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Chiropractic Strokes Again: An Update

The risk of stroke with neck manipulation has been addressed on SBM before by Dr. Crislip, by myself, by chiropractor Samuel Homola, and by Jann Bellamy. I have listed the links at the end of this article for the convenience of interested readers. Recent studies merit a followup.

A case report published in the Annals of Internal Medicine July 17, 2012, describes a 37 year old nurse who had a history of chronic neck pain. She had been getting neck manipulations from her chiropractor once a month for 12-15 years! (One can only conclude that the manipulations had not accomplished much.) She developed a new symptom (pain when turning her head up and to the right), and at her 4th visit in a week, during neck manipulation, she heard a loud pop and immediately had the sensation that the room was spinning. She developed visual disturbances, vomited, and had a loss of balance, persistently falling to the left. The chiropractor failed to recognize her symptoms as signs of a stroke. Instead of rushing her to the ER, he performed an  “occipital adjustment” in an attempt to relieve her symptoms. She went to the ER 1.5 hours after the event and was found to have a cervical artery dissection. She was discharged from the hospital after 48 hours but has residual symptoms. The authors’ conclusion:

Although incidence of cervical artery dissection precipitated by chiropractic neck manipulation is unknown, it is an important risk. Given that risk, physical therapy exercises may be a safer option than spinal manipulation for patients with neck pain.

Another case report published in the Journal of Neuroimaging  on July 20, 2012, describes a 63 year old man with a history of surgery for carotid artery disease who sought chiropractic care for neck pain. He developed clumsiness in one hand with impaired touch sensation shortly after neck manipulation. Diagnostic studies revealed an acute ischemic stroke that was attributed to an embolus from disruption of carotid artery calcifications. They concluded that it suggested a causal association, especially in the absence of any other predisposing events. They recommended that patients with extensive carotid artery calcifications be advised against neck manipulations.
In December 2011 a study appeared in the Journal of Neurosurgery under the title “Craniocervical arterial dissections as sequelae of chiropractic manipulation: patterns of injury and management.”  It used a database of patients with endovascular disease to identify 13 patients who experienced cervical artery dissections following neck manipulation. It begins with a review of the literature with a long list of references supporting a causal association between high-velocity, low amplitude (HVLA) maneuvers and strokes. It describes a probable mechanism: a tear is produced in the artery wall (a dissection) and either a clot is propagated from the area of dissection or the dissection narrows the artery enough to impair blood flow.

The treatment of choice for these arterial injuries has been anticoagulation therapy. Because of the severity of the dissections in some of their patients, these authors used a more aggressive approach with stent placement and craniotomy to relieve brainstem compression. They describe the outcomes.

They describe two of their cases in detail. One, a 30 year old man, noted pain immediately after neck manipulation. He had a dissection that almost completely obstructed a neck artery. After a complicated hospital course and rehabilitation, he has residual paralysis and difficulty with speech, is unable to work, and depends on his wife for care.

In another case, a 54-year-old presented the day after neck manipulation with headache, incoordination, and difficulty walking. After intensive treatment for arterial dissection and thrombosis, he recovered completely.

Of 13 patients in their series, 9 recovered completely, 3 were permanently disabled, and one died.

They go on to point out:

Patients often visit the chiropractor complaining of head or neck pain, and a certain percentage may have preexisting arterial dissections. Nonetheless, as demonstrated in this series, patients can present within hours to days of chiropractic manipulation with new objective neurological deficits or more severe neurologic complaints. This temporal relationship suggests that either the arterial injury was produced de novo or made worse as a result of manipulation. Worsening of the patient’s complaint or the manifestation of a new neurological deficit after cervical manipulation should prompt urgent medical evaluation.

This undermines the speculations of the Cassidy study, which is often cited by chiropractic apologists. It argued that strokes are not caused by chiropractors but that a stroke is already in progress and is causing neck pain and that is the reason patients consult a chiropractor. Dr. Crislip did a good job of demolishing that study.

Chiropractors always object to being singled out because the culprit is neck manipulation and that is also practiced by other providers.  Nevertheless, chiropractors perform the vast majority of neck manipulations and have claimed manipulation therapy as their raison d’etre. In every case in these new articles, the manipulation was performed by a chiropractor. And in at least one case, the chiropractor was clearly negligent: he failed to recognize stroke symptoms as an emergency and tried to treat the symptoms with more manipulation.

In an earlier study, patients under 45 who suffered a vertebrobasilar stroke were 5 times more likely than controls to have had neck manipulations in the previous week. The actual magnitude of the risk is impossible to quantify, and perceptions differ.  There is reason to believe that many cases are not recognized or reported. Typically, a single chiropractor was aware of each case of manipulation-related dissection while 3-4 neurologists were involved in the patient’s treatment. 1 out of every 48 chiropractors and 1 of 2 neurologists were aware of a case over their lifetime.
Despite some loud protestations, chiropractors do acknowledge the risk. Provocative testing before cervical manipulation is widely recommended in the chiropractic literature. The validity of such testing is questionable, and at any rate the HVLA maneuver is not part of the provocative test and it is the likely culprit. Regardless of the magnitude of risk, the existence of a risk is undeniable and patients should know there is a risk before they agree to treatment. The Association of Chiropractic Colleges suggests informed consent but does not mandate it. Even  knowing about the risk won’t protect patients entirely. I know of one case where a patient fully intended to avoid neck manipulation, yet the chiropractor manipulated her neck without any warning and she suffered an immediate stroke on the table. And there wasn’t even any indication for neck manipulation: she was being treated for shoulder pain, not neck pain.

It’s been said before, but I’ll say it again: any degree of risk is unacceptable when there is no benefit. A Cochrane systematic review has shown that HVLA manipulations are no more effective for neck pain than gentle mobilization and that neither is effective unless used in conjunction with an exercise program. And there is even less evidence for benefit in non-neck-related conditions. NUCCA practitioners and other chiropractors who manipulate necks for almost any complaint are clearly out of line.

Related SBM articles

And there’s more chiropractic posts listed on SBM’s Chiropractic page.

Posted in: Chiropractic

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107 thoughts on “Chiropractic Strokes Again: An Update

  1. Retro Pastiche says:

    So let me get this right. Correlation does equal causation except when it comes to their own brand of woo. And science that indicates the woo is unnecessary and high risk is wrong except for the poorly constructed “studies” that are right?

    Where is this amazing world where trees grow upside down and fairies grant wishes?

  2. tgobbi says:

    A high-profile clueless chiropractor in my area regularly shows up at local art shows and “health” fairs with a little black electronic subluxation-detector box, offering free on-the-spot exams. (I’ve written about this guy on various forums on several occasions). He connects electrodes to the prospective customer’s neck and a multicolored printout emanates from the machine. The first time I encountered him I submitted to the exam and was handed a printout that very clearly showed what the DC deemed to be my “trouble spots.” At the time I contacted Dr. Hall to ask if she knew anything about the device which, no surprise, she did. I no longer have the email with her specific comments but I remember her stating that the device and its results were meaningless.

    On the occasion of my examination I feigned ignorance of chiropractic. In fact I’d already been a critic of the field for
    several decades and I always take advantage of such opportunities to further my knowledge of the affronts to science and reason that constitute mainstream chiropractic. (This has become more difficult in recent years because I’ve developed a reputation in the local chiropractic community. I’ve tried to overcome this by using an alias when filling out their forms). After the electrodes were removed from my neck the “doctor” expressed concern over what he saw and offered the standard free (or reduced-price) appointment for further evaluation and treatment. Maintaing my assumed ignorance I mentioned having read that there might be the danger of stroke associated with chiropractic neck manipulation. The “doctor” pooh-poohed this possibility and proclaimed that there’s more danger of having a stroke by turning one’s head to glance in the rearview mirror while driving or by tilting the head backwards for a shampoo in a hair salon. According to what I’ve read and observed over time this is pretty much the typical way that DCs have concocted to deny the likelihood that they’re performing a potentially dangerous procedure on an unsuspecting public.

  3. Dr. Hall – I wish this article could be syndicated across the country, in every single news publication.

    Your last paragraph hits the nail on the head. It’s as truthful and realistic as can be. There is just no reason to perform HVLA adjustments on the neck. Ever. There is just no reason to ever do it. Even one injury for this pointless quackery is too many.

  4. windriven says:

    “And in at least one case, the chiropractor was clearly negligent: he failed to recognize stroke symptoms as an emergency and tried to treat the symptoms with more manipulation.”

    Negligent or consistent? Manipulation is what they do. When the only tool you have is a hammer every problem looks like a nail. Frightening.

    “[A]ny degree of risk is unacceptable when there is no benefit.”

    And that is the rub, isn’t it? Many people claim significant improvement in pain and range of motion.

    More to the point the same results would be expected from treatment by a competent physical therapist, possibly at lower cost and certainly without the bullhockey of subluxations. To suggest that chiropractic manipulations never produce benefits (and that is not actually what Dr. Hall said here) is a losing strategy; right or wrong, thousands of chiropractic patients will line up to tout the benefits. By shifting the discussion to the superior results of medically directed, scientifically defensible physical therapy we can marginalize chiropractic and expose it for what it is.

