it or your neck by rolling it around shouldn’t cause any damage. But, if you use your hands to twist your neck around to get it to pop, you risk possibly damaging the vertebrae in your neck (either slipping,cracking, or even possibly rupturing a disk in extreme cases).”

    In short, the more like chiropractic thrusts, the worse; the more like gentle mobilization, the better.

  4. Joe says:

    The latest issue of Dynamic Chiro http://www.chiroweb.com/columnist/edwards/index.html says the customer presents in the chiro office with VBA dissection in progress, and the chiro just gets the blame!? I thought they had a growing recognition of their culpability, while they played it down as a normal risk accompanying any therapy. As Harriet said- there is no need for the neck-snap in the first place. That is, risk/benefit results in division by zero, an unacceptably large number.

  5. Blue Wode says:

    Thank you, Dr Hall, for such a straightforward and impartial article on this topic.

    It’s particularly interesting that you say that “chiropractors are well aware of the risk”, because that doesn’t appear to be universally true. For example, as recently as December 2006, Peter Dixon, Chairman of the General Chiropractic Council (the UK regulatory body), claimed that “there’s no available evidence to show that manipulation of the neck by chiropractors has ever caused a stroke”:
    http://www.gcc-uk.org/files/link_file/DAILY%20MAIL%2012%20December%202006.pdf

    Perhaps that statement would have been less misleading if Mr Dixon had cared to mention that there has never been a formal reporting system in place in the UK to which patients can report any complications they may experience during, or following, their chiropractic treatment. In addition to that, he also failed to mention that despite the fact that (chiropractic) spinal manipulation is widely used on children, paediatric safety data are virtually non-existent:
    http://www.ncahf.org/digest07/07-14.html

    With regard to your comments that everyone deserves to know about the potentially life-threatening risks associated with chiropractic neck manipulation, it’s disappointing to learn that chiropractors themselves are, in many cases, not telling their patients of the risks when carrying out their legal obligation to obtain informed consent:

    Consent: its practices and implications in United Kingdom and United States chiropractic practice: Results from this survey suggest a patient’s autonomy and right to self-determination may be compromised when seeking chiropractic care. Difficulties and omissions in the implementation of valid consent processes appear common, particularly in relation to risk.
    http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17693332&ordinalpos=6&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum

    Consent or submission? The practice of consent within UK chiropractic: Results suggest that valid consent procedures are either poorly understood or selectively implemented by UK chiropractors.
    http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=Retrieve&db=pubmed&dopt=AbstractPlus&list_uids=15726031

    Perhaps the reason for this is that chiropractors don’t want to deter patients from proceeding with their treatment. For the UK, that would be entirely understandable since most chiropractors work in private practice.

    For those who haven’t read it, in their new book ‘Trick or Treatment? Alternative Medicine on Trial’, Professor Edzard Ernst and Simon Singh propose that all chiropractors be compelled by law to disclose the following to their patients about chiropractic therapy:

    “WARNING: This treatment carries the risk of stroke or death if spinal manipulation is applied to the neck. Elsewhere on the spine, chiropractic therapy is relatively safe. It has shown some evidence of benefit in the treatment of back pain, but conventional treatments are usually equally effective and much cheaper. In the treatment of all other conditions, chiropractic therapy is ineffective except that it might act as a placebo.”

    And perhaps the following information which is provided by The Chiropractic Stroke Awareness Group could be added to that:

    “Did you know that a cervical adjustment can tear or crush an artery to your brain causing a stroke?

    Did you know that it can take days or weeks after the artery is torn before you actually have a stroke following a chiropractic adjustment?

    Symptoms
    Nausea, vomiting, dizziness, weakness, slurred speech, sudden numbness on one side of the body, vision problems, severe headache”

    http://www.chiropracticstroke.com/

    For anyone wishing to learn more about chiropractic, the Kinsinger Report on Chiropractic 2008 (approx. 42 mins) is well worth viewing:
    http://ph-ms.ouhsc.edu/ah/rehab/kinsinger.wmv

  6. wertys says:

    I think that if you looked at the documented benefits of neck manipulation (marginal, but probably positive in acute neck pain, probably absent in chronic neck pain) vs the documented potential for catastrophic complications, you would conclude that it wasn’t worth the risk. In the case of epidural anaesthesia, the rate of complications which can be catastrophic is balanced by the well-documented reductions in general anaesthetic complications and postoperative respiratory complications. The search for better and safer ways of doing the same thing is ongoing, and in a few years epidurals may well be obselete. Again, if the risk is known about and efforts have been made to identify at-risk patients which are not reliable, the treatment should be dropped from the ‘therapeutic’ armamentarium of manipulative therapists.

    What’s so hard about that ?

    (closes eyes and waits for roof to fall in…)

  7. Tweyman says:

    I agree with most of the article except comparing the risk of cervical manipulation to Cig smoking. When you show the risk in 1-millions or even 1-40,000 the risk of cig smoking is much more. Also, the risk of over the counter medication has been listed as 1-10,000. So is there risk, yes, most everything has risk, just listen to Persciption med adds on the TV, the side effects are worse than what you are taking the meds for in the first place.

    I was also surprised from the reply on if “self adjusting was bad”. The reply, as long as its not done by a Chiropractor it maybe safer is absurd. The article itself talked about the mechanism of the manipulation as being the culprit. Rotation, extension are the two evils. Self manipulation does both, rotating the neck in circles to “stretch the neck” is also very dangerous and risky yet they still teach this in some exercise classes.

    If the neck is manipulated by a Board Licensed Doctor of Chiropractic who understands the risks, uses techniques that use NO rotation and No extension than the risk is very, very low. Just as if you get medications from a Board licensed Medical Doctor vs ordering meds on line. Doctors of Chiropractic are just that, they are Doctors and most know the right from the wrong, yet you see Therapists, karate instructors, Medical Doctors with no training, yoga instuctors and friends “popping necks”. This is very dangerous. Done by the rightly trained person, who understands the proper anatomy, proper biomechanical and neurological function, and proper low risk techniques, the results can be fantastic.

    You can talk about people dying on a a Chiropractic table, but then you can also talk about the millions who die on the surgical table or in the hospital. Those who went in for routine problems and never walked out, I bet those numbers are higher.

    When properly trained, properly educated and doing what they do best the results can be amazing. All health care providers have a place in the health care field and all do amazing things. To say never let a Chiropractor touch a neck is ignorant. I would say, never let an untrained person manipulate your neck. That includes self manipulation, a medical doctor or therapist with no training, your trainer or yoga instructor or the guy down the street. That is a risk I would not want to take.

    Thank you for your good articles.

  8. Harriet Hall says:

    Tweyman,

    Either you didn’t read carefully or I didn’t write as clearly as I thought.

    “comparing the risk of cervical manipulation to Cig smoking” – I wasn’t comparing them. Smoking is the leading preventable cause of death; neck manipulation is far less dangerous. I mentioned them together only to show that we allow people the right to take risks, and that I support that right as long as they know they are taking a risk.

    “the risk of over the counter medication has been listed as 1-10,000″ Where did you get that number? Surely not deaths: perhaps side effects? As a matter of fact, my article mentioned the risks of medication. We need to look at the risk/benefit ratio for any treatment, and if the benefit of neck manipulation is no greater than the benefit of gentle mobilization, I don’t see how any degree of risk can be justified.

    “as long as its not done by a Chiropractor it maybe safer is absurd” That’s not what I said. Please read again. Simple rotation and extension can rarely cause stroke in susceptible patients, but high-velocity chiropractic thrusts have been linked to stroke in young healthy people because of traumatic tears in the artery. I think most reasonable people would agree that the more like a rapid, forceful chiropractic thrust, the greater the danger.

    “If the neck is manipulated by a Board Licensed Doctor of Chiropractic who understands the risks, uses techniques that use NO rotation and No extension than the risk is very, very low”
    If there is no rotation or extension, then that is not chiropractic manipulation.

    ” the results can be fantastic.” This is not supported by the literature.

    “You can talk about people dying on a a Chiropractic table, but then you can also talk about the millions who die on the surgical table or in the hospital.” Apparently you didn’t understand what I said about the “tu quoque” fallacy. Please read my article again.

    “I would say, never let an untrained person manipulate your neck.” I agree with you there; but even trained people can do damage. I would say, let a trained person do gentle mobilization but never let anyone do high-velocity chiropractic-type thrusts.

  9. Tweyman says:

    “If there is no rotation or extension, then that is not chiropractic manipulation”

    Where did you get your information, there are many techniques performed by Licensed Chiropractors that do not use Rotation or Extension. The use of a high-velocity LOW AMPLITUDE thrust can be done with the neck not in extension and no rotation and the results are fantastic. There are only a few techniques still taught but rarely used that put the neck in extension and rotation and most Licensed Chiropractors do not use these techniques anymore.

    Just as surgeons have changed their techniques in time due to advances in knowledge, literature and risks, Chiropractic Techniques have also advanced, changed and evolved.

    Instead of saying “never let anyone do high-velocity chiropractic-type thrusts” take out the word Chiropractic and just add, “never let anyone do high-velocity untrained thrusts into ones neck”. I have seen Osteopaths manipulate cervical spines with “osteopathic manipulation” that made my toes curl. Using crude rotational moves that would should be banned. I have seen Neurologist manipulate cervical spines with High Velocity High Amplitude thrusts that should be rendered malpractice.

    You missed one word in your letter, low amplitude, that makes a lot of difference. Calling cervical manipulation, Chiropractic-type manipulation is like calling Fascial tissue- kleenex. Its a brand and you are using it too broad based. The changes can be subtle and a good licensed Chiropractor knows when to use what technique for what condition and there are hundreds of techniques out there.

    I agree with you on a high velocity move with extension and rotation should be outlawed and never used. Make sure you target osteopaths, neurologist, Physical therapists and other practioners. Knowledge is power and I am glad that you are calling attention to moves that can cause damage, just don’t single out the profession who has evolved and is doing its best to do it correctly. When comparing risks, manipulation done by Chiropractors is very, very low. Manipulation of cervical spine done by others can be higher.

  10. Harriet Hall says:

    Tweyman’s comments point out one of the difficulties in determining the risk of neck manipulation: the wide variation in techniques. Chiropractors use over 200 different techniques. The Cochrane review I referred to only distinguished generally between “manipulation” and “mobilization.”

    According to Samuel Homola, DC, “Manipulation is a hands-on procedure used to restore normal movement by loosening joints and stretching tight muscles. In some cases, manipulation will restore normal movement by unlocking a joint or by breaking down adhesions. A popping sound often occurs when a spinal joint is stretched a little beyond its normal range of motion. Mobilization simply stretches soft tissues by moving joints through a full range of movement.”

    The classic manipulation technique that most people associate with chiropractors “cracking the neck” is the high velocity/low amplitude SMT thrust. The article I mentioned from the chiropractic literature specified this particular technique in an unconvincing attempt to show that neck manipulation by chiropractors was safe.

    If there is a technique that counts as “manipulation” that is safer than “mobilization,” the Cochrane review did not consider it, and I don’t think there is anything in the literature that substantiates it.

    I don’t accept that chiropractic “has evolved and is doing its best to do it correctly.” A minority of chiropractors may fall into that category, but there are still a lot of chiropractors out there who are doing the most dangerous type of manipulation and who are doing it for the wrong indications.

    I’m “targeting” anyone who uses these risky techniques inappropriately. They are indeed used by osteopaths and others, but the majority of manipulations are performed by chiropractors, and chiropractors are the ones who have been implicated in the published studies of stroke risk.

    You say manipulation done by non-chiropractors carries a higher risk. Do you have any evidence to support that claim? I would think what matters is whether the practitioner was properly trained in SMT and has good judgment rather than what title he holds. I would rather have a properly trained PT work on my neck than a chiropractor who believes in mythical subluxations.

  11. Joe says:

    Tweyman, watch the video linked, above, by Blue Wode. In fact, you can just listen to it while you are doing something else. Dr. Kinsinger has scores of case reports of stroke following manipulation by chiros, and none by PTs. He draws the reasonable conclusion that the difference is because PTs are better educated to recognize the indications for manipulation, and better trained in administration of it. It helps that they do not study fairy-tale subluxations, and they do see people who need therapy in their clinics (as opposed to young, healthy friends who are recruited to pose as customers in chiro clinics).

    As for your claim “we don’t do that any more” is nonsense. Look at the dates in the cases Harriet cited.

    Moreover, nobody really knows what chiros do in practice; there are more than 100 unproven methods in use. They range from NUCCA nuttiness (see the report of the woman whose neck was manipulated for pain in the tailbone!?) to the Logan technique which focuses on the other end.

    The chiropractic license is conferred by other chiros, who believe in such nonsense as subluxations. It cannot be taken seriously. Can you cite anything that is treatable on the basis of a subluxation? Manipulation, after all, is not chiropracty.

  12. Tweyman says:

    Wow there is some bias out there. I don’t argue that better research needs to be done.I also think that the Chiropractic Profession needs to continue to work on improving the literature out there, the information to the public and getting the word out on all the differences out there. For example, are you aware that there are fellowships and specialalities in the profession? Such as pediatric, orthopedic, sports specific, radialogy and neurology? These are 4 more years of education with longer residencies yet most people do not know about that. Its said that the information is slow to get to peoples ears and minds.

    The other problem, most techniques are done with hands, so the results are hard to put into Pub med papers since hands vary. I have seen the same ACL surgery performed by two different surgeons with a very similar person yet two different results. Why one of the surgeons was more skilled and used newer techniques. To put down the profession of the unskilled would be unfair. There are good and bad in all professions.

    No offense Harriet, but to say “I don’t accept that chiropractic “has evolved and is doing its best to do it correctly.” is ignorant. That is like saying that medicine has not evolved in 50 years, look back at what was legal to do 30 years ago. The problem is only the bad seem to make the news and the good Docs who are evolving do not. Techniques are always changing and the Good Docs are always evolving and learning. 10% always make the most news in any profession.

    The other comment that PTs and Osteopaths have not causes strokes is untrue as well. There are many osteopaths who use manipulation as their main source of healing and some of their techniques involve a lot of rotation in the cervical spine. Yet, they do a lot of good as well, so do the PTs who manipulate.

    The education in Chiropractic School is very good. There are those that have strong feelings of the “subluxation therory” and those that don’t. The license that is given is by other licensed Chiropractors, true, but so is the PT credential and Medical Doctors is given by their peers. Is that wrong, no.

    There are many Professional and College teams that use Good Chiropractors, Pts, MDs in harmony to give the patient what is needed. Its easy to find the 10% who give every profession and bad name and cause most of the risk, to put down a profession is wrong, to go after to individual practioner who is doing wrong is right. With health care the way it is we need to focus on getting rid of the practioners (ie Medical Doctors, Chiropractors, Therapists) who are using old techniques, are not staying up on the education and who are causing the damage that has been reported in this blog.

  13. Joe says:

    Tweyman, anybody who has properly studied anatomy and physiology, and chiro, is bound to be biased. I take it you are not going to provide references to treatments of subluxations.

    Of course PTs and MDs are credentialed by their peers; but their peers don’t believe in fairy tales such as chiropractic subluxations and Innate Intelligence. And those are the reasons chiro is a cult, not a profession. When Palmer’s ideas are shown to be ridiculous, they cannot be abandoned. Many chiros still believe that DD cured deafness, despite the anatomical implausibility and the lack of any subsequent replications.

    “Chiropractic specialties” yes, we know about them. There is a tarot-card reader near me who specializes in round (rather than rectangular) cards. It doesn’t make her any better informed.

    As for “… PTs and Osteopaths have not cause[d] strokes …” it may be untrue; but I did not say that. Listen to the Kinsinger video, cited by Blue Wode. He does not say that either.

    You wrote “The education in Chiropractic School is very good.” I must ask, “compared to what.” How would you know?

    You wrote “There are those that have strong feelings of the “subluxation theory” and those that don’t.” According to the McDonald study approximately 90% subscribe to that fairy tale, and the Association of Chiropractic Colleges says it remains the focus of chiro. If you take that away, chiro is just massage (with the possibility of killing people).

    You wrote “There are many Professional and College teams that use Good Chiropractors …” Many of them pray a lot, too; that doesn’t help, either. Tiger Woods wears (wore?) a red shirt on the final day of every tournament for luck. I will concede that a chiro can be a competent masseur; but I would just go for a massage from someone without delusions about health care (subluxations, Innate).

  14. Harriet Hall says:

    On the Healthfraud discussion list on the Quackwatch website, we had a long discussion over many months with Stephen Perle, a DC and a professor of chiropractic at Bridgeport University who is valiantly trying to reform chiropractic from within. He tried his best, but was unable to convince us that the scientifically oriented chiropractors make up more than a small fraction of those in practice. There are no good published studies of how many chiropractors reject irrational methods, but I know of 2 unpublished, informal studies showing that the majority of chiropractors accept the subluxation myth and use nonsensical methods like applied kinesiology. Their own published studies show that half of chiropractors endanger our public health by failing to support immunization, and about a third of them actively discourage it.

    I’m well aware that chiropractors can become specialized in areas like chiropractic neurology. Here’s an example of the quality of the information students learn: http://www.chirobase.org/06DD/blindspot.html

    If one of the major teachers of chiropractic neurology is this clueless about science and logic, I don’t have high hopes for his students.

