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Chiropractic’s Pathetic Response to Stroke Concerns

The chiropractic industry must be feeling the pressure. Billboards, signs on the sides of buses, chiropractic victims’ organizations, and lawsuits are telling the world that chiropractic neck adjustments can cause strokes. The risk is very small, but it is very real. We have addressed the subject before on this blog here, here, and here.

Chiropractors are in denial and are trying to shift the blame elsewhere. A correspondent sent me copies of a pamphlet and a “distribution kit” that the FCER (Foundation for Chiropractic Education and Research) is selling to chiropractors so they can inform the public about cervical artery dissection (CAD). It is advertised as a campaign to help the public recognize warning signs of stroke; but in my opinion, it amounts to a cynical, self-serving ploy to divert attention away from neck manipulation and to spread biased information about the recent study in Spine by Cassidy et al.

Dr. Crislip has already eviscerated the Cassidy study so I will only describe it briefly here. It compared patients who had had a vertebral artery stroke to controls and looked at health billing records to see if they had visited a doctor or a chiropractor in the previous year. Patients with strokes were more likely than controls to have seen a provider but they were not more likely to have seen a chiropractor than to have seen a doctor before their hospitalization. They concluded “The increased risks of VBA [vertebrobasilar artery] stroke associated with chiropractic and PCP [primary care provider] visits is likely due to patients with headache and neck pain from VBA dissection seeking care before their stroke.” This is nothing but speculation and is not supported in any way by the data in the study.

The Cassidy study did not even try to determine whether patients who saw chiropractors had their necks manipulated. It was not designed to answer the real question: whether rapid thrust neck adjustments can cause strokes in patients who would not otherwise have strokes. The answer to that question is clearly “yes.” We have plenty of “smoking gun” case reports of patients who had no symptoms of stroke until their neck was rapidly manipulated by a chiropractor and who were subsequently found to have tears in the vertebral artery, often bilaterally. There is a plausible mechanism related to the anatomy and the way the artery is tethered between two bony restrictions and stretched by rotation/extension. When a healthy asymptomatic young person collapses on the chiropractor’s table immediately after a neck adjustment and is found to have torn arteries, there can be little doubt about what happened.

It is likely that chiropractic strokes are under-reported: Sandra Nette’s class action suit is being joined by victims who had not previously reported their experiences, and one of my neighbors recently had a mild stroke after a chiropractic neck adjustment and will never see a chiropractor again but he did not sue and his case was not reported in any medical journal. I don’t think he even went back to tell the chiropractor what had happened.

The FCER kit includes a patient template letter, an attorney template, an MD template, and a media release template designed to be personalized with the individual chiropractor’s name and printed on his letterhead and sent out with a copy of the pamphlet. They say the chiropractic profession [sic] is trying to reduce the incidence of stroke from treatment by educating practitioners and patients about the warning signs of CAD and that both medical and chiropractic treatment (spread the blame!) of neck and head pain “can make the problem worse” when those symptoms are present.

They are logically inconsistent: they say they are trying to reduce the incidence of stroke “from treatment,” but at the same time they are saying a vertebral artery dissection (essentially a stroke in progress) was already present before treatment and symptoms of head and neck pain from stroke were the reason patients sought treatment. They seem to be admitting that neck adjustments can cause strokes but at the same time they are implying that the beginnings of the stroke preceded the treatment, so the treatment isn’t really responsible.

The press release says

The research in the journal Spine, which showed that patients seeking inappropriate treatment for CAD – regardless of whether treatment was delivered by a medical or chiropractic doctor – were are [sic] at risk for stroke.”

This is a complete misrepresentation of the study, which did not differentiate between strokes due to CAD and strokes caused by other mechanisms, did not present any evidence that patients who sought care already had CAD, and did not even record what symptoms led patients to seek care or what treatments were given. And of course it couldn’t show that patients were “seeking inappropriate treatment.”

In an ideal world, Spine would issue a statement that their study was being mis-represented and mis-used. As the New England Journal of Medicine has done in the past.

The pamphlet has a handy table contrasting the symptoms of CAD, migraine, tension headache and neck pain. CAD is characterized not by head or neck pain, but by dizziness, double vision, difficulty swallowing, speaking or walking, intense nausea or vomiting, numbness and confusion. We have no way of knowing whether the patients in the Cassidy study had these symptoms or had CAD when they sought treatment.

If CAD was already present, but the patient only had head or neck pain without these neurologic symptoms, there would be no reason to suspect CAD and neither the patient nor the chiropractor would see any contraindication to neck manipulation. Manipulation could be expected to produce further tearing, bleeding, and completed stroke, and might well kill the patient. In the absence of neurologic symptoms, there is no reliable way to predict which patients are at risk of stroke.

If the usual neurologic symptoms of CAD were present, any health care provider should have been able to recognize the warning signs of an emergency and send the patient directly to a hospital rather than trying any outpatient treatments. Neck manipulation is clearly contraindicated in these cases. It is good to educate patients, but I don’t see any need for this campaign to “educate practitioners.” If there are chiropractors or MDs out there who can’t already recognize the warning signs of stroke, they should lose their licenses.

But what about the patients who present for care with no symptoms of CAD and without even complaining of head or neck pain? Stroke victims are clearly NOT just patients who went to a chiropractor with head or neck pain. Some were being treated for things like low back pain or shoulder pain. Some patients like Sandra Nette had no pain at all: she had a catastrophic stroke after neck manipulation done simply for health maintenance purposes. Laurie Jean Mathiason, a 20 year old woman, received 186 manipulations of her neck over a 6 month period when her original complaint was lower back pain. The 186th one killed her. 186 treatments in 6 months? I can’t help but ask: how many treatments does it take before you realize that they aren’t working?

The pamphlet resorts to the fallacious “death by medicine” tu quoque argument, saying that the risk associated with non-steroidal anti-inflammatory drugs (NSAIDs) is much greater than the risk of injury from neck adjustments. At least there is evidence that NSAIDs relieve pain; there is no evidence that neck adjustments relieve low back pain, shoulder pain or pain elsewhere in the body that is commonly treated with neck adjustments. There is no evidence that neck adjustments maintain health. There is evidence that neck adjustments relieve certain types of neck and head pain, but there is no evidence that the presumably more dangerous rapid thrusts are any more effective than gentle mobilization methods.

Their own arguments undermine their position. The pamphlet says the risk of stroke with neck adjustments is estimated at anywhere from one in 4 million to one in 400,000, and it also says “ANY risk of injury is too big” – so isn’t that a reason to avoid neck adjustment entirely? And it says providers should choose “the treatment that is likely to provide the greatest benefit compared to risk.” Since chiropractic has not given us any evidence that rapid thrust neck adjustments offer any significant benefit, doesn’t that rule them out as a viable option?

They list all the other factors that have been associated with CAD, such as hanging out the laundry, sitting in a barber’s chair, turning the neck while driving, Tai Chi, watching aircraft… anything that extends and rotates the neck. The unspoken implication is that the stroke would have happened anyway even if the patient hadn’t seen a chiropractor, and that chiropractic manipulation is no more traumatic than watching airplanes. That’s clearly wrong, because more force is exerted when a chiropractor rapidly twists a relaxed neck than when someone extends his own neck to look at the sky. When someone turns his neck himself, his muscles actively stabilize the neck and protect it from injury.

If chiropractors really wanted to understand the risks and minimize them, here’s what they could do. They could establish a database of every patient who received neck manipulations, listing their presenting symptoms, specifying exactly which type of neck manipulations were done, and following each patient up with phone calls to determine whether symptoms of stroke had developed after treatment. That would (1) establish the true incidence of stroke following neck adjustments, (2) determine whether strokes were more common with certain specific types of adjustments, and (3) determine whether patients were seeking “inappropriate” care for pre-existing symptoms of CAD. This could be done at little expense and would answer clinically significant questions.

This FCER public information campaign is a disgrace. It misinterprets the Cassidy study and it fails to address the real issues. It’s marketing, not public service. And it’s not science. If chiropractors really want to reduce the risk of stroke, this is not the way to go about it. I can only echo Eeyore from Winnie the Pooh, “Pathetic,” he said. “That’s what it is. Pathetic.”

Addendum: Coincidentally, just as I was writing this I received this e-mail anecdote from a reader: “I had been physically assaulted several days earlier and just wanted to be looked over. I wasn’t in any pain, no physical problems whatsoever, just a cut on my head… The chiropractor twisted my neck really hard, and for a whole year now I’ve been having neck pains on a daily basis.” Not a stroke, but an example of a patient who had NO symptoms before neck adjustment and who had them afterward. Whether or not you believe the treatment caused his chronic neck pain, it is clear that there was NO indication for neck manipulation in this patient. Even if the risk is less than one in 4 million, what benefit would have justified the risk for this patient?

Posted in: Chiropractic

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99 thoughts on “Chiropractic’s Pathetic Response to Stroke Concerns

  1. hatch_xanadu says:

    Unfortunately, since one mustn’t assume association = causation, it’s those “smoking gun” cases that most dramatically and reliably illustrate the risks. (I wouldn’t go so far as to say it’s a “good thing” we have those cases, since there are serious injuries and deaths involved, but they do give us an obvious starting point.) Many of the other examples you cite are, of course, anecdotal and not reliable.

    The authors of the Cassidy study were most certainly “fishing” in their conclusion. But any study in such a vague population, and with so many factors at play, would be inconclusive at best. Speculation wouldn’t have a place in that sort of study. Maybe a better study would closely examine the physiology of those “smoking gun” cases and work backward?

    Your recommendations for a chiropractic database are excellent. And maintaining such a database would benefit patients receiving chiropractic manipulations of *all* kinds — and begin to address, concretely, whether chiropractic is “working” at all. I suppose that’s the scary part.

  2. hatch_xanadu says:

    And this, from the FCER pamphlet ad, concerns me: “Current research finds no difference between chiropractic care and medical care and the risk of stroke”.

    What does that mean?

  3. Joe says:

    Bilateral artery dissection is chiropractic’s unique gift to humanity.

    The chiro fan magazine “Dynamic Chiropractic” had a recent article titled “Chiropractors Eating Their Own.”
    http://www.chiroweb.com/archives/26/02/11.html
    The author bemoans the fact that some chiros are now advertising “Spinal correction without twisting or popping the neck.” He thinks this emphasis on safety makes their industry look bad(!?).

  4. Canucklehead says:

    As a PT I am regularly required to ‘clean up’ after chiropractic manipulations; clients having neck manipulations and then suffering neck problems for a long time afterwards (one client had neck pains for 2+ years after manipulation and he only went in for a quick check up). I fail to see how neck manipulation can be considered an acceptable treatment for hip or back pain.
    I always tell clients if you have three or four treatments and your problem doesn’t improve significantly it’s time to look elsewhere, this goes for PT, Chiro, Massage and the rest of the Woo world. I also advocate that they absolutely avoid neck manipulation by any practitioner!

  5. Blue Wode says:

    Harriet Hall wrote: “If chiropractors really wanted to understand the risks and minimize them, here’s what they could do. They could establish a database of every patient who received neck manipulations…”

    Four years ago, the UK chiropractic regulatory body, the General Chiropractic Council (GCC), told the UK-based group, Action for Victims of Chiropractic (AVC), that it understood that the British Chiropractic Association (BCA) was implementing a database to which the patients could report any adverse events they might experience following treatment. See the letter that the GCC sent to the group in AVC’s August 2005 news item here:
    http://www.chirovictims.org.uk/victims/news.html

    The following month, in response to a news story in Nature entitled “Survey questions safety of alternative medicine” (Nature 436, 898; 200510.1038/436898b) which quoted Edzard Ernst as saying that complementary and alternative medicine (CAM) organisations were not doing enough to monitor adverse reactions, a representative of the BCA, Barry Lewis, responded by saying that, in tandem with the Anglo European Chiropractic College, the BCA had set up a “chiropractic reporting and learning system” and went on to say the following:

    Quote:
    “More than 1,200 practitioners who are members of the BCA have recently received an information pack to enable them to participate in the scheme. Resulting data will be analysed at the Anglo-European Chiropractic College and outcomes will be relayed to the profession, through our newsletter, journal and website, so practitioners may learn from the experience of others. The intention is that the scheme will, if successful, be offered to other chiropractic associations within Europe in 2006.”

    http://www.nature.com/nature/journal/v437/n7058/full/437476d.html

    There appears to have been a deafening silence on the matter ever since.

  6. Joe says:

    This is interesting- LifeWest (chiro school) has posted notes on vertebral artery dissection (VAD) (which can lead to stroke).
    http://www.lifewest.edu/classnotes/hipaa/vad81502.shtml
    Read down, and you’ll see they list chiro as a cause of VAD. Most chiros have been denying any such connection and/or claiming it is so rare as to be inconsequential. One can only hope the school tells it students to absolutely stop cracking people’s necks.

  7. pmoran says:

    “One can only hope the school tells it students to absolutely stop cracking people’s necks.”

    It is obviously difficult enough as it is for chiropractic respond rationally and coherently to the stroke problem, so let’s not go too far.

    We do not have enough evidence to be able to say that neck manipulation is futile and unsafe endeavor under all circumstances. We do have enough to say that, if used at all, it should be a relatively late resort for fully informed patients who have one or two distressing conditions that have not responded to safer treatments.

  8. David Gorski says:

    We do not have enough evidence to be able to say that neck manipulation is futile and unsafe endeavor under all circumstances.

    A statement of similar accuracy:

    We do not have enough evidence to be able to say that vaccines do not cause autism under all circumstances.

    I fear that some antivaxer will quote mine me when they see this, but the above is, strictly speaking, a true statement. Does that mean we should accept the claim that vaccines cause autism? Of course not. We have considerable evidence from large, well-designed trials, all of which have failed to find a link between vaccines and autism. If there is a risk, it is incredibly tiny.