  5. @windriven, I whole-heartedly agree with you. But how will we ever convince the idiots on Twitter who think it’s cool to have “regular adjustments” from their quackropractor, along with their routine cupping and spooning treatments?

  6. DevoutCatalyst says:

    Have you written about yoga and strokes, Harriet? Some of the postures stretch the neck in ways that would make a chiropractor cringe.

  7. daedalus2u says:

    DC, I think there is a very large difference between movements forced via external manipulation and self-movement via voluntary muscles. In the latter, pain is a signal that can tell you when a limit has been reached. There is no signal that tells a chiropractor when he/she has exceeded a safe range.

  8. tgobbi says:

    # DevoutCatalyston 14 Aug 2012 at 10:57 am
    Have you written about yoga and strokes, Harriet? Some of the postures stretch the neck in ways that would make a chiropractor cringe.

    Although I am neither Dr. Hall nor a healthcare professional, I’d like to presume to dare a response to the question pending her comments:

    The key to the chiropractic/neck manipulation/stroke problem is the “high-velocity, low amplitude maneuver.” To the best of my knowledge nothing in yoga compares to this. My non-professional guess is that yoga is no more invasive than what transpires in physical therapy.

    If I’m wrong, someone please correct me!

  9. DevoutCatalyst says:

    This caught my eye,

    “…The spike in clinical reports made yoga strokes a common feature of medical concern. The danger was judged to be at least partly due to underlying weaknesses in the vertebral arteries of some individuals. But it was difficult if not impossible to know who was at risk. So the warnings spread. They appeared not only in medical journals but in textbooks as health specialists gained new appreciation of the threat. Science of Flexibility, whose first edition appeared in 1996, featured a section called X-Rated Exercises. It linked strokes to poses that stretched the neck far backward, including the Wheel and the Cobra. In summarizing the medical findings, the book’s author called the value of the postures too small “to justify the potential, although rare, risk of vertebral artery occlusion.” He suggested avoidance….”

    Broad, William J (2012-02-07). The Science of Yoga (p. 121). Simon & Schuster, Inc.. Kindle Edition.

  10. Mark Crislip says:

    The residents presented a case a couple of years ago of a young female who apparently tore her vertebral artery while aggressively yoga-ing. Her symptoms occurred while doing a yoga position that was hyperextending the neck. Could, of course, have been coincidence.

  11. cervantes says:

    Well now, as far as these risks supposedly associated with yoga —

    There is risk in everything we do, after all. The most dangerous thing most people do is ride in a car, but most people do it every day. Whatever dangers there might be in doing yoga exercises, it is far safer than driving! I might happen to eat contaminated food, but I’m still going to eat.

    And every medical intervention has risks. There are risks associated with taking any of the most widely prescribed medications, every kind of surgery. It’s even dangerous to get in your car and go to the doctor, and you might get mugged in the parking lot.

    The question is whether any small risk associated with yoga is worth it to the people who enjoy the practice and get benefits from it, not whether some risk exists. Of course it does. I might get carpal tunnel syndrome from commenting on blogs. We need to keep issues in context and proportion.

  12. Scott says:

    @ cervantes:

    What you say is true as far as it goes. But, if the risks of yoga (or anything else) can be reduced at reasonable cost (whether that be monetary, time, etc.), without reducing the benefit of said activity, then they should be.

    Turning that back to the original topic, the risks of chiropractic neck manipulations can be eliminated at no cost without reducing the benefit (that being zero, if we exclude the benefit to the chiropractor’s wallet). So they should be – by eliminating chiropractic neck manipulation.

  13. windriven says:

    @SkepticalHealth

    “But how will we ever convince the idiots on Twitter who think it’s cool to have “regular adjustments” from their quackropractor, along with their routine cupping and spooning treatments?”

    I think we need to convince physicians to burn incense in their offices, serve waiting patients herbal teas with a twist of lemon and shake caduceus-inscribed marimbas while repeating incantations in a vaguely disturbing monotone.

    Then they can get on with the practice of medicine. I wonder how you’d code that?

  14. mr. grieves says:

    “I know of one case where a patient fully intended to avoid neck manipulation, yet the chiropractor manipulated her neck without any warning and she suffered an immediate stroke on the table.”

    Sounds very similar to the case of Kevin Sorbo (yes, the bastards even managed to take out Hercules), he received a neck adjustment without giving consent and suffered a stroke. See the video below:

    http://www.youtube.com/watch?v=cvmVnfJpY8E

  15. lizditz says:

    OK, a poll:

    Are they chiroquacktors (alt spelling: chiroquactors)

    or

    quackropractor

    Inquiring minds want to know.

    It’s the “chiropractic neurologists” who make me see the most red, frankly.

  16. joebrence9 says:

    “Turning that back to the original topic, the risks of chiropractic neck manipulations can be eliminated at no cost without reducing the benefit (that being zero, if we exclude the benefit to the chiropractor’s wallet). So they should be – by eliminating chiropractic neck manipulation.”

    According to an article published in the Journal of Orthopedic and Sports PT this year, the effects of applying a piece of tape to the neck was just as effective at reducing mechanical neck pain as a cervical manipulation.

    Manuel Saavedra-Hernández, Adelaida M. Castro-Sánchez, Manuel Arroyo-Morales, Joshua A. Cleland, Inmaculada C. Lara-Palomo, César Fernández-de-las-Peñas. Short-Term Effects of Kinesio Taping Versus Cervical Thrust Manipulation in Patients With Mechanical Neck Pain: A Randomized Clinical Trial. J Orthop Sports Phys Ther 2012;42(8):724-730.

  17. @windriven, it’d be a 9921-stupid! :) (kidding!)

  18. @liz, I’d go with quackropractor, because it better disparages the “profession” these dummies chose to use to defraud the public with.

  19. mousethatroared says:

    Windriven “I think we need to convince physicians to burn incense in their offices, serve waiting patients herbal teas with a twist of lemon and shake caduceus-inscribed marimbas while repeating incantations in a vaguely disturbing monotone.

    Then they can get on with the practice of medicine. I wonder how you’d code that?”

    No, No, It’s much harder to take market share by imitating an established brand. Doctors need to establish their own atmosphere to build a unique brand.

    I see an Old English Pub theme with a nice glass of single malt when you sign in and hand over your insurance card and driver’s license…

    But I’m guessing that would be viewed as “unhealthy”.

  20. pmoran says:

    Re yoga: there have also been reports of stroke after visits to the hair-dressers, possibly from the neck extension during washing the hair.

    http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(05)63608-2/fulltext

  21. lizditz says:

    OK, how chiropractic neurologists market themselves

    http://www.youtube.com/watch?v=F_zurwreA6A

    I wouldn’t advise SkepticalHealth to watch it, though, it will make his bloodpressure go through the roof.

  22. mousethatroared says:

    When I was a younger person and danced we were taught a lot of head movements (modern dance and jazz). We were also specially taught that tipping one’s head back too far was DANGEROUS. My instructor were not specific on why it was, but it was pretty clear to me what position was okay and what wasn’t.

    Jazzercise is not what I did, but this link has a good illustration on good and bad neck position.
    http://www.jazzercise.com/learn_dos.htm

    All the yoga and other exercise classes I have taken, that I recall, have had similar cautions.

    This is one reason that I sometimes dislike having my hair washed at a hair salon. They often put you in the exact position that I have been instructed was dangerous. It’s pretty darn uncomfortable too.

    I always thought it was more a matter of neck strains, pulled muscles, maybe disc damage. I never realized there was any other possible risk.

  23. joebrence9 says:

    “Emma’s first adjustment”…

    Fast forward to 50 seconds,
    http://www.youtube.com/watch?v=nTx2UxvaMro&feature=fvwrel

    Looks safe…

  24. ConspicuousCarl says:

    SkepticalHealth:

    I prefer chiroquacktor because I think losing the chiro- makes the reference vague when used out of context. The perfect vowel sound match up is also attractive.

    joebrence9:

    That kind of jackass makes me want to strangle my monitor.

  25. windriven says:

    @ mouse

    Touche! A nice Highland or Speyside preferably. Some of the Islays taste like old surgical dressings.

    But I don’t think that is going to pull the adjustment set away from their chiros :-(

  26. Chiroquackter!!

    Interestingly, no chiropractors have commented so far.

  27. mattyp says:

    Thanks for the queue Skeptical Health. Or did you want chiropractors, not students?

    “at her 4th visit in a week”
    Ummmm… this had me concerned from the get-go.

    “during neck manipulation, she heard a loud pop”
    Does the pop indicate the cavitation sound heard during manips/adjustment or something more sinister? Would a tearing artery make a sound that is audible to the patient?

    “and immediately had the sensation that the room was spinning. She developed visual disturbances, vomited, and had a loss of balance, persistently falling to the left.”
    That the chiropractor failed to recognise this as serious neurological deficit is disturbing. Chiropractors claim to be experts at the spine and the nervous system, and this is clearly a nervous system in distress.