    As for chiropractic evolving, evolution is more than just developing and refining techniques; it must also involve testing techniques and discarding those that don’t work or that don’t work as well. Medicine has tested and given up countless treatments and diagnostic procedures over the last century. I have repeatedly challeged chiropractors to tell me one thing that chiropractic as a whole has given up: the only thing I have been able to find that no chiropractor is still doing is the bogus nerve tracing technique that BJ Palmer invented.

    I’ll believe chiropractic is evolving when the major chiropractic organizations and schools reject the subluxation myth and things like applied kinesiology and when they firmly endorse vaccination.

    I don’t claim that osteopaths and PTs have never caused strokes. I only claim that the evidence we have suggests that the majority of manipulation-induced strokes are caused by chiropractors, many of whom are using manipulation for the wrong indications.

    I have no problem with chiropractors who limit their practice to evidence-based short term treatment of musculoskeletal problems. Unfortunately, they represent only a small fraction of practicing chiropractors, and when they speak out, they are often reviled and attacked by their less scientific colleagues.

  15. Beachdoc says:

    Harriet et al.,

    I must admit there is a huge struggle within our profession (and Joe, it’s a profession, not a cult) to weed out the unscientific rhetoric and evangelistic sales pitches and replace them with science based practice.

    This was specifically why the chiropractic physicians in Florida raised $1 Million to support a research institute at Florida State University. Unfortunately for our profession and for our patients, this effort was thwarted by those “cult-ish” type chiropractors.

    I, like Stephen Pearle (who is a friend and whom I consider a mentor) and many others don’t understand why these subluxation based (aka “straight”) chiropractors are so confidant with their positions that subluxation does everything they say; are afraid of having a world class research facility actually investigate their theories. Rather, they made a concerted effort to squash what would have and could have led to an evolution in chiropractic science. And, Stephen is right when he says those straight type chiropractors are in the minority. They are extremely vocal. We on the otherhand, continue to push on with our evidence based practice and the push for continued research. Hey, if the research proved their point, then I’d tout it as well. But not until such a time as credible works prove the theories.

    Because our profession has been under the magnifying glass for such a long time, we have managed to get some credible peer reviewed research out there. But it is not enough, more definately needs to be done and there is much currently under way.

    Regarding cervical spine adjustments and stroke, it’s on the mind of every chiropractic physician out there. Personally, I have a written informed consent that describes the risks as we know them. In my office, the patient must read and sign the inform consent, which not only covers the risks of verebral artery dissection type stroke(the paper simply says stroke), but also includes the risks of other therapies such as Ice and Heat, EMS, Exercise, Stretching etc. This often leads to a brief conversation and ends in a benign fashion with the patient givine their consent.

    The important thing for us is to be aware that most people come to the chiropractic physician with the stroke already in progress. Signs of neck pain, headache, migraine type headaches are all reasons for patients to present, however they physician needs to stop and asses the patient and not just brush it off as just another headache.

    does the patient present withsigns of diplopia, dizziness, drop attacks, dysphagia, dysarthria, ataxia of gait, nausea, numbness & nystagmus? Do they describe the “worst headache of their life”???

    If so, the correct thing to do is call 911 and get them to the ER asap. Not, adjust them and see how they feel.

    There is a huge separation between the subluxation based and the evidence based chiropractors in this country, and the gap is widening.

    For the individual who suffers a vascular accident; as well as their family and friends, it must be horrible. But the numbers of these cases are much less than are pointed out in literature. 1 of these patients will visit 1, 2, 5 or more neurologists and it gets reported by each. That 1 case has now turned in to 2 or 4 or more and each is reported as a seperate incident.

    Additionally, there are papers that show that so called “chiropractic manipulations” causing vascular accidents were never performed by a chiropractor. That they used the term chiropractic manipulation as a general term, even though a properly trained and licensed chiropractor wasn’t involved. There have even been letters published in the very same journals admitting to the errors in terminology. Here’s a link to one such summary:

    http://www.chiro.org/ChiroZine/ABSTRACTS/Inappropriate_Use_of_the_title.shtml

    Personally, I have a great relationship with the local medical community. I have a cardiologist, cardiothoracic surgeon, 1 general family practice physician, 1 pediatrician, 3 nurses & 2 physical therapists currently actice as patients. I actively get referrals from the pediatrician, 2 local internists (several have been specifically for headaches) and a local orthopedic surgeon; and I refer patients back to them.

    The difference? Taking a good history, doing a good examination, keeping proper records and practicing evidence based chiropractic and develping a good relationship with my colleagues in the medical community. Over the years of practice, I’ve had 2 people walk into my office with an active stroke in progress, 3 people having mid-back pain and radiating arm pain in the early stages of a myocardial infarction. All were immediately sent to the local E.R., and all are alive and relatively well. Hopefully, most of them changed their eating and exercise habits.

    I would ask that before further condemning my profession, you look into the works of:
    1. Scott Haldeman, DC, MD, Ph.D (his medical specialty is neurology)
    2. John Triano, DC, Ph.D
    3. David Seaman, DC, DACAN

    These are the people whom I seek out when attending continuing education seminars as well as others who speak int he area of sports medicine, nutrition and rehabilitation. Most of the chiropractors I know and all of the ones I consider colleagues do not practice subluxation theory chiropractic, but chiropractic based on evidence published, guided by some of the works of the 3 aforementioned. Studies on the effectiveness of spinal manipulation have been published in Spine, JMPT and others. There more out there and I don’t have the luxury of time to get all of the references.

    Chiropractic physicians (specifically chiropractic sports physicians) have been on the medical team for the US Olympic Team since the 1980s. Additionally, all NFL teams, most MLB and NBA teams all have chiropractors for their athletes. If chiropractic were that dangerous, why we these organizations allow their elite athletes to be exposed to that great of a risk? Why is it that $1-Million in malpractice insurance cost only $3-5 thousand dollars a year? Because, the risks are minimal for causing harm. Weight the risks vs the benefits and the only conclusion is that for the conditions we treat, chiropractic is safe and effective.

    I would like to leave you with the following, which pretty much sums up the neck adjustment-stroke issue and that my colleagues and myself view as credible. All referenced for Dr. Lauretti’s article are provided at the bottom of the article.

    What are the Risk of Chiropractic Neck Treatments?
    ________________________________________
    By William J. Lauretti, DC

    Several recent news items have reported on the supposed risks of chiropractic manipulation to the neck. As a practicing chiropractor who uses neck manipulation everyday in my practice, I find these reports exaggerated and alarmist. In seven years of practice, I have personally performed, received and/or witnessed well over 7,000 neck manipulations, without a single significant complication. Clearly, the risks of neck manipulation are not as extreme as some of the more irresponsible reports imply. I believe the rash of sensationalist reporting has obscured the three key questions involved in this issue:

    1. Just how risky is chiropractic neck treatment (cervical manipulation)?

    2. How risky are the other common treatments for neck symptoms compared with chiropractic treatments?

    3. How effective is chiropractic neck treatment compared to other common treatments?

    This essay will discuss these points and attempt to clarify this issue for consumers, health care practitioners and policy makers.
    How Risky is Cervical Manipulation?

    Every published study which has estimated the incidence of stroke (CVA) from cervical manipulation has agreed that the risk is 1 to 3 incidents per million treatments. Dvorak, (1) in a survey of 203 practitioners of manual medicine in Switzerland, found a rate of one serious complication per 400,000 cervical manipulations, without any reported deaths, among an estimated 1.5 million cervical manipulations. Jaskoviak (2) reported approximately 5 million cervical manipulations from 1965 to 1980 at The National College of Chiropractic Clinic in Chicago, without a single case of vertebral artery stroke or serious injury.

    Henderson and Cassidy (3) performed a survey at the Canadian Memorial Chiropractic College outpatient clinic where more than a half-million treatments were given over a nine-year period, again without serious incident. Eder (4) offered a report of 168,000 cervical manipulations over a 28 year period, again without a single significant complication. After an extensive literature review performed to formulate practice guidelines (5), the authors concurred that “the risk of serious neurological complications [from cervical manipulation] is extremely low, and is approximately one or two per million cervical manipulations.” The “one in a million” estimate was echoed in another extensive literature review performed by the RAND corporation (6).
    In another survey, based on a computerized registration system in Holland, Patjin (7) found an overall rate of one complication in 518,886 manipulations. A survey done at Stanford University (8), asked every neurologist in California if they saw any neurological complications they thought resulted from chiropractic treatment in 1990-91. Their survey found 55 reported CVAs statewide over that two-year period. During that period there were about 110 million office visits to chiropractors in California, and between 33 and 50 million neck adjustments. Other experts on manipulation (9)have published opinions that the risk of stroke from cervical manipulation is two or three more-or-less serious incidents per million treatments.

    In addition to these published studies, data from the National Chiropractic Mutual Insurance Company (NCMIC), which insures over 50 percent of US chiropractors, is also useful for estimating the risk of cervical manipulation. Since chiropractors deliver 80-90 percent of the spinal manipulation performed in the US, and this company insures about one-half of the profession in the US, this malpractice insurer is a good source of statistics on this subject. According to a member of NCMIC Board of Directors (personal communication with Louis Sportelli, DC, Dec. 21, 1994), in the three years of 1991-92-93, NCMIC closed a total of 96 claims for CVA; of this total 61 were closed with payment, and 35 were closed without payment. If one concludes that there was little or no merit to the 35 claims which were closed without payment, this would represent an average of 20 CVA claims per year.

    If these NCMIC chiropractors are similar to the national average, they see approximately 120 patient visits per week (10). Curtis and Bove (11) report that rotary adjustments of the cervical spine comprise about 30% of the visits made to chiropractors. Therefore, chiropractors insured by NCMIC each performed some 1800 cervical manipulations in each of those three years. Considering these numbers, we calculate that NCMICs 24,000 DCs perform some 43,000,000 cervical manipulations per year. If this leads to 20 strokes, that’s a rate of less than one stroke per 2 million cervical manipulations.

    Another study based on malpractice history was done in Canada (12). This study reported there were 13 documented CVAs related to chiropractic care in Canada (with no reported deaths) over a 5 year period. The author estimated there were at least 50,000,000 cervical manipulations performed by Canadian chiropractors during that time period. He concluded that a reasonable estimate of risk is 1 serious neurological complications per 3,000,000 neck manipulations.

    Finally, in what might be the best documented study to date, Klougart et al (13). sought to identify the total number of cases of CVAs related to chiropractic manipulation that occurred in Denmark over a ten-year period. They surveyed all members of the Danish Chiropractors’ Association, and cross-referenced the members’ reports of CVA occurrences with published cases, official complaints and insurance data. Then they estimated the total number of neck manipulations performed by chiropractors over the same time period from the survey responses cross-referenced with insurance reimbursement data. They found five cases of “irreversible CVA after chiropractic treatment” occurred in Denmark between 1978 and 1988, in the course of 6,600,000 cervical spine treatment sessions. They estimated a risk of 1 CVA per 1,320,000 cervical spine treatments sessions, and 1 CVA per 414,000 cervical spine sessions using rotation techniques in the upper cervical spine.

    Based upon these studies, the most reasonable estimate of the risk of stroke from cervical manipulation is one-half to two incidents per million manipulations performed. Only a minority of these cases are fatal. About one-third of the cases of stroke following cervical manipulation reported in Terrett’s review of 107 cases (14) resolved with mild or no residuals. In a later review, Terrett (15) found a total of 126 cases of vertebrobasilar accidents following manipulation reported in the international literature from 1934-1987, of which 29 cases resulted in death. This yields a mortality rate of 23% among the incidences reported in the literature. While it has been argued that the rate of strokes may be significantly under-reported in the literature, it is probable that the rate of deaths are proportionally over-reported, since it is likely the more serious and impressive cases would be described in the literature. Therefore, a conse! rvat ive estimate of the risk of death from stroke caused by neck manipulation is about one fatality per 4,000,000 neck manipulations.

    Risks of Other Common Treatments for Neck Symptoms

    For proper perspective, the risks of chiropractic neck treatment should be compared to the risks of other treatments for similar conditions. For example, even the most conservative “conventional” treatment for neck and back pain, prescription of Non-Steroidal Anti-Inflammatory Drugs (NSAIDs), may carry a significantly greater risk than manipulation. One study (16) found a 4/10,000 annual mortality rate for NSAID induced ulcers among patients treated for non-rheumatic conditions such as musculoskeletal pain and osteoarthritis; that extrapolates to 3,200 deaths in the US annually.

    While it might be argued that the population covered in this study were only patients under long-term NSAID therapy, and that acute use carries far less risk, it is not true that these complications are limited only to chronic NSAID users. Gabriel et al, in a meta-analysis, found short-term NSAID use was actually associated with a much higher rate of GI complications than chronic use (17). They calculated that the odds ratio for adverse GI events associated with NSAID use was 1.92 for more than 3 months of NSAID exposure, but 8.00 for less than 1 month of NSAID exposure.

    Less conservative treatments such as neck surgery are also commonly used for conditions very similar to the conditions chiropractors treat using spinal manipulation. There is a 3-4% rate of complication for cervical spine surgery, and 4,000-10,000 deaths per million neck surgeries (18).

    Effectiveness of Chiropractic Neck Treatment

    Numerous recent studies have found that spinal manipulation provides superior clinical outcomes compared to conventional care for neck and back complaints. Dozens of other studies have shown chiropractic care to be more cost-effective and more preferred by patients than medical care for several conditions.
    A comprehensive literature review (6) concluded, “In summary, evidence from the literature supports the conclusion that cervical spine manipulation and/or mobilization may provide at least short-term pain relief and range of motion enhancement for persons with subacute or chronic neck pain.” They also concluded, “the literature is sparse but suggests that cervical spine manipulation and/or mobilization may provide short-term relief for some patients with muscle tension (and other nonmigraine) headaches. The evidence for long-term benefit is much less conclusive.”

    The highest rated, large-scale, randomized trial comparing manipulative therapy to general practitioner management (including NSAIDs) in the treatment of back and neck pain was performed by Koes (19). He found manipulative treatment significantly superior, with the advantages for the group treated with manipulation persisting even at the 12-month follow-up.
    More studies are currently underway comparing the effectiveness of cervical manipulation with other treatments for neck pain, headache and related conditions.

    Ironically, despite their well-documented risks and widespread use, the evidence supporting the effectiveness of NSAIDs for neck pain is extremely limited. In a recent review of medications used for neck pain, the authors noted that the current standard of accepted practice “may rest on a quagmire of possibly valid, but unproven, treatments” (20). Even though NSAIDs are considered to be a well-established treatment for musculoskeletal pain, in a recent Medline search (1966 to 1996), we were unable to locate even a single randomized, controlled trial examining the use of NSAIDs specifically for neck pain.
    ________________________________________

    SUMMARY:
    **A reasonable estimate of the risks of stroke following cervical manipulation is 1/2 to 2 incidents per one million treatments.

    **About one-third will resolve with mild or no residuals (probably more due to reporting bias).

    **About one-fourth will prove fatal (probably less due to reporting bias).

    **Therefore, there are about 40-50 manipulation-caused strokes in the US per year, and perhaps a dozen deaths.
    To place this in perspective, if we agree that the risk of dying from a stroke after a neck adjustment is 1/4,000,000, there may be as much as a 100 times greater risk of dying from an ulcer due to taking a prescription NSAID like Motrin. If you drive about 8 miles each way to get to your chiropractic appointment, you have a statistically greater risk of being killed or seriously injured in a car accident getting to the office than of having a serious complication from your treatment.