    In terms of chiropractic, we have lots of evidence that cracking people’s necks does them no good. We also have pretty good evidence that in some people it carries a not inconsequential risk of stroke. However, as you say, we cannot prove that “under all circumstances” chiropractic manipulation of the neck is of no benefit. However, we can say that, if there are circumstances in which it might benefit, they are pretty darned limited–rather like how we can say that if vaccines do contribute to autism it must be sufficiently rare as not to be detectable in all the large studies done. The difference, of course, is that, even if that tiny risk of autism from vaccines existed, the benefits of vaccines are real and tangible. They are quantifiable. Not so chiropractic manipulation of the neck.

  9. khan says:

    I went to a chiropractor for lower back pain back in 2000 (the doctor at the clinic recommended such).

    It seemed that he did help with the back pain. But he always wanted to suggest neck adjustments and ongoing adjustments and posters in his office suggested chiropractic for migraines and colic…

  10. Harriet Hall says:

    I think we can clearly say, based on the evidence, that
    (1) So-called preventive maintenance adjustments are not indicated.
    (2) Neck adjustments do not benefit any condition below the neck.
    (3) Neck adjustments do benefit cerrtain head and neck pain conditions, but the rapid adjustments are not more effective than gentle mobilization.

    It would be prudent to avoid neck adjustments except for gentle mobilization techniques for head and neck pain only. A few rational chiropactors do just that.

    I submit that if chiropractic were a product sold by Big Pharma, there would be a huge public demand for just such limitations, if not for complete removal of the product from the market. I suspect that if a similar risk were associated with a surgical procedure, surgeons would already be busy studyiing it and trying to reduce the risk rather than trying to deny it and deflect attention. But then, I doubt if surgeons would be doing the procedure in the first place if they didn’t have better evidence of effectiveness.

  11. Skip says:

    As an Osteopathic Medical Student my first thought was concerning the technique used for the neck manipulation. In our ‘literature’ we are often told… and told in big red flashing words… never to do particular “High Velocity/Low-Amplitude” (HVLA) techniques because of CAD risk.

    I wonder if there is any difference between the manipulative techniques between what a Chiro is taught and an Osteopath. We are indoctrinated daily in Manipulative Medicine despite the lack of evidence. We are told how much ‘better’ we are over the allopathic physicians. Maybe one day we’ll receive a little Red book when our re-education is complete.

    I think it would be interesting to compare the different manipulative techniques used by Chiropractors, Osteopathic Physicians and Physical Therapists.

  12. pmoran says:

    I agree with everything you say Harriet, except that chiropractors have an additional bind: the gentler the neck “mobilisation”, the less likely it is that it actually does anything. The same applies to the dinky little gadgets that they use to supposedly “adjust” spines.

  13. Harriet Hall says:

    Peter,

    Gentle mobilization does just as much as less gentle manipulations. A Cochrane review which I cited in a previous post concluded “Mobilization and/or manipulation when used with exercise are beneficial for persistent mechanical neck disorders with or without headache. Done alone, manipulation and/or mobilization were not beneficial; when compared to one another, neither was superior.”

  14. Karl Withakay says:

    It’s interesting to note, that so many conspiracy minded alt-med wooists claim that “allopathic” medicine is more concerned about profit that patient welfare, and since there’s more money in a treatment than there is in a cure, Big Pharma and the Cancer Industry don’t want to find cures for various diseases and cancer, just profitable long term treatment.

    It’s interesting to note, because it seems many, if not most, chiropractors are all about long term maintenance and regular visits to the chiropractor’s office for “preventative maintenance” and regular adjustments, even if the patient does not have any problems anymore. Chiropractic seems like it is as big a racket as there is out there in the alternative to medicine world.

    I’ve gone to an MD and had them tell me everything was OK, and I didn’t need any medication, treatment, or tests numerous times; how many people have ever gone to a chiropractor and had the “doctor” tell them they were fine, there was nothing to worry about, and they didn’t need any kind of adjustment?

  15. DBR says:

    Wow this is interesting. I saw a chiro when I was pregnant to help with some major hip pain – it sure seemed to help, but strangely enough he did neck adjustments too. Well one day he was very busy and running late, so I agreed to see another chiro in the office. New chiro was quite young and didn’t really seem to know what he was doing……. and he did my neck as well (I actually thought about telling him no, but I did not – foolish!) Well when he adjusted my neck it hurt like hell! I became dizzy and started crying. I was so scared. But – the best part – you know what they told me??? When the C1 vertebrae is adjusted, it can release emotional pain – that is why I was so upset. Nope, it wasn’t a bad adjustment, it was just my inner turmoil finally being released. Mmmhmmm.

    Well senior chiro then made time to see me and said the young’un had neglected to also adjust my C2 vertebrae which explained the pain – and he too said it was probably an emotional release. I made it clear that I really had no inner demons clamoring to be set free, but I’m sure they all chalked my reaction up to being a hysterical pregnant woman.

    Anyway my experience isn’t the kind of thing that gets reported, but I wonder how many other “emotional releases” happen every day in chiro offices.

  16. Joe says:

    @Skip,

    You might like this (42 min.) video http://ph-ms.ouhsc.edu/ah/rehab/kinsinger.wmv In it, doctor Kinsinger argues that PTs don’t cause strokes because they are more selective about providing neck manipulation (as well as less brutal). Some chiros only snap necks (NUCCA). There is other, published evidence that PTs are safer http://www.ptjournal.org/cgi/content/full/79/1/50

    A comparison of PT, DO and DC manipulations (that you suggest) while interesting, is problematic. According to TF Bergman, D.C. (former editor of “Chiropractic Technique”): “[T]here is no known basis in fact for chiro practices, and a chiropractic group counts 100 of these practices.” [Advances in Chiropractic vol. 2, DJ Lawrence, ed. (Mosby, 1996)] In other words, it is difficult to say what a “typical” chiro actually does. Harriet Hall even wrote about one who did neck manipulation without actual manipulation of the neck! http://www.sciencebasedmedicine.org/?p=3

  17. Harriet Hall says:

    DBR,

    Your story is frightening. Is it possible that the neck manipulation caused a small tear in your vertebral artery that healed without actually causing a stroke? Is there any other plausible explanation for the pain and dizziness? You may have had a lucky escape.
    Events like this do not get reported – one wonders how often they occur. And one can guess why chiropractors are not interested in keeping statistics and finding out.

  18. Joe says:

    Adverse effects in chiro have been estimated “[A]bout 50% of the patients experienced mild and transient adverse effects (e.g., local discomfort, headache, tiredness and radiating discomfort) after the procedure. ” http://www.cmaj.ca/cgi/content/full/166/1/40

  19. Karl Withakay says:

    Harriet, RE DBR: I am not a doctor, nor am I not terrible familiar with internal anatomy, so I don’t know how plausible this is, but is there anyway the vertebral artery could have become momentarily “kinked”, temporarily interrupting the flow of blood without actually tearing?

  20. pmoran says:

    Harriet: “Gentle mobilization does just as much as less gentle manipulations. A Cochrane review which I cited in a previous post concluded “Mobilization and/or manipulation when used with exercise are beneficial for persistent mechanical neck disorders with or without headache. Done alone, manipulation and/or mobilization were not beneficial; when compared to one another, neither was superior.””

    Well, maybe. But do you you not yourself suspect that such studies are measuring mainly background noise, especially the extent to which placebo responses are leaking past the controls?

  21. Harriet Hall says:

    Karl,
    The artery is kinked when the neck is turned. See the picture at http://www.sciencebasedmedicine.org/?p=94 I don’t know whether it’s possible that it could temporarily interrupt blood flow, but if it did happen I would think as soon as the kinking was relieved the symptoms would disappear, so the patient would complain of symptoms during but not afterwards. And it would still qualify as an adverse effect of neck manipulation.

    pmoran,
    I suspect all such studies. By their nature, they can’t be double blinded, and they are subject to several possible sources of error. I have not seen any convincing replicated high quality evidence that neck manipulations benefit any condition.

  22. Skip says:

    Joe,

    Thank you very much for your response, I’ll go through the material you suggested early next week. As I am currently being taught manipulation, I’m very interested in what the PT literature says… that assumes of course, that the PT literature is more robust than the DC or the DO literature.

    -Skip

  23. Karl Withakay says:

    Thanks for the clarification, Harriet.

    I don’t have much respect for chiropracty anyway, but the violent neck manipulation never seemed like a good idea to me even before I heard of the stroke possibility.

    I honestly wonder which has a higher probability, winning the lottery or vertebral artery stroke from chiropractic manipulation.

    Cognitive dissonance is an interesting phenomenon.

  24. user9999 says:

    It seems like the only people that are actually responding on these forums are PTs or PT students (who for some reason think that chiropractors want their jobs… which BTW, we know what you do is important, but we don’t want to do it!) and naive lay-people who got convinced somewhere along the way that chiropractors (and not the super-sized meals and lack of exercise) caused their pain or strokes.

    First off, for God sakes… we’re in 2009 now. Chiropractic isn’t disputed in the literature or some kind of pseudo-science… The ones that are disputing it still are doing so with an agenda…. biased, dogmatic people who aren’t recognising the best interest of the patients. I’m in chiropractic school and many of us (myself included) went to very elite undergrad universities and can out-diagnose a great number of med-students hands down when dealing with arthritide or neurologic disorders. We didn’t get rejected from med school, but actually CHOSE chiropractic school. Crazy, huh?

    Yes, there are some old school docs out there who are preaching that chiropractors can be an end-all to any disease, but the ones in school now are very highly trained students (at my school anyways).

    We’ve got research programs with Mass. General Hospital working with Harvard and BU on acupuncture studies and working with WashU in St. Louis on pregnancy studies (involving chiropractic vs allopathic treatments) and getting fantastic results. I don’t know if it’s ignorance or some personal vendetta against chiropractors, but to the ones who are up to date on the research, the people in these forums just sound either ignorant or idiotic.

    The first patient I ever saw was a 23 year old college student who had headaches and neck pain since elementary school. Her headaches were a 8 or 9/10 on a numerical pain scale and the neck pain was a 6 or 7 at least once a week. It was milder pain on a daily basis and severely affecting her entire quality of life. I presented her with a thorough B.R.A. and obtained I.C. After 2 weeks of HVLA cervical adjustments, she was headache free and 90% neck-pain free. For those who say that isn’t worth a 1:400,000 or 1:10,000,000 chance… whatever it actually is… risk of alleged chiropractor-induced stroke, I’d say tell her that and have her going back to her excruciating pain. Prescription meds and surgery are SOOO much more risky than chiropractic adjustments (which is why we pay less than $1000 per year for malpractice). We know how to rule out high-risk populations for stroke, and whether or not there is actually a correlation, we don’t use HVLA on them. And the people who think PTs and DOs are more suited to perform manipulations just make me laugh. We have 9 straight semesters of graduate school doing manipulation and literally hundreds of hours more practice. It may be easy to get into the chiropractic schools, but it’s far from easy to actually finish! It’s ridiculous to think that anyone out there is better than chiropractors in relation to manipulative therapy.

    We all have our place. The rehab needs done, that’s why we have PTs… the ER, prescription, and surgical work needs done, so we have DOs and MDs. The conservative musculoskeletal stuff… leave it to the chiros and we’ll all be better off.

  25. nwtk2007 says:

    user9999,

    I think you will find that the biased anti-chiro groups have a great deal of difficulty objectively speaking about chiropractic.

    You are correct in your assessment about the current state of chiropractic and PT. PT’s are not much more trained to do PT than the average massage therapist. OK, a bit more, but not much.

    In Texas they are pushing for rights to see patient’s without referral. Can you imagine? Being responsible for diagnosing with the training they receive?

    I mean I like’em alright. I work with one and have worked with several over the years. But what they do in terms of musculoskeletal conditions is very limited and I have never in my life met a more territorial, defensive group of people. They know in their hearts they lack training to manage patient care, but they push for it because they are totally dependent on referrals from doctors, at least in Texas.

    But trust me, these biased guys here will not listen. If they respond at all, it will be with the same ad hominem attacks that they claim chiro’s use. That said, maybe they won’t, this time.

  26. Harriet Hall says:

    Our chiropractor commenters are proud of what they do and can present lots of anecdotes, but so could medieval bloodletters. This is a science-based medicine forum, and as I showed in a previous post, chiropractic is not a science. It is based on a myth. Its practitioners have happened on a few useful tricks to help a minority of patients with musculoskeletal pain but their ministrations have not been demonstrated to have better outcomes than conventional treatments. An unbiased scientist, Edzard Ernst, a professor of complementary medicine, reviewed all the published literature and concluded that “Chiropractors, on the other hand, might compete with physiotherapists in terms of treating some back problems, but all their other claims are beyond belief and can carry a range of significant risks.” A number of rational chiropractors have seen the light and have given up HVLA methods or have left the “profession” or have harshly critiqued chiropractic as Samuel Homola did in his book “Inside Chiropractic.”

    “We know how to rule out high-risk populations for stroke” Even if you do, that’s not enough, since most of the “smoking gun” incidents are in young, healthy, low-risk patients. The chiropractic literature itself has addressed the problem of not having a reliable way to predict who is really at risk of a stroke from neck manipulation.

    Posts like yours do nothing to convince us. We require high-quality evidence, not stories about HVLA neck manipulations helping one patient who didn’t have a stroke. We had plenty of that kind of evidence for bloodletting, even though it did more harm than good. Every quack peddler of snake oil has that kind of anecdotes and claims. If we had the same kind of evidence for the efficacy of chiropractic as we do for the efficacy of antibiotics, there would be no controversy.