    “he performed an “occipital adjustment” in an attempt to relieve her symptoms”
    Shakes head…

    “Another case report published in the Journal of Neuroimaging on July 20, 2012, describes a 63 year old man with a history of surgery for carotid artery disease who sought chiropractic care for neck pain”
    Assuming this came up in a patient history, the patient should have been immediately referred to a medical doctor for further investigation.

    “They recommended that patients with extensive carotid artery calcifications be advised against neck manipulations.”
    Seems more than reasonable.

    “It’s been said before, but I’ll say it again: any degree of risk is unacceptable when there is no benefit. A Cochrane systematic review has shown that HVLA manipulations are no more effective for neck pain than gentle mobilization and that neither is effective unless used in conjunction with an exercise program.”

    FWIW, my training has advised me that treatment with HVLA without an exercise program is not acceptable care. HVLA (if/when appropriate) must be used in conjunction with appropriate exercise, such as retraining of postural muscles that may be contributing to neck pain, as well as better educating the patient on how they can avoid episodes of neck pain in the future. My supervisors won’t approve a treatment unless it contains these factors.

  28. marcus welby says:

    mattyp: presumably the pop was the cavitation sought by chiropractors with their neck cracking so that the patient is impressed that something must have been out of place and now is adjusted. The vertebral artery dissection or subsequent embolization of clot to the brain would be silent but can be deadly. The Vertebral artery is usually torn exactly where the anatomy would predict, just after it exits the C-1 boney tunnel and makes a 90 degree turn on its way to enter the foramen magnum and cranial vault. Knowing that 50% of cervical spine rotation occurs between C-1 and C-2 and that the vertebral artery is usually torn exactly where it exits the bony canal should preclude any thoughtful individual from doing anything beyond very gentle rotation maneuvers with the neck.

    http://www.google.com/imgres?q=anatomy+of+vertebral+artery&hl=en&sa=X&biw=1280&bih=878&tbm=isch&prmd=imvns&tbnid=tMV0qSFI7K8MiM:&imgrefurl=http://catalog.nucleusinc.com/generateexhibit.php%3FID%3D8249&docid=7bUallUz4odBlM&imgurl=http://catalog.nucleusinc.com/imagescooked/8249W.jpg&w=432&h=329&ei=W6wrUM6pIoq08AT1p4HwBQ&zoom=1&iact=hc&vpx=387&vpy=568&dur=5965&hovh=196&hovw=257&tx=149&ty=146&sig=114201964744708384098&page=1&tbnh=143&tbnw=188&start=0&ndsp=25&ved=1t:429,r:20,s:0,i:138

  29. jhawk says:

    MW or anyone,

    I put these two cadaver pre-lim studies here because it is relevant and am curious what your thoughts are? It may look like I am defending cervical manipulation but I assure you I am not, I rarely use it anyway. I am honestly looking for educated opinions on these two studies. Is it possible that exactly where the anatomy would predict for dissection is misleading us?

    http://www.ncbi.nlm.nih.gov/pubmed/12381972

    http://www.jmptonline.org/article/S0161-4754(10)00084-9/abstract

    Let the bashing begin!

  30. Scott says:

    I can’t get to the full text, but the abstracts raise a couple of issues for me:

    – What specific techniques were tested (HVLA or otherwise)? My understanding is that this sort of “adjustment” encompasses a range of different techniques. Presumably different techniques will result in different strains. Likely different chiropractors will also produce different results. Are two chiropractors and the range of techniques tested adequate to cover the full spectrum? (I would hope this would be discussed at more length in the full text, but it’s one obvious place the studies could entirely fail to be relevant.)

    – If the results were borne out, that would simply say that the mechanism is less straightforward. At this point there’s enough evidence to demonstrate that such adjustments DO cause strokes even if the most obvious answer to WHY they cause strokes were to be disproven.

  31. jhawk says:

    Scott,

    “What specific techniques were tested (HVLA or otherwise)?”
    From the article,
    “First, ROM testing in flexion, extension, rotation, and lateral bending was performed. During the ROM testing, the head was moved passively to the end-range point, when no further movement could be produced. Next, VBI testing by placing the neck into extension plus rotation (ie, Houle’s test) was performed. The SMTs consisted of a combined lateral/rotary “break” adjustment with a second metacarpal contact with the cadaver supine and a pure lateral and a pure rotatory adjustment. These SMTs were delivered to specific
    lev els of the cervical spine: C1/C2, C3/C4, and C6/C7.” so yes, HVLA plus some others.

    “Are two chiropractors and the range of techniques tested adequate to cover the full spectrum?”

    The average peak force of cx spine maipulation has been measured in other studies at 100 to 150 N. As to techniques, they tested the ones most likely to cause dissection so the others most likely have even less force production.

    “If the results were borne out, that would simply say that the mechanism is less straightforward”

    I would even make this a little more specific, as did the authors, and say the mechanism for dissection is less straightforward.

  32. jhawk says:

    and even more specific…………less straight forward in cadavers!

  33. Honestly, with the education they receive, I’m surprised the chiropractors in that study could differentiate between a corpse and a patient.

  34. pmoran says:

    MW or anyone,
    I put these two cadaver pre-lim studies here because it is relevant and am curious what your thoughts are? It may look like I am defending cervical manipulation but I assure you I am not, I rarely use it anyway. I am honestly looking for educated opinions on these two studies. Is it possible that exactly where the anatomy would predict for dissection is misleading us?
    http://www.ncbi.nlm.nih.gov/pubmed/12381972
    http://www.jmptonline.org/article/S0161-4754(10)00084-9/abstract
    Let the bashing begin!

    If cervical manipulation was actually gentler on neck structures than is testing for normal range of movement, as claimed here, what on earth does it do? This would be a further argument against the likelihood of therapeutic benefits beyond placebo.

    It is also possible that anatomical variants make some patients more prone to this rare complication of neck manipulation and certain other activities.

  35. jerry_sprom says:

    pmoran,
    perhaps it is gentler than the forces of exerted during passive end ROM testing in this study because a HVLA thrust during a neck adjustment/manipulation doesn’t take the head into full rotation, lateral flexion or flex/extension. Thus exerting less strain on the VA.

  36. jhawk says:

    pmoran,

    “If cervical manipulation was actually gentler on neck structures than is testing for normal range of movement, as claimed here, what on earth does it do? This would be a further argument against the likelihood of therapeutic benefits beyond placebo.”

    It imparts motion to the joints and per this study does not strain the VA while doing this. A gentler mobilization is already used by many chiro’s and many PT’s to impart motion as well, should this be thrown out just because it is gentler?

    “It is also possible that anatomical variants make some patients more prone to this rare complication of neck manipulation and certain other activities.”

    I would think so. On a little different note, the authors talked about the cadaver population in this study and concluded that they were a worst case scenario group for such complications to occur due to thier age and most dying of cardiovascular disease. One even had a large aneurysm that did not tear.

  37. jhawk says:

    jerry sprom,

    I think you are correct and agree.

  38. Harriet Hall says:

    I don’t see cadaver studies as relevant. They don’t counteract the evidence that injuries occur.

  39. jerry_sprom says:

    @harriet Hall,
    This study is relevant to determining a mechanism of action for the association between neck manipulation and VA stroke. As you are aware it has been postulated that the force of a neck manipulation tears the VA, this study suggests that it is unlikely that there is enough force created during a (diversified) neck manipulation to disrupt the VA. The study is not trying to counteract the case studies you mention above, just that the mechanism of action for the injury that is widely spoken of is unlikely.

  40. Harriet Hall says:

    @jerry,

    But the chiropractors like to remind us that simply getting one’s hair shampooed can also cause a stroke (the salon stroke syndrome). Do you see the inconsistency? Surely a study of cadavers would show that simply assuming the hair-washing position does not constitute the force required to tear an artery, but those strokes are documented. There might be other mechanisms, like kinking the artery and triggering plaque disruption or a clot. If we know it occurs, it’s not so important to understand the possible mechanisms.

    They seem to be arguing that because they couldn’t tear the arteries in a cadaver, chiropractic neck manipulations can’t cause strokes. That doesn’t follow.

  41. pmoran says:

    pmoran,
    perhaps it is gentler than the forces of exerted during passive end ROM testing in this study because a HVLA thrust during a neck adjustment/manipulation doesn’t take the head into full rotation, lateral flexion or flex/extension. Thus exerting less strain on the VA.

    That might explain the cadaver results, and it would very likely make neck manipulation safer, but since when has this been the recommended way of performing spinal manipulations, in general? For what it is worth, this is the first I have heard of performing them entirely within the normal range of movement (ROM)–and that is the only way they could be LESS stressful on the VA than the testing for ROM. (I suppose those clicking devices may permit this kind of manipulation but we again come up against the unlikelihood of any physiological effects).

    It may be unrealistic to expect the total banning of neck manipulation in any short term, but we would like to see more consideration given to how to make it safer, along with normal standards of informed consent. The elements of chiropractic that continue to deny the risk are making that harder.