    The chiropractic profession has a well established record of safety and efficacy, and chiropractors’ malpractice insurance rates remain among the lowest in the health professions. The profession is leading the way in research to learn more about complications from treatments, and working to reduce them still further. Despite occasional sensationalistic reports in the media, the facts show that chiropractic treatments rank among the safest and most effective form of health care ever offered.
    ________________________________________
    Bill Lauretti, DC
    Bethesda, Maryland

    Editorial Director, Chiropractic OnLine, the American Chiropractic Association’s Web Page.
    This essay is based on an article which was published in the Journal of Manipulative and Physiological Therapeutics in October, 1995. The author will gladly send a reprint to any interested parties upon request. An expanded version will appear as a chapter in Contemporary Chiropractic (Daniel Redwood, DC, Editor), a text book to be published in 1997 by leading medical publisher Churchill Livingstone.
    ________________________________________
    REFERENCES:
    1. Dvorak J, Orelli F. How dangerous is manipulation to the cervical spine? Manual Medicine 1985; 2: 1-4.
    2. Jaskoviak P. Complications arising from manipulation of the cervical spine. J Manip Physiol Ther 1980; 3: 213-19.
    3. Henderson DJ, Cassidy JD. Vertebral Artery syndrome. In: Vernon H. Upper cervical syndrome: chiropractic diagnosis and treatment. Baltimore: Williams and Wilkins, 1988: 195-222.
    4. Eder M, Tilscher H. Chiropractic therapy: diagnosis and treatment (English translation). Rockville, Md: Aspen Publishers, 1990: 61.
    5. Haldeman S, Chapman-Smith D, Petersen DM. Guidelines for chiropractic quality assurance and practice parameters. Gaithersburg, Md: Aspen Publishers, 1993: 170-2.
    6. Coulter ID, Hurwitz EL, Adams AH, et al. The appropriateness of manipulation and mobilization of the cervical spine. Santa Monica, CA: RAND Corporation 1996: xiv. (RAND Home page: http://www.rand.org).
    7. Patijn J. Complications in Manual Medicine: A Review of the Literature. J Manual Medicine 1991; 6: 89-92.
    8. Lee KP, Carlini WG, McCormick GF, Albers GW. Neurologic complications following chiropractic manipulation: A survey of California neurologists. Neurology 1995; 45: 1213-5.
    9. Guttman G: Injuries to the vertebral artery caused by manual therapy (English abstract), Manuelle Medizin 1983; 21: 2-14.
    10. Plamandon RL. Summary of 1992 ACA annual statistical survey. ACA J Chiropractic 1993; 30 (Feb): 36-42.
    11. Curtis P, Bove G. Family physicians, chiropractors, and back pain. J Family Practice 1992; 35 (5): 551-5.
    12. Carey PF. A report on the occurrence of cervical cerebral vascular accidents in chiropractic practice. J of Canadian Chiropractic Assoc 1993; 37 (2): 104-6.
    13. Klougart N, Leboeuf-Yde C, Rasmussen LR. Safety in chiropractic practice. Part I: The occurrence of cerebrovascular accidents after manipulation to the neck in Denmark from 1978-1988. J Manipulative Physiol Ther 1996; 19: 371-7.
    14. Terrett AG. Vascular accidents from cervical spine manipulation: Report of 107 cases. J Aust Chiro Assoc 1987; 17: 15-24.
    15. Terrett AG, Kleynhans AM. Cerebrovascular complications of manipulation. In: Haldeman S., ed. Principals and Practice of Chiropractic. Norwalk, Ct.: Appleton & Lang, 1992: 579-98.
    16. Fries, JF. Assessing and understanding patient risk. Scand J Rheumatol 1992; Suppl. 92: 21
    17. Gabriel SE, Jaakkimainen L, Bombardier C. Risk for serious gastrointestinal complications related to use of nonsteroidal anti-inflammatory drugs; a meta-analysis. Ann Int Med 1991; 115: 787-96.
    18. The cervical spine research society editorial committee. The Cervical Spine, Second edition. Philadelphia: J.B. Lippincott Company 1990: 834.
    19. Koes BW, Bouter LM, et al. Randomized clinical trial of manipulative therapy and physical therapy for persistent back and neck complaints. BMJ 1992; 304: 601-5.
    20. Dillin W, Uppal GS. Analysis of medications used in the treatment of cervical disc degeneration. Orthop Clin North Am 1992; 23(3): 421-33.
    Suggested Additional Reading:
    Terrett AGJ. Vertebrobasilar stroke following manipulation. West Des Moines, IA: National Chiropractic Mutual Insurance Company: 1996 (NCMIC Home page: http://www.ncmic.com).
    Dabbs V, Lauretti WJ. A risk assessment of cervical manipulation vs. NSAIDs for the treatment of neck pain. J Manip Physiol Ther 1995; 18(8): 530.
    Dock DP. A false claim: Stroke from manipulation. Duluth, MN: Dr. Daniel P. Dock 1994. To order call: (218) 525-2033.

  16. Joe says:

    Chiropracty is a cult. The proof is that cannot shed the originator’s notion of subluxations even though that idea is fully discredited. From the Association of Chiropractic Colleges (ACC), 2006:
    http://www.chirocolleges.org/paradigm_scope.html
    “Chiropractic is Concerned with the preservation and restoration of health, and focuses particular attention on the subluxation.”
    There own survey (McDonald, 2003) shows 89% favor retaining subluxation in their practice. The ACC goes on to describe:
    “A subluxation is a complex of functional and/or structural and/or pathological articular changes that compromise neural integrity and may influence organ system function and general health.” This sounds like “anything we can claim to fix and bill you for.”

    Then there is the problem of Innate Intelligence
    http://www.jcca-online.org/client/cca/JCCA.nsf/objects/Commentary+The+meanings+of+Innate/$file/3-Commentary%20Keating.pdf
    “Since the notion was first introduced by D.D. Palmer circa 1904, “Innate Intelligence” has been a source of inspiration, confusion and derision for chiropractors. …”
    They don’t deny Innate, they kinda sweep it under the carpet.

    Chiros also continue to believe that, in 1895, DD Palmer cured deafness with a chiropractic adjustment of the thorax; despite the implausibility and the fact that feat has never been repeated. Slavish devotion to the originator of a notion is a pathognomonic feature of a cult.

    As for being a “profession,” that word is used loosely these days to mean a member of an identifiable group. In that sense, chiro is a profession since it is characterized by opposition to criticism.

  17. Harriet Hall says:

    Beachdoc says, “Most of the chiropractors I know and all of the ones I consider colleagues do not practice subluxation theory chiropractic, but chiropractic based on evidence published.”

    This is a testimonial, not evidence. I think Beachdoc is associating with members of a small minority rather than a random sample of chiropractic reality. His statement is contradicted by other data including the study Joe cites by chiropractors themselves.

    As for chiropractic being a cult, at least one chiropractor has said it is. The full text of Samuel Homola’s book “Bonesetting, Chiropractic and Cultism” is available at http://www.chirobase.org/05RB/BCC/00c.html

    Beachdoc says there is a greater risk of an auto accident on the way to the chiropractor’s office. Actually, that’s something I worry about. The risk of multiple trips to and from a chiropractor’s office must be added to the risk of the treatment itself. Other treatment options tend to require less travel.

    He says “the facts show that chiropractic treatments rank among the safest and most effective form of health care ever offered.” I don’t think the facts show any such thing. Neither do Edzard Ernst or Simon Singh, who wrote an interesting article in the Guardian at http://www.guardian.co.uk/commentisfree/2008/apr/19/health that concludes “if spinal manipulation were a drug with such serious adverse effects and so little demonstrable benefit, then it would almost certainly have been taken off the market.”

    I hope Beachdoc noted that I did not call for chiropractors to be taken off the market. I only asked that the risk/benefit ratio be considered and that patients be adequately informed.

    That goes for any treatment for any condition, from neck manipulation to NSAIDs. The safest treatment of all is tincture of time. I think that option should be offered to every patient unless there is reason to think non-treatment would result in permanent damage.

  18. quackdoctor says:

    Be very careful in reading this article. Dr. Hall does not have a clue what she is talking about. I have studied her posts on another forum. She clearly has no understanding of what chiropractic is. She is totally misguided. It is a shame because she is an intelligent person. Outside of the stroke issue she has made no tangible attempt to understand chiropractic. What I mean by this is that if she was sincere then she would take the time to spend a week in a top chiropractor’s office to experience on a clinical level what is done. You see you really cannot understand a field that involves art to a large degree by simply studying it in articles and slanted resources. If she were to take the time to see a few hundred patients with an experienced DC then she might get some insight. As far as the stroke issue. It has been even said in a major medical journal that this has been used as a weapon against chiropractors. It is extremely rare. A handful of cases are used by the anti chiropractic camp to discredit a procedure that is very safe. She does not mention that her own field is full of dangerous and unproven treatments that cause death in patients all of the time. She also fails to mention that even though there are very few strokes from manipulation the chiropractic profession is teaching and using methods to eliminate or reduce risk. She is obsessed with chiropractic but looks not at her own camp. Many people are killed by cosmetic surgeons every year and the precedures are not necessary. They play off the vanity of people and put them at risk. There are many other examples. But she is obsessed with a witch hunt on chiropractic. It is my experience from observing Dr Hall’s posts that she has an irrational fear of chiropractic. She is very selective about what she let’s into her head. You see you really cannot understand what another person knows or does without walking in their shoes. If she spent a week actually keeping her mouth shut and watching in a top DCs office she would learn something. If she ever bothered to come out to the National University of Health Sciences and spend a few days in classes and a week in the clinic she would learn something. I am sure they would have her. She would learn what chiropractic physicians know about MRI, CT, radiology and she does not. She would learn about how DCs actually manage patient using all forms of exams from eyes to gyn. She would experience the clinical reality of how chiropractic corrects imbalances in the NMS system. She would be shown the “subluxation” that she rejects as it can only be understood by experiencing hands on evaluation and reduction. If Dr Hall was open minded she would study the work of Joseph Janse and Fred Illi. But I know she will never do that. Not in a million years. So before listening to Dr Hall aske her these questions. 1. Have you ever spent a week in a chiropractors office to experience what they do? 2. Have you ever had a problem addressed by a DC or been under regular chiropractic care? 3. Can you Dr. Hall explain in some depth how the mechanics of the lower extremity, pelvis and spine relate in gaiting? 4. Have you ever observed the Derifield response as it relates to the cervical spine and the pelvis? And finally Dr. Hall what is a radiographic finding on a flat plate film in the soft tissues that is associated with Cordoma? Dr Hall in her day may have been a good surgeon but she does not no the first thing about modern chiropractic care as practiced by competent doctors. She is pathologically biased to an irrational degree. Instead of picking on problems in the profession she should look to the good. But she will never do that as with all religious zelots she is apparently trapped in a mindset. She cannot possibly know what she is talking about until she experiences chiropractic care on a high level for herself both as a patient and as an observer of a clinician. Lastly you will notice that she fails to mention that osteopathic physicians have caused a few strokes too but we never see their cases advertised. Her attack is on chiropractic by principle. It would seem that since DOs are part of the traditional medical system and in hospitals that she would be concerned with their practice. And she has no ground to say they do not believe what the DCs do. All you have to do is look at the position statements of the AOA. If Harriet would do as I say and experience reality she would actually learn something. But that is never going to happen. Because this attacking of chiropractic is obviously part of who she is. In the metabolism of the body there are two parts. One builds up the body and one tears it down. The same is true with humanity. To be focused on always tearing down something is in my opinion very imbalanced. So what about it Harriet. When are you going to tour National and spend a week there and in a top DCs office? Whe are you going to experience the care for your self? When you do that I will be more than willing to consider your position. But until then I view you as that guy that attacked windmills on horseback. If the child will open the closet they will find that there really is not a scary ghost in there. It is just a closet. No more and no less.

  19. Blue Wode says:

    @ Beachdoc

    You said: “I must admit there is a huge struggle within our profession (and Joe, it’s a profession, not a cult) to weed out the unscientific rhetoric and evangelistic sales pitches and replace them with science based practice.”

    Well, here in the UK there doesn’t seem to be any ongoing struggle. Although UK chiropractors became regulated by statute in 2001, which created a new code of ethics requiring their provision of care to be evidence-based, it would seem that the members of all four UK chiropractic associations continue to buy into the subluxation myth:

    The British Chiropractic Association’s website says “As you go through life, a loss of proper function (movement) in the vertebrae, which some chiropractors call a subluxation, may interfere with the healthy working of your spine and the nerves that run through it. This may affect your body’s natural ability to recover from injury and you may find yourself increasingly unwell, unable to shake off apparently minor aches, pains and even some illnesses.”
    http://www.chiropractic-uk.co.uk/gfx/uploads/textbox/Servicing%20your%20spine.pdf

    The UK McTimoney Chiropractic Association says “By correctly training hands as an instrument of innate intelligence, healing can be encouraged to take place by the detection and correction of bony subluxations (slight displacements)”:
    http://www.mctimoney-chiropractic.org/mca_objectives.htm

    The UK United Chiropractic Association says (on the subject of ‘vitalism’) “We ascribe to the idea that all living organisms are sustained by an innate intelligence, which is both different from and greater than physical and chemical forces. Further we believe innate intelligence is an expression of universal intelligence…We recognize that interference to innate intelligence (subluxation) diminishes healing capacity, with an alteration in the dynamic interrelationship between mental, physical and social aspects of the whole person”:
    http://www.united-chiropractic.org/modules/content/index.php?id=4

    And the Scottish Chiropractic Association says “Chiropractors are able to examine and evaluate a child’s spine to determine if they can help problems such as colic, asthma, bedwetting, eczema and sleeping difficulties. Chiropractors advise that a child’s spine be checked for subluxations and postural distortions before any symptoms are even present”:
    http://www.sca-chiropractic.org/index2.htm

    Indeed, if its (vague) definition of ‘subluxation’ is anything to go by, it would seem that the regulatory body, the General Chiropractic Council, makes a huge allowance for the UK’s unscientific chiropractic community:

    “Q8. What is a subluxation and can it do me harm?
    A8. A subluxation complex or ‘subluxation’ is the term used by chiropractors to describe a loss of function in the spine and nervous system due to a reduction in its normal motion or alignment and this can affect the quality of your life.”
    http://www.gcc-uk.org/page.cfm?page_id=6

    Beachdoc said: “Regarding cervical spine adjustments and stroke, it’s on the mind of every chiropractic physician out there.”

    But is that because they’re genuinely concerned about patient safety, or because they’re more concerned that too much bad publicity might see their (often lucrative and whole-family dependant) patient bases starting to dwindle?

    I would also add that whilst it is commendable that you obtain written informed consent from your patients, it doesn’t excuse the many chiropractors who apparently don’t do so (see the two links in my earlier post). Furthermore, if chiropractors are truly concerned about patient safety, then why aren’t all of them handing out fact sheets to their patients as a matter of routine – similar to the Patient Information Leaflets which accompany OTC medications – advising them of the benefits and risks of their treatment? FYI, here’s a sample fact sheet on chiropractic that’s currently available in the UK:
    http://www.ukskeptics.com/factsheets/Chiropractic.pdf

    Beachdoc said: “There is a huge separation between the subluxation based and the evidence based chiropractors in this country, and the gap is widening.”

    I’m interested to know how you expect patients to be able to distinguish between those two types of chiropractors. And perhaps more to the point, why, in the 21st century, should they be faced with such a dilemma in the first place?

    Beachdoc said: “I would like to leave you with the following, which pretty much sums up the neck adjustment-stroke issue and that my colleagues and myself view as credible.”

    In the interests of balance, I’d like to leave you with the following which was written by a well respected British scientist who does not have a vested interest in chiropractic. It sums up the neck adjustment-stroke issue from a scientific perspective:

    “In conclusion, spinal manipulation, particularly when performed on the upper spine, has repeatedly been associated with serious adverse events. Currently the incidence of such events is unknown. Adherence to informed consent, which currently seems less than rigorous, should therefore be mandatory to all therapists using this treatment. Considering that spinal manipulation is used mostly for self-limiting conditions and that its effectiveness is not well established, we should adopt a cautious attitude towards using it in routine health care.”

    Adverse effects of spinal manipulation: a systematic review
    Ernst E, J R Soc Med 2007;100:330-338
    http://jrsm.rsmjournals.com/cgi/content/full/100/7/330

  20. Harriet Hall says:

    Quackdoctor’s ad hominem rant does not deserve an answer, but for the record I would like to say that most of what I know about chiropractic I have learned directly from chiropractors. There is nothing I say about chiropractic that some chiropractors don’t say themselves. A friend of mine is a chiropractor, and whenever he reads something I have written about chiropractic he writes to tell me he approves of what I wrote. I have had several other chiropractors e-mail me to thank me for exposing the abuses of their colleagues.

    I’m not an enemy of chiropractic; I’m a proponent of science-based medicine. In fact, I have been criticized for my degree of tolerance by ex-chiropractors and medical colleagues who think chiropractic should be abolished. I don’t agree; I think there is a place for chiropractors who give up the subluxation myth and the other nonsense and who follow guidelines like those of the National Association for Chiropractic Medicine.

    I’ve had many discussions with chiropractors over the years and I’ve noticed that when they run out of credible evidence and good arguments they almost always resort to ad hominem attacks. If Quackdoctor had anything of substance to contribute to this discussion he would have done so instead of trying to discredit me personally.

  21. quackdoctor says:

    I think my post was not an attack and basically contained a lot of substance. My main point is that Harriet has done a lot of talking about chiropractic. Her chiropractic friends are people who see things in a similar way that she does. There are some problems in the profession. But trust me when I tell you. I am very skeptical and analytical. I come from a family of MDs. All I can say is that I wish Harriet could understand that she is not going to understand chiropractic until she spends time in a chiropractirs office. And by that I do not mean a chiropractor that does things her way. She believes for example that there is no reason to adjust the cervical spine when there is an imbalance in the pelvis or low back. (I am not even sure she knows what an imbalance is). But if she was to allow a top chiropractor to show her why she is wrong on a number of patients she would change her concepts I am sure. She cannot appreciate what a chiropractor is taught in school because she has never sat in classes. She assumes that her chiropractic friends are good chiropractors who have accurate information. But alas they may not. I really wish she would just spend some clinical time quietly observing a top chiropractor that deals with balance in the spine and can really analyse and adjust. Harriet actually is convinced for example that altered dynamics in the cervical spine cannot cause a functional short leg in a patient and imbalance them. To her full spine adjusting for a pain in the lower back does not make sense. Well it did not make sense to me either until I actually was taught and practiced for a while. Again I suggest she study Joseph Janse and Fred Illi. Come out to National College and spend some time seeing what the reality is. I wish she would break away from her chiropractic friends and quietly listen to what top full spine chiropractors have to say. And observe them. Because until she does she will not speak with any authority on the field. She does the sam thing other Skeptics of chiropractic like Steve Barrett do. They read about chiropractic. Maybe even pose as a patient for a free exam like Dr Barrett. But what they do not do is go to a chiropractor for a legit need and see how things are done. What they do not do is to spend time clinically studying with a top chiropractor. What I am saying is that Harriet perceives an acceptable chiropractor to be what she has constructed in her mind. But I am a very medical person and have had the advantage of seeing a lot of patients as a chiropractor for 25 years. All I can tell you Harriet is that there is truth to a lot of what these chiropractors are sayins. And it is a truth that you cannot understand until you study it on patients. Yes there are nutjobs in the field. I cannot change that. But there is something to this concept of “subluxation”. But subluxation is not what the chiropractors articulate it as. Instead of crying “prove it”. I wish Harriet would let a few people who were really good show her what they see and do. Then maybe she could as a very smart person come up with some ideas on how to document what she would see. Now I am actually a very medical person. But I also understand that spines become imbalanced. The only reason I know that is because I have practiced. I had no adgenda. I was not in it for the money. I have never quacked anyone. I never got rich on this stuff. I practiced ethically and quietly observed peoples spines. I arrived at some understanding over 25 years on how the spine works and responds to adjustments. What I see is people like Harriet on one side shaking their heads No No No on one side and some fanatical chiropractors on the other saying Yes Yes Yes. And I and a good many others are in the middle seeing the truth. So anyway Harriet you have my sincere apology if I projected myself as attacking you. I really did not mean to. But you are an intelligent person. You have been a surgeon and are an author among other things. I just wish you would be able to see clearly. There is much you know but there is much you do not about this field. When it comes to understanding truthful chiropractic and the spine either you get it or you don’t. Many of the people Harriet associates with will never get it. They just won’t. But I am hoping that Harriet will get it. And the only was to do that is to see it first hand. I am hoping that she will see that there is a baby in the bathwater and not to let the baby go down the drain.