    If chiropractic wants to re-invent itself as the expert for conservative care of back and other musculoskeletal complaints, it will have to weed out the mythology, the pseudoscience, the anti-vaccine propaganda, the applied kinesiology, and all the other baggage. On the Quackwatch healthfraud discussion list, Stephen Perle claimed he and others were working to reform chiropactic from within. I would welcome that, but I don’t see it happening.

  27. Joe says:

    @user9999,

    Why do you resort to anecdote? Is it because there is no definitive research backing your claim (implying that the HVLA cervical adjustment is more effective than safer treatments)? Keep in mind that publications in quack magazines (e.g., JMPT) compare, unfavorably, to high-school science-fair reports. I don’t look at them any more. Do not succumb to the notion that science journals “automaticallyreject” chiro research. That is not true, some papers are deemed acceptable; that does not mean they are right. No peer-reviewed publication is engraved in granite.

    Given that the Association of Chiro Colleges says that the [chiro] subluxation is central to chiro practice http://www.chirocolleges.org/paradigm_scopet.html and the fact that said subluxation does not exist, all the time you spend learning about it is wasted. The Innate Intelligence does not exist, either. However, since it was invoked by Palmer it cannot be discarded; cults (such as chiro) cannot deny their founder’s notions, no matter how absurd.

    You also wrote “I’m in chiropractic school … and can out-diagnose a great number of med-students hands down when dealing with arthritide or neurologic disorders.” Where is the evidence for that??

    If true, is it significant? When doctors finish post-grad training in those subjects, they are better educated than chiros. You need to consider the practicing individual.

    Do you believe you can cure deafness by adjusting someone’s back, or that Palmer did?

    You should go to http://www.quackwatch.org or http://www.chirobase.org and educate yourself. Or, if you can, tell us how any particular article found there is wrong (with citations to legitimate literature, not mere argument). I warn you, nobody who has ever assured me they would do so has ever returned from that mission.

  28. nwtk2007 says:

    You see user9999, they even admit that they will not read or consider chiropractic research. A look back at the previous threads here will show that Joe refuted a study and later admitted he did not read it.

    They also insist on using the broad brush on chiropractic and lump us all into the group that claims to cure cancer, etc. thru manipulation of the spine.

    Joe suggests that you go to chirobase and quackwatch. I would encourage you to do so and also go to Truth in Treatment, Drvertebrae’s blog and get a link to another forum for addressing these anti-chiropractic claims.

    The link is

    http://speakchirotalk.21.forumer.com/login.php?redirect=privmsg.php&folder=inbox&sid=dab11373b079739ae7fd989971d2c799

    and for Truth in Treatment

    http://truthintreatment.blogspot.com/.

    Just for the record, you will notice Dr Hall’s anecdotal story about “a reader” who was “injured” by the chiropractor. Quite naturally and being thoroughly biased, there is no question of the validity of this “reader’s” story by Dr Hall.

  29. Harriet Hall says:

    I have read and considered a great deal of chiropractic research, and I have been appalled by the poor quality. I can elaborate if need be.

    I didn’t think anyone claimed to cure cancer by manipulating the spine. According to the chiropractic literature I have read, they don’t claim to cure anything. They only claim to restore the normal alignment of the spine to allow normal nerve function so Innate can return the body to health. A chiropractor’s ad in my local paper today attributes carpal tunnel syndrome to “nerve compression in the neck that blocks the flow of necessary cellular material to the end of the nerve in the wrist.” (!?)

    For the record, I did question the validity of my anecdote to the extent of saying that even if you didn’t believe the manipulation caused the symptoms, it was an example of a treatment done without a valid indication. I have heard many similar stories, and I have no reason to think the patients are all lying, any more than I have reason to think user9999 was lying about his patient.

  30. user9999 says:

    Joe,

    You use http://www.quackwatch.org and http://www.chirobase.org as credible sources, but deny reputable peer reviewed journals such as JMPT or Spine for their research. That, my friend, is quackery. Most of the stuff on those sites is 10 years old anyways. The journals have a vast amount of literature supporting HVLA for mechanical pain syndromes and a number that show their effectiveness over mobilization. Even though I’m sure you won’t read them, I’ll point you to some. You’ll have to google them because it would be too long to list the summary for each of them.

    1. Response of lumbar paraspinal muscles spindles is greater to spinal manipulative loading compared with slower loading under length control.

    Pickar JG, Sung PS, Kang YM, Ge W.

    Spine J. 2007 Sep-Oct;7(5):583-95. Epub 2007 Jan 10.

    2). Immediate effects on neck pain and active range of motion after a single cervical high-velocity low-amplitude manipulation in subjects presenting with mechanical neck pain: a randomized controlled trial.

    Martínez-Segura R, Fernández-de-las-Peñas C, Ruiz-Sáez M, López-Jiménez C, Rodríguez-Blanco C.

    J Manipulative Physiol Ther. 2006 Sep;29(7):511-7.

    3. Immediate effects on pressure pain threshold following a single cervical spine manipulation in healthy subjects.

    Fernández-de-las-Peñas C, Pérez-de-Heredia M, Brea-Rivero M, Miangolarra-Page JC.

    J Orthop Sports Phys Ther. 2007 Jun;37(6):325-9.

    4. Paraspinal muscle spindle responses to the duration of a spinal manipulation under force control.

    Pickar JG, Kang YM.

    J Manipulative Physiol Ther. 2006 Jan;29(1):22-31.

    Also, you obviously didn’t hear what I said about the old school docs vs the newer graduates. I don’t knock doctors that use the word “subluxation” because whatever their paradigm, they are helping patients. I’ll take conservative treatment any day if it can help a patient avoid having their spine cut. I don’t use the word, subluxation because I choose to address problems in terms of adhesions, fixations, faulty biomechanics, and aberrant joint motion. This is where the current literature is at and in my opinion, it is the best way to address the problems. Please stop labeling all of us with the “pinched nerve” or “bone out of place” models.
    (There is, however, an accepted mechanism out there known as “neurogenic inflammation” which could possibly explain some of the visceral relief through the afferentation model and shed some light on some of the outlandish claims that some chiropractors present. Pretty fascinating stuff actually and all evidence-based!)

    You asked about the out-diagnosing med-students and I’m afraid I was misunderstood. I only state this because of the frequent misconception that chiropractic students are inadequately trained. I’ve got a number of friends who are students and graduates from medical school and we’ll troubleshoot cases together from time to time. When necessary, I have to give them advice on a diagnosis or treatment. I wasn’t saying this to brag or downplay their education. It is very rigorous and the residency is something we lack and therefore must make up through clinical experience in the first few years following graduation. I was just stating that we’ve got very similar educational backgrounds. PTs have far less training so I don’t really see the need to mention them in the same genre of education. I’m sure it is demanding as well, but I’d compare that to my masters degree in sports science and rehab. It’s not on the same level as the D.C. degree. It just doesn’t come close when we talk about classroom and clinic hours.

    Whether or not you think I made up the case about my patient doesn’t matter. This is just something I thought I’d share as I’ve seen, clinically, that HVLA can be very beneficial for certain people. It is a true story and for the record, I did mobilization on the first visit along with some muscle work (because the school forbids us to adjust on the first visit before we establish the diagnosis and treatment plan) and there wasn’t much change. The second visit, within 10 minutes of adjusting her with HVLA, her headache was gone. This whole forum is based on anecdotes, so I’m going to let my patient’s experience be heard in addition to all the stuff flying around here.

    Now I can see why there aren’t more chiropractic fans commenting on here though. There is no way to win when people who claim to be science based only look at the evidence supporting their case! My post probably will only be half-read or misinterpreted again, but I don’t really care. It’s not worth the time to debate people who have no intention of investigating new literature. It just made me feel better to at least try and present some knowledge of actual evidence-based care .

  31. Harriet Hall says:

    When citing studies, it is bad form to only cherry pick those that support your point of view. And systematic reviews of clinical outcomes trump reports of muscle spindle responses. You didn’t mention these:

    http://www.ajph.org/cgi/reprint/92/10/1634.pdf
    This study showed that manipulation was not superior to mobilization.

    http://www.ncbi.nlm.nih.gov/pubmed/15247576 This was a Cochrane systematic review that concluded “Mobilization and/or manipulation when used with exercise are beneficial for persistent mechanical neck disorders with or without headache. Done alone, manipulation and/or mobilization were not beneficial; when compared to one another, neither was superior.”

  32. nwtk2007 says:

    I don’t suppose YOU are cherry picking are you Dr Hall?

    I haven’t seen anyone here list the studies just listed by user9999 in the last year or so.

  33. user9999 says:

    “http://www.ajph.org/cgi/reprint/92/10/1634.pdf
    This study showed that manipulation was not superior to mobilization.”

    Did you forget to mention the concluding statements of that study?

    “manipulation may be more effective than mobilization for specific clinical indications. Future studies should be designed and conducted to help identify such patient subgroups.”

    I agree completely.

    “http://www.ncbi.nlm.nih.gov/pubmed/15247576 This was a Cochrane systematic review that concluded “Mobilization and/or manipulation when used with exercise are beneficial for persistent mechanical neck disorders with or without headache. Done alone, manipulation and/or mobilization were not beneficial; when compared to one another, neither was superior.””

    I agree. I always prescribe exercises to my patients to balance muscle pull and strength. The fact still remains that mobilization has not been shown to be more effective than manipulation, but numerous sources have shown manipulation to be more effective in a number of specific clinical presentations (some that I cited above).

  34. Harriet Hall says:

    Of the 4 studies listed by user9999, two were lab studies in cats, one measured pain sensitivity over the lateral epicondyle of the elbow in 15 asymptomatic patients. Only one was a study of patients with neck pain. It compared immediate effects on pain of a single manipulation or mobilization treatment – it did not assess clinical outcomes.

    I am not impressed.

    No, I didn’t “forget” to mention those concluding statements: I omitted them on purpose because they are not part of the conclusion from the study but are mere speculation by the authors.

  35. wertys says:

    @user9999

    The fact remains that chiropractors, whether new or old are not doing science, because they believe that they already know the answers. Despite the many claims to be ‘evidence-based’ you don’t have to look too far to find unsupported or disproven claims being made for chiropractic techniques.

    If one started with the hypothesis that by performing certain manipulative technques you were improving neck pain symptoms, and then designed a study to carefully exclude all possible biases, including those of the person conducting the study, and also put forward findings which would falsify the hypothesis, you would be doing science.

    If chiropractors changed their practice along the lines of what well-conducted studies show, they would be doing science.

    If they accepted ideas based on evidence, not ideology, they would be doing science.

    If you decided that the education you are so proud of taught you that many treatments are proposed but most fail to pass muster in clinical practice, you’d be thinking scientifically.

    If you start doing studies you think you know the answer to, and only ever find what you expect, you aren’t doing science anymore.

    If you don’t like the term ‘subluxation’ and never use it, then you are at odds with your senior colleagues, who firmly hold that they exist and should be treated. If you consider yourself well-versed in ‘sports science and rehab’ you might be interested to find out that although it might have been taught and supervised by chiros, the research that underpins it and the knowledge you are picking up was almost certainly NOT generated by chiros, but by real scientists, who do real science.

    If you want to talk the science-based talk, you have to walk the walk. Science criticises, challenges and only gives provisional, grudging acknowledgement. Pseudoscience is nicer because you don’t have to change your thinking when faced by the real world.

  36. user9999 says:

    Wertys,

    I actually wrote you a lengthy response, but as I looked back at what you wrote, I decided you didn’t have one actual thing of substance to say. It was all just biased opinions, so I have no reason to even bother with you. I’ll just say that I’ve had a number of the same professors that teach at WashU med school and St. Louis college of pharmacy in my chiropractic curriculum, so go ahead and attack the education we receive.

    Harriet,

    Nothing you said actually takes away from the credibility of those studies. They’re legitimate studies published in peer-reviewed journals. I guess you’re just trying to downplay them. Did you actually read them? There is some pretty valuable information we can take from them.

    You also said “Only one was a study of patients with neck pain. It compared immediate effects on pain of a single manipulation or mobilization treatment – it did not assess clinical outcomes.”

    Last I checked, pain is a clinical outcome assessment tool… A pretty valuable one for patients and insurance billing anyways.

    For some reason, I get the impression I’ve wasted a lot of my time by responding to posts on this thread. Everyone is still scraping the bottom of the barrel in attempts to legitimately call DCs quacks, despite the current state of the profession and the numerous physicians who readily refer to and seek treatment from DCs themselves. Disappointing.

  37. Harriet Hall says:

    I didn’t say the studies weren’t credible; I said I wasn’t impressed. By clinical outcomes, I meant what we call POEMS – Patient Oriented Evidence that Matters. Saying they felt less pain immediately after treatment is a data point, not an outcome. It doesn’t tell us how they felt the next day or the next week, and it doesn’t tell us if the eventual outcome was better than it would have been without any treatment.

    If I were recommending a new drug and all I could cite were studies showing that it lowers cholesterol in cats or in people with normal cholesterol, I doubt if you would be impressed. You would want to know whether the drug reduces the incidence of heart attacks or deaths in patients with high cholesterol levels. You would also want to know what side effects it had. You would want to know the risk/benefit ratio. You would want to know how it compared to other treatment options. You would demand high quality evidence for a drug treatment, but you are quite willing to accept lower standards for chiropractic treatments.

    “the numerous physicians who readily refer to and seek treatment from DCs themselves” ?? Now who’s scraping the bottom of the barrel? You can’t prove your points with evidence, so you have descended to using the argument from popularity, a logical fallacy.

  38. Joe says:

    user9999 on 17 Feb 2009 at 9:06 pm wrote “You use http://www.quackwatch.org and http://www.chirobase.org as credible sources, but deny reputable peer reviewed journals such as JMPT or Spine for their research.”