  42. What do I know about chiropractors? Well, I know they are unintelligent, poorly educated fools who practice a form of quackery and try to pass themselves off as legitimate medical providers. That’s an indisputable fact. Do I even waste my time reading when a handful of chiropractors publish a ridiculous “study” in a chiropractic journal that tries to lend credence to the idea that chiropractic treatment is safe? No. I don’t.

    Fact: We have no good treatment for “neck pain.”

    Fact: Chiropractic manipulation of the neck is never indicated because it is not in any better than a number of other treatment modalities that are much safer.

    Fact: Chiropractors are possibly the worst offenders at spreading misinformation and raping their dying patients of money.

  43. Dear FDA, FTC, CDC,

    I am a licensed medical doctor. I make a very comfortable living. I will give it all up and become a government slave if you let me be an internet watchdog and have the power to prosecute any quack website that makes blatantly false claims. I will also go after any and every chiropractor that makes false claims about what they can treat, that has invented diseases (that don’t have ICD9 codes!), and that offers completely fake, ineffective, and dangerous treatments. All I ask is that you give me the power to rid our country of rank and rampant quackery.

    Thank you

  44. jerry_sprom says:

    pmoran,
    the manipulative techniques that were used in this study in my experience are one the most common type of techniques used to manipulate the neck (at least by chiropractors). The authors used a diversified technique, one involving rotation and lateral flexion and the other a straight lateral thrust. The contact point is thought to allow tension at a specific segment of the neck (presumably the area of hypomobility), but not tension the entire neck. Using these techniques, the neck wouldn’t be taken into extreme end ROM. What do you think is the ‘recommended’ way a neck manipulation should be performed?

    @Harriet Hall
    I see inconsistencies from both sides.

  45. rwk says:

    Dear Skepticalhealth,
    If we knew who you were your career would be over. Period.

    Here for all SBM bloggers to admire:

    http://twitter.com/SkepticalHealth

  46. jhawk says:

    pmoran,

    jerry sprom is exactly right in his descritpion on manipulation not being at end range.

    HH,

    “There might be other mechanisms, like kinking the artery and triggering plaque disruption or a clot.”

    This is clearly stated in the study. From the article, “An ischemic event sustained in the vertebrobasilar system
    during SMT can arise from a variety of causes such as pinching or kinking of the VA during neck movement,
    vasospasm of the VA, systemic shock or hypotension, physical obstruction of the VA by a dislodged thrombus, embolus, or atherosclerotic plaque, and a traumatic tear in the VA. This study focused on the last possibility by directly evaluating the strains and forces exerted on the VA itself during SMT.”

    This study only calls into question the dissection of the VA of which Marcus Welby described as being the exact location where anatomy would predict a tear to occur.

    “They seem to be arguing that because they couldn’t tear the arteries in a cadaver, chiropractic neck manipulations can’t cause strokes. That doesn’t follow.”

    From the discussion, “The clinical relevance of these results is equivocal, mainly because these were single, manipulative thrusts in a non-living subject. Although we can comment on the biomechanical
    properties of the VA, we cannot interpolate these results into a living system.”

    SH,

    “Do I even waste my time reading when a handful of chiropractors publish a ridiculous “study” in a chiropractic journal that tries to lend credence to the idea that chiropractic treatment is safe? No. I don’t.”

    This study was done by a PhD in Kinesiology, a reasearch tech in the lab and PhD kinesiology student who is a DC.

  47. Harriet Hall says:

    “we cannot interpolate these results into a living system.”

    So the experiment was ultimately useless. One wonders why they even bothered.

    Anyway, many chiropractic related strokes are documented cases of vertebral artery dissection, so they couldn’t have eliminated that as a possibility.

  48. pmoran says:

    pmoran,

    jerry sprom is exactly right in his descritpion on manipulation not being at end range.

    Well I ask “since when?” — aren’t there videos around showing otherwise? Why has this not been made much of before?

    And why not?.

    Is this an admission that end range manipulations, whether intentional or due to operator misjudgement, ARE able to damage the artery and that these studies are irrelevant to that question?

    As Harriet says, there is no reasonable escape from the fact that these injuries are occurring, and within chiropractic practice as well as outside it. Non-chiropractors may indeed be the most dangerous if allowed to continue in a state of ignorance concerning the risks of this procedure, although it is difficult to imagine that any physiotherapist or doctor has not heard of it.

  49. nobs says:

    # joebrence9on 14 Aug 2012 at 5:33 pm

    “Turning that back to the original topic, the risks of chiropractic neck manipulations can be eliminated at no cost without reducing the benefit (that being zero, if we exclude the benefit to the chiropractor’s wallet). So they should be – by eliminating chiropractic neck manipulation.”

    According to an article published in the Journal of Orthopedic and Sports PT this year, the effects of applying a piece of tape to the neck was just as effective at reducing mechanical neck pain as a cervical manipulation.

    Manuel Saavedra-Hernández, Adelaida M. Castro-Sánchez, Manuel Arroyo-Morales, Joshua A. Cleland, Inmaculada C. Lara-Palomo, César Fernández-de-las-Peñas. Short-Term Effects of Kinesio Taping Versus Cervical Thrust Manipulation in Patients With Mechanical Neck Pain: A Randomized Clinical Trial. J Orthop Sports Phys Ther 2012;42(8):724-730.

    HUH ???? This is a non-sequitor.

    Your claim: “the risks of chiropractic neck manipulations can be eliminated at no cost without reducing the benefit (that being zero, if we exclude the benefit to the chiropractor’s wallet). So they should be – by eliminating chiropractic neck manipulation.”

    —-> Then: in an attempt to support your above claim against “chiropractic neck manipulation” you cite a study in which all of the cervical manipulations were performed by PTs…. NOT …. DCs.

    HMMM …….. HMMMMMMM ! ???

  50. jerry_sprom says:

    pmoran.
    “since when”….as far as I am aware, ever since States’ manual on diversified technique has been around. The most common cervical techniques used are the ones described in the study. You may have seen technique that involve thrusting into end range of motion, but I would put it to you that they are probably not the ones described in the study. The goal of the technique is to create tension specifically to a spinal motion unit, not the entire neck. In my training this was always the case.

    I am not sure it is an admission that a end ROM thrust technique are able to damage the artery. In the earlier article, the authors noted that the strain on the vertebral artery during neck manipulation amounted to only about 10% of that required to cause failure of the artery. During end ROM (rotation) it was about 13%. So I would suggest it would still take a significant thrust, in full rotation to cause mechanical disruption to the artery.

    @Harriet Hall
    If these studies had been done and showed that the strains on the VA during neck manipulation were enough to cause tearing of the VA, would you still consider them to be useless, or would you be incorporating them into your next blog on chiropractic and strokes?

    These are preliminary studies and there appears to be more in the pipeline.

    1. Harriet Hall says:

      @jerry,
      “If these studies had been done and showed that the strains on the VA during neck manipulation were enough to cause tearing of the VA, would you still consider them to be useless, or would you be incorporating them into your next blog on chiropractic and strokes?”

      We KNOW vertebral arteries are dissecting. If a study confirmed exactly how that occurs, sure, I’d report it. Especially if it contributed to a way to prevent the damage or to pre-screen patients who are more vulnerable. But a study on cadavers that says the strains applied to the artery are insufficient to tear the artery is essentially useless, since we know the arteries DO tear.

  51. nwtk2007 says:

    Thanks for posting the link rwk. “Dr” Skeptical is quite the piece. My guess is now, he ain’t no doc. But who knows. One thing is certain, with all the problems in medicine today, I’m sure he is a major contributor. Either way, he certainly has a problem.

  52. joebrence9 says:

    @nobs
    ” Then: in an attempt to support your above claim against “chiropractic neck manipulation” you cite a study in which all of the cervical manipulations were performed by PTs…. NOT …. DCs.

    HMMM …….. HMMMMMMM ! ???”

    Cervical manipulation is cervical manipulation. Whether performed by PTs or DCs, the techniques used are non-specific and unnecessary.

  53. jhawk says:

    HH,

    “If we know it occurs, it’s not so important to understand the possible mechanisms.”

    Wow! I am picturing Galileo a the top of the tower of Pisa dropping balls and saying yep they fall and we know it let’s not figure out why!!!

    “We KNOW vertebral arteries are dissecting.”

    Yes, arteries are dissecting but this study is showing there is not enough force with cx manipulation to cause the tearing.

    “But a study on cadavers that says the strains applied to the artery are insufficient to tear the artery is essentially useless, since we know the arteries DO tear.”

    Why? Do you predict that thesse cadaver arteries have a different tear threshold than non-cadaver arteries?

  54. Wow! Our resident chiroquackters are certainly turning out to hang their hats on a very small “study” that attempts to cast doubt on the fact that chiropractic manipulation of the neck causes strokes. Do I think that the findings of a couple of goobers who looked at six vertebral arteries in cadavers in a study designed to try to vindicate cervical spinal manipulation is legitimate? No. Do I think that manipulating dead tissue under “scientific conditions”, that isn’t physiologically active, doesn’t contain blood, and in no way resembles reality matters? No. Also, I didn’t bother to read the full study because superficially it is very uninteresting, but what was the define point of failure? And go ahead and ask yourself if that in any way resembles what happens when an artery is damaged and begins to disect?