  22. Harriet Hall says:

    I must be getting smarter. First “She clearly has no understanding of what chiropractic is.” and now “There is much you know but there is much you do not about this field.”

    Quackdoctor’s thesis seems to be “if you see it you will believe it.” I don’t accept that as a valid method of learning the truth. We humans are too prone to errors of perception, fallacies of reasoning (particularly post hoc ergo propter hoc), seeing patterns where there are none, and jumping to false conclusions. The only thing that has any hope of avoiding those pitfalls is the scientific method.

    “Either you get it or you don’t” doesn’t wash. Our criteria on the science-based medicine blog is “Either you have credible scientific evidence or you don’t.” Chiropractic doesn’t. Despite over 100 years of trying, chiropractors have never even been able to demonstrate the reality of the subluxation that is their whole raison d’etre.

    Quackdoctor’s faith in chiropractic is based on personal belief and experience, not on evidence derived from the scientific method. He hasn’t given us a shred of evidence, just unsupported statements. He is the one who “doesn’t get it” about science.

    He considers Joseph Janse an authority. Janse wrote “…in virtually all diseases a subluxated vertebra has something to do with their causation in one way or another.” That goes way beyond even D.D. Palmer’s original guesstimate of 95% and amounts to nothing but pure unadulterated bull spit.

  23. quackdoctor says:

    Actually Harriet Joseph Janse said that many many years ago. In the early days. Also I think if you checked the quote is taken out of context. Times changed. Please check the date on your quote. Then give me some quotes by him in his later years. Everybody changes. I believe in the early days Dr Janse was against vaccines but he changed with the times. Often people who are anti chiropractic will quote fron antiquated sources. This is common on quackwatch for example. Ot they quote from Ralh Lee Smith or Holuma(spelling). Books about chiropractic written 40 years ago. Instead of quoting Joe Janse as you did why did you not find out what he contributed to biomechanics. Who do you think was key in the discovery that the SI joints move> Forgot to mention that. Did you not? Forgot to mention the fact that he essentially started the CCE and is refered to as the apostle of chiropration education. But you picking an old quote is reflective of exactly what I say. So Harriet what year was it that Dr Janse said that? 60 years ago, 70 years ago ? And what else did he say? Read the rest of the page. Now as far as science goes. I am more familar with it than you my friend. You are a clinician. I have a PhD and a DC. So I am well aware of science. That is why I recommended that you spend time with chiropractic doctors yourself. Surely a critical thinker like you would not be deceived. Measurements of subtle changes in spinal balance are easily observed by clinician who know what to look for but unfortunately they are not as easy to document. We have yet to find accurate methodologies to register postural and mechanical changes. Attempts have been mad with bilateral scales and other methodolgies. Radiographs are of no help. But experienced clinicians aare well aware of the changes. When you for example mesure a LMN deep tendon reflex with a Taylor Hammer you can appreciate the change and accept it and note it. Well the same goes for things like functional short legs and the spine. Certain judgements are made subjectively about reflexes by neurologists and other clinicians like “Trace” or “hyperreflexic”. Well the same is true for other phenomaena in terms of the NMS system. And science is a wonderful thing but sometimes it can be applied incorrectly. Like a study I was reading about how CPR is just as good as having a difibrillator for the public. Well no matter what the current science says if I am in trouble I hope the machine is around. So I will say again that you can keep throwing up the science stuff. But as a surgeon you know that art and experience comes into play. And personally I want my surgeon to be an artist and know science. I do not want a scientist who is a lousy artist as a surgeon. The almost entire field of psychiatry is not based in science from the diagnostic perspective. Sure the pharmacology is scientific but the diagnosis is totally subjective for the most part. How much science is there in surgery for AA? One vascular surgeon says one thing as far as cutting and another holds a different threshold. Where is the science in that? Harriet I trust that you are intelligent enough to not be fooled when observing a chiropractor treat a few hundred people. I trust that you are bright enough to sit in on classes at National and decide if science or woo woo is being taught. Many years ago my father who was a pioneering pulmonologist began using steroids in pulmonary patients. This was long before science caught up. Well I am sure he saved a lot of lives. And also my brother who is an internist one time said to me “You know Dad is not as scientific in his patient management in the ICU as we are today” “Today everything is science” He kind of insinuated that our father approached patients like a cook making a soup. Tasting the soup and altering it’s chemistry somewhat subjectively. And my brother could make a soup “scientifically”. He knew just what the patient(soup) needed. Well I will tell you if I was sick in the hospital I would want my Dad with 40 years in critical care keeping me alive over some young “science” doctor. Now I am not downplaying the kid and his science. But I want someone who knows what the drugs do verses someone who has read about it. I will take the fine cook over the technician. Well the same applies in many things. Science has just not caught up with measuring obvious changes in the NMS system that we see in manipulation and adjusting. lastly. When you have honestly spent a considerable amount of time in a number of chiropractors offices taking lessons I will be more than willing to consider your input. But until you do that I simply cannot listen to what I know not to be true. I personally do not critisize medicine on much because I have not walked in their shoes very much. I stand mute and listen. You would be very wise to do the same in a chiropractic doctors office. If I thought one thing about a heart murmur and a cardiologist said I was wrong I would welcome the chance to be shown by him what he heard. The guy just might know something I did not. If his explaination did not add up I would study further. But I would listen to what he had to say and show me. In any event Harriet I have read a lot of what you have written. You are a smart person. But I think you secretly want to be a chiropractor. And you may have some love/hate thing going on. And remember when your old and sick and have sore feet jsut ask and I’ll gently manipulate them and do some soothing ultrasound to make you feel better. No matter what the PT’s or the science protocols say.

  24. Beachdoc says:

    Harriet & Joe,

    In regards to the term subluxation, what was described in the past from the likes of D.D. & B.J. Palmer to what someone like Dr. David Seaman, a professor at Palmer College Florida describes are two totally different animals.

    Personally, I will use terms like spinal joint dysfunction, biomechanical dysfunction or joint fixation because it better describes what is actually happening rather than the term subluxation. It’s a more functional descript term.

    The problem isn’t the word subluxation, but rather how it is defined.

    If you read the works of David Seaman, a chiropractic neurologist, you will better understand what I and many others in my profession feel is an accurate description of what takes place when a joint doesn’t function how it was designed; why it causes pain and how that can also manifest in problems other than just pain.

    You have to admit, it’s much easier to explain to a patient a bone out of place pinching on a nerve causing their aches and pain rather than describing how Type 1, 2 & 3 mechanoreceptors being stimulated during normal joint function versus nociceptor stimulation during aberrant joint function, how the brain interprets this and how this could lead to the patient’s complaint(s).

    I and many of my colleagues look forward to and welcome the forthcoming research in this area. It is those who would block this research from even happening so they can continue to practice their theories as if they are facts that I worry about.

    As far as “a tincture of time” most patients have tried this themselves and that is why they present to my(our) office(s). Their tincture of time hasn’t worked.

    For all those that say chiropractic doesn’t work and don’t want to believe the positive research that has been published, I always offer the following tid bit on how to get rid of the chiropractic profession…I tell this to every M.D. who things “medicine” is the “Be All-End All” of healthcare…

    …Fix all your patients and there won’t be a need for chiropractors…

    All I’m saying is that chiropractic does in fact have a place in the healthcare team. With the exception of a life threatening emergency, when medical methods fail, prior to surgery, chiropractic should be tried.

    As far as what takes place in other countries Joe, I can’t comment. I know what the trends are here because I’m involved here. The subluxation theory teachings in all but a couple of the schools have changed quite a lot over the past couple decades and continue to evolve as new evidence is discovered. I think that’s what science is all about.

    I still hold that our malpractice rates are so low because the practice is very safe. Patients continue to return and refer their family and friends because it’s effective.

    I look forward to more stimulating discussion.

    Healthfully yours…

    Beachdoc

  25. Harriet Hall says:

    Quackdoctor says, “So I am well aware of science. That is why I recommended that you spend time with chiropractic doctors yourself.” If he thinks spending time observing chiropractors is valuable as scientific evidence, he clearly does not understand what science is all about. He goes on to essentially reject science in favor of art and experience. He needs to go to some other forum that accepts his world view. This blog is about science-based medicine.

  26. Harriet Hall says:

    Beachdoc,

    Are “spinal joint dysfunction, biomechanical dysfunction” really better terms than subluxation? They seem pretty general and could be used as an excuse to refer to any kind of musculoskeletal pain. Restricted range of motion is something that can be objectively measured. Muscle spasm likewise. Pain with no objective findings is probably very common.

    What’s wrong with simply saying “Patients with complaints like yours have frequently said they felt better after this treatment. We don’t really know why. We can try it for a few treatments but will stop if it doesn’t seem to be helping.”

    I don’t see any problem with seeing a chiropractor before surgery, as long as safe, rational techniques are used. Even if it only has a placebo effect, it may reduce symptoms and give time a chance to work. Unfortunately, if a patient picks a chiropractor at random out of the phone book, he’s likely to get quacked.

    Tincture of time may work better than you think. Many of the things people go to chiropractors for are self-limited. There are thousands of patients who ignore their symptoms or treat them with simple home remedies and never seek care. One man I know of had back pain that just wouldn’t go away, and he finally broke down and made an appointment with a chiropractor for a Monday. Over the weekend before the appointment, his pain disappeared and never came back. If he had seen the chiropractor on Friday, he would have been forever convinced that chiropractic had cured his back pain.

  27. Quackdoctor, I love your screen name. About 60 years ago in the suburbs of NY, we had neighbors surnamed Quack, but as far as I know none of them were in the health care business.

    You mentioned that you have a PhD. Did I miss something or did you tell us what it is in and where it is from? I’d be most interested in knowing.

    You referred to “top DCs” several times. Can you tell us what criteria to use so that we can distinguish the top practitioners from the opposite kind?

    You said you would like Dr. Hall to spend a week at a chiropractic school. Is that your personal wish or has a school extended her the invitation? If the invitation comes from a school, I hope that if Dr. Hall is unable to take them up on it that they permit another allopath, scientist and/or Skeptic of her choice to go. I think the report would be fascinating.

  28. Tweyman says:

    you like research, I am sure you are familar with this paper that was published in Spine, Feb 2008 that “We found no evidence of excess risk of VBA stroke associated chiropractic care compared to primary care.” I am sure Harriet won’t like this since retirement she makes a living with books and articles written about putting down alternative care.

    Risk of Vertebrobasilar Stroke and Chiropractic Care: Results of a Population-Based Case-Control and Case-Crossover Study.

    Supplementary Research Studies

    Spine. 33(4S) Supplement:S176-S183, February 15, 2008.
    Cassidy, J David DC, PhD, DrMedSc *+++; Boyle, Eleanor PhD *; Cote, Pierre DC, PhD *+++[S]; He, Yaohua MD, PhD *; Hogg-Johnson, Sheilah PhD +[S]; Silver, Frank L. MD, FRCPC [P][//]; Bondy, Susan J. PhD +
    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.

  29. pmoran says:

    Re the Spine study: Gee, I would like to see more than the abstract, as there are a lot of questions.

    There are a number of reasons why any association between actual cervical manipulation (CM) and stroke could be diluted in such a study. For one thing, some doctors might perform CM or refer to physiotherapists who do it. Also how many of those those attending chiropractors ALSO attended MDs? Probably the majority. There is an extremely high rate of all medical attendance in bulk-billing medical systems, which I assume applies here.

    Also, why did they choose to look at billing “in the year before” the stroke date? Is that what they actually did, affording attandance to a doctor eleven months before the stroke equal significance to the experiencing of paralysis while still on the practitioner’s table? Surely if looking for a causal association the information of interest is the rate of actual cervical manipulation in the 3-4 days prior to the onset of neurological symptoms. Were they not able to extract that information?

  30. Blue Wode says:

    @ Tweyman

    Re the recent study in Spine: The integrity of its lead author, David Cassidy DC, was recently called into question by Sharon Mathiason, a mother whose daughter died following neck manipulation by a chiropractor for a tailbone injury (see the last paragraph of Dr Hall’s article):

    “This new ‘study’ itself is a review of billing records. No patient charts or tests were examined. There was no new scientific data. The authors took 819 strokes and then used billing records to see who had seen a doctor in the past year and who had seen a chiropractor. Considering that billing payments were very limited for chiropractors in Ontario and now thank God have been completely eliminated, this is a very poor record of the actual number of visits to a chiropractor. Did the scientists not realize this simple statistical fact?

    Of course, the strokes caused by the chiropractors happened in their offices while none happened in the office of the doctors. Where did they tell us that? According to the logic of this study, if my daughter Laurie or anyone else saw your medical doctor in January and then had a stroke in December after having a neck manipulation, it did not count against the chiropractor. Almost everyone has seen their doctor within a year. You would get the same result if she had stopped at McDonald’s to buy a hamburger and then went to the chiropractor.

    The Globe and Mail [a newspaper in which the study was recently featured] is also negligent in not identifying the principal author, David Cassidy, as a chiropractor, one who has been sued in Saskatchewan, in 1999, by his research assistant for falsifying data, and one whose work is stated in the New England Journal of Medicine as “all of the study’s authors conclusions are completely invalidated by their methods”.

    David Cassidy, before he was dismissed from the University of Saskatchewan, was called as an “expert” witness by the Chiropractic Association of Saskatchewan (CAS) at my daughter’s inquest.

    In the Globe and Mail article co-author David Cassidy is quoted “Has it ever happened that a chiropractor has caused a stroke? I can’t say it’s never happened. But if it’s happening, it’s not happening at a greater risk than when it is at a GP office”. Well guess what, chiropractor David Cassidy admitted on the stand into the death of my daughter they he had manipulated the neck of a woman and caused a stroke, a very severe one called Wallenberg’s syndrome. Did he say it never happened because this poor woman also saw her doctor in the past year? I doubt if he has ever seen a patient coming out of a doctor’s office having a stroke after a neck manipulation.

    There would be no greater gift in memory of my daughter and all the others for government to impose a scientific standard on highest neck manipulation just as standards exist for all medications. This would eliminate 99% of all chiropractic highest neck manipulations.”

    More…
    http://www.chirowatch.com/Chiro-strokes/gm080120stroke.html

    @ Beachdoc

    You said: “There is a huge separation between the subluxation based and the evidence based chiropractors in this country, and the gap is widening.”

    As I asked in a previous post, I’m really interested to know how you expect patients to be able to distinguish between those two types of chiropractors. And perhaps more to the point, why, in the 21st century, should they be faced with such a dilemma in the first place?

  31. Harriet Hall says:

    I agree with pmoran. I have questions about this new study and I’m not sure what it adds to the mix. It certainly does not invalidate all the previous evidence. It says nothing about the patients who have collapsed on the table when being treated for symptoms not related to the head or neck. It says nothing about the relative benefits of neck manipulation compared to gentle mobilization and other treatments. I stand by what I said in my post: there is a small risk and we don’t really know its magnitude.

    Tweyman said, “I am sure Harriet won’t like this since retirement she makes a living with books and articles written about putting down alternative care.”

    That kind of comment is entirely uncalled for.

    It’s not a matter of what I like or dislike, it’s a matter of trying to sort out the truth. If alternative medicine gets a lot of criticism on this blog it’s because this is a science-based medicine blog and the very definition of alternative medicine is that it is not supported by enough evidence to have earned itself a place within scientific medicine. I have nothing against people using alternative medicine as long as they are not misled into thinking there is more evidence for it than there really is.

    And just for the record, I don’t make a living with books and articles. I haven’t earned one penny since retirement (except from jury duty).

  32. Beachdoc says:

    Well, as far as finding a good chiropractic physician, here in Florida you can look up their educational background, post graduate history, license status on the Florida Department of Health’s MQA web site for starters. Patients should ask their friends for references, not just find a doctor in the phone book or from some cheesy ad. Next, I’d call the physician’s office and ask questions, find out more about their education and specifically about treatment methods and philosophy. Ask to see a C.V. Ask if it’s okay to stop by, meet the doctor and staff and ask the doctor a few questions.

    There are several chiropractors in the city where I practice that are typical chiro-evangelists. Eventually, people with real musculo-skeletal problems make it in to my office and the difference is quite apparent.

    It’s no different that in finding a good MD-internist or family practitioner.

    Quality control in all physician disciplines varies. State boards, specialty boards can only go so far. It’s no different if its a DC, DO or MD. There are “Quacks” in all of our various disciplines.