    JMPT is refereed by quacks, so the evaluations are not reputable; the “peer review” is a sham. If you think chirobase is not credible, choose an article and show us the mistakes. In the meantime, I will take it that you cannot provide any definitive clinical research to support your work.

    user9999 “Also, you obviously didn’t hear what I said about the old school docs vs the newer graduates. I don’t knock doctors that use the word “subluxation” because whatever their paradigm, they are helping patients. I’ll take conservative treatment any day … I don’t use the word, subluxation because I choose to address problems in terms of adhesions, fixations, faulty biomechanics, and aberrant joint motion. … There is, however, an accepted mechanism … Pretty fascinating stuff actually and all evidence-based!”

    You missed the point that the “chiro-paradigm” I cited is current. You simply changed the terminology, there is still no basis for what you do. A treatment with no proven benefit beyond safer procedures can hardly be called “conservative.” Is there compelling, clinical evidence for the “fascinating stuff” than you have already provided?

  39. nwtk2007 says:

    Joe – “JMPT is refereed by quacks, so the evaluations are not reputable; the “peer review” is a sham.”

    Ad hominem at it’s best.

  40. Harriet Hall says:

    I don’t go as far as Joe. I would be quite willling to accept good research published in JMPT and I wouldn’t prejudge any study as not reputable simply due to where it was published. On the other hand, I have been appalled by the abysmal quality of some of the research published in JMPT, the kind of thing I NEVER see in more prestigious journals like the NEJM. For example, this laughable study I reviewed for Quackwatch:
    http://www.chirobase.org/06DD/blindspot.html
    I did a more thorough analysis for the Scientific Review of Alternative Medicine where I described many other flaws, including the fact that the listed references did not support the referenced statements in the article, and one even directly contradicted it.
    I corresponded with the author of this study and I was unable to get him to recognize that he was using circular reasoning and that he had failed to validate his test. And this guy teaches chiropractic neurology!

    There is a difference between ad hominem and opinion based on experience. “The JMPT is stupid so I won’t believe anything it says” is ad hominem. “I have read many JMPT articles that were of poor quality so I do not consider it a generally reliable source.” is not ad hominem but common sense based on evidence.

  41. Joe says:

    nwtk2007 on 18 Feb 2009 at 12:36 pm wrote “Joe – “JMPT is refereed by quacks, so the evaluations are not reputable; the “peer review” is a sham.” Ad hominem at it’s best.”

    As much as I dislike philosophy, my thesis is that there is a place for ad hom. This is one of those places. When someone is cited as an authority (reviewer), it is legit to observe that the person is not an authority. When it comes to health care, chiropractors are not even amateurs. Thus, their endorsement of any treatment is meaningless.

    It is true that bona fide reviews in genuine, medical literature can be wrong. However, the odds are much more in favor of well-educated reviewers as opposed to quacks.

    On a personal note, it seems you cannot provide compelling research citations supporting your claims (beyond being a masseur), and cannot provide convincing evidence that the articles at quackwatch/chirobase are substantially wrong.

  42. nwtk2007 says:

    On a personal note to you Joe, I doubt if there could be any evidence that you would find compelling.

    Your history of assessing papers and studies without reading them is a testiment to your integrity and, to be quite honest, abilities, as relates to being scientific.

    I am sure that you and your buddies at Chirotalk have developed this talent to the extreme and thus it would be unfruitful to waste my time with you by presenting anything for your scrutiny.

    In fact, you just reinforce what I have said all along about the anti-chiropractic cultists who, in their own extreme bias, have developed an almost religious devotion to lying about that which you oppose. You know, the idea that the ends justify the means.

    You remind me of the insurance whore doctors who promote themselves as experts in healthcare, but in essence, simply parrot the wishes of the insurance companies to which they prostitute themselves out to. Talk about defrauding the public.

    So I would advise user9999 to refrain from wasting anymore time here. It serves no purpose but to promote a dishonest anti-chiropractic position, although not necessarily applicable to all of those who would here profess to be scientific.

  43. Harriet Hall says:

    Another ad hominem attack by nwtk2007. It’s not that we don’t find the evidence compelling, it’s that you haven’t been able to offer any compelling evidence.

    9999 offered two cats, an elbow and one clinical study that was not only problematic but that contradicted the results of a major systematic review of all published studies. You would laugh at us if we offered that kind of evidence for a drug. We are laughing at you.

  44. SGV says:

    As a 2005 graduate of a chiropractic college, I can offer a different perspective than the chiropractic student above. The subluxation model is alive and well in the chiropractic field. It is not just among the “old guard” but the new graduates as well. In fact, in order to pass the national boards we had to “set-up” on a mock patient according to a subluxation listing of a bone out of place and describe the direction of thrust. One of my listings was “superior femur.” How stupid.

    My former friends who are still practicing chiropractic are talking up the “subluxations kill” game to their patients and trying to weasel out thousand plus dollar pre-payments for a year of “care” because it takes adjustments three times per week to really remove subluxations and get the person on the “road to health.” Of course, because the person was subluxated for so long, they will require a lifetime of “care” to stay in optimal health. They are no longer my friend and after many email fights, the first one started because of this video: http://www.youtube.com/watch?v=Sbr3Mr6FS2I

    Before they revealed this practice motif to me, I did not know these kind of practices were occurring. I was horrified.

    As far as what our school and what the chiropractic literature had to say about strokes, Dr. Hall is extremely accurate. I saw nothing but excuses and “the world is against us” rhetoric. The students were indoctrinated to despise and distrust medicine and those of us practicing were warned not to talk to the media if they called, but to refer them to “the experts”.

    I do not have the space to really, accurately describe the truly weird things that I have seen and heard about during my time chiropracting. I got out, and went back to school. I can tell you all, a state college is massively more difficult than chiro-school.

    Side note: I did intern with a JMPT reviewer and he is a stand up guy, as evidence based as any chiropractor can be, and he opened my eyes to what really occurs in chiropractic. I only wish I would have met him before I wasted seven years and $150K in student loans.

  45. nwtk2007 says:

    Harriet,

    To say that the JMPT is a sham because it is a chiropractic journal is ad hominem, as are all of Joe’s comments where he dissmisses input because it is chiropractic in origin. He himself even admits to it and states his belief that there is a place for it here.

    To say that he is hypocritical in his use of the ad hominem position is not ad hominem.

    Perhaps you are not as smart as you think you are.

    Perhaps you are the one being laughed at in places outside your “circle”.

    No doubt you are articulate on many topics, but in your anti-chiropractic stance, you are biased and hypocritical if you support Joe’s position and additionally throw out an insult or two in his favor. No doubt also your “circle” will support you in your hypocrisy, but then most “circles” of cronies do.

    You are also right that I would laugh at the evidence you have presented for chiropractic causing strokes. I still am. As I have stated before, you yourself would not accept such a thin argument here if it were on any other topic.

  46. Harriet Hall says:

    Can’t you read? I wasn’t supporting Joe’s position. I was explaining the difference between ad hominem attacks and justifiable opinions based on evidence.

    And you are wrong about the thin evidence – if there were any treatment in conventional medicine with the kind of “thin” evidence we have for stroke and chiropractic, we would balance the possibility of risk (however remote) against the probability of benefit. You have presented NO evidence to support any benefit of neck manipulation for the kind of non-neck indications associated with many of the smoking gun cases (maintenance adjustments, low back pain, shoulder pain). I maintain that HVLA manipulations should never be used for anything but musculoskeletal neck and head pain, and caution and informed consent should be exercised in those cases. Many chiropractors agree with me. Many have given up HVLA in favor of mobilization. So I’m supported by a lot of your own colleagues as well as by my “circle of cronies” – whoever they may be. I don’t depend on anyone’s support.

    You guys are only exposing yourselves to ridicule when you try to snow us with cats and elbows instead of high-quality evidence.

    And I’ve told you on previous threads, I resent it when you accuse me of being anti-chiropractic. I’m not against everything chiropractors do, I’m only against treatments that are not science-based. I have no problem with rational chiropractors who eschew the subluxation myth and who limit themselves to evidence-based treatment of musculoskeletal conditions and who don’t discourage immunizations or offer quack remedies or try to discourage conventional medical care. If you could get rid of the nonsense in chiropractic, I would support it. You should be glad I am so liberal – others, including some ex-chiropractors, are calling for a complete abolishment of chiropractic in all forms.

  47. nwtk2007 says:

    Harriet,

    You write your little peiee about chiropractors and get a little bent out of shape when there is a bit of backlash.

    Please.

    And, of course, I see what you are saying.

    But this was your response to me – “Another ad hominem attack by nwtk2007.”

    There was nothing ad hominem about my “attack”. Joe has openly admitted that he doesn’t read chiro research and Joe has also admitted that he assesses it without reading it.

    I merely reiterated what his position is and has been. I also pointed out what it reminded me of and the bias therein.

    NOTHING ad hominem about that. And definitely nothing directed at you in that particular post which you said was an ad hominem “attack”.

    And since the subject is so very important to you, why not do and article about the evidence for stroke. Line it all up, both the pro’s and the con’s and let’s weigh it all out and see if it indeed passes the Science Based muster. Lets see if you don’t go cherry picking. Lets see how much there actually is since you feel it is so compelling. Put it all in one basket so to speak. Hell, if it so great in amount then I am sure someone will want to have it at their disposal to use as evidence in the cases about chiropractic induced stroke.

  48. Harriet Hall says:

    I looked at everything I could find on the subject before I wrote “Chiropractic and Stroke” and I stand by what I wrote.
    http://www.sciencebasedmedicine.org/?p=94

    The “con” evidence for chiropractic stroke has already been summarized many times, for instance at http://www.quackwatch.org/01QuackeryRelatedTopics/chirostroke.html
    Sandra Nette’s lawyers also have all the “con” evidence at their fingertips and have described it in their lawsuit.

    I have not found, and you chiropractic commenters have been unable to show us, ANY convincing “pro” evidence for doing HVLA neck manipulation in preference to gentle mobilizations. (Instead, you try to snow us with studies about cats and elbows and hope we won’t notice).

    And we certainly don’t have ANY “pro” evidence that it helps low back pain, shoulder pain, health maintenance, or any of the other irrational indications that have led to “smoking gun” strokes in young healthy patients. There are chiropractors out there offering neck manipulation to up to 90% of their patients for everything from ear infections to low back pain.

  49. nwtk2007 says:

    Harriet – “I looked at everything I could find on the subject before I wrote “Chiropractic and Stroke” and I stand by what I wrote.”

    No you didn’t and you know it very well.

    Harriet – “I have not found, and you chiropractic commenters have been unable to show us, ANY convincing “pro” evidence for doing HVLA neck manipulation in preference to gentle mobilizations.”

    Do you even understand what HVLA is and how it compares to “gentle mobilizations”? The true problem, but not supported by “evidence”, are the high amplitude manipulations: the exaggerated manipulations which go beyond the gentle “mobilizations” performed by most chiro’s. A true HVLA is not high amplitude. The dangerous manipulations are high velocity and “high” amplitude.

    A vertebral artery is not torn by velocity but by amplitude. (One could argue that momentum might be the key here, but there are two ways of viewing momentum, in terms of velocity and force. But amplitude is not a part of that equation.)

    It doesn’t take a lot to move a joint beyond it’s normal ROM and release it to be more freely mobile. And the benefits are unmistakable.

    The chiro’s who perform those “high amplitude”manipulations are akin to the medical professionals who make the mistakes they make which kill so many everyday.

    It takes a skilled hand to do “mobilization” and “manipulation” which is both beneficial and effective just as it takes a superiorly trained medical professional to avoid the “killing” mistakes.

    It is in the education and training. Compare the two and look at the dangers despite the benefit to so many. Which is truly more dangerous?

    I wouldn’t argue that poor technique in manipulation could do the damage to a vertebral artery. And I wouldn’t defend something that kills rampantly and injures so many either, despite the benefits to a majority of users.

    Is there any chance that you might eventually see that your house is much dirtier than the chiro’s? People benefit from chiropractic care. You can argue till the cows come home and it won’t change the fact that so many go back to them over and over again for help which the medical community can’t or hasn’t offered.

    Is it science based? Not enough, that’s for sure. Will it change? Who knows. But try to contain your bias.

    You’re a pretty good writer and can express yourself quite nicely. Many in my field enjoy you and your wit. I, for one, appreciate your “liberal”-ness as you have alluded to. Your original article was balanced and you even presented opposing studies, albeit with a certain “bias” twist. But be honest, you didn’t read all you could on the subject before you wrote it.

  50. Harriet Hall says:

    I don’t appreciate being accused of lying.

    I read what I could find. I’m quite willing to admit that there may be evidence I did not find, and I have given you every opportunity to show me such evidence. All I get is cats and elbows and unsuppported claims that HVLA neck manipulations “benefit a majority of users” [including for low back pain and health maintenance?!] and now an unsupported assertion that improperly performed high amplitude maneuvers are what cause strokes. That may be, but to convince me you’ll have to show us something more than your unsupported claims.

    Where’s the evidence?

    I know people go back to chiropractors because they “believe” they are getting effective treatment. Are they right? May so, maybe not.

    Where’s the evidence?

    Bloodletters and their patients in the Middle Ages would have said things very similar to what you are saying. When we looked at the evidence, we found out they were all wrong. And you could be too.

    Where’s the evidence?

  51. lou says:

    I won’t lie, I am embarassed to be a part of the human race right now. I cannot even begin to fathom what kind of diluted logic and thought patterns people are thinking, but it is nothing short of insanity. I would respond coherently, but what would I be doing but encouraging these little people talking to the corner in their wall? I am offended by stupidity. And here I was thinking you couldn’t get stupider than creationists.

    Offended.

  52. NuccaDoc says:

    Dr. Hall, come now … if you are going to put yourself across as being purely in it for the science and EBM, then it’s got to be evenly distributed across all fields!