    This is the problem with idiots doing science. They just do idiotic science.

  55. jhawk says:

    SH,

    The “goober” Walter Herzog, one of the authors of this study, has a PhD in biomechanics and is associate dean of research of kinesiology.

    “And go ahead and ask yourself if that in any way resembles what happens when an artery is damaged and begins to disect?”

    They were using “damaged” arteries.

  56. Harriet Hall says:

    @jhawk,

    Nowhere did I say that we should not figure out why. But “why” may not be easy to pin down, and there may be more than one mechanism; and until we know why, we can still take appropriate action, avoiding neck manipulations to reduce the risk of stroke.

    If you want my prediction: yes, I think these cadaver arteries are different from the ones that tear. I would guess the ones that tear have inherent weakness or atherosclerotic plaques, defects that cannot be easily ruled out prior to manipulation. If anything, the study only tended to corroborate what we already knew: MOST vertebral arteries do not tear with neck manipulation. Think about it: if the cadaver study had shown arteries tearing, one might expect every patient’s arteries to tear with manipulation.

  57. pmoran says:

    jerrysprom:i>I am not sure it is an admission that a end ROM thrust technique are able to damage the artery. In the earlier article, the authors noted that the strain on the vertebral artery during neck manipulation amounted to only about 10% of that required to cause failure of the artery. During end ROM (rotation) it was about 13%. So I would suggest it would still take a significant thrust, in full rotation to cause mechanical disruption to the artery.

    That may well be so for most patients.

    We cannot accept this as the whole story. We have to factor in that vertebral artery dissections (VADs) also occur spontaneously, or after other minor injuries and events, even in the relatively young. This is the basis for the argument being made from the Cassidy study.

    The model that best fits the facts is that of an artery that is vulnerable to dissection through a highly unusual anatomical arrangement, frequently stressed in normal use (which is known to produce vessel weakness), and probably especially vulnerable to damage in some individuals through anatomical anomalies, past trauma (such as neck manipulations!?!) or rare arterial diseases e.g. Fibromuscular dysplasia.

    If so, we might expect almost any kind of neck “manipulation”, even attempts at full mobilisation, to occasionally trigger a VAD. And there is no way of being sure about who is at risk.

    I think something like this is the message that we should be sending out: manipulative interventions of any kind should, if used at all, be reserved for those who don’t respond to a prolonged trial of simpler measures.

    It is difficult to advise what do do if manipulation is decided upon after proper informed consent, as there is so little evidence to go on.

    It is tempting to say “be gentle and avoid extreme positions” but not entirely rational because of the “well, then, what does it ‘do’” question. We are probably dealing with a treatment that has a very low “therapeutic ratio” in that the risks are rare, but potentially triggerable by the mildest of interventions.

  58. jerry_sprom says:

    pmoran,
    I think you make some valid points.

    I would also add that it is highly likely, based on the studies we are discussing, that for the rare patients in the categories you outline above ie: anatomical variants, rare arterial diseases etc, would be more likely to suffer an arterial dissection from the assessment that they undergo in order to diagnose their condition. ie: if the ROM testing, VBI testing and any cervical orthopedic tests place more strain on the artery than does the manipulation itself, perhaps the patient would be more likely to suffer the injury as a result of their examination rather than the manipulation. Is the assessment inherently more risky than the treatment?

    In order to provide a person suffering from neck pain “a prolonged trial of simpler measures”, presumably an assessment and diagnosis has been performed. Should the practitioner even perform an assessment that includes these tests if we think these tests place enough strain on the VA in a potentially vulnerable patient? If not, then do we make a diagnosis and prescribe a treatment regime from a patient history only and not physically assess the patient?

  59. The issue is that you’re assuming chiropractic treatment has merit. It doesn’t. There is no reason for a chiropractor to ever “treat” a person. You’re less educated and less trained than a physical therapist. If you had any self-respect, or care for the person who you are about to injur, you would simply send them to a PT instead, turn off the lights, close the doors, and go back to college, you scum sucking morons.

  60. pmoran says:

    jerry_sprom: I would also add that it is highly likely, based on the studies we are discussing, that for the rare patients in the categories you outline above ie: anatomical variants, rare arterial diseases etc, would be more likely to suffer an arterial dissection from the assessment that they undergo in order to diagnose their condition. ie: if the ROM testing, VBI testing and any cervical orthopedic tests place more strain on the artery than does the manipulation itself, perhaps the patient would be more likely to suffer the injury as a result of their examination rather than the manipulation. Is the assessment inherently more risky than the treatment?

    That’s a stretch. Cannot ROM testing be performed by asking the patient to demonstrate it? IF “VBI testing” involved testing for neurological effects from various neck manoeuvres that may well be dangerous for a few, and arguably of little use in making manipulation much safer. Any other testing would have to be judged on its merits, bearing in mind the limited evidence for benefit from any specific treatment for neck pain, let alone whether additional diagnostic information helps outcomes in the usual case of musculoskeletal neck pain.

    In order to provide a person suffering from neck pain “a prolonged trial of simpler measures”, presumably an assessment and diagnosis has been performed. Should the practitioner even perform an assessment that includes these tests if we think these tests place enough strain on the VA in a potentially vulnerable patient? If not, then do we make a diagnosis and prescribe a treatment regime from a patient history only and not physically assess the patient?

    That would a bigger stretch. Inspection and normal palpation techniques should be safe.

    Can you give an example of an examination technique that might be risky but which is also of demonstrated importance for outcomes?

  61. jerry_sprom says:

    pmoran
    VBI testing – Hautants Test, DeKleyn Test, Maximal cervical compression test.
    Orthopedic tests – Maximal cervical compression test, jacksons compression test, spurlings test, Upper limb tension tests. All of these place the neck into a high degree of extension, rotation and or lateral flexion.
    ROM – passive ROM testing, Flexion-Rotation test for upper cervical mobility

    Whilst the validity and specificity of these tests may vary, my understanding is that there is still a medicolegal requirement that these tests be performed, presumably for all manual therapists.

    You may find this link interesting http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1635718/

    “Inspection and normal palpation techniques should be safe” – but are they enough help a practitioner to develop differential diagnosis or a working diagnosis and subsequently provide treatment? I would be interested to know what is the specificity and validity of inspection and palpation would be.

    Perhaps my comments seems like a stretch, because it is hard to comprehend that end ROM testing places more strain on the vertebral artery than does a manipulation (as performed in these studies).

  62. jhawk says:

    HH,

    “But “why” may not be easy to pin down, and there may be more than one mechanism; and until we know why, we can still take appropriate action, avoiding neck manipulations to reduce the risk of stroke.”

    I can agree with you here.

    “If you want my prediction: yes, I think these cadaver arteries are different from the ones that tear. I would guess the ones that tear have inherent weakness or atherosclerotic plaques, defects that cannot be easily ruled out prior to manipulation. If anything, the study only tended to corroborate what we already knew: MOST vertebral arteries do not tear with neck manipulation. Think about it: if the cadaver study had shown arteries tearing, one might expect every patient’s arteries to tear with manipulation.”

    I agree with most of what you say but I would like to add that the VA’s used in this study were considered by the author’s to be a worst case scenario because the average age was 86.4, most died of cardiovascualar disease (possibility of plaquing) and one even had a large aneurysm (weakening you mentioned). I think it would be interesting to find more VA’s with these defects and test them but it would still be in cadavers.

  63. Harriet Hall says:

    @jhawk,

    “it would be interesting to find more VA’s with these defects and test them but it would still be in cadavers.”

    Those defects can be detected in the living with imaging studies. If a correlation were found, what would come next? Subjecting every patient to expensive imaging studies prior to manipulation? That hardly seems practical, and the whole question is moot if no clear benefit can be shown for neck manipulation.

  64. marcus welby says:

    The majority of VAD strokes occurring after chiropractic neck manipulation have occurred in relatively young women with no evidence of atherosclerosis and there is general agreement that no testing will detect the likelihood of such an occurrence. Many of the women were being twisted for treatment of headaches, but I have spoken with relatives of a young woman who died in her early 20s following over 150 neck crackings for treatment of coccydynia (tailbone pain) and to survivors who had neck cracking for treatment of shoulder pain and low back pain. And one unfortunate older gentleman in a wheelchair who has now died. The patient mentioned above, who had neck cracking for treatment of shoulder pain recovered well after a craniotomy. Atherosclerosis does not be a part of the danger of VAD and stroke but may be a factor when the less common carotid artery rupture or dissection occurs.

  65. weing says:

    Not sure how the arteries were tested in the cadavers. Was there blood flowing through them during manipulation? If so, what pressures were maintained?

  66. Quill says:

    “Fact: Chiropractic manipulation of the neck is never indicated because it is not in any better than a number of other treatment modalities that are much safer.”

    Exactly so.