    You know how many times I’ve seen a patient with shoulder pain where the orthopedist didn’t even lay their hands on the patient? Just wrote an Rx for Meds or injected cortisone and off they went. These patients are so curious as to why I did a complete orthopedic exam of their shoulder when their orthopedist didn’t.

    As far as pseudoscience, I guess it must make you cringe when an MD prescribes antibiotics for someone with the common cold huh? We all know the common cold is caused by a virus, (actually a variety of them), so what’s the rationale?

    The point is that within each of our professions, you will find people who don’t practice up to acceptable standards. But, unfortunately, until a better system is developed, the patient must take responsibility to find out about their doctor prior to getting treatment.

    Most people will do more research on a new car than on a potential new doctor.

    Again, if you are going to continue to actively promote against my profession, I would suggest you have a sit down discussion with:

    Scott Haldeman, DC, MD, Ph.D
    John Triano, DC, Ph.D
    David Seaman, DC, DACAN

    Scott and John have done much investigation into the stroke issue. David has written extensively on the neurology behind joint dysfunctions or however you want to call it..the “lesion” chiropractors adjust.

    These are the people in my profession whom I look to for information and leadership in these areas.

    I look forward to more stimulating discussion

    Beachdoc

  33. Joe says:

    Beachie wrote “Quality control in all physician disciplines varies. State boards, specialty boards can only go so far. It’s no different if its a DC, DO or MD.”

    Quality control for chiros is different because chiros begin with quackery; quality control does not get any worse than that. DOs and MDs don’t spend time learning about chiro subluxations, Innate, and treating deafness with thoraxic “adjustment.” Moreover, real doctors spend many years, post-doctoral, practicing diagnosis and treatment of people with real illnesses. Chiros move immediately, after school, into recruiting healthy customers for unnecessary, regular “maintenance” adjustments.

    Give us something to work with, here, do you realize there are no chiro subluxations (“spinal lesions” if you prefer), or Innate? Do you accept that the Palmers’ stories are just fairy tales? How many times do you crack someone before sending them on to medical care? Do you think healthy people should have regular spine checks and/or adjustments? Can you treat visceral diseases?

  34. Harriet Hall says:

    Beachdoc said, “I guess it must make you cringe when an MD prescribes antibiotics for someone with the common cold huh?”

    Yes, of course it does. And I am just as quick to speak out against that practice as I am against irrational practices in chiropractic. The medical profession as a whole has condemned using antibiotics for colds. Chiropractic as a whole has never condemned much of anything.

    Does it make you cringe when a chiropractor diagnoses allergies by applied kinesiology or treats asthma with neck manipulation?

    “Again, if you are going to continue to actively promote against my profession,”

    I am not “actively promoting against your profession.” I’m pointing out practices that are not science-based. I’m not campaigning to abolish chiropractic. I don’t advise people not to see a chiropractor; I only want to make sure they understand what they’re doing.

    I recommend using guidelines like these to choose a chiropractor:
    http://www.quackwatch.org/01QuackeryRelatedTopics/chirochoose.html
    http://www.chirobase.org/13RD/chiroguidelines.html

    “I would suggest you have a sit down discussion with:… the people in my profession whom I look to for information and leadership in these areas.”

    That’s not how scientists do things. We try to evaluate published data rather than listening to advocates. It sounds like you look more to authority than to evidence.

  35. Blue Wode says:

    @ Beachdoc

    You said: “as far as finding a good chiropractic physician, here in Florida you can look up their educational background, post graduate history, license status on the Florida Department of Health’s MQA web site for starters.”

    What is the point of looking up a chiropractor’s educational background, post graduate history and license status when, regardless of credentials, it’s so easy for them to dupe patients into unnecessary or inappropriate treatment? In other words, how could a patient *know for sure* that a chiropractor had abandoned subluxation-based/pseudoscientific practices? Unfortunately, if the sales tactics put forward by this fairly well known chiropractic marketing outfit are anything to go by, chiropractors can be taught, quite easily, to give a false impression about their intentions:

    “Chiropractic Simplified—Chiropractic described in 100 words without using the terms adjustment or subluxation. Use it in your patient conversations and see more people “get” chiropractic.”
    http://www.patientmedia.com/previewproducts/audio/seminar.htm

    Interestingly, that quote also suggests that if adjusting a subluxation were a valid therapeutic approach, then chiropractors wouldn’t have to pretend that they’d dropped it.

    You said: “Patients should ask their friends for references”

    How can that be good advice? What if those friends have bought into the subluxation-based ‘Big Idea’ treatment-for-life ‘wellness hard sell’?

    You said: “ask questions, find out more about their education and specifically about treatment methods and philosophy” and “ask to see a C.V. Ask if it’s okay to stop by, meet the doctor and staff and ask the doctor a few questions”.

    But how would people know what relevant questions to ask? Where does the public start with the enormous amount of misinformation (much of which is contradictory and confusing) that seems to be deliberately foisted on it by chiropractors? For example, here in the UK the regulatory body, the General Chiropractic Council (GCC) requires that

    “…all chiropractors must ensure that all the information they provide, or authorise others to provide on their behalf is factual and verifiable, is not to be misleading or inaccurate in any way, does not, in any way, abuse the trust of members of the public nor exploit their lack of experience or knowledge about either health or chiropractic matters, and does not put pressure on people to use chiropractic, for example by arousing ill-founded fear for their future health or suggesting that chiropractic can cure serious disease”. See page 5 here:
    http://www.gcc-uk.org/files/link_file/F2P2005_6.pdf

    Indeed, one of its regulations even states that “chiropractors’ provision of care *must* be evidence based”. See section A2.3 of the GCC’s Standard of Proficiency here:
    http://www.gcc-uk.org/files/link_file/COPSOP_8Dec05.pdf

    However, as outlined and referenced in a previous post, the reality of chiropractic practice in the UK appears to be very different when you consider that all four UK chiropractic associations buy into, and promote, the subluxation theory and/or the concept of ‘innate intelligence’.

    It’s truly bewildering.

    You said: “The point is that within each of our professions, you will find people who don’t practice up to acceptable standards. But, unfortunately, until a better system is developed…”

    So are chiropractors taking an active role in developing a better system or would it not be in their interests to do so? Why not be proactive and start bettering the system right now by telling patients about the very slim scientific evidence base for chiropractic? Let’s have some honesty. What is there to stop every chiropractic licensing board/regulator/association (world-wide) issuing the simple statement about chiropractic which has been proposed by Professor Edzard Ernst and Simon Singh in their book ‘Trick or Treatment? Alternative Medicine on Trial’? For those who may have missed the statement, here it is again:

    ***This treatment carries the risk of stroke or death if spinal manipulation is applied to the neck. Elsewhere on the spine, chiropractic therapy is relatively safe. It has shown some evidence of benefit in the treatment of back pain, but conventional treatments are usually equally effective and much cheaper. In the treatment of all other conditions, chiropractic therapy is ineffective except that it might act as a placebo.***

    You said: “…the patient must take responsibility to find out about their doctor prior to getting treatment.”

    How can you seriously expect patients take on that responsibility i.e. make informed choices about their treatment – and the person who administers it – when there is no officially recognised source to which they can turn for *factual and accurate* information on chiropractic?

  36. apteryx says:

    Tweyman quoted the following:

    “In those aged <45 years, cases were about three times more likely to see a chiropractor or a PCP before their stroke than controls…. 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…. The increased risks of VBA stroke associated with chiropractic and PCP visits is [sic!] likely due to patients with headache and neck pain from VBA dissection seeking care before their stroke.”

    Since there seems to be no guarantee of timing here, the first thing I wonder is whether people who go to a chiropractor complaining of headache or neck pain are much more likely to get their necks twisted than someone who goes in complaining of a backache.

    The authors assumed that the increased risk rates associated with both PCP and chiropractic visits are artifacts. We don’t know of a mechanism whereby PCPs would cause VBA strokes; they might put you on medication that causes a stroke, but it probably wouldn’t be a VBA stroke. It seems obvious to me that people who go to a doctor regularly will be frailer, if elderly, or will (as a group) have more cardiovascular health problems or risk factors than people who don’t, and that those characteristics might make them more susceptible to rare vascular problems. But I’m not sure the same is true of people who go to chiropractors; people who suffer from backache or a sore neck following a car accident do not necessarily have more cardiovascular risk factors than those who don’t.

    It is interesting that the increased risk from chiropracty only showed up in under-45 patients, but that isn’t proof that it’s coincidental. Alternate hypotheses: (a) you have to have some innate weakness to be vulnerable to VBA stroke, and while people with that vulnerability will rarely have spontaneous strokes while young, as they age they may start having spontaneous strokes in numbers that swamp the few caused by neck manipulation; or (b) chiropractors in practice do not wrench the necks of older patients around as far or as hard, perhaps recognizing that they are stiffer and frailer, and not wanting to do them an injury; younger people therefore are more often subjected to the extreme manipulations that carry meaningful risk.

  37. Beachdoc says:

    Risk of vertebrobasilar stroke and chiropractic care: results of a population-based case-control and case-crossover study.

    Cassidy JD, Boyle E, Côté P, He Y, Hogg-Johnson S, Silver FL, Bondy SJ.

    Centre of Research Expertise for Improved Disability Outcomes, University Health Network Rehabilitation Solutions, Toronto Western Hospital, Toronto, ON, Canada. dcassidy@uhnresearch.ca

    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.

    PMID: 18204390 [PubMed - indexed for MEDLINE]

  38. Beachdoc says:

    1: Spine. 2008 Feb 15;33(4 Suppl):S170-5. Links
    Examining vertebrobasilar artery stroke in two Canadian provinces.Boyle E, Côté P, Grier AR, Cassidy JD.
    Centre of Research Expertise for Improved Disability Outcomes, University Health Network Rehabilitation Solutions, Toronto Western Hospital, Toronto, Ontario, Canada. eboyle@uhnresearch.ca

    STUDY DESIGN: Ecological study. OBJECTIVES: To determine the annual incidence of hospitalized vertebrobasilar artery (VBA) stroke and chiropractic utilization in Saskatchewan and Ontario between 1993 and 2004. To determine whether at an ecological level, the incidence of VBA stroke parallels the incidence of chiropractic utilization. SUMMARY OF BACKGROUND DATA: Little is known about the incidence and time trends of VBA stroke diagnoses in the population. Chiropractic manipulation to the neck is believed to be a risk factor for VBA stroke. No study has yet found an association between chiropractic utilization and VBA diagnoses at the population level. METHODS: All hospitalizations with discharge diagnoses of VBA stroke were extracted from administrative databases for Saskatchewan and Ontario. We included incident cases that were diagnosed between January 1993 and December 2004 for Saskatchewan and from April 1993 to March 2002 for Ontario. VBA cases that had previously been hospitalized for any stroke or transient ischemic attack (TIA) were excluded. Chiropractic utilization was measured using billing data from Saskatchewan Health and Ontario Health Insurance Plan. Denominators were derived from Statistics Canada’s annual population estimates. RESULTS: The incidence rate of VBA stroke was 0.855 per 100,000 person-years for Saskatchewan and 0.750 per 100,000 person-years for Ontario. The annual incidence rate spiked dramatically with a 360% increase for Saskatchewan in 2000. There was a 38% increase for the 2000 incidence rate in Ontario. The rate of chiropractic utilization did not increase significantly during the study period. CONCLUSION: In Saskatchewan, we observed a dramatic increase in the incidence rate in 2000 and there was a corresponding relatively small increase in chiropractic utilization. In Ontario, there was a small increase in the incidence rate; however, chiropractic utilization decreased. At the ecological level, the increase in VBA stroke does not seem to be associated with an increase in the rate of chiropractic utilization.

    PMID: 18204389 [PubMed - indexed for MEDLINE]

  39. Beachdoc says:

    Both of the above published in SPINE in 2008.

    Interesting conclusions huh?

    Imagine a well respected orthopedic journal like SPINE with an editorial and peer review panel made up of Ph.Ds and M.D.s publishing these 2 articles in the same year.

    How about we continue this discussion and both agree that our references don’t go back further than 2006?

  40. Harriet Hall says:

    Beachdoc,

    Apparently you haven’t been reading the comments. Tweyman already posted one of these studies, and we have already discussed its poor design and questionable conclusions. The other study is a related one and is even worse. To presume to learn something about stroke causation by comparing rates of stroke to rates of chiropractic utilization is to mistake correlation for causation. Please go back and read my May 4 comment.

  41. Joe says:

    Beachie, perhaps it was on another thread that someone observed one cannot draw any conclusions for the first paper from the abstract (and the article requires payment of a fee).

    As for the second article, local spikes in the occurrence of rare conditions are statistically common. For every increased occurrence in one region, there are decreased occurrences elsewhere. Over time, they balance. One wonders why the authors saw fit to publish that trivial observation. If the increased cases were really significant, it could imply some (new or increased) cause other than chiro. The authors’ analysis is insignificant.

    Does anyone know why this stuff was published in a “supplement” to spine? Was it peer-reviewed, or “proceeds” of a symposium?

    Beachie wrote “How about we continue this discussion and both agree that our references don’t go back further than 2006?” No, research does not have a two-year expiration date. Only properly refuted, early articles are properly ignored. Think about it- do you want to ignore all of the claims of chiro from Palmer and going forward? I do; but because they are properly discredited, not because they are old.

  42. pmoran says:

    These studies seem to equate chiropractic attendance with cervical manipulation, implying that just about any patient who attends a chiropractor for any condition will get their neck manipulated.

    That is the guts of the problem for me. Chiropractic’s unique theoretical and commercial investment in cervical manipulation is creating a clear conflict of interest. The available evidence warrants a precautionary approach in which cervical manipulation should scarcely be considered the first line of treatment for ANY condition, let alone employed for the many dubious purposes within chiropractic.

    If chiropractic wants to be seen as a responsible profession it cannot continue stalling. It has itself in the past regarded stroke as a potential complication of cervical manipulation, even devising tests supposedly able to select out those at risk. It seems to be only since the matter became more widely known publicly that influential elements of chiropractic have chosen to dispute that the risk exists at all.

  43. Beachdoc says:

    Doctors May Be Third Leading Cause of Death
    by Joseph Mercola, D.O. | Published 3/15/2000 | Pharmaceutical Industry News | Rating:

    Joseph Mercola, D.O.

    Dr. Mercola is a licensed Osteopathic physician and board-certified in family medicine. He served as the chairman of the family medicine department at St. Alexius Medical Center for five years and has been trained in both traditional and natural medicine. Dr. Mercola has been practicing natural medicine actively since 1990 and is the publisher of http://www.mercola.com, the most visited health site on the internet.

    View all articles by Joseph Mercola, D.O…. Doctors Are The Third Leading Cause of Death in the US, Causing 250,000 Deaths Every Year

    This week’s issue of the Journal of the American Medical Association (JAMA) is the best article I have ever seen written in the published literature documenting the tragedy of the traditional medical paradigm.

    This information is a followup of the Institute of Medicine report which hit the papers in December of last year, but the data was hard to reference as it was not in peer-reviewed journal. Now it is published in JAMA which is the most widely circulated medical periodical in the world.

    The author is Dr. Barbara Starfield of the Johns Hopkins School of Hygiene and Public Health and she describes how the US health care system may contribute to poor health.

    ALL THESE ARE DEATHS PER YEAR:

    12,000 — unnecessary surgery 8
    7,000 — medication errors in hospitals 9
    20,000 — other errors in hospitals 10
    80,000 — infections in hospitals 10
    106,000 — non-error, negative effects of drugs 2

    These total to 250,000 deaths per year from iatrogenic causes!!
    What does the word iatrogenic mean? This term is defined as induced in a patient by a physician’s activity, manner, or therapy. Used especially of a complication of treatment.

    Dr. Starfield offers several warnings in interpreting these numbers:

    First, most of the data are derived from studies in hospitalized patients.

    Second, these estimates are for deaths only and do not include negative effects that are associated with disability or discomfort.

    Third, the estimates of death due to error are lower than those in the IOM report.

    If the higher estimates are used, the deaths due to iatrogenic causes would range from 230,000 to 284,000. In any case, 225,000 deaths per year constitutes the third leading cause of death in the United States, after deaths from heart disease and cancer. Even if these figures are overestimated, there is a wide margin between these numbers of deaths and the next leading cause of death (cerebrovascular disease).

    Another analysis (11) concluded that between 4% and 18% of consecutive patients experience negative effects in outpatient settings, with:

    116 million extra physician visits
    77 million extra prescriptions
    17 million emergency department visits
    8 million hospitalizations
    3 million long-term admissions
    199,000 additional deaths
    $77 billion in extra costs

    The high cost of the health care system is considered to be a deficit, but seems to be tolerated under the assumption that better health results from more expensive care.

    However, evidence from a few studies indicates that as many as 20% to 30% of patients receive inappropriate care.

    An estimated 44,000 to 98,000 among them die each year as a result of medical errors.2

    This might be tolerated if it resulted in better health, but does it? Of 13 countries in a recent comparison,3,4 the United States ranks an average of 12th (second from the bottom) for 16 available health indicators. More specifically, the ranking of the US on several indicators was:

    13th (last) for low-birth-weight percentages
    13th for neonatal mortality and infant mortality overall 14
    11th for postneonatal mortality
    13th for years of potential life lost (excluding external causes)
    11th for life expectancy at 1 year for females, 12th for males
    10th for life expectancy at 15 years for females, 12th for males
    10th for life expectancy at 40 years for females, 9th for males
    7th for life expectancy at 65 years for females, 7th for males
    3rd for life expectancy at 80 years for females, 3rd for males
    10th for age-adjusted mortality

    The poor performance of the US was recently confirmed by a World Health Organization study, which used different data and ranked the United States as 15th among 25 industrialized countries.