    I’ve seen you rag on chiropractic adjustments in a variety of different angles of attack, and simultaneously sing the praises of vaccines and other “proven” (to your mind) medical procedures. Better be careful, as I think your bias might be showing and that would be unseemly for a woman of your stature. ;~)

    http://www.webmd.com/cold-and-flu/news/20050214/do-flu-shots-save-lives

    Recent population-based study published in the Feb. 14 issue of the journal Archives of Internal Medicine by the National Institute of Allergy and Infectious Diseases (NIAID):
    - examine flu deaths for the entire U.S. population from 1968 until 2001.
    - The percentage of elderly Americans who got annual flu shots rose steadily from around 15% before 1980 to 65% in 2001.
    - Funnily enough, deaths due to flu and flu-related complications have remained the same through that same period.

    Yes, it was population-based and not a RCT.
    Yes, there have been studies published which showed a “50% reduction” as a result of flu vaccination.

    But which is more likely … that a look across the entire population of the US over the course of 30+ years done by a government-funded organization somehow magically had confounding factors which made the “ACTUAL” 50% decrease appear as if nothing happened? (there’s a great graph floating around from the WSJ that I cannot find a link for which I assume was taken from this paper).

    OR … that the bias/structure/design of the much smaller and privately funded research studies just MIGHT have drawn conclusions which were not entirely there?

    Then don’t even get started on the polio vaccine – since the only cases of polio which have occurred since improvements in clean water supply were implemented have been a direct result of vaccination. Also let’s not mention that cases of polio in the US started to dramatically drop 2 YEARS before the vaccine was being distributed across the population. We’ll also conventiently ignore the fact that polio is a virus with a fecal-oral route of infection … eat/drink less poop = less polio.

    But of course vaccines don’t carry horrible (yet rare??) side effects like autism, paralysis, and stroke (at least none that’s PROVEN in the literature)! But then again, the causal relationship between chiropractic neck adjusting and strokes has not been PROVEN either … simply another seemingly associated occurrance with plenty of conjecture, guesswork and allegation attached.

    So please clarify your stance for me and where the “line in the sand” is …

    Dr. Hall’s stances:
    1. chiropractic neck adjustments are dangerous and have no value, therefor any risk of stroke is unacceptable.

    - despite the fact that only SOME studies and reviews show neck manipulation to be “no better than” other types of care, but some studies find it MORE effective with better patient satisfaction
    - despite the fact that there has not once been a published research paper indicating a causal relationship between neck manipulation and stroke – plenty that indicate exceedingly rare association, but none that show causation (despite the best efforts of many anti-chiro groups).

    2. vaccines are apparently well documented as being effective and good, and that side effects are minimal

    - despite the fact that the literature supporting vaccination is primarily associative (polio) and does not take into account natural variables, or is shown to be either grossly overstated or plain wrong (flu) when comparing population demographics to the smaller RCTs.
    - despite the fact that while (much like chiro stroke) there has never been PROOF (scientifically) of association of such symptoms as autism, paralysis and stroke with shots, it has also been admitted (in court I might add) that the causal connection could not be denied.

    Now explain to me again how those 2 cases are different and how your wonderfully scientific and non-agendized brain can come to two radically different stances based off of what appears to be very similar available data.

    You may also want to have a chat with Dr. David Eddy, MD ( http://www.businessweek.com/magazine/content/06_22/b3986001.htm ) regarding EBM and risk-benefit discussion regarding care. While it may be true that chiro care hasn’t got as much support as pure EBM-ers would like, the 12-15 that we allegedly kill annually trifles when compared to the #1 killer in the US today – iatrogenic illness ( http://ourcivilisation.com/medicine/usamed.htm ). Particularly in the spirit of this blog when a good 75-80% of what is performed within the medical paradigm has no backing in the scientific literature. Not saying that excuses anyone from evidencing what they do, but it does beg the question of why so many like yourself seem bent on hammering chiropractic for a 1/4,000,000 death rate on cervical minipulation while blithely accepting the same from your own profession.

  53. Harriet Hall says:

    NuccaDoc,

    You can find studies to support almost anything, but real scientists try to weigh the preponderance of ALL evidence.

    RE: vaccination – I refer you to the several excellent articles on this blog. You can go comment and argue there. Over half of chiropractors are anti-vaccine, or at least fail to recommend vaccination. This is one of my biggest concerns about chiropractic.

    Perhaps you did not read carefully enough to realize that I recognized that neck manipulation does help with certain kinds of head and neck pain. You did not offer any evidence that neck manipulation is effective for shoulder pain, low back pain or health maintenance, or any of the other non-neck indications that have been associated with stroke, nor did you offer any evidence that HLVA manipulation is better than gentle mobilization.

    Your understaning of scientific evidence is suspect when your preferred treatment: NUCCA, is so irrational that it is rejected even by most of your chiropractic colleages.

  54. Dr Benway says:

    NuccaDoc, please educate yourself regarding tu quoque.

  55. NuccaDoc says:

    @Dr. Benway,
    Read my post – you may want to educate yourself on tu quoque. I never dismissed her argument or claims regarding chiropractic and stroke – simply requested clarification on how she came to the stance she has given that she has taken the other side of the fence in other similarly supported debates. I simply wanted to determine where she saw the scientific and EB differences which cause her to argue so strongly against one while supporting the other without reserve.

    The question is valid and applicable given her assertion (here and in previous posts) that her stance against “chiropractic” neck adjusting was not based off of an agenda, but off of the evidence. If such is the case, then there MUST be quite substantial evidence differences between the two which I am apparently unaware of that cause her to form such radically different evidence-based opinions from what appear on the surface to be quite similar knowledge bases. I would think that here more than anywhere, one might realize and admit that just because something has ALWAYS been done a certain way or that because EVERYONE says so does not necessarily make it true or accurate.

    @ Dr. Hall,
    “You can find studies to support almost anything, but real scientists try to weigh the preponderance of ALL evidence.”
    - REALLLY?!?!??! I never would have guessed that without your expert tutelage! *sigh* Of course you can find studies that say whatever you want about pretty much anything. Which is WHY in addition to the sheer VOLUME of research you take into account, the source and agenda of the author must also be considered. Or does that only get taken into account when it’s a piece that opposes the particular view you are looking to support?

    I’m not interested in arguing vaccination … as you so eloquently put, you can find studies that say just about anything. I merely pointed it out as an example of similar evidence bases as those of chiropractic neck adjusting for conditions you listed (supported by anecdotal and clinical experience – much like the vaccines – but not necessarily by research). I have personal views on vaccination with various vaccines which are based off of the preponderance and VALIDITY of ALL the evidence as well as a weighting of the risk/benefit which I am quite comfortable with but has no relevance here.

    “Perhaps you did not read … ”
    - perhaps you missed the fact that I never once said that it WAS effective for any of those … who is not reading? I simply took the same tack that you and numerous other anti-chiro internet pundits use and pointed out all the holes, weak spots, and logical inconsistencies in your presentation of the “facts” as you see them to be. You are right, the level of EBM evidence supporting HVLA neck treatments for those conditions is weak …. however, anyone forming an honest and minimally-biased opinion on the risks of stroke from those same treatments (when they are properly administered! *) would have to also list THAT association as weak.

    “Your understaning of scientific evidence is suspect when your preferred treatment: NUCCA, is so irrational that it is rejected even by most of your chiropractic colleages.”

    - Why don’t you tell me a little bit about NUCCA? Blind me with your brilliant expose on how irrational it is! Do you realize at all how pathetic that statement is coming from a person who launched an all-out personal assault on the professional character and livelihood of a doctor over MONTHS because you saw a single sensationalized television segment?

    But of course, EVERYTHING we see on TV and the news is 100% accurate! They couldn’t have possibly cherry-picked a few shots and sensationalized it up to grab a larger percentage of the viewing audience. How do your actions regarding Dr. Hoeller jive with your “lack of an agenda” and “preponderance of evidence”?

    I know that you are retired, but grow up!

    * “properly administered”
    In order to clarify this statement, I’m going to TRY and explain things in such a way that my 7-year-old could grasp it … hopefully that’ll be enough for here. It’s been well documented and is generally understood that rotation PLUS extension of the upper cervical spine can stress the VBA and in those individuals who are prone to intimal damage could result in stroke. However a PROPERLY ADMINISTERED upper neck HVLA adjustment does NOT combine extension with rotation. It is taught and repeatedly drilled that supine cervical adjusting of that sort is done with no extension.

    Now I know that this is going to be a real stretch for a lot of you, so try to keep up … just because a procedure is occasionally performed WRONG and results in adverse events does not mean that the procedure itself carries the same risk. It would be like saying that surgery should not be allowed because occasionally a surgeon leaves an item in the patient. It’s not part of the procedure as it is taught, and it is not generally acceptable practice of the procedure …. but it happens and occasionally the patient suffers as a result. You’ll notice that in the studies done on cervical SMT and stroke which were done at any of the schools covering decades and millions of patients, there is not a single case of stroke … couldn’t that be because in the teaching environment and with new graduating students they keep those lessons like NO EXTENSION at the forefront of their minds and that only once complacency sets in and practitioners get sloppy in their technique do the IMPROPERLY administered neck manipulations start to sneak in? I’m not saying that must be the case, but even assuming only a 1 in 1 million chance of stroke from properly administered neck manipulation, from the numbers in the studies that I have seen there is only a ~25% chance that not one stroke would have been reported by blind luck.

  56. nwtk2007 says:

    Dr Hall is apparently forgetting what she actually said in the past and thus probably doesn’t remember the evidence either way.

    She has many times said that she thinks there is some evidence for manipulation regarding low back pain, but has emphatically stated that there is no evidence for any benefit to the cervical spine, but later she recanted that and said there was benefit to the cervical spine but ……… and then therefore there is never a good reason to manipulate the cervical spine …. I don’t really know now. I’ll have to go back and see.

    I still get a kick out of the tu quoque defense in light of the dangers of medicine. No doubt it is better to treat neck pain and neck injury with something that is implicated in better than 3000 deaths per year than something implicated in less than say, any? deathsper year based upon evidence.?.?

    It’s those smoking guns, see?

    I think the term chery picking has been thrown out there also.

    Dr Hall – “real scientists try to weigh the preponderance of ALL evidence. ”

    Yes, only “real scientists” can do that. Does this have even the slightest of ad hominem undertone to it?

    Guess not.

    Dr Hall – “nor did you offer any evidence that HLVA manipulation is better than gentle mobilization.”

    Isn’t it HVLA? Or is it LVHA? I mean what really is going on in chiropractic manipulation, especially the one’s implicated in stroke? Is there any “velocity” or “amplitude” in “gentle” manipulation? I thought they were saying it was the rotation that was the “culprit”?

    According to Dr Hall’s explanation of how the vertebral artery is stressed by C1 in it’s position related to C2, would there be a problem with manipulation of the lower cervical’s, say C3 to C6? Based upon this hypothesis, it would appear that NUCCA would be the most dangerous of the “techniques”.

    Gosh, it’s all getting so mixed up now.

  57. nwtk2007 says:

    And NUUCA is not rejected by other chiro’s. We just don’t know much about it and understand it in the way that the NUCCA doctors know it and use it.

    Reject it? Na.

  58. Harriet Hall says:

    NuccaDoc and nwtk2007,

    I’m still waiting to see your evidence that neck manipulation is beneficial for health maintenance, shoulder pain, low back pain or any indication other than head and neck pain. Or that HVLA is more effective than gentle mobilization. Or that the risk of stroke is only with improperly done manipulations.

    If NUCCA is effective, why isn’t it taught to everyone in chiropractic school? No, non-NUCCA chiropractors may not “reject” it, in the sense that they don’t want to criticize anyone else’s irrational, unproven method because someone might criticize their own preferred method by the same criteria. But they clearly are not rushing to incorporate it into their own practices. In chiropractic, there are over 200 techniques and few attempts to compare them – it’s a matter of “anything goes” or “it works for me.”

    The NUCCA chiropractor that I criticized was shown a video that clearly showed she was not touching the patient, and she said, “My whole thing is that I’m touching.” Draw your own conclusions.

  59. Harriet Hall says:

    I just reread the accusation that I “launched an all-out personal assault on the professional character and livelihood of a doctor over MONTHS because you saw a single sensationalized television segment?”

    This is a gross misrepresentation. Here’s what happened: I watched a video that was prominently featured on Johanna Hoeller’s own website. Then I described the video to others on the Quackwatch healthfraud discussion list, and on this blog http://www.sciencebasedmedicine.org/?p=3

    The video demonstrated she was delusional (believing she was touching when she clearly was not) and it showed she was performing a procedure not approved by Washington State law, and I reported her to the Washington State Chiropractic Quality Assurance Commission. The Commission failed to do what their their job mandates them to do, prompting me to write a couple of letters of protest to state officials (which did no good).

    It would be much more fair to say that based on the chiropractor’s own videotaped testiimony on her website, I acted responsibly to point out her delusion and to report her use of an unauthorized procedure to the proper authorities. This was in no way a personal assault, and was not an attack on her character or her livelihood. I would have been content if the Commission had ordered her to stop doing no-touch chiropractic and let her continue doing the authorized NUCCA procedures. I would have hoped that they would first get a mental health evaluation to make sure this was an isolated delusion and not part of a more extensive mental disorder.

    I sincerely hope that if any chiropractor sees evidence on an MD’s website (or elsewhere) that he is delusional and is practicing medicine in a way not authorized by the laws of his state he will do no less than I did, not out of any personal animosity or ideology but out of siimple concern for the law and for patient welfare.

  60. Dr Benway says:

    Ok, NuccaDoc. I see you were more interested in HH’s personality and, in your eyes, hypocrisy, rather than the matter of neck adjustments and stroke risk.

    I really prefer to talk about issues rather than personalities.