    And yet one can imagine the chiropractic community spinning part of this story into something like “Chiropractic manipulation shown to be safe and effective for the dead! Imagine what it can do for the living, especially with weekly adjustments!”

    Parenthetically, for the past two months I’ve been experiencing odd lower back pains, sometimes shooting pains accompanied by soreness that never seems to be in exactly the same place. Some of my acquaintances who find “alternative” medicine to be more real than “western” medicine all but insisted on me seeing a chiropractor, an acupuncturist and a cranial sacralist. (I actually like that term, cranial sacralist. It has such a Theosophical ring to it.) Anyway, last week I also had my regular visit with my internist. I described my symptoms and she said “How old is your mattress?” :-) So I’ve now got a new bed, all symptoms resolved and life is good again. And not one high velocity thrust, needle in the skin or incantation involved. (Although I think at least one person will logically conclude that all this proves is that there is a conspiracy between Big Pharma and Big Bed.)

  67. Speaking of terribly sad stories of people who were essentially murdered by chiropractors while being “treated” completely ineffectively and inappropriately, does anyone know what happened to Sandy Nette? Her old website (sandynette dot com) just redirects to some Chinese type. Did she pass away? Or did she take her site down in part of her class action suit?

    Here is her story:

    http://www.youtube.com/watch?v=SHX7m09OZ8E

    The comments are rather interesting. Psychotic chiropractors are adamant that cervical manipulation doesn’t cause stroke. No where do they seem to question whether or not there is any benefit to ever manipulating someones neck (there isn’t.) If any chiropractor is reading this, I sincerely hope you *NEVER* “adjust” someone’s neck. You’re free to be as stupid and commit as much fraud as you want, but please do not purposefully and pointlessly murder people with your absolutely idiotic neck adjustments. Just don’t. Don’t be an idiot.

  68. pmoran says:

    Perhaps my comments seems like a stretch, because it is hard to comprehend that end ROM testing places more strain on the vertebral artery than does a manipulation (as performed in these studies).

    Again, these studies are soft evidence of that, and not only because they involve a very artificial set-up in the cadaver. We are also being required to believe that the ROM testing and the manipulations used here were performed in an honest and realistic manner, and are fully representative of the range of methods being used in the real world by chiropractors and others. That is extremely unlikely. There will always be carelessness in some and the temptation to go a little further in the hope of better results.

    So, yes, your implications are hard to accept, especially while we are, in fact, regularly seeing strokes after cervical manipulation but not so much if at all after ROM testing (even though, on my model, VAD would be a theoretical but rather rarer complication of that — also after testing for VBI) .

  69. jerry_sprom says:

    pmoran,
    If I read your post correctly, you are now questioning the honesty of these researchers to perform their research correctly. Thats quite possibly a stretch too. Like I have mentioned previously, this is the second such study by these authors, the study took into account the most common techniques used by chiropractors (diversified technique). Of course practitioners could use other and less commonly used techniques or perhaps perform them incorrectly or carelessly. The authors could test different manipulative positions and that may help solve the first issue. I am not sure how they can factor in an incorrectly or carelessly performed manipulation. Perhaps it highlights the importance of being well trained when performing manual therapies. Furthermore, there appears to be more studies in progress.

    I dont believe your assertion that we are ‘regularly seeing strokes after cervical manipulation’ is supported by the evidence. You and other commentators have already agreed that these are rare events.

    This, from a recent comment by David Chapman-Smith regarding recent commentary in the BMJ by Wand et al
    “From the perspective of logical and reasonable persons Wand et al. are advocating an untenable position – that a widely used treatment of proven benefit be abandoned because of unproven potential for harm. The logical course in this situation, as suggested by Cassidy et al., is further research into benefits and risks of harm – not abandonment.” Further research continues.

    Thanks for the discussion.

  70. pmoran says:

    Jerry, I have already stated here that it is unrealistic to expect neck manipulation to be abandoned in the short term. I have more modest here-and-now objectives, in line with the way risks and potential risks are normally handled within medicine.

    If neck manipulation was a drug wtih comparable evidence of risk, there is no question that warnings would have gone out long before now to all practitioners concerning the worrying association with stroke, along with advice as to when and how it should be used, if at all, also advice concerning its incorporation into informed consent (in its other guise as a medical procedure).

    We would not postpone action pending further study. How many patients might die or suffer serious injury while we await a “smoking gun” that may never quite come to the not wholly disinterested satisfaction of the chiropractic profession?

    The passive, temporising, approach suggested by your last paragraph is thus NOT the “logical course”. That would only be acceptable so if we knew in advance that present decisions had neutral consequences for our patients. If we knew that there would be no need for any further study.

    It is on our all our heads if ancient rivalries and turf protection is allowed to paralyze rational responses to this matter.

  71. weing says:

    @jerry_sprom,

    I don’t understand how cadaver studies can be extrapolated to the living. Where is the accounting of the shear stresses on the arteries from blood flow?

  72. nobs says:

    “# pmoranon 19 Aug 2012 at 2:37 am

    Jerry, I have already stated here that it is unrealistic to expect neck manipulation to be abandoned in the short term. I have more modest here-and-now objectives, in line with the way risks and potential risks are normally handled within medicine.

    If neck manipulation was a drug wtih comparable evidence of risk, there is no question that warnings would have gone out long before now to all practitioners concerning the worrying association with stroke, along with advice as to when and how it should be used, if at all, also advice concerning its incorporation into informed consent (in its other guise as a medical procedure).

    We would not postpone action pending further study. How many patients might die or suffer serious injury while we await a “smoking gun” that may never quite come to the not wholly disinterested satisfaction of the chiropractic profession?

    The passive, temporising, approach suggested by your last paragraph is thus NOT the “logical course”. That would only be acceptable so if we knew in advance that present decisions had neutral consequences for our patients. If we knew that there would be no need for any further study.

    It is on our all our heads if ancient rivalries and turf protection is allowed to paralyze rational responses to this matter.”

    Dr. Moran- Thank-you for being one of (or what appears to be, the ONLY one) here genuinely interested in an honest exploration of the issues, evidence and facts.

    The prevailing attitude of bloggers here is: “My mind is made up- Don’t confuse my dogma with facts”.

    Several comments in your above post lead me to believe that most(if not ALL?) of your ahem….”information” relative to chiropractic in general, and manipulation associated strokes, specifically, is unfortunatley sourced to this(SBM) blog site.

    Please allow me to refer you to THIS blog site: http://smperle.blogspot.com/search/label/chiropractic%20stroke

    The above link I selected for you is only to stroke related issues, and thoroughly debunks much of what is touted here as “fact”. I think you will find it VERY informative, and also contrary to what you have been misleadingly led to belive here(SBM).

    Additionally, I do think you will find the entire site (http://smperle.blogspot.com/ ) informative, and give you a much more realistic, truthful, and accurate account of the chiropractic profession at large.

    Please feel free to “comment” to Dr. Perle on any of his blog entries. He welcomes any/all genuine non-vitriolic comments. He WILL respond.

    Thank-you in advance for your consideration.

    moments, to

    1. Harriet Hall says:

      @nobs,

      The Perle article doesn’t “debunk” anything. It is a quibbling criticism of an article by Edzard Ernst, an article that covered published reports of deaths but did not look at non-fatal strokes. Perle is probably one of the most reasonable chiropractors out there. I’m very familiar with his thought processes from his long participation in the Healthfraud discussion list. He talked the talk about science and the need to reform chiropractic, but eventually he made statements about “reformed” chiropractic that he was unable to support with evidence. If I remember correctly, he also thought the activator gadget was effective and when I asked for his evidence he did not respond. He was asked pointed questions that he could not answer, and he chose to depart the list at that time.

      The chiropractic literature shows that chiropractors acknowledge the (small) risk of stroke with neck manipulation, and their insurance companies pay out claims for strokes. The only thing that they question is how often these strokes occur.

      What we non-chiropractors question is whether there are any proven benefits of neck manipulation that might outweigh the risks of stroke. Systematic reviews like this http://www.ncbi.nlm.nih.gov/pubmed/22621391 and this Cochrane review http://www.ncbi.nlm.nih.gov/pubmed/15247576 shed serious doubt on the efficacy of neck manipulation.

      As Pmoran pointed out, if neck manipulation were a drug it would not be on the market. A drug with that amount and quality of evidence for efficacy and safety would never have been approved.

  73. @nobs, are you out of your mind? You are referring people to a website run by a “professor of chiropractic”, and he is going to be an unbiased and good source of information when it comes to whether the practice of chiropractic is safe? No thank you.

    Manipulation of the neck is *NEVER* indicated. EVER.

  74. Do you want the truth about used car salesmen? Quit reading all that garbage on Consumer Reports and the BBB. Come to this other website, that is run by a used car salesmen, and he will give you the true facts about how honest they are!!!