    There is a perception that the American public “behaves badly” by smoking, drinking, and perpetrating violence. However the data does not support this assertion.

    The proportion of females who smoke ranges from 14% in Japan to 41% in Denmark; in the United States, it is 24% (fifth best). For males, the range s from 26% in Sweden to 61% in Japan; it is 28% in the United States (third best).

    The US ranks fifth best for alcoholic beverage consumption.
    The US has relatively low consumption of animal fats (fifth lowest in men aged 55-64 years in 20 industrialized countries) and the third lowest mean cholesterol concentrations among men aged 50 to 70 years among 13 industrialized countries.
    These estimates of death due to error are lower than those in a recent Institutes of Medicine report, and if the higher estimates are used, the deaths due to iatrogenic causes would range from 230,000 to 284,000.

    Even at the lower estimate of 225,000 deaths per year, this constitutes the third leading cause of death in the US, following heart disease and cancer.

    Lack of technology is certainly not a contributing factor to the US’s low ranking.

    Among 29 countries, the United States is second only to Japan in the availability of magnetic resonance imaging units and computed tomography scanners per million population. 17
    Japan, however, ranks highest on health, whereas the US ranks among the lowest.

    It is possible that the high use of technology in Japan is limited to diagnostic technology not matched by high rates of treatment, whereas in the US, high use of diagnostic technology may be linked to more treatment.

    Supporting this possibility are data showing that the number of employees per bed (full-time equivalents) in the United States is highest among the countries ranked, whereas they are very low in Japan, far lower than can be accounted for by the common practice of having family members rather than hospital staff provide the amenities of hospital care.

    Journal American Medical Association Vol 284 July 26, 2000

    ——————————————————————————–

    COMMENT: Folks, this is what they call a “Landmark Article”. Only several ones like this are published every year.

    One of the major reasons it is so huge as that it is published in JAMA which is the largest and one of the most respected medical journals in the entire world. I did find it most curious that the best wire service in the world, Reuter’s, did not pick up this article. I have no idea why they let it slip by.

    I would encourage you to bookmark this article and review it several times so you can use the statistics to counter the arguments of your friends and relatives who are so enthralled with the traditional medical paradigm. These statistics prove very clearly that the system is just not working. It is broken and is in desperate need of repair.

    I was previously fond of saying that drugs are the fourth leading cause of death in this country. However, this article makes it quite clear that the more powerful number is that doctors are the third leading cause of death in this country killing nearly a quarter million people a year. The only more common causes are cancer and heart disease. This statistic is likely to be seriously underestimated as much of the coding only describes the cause of organ failure and does not address iatrogenic causes at all.

    Japan seems to have benefited from recognizing that technology is wonderful, but just because you diagnose something with it, one should not be committed to undergoing treatment in the traditional paradigm. Their health statistics reflect this aspect of their philosophy as much of their treatment is not treatment at all, but loving care rendered in the home.

    Care, not treatment, is the answer. Drugs, surgery and hospitals are rarely the answer to chronic health problems. Facilitating the God-given healing capacity that all of us have is the key.

    Improving the diet, exercise, and lifestyle are basic. Effective interventions for the underlying emotional and spiritual wounding behind most chronic illness are also important clues to maximizing health and reducing disease.

    Related Articles:

    Medical Mistakes Kill 100,000 per year

    US Health Care System Most Expensive in the World

    Author/Article Information:

    Author Affiliation: Department of Health Policy and Management, Johns Hopkins School of Hygiene and Public Health, Baltimore, Md.

    Corresponding Author and Reprints:

    Barbara Starfield, MD, MPH, Department of Health Policy and Management, Johns Hopkins School of Hygiene and Public

    Health, 624 N Broadway, Room 452, Baltimore, MD 21205-1996 (e-mail: bstarfie@jhsph.edu).

    REFERENCES

    1. Schuster M, McGlynn E, Brook R. How good is the quality of health care in the United States? Milbank Q. 1998;76:517-563.

    2. Kohn L, ed, Corrigan J, ed, Donaldson M, ed. To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press; 1999.

    3. Starfield B. Primary Care: Balancing Health Needs, Services, and Technology. New York, NY: Oxford University Press; 1998.

    4. World Health Report 2000. Available at: http://www.who.int/whr/2000/en/report.htm. Accessed June 28, 2000.

    5. Kunst A. Cross-national Comparisons of Socioeconomic Differences in Mortality. Rotterdam, the Netherlands: Erasmus University; 1997.

    6. Law M, Wald N. Why heart disease mortality is low in France: the time lag explanation. BMJ. 1999;313:1471-1480.

    7. Starfield B. Evaluating the State Children’s Health Insurance Program: critical considerations. Annu Rev Public Health. 2000;21:569-585.

    8. Leape L.Unecessarsary surgery. Annu Rev Public Health. 1992;13:363-383.

    9. Phillips D, Christenfeld N, Glynn L. Increase in US medication-error deaths between 1983 and 1993. Lancet. 1998;351:643-644.

    10. Lazarou J, Pomeranz B, Corey P. Incidence of adverse drug reactions in hospitalized patients. JAMA. 1998;279:1200-1205.

    11. Weingart SN, Wilson RM, Gibberd RW, Harrison B. Epidemiology and medical error. BMJ. 2000;320:774-777.

    12. Wilkinson R. Unhealthy Societies: The Afflictions of Inequality. London, England: Routledge; 1996.

    13. Evans R, Roos N. What is right about the Canadian health system? Milbank Q. 1999;77:393-399.

    14. Guyer B, Hoyert D, Martin J, Ventura S, MacDorman M, Strobino D. Annual summary of vital statistics1998. Pediatrics. 1999;104:1229-1246.

    15. Harrold LR, Field TS, Gurwitz JH. Knowledge, patterns of care, and outcomes of care for generalists and specialists. J Gen Intern Med. 1999;14:499-511.

    16. Donahoe MT. Comparing generalist and specialty care: discrepancies, deficiencies, and excesses. Arch Intern Med. 1998;158:1596-1607.

    17. Anderson G, Poullier J-P. Health Spending, Access, and Outcomes: Trends in Industrialized Countries. New York, NY: The Commonwealth Fund; 1999.

    18. Mold J, Stein H. The cascade effect in the clinical care of patients. N Engl J Med. 1986;314:512-514.

    19. Shi L, Starfield B. Income inequality, primary care, and health indicators. J Fam Pract. 1999;48:275-284.

  44. Joe says:

    Mr. beachie, I don’t know whether to s**t or go blind. Thanks for the amusing endorsement of Joe Mercola, D’oh.

    On the other hand, don’t you know any equally profound chiroquacktors? Why do you have to stray afield?

  45. Harriet Hall says:

    Beachdoc is doing that “tu quoque” thing again.

    We are well aware that modern scientific medicine is not perfect. That’s what this blog is all about – trying to make it better!

    Errors happen, and medicine is trying hard to reduce the error rate. The numbers in those articles are very misleading for a number of reasons that have been discussed seriously and at length elsewhere. I’ll just say briefly that the biggest error is that they don’t put the risks of modern medicine in perspective with the benefits. And I’ll offer a parody I wrote of Mercola’s “Death by Medicine” at http://www.geocities.com/healthbase/death_by_medicine.html. I compared it to Death by Food.

    Mercola is notoriously unscientific. You might want to read what Wikipedia says about him at http://en.wikipedia.org/wiki/Joseph_Mercola.

    Any doctor in his right mind recognizes that prevention is better than “Smokey the Bear” medicine where you stamp out forest fires. Prevention based on science is likely to do more good than prevention based on unproven beliefs.

    As for “the underlying emotional and spiritual wounding behind most chronic illness” (?!!) – what on earth are you talking about?

  46. daedalus2u says:

    I think a better thing to measure regarding stroke and Chiropractic would be the number of stroke patients each individual Chiropractor has had in their career. If there is no association between Chiropractic actions and stroke, the distribution should be low and nearly uniform. If there is an association, then it is most likely due to relatively few bad actors.

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  48. Dr.Ken says:

    daedalus2u,

    In respones to your question, based on the 1:1,000,000 statistic, 1 chiro in 5 will have a noticeable event relating to stroke in a 30 year career span. This is using the average number of weekly visits per an ACA survey. DCs having a lower average, would be less likely to have an event, whereas a high volume practitioner would have a greater likelihood.

    I was at a research seminar a couple of years ago, and based on one studies conclusions and using the same career and visit numbers, a serious event will occur in 1 in 15 careers.

  49. Joe says:

    Mr.Ken,

    Given a conservative estimate of 60,000 chiropractors in the USA; if 1 in 15 causes a stroke, that’s 4,000 strokes. And, they are unnecessary; the “benefits” (if any) from the chiro neck-snap can be achieved, more safely, otherwise. With benefit=0, the risk/benefit ratio is an unacceptably large number (division by zero).

    On top of that, the risks are only beginning to be appreciated. For well-understood reasons, strokes caused by the neck-snap can take days to develop. The chiro may never know that the customer did not return because he disabled/killed her. The estimates of the number of, unnecessary, chiro-induced strokes is likely to rise.

  50. Joe says:

    http://www.ptjournal.org/cgi/content/full/79/1/50

    “The literature does not demonstrate that the benefits of MCS [Manipulation of the cervical spine] outweigh the risks.”

  51. Dr.Ken says:

    joe,

    The statistics I present were not only for stroke, but for a “noticeable event”, which may include such things as excessive dizzyness, nausea, or other symptoms, but not necessarily stroke. Also that would be a possible 4,000 events over a 30 year time frame, or 133/year for 60,000 DCs, and 374,400,000 manipulations.

    I recall reading about a CA malpractice case involving informed consent as it relates to this subject. The court felt that the risk for stroke was so miniscule, that to require informed consent for such a procedure, would make informed consent disclosures in other health professions so long, as to make them too taxing on patients to read.

    Also I find it odd, that if mobilization is as good as manipulation, why were physical therapists trying to get manipulation including cervical, added to their scope of practice here in WA state?

  52. Joe says:

    Mr,Ken,

    Well, it would help if you cited your sources. What, exactly is your source for one in a million, I was being generous. Chiros keep pulling such stats out of who-knows-where in the hope of impressing the numerically challenged. Where is your data?

    Nonetheless, one chiro-induced stroke is too many.

    You have not presented anything that disputes the fact that “The literature does not demonstrate that the benefits of MCS [Manipulation of the cervical spine] outweigh the risks.” I cited my source.

    Then there is ‘Journal of Pain and Symptom Management’ Volume 35, Issue 5, May 2008, Pages 544-562: “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.”

    Ken wrote “I recall reading about a CA malpractice case involving informed consent as it relates to this subject. …” This may surprise you- sometimes legal cases are not settled on scientific considerations. Think of Wilk vs. AMA (1987?) the court found the AMA had good reason to object to chiro; but under the law of commerce it could not impede chiro. That is, laws do not validate chiro.

    Ken wrote “Also, I find it odd …” I find it interesting that you can study (imaginary) subluxations, and then find anything “odd.”

  53. alonmarcus says:

    Its interesting to note that after statements like “with my medical training i can tell you there is no basis for NUCCA upper cervical technique” a controlled study done at University of Chicago Hypertension Center documented sustained reduction in blood pressure ofter NUCCA treatment in a randomized study. I am as skeptical as anyone but the elitist attitude of many simply shows the weakness of the human ego. We have a lot to learn and looking at all information via a single filter just tends to reinforce an already held belief.

    Alon Marcus

  54. Blue Wode says:

    Alon Marcus said: “Its interesting to note that after statements like “with my medical training i can tell you there is no basis for NUCCA upper cervical technique” a controlled study done at University of Chicago Hypertension Center documented sustained reduction in blood pressure ofter NUCCA treatment in a randomized study. “

    That doesn’t mean that it’s a valid therapeutic approach, or that it’s ever likely to be. This from an academic posting to another list:

    “…this is a study frequently cited by the general run of chiropractors to justify their routine upper cervical neck-cracking.
    What they don’t mention is that “The subtle adjustment is practiced by the very small subgroup of chiropractors certified in National Upper Cervical Chiropractic (NUCCA) techniques. The procedure employs precise measurements to determine a patient’s Atlas vertebra alignment.”

    Taking all that with many large grains of salt, what it boils down to is a specialized procedure performed by few chiros, which in this instance is cited as having a small effect on blood pressure in a small group of test subjects over a short study period.

    *The odds of there ever being a large-scale trial of this proving to be a cost-effective, safe procedure that works long-term are not very high*.

    Much easier for chiros just to cite this study without appropriate context and rely on testimonials for the remainder of their “evidence”.”

    Alon Marcus said: “I am as skeptical as anyone”

    That’s surprising. If one clicks on his name it produces a web page which makes all sorts of unsubstantiated claims about a variety of health matters.

  55. Joe says:

    @alon,

    For some reason, you did not give a proper citation to the NUCCA study. It can be found here http://www.ncbi.nlm.nih.gov/pubmed/17252032?ordinalpos=6&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum
    Although I only have access to the abstract, we can see that the small study size (50 subjects) means it is not definitive. Then, we can see that the average, baseline “atlas mis-alignment” between the control and treatment groups is quite different. After that, one wonders why “lateral displacements are” reported in ‘degrees,’ and how they measured such small angles (ranging from 0.04 to 1.0) on such a crude instrument as an x-ray. I think if I had the full article, it would be clear why such an interesting result was not published in a mainstream journal.

    On top of that, one has the research done by Crelin http://www.chirobase.org/02Research/crelin.html showing that chiropractors cannot alter the relationships between/among vertebrae.

    I doubt the NUCCA article amounts to anything.

  56. Dr.Ken says:

    Joey,

    No matter what I say or eveidence I can present, your mind will not let you objectively review the studies. Therefore there is no need to continue this dialogue. You make false assumptions about me which I insulting. I will not carry on a discussion with someone with such a closed mind.

  57. Joe says:

    @Kenny,

    You have not, yet, provided any evidence. Don’t go away angry, just- go away.

    False assumptions … ?

  58. Harriet Hall says:

    Dr. Ken said, “Also I find it odd, that if mobilization is as good as manipulation, why were physical therapists trying to get manipulation including cervical, added to their scope of practice here in WA state?”

    There could be many reasons. The mere fact that a treatment is popular says nothing about its efficacy or safety. Instead of “finding it odd,” it would be more productive to show us what evidence you have that makes you think that cervical manipulation is superior to mobilization.

    As for the NUCCA study, it was a preliminary study that surprised even the people who carried out the study. Unless it can be replicated by other researchers with more subjects in well-designed, well-controlled studies, it is meaningless. Even the majority of chiropractors reject NUCCA, and its basis is implausible, so the whole thing remains very questionable.

    Dr. Ken,
    You are picking on Joe for not objectively reviewing the studies. I think I have objectively reviewed the studies. Do you find fault with my article?

  59. Joe says:

    Mr.Ken,

    Perhaps I was flippant, and out of place, in suggesting that you should go away. Can you cite good data? What were my false assumptions?

  60. alonmarcus says:

    Blue Wode
    If you ever read any of my writing you would see that i do highlight many of the weaknesses in evidence having to do with alternative medicine. However i do not believe the picture is black and white. For example, if you read what many in this forum and other medical writers have written about acupuncture you can see they have close to zero knowledge of this tradition, but still feel quite comfortable making statements about clinical studies on acupuncture (this is in part a problem of the poor quality of early publications/books about Chinese medicine done by people who do not speak Asian languages). Statements such as the Chinese believed there is these unseen meridians (channels) were energy (qi) circulate show complete ignorance of Chinese medicine. Let me give you an example you could probably relate to. Lets say i am going to do a study on the efficacy of “antibiotics” in treating fevers (first wrong question). I then choose a non broad acting antibiotic and give it in inadequate dose and inadequate frequency, when this study fails i make the statement that Antibiotics do no better than placebo in treating fevers of any kind. I think we would both agree this would be a misleading and useless study. Unfortunately there is not a single study in western languishes that allows acupuncture using appropriate design allowing for the continually changing protocol used within its own tradition. There are many such studies done in China, Japan, Taiwan, Korea, Vietnam, and other Asian countries using objective messurments. The problem is that comities that approve studies and fund these studies in the west have always rejected studies which allow the flexibility needed for proper acupuncture practice (just showing clear bias). At the same time let me make it clear i do believe there is much exaggerated claims about what acupuncture can do but there is also a huge body of good evidence coming out of Asian universities. Would it be nice if we all truly agreed how evidence is collected and what needs to be done for objective study of all medical systems. But until you (in the abstract) at least show a minimal amount of understanding of subjects you so easily pass judgment on i thin we a doomed to continue to have this conversations.
    Good science must start with good understanding of the subjects one is going to study without which you can not begin to know if your design is appropriate.
    Alon Marcus

  61. Harriet Hall says:

    alonmarcus,

    Your arguments about acupuncture research don’t hold water. Acupuncturists were involved in the design of most studies. If you are claiming that a controlled study can’t be done because individualized treatment is necesssary, there are ways to control for that. It is common for proponents of alternative medicine to ask for special treatment for their methods, for exemption from the normal scientific methods, but that is not justified. In any case, it would be a simple matter to pick a specific pain or problem and compare individualized acupuncture to a standardized sham acupuncture.