  61. nwtk2007 says:

    Harriett – “I’m still waiting to see your evidence that neck manipulation is beneficial for health maintenance, shoulder pain, low back pain or any indication other than head and neck pain. Or that HVLA is more effective than gentle mobilization. Or that the risk of stroke is only with improperly done manipulations.”

    I don’t think there will be much evidence presented related to cervical manipulation related to treating shoulder pain or low back pain or health maintenance. There might be some but I’ll leave that for NUCCA if he/she is so motivated. Considering the “thoroughness” of the review of evidence here so far, I personally think it would be a waste of time.

    Also, considering how rarely strokes are alleged to be associated with chiropractic manipulation, I doubt if there will be any up coming research into the gentle vs HVLA manipulation question as well. The actual evidence that manipulation causes stoke is so weak that this type of study could never be done.

    The “gentle” manipulation is an interesting one. I would assume it is meant that only PT’s do this, or that the manipulations that they do are the “gentle” type. I have now had demonstrations of gentle manipulations by three PT’s and I can see no difference in forces, velocities or amplitudes as it has been shown thus far. I also have patients who have been manipulated by Osteopaths and they tell me it is no different than the manipulations they receive in their treatment at my clinic.

    There appears to be a lot of “belief” that manipulation causes strokes, but that is about all it amounts to. I guess you could also say that I “believe” 500 people die everyday due to medical mistakes and that, to me, is a much, much bigger concern. But that’s just my “beliefs” and “bias” getting in the way I guess. As I see it, the hypocrisy issue mentioned by Dr Benway is clear and present.

  62. Harriet Hall says:

    nwtk’s answer speaks for itself. I could point out each logical fallacy, but I think other readers will easily spot them and will recognize that he has no ammunition and is grasping at irrational straws in a last-ditch effort to defend himself. It’s really rather sad.

  63. nwtk2007 says:

    That’s all you’re about isn’t it Harriett.

    I would say that you have nothing. I might do it for you but I am still waiting for the compilation of all this evidence that manipulation causes strokes.

    Just think of all the help you could be to Ms Nette if you would just compile it all right here for all to see.

    “Oh, I also know someone who had a stroke after a chiropractic adjustment!”

    What a joke!

  64. Joe says:

    @Nitwit2007,

    You are becoming increasingly incoherent. I’ll take it that, even when sober, you have no reliable information to impart.

  65. Harriet Hall says:

    If nwtk2007 thinks my argument consists of “I know someone who had a stroke” he can not have read or understood what I wrote. I may not have a definitive controlled study showing neck manipulation can cause stroke, but it’s not accurate to say I have “nothing.” There are studies showing an association, there is a plausible mechanism, and there are the “smoking gun” cases.

    No one has even tried to explain the “smoking gun” examples of patients collapsing on the chiropractor’s table. If these were due simply to chance, there should be even more reports of patients collapsing with a stroke as they sat in a chair in their doctor’s office. No one has offered even a single example of a patient collapsing during a massage treatment.

    Science-based medicine does not mean we have to wait for perfect evidence: it means using the best evidence we do have to reach a tentative conclusion.

  66. nwtk2007 says:

    Joe, you are the very guy who admitted to assessing research studies without reading them.

    Incoherent? Get real.

    Reliable information? Why don’t you make some up. Again.

  67. nwtk2007 says:

    Harriett, if you have “something” then compile it for display.

    Tell me something Harriett, does 500 deaths per day due to mistakes and errors represent a “smoking gun”?

    Or 3000 per year due to an over the counter drug called ibuprofen?

    How many other smoking guns are there in the medical arsenal?

    The number two, or three leading cause of death in the US? Could that be a smoking gun?

    Display your evidence for this killer called manipulation.

  68. Harriet Hall says:

    If you had read my original post on chiropractic and stroke and had clicked on the links, you would realize I had already displayed the evidence. Here’s a list of references from just one of the links:

    Pratt-Thomas HR, Berger KE: Cerebellar and spinal injuries after chiropractic manipulation. Death case. J Amer Med Assoc 1947; 133(9):600-3
    York v. Daniels. Medicolegal abstracts. Chiropractors Injury to spinal meninges during adjustments. Death case. J. Amer. Med Assoc. 1955; 159 (8) 809
    Smith RA, Estridge MN. Neurological complications of head and neck manipulations. (Death case) J. Amer. med. Assoc. 1962; 182 (5) 527-31
    Lorenz R, Vogelsang HG Thrombose der arteria basilaris nach chiroprakitschen manipulationen. Death case. Deutsche Med. Wochenschrift 1972; 97:36-43
    Beatty RA. Dissecting hematoma of the internal carotid artery following chiropractic cervical manipulation. J. Trauma 1977; 17 (3): 248-9
    Easton JD, Sherman DG. Cervical manipulation and stroke. Stroke 1977; 8(5) 594-7
    Nyberg-Hansen R, Loken AC, Tenstad O. Brainstem lesions with coma for five years following manipulation of the cervical spine. Death case. J. Neurol 1978; 218: 97-105
    Zak SM, Carmody RF. Cerebellar infarction from chiropractic neck manipulation: Death case. Case report and review of the literature. Ariz. Med. 1984; 41 (5) 333-7
    Mas JL, Henin D, Bousser MG et al. Dissecting aneurysm of the vertebral artery and cervical manipulation. Death case. A case report with autopsy. Neurology 1989; 39 (4) 512-5
    Sullivan EC. Brain stem stroke syndromes from cervical adjustments. Report on five cases. Death case. J. Chiro Res. & Clin. Investigation 1992; 8 (1) 12-16
    Norris JW, Beletsky V. SPONTADS data. Canadian Stroke Consortium. 2001
    Norris JW, Beletsky V. Zurab G. Nadareishvili. Sudden Neck Movement and cervical artery dissection. C.M.A.J. 2000 (07) 163. 38-40
    SPONTADS. Canadian Stroke Consortium. May 2001
    Rothwell DM, Bondy SJ, Williams I. Case control study of chiropractic manipulation and stroke. Stroke 2001 (5) 1054-1060
    Chan M. Nadareishvili Z. Norris. J. Diagnostic Strategies in Young Patients With Ischemic Stroke. Can J Neurol. Sci 2000; 27; 120-124
    July recommendations. Inquest concerning the death of Laurie Jean Mathiason. September 1998. Saskatoon, Saskatchewan. Canada.
    D.C.F. Ontario.
    Chiropractic and Children: Infants and Toddlers. Ontario Chiropractic Association. Distributed from Canadian Memorial Chiropractic College, Toronto. 2001.
    A Statement by the Chairman of the Departments of Pediatrics of Pediatric Hospitals in Canada. August 1994.
    Spiegelblatt L. Francoeur E. Letter correspondence. Professor Michael de Robertis. York University. Canadian Pediatric Society. 1988 Nov. 17.
    Shafir. J. Pediatrics 1992; 120:226-9
    Nickerson HJ, Silberman TL. Journal of Pediatrics 1992. Letter.
    Klin Padiatr. 2001 March-April; 213(2): 76-85

    No, it’s not definitive proof, but it is certainly cause for reasonable concern. Even the World Chiropractic Alliance’s website acknowledges that there is a small risk of 1 to 3 strokes per million adjustments.

    I thought by now you would understand that tu quoque is a logical fallacy. I’m embarrassed for you.

  69. nwtk2007 says:

    Harriett, you cut and paste very well from the Neck911 site.

    Is this all there is since 1955 for such a “dangerous procedure”?

    As you say, not definite evidence. An understatement to say the least.

  70. nwtk2007 says:

    Here’s one for you about causes of stroke:

    For the study, Morgenstern and colleagues examined stroke data on residents of Nueces County, Texas, between January 1, 2000, and June 2003.

    During that time, county residents suffered a total of 1,247 ischemic strokes, the most common type caused by a blocked artery that chokes off bloodflow to the brain.

    They used U.S. Census Bureau demographic and socioeconomic data to determine the number of fast-food restaurants in each neighborhood. And they compared neighborhoods with the lowest number of fast-food restaurants — fewer than 12 — to those with the highest number — more than 33.

    They found the relative stroke risk rose 1 percent for each fast-food restaurant in a neighborhood.

    http://www.msnbc.msn.com/id/29288554/

    It would appear that the addition of one fast food restaurant in a neighborhood causes more strokes than all of chiropractic combined.

  71. nwtk2007 says:

    Or how about the stroke risk associated with the use of beta-blockers:

    (NaturalNews) Beta-blockers, also called beta-adrenergic blocking agents, comprise a class of drugs used to treat high blood pressure, heart rhythm disorders and migraines. By blocking the effects of the hormone adrenaline in the body, they slow the heart beat and lower blood pressure. So doctors have routinely prescribed these medications to people undergoing non-cardiac surgeries, reasoning the drugs would protect the cardiovascular system during the stress of an operation. But new research published in the Lancet medical journal and available on-line (http://press.thelancet.com/bblocker…) concludes using beta-blockers in this way isn’t a great health-protecting strategy for surgery patients. In fact, the opposite may be true: the study shows they are associated with an increased risk of stroke and other potentially serious medical problems.

    Dr Sripal Bangalore of Brigham and Women’s Hospital in Boston and Professor Franz Messerli of St Luke’s-Roosevelt Hospital and Columbia University College of Physicians and Surgeons in New York, headed a meta-analysis of 33 beta-blocker studies involving 12,306 surgical patients. They found the drugs were not associated with any significant reduction in the risk of all-cause mortality, cardiovascular mortality, or heart failure. In a statement released to the media, the researchers pointed out that beta-blockers did reduce the risk of non-fatal heart attack by 35% and reduced the risk of less serious heart blood vessel blockage by 64%. However, the significance of these reductions pale when faced with the fact the drugs doubled the risk for stroke.

    http://www.naturalnews.com/024838.html

    The last sentence is in bold in the original article. Is the Lancet journal one of those rag’s mentioned by Joe?

    Do you think there are more strokes associated with chiropractic manipulation or the use of beta-blockers? Do Bp meds have the warning that while reducing high Bp they actually might increase the risk of stroke?

    I know, tu quoque.

  72. Harriet Hall says:

    For the record, I have not consulted the Neck911 website. The list was cut and pasted from the 2002 Statement of Concern to the Canadian Public from Canadian Neurologists http://www.chirobase.org/15News/neurol.html

    I did not cite (but should have) http://www.quackwatch.org/01QuackeryRelatedTopics/chirostroke.html where even more evidence is presented.

    It is obvious what nwtk2007 is doing. He asks for evidence; I give it to him (again). I say up front that it is not definite evidence but cause for concern; he says “not definite” is an understatement and ignores the issue of “cause for concern.” I tell him a major chiropractic organization recognizes the risk; he doesn’t comment. To top it off, he accuses me of cutting and pasting from an anti-chiropractic activist website.

    However minimal the risk, he is unable to present any clear evidence of benefit for HVLA neck manipulations exceeding the benefit of gentle mobilization. His only recourse is to talk about the risks of medical treatments (without, of course, mentioning that they have proven benefits and their risks are recognized and monitored).

    I have long held the position that I would support chiropractors who gave up the pseudoscientific baggage and limited themselves to evidence- based treatment of musculoskeletal conditions. After a few discussions like these, I’m beginning to wonder if there is a single chiropractor out there who is capable of critical thinking. I’m trying to maintain objectivity but am increasingly tempted to jump on the “ban chiropractors” bandwagon. Keep posting, guys, you may convert me.

  73. Harriet Hall says:

    The Bangalore study offers several teaching points.

    (1) nwtk2007 did not notice that the study was about one specific use of beta blockers to protect the heart during surgery and had no bearing on the more common use of beta blockers as treatment of hypertension. When used for hypertension, beta blockers decrease the risk of stroke. (RR=0.8)

    (2) Doctors took the trouble to measure the stroke rate repeatedly in different studies and to do a meta-analysis.

    (3) The risk of using beta blockers for surgery was recognized and recommendations changed. It has also been recognized that beta blockers are less protective than other treatments for hypertension and are no longer the first drug of choice.

    (4) Doctors are constantly monitoring the effects and risks of treatments and comparing treatments to find the best. Chiropractors are not.

    (5) If chiropractors were half as responsible as doctors, they would have done the necessary studies and we would already know what the risks of neck adjustment really are, so we would not be having this discussion.

    (6) If HVLA neck adjustment were a drug, the existing evidence would have resulted in FDA warnings or possibly even removal from the market.

    nwtk2007, you just dig yourself in deeper with every comment.

  74. user9999 says:

    HarrietHall,

    “9999 offered two cats, an elbow and one clinical study that was not only problematic but that contradicted the results of a major systematic review of all published studies. You would laugh at us if we offered that kind of evidence for a drug. We are laughing at you.”

    You really make it difficult to have a logical discussion. You asked for research and I gave you some. You noticed that two were done on cats, one on pressure pain threshold in an extremity – post adjustment, and lastly one measuring pain, but in your opinion lacking clinical outcome because it doesn’t agree with the research that you presented.

    First off, I find it laughable that you would criticize using animals for objective measurements such as muscle spindle response and length control. Is medical testing never done with animals anymore? Does animal testing invalidate a study? To someone who doesn’t read a lot of research, you can make me look silly, but to those who know how research is done and the benefit of objectivity we have in using animals, you sound quite ridiculous to deny a valid study based on that criteria. This is the only way to take the patient out of the equation and get truly valid, raw data.

    Your remarks of treating other areas like the shoulder with cervical spine adjusting make me question your knowledge in neuromuscular anatomy. Do you think the muscles of the C/S only exist in the C/S? Instead of receiving the study as a merit for further study, you throw it out. This is a study demonstrating extremity pressure pain threshold response IN THE ELBOW after adjusting the cervical spine. Instead of receiving it as addressing some of your questions about possible benefits below the neck from a cervical adjustment, you laugh at me for giving it to you. Ridiculous.