  75. weing says:

    @nobs,

    Are you trying to say that VADs and strokes do not occur after neck manipulation? I think the more relevant question is how frequently they occur? The cases reported in the literature are more than likely just the tip of the iceberg. I assume you are a chiropractor and are obviously in denial of this happening. If it is happening, and you are truly concerned about public safety, don’t you want to put a stop to a procedure that is dangerous? And make your colleagues aware of it and have a concerted effort to stop it? I remember when I was in training, frequent PVCs noted on Holter monitoring were routinely treated with type 1 antiarrhythmics. Then the studies came out that those so treated were dying faster than those not treated. We changed our behavior and quickly. Same with rapid lowering of BP in the ER with sublingual nifedipine.

  76. @weing, are you saying you don’t like getting paged by the night shift nurse who is concerned that your hypertensive urgency pt’s BP is 165/85? :) (kidding! For those that don’t know, with certain patients we actually don’t mind that the BP is elevated, and we want to lower it very slowly, because sometimes their elevated BP may be the only thing that’s actually allowing them to perfuse their brain with blood.)

  77. jhawk says:

    HH,

    “If a correlation were found, what would come next?”

    I was actually thinking the other direction. It would be interesting if it was found that the compromised VA’s didn’t dissect. It would just lead to more studies needing to be done but interesting IMO.

    ” Subjecting every patient to expensive imaging studies prior to manipulation?” I hope this is rhetorical but I will answer anyway, no way.

    “That hardly seems practical, and the whole question is moot if no clear benefit can be shown for neck manipulation.”

    Yep, but I still think it is interesting from a basic science, biomechanical perspective.

  78. @jhawk, it’s an established fact that VAD/stroke occurs sometimes after cervical spine manipulation. We don’t know in which population this is more likely to happen. We also know that there is no good reason to ever perform cervical manipulation, in light of the fact that it’s not (very) effective, and equally or more effective treatments exist that are not associated with VAD/stroke. So would you advocate that all chiropractors cease cervical spine manipulation? Or would you say “more studies need to be done”, and let this pointless, but dangerous, “treatment” to continue?

    Or, in a single question (rwk, nwtk2007, please chime in): please describe a scenario in which you would manipulate the neck of a patient instead of recommending one of a number of other therapies that are as effective, but infinitely safer? (ie, handing someone an exercise video, simply taking pain medication and waiting it out, or apparently just putting tape randomly on someone’s neck.)

    I still find it extremely bizarre that chiropractors are so ready to hang their hat on a completely irrelevant study that looked at like 6 corpses. I guess that’s partly because they have almost no formal education in science.

  79. jhawk says:

    pmoran,

    “If neck manipulation was a drug wtih comparable evidence of risk, there is no question that warnings would have gone out long before now to all practitioners concerning the worrying association with stroke, along with advice as to when and how it should be used, if at all, also advice concerning its incorporation into informed consent (in its other guise as a medical procedure).”

    Stroke caused by cx manips is taught in chiropractic school as a risk factor and informed consent plus PARQ conference is a requirement. I agree with you that more needs to be done as obviously the above hasn’t gotten the word out so to speak.

  80. jhawk says:

    SH,

    “Or, in a single question (rwk, nwtk2007, please chime in): please describe a scenario in which you would manipulate the neck of a patient instead of recommending one of a number of other therapies that are as effective, but infinitely safer? (ie, handing someone an exercise video, simply taking pain medication and waiting it out, or apparently just putting tape randomly on someone’s neck.)”

    A patient that is non-responive to these other types of treatment. I also think manipulation does an excellent job for meniscoid entrapment patients (only clinical experience here).

    “I still find it extremely bizarre that chiropractors are so ready to hang their hat on a completely irrelevant study that looked at like 6 corpses.”

    I don’t think any commenter here is hanging there hat on this study. Everyone is aware more studies are needed.

    “I guess that’s partly because they have almost no formal education in science.”

    This is false. And no I do not have onus of proof because this is a blatant, inflammatory lie.

  81. So basically you are suggesting that you would use cervical spine manipulation if other therapies have failed. Tell me, how many times have you had a patient come into your chiropractic office complaining of neck pain, and you said “Ok, let’s give you this exercise video and we’ll teach you some exercises you can do at home. You can just pay me $5 for the video, and whatever my rate is for an initial consultation. Come back in two weeks and we’ll re-evaluate your pain then.” And when they come back multiple times over the next few months, how many times have yous said “Ok, I will refer you to a pain specialist, who can put you on chronic pain medication while we wait for this to heal. While we’re at it, keep trying to move your neck through a full range of motion.” And then, how many times have you said “Ok, well let me put tape randomly on your neck to see if that will trick your mind into healing the neck pain?” How many times have you exhausted the list of superior & safer therapy before initiating c-spine manipulation?

  82. Doctors used to screen for lung cancer with a yearly chest x-ray. It turned out that this screening procedure was useless and needlessly exposed patients to ionizing radiation. This practice was stopped. Why is it that chriopractors are unable to stop a deadly practice that has almost no benefit? Study after study has demonstrated that the risk of cervical manipulation outweighs the benefit. Why not just accept this and move on? @jhwak, that is why I say chiropractic is inherently unscientific. They’re practice is not altered by science. They practice in spite of it. (I won’t even go into the whole thing about them being lower intelligence students or being formally taught quackery in school.)

  83. I have another question. Where do SO MANY chiropractors get the idea that you can manipulate the c-spine and “cure” problems in the lower back, or cure any of a number of other diseases? It’s a pretty interesting phenomenon that SO MANY chiropractors all believe the same completely fake garbage (did you see the chiropractic gimmickery post?), and yet they believe they are educated in the sciences.

  84. jhawk says:

    SH,

    “So basically you are suggesting that you would use cervical spine manipulation if other therapies have failed. Tell me, how many times have you had a patient come into your chiropractic office complaining of neck pain, and you said “Ok, let’s give you this exercise video and we’ll teach you some exercises you can do at home. You can just pay me $5 for the video, and whatever my rate is for an initial consultation. Come back in two weeks and we’ll re-evaluate your pain then.” And when they come back multiple times over the next few months, how many times have yous said “Ok, I will refer you to a pain specialist, who can put you on chronic pain medication while we wait for this to heal. While we’re at it, keep trying to move your neck through a full range of motion.” And then, how many times have you said “Ok, well let me put tape randomly on your neck to see if that will trick your mind into healing the neck pain?” How many times have you exhausted the list of superior & safer therapy before initiating c-spine manipulation?”

    The vast majority of my patients have had their pain for at least 3 weeks, have already tried nsaids, ice and heat. Many have already consulted with an MD and many have seen PT’s as well. Quite a few have even undergone surgery and are still in pain. I give out cx exercises without adjusting the spine on a daily basis and do this much more commonly than cx spine adjusting. Almost never refer to chronic pain specialist but send out to orthopedists often and haven’t tried the tape thing.

    ” Study after study has demonstrated that the risk of cervical manipulation outweighs the benefit. Why not just accept this and move on? ”

    I have talked about this before with LB pain. I think many of the studies come to an equivocal conclusion because neck pain is not a diagnosis, it is a symptom. These patients need to be categorized by what is causing there neck pain (not saying this is easy) before a treatment is rendered.

    “I have another question. Where do SO MANY chiropractors get the idea that you can manipulate the c-spine and “cure” problems in the lower back, or cure any of a number of other diseases? It’s a pretty interesting phenomenon that SO MANY chiropractors all believe the same completely fake garbage (did you see the chiropractic gimmickery post?), and yet they believe they are educated in the sciences.”

    I am not sure. I don’t really see the neck effecting the LB clinically (any other chiro’s here see this?). I do see the foot effecting the knee and hip and vice versa a lot though. I have not seen the gimmickery post.

  85. jhawk says:

    SH,

    “So basically you are suggesting that you would use cervical spine manipulation if other therapies have failed. Tell me, how many times have you had a patient come into your chiropractic office complaining of neck pain, and you said “Ok, let’s give you this exercise video and we’ll teach you some exercises you can do at home. You can just pay me $5 for the video, and whatever my rate is for an initial consultation. Come back in two weeks and we’ll re-evaluate your pain then.” And when they come back multiple times over the next few months, how many times have yous said “Ok, I will refer you to a pain specialist, who can put you on chronic pain medication while we wait for this to heal. While we’re at it, keep trying to move your neck through a full range of motion.” And then, how many times have you said “Ok, well let me put tape randomly on your neck to see if that will trick your mind into healing the neck pain?” How many times have you exhausted the list of superior & safer therapy before initiating c-spine manipulation?”

    The vast majority of my patients have had their pain for at least 3 weeks, have already tried nsaids, ice and heat. Many have already consulted with an MD and many have seen PT’s as well. Quite a few have even undergone surgery and are still in pain. I give out cx exercises without adjusting the spine on a daily basis and do this much more commonly than cx spine adjusting. Almost never refer to chronic pain specialist but send out to orthopedists often and haven’t tried the tape thing.

    ” Study after study has demonstrated that the risk of cervical manipulation outweighs the benefit. Why not just accept this and move on? ”

    I have talked about this before with LB pain. I think many of the studies come to an equivocal conclusion because neck pain is not a diagnosis, it is a symptom. These patients need to be categorized by what is causing there neck pain (not saying this is easy) before a treatment is rendered.