    Have you read “The Biology of Acupuncture” by SongPing Han and George Ulett? Both are experienced practitioners of traditional Chinese acupuncture. They have read the literature and done their own research. They conclude that it makes no difference where you put the needles, and that electrical stiimulation at one point on the wrist works as well as traditional acupuncture.

    The huge body of evidence coming out of Asian research is not credible until it is replicated in the West. The high percentage of positive studies coming out of China is not because they understand acupuncture better, but because negative studies are simply not published in China. Published Chinese research in every field is overwhelmingly positive, for cultural and political reasons. If a researcher in China published a study showing acupuncture didn’t work, he would lose face and lose his job.

  62. Joe says:

    @Alon,

    You wrote “Statements such as the Chinese believed there is these unseen meridians (channels) were energy (qi) circulate show complete ignorance of Chinese medicine.”

    So, enlighten us- with references. If you argue it is all in languages we don’t understand- I won’t believe you. Do you expect us to believe that everything about acupuncture, in English, is wrong; that is- misunderstood? Gun dan!

    You wrote “Lets say i am going to do a study on the efficacy {snip}”

    That is a straw-man argument; you concoct an absurd situation (that none of us would adopt), then show it is absurd. That is easy to do, and proves nothing.

    You wrote “Would it be nice if we all truly agreed how evidence is collected and what needs to be done for objective study …”

    Scientists have pretty-much agreed on that, it is the proponents of quackery who object; because their low standards can’t pass the tests.

  63. alonmarcus says:

    You are welcome to read any of the newer acupuncture texts published in the last few years by linguistically and professionally qualified people. You will read about the complexity of acupuncture channels. For example you can look at The Channels of Acupuncture: Clinical Use of the Secondary Channels and Eight Extraordinary Vessels by by Giovanni Maciocia. This book covers some of the channels that have nothing to do with the usual ones you see in older books and charts. There are hundreds of texts in Chinese that cover different aspects of the channel systems. The “channles” in chinese medicine have blood flow, others are muscular, yet others
    involved Qi, which has nothing to do with invisible energy, among others. If you are interested in the concept of Qi read A Brief History of Qi by Yu Huan Zhang, Zhang Yu Huan and Ken Rose. For more about Qi in medicine you can read A Practical Dictionary of Chinese Medicine by Nigel Wiseman, Ye Feng.
    As far as controlled studies i only said there has not been a single study done in the west that allowed for any of the traditional paradigms (which by the way are quite numerous), i never said i could not be done. I have pushed for years to get it done but you are wrong if you think there is no resistance from traditional medical researches regarding flexible protocols. I am quite aware of SongPing Han and George Ulett, neither of which have traditional training. Ulett’s work covers the most basic ideas of some modern concepts. It lacks any traditional depth.

    “Scientists have pretty-much agreed on that, it is the proponents of quackery who object; because their low standards can’t pass the tests.”
    This statement again makes my point, until you truly understand what is to be studied and allow for full exploration such statements are empty. They work well within some scientific disciplines, but many in other than the medical profession have been discussing the limitations reductionism.
    As far as research from Asia i would agree with your criticisms of Chinese research, i have been very vocal criticizing this literature, but this is not true for Taiwan, Korea and Japan. There is much good research done in these countries.

    Alon

  64. Harriet Hall says:

    I see. Anyone who gets negative results must not be studying the “real” acupuncture. What a convenient out! And the traditional paradigms are “quite numerous” so when one fails you can always test another one. This amounts to creating an unfalsifiable hypothesis. And you think acupuncture doesn’t lend itself to the “reductionist” scientific method. If you know of any better way of determining the truth than a rigorous application of the scientific method, please tell us. I don’t think so. I think the only limitations of medical research are the limitations of poor research design.

    I think Ulett and SongPing Han would disagree with you about their training. They certainly thought they got traditional training. They have a combined experience of 60 years. SongPing Han trained in China and has first-hand knowledge of Professsor Ji-Sheng Han’s 3 decades of scientific investigation of acupuncture at Beijing Medical University.

    Qi was originally vapor arising from food, or noxious vapors arising from a corpse. The real original acupuncture was probably a form of bloodletting (based on analysis of original documents by Chinese scholars). “The “channles” in chinese medicine have blood flow, others are muscular, yet others involved Qi,” – yes, they’re all different because no-one can even agree on how many meridians there are or whether the “channels” contain blood, air, muscle or qi. And no one has ever seen any of these channels. The ancient Chinese didn’t do human dissection; they just made up these mythical structures. Acupuncture can be pretty much anything you want it to be.

  65. alonmarcus says:

    Here we go again, ignorance, the ancient Chinese did do dissections and this has been documented in many classical texts. Why then they came up with what they did (obviously ignoring much of the information), i have no idea. But at least you should know your facts and not repeat old myths written and repeated by early western practitioners with little to no access to the classical litrature.
    Having different paradigms just mean there is more than one to test, no excuses. And its simple to design clinical studies, just have an independent assessment of outcome utilizing objective methods. The intervention is put in a black box allowing for the full tradition to be used. Compare outcome to your favored biomedical treatment for the same condition.
    Ji-Sheng Han spent almost his entire career working with animal models and contributed a lot to the understanding of neurochemical mechanisms, he has not studied classical or even modern clinical acupuncture.
    Obviously there is no point in going round and round. Have comfort in your beliefs.

    Alon

  66. Blue Wode says:

    @ alonmarcus

    Thank you for your reply. As the topic of this thread is about chiropractic and stroke, it might be an idea for you to visit Steven Novella’s blog if you wish to participate in further discussions on the subject of acupuncture. Dr Novella is an academic clinical neurologist at Yale University School of Medicine, and I suggest that his blog post ‘Does acupuncture work or not?’ would probably be a good place for you to start:
    http://www.theness.com/neurologicablog/?p=14

    Returning to the topic of chiropractic and stroke and the NUCCA blood pressure study, you and other readers might be interested in the following news report which is accompanied by a 3.5 minute video segment (it takes about a minute to load). This from the transcript:

    “Doctor George Bakris, a hypertension expert at the University of Chicago Medical Center, decided to find out if there really was some kind of connection.

    -snip-

    There are still a lot of unanswered questions, including who will benefit from this and what actually happens physically when this part of the vertebra is realigned.

    Doctor Bakris cautions patients to stick with their proven treatments for now.

    “This is not available now for everybody, so everybody is going to rush out, no, it’s still investigational,” he said.

    Dr. Bakris says there still needs to be a lot of research done on this before mainstream doctors will even consider this a possibility.”

    http://abclocal.go.com/wls/story?section=news/health&id=6033564

    In essence, it seems to underline the comments already made by Dr Hall and Joe.

  67. Harriet Hall says:

    “the ancient Chinese did do dissections and this has been documented in many classical texts. ”

    OK, I’ll re-phrase: the ancient Chinese did not discover channels or meridians or acupuncture points through human dissections. They made them up, “intuited” them, or hypothesized their existence based on anecdotal results of sticking needles in people. Just as chiropractors hypothesized “subluxations” based on their experience that manipulating spines seemed to make people feel better.

    “Having different paradigms just mean there is more than one to test”

    It also suggests there is a greater likelihood that they are wrong. How would you even decide which paradigm to invest your research dollars in?

    “Ji-Sheng Han spent almost his entire career working with animal models and contributed a lot to the understanding of neurochemical mechanisms, he has not studied classical or even modern clinical acupuncture.”

    That’s beside the point. Ulett and SongPing Han DID study traditional acupuncture. Or do you deny that too?

    “its simple to design clinical studies, just have an independent assessment of outcome utilizing objective methods. The intervention is put in a black box allowing for the full tradition to be used.”

    That’s exactly what I suggested above. It’s curious that the proponents of acupuncture have not limited themselves to such studies. The same goes for homeopathy and other alternative systems.

    One problem with designing such studies is creating an adequate placebo control. If the “traditional” acupuncturist is changing techniques according to patient response, you have all sorts of confounding factors: attention, suggestion, interpersonal interaction phenomena, all sorts of psychological factors. You would have to compare “traditional” acupuncture to some made-up rigamarole that could be expected to have comparable psychological effects.

    In fact, I think acupuncture is “the ultimate placebo” – a very effective one. Any physiologic effects are minor. And even endorphin release is consistent with placebo response.

  68. alonmarcus says:

    I agree with you in many ways and the idea of this interaction between therapist and patient is stressed in all classical literature, ie to maximize the patient’s belief systems, expectations, and participation. Techniques to do that are described and are part of traditional interventions.
    I cannot speak of Han training in great detail but i believe he went through Chinese programs for MDs (as for Ulett see below, i do not think he reads Chinese and therefore has had extremely limited access). These programs do not even come close to being traditional training. They are programs developed after the communist revolution and are actually a kind of Herbalized acupuncture. In other words in order to modernized the practice of Chinese medicine and acupuncture they created a single paradigm that was supposed to cover both Chinese herbal medicine (which by the way is the main therapeutic intervention in Chinese medicine) and acupuncture. They called it Traditional Chinese Medicine (TCM).
    Most of the western trained, or those that had short courses in china learned this paradigm. In the west many biomedical organization then took this modern and definitely not classical approach and created even “simpler” courses, some with as little as 2 weeks trainging thinking (with typical western biomedical ego) they know what they are doing. Just about 100% of “controled” studies have been done by these practitioners. So when you say “acupuncturists” were involved in designing the studies you need to understand this history.
    I am with all of you regarding the need to collect evidence and again you are right this can be done with little effort. I do not believe alternative medicine deserves a pass from evidence based practice but i do believe you truly need to understand what you are studying before you can make any judgment or create study design. If we are to replicate this TCM style acupuncture then we need to allow for the same frequency and dosage (strength of stimulation) done in China. This means daily treatments, depending on conditions, for prolonged periods. If we are to study more classical approaches, and personally i think outcomes are usually better, then we need to allow for the full paradigm in the study design.

    Alon

  69. pmoran says:

    “If we are to replicate this TCM style acupuncture then we need to allow for the same frequency and dosage (strength of stimulation) done in China. This means daily treatments, depending on conditions, for prolonged periods. ”

    Let’s get down to specifics, shall we?. We can’t decide whether a claim is worth investigating until we know what it is, exactly.

    So, what do you think authentic TCM is good at? I warn you in advance that such an intensive program of hands-on treatment would NOT be cost-effective for any common ailment within Western medical systems.

    If the claim is that it can help cure diseases that can be otherwise difficult to treat such as advanced cancer, we are surely entitled to see a few of the cured patients before being expected to try it out ourselves.

    The reason for the lack of interest in TCM is that we can be fairly sure from the already published material that TCM does NOT possess the answer to any of medicine’s great unsolved problems. We need a claim worth investigating before diverting scarce resources.

  70. alonmarcus says:

    Since this is only going to become an exercise in futility i just dont think there is any reason to continue. If you were serious at all the literature is out there.

    alon

  71. pmoran says:

    I was deadly serious. By not being prepared to go into bat for any specific TCM claim you make my precise point. You are theorising in your armchair, and not confronting the realities of medical practice and research.

  72. Harriet Hall says:

    alonmarcus said “the literature is out there”

    Yes, and the literature has been reviewed and has been found to be consistent with the hypothesis that acupuncture is not superior to placebo.

  73. Synaptix says:

    Thought this might be a good talking point in relation to this article.

    http://www.ctv.ca/servlet/ArticleNews/story/CTVNews/20080613/chiro_lawsuit_080613/20080613?hub=TopStories

  74. Harriet Hall says:

    The link Synaptix provided doesn’t tell the worst of it. The patient developed symptoms in the chiropractor’s office and the chiropractor failed to recognize the medical emergency and let her leave and attempt to drive herself home.

    I’m intrigued to see what develops from this lawsuit. What would happen if a medical doctor prescribed a prescription drug for off-label indications knowing that there was no scientific rationale for using it for that condition, that there was no evidence that it would help the patient, and there was a small risk it would harm the patient? And what if he told the patient (or let the patient believe) this drug “would” relieve her symptoms and carried “no” risk? And then the drug produced a devastating reaction like a crippling stroke? I think that kind of lawsuit would have an excellent chance of winning, and the neck manipulation lawsuit is essentially the same situation. In fact, it’s much worse, because the patient didn’t really have anything wrong with her – she was getting “maintenance” adjustments.

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  76. Dr. B says:

    Dear Dr. Hall,
    As a practicing chiropractor of 25 years I thank you for raising the important topic of spinal manipulative therapy of the cervical spine and its connection to vascular accidents in your forum. While the article addresses events associated with this topic, what it really does well is pointing out the issue with which the profession struggles. Namely, taking a proactive role in assuring that its procedures are safe and effective for the general public. Only by conducting proper scientific inquiry with the welfare of the community in mind, will the profession attain the credibility it seeks. Thanks again for the article and keep up the good work.

  77. Jim Swanson says:

    Paralyzed Alberta woman sues chiropractors, province for $500M
    June 13, 2008, The Canadian Press

    http://www.cbc.ca/canada/edmonton/story/2008/06/13/chiro-lawsuit.html

    A woman who says she became paralyzed after having her upper spine manipulated is suing the Alberta College and Association of Chiropractors and the provincial government for half a billion dollars.

    The class-action lawsuit filed by Sandra Nette involves an alleged incident at an Edmonton chiropractor’s office last Sept. 17.

    “A perfectly healthy young woman’s life has been irreparably and devastatingly damaged as a result of her exposure to a chiropractor’s manipulation of the vertebrae in her upper neck to correct alleged subluxations,” the statement of claim says.

    “The procedure is an ineffective and dangerous one which chiropractors employ routinely. Ideological practitioners of chiropractic masquerading in the white smock of science perpetuate its unregulated, indiscriminate use with the condonation and protection of their supposed regulator against all reason. It has got to be stopped.”

  78. Maybe says:

    I will never trust another chiropractor again as I was one of the unlucky who had a stroke on the table as he tweeked my neck.
    My whole right side went dead and parts of my right still are dead.

    I know it’s rare. But I wasn’t told of the dangers. I am still not the same at all, and it’s been over 4 months.

  79. vipiv says:

    I’ve read through this page and the series of comments and counter-comments. Seems there is a fair amount of ax-grinding going on here. Stepping beyond the stated mission of advocating for science-based medicine, voices like Dr. Hall’s and Joe’s seem to be relentlessly “gunning” for those ever-dangerous practitioners of chiropractic (FYI Joe, there is no such thing as “chiropracty.”)

    Is the perceived problem—one which a recent contributor points out has no scientifically proven causation, and remains at this point in time only a speculative correlation (ethics pretty much prohibit any airtight human studies to prove or disprove the CM/stroke hypothesis)–really worth all this time & effort in discussion, in the sheer actuarial public health sense? Or is there some other, unacknowledged motivation here? No doubt all readers of this page care about the health and welfare of the consumer public, or we never would have made it to this site in the first place—much less, read this far! But allocation of attention and resources is certainly important; triage, if you will. Fancy Latin names for logical errors notwithstanding, Harriet, the simple fact is that allopathic procedures are the third leading cause of death throughout North America. The other simple fact is, insurance companies have never been dummies when it comes to their money… and a chiropractor can buy the same level of malpractice insurance coverage for a fraction of what MDs must pay. How else to account for that?

    Simply put, no one here wants death and destruction. But if there are simultaneously 1) a trash can fire, and 2) an apartment building conflagration, which event do we respond to first, with the greatest attention? I’m talking here about all the time & effort spent thus far on this particular thread; the vehemence and relentless pursuit of a phenomenon that everybody agrees—IF the phenomenon is actual, which has never been scientifically proven—is a tragic, albeit quite statistically rare, occurrence. Need I remind people there are events in the world like Darfur, climate change, child prostitution, land mine injuries, automobile accidents… all preventable and, like the eradication of smallpox as an example, would have far, far greater impact on morbidity and mortality statistics than if one’s campaign to curtail spinal adjustments to the neck were 100% successful?

    The disparaging tones that have emerged in this discussion (e.g., Joe choosing to call Beachdoc “beachie”) only serve to indicate some sense of arrogance, the attitude of the righteous. This supplants a respectful treatment of the issue in which we all agree to disagree. I believe there’s a notion operating here, that there must be some bottom line which is ULTIMATELY RIGHT.

    But what if there isn’t? Then it’s just a lot of tail-chasing, both one’s own and others’.

    There was mention of prevailing paradigms. For anyone familiar with the seminal text on that (Thomas Kuhn’s The Structure of Scientific Revolutions), there is an understanding that there may be no such thing as the once-and-for-all truth. Our word science, from the Latin “Scientia,” implies a search for knowledge. Unfortunately we tend to forget that knowledge and reality are two very distinct categories (luckily with some appreciable overlap at any given observational moment.)
    If Harriet Hall considers herself a true scientist, or at least a promoter of such, then—given her great amount of attention devoted to this “problem” of chiropractors—she would take up the offer to immerse herself in a week of academic and clinical environment at National. Margaret Mead would have had no trouble seeing the necessity & wisdom of this. In Galileo’s day, the predominant “science” (body and means of acquisition of accepted knowledge) was really the Church of Rome. So the “deciders” of Galileo’s day had no problem with knowing that they did not have to look through his telescope. Don’t bother me with any uncomfortable facts—I’ve already decided what the Truth is.