    Lastly your critique of the randomized control trial on neck pain and active range of motion lacking clinical outcome. A study addressing your questions of HVLA over gently mobilization and you say that it doesn’t count because it didn’t meet your criteria of clinical outcome. Pain and range of motion don’t meet your criteria. I think if you have such great ideas of research and such specific requirements, you probably would have to do the research yourself. Maybe that would be the best thing anyways, because you don’t seem to be willing to look seriously at research which doesn’t follow the traditional medical paradigm. I agree that I would have been interested to see the longer term effects of the study, but just because it wasn’t made available doesn’t invalidate the material they gave. The study was limited but not useless.

    Why would I ever go through the trouble of finding you more studies (which are readily available to anyone who is objectively looking) when you reject the valid studies I give you? You just attempt to make me look like I’m giving you irrelevant information instead of saying “okay, maybe there is some validation for cervical adjusting, but it’s not enough evidence to change my mind yet.” That would have been more appropriate than your poor response. It’d be pointless and just further insulting to you and myself to continue in a dialogue with you.

    Lastly you said “If HVLA neck adjustment were a drug, the existing evidence would have resulted in FDA warnings or possibly even removal from the market.” With the current information that we have on the correlation of C/S HVLA , this is a ludicrous statement. I don’t deny that there could be a risk (as with any medical procedure), but to say that 4 or 5 out of a million (probably less than that from where the literature is currently pointing) people having strokes would merit a recall just demonstrates your ignorance in FDA testing. I agree with a warning, which I give to each patient (in their Benefits, Risks, and Alternatives consult) but you just make outlandish statements in attempts to galvanize your argument.

    The only thing I think we can agree on is that we need more research. It is, however, very difficult to do placebo based studies with chiropractic, and I’m sure that is much of the reason for the poor studies you describe. The only easy placebos come with the instrument adjusting, which is probably the reason that they have the strongest research. With any kind of mechanical therapy, there are going to be limitations in the studies. I believe, from my clinical experience, that research will only validate chiropractic treatment further, so I do anxiously await more. At any rate, it is futile to try to have logical discussions with people on these sites. It was fun, but I’m sure it was useless to the type of people that frequent these sites anyways. Their mind is made up.

  75. user9999 says:

    I noticed I said “lastly” twice. Forgive me… guess I got carried away. An edit feature would be nice!

  76. Harriet Hall says:

    There’s nothing wrong with cats and elbows per se, but then you have to go on to POEMS – Patient Oriented Evidence That Matters. If HVLA neck manipulation is superior to other methods for neck pain, shoulder pain or any other indication, chiropractic has had over a century to demonstrate that to everyone’s satisfaction; they have tried and failed. Yes, we sure do need more research, and it doesn’t even require placebo controls, because you could compare methods. Oh, gee, they already did that – Cochrane said manipulation wasn’t any better than gentle mobilization, and neither worked unless you added exercise. I’m keeping an open mind, but I’m not holding my breath.

  77. nwtk2007 says:

    Harriett – “(1) nwtk2007 did not notice that the study was about one specific use of beta blockers to protect the heart during surgery and had no bearing on the more common use of beta blockers as treatment of hypertension.”

    Gee, it is pretty hard to miss considering I was the one who pointed out the study, but I also wanted to point out this study as well but in my haste left it out.

    “Researchers at Columbia University in New York found that people who are on beta-blockers for high blood pressure may be at higher risk for death of all causes, including: heart attack, stroke, and heart failure. This study was published in the Journal of American College of Cardiology (Oct. 28, 2008).”

    But as you say, they are not the first drug of choice for Bp control.

    Harriett – “(6) If HVLA neck adjustment were a drug, the existing evidence would have resulted in FDA warnings or possibly even removal from the market.”

    You didn’t really write this did you Harriett?

  78. Harriet Hall says:

    Many meta-analyses have shown risk reduction with beta blockers. The issue is complex. See http://cme.medscape.com/viewarticle/573023

    But all that is irrelevant to the topic under discussion.
    It’s been fun playing “spot the logical fallacy” but I think I’ll stop now.

  79. NuccaDoc says:

    Dr. Hall, next time you want to present “evidence”, you might want to actually look at the sources rather than simply cutting and pasting from an agenda-based website. Of your list of 21 “sources” you posted;

    First nine were all case studies (total of 14 individual cases with one being non-chiropractic adjusting, and most being completely unavailable through any form of online searching) Since I couldn’t find text for any of them really, would you care to enlighten us on what conclusions can be inferred from them especially taking into account their specific situations in each case? After all, if they provide YOU with enough reason to question the risk-benefit of neck manipulation, you MUST have at least read them!

    The next 2 (Norris) were of the same information/study –
    of 74 cases found in a year, “stroke resulting from neck manipulation occurred in 28% (21/74) of our cases.” Now aside from the fact that there is no rationale or evidence given to support the conjecture that those strokes RESULTED from the neck manipulation, the article concludes that “Until a high-risk group can be identified, chiropractors should inform all patients of possible serious complications before neck manipulation. This is already emphasized in their current training programs.”

    Then we come to Rothwell … funny how on one hand you denounce the latest neck pain task force study in Spine, yet list this study as a valid indicator when the design is identical except that the latest one which downplays the specific role of neck adjusting in stroke causality included looking at medical physician visits as well. Again, pick a selection criteria, Harriet … or at least READ the sources you cite!

    The Chan article abstract at least had nothing to do with the association between chiropractic neck adjusting and stroke aside from referencing studies done which cited it as a “cause”. Couldn’t find the full text, but the abstract was pretty clear to the nature of the article.

    Now we get into the really powerful EBM sources!! (NOT!!)

    July recommendations. … what is this exactly? Court transcript? Have you read it? Funnily enough, the only references I can find to it are from the “letter of concern” you mentioned and places it has been repeated.

    Chiropractic and Children … ditto remarks from above.

    A Statement by the Chairman … hmmm. Seeing a trend here. None of these are obviously what we would consider research-quality sources. Letters and opinion pieces maybe, but not even the level of a case study!

    Spiegelblatt … another letter!! Wow … compelling!

    Shafir. J … Does this even exist?? Can’t find the author listed anywere!

    Nickerson HJ … ooooh!!! not another letter!

    Klin … again, what does this reference? Can’t find anything on pubmed that would have any relevance to neck adjusting and stroke.

    So to summarize your “evidence”, we have:
    - 9 articles containing 14 case studies (1 non-chiropractic), none of which I am guessing you have read.
    - 2 citations to a source that states chiropractic is doing exactly what it should be doing,
    - 1 study which draws conclusions which are strongly mitigated by more recent and more complete research done with the same design,
    - 1 citation that talks about diagnostic strategies for patients with strokes, but makes no actual correlations between manipulation and stroke that is not referenced from other material,
    - finally a smattering of opinion letters and untraceable court documents (?)

    WOW!! That’s really some compelling evidence there! Let’s all rethink our world view based on such strong information!

    Finally,
    “I did not cite (but should have) http://www.quackwatch.org/01QuackeryRelatedTopics/chirostroke.html where even more evidence is presented.”

    I’m not even going to bother looking through that list unless you can actually point me to one piece you have ACTUALLY READ and uphold as supporting your stance. I’ve already wasted enough time looking through this other drivel that you posted up as “evidence” to bother doing any more without due diligence from your end.

  80. NuccaDoc says:

    I’ll freely admit that I have not read all of these so I can’t guarantee the quality of each. Also, being primarily in support of orthogonally-based upper cervical adjusting and techniques, they may not specifically deal with the “standard” HVLA cervical adjusting that everyone seems to think is universal, but you asked for some support of high neck adjusting as being beneficial for other conditions than your standard neck pain, so here you go:

    (P.S. you could also just as easily look into Dr. Kirk Eriksen’s text book “Upper Cervical Subluxation Complex: A Review of the Chiropractic and Medical Literature” if you wanted to see pretty much every reference available and published prior to 2003)

    DISCLAIMER: Orthogonally-based upper cervical care is not a treatment for conditions or diseases, however, this subluxation-centered care has been shown to have an associative effect on various conditions some of which have been listed below.

    Bakris G, Dickholtz M Sr, Meyer PM, Kravitz G, Avery E, Miller M, Brown J, Woodfield C, Bell B. Atlas vertebra realignment and achievement of arterial pressure goal in hypertensive patients: a pilot study. J Hum Hypertens. 2007 May;21(5):347-52. Epub 2007 Mar 2.

    Khaled A. Khorshid Bio, DC, MS, MBBCh; Roy W. Sweat Bio, DC; David A. Zemba, Jr. Bio, DC; Brett N. Zemba Bio, DC. Clinical Efficacy of Upper Cervical Versus Full Spine Chiropractic Care on Children with Autism: A Randomized Clinical Tria. JVSR March 9, 2006, pp 1-7

    Eriksen K, Owens EF. Upper Cervical Post X-ray Reduction and Its Relationship to Symptomatic Improvement and Spinal Stability. Chiropr Res J, 1997; 4(1):10-17.

    Sherwood KR, Brickner DS, Jennings DJ, Mattern JC. Postural Changes After Reduction of the Atlanto-Axial Subluxation. J Chiropr Res, Summer, 1989; 5(4):96-100.

    Hoiriis KT. Case Report: Management of Post-Surgical Chronic Low Back Pain with Upper Cervical Adjustment. Chiropr Res J, 1989; 1(3):37-42.

    Vaillancourt PJ, Collins KF. CASE REPORT: Management of Post-Surgical Low Back Syndrome with Upper Cervical Adjustment. Chiropr Res J, 1993; 2(3):1-16.

    Robinson SS, Collins KF, Grostic JD. A Retrospective Study: Patients with Chronic Low Back Pain Managed with Specific Upper Cervical Adjustments. Chiropr Res J, 1993; 2(4): 10-16.

    Oliverio AB. Review of the Literature Adjusting Only the Cervical Spine and its Effect on Low Back Pain. Chiropr Res J, 1994; 3(1):3-6.

    Brown M, Vaillancourt P. Case Report: Upper Cervical Adjusting for Knee Pain. Chiropr Res J, 1993; 2(3):6-9.

    Eriksen K. Correction of Juvenile Idiopathic Scoliosis After Primary Upper Cervical Care: A Case Study. Chiropr Res J, 1996; 3(3):25-33.

    Basu KS, Blankenship NK. Chiropractic and Scoliosis: A Case Study. Chiropr Res J, 1999; 6(2):71-76.

    Kessinger RC, Boneva DV. The Influence of Upper Cervical Specific Chiropractic Care on Lumbar Range of Motion. 17th Annual Upper Cervical Spine Conference, Life University, Marietta, GA, February 3-4, 2001.

    Eriksen K. Management of Cervical Herniated Disc with Upper Cervical Chiropractic Care: A Case Study. J Manipulative Physiol Ther, 1998; 21(1):51-56.

    Glick DM. Conservative Chiropractic Care of Cervicobrachialgia. Chiropr Res J, 1989; 1(3): 49-52.

    Collins KF, Barker C, Brantley J, Planas V, Roopnarine C, Thornton P. The Efficacy of Upper Cervical Chiropractic Care on Children and Adults with Cerebral Palsy: A Preliminary Report. Chiro Pediatrics, 1994; 1(1):13-15.

    Aguilar AL, Grostic JD, Pfleger B. Chiropractic Care and Behavior in Autistic Children. J Clin Chiropr Pediatr, 2000; 5(1):293-304.

    Trotta N. The Response of an Adult Tourette Patient to Life Upper Cervical Adjustments. Chiropr Res J, 1989; 1(3):43-48.

    Goodman RJ, Mosby JS. Cessation of a Seizure Disorder: Correction of the Atlas Subluxation Complex. J Chiropr Res Clin Invest, 1990; 6(2):43-46.

    Thomas MD, Wood J. Upper Cervical Adjustments May Improve Mental Function. J Man Med, 1992; 6:215-216.

    Kirby SL. A Case Study: The Effects of Chiropractic On Multiple Sclerosis. Chiropr Res J, 1994; 3(1):7-12.

    Smith JL. Effects of Upper Cervical Subluxation Concomitant with a Mild Arnold-Chiari Malformation: A Case Study. Chiropr Res J, 1997; 4(2):77-81.

    Selano JL, Hightower BC, Pfleger B, Collins KF, Grostic JD. The Effects of Specific Upper Cervical Adjustments on the CD4 Counts of HIV Positive Patients. Chiropr Res J, 1994; 3(1):32-39.

    Hunt JM. Upper Cervical Chiropractic Care and the Resolution of Cystic Hygroma in a Twelve-Year-Old Female: A Case Study. J Clin Chiropr Pediatr, 2000; 5(1):315-317.

    Hunt JM. Upper Cervical Chiropractic Care of a Pediatric Patient with Asthma: A Case Study. J Clin Chiropr Pediatr, 2000; 5(1):318-321.

    Hunt JM. Upper Cervical Chiropractic Care of an Infant with Irregular Bowel Function: A Case Study. J Clin Chiropr Pediatr, 2000; 5(1):312-314.

    Eriksen K. Effects of Upper Cervical Correction on Chronic Constipation. Chiropr Res J, 1994; 3(1):19-22.

    Goodman R. Hypertension and The Atlas Subluxation Complex. J Chiropr Res Clin Investigation, 1992; 8(2):30-32.

    Knutson, G. Significant Changes in Systolic Blood Pressure Post Vectored Upper Cervical Adjustment vs Resting Control Groups: A Possible Effect of the Cervicosympathetic and/or Pressor Reflex. J Manipulative Physiol Ther, 2001; 24:101-109.

  81. Blue Wode says:

    NuccaDoc posted the following quote on 3rd March 2009 at 2.20am: “Until a high-risk group can be identified, chiropractors should inform all patients of possible serious complications before neck manipulation. This is already emphasized in their current training programs.”