    “I have another question. Where do SO MANY chiropractors get the idea that you can manipulate the c-spine and “cure” problems in the lower back, or cure any of a number of other diseases? It’s a pretty interesting phenomenon that SO MANY chiropractors all believe the same completely fake garbage (did you see the chiropractic gimmickery post?), and yet they believe they are educated in the sciences.”

    I am not sure. I don’t really see the neck effecting the LB clinically (any other chiro’s here see this?). I do see the foot effecting the knee and hip and vice versa a lot though. I have not seen the gimmickery post.

  86. ADJUSTING!?!?!?!?!?!?! ARGH! *MELTDOWN* WHAT ARE YOU ADJUSTING!?!?

  87. nwtk2007 says:

    HH – “As Pmoran pointed out, if neck manipulation were a drug it would not be on the market. A drug with that amount and quality of evidence for efficacy and safety would never have been approved”

    That is an interesting point. Given the risks of ibuprofen, and I doubt it saves lives, couldn’t the same argument be made? Or does it save lives? This is not a que quo what ever, just a simple question.

    And yes SH, I have been monitoring your transmissions.

  88. Harriet Hall says:

    @nwtk2007,

    No ibuprofen doesn’t save lives, and neither does neck manipulation. I don’t know why you even raise the question.

    Ibuprofen has been shown effective in relieving pain and inflammation, reducing fevers, and in other uses like treating patent ductus arteriosus. Its mechanism of action is known. The efficacy of neck manipulation has not been established for any indication.

    Ibuprofen was approved by the FDA after the usual phase I, II and III trials, and post-marketing studies have confirmed its efficacy and safety to the point that it was approved for OTC sale. You can’t seriously compare the amount and quality of evidence for ibuprofen to that for manipulation.

    The real point is the balance between risks and benefits. Ibuprofen is the safest of all the NSAIDs. It is sold with a package insert containing appropriate warnings. It would be safest to never use any treatment that might cause serious side effects, but a lot of people are willing to take the small risk of ibuprofen side effects to get the benefits it offers. Attitudes towards risk vary. If patients are informed that there is a small risk of stroke and no good evidence of efficacy for neck manipulation, they might still choose to try it. But those who offer it with false assurances of effectiveness and safety are unethical.

  89. marcus welby says:

    The apparent reason for so many chiropractors using neck manipulation to treat obviously unconnected ailments is some variety and combination of the following factors:
    1. They believe in the “hole in one” theory that all ailments are caused by the dysfunction they imagine to occur at the foramen magnum.
    2. They have little else to offer and charge for to someone with shoulder pain or coccyx pain, or bed wetting or ear infection, so they twist their neck.
    3. Some utilize high neck manipulation as the only treatment for virtually every “diagnosis”.

  90. I always find it *so* interesting how our resident chiropractors will chime in for certain things, but when asked a certain string of questions always just disappear. But then they’ll creep back to the forum with the same username, only to disappear again when asked a similar line of questioning. It’s always half-truths, no-truths, and obfuscation. The complete opposite of both medicine and science. Hope you’re all de-licensed. :)

  91. pmoran says:

    SH, I don’t think anyone comes here unless they wish to test out certain viewpoints. Anyone with purely fraudulent intent couldn’t care less what we think. We would also quickly identify the frankly deluded and ignore them.

    You simply cannot expect to change deeply entrenched beliefs overnight, especially while they are being constantly reinforced within their native tribal environment, and also by compelling patient responses. The evidence can sometimes be a little murky, also.

    Even frankly silly beliefs may thus have to be chipped away at over a very long time, and they may never be dislodged in our lifetimes. The question is: “Do insults help?”

  92. jhawk says:

    SH,

    “ADJUSTING!?!?!?!?!?!?! ARGH! *MELTDOWN* WHAT ARE YOU ADJUSTING!?!?’

    Adjusting, manipulation, mobilization are all pretty much the same thing. What am I adjusting….hypomobile joints.

    “I always find it *so* interesting how our resident chiropractors will chime in for certain things, but when asked a certain string of questions always just disappear. But then they’ll creep back to the forum with the same username, only to disappear again when asked a similar line of questioning. It’s always half-truths, no-truths, and obfuscation. The complete opposite of both medicine and science. Hope you’re all de-licensed.”

    Was this directed at me? I have answered all of your questions and you had no wothwhile response. Sorry if not in a timely fashion as I do have a life outside of SBM!

  93. rockies says:

    @windriven

    “I think we need to convince physicians to burn incense in their offices, serve waiting patients herbal teas with a twist of lemon and shake caduceus-inscribed marimbas while repeating incantations in a vaguely disturbing monotone.”

    Your comment about shaking a caduceus-inscribed MARIMBA is rather funny….a Marimba is a rather large version of xylophone which weighs approximately 75 pounds and would be interesting to see someone shake…

    Anyway, all the comments about quackopractors is rather a shame. Have any of you been to a chiropractor? I had been plagued with a constant low-level dizziness/vertigo for over 20 years and it had gotten to a point that I could not drive, work, or do anything other than sit like a lump in my chair. I had been to all the “normal” medical specialists you could possibly imagine all over the country and all I got was “we don’t know what’s wrong – here take this drug and let me know if it works” and nothing ever did. After going to a chiropractor, she adjusted me many times – OH, NO! with neck manipulation – and was able to make the spinning stop! And it hasn’t returned! Many professional athletes – football, basketball, tennis, golf, etc., get chiropractic adjustments. If it wasn’t doing any good, would they still go?

    And as others have said, if the vertebral artery has an inherent weakness, then couldn’t anything that twists the neck at an unusual angle such as looking up or to the side do this too? It seems to me that if the medical community stuck with only so-called safe and proven ideas and theories, then we wouldn’t move forward. What about all the drugs that have been scientifically studied yet have shown horrendous side-effects, even death, that have been accepted and people don’t think twice about taking because “my doctor said I could”. Common sense, logic and intitution will usually be appropriate guidance for most everyone. If you don’t want your body “adjusted” don’t go! But don’t damn them because you don’t believe in them. This is still a free country!

  94. Just a small update. Sandy Nette, a victim of chiropractic cervical manipulation, was awarded over $4,000,000 in her lawsuit. While the money should help pay her medical bills and make the rest of her life somewhat easier, this poor lady will never have her life back. It was ruined by a selfish chiropractor practicing absurd quackery. De-license these despicable quacks now before they hurt more people with their useless treatments.

    http://www.edmontonjournal.com/Woman+injured+chiropractor+gets+millions+settlement/7346971/story.html

    1. Harriet Hall says:

      There is more to the Sandy Nette story. The chiropractor admitted that he had forged Sandra’s name on a consent form after her stroke. This was a clearly criminal act, yet he is not being prosecuted. Ironically, the chiropractor is not currently practicing because he has shoulder pain that apparently chiropractic was unable to successfully treat.

  95. rwk says:

    They should De -license the quacks responsible for this:
    http://www.webmd.com/news/20121003/4-dead-tainted-spinal-steroids?src=NEWS

    How much do you pay a year for malpractice SH ?

    I don’t suppose you’ve ever harmed anyone though.

  96. I always appreciate that flawed argument from chiropractors and other such quacks. You simply cannot comprehend the risk of practicing legitimate medicine because the concept is completely foreign to you. You operate in a world where almost everything you do is of minimal consequence to your customer, and I operate in a world where almost everything I do is of maximal consequence to my patient’s life.

    By and large, if you perform any of your treatments incorrectly, your client would never know the difference, because most likely they will not improve except slowly over the natural course of whatever is causing their pain (unless of course you are doing cervical spine manipulations, in which case you should be put in jail.) If I make an equivalent mistake, people can die. Medicine is hard, and it’s based around taking calculated risks to save lives.

    To answer your question, in my years yes I have made mistakes, and anyone who says differently is lying. I have never permanently harmed anyone (knock on wood.) The difference between you and me is that I was treating someone with scientifically proven medicine for legitimate disorders that, in some cases, would have killed them within several weeks if not hospitalized. You, on the other hand, are treating people with ineffective and/or disproven methodologies for disorders that, while sometimes debilitating, are not life threatening and are more often than not self-limited and would improve without your quackery.

  97. rwk says:

    http://summaries.cochrane.org/CD001824/injection-therapy-for-subacute-and-chronic-low-back-pain

    Too bad the “Doctors” didn’t read this (especially the last bit) to the patients before injecting.

    They were practicing scientifically proved medicine weren’t they?
    They probably even said something like ” Oh,let’s try this,
    it might help you”.

  98. rwk says:

    no one here is defending that chiropractor. the shoulder bit is irrelevant though.

  99. Harriet Hall says:

    Why is the shoulder irrelevant? At least some chiropractors are still claiming that the body will heal itself if the spine is kept in optimal alignment. The fact that this chiropractor was providing preventive and maintenance adjustments to Sandra Nette shows that he was one of those rather than a reform chiropractor who provided manipulation for legitimate indications.

    Why did the chiropractic associations not speak out and call for him to be prosecuted for his criminal forgery?

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