    It is interesting that even after the prevailing paradigm shifts completely, the old ones will still “work” nicely in most cases. For instance, the Copernican/Keplerian revolution occurred hundreds of years ago, and “everybody knows” that the Earth (much less the sun) is not the center of the universe… yet, one can still use the Ptolemaic star system just fine, to navigate the oceans world-wide. Another example is Newtonian physics, which doesn’t work at all for our current frontier scientific inquiries (the macro and micro universes), but is tremendously handy for human-scale applications to this day. All I am suggesting here is that given the huge relative dangers of allopathic procedures, it may be time to realize their limits of usefulness, and be on the lookout for the supplanting paradigm. And to insist that Western drug medicine is “fully scientific” is quite misinformed if not delusional. There is no decent science proving the mechanism of the recent class of antidepressants known as SSRIs, for instance. Sure, there’s a lot of reasonable speculation involving serotonergic effects, but no proof. The FDA recently chastised one pharmaceutical giant for making unsupported statements concerning the action of their AD darling. Hypothesis is science-in-embryo; it is specifically not to be construed as accepted fact, until the hypothesis is extremely well-supported with multiple rounds of replicable research.

    Yes, every profession has its share of bad apples. My mother was killed by her trusted (and well-regarded in the community) MD. He was a flippant prescriber and shoot-from-the-hip diagnostician. So it was that she, a lifelong smoker and lover of bacon, was told that her chest region pressure and pains were due to “esophageal spasm.” She was never given a cardio workup. What she was given were several concurrent drugs, including: a smooth muscle relaxant and a bronchodilator (for incipient asthma, a condition she actually did suffer from), BOTH of which meds were not only contraindicated in the presence of heart disease, but should never be given, according to the PDR, together.
    She died relatively young, 20 minutes into a single MI.
    The same “doctor” went on to try to finish off my dad. With zero blood work, he told my father that he had diabetes. In the office the doc insisted he take a sizable dose of an insulin-potentiating oral med. Driving home from his appointment, my dad went into a coma, and his car into a ditch. The ER physician was on the phone to me saying “It’s crazy, his glucose is down at 30 and I can’t seem to bring it up!” When I told him that my father had been to a doctor’s appointment, they learned the mistake and then knew what to do to bring him out of it.

    These kinds of incidents are all too common. There’s no “science” behind them, just stupid recklessness with the extremely potent tools that MDs use. What are the odds that both my parents, who had two children that are chiropractic physicians, should have experienced these disasters? Probably the incidence is far greater that anyone can measure, because my parents’ kids happened to be well-trained physicians who were able to divine the scenarios I related. Most of it passes under everyone’s radar.
    (We presented the facts as we had them to our state medical board, and this medical quack was relieved of his license.)

    I am making a plea here for a sense of perspective. The old game of “let’s dump on the chiropractors” is just that, old and getting older. Medical iatrogenesis, particularly drug prescribing mistakes, overwhelmingly dwarf this supposed CM/CVA problem. But do you advocate that MDs quit prescribing drugs?
    Common sense: don’t let your chiropractor prescribe you any drugs, and don’t let anyone other than a licensed DC administer a manipulation to your C-spine. With such a policy, the odds of tragedy remain infinitesimal. And save yourselves from a case of repetitive motion injury by reorienting discussion toward a topic that is actually helpful.

  80. Graham Maynard says:

    Not just strokes either.

    Hence getting a message out to the greater public is most important.

    See ….. http://www.gmweb1.net/

    Graham.

  81. Harriet Hall says:

    Vipiv has offered an impassioned defense (and counterattack) that was unwarranted by the content of the blog post. He has repeated arguments that have already been refuted elsewhere on this blog. He disparages “fancy names” for logical fallacies and proceeds to commit a series of them.

    I am not an enemy of chiropractic; I am an enemy of poor science and poor reasoning wherever I find them. I criticize bad practices in conventional medicine just as readily as I criticize them in chiropractic.

    I think I wrote a very fair assessment of a problem that chiropractors themselves have recognized. I said that stroke is a rare complication, that no one knows the real incidence, that patients have the right to choose neck manipulation, that they have the right to know neck manipulation carries a risk no matter how small it may be, and they have the right not to be misled about the benefits of manipulation.

    No rational, ethical chiropractor would disagree with any of that.

    Only a “true believer” would feel it necessary to mount a defense like Vipiv’s, reacting to something I didn’t even say.

  82. Joe says:

    Vipiv wrote “… don’t let anyone other than a licensed DC administer a manipulation to your C-spine.”

    Would that be like the licensed DC that “locked in” Ms. Nette? It seems that needless strokes are the specialty of licensed DCs.

    And, no, I will never refer to a DC as “doctor” because the degree itself is absurd. It is based on the study of fairy tales (subluxations, Innate, curing deafness with a blow to the back). Even admirable people (e.g., Samuel Homola) who eschew that nonsense and work within the constraints of evidence have bogus credentials.

    Chiropractic credentials do not translate to ‘health professional’ status just because one denies subluxations. (An astrologer who realizes the stars and planets have no predictive value is not an astronomer.) Chiros who decide to work rationally are on their own to figure out how to do so. It makes more sense to go to a physical therapist than to a DC who may, or may not, know how to help.

  83. Maybe says:

    In California, DC’s don’t need to have malpractice insurance.
    Mine did NOT have it. Makes me think of him more of a quack now for sure. Just in it for the money.

  84. Harriet Hall says:

    Maybe,

    I don’t know what you mean by “need” to have malpractice insurance. There are certainly plenty of DCs in California who carry insurance. There is no law requiring either MDs or DCs to have malpractice insurance, but they get insurance if they want to protect their assets. DCs everywhere can be sued. And are sued. And the chiropractic insurance companies pay claims. Here’s one company’s breakdown of claims paid in 2002:

    Disc 32.7%
    CVA 9.0%
    Vicarious liability 4.7%
    Professional discipline 10.2%
    Aggravation 5.6%
    Failure to Dx 7.8%
    Fracture 10.4%
    Other 19.6% (Treatment, burns, strains, sprains, soft tissue, TMJ)

    If your chiropractor didn’t carry insurance, I would chalk it up to poor judgment on his part, the same kind of poor judgment that may have led him to accept chiropractic myths like subluxations.

  85. vipiv says:

    Although the topic of malpractice insurance has again been mentioned, none of the responses above to my posting of July 9 had anything to say about this point (quoting myself):

    “the simple fact is that allopathic procedures are the third leading cause of death throughout North America. The other simple fact is, insurance companies have never been dummies when it comes to their money… and a chiropractor can buy the same level of malpractice insurance coverage for a fraction of what MDs must pay. How else to account for that?”

    I continue to insist that what is mostly going on here is a form of “profession assassination.” If not so, Dr. Hall as the moderator would have reigned in, at least just a bit, commenters such as Joe, who seems to know very little about the actual curricula at the various federally-accredited chiropractic colleges. It is easy to despise what one chooses to remain ignorant about–hence all the destructive “isms” of any society, e.g. racism, sexism, ageism, etc.

    Public health stats indicate that, contrary to Joe’s assertion, “needless strokes are the specialty of” spouses, hair stylists/barbers, licensed professionals other than DCs, and finally DCs–in descending order. In other words, and to repeat the final point in my last post, if you EVER get your neck manipulated by ANYONE, all the accumulated information suggests you are far better off having that done by a chiropractor.

    So unless the topic of this particular blog is reoriented to “Neck manipulations should never occur,” I find these comments to be exactly as I said before: prejudiced against a specific profession, namely, chiropractic.

    Every action in the world carries attendant dangers. We should be rational in our analysis of such (and for heaven’s sake, don’t ever drive your car to the store for groceries, which is many dozens of times more risky than a neck manipulation!)

  86. Harriet Hall says:

    vipiv wants an answer to his previous comments: “the simple fact is that allopathic procedures are the third leading cause of death throughout North America. The other simple fact is, insurance companies have never been dummies when it comes to their money… and a chiropractor can buy the same level of malpractice insurance coverage for a fraction of what MDs must pay. How else to account for that?”

    OK. I answered the “death by medicine” charge in another post. See: http://www.sciencebasedmedicine.org/?p=136

    The explanation for lower malpractice insurance for chiropractors is simple: the patients they see are not as sick. It’s the same reason there are lower malpractice insurance rates for pediatricians than for neurosurgeons. The same reason midwives pay less than obstetricians.

  87. Harriet Hall says:

    vipiv said,

    “Dr. Hall as the moderator would have reigned in..”

    I’m not the moderator. I comment here the same as anyone else. We don’t have a “moderator” and we don’t censor anything that is written here.

    “what is mostly going on here is a form of “profession assassination.”

    Not at all. I am not one of those calling for the abolition of chiropractors; I’m only calling for the abolition of dangerous procedures with no evidence of benefit, and for the abolition of quackery. If you think abolishing those things amounts to abolishing your “profession” then that doesn’t say much for your profession, does it?

    “contrary to Joe’s assertion, “needless strokes are the specialty of” spouses, hair stylists/barbers, licensed professionals other than DCs, and finally DCs–in descending order.”

    References, please! What is the incidence of vertebral artery tears by all those others? And how many of those others claimed to be treating a nonexistent condition (subluxations)?

    “don’t ever drive your car to the store for groceries, which is many dozens of times more risky than a neck manipulation!”

    At least when you go to the store, you come back with groceries. When you get a neck manipulation for neck pain, you come back with nothing you couldn’t have gotten from a gentle mobilization. When you get a neck manipulation for “maintenance” or for non-musculoskeletal problems, or for a tailbone injury, you get scammed.

    You are very defensive, but there is one thing conspicuously absent from your comments: any evidence that rapid thrust neck manipulations have any benefit that could not be obtained by gentle mobilization. If there is no benefit, any degree of risk is unjustified. If you had any evidence, you would have given us that evidence instead of making the kind of comments you did.

  88. Joe says:

    vipiv on 18 Jul 2008 at 1:40 am wrote “Joe, who seems to know very little about the actual curricula at the various federally-accredited chiropractic colleges.”

    I do know the “chiropractic paradigm” http://www.chirocolleges.org/paradigm_scopet.html which says that your “education” is based on the “subluxation” (which is a fairy tale).

    As for accreditation, there are accredited schools of astrology (The New York Times, August 28, 2001). Accreditation does not mean that what is taught is legitimate. It means that the school has a physical presence and is financially sound. It is meant to assure that federally-backed student loans are not stolen. In the case of chiropracty, the feds allow them to accredit their own schools; which leaves the inmates in charge of the asylum.

  89. vipiv says:

    No moderator: I guess then I was mislead by the message I received the first time I posted, to wit: “Your comment is awaiting moderation and will be posted soon.”

    Why is it that Harriet’s, and only Harriet’s, comments are surrounded by a blue box, on my screen at least? Does it imply anything? How do I get my own special box?

    Defensive deschmensive. Try being part of a valid profession whose members have been systematically jailed (for “practicing MEDICINE without a license”–what a joke!), ostracized, slandered and generally dumped upon for 9 or 10 decades; then tell me what you mean by “defensive.” Do you call African Americans or Asian Americans or Native Americans “defensive” as well? I stand by my “isms” point.

    I have all along worked with licensed massage therapists. That profession has had to surmount the same kind of ugly prejudice as has my own. Practitioners have had to resort to prepending the term “therapeutic” in any public notice–as if it wasn’t originally that, ever! Chalk it up to the small-minded minority who go immediately to a prurient rendering, because they are touch-phobic or governed by models of fundamentalist fear… it says far more about the decriers, than about the noble profession. Witch burners still abound, and quack is the new witch. If you think I am overstating, try spending a few decades in an underdog profession. You’ll get it.

    As for Joe’s blinders:
    the typical chiropractic college curriculum resembles that of any medical school. Half of my instructors also taught at our state’s medical college, a highly-regarded educational and research institution. They were teaching the same material at both places.
    Even though I already held two bachelor’s degrees in “soft” sciences, I was required to take another full year of hard sciences–organic chem, microbiology, physics, zoology, etc.–for admission into chiro college. Once there, I pursued course work beginning with gross anatomy including a year of human dissection; physiology; biochemistry; neuroanatomy; neurology; histology; 12 full courses in radiology and radiographic technology (I have never had an X-ray centered practice–don’t really believe in it–but I can read pathology on X-rays better than most MDs); and in the upper division courses, material such as toxicology, cardiology, pulmonology, dermatology, ob/gyn, proctology, minor surgery, etc.

    My education took place 30 years ago. I logged significantly more classroom hours than the average medical student. Standards have only improved since then. Medical schools now see the value of chiropractic manipulative therapies, and have begun to offer optional coursework. There are an increasing number of MD-DCs. Most chiro colleges (except the dug-in “straights”) have long since abandoned the old-fashioned concept of subluxation, favoring a dynamic motion/mechanical compensation model of joint function. The influence of spinal joints and their associated soft tissues on proximal nerve function is the basis, which has been supported by an ever-increasing body of animal and human studies (see Suh, et. al., for example) reported in medically-accepted peer-reviewed journals.

    People who don’t know the above facts are working overtime to remain ignorant.

    “References please!” Well I’m an old guy but still practicing and don’t have time to dig up links, etc. Challenge me if what I have presented is not the case–I went to a seminar years ago which presented the then-current public health stats on exactly which categories of people inflicted neck manipulations which were then associated with CVA; as well as, the relative dangers of being struck by lightning twice in the same location, going down in an airliner, driving to the store for groceries, etc. But I continue to stand by my main point, which (not to be tedious) is: this forum appears to exist, at least in part, for the purpose of dumping on my profession while ignoring the ACTUALITY of occurrence when it comes to morbidity and mortality statistics. Triage. Trash can fire vs. apartment house fire–remember?

    And I do agree with Joe on the notion of disparaging “chiropracty.” It’s a ridiculous thing that should never have existed. [Oh wait--it never did.]

  90. Harriet Hall says:

    vipiv asks why it said

    “Your comment is awaiting moderation and will be posted soon.”

    To clarify: when someone posts for the first time, the comment is delayed just long enough for Dr. Novella to make sure it isn’t something grossly inappropriate. I have access to the comments awaiting moderation, and to my knowledge no comment has ever been rejected. After your first comment has been cleared, your subsequent comments are posted without any kind of moderation or delay.

    “Why is it that Harriet’s, and only Harriet’s, comments are surrounded by a blue box, on my screen at least? Does it imply anything? How do I get my own special box?”

    The blue box only means the comment was written by the blog author. You don’t get one.

    “References please!” Well I’m an old guy but still practicing and don’t have time to dig up links, etc.”

    Translation: I don’t have any evidence; I just want you to believe everthing I say just because I say so.

    There is one thing conspicuously absent from your comments: any evidence that rapid thrust neck manipulations have any benefit that could not be obtained by gentle mobilization. If there is no benefit, any degree of risk is unjustified. If you had any evidence, you would have given us that evidence instead of making the kind of comments you did.

    If you didn’t have such a chip on your shoulder, you would recognize that what I wrote did not attack the chiropractic “profession” but a specific practice that carries a small risk and is not evidence-based.

  91. nwtk2007 says:

    Hey vipiv,

    It is not a direct attack but there are the trolls out there who will jump in to repeat the same comments they make over and over on other forums.

    I was just trolling by and thought I would comment.

    Harriett’s pretty fair and so are a few others. There are some things to learn here.

  92. Graham Maynard says:

    Hi Harriet,

    Your recent comments are well reasoned.

    However I take a different view.
    Chiropractors will not ensure that their illogical, unproven and dangerous head jerking will STOP, so therefore I say that they MUST be preventing from practicing.

    No chiropractor has any basis to argue otherwise with anyone their own have already injured !!!
    And the list of those surviving with injuries has been steadily growing.
    The problem here being that injuries can be devastating, and NOT just minor side-effects.

    How arrogant these people are who think their can ignore those who they leave suffering with life changing disabilities which they won’t even acknowledge !
    Chiropractic methods are an insult to human intelligence, and an insult upon humanity.

    Cheers …… Graham.
    http://www.gmweb1.net/

  93. nwtk2007 says:

    Dr Maynard, on your web site is the discription from a person who says a chiropractor did this :

    “I suffered serious injuries in 1993 – complex skull fracturing from above neck to behind nose, also around left ear and pituitary; these last two aspects did not ‘heal’ properly, never will, and are steadily becoming worse. With these were – intra-cranial bleeding, a dislodged left styliod still floating amongst muscles, nerves, artery etc. behind my jaw, torn pharyngeal + head-neck + cranio-spinal tissues, and much more; ”

    I don’t mean to be a skeptic, but I find it hard to believe that a chiropractor did all this.

    How about a little more detailed account of this story? Where did it occur? Did the patient go to the ER? Was his injury verified and by whom? Etc.

    Just saying it was done by a chiropractor is not exactly good evidence, as the pro EBM guys on this forum would be so quick to point out.

    How ’bout it Mr Maynard?

  94. Harriet Hall says:

    Graham,

    You sound like John Badanes, an ex-chiropractor who calls for the total abolition of chiropractic. I don’t, for two reasons:

    (1) It just isn’t going to happen. There are too many people who love their chiropractors, too many chiropractors who need to make a living, and too many lobbyists supporting them.

    (2) There are some chiropractors like Samuel Homola and the National Association for Chiropractic Medicine who stick to evidence-based treatments, reject the woo, and help people. And they don’t manipulate the neck; just provide gentle mobilization for appropriate indications.

    I think the best course is to support rational chiropractors, attack obvious abuses like neck manipulation, applied kinesiology, and anti-vaccine propaganda, and hope for the best.

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