    Sadly, it would appear that that crucial aspect of chiropractors’ training is, in many cases, being ignored:

    Quote:
    “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.”

    Langworthy JM, and Cambron J., Consent: Its Practices and Implications in United Kingdom and United States Chiropractic Practice. Institute for Musculoskeletal Research and Clinical Implementation, AECC, Bournemouth, UK [July-August 2007]
    http://tinyurl.com/6ajn5d

    Those findings also suggest that many parents will not be warned that paediatric safety data on chiropractic spinal manipulation are virtually non-existent: http://pediatrics.aappublications.org/cgi/content/abstract/peds.2006-1392v1

    One can only conclude that the reason why so many chiropractors fail to obtain fully informed consent is that it works against their financial interests. For example, at an inquest in Canada which involved a chiropractor who had allegedly caused a patient to suffer a stroke through neck manipulation, the chiropractor, when pressed as to why he wasn’t telling his patients about the “potentially catastrophic injuries and death” which could result from neck manipulation, replied that if he were to tell patients “I can kill you”, then “half of them would walk out”. See here:
    http://www.chirowatch.com/Chiro-Lewis/oakley-closing.html

    BTW, bearing in mind that the title of this blog post is ‘Chiropractic’s Pathetic Response to Stroke Concerns’, it’s interesting to note that the UK regulatory body, the General Chiropractic Council (GCC), declared the following in Item 7 of the Minutes of its 2nd March 2006 meeting…

    Quote:
    “If chiropractors are to provide a safe clinical experience for patients then a reporting procedure needs to be put in place, within the clinics and within the profession as a whole, which allows for adverse events and near misses to be shared on an anonymised basis so that we can all learn from them.”

    http://www.gcc-uk.org/files/link_file/C-020306-Open1.pdf

    …because, three years on, there’s still no sign of a reporting procedure despite one of the GCC’s primary duties being that of *protecting patients*.

  82. Joe says:

    Nucca,

    What is that bogus “disclaimer”? “… this subluxation-centered care has been shown to have an associative effect on various conditions …”

    Didn’t you get the memo? Chiropractic subluxations do not exist. Also, what is an “associative effect”? Yes, you wrote that you cannot ‘treat’ conditions; so, what do you actually do for people?

    The first article you cite is quite feeble (too few subjects and a ludicrous claim of having made a tiny change in the vertebra), if it were realistic it would be big news. And it got immediate attention (an opinion piece in Nature); two years later, there is no more.

    I do not have ready access to the rest of the articles you cite, primarily because the magazines are worthless (I only have JMPT back to 1999, but it is worthless, too). The magazines are so bad that they are not even indexed in PubMed.

    The reports you cited that concern children are quite worrying, worse is the fact that two of your magazines have “pediatrics” in the title.

    What you have demonstrated is that you have no definitive proof of any claim; but you have beliefs and you want to proceed as if they were valid. After all, beliefs can be quite powerful- they saved Tinker Bell.

  83. NuccaDoc says:

    Joe,

    The disclaimer was for you and your ilk who would wail and gnash their teeth and fling poop had I not put it in. “What??? How do you treat [insert condition X] by [derrogatory euphemism for upper cervical adjusting] someone behind the ear?”

    I provide subluxation-based care … you may not believe they exist, but as you and your friends are so fond of pointing out, belief does not make something true. I am guessing you believe the moon landing was a hoax and that the earth being round is a giant conspiracy as well. No one has ever done a study of either prooving that either is actually a reality.

    What I do for people is remove the misalignment of their upper cervical spine which I verify having done through physiologic and radiographic measurements. It IS a small amount, but if you’d paid a bit more attention in class, you might have remembered the density of proprioceptive fibres is highest in the upper cervical spine …. I’m sure that’s just vestigial though.

    The rest of your “comments” are just more of the same old tune from a tired and fading sect. You seem to have missed the laughable point that half of those “rags” that you discounted were listed as sources for the stroke arguement as well! Oops! I guess if there is no proof/evidence of upper neck adjusting helping more than just neck pain, then there is also no proof/evidence that neck adjusting in any way increases your risk of stroke.

    If you don’t want to continue looking like an agenda-driven, hypocritical nutbag, then pick a selection criteria for evidence and stick with it (without one of the criteria being it supports your stance). Hell, if you want to make those selection criteria known, I’d be happy to discuss those references in design, validity, and confounding factors. Until then you just keep on telling that lightpost to get out of your way.

    “but you have beliefs and you want to proceed as if they were valid.”
    Pot. Kettle. Black.

  84. nwtk2007 says:

    Hey Joe, what’re you do’in?

    Pick’in cherries! Cherry pick’in!

  85. Joe says:

    NuccaDoc on 03 Mar 2009 at 12:38 pm wrote “I provide subluxation-based care … you may not believe they exist …”

    My knowledge is that chiropractic subluxations do not exist. Keep on with your beliefs, they keep a lot of fairies alive.

  86. pmoran says:

    Nuccadoc ” —- pick a selection criteria for evidence and stick with it — ”

    That’s easy. To demonstrate the claimed clinical effects, three sizable, independent, randomized controlled trials (placebo controlled and double blinded when subjective outcomes are being assessed) giving the same positive results. That is what the FDA asks for with a new drug. This will exclude placebo and all the other possible non-treatment-related explanations for the claimed effects to a reasonable standard of “proof”:

    But even that might not be enough to overcome doubt concerning this bit of medical tomfoolery (meaning Nucca — obligatory derogatory descriptor as requested).

    Nucca, and indeed the whole of subluxation-based chiropractic, shot itself in the foot from the start by never ever being able to show in adequately controlled, blinded and replicable studies that subtle subluxations exist and are corrected by any kind of adjustment. It is this failure to take simple, obvious, NECESSARY steps to validate core claims that characterises pseudoscience and quackery and creates unrelenting skepticism in the scienitfic world.

    There is no shame in being fooled by the clinical results into thinking that you have a brilliantly successful medical treatment. You are probably even helping some patients through placebo influences and your tender care.

    And I am sure some of the xrays do look better to you in the “after” films. But the tiny differences described in any of the published non-blinded studies look to be well within the range of error within radiographic positioning and measurement, especially when assessment is allowed to combine with conscious and unconscious human bias.

  87. Calli Arcale says:

    NuccaDoc:

    I am guessing you believe the moon landing was a hoax and that the earth being round is a giant conspiracy as well. No one has ever done a study of either prooving that either is actually a reality.

    Poor Eratosthenes. Nobody ever seems to appreciate his ground-breaking research proving not only that the Earth is round but that it’s 252,000 stadia (about 39,690 km) around.

    It’s interesting that you equate skepticism of a spherical Earth with skepticism of chiropractic subluxations. This strongly suggests to me that you have no conception of the extent of evidence that exists for a spherical Earth, which in turn strongly suggests that you did poorly in high school science classes, or were woefully underserved by your high school science curriculum. (The latter is entirely possible; I’ve seen far too many high school science programs utterly fail to prepare their students for anything.)

  88. Harriet Hall says:

    DD Palmer himself has spoken from the grave, chastising his followers for trying to justify chiropractic with science, saying chiropractic is a religion. See http://www.randi.org/site/index.php/swift-blog/461-a-message-from-the-spirit-world.html

  89. NuccaDoc says:

    Blue Wode,

    First off, thanks for the links … makes following up and discussion much easier.

    You quote from Langworthy was accurate from the abstract. Without access to the whole text I couldn’t critique the study design itself, but I am curious what criteria he was applying as an acceptable level of informed consent – and then if anyone anywhere would not be found lacking. That doesn’t excuse the shortfallings of anyone (chiropractors included), but it does beg the question of “how much is enough?”

    The reason I bring this up is that the rest of the abstract seems to pretty clearly indicate that the chiropractors WERE doing informed consent, but “Results suggest chiropractors view consent as an event rather than a process and revealed important omissions in key areas.” Unfortunately no specifics were described in the abstract, and so not much else can be said from my end. If you have a full version of the study I’d love to see it.

    ***

    With regards to your comments on the pediatric paper, I find it interesting that you come to that statement which – while being absolutely true – assumes that there is a significant risk involved which is not represented in the paper itself. To look at information taken directly from the paper itself, the authors searched 8 medical literature databases from their beginning to June 2004 and managed to find a total of 13 studies which reported spinal manipulation of minors with reported adverse events. So from all the available indexed literature from the beginnings of recorded info to 2004 they were able to identify 14 cases of direct adverse events (9 serious), and 20 cases of delayed diagnosis with most of those not specifying the duration of delay, although in the cases where it WAS specified (assuming the patient was not reporting significant improvements), the attending chiropractor was obviously negligent! Re-eval and considerations for external referral should happen after 2-4 weeks of conservative care with no improvement according to what I know of what is being currrently taught at the colleges and continuing education courses. All health practitioners miss diagnoses … but responsible care requires that other causes or treatments be considered when patient progress is exceptionally slow or absent.

    To get back on track with the article though, even assuming that only 10% of the adverse events were reported over this time frame (using the authors numbers and references), that still makes for a total of maybe 140 cases (90 major) of direct adverse events associated with pediatric chiropractic care in a search covering 100 years of indexed literature. Then considering that (also from the article) children made an estimated 30 million visits to chiropractors in 1997 and 31% of children “sought” chiropractic care, the astronomically low incidence rate estimate would be staggering! How do you propose to get adequate risk assessments when the incidences are most likely in the 1-in-billions range – even assuming only 1% are reported? Even a decade-long study encompassing every practicing chiropractor and chiropractic adjustment wouldn’t be a big enough sample size to provide solid statistical data.

    The study drew the only conclusion it could … there’s not enough evidence to draw any conclusions. They just didn’t mention that it’s unlikely that there even could be enough evidence based on the apparent incidence rate and taking into account vast under-reporting.

    ***

    Your evidence supporting the conclusion that “One can only conclude that the reason why so many chiropractors fail to obtain fully informed consent is that it works against their financial interests.” is exceptionally weak at best, being a transcript of the plaintiff’s attorney’s closing arguments. Not exactly an unbiased source. If that is true in that case, then I’d expect that his malpractice insurance would not have covered the costs of defending him in that case … since my insurance (insures more than 80% of the chiropractors in Canada) clearly states that if you do not use their informed consent sheet that you may well be denied your coverage in the event of a claim. I cover the informed consent with all my patients before proceeding with care and have not had a single person choose to not continue with treatment as a result of the “risk of stroke”. Of course, I don’t use rotational manipulations either, so it becomes essentially a non-issue.

    ***

    I’m sorry, I’m not familiar with the functioning or actions taken by the regulatory board of UK chiropractors, and I’m all read-out for today. Just quickly looking at the quote you posted and considering what myself and others have been trying to design as an automatic reporting option for outcomes and adverse reactions here in Canada, it’s not something you can throw together overnight. The 3 years since that proclamation has been made is really quite early still to expect a fully-functioning system to be in place and used across the profession over there … particularly when there is no successful system anywhere to base a design of one off of. Just because something hasn’t been done yet isn’t because we are not trying … however, chiropractors have the distinct pleasure of not having full support of hospitals, government funding, or big pharma money so we get to spend a lot of time running our practices (businesses) in addition to dealing with moving towards ideal scenarios.

    Something to maybe consider for those who cast stones at my profession … medicine enjoyed general acceptance and funding during it’s growing stages towards more EBM … forgive us if we are a little slow seeing as we have little such support.

  90. Blue Wode says:

    Thank you for your reply, NuccaDoc.

    You wrote: “Your quote from Langworthy was accurate from the abstract. Without access to the whole text I couldn’t critique the study design itself, but I am curious what criteria he was applying as an acceptable level of informed consent – and then if anyone anywhere would not be found lacking. That doesn’t excuse the shortfallings of anyone (chiropractors included), but it does beg the question of “how much is enough?”

    I don’t understand what you mean by “how much is enough?”. You quoted a study which said that “chiropractors should inform all patients of possible serious complications before neck manipulation. This is already emphasized in their current training programs.” What is so difficult about informing *all* potential chiropractic neck manipulation patients about risk?

    I also note that the conclusion of the abstract [http://tinyurl.com/6ajn5d ] says that “Practitioners *felt* that a serious adverse event occurred so infrequently that this, coupled with a lack of convincing evidence regarding the risk associated with certain treatment, rendered the routine discussion of major risk unnecessary”. If you’re prescribed a prescription medication, it’s always accompanied by a patient information leaflet outlining the benefits, side effects (rare or otherwise) and contra-indications of the treatment. What is the *reliable* equivalent regarding chiropractic treatment?

    You wrote: “With regards to your comments on the pediatric paper, I find it interesting that you come to that statement which – while being absolutely true – assumes that there is a significant risk involved which is not represented in the paper itself.
    -snip-
    The study drew the only conclusion it could … there’s not enough evidence to draw any conclusions.”

    The paediatric paper considers the risk/benefit ratio of chiropractic treatment. As there is no credible evidence that chiropractic benefits children in any way, it cannot be anything other than unethical to subject children to the potential risks of treatment.

    Interestingly, the whole neck manipulation/stroke issue is put very succinctly in paragraph 146 of the Statement of Claim of former Canadian chiropractic patient, Sandra Nette, and her husband, David:

    Quote
    “Incredibly, and acting in bad faith, the College [Alberta College and Association of Chiropractors] attacked the new and surprisingly high number of vascular accidents associated with chiropractic services that were published medical literature and reported in the media by demanding a level of evidence it has never demanded of itself.”
    http://www.chirobase.org/08Legal/nette.html

    In other words, why must there be compelling evidence for risk, when, apart from some evidence that it can deliver short-lived pain relief in a sub-group of low back pain sufferers, there is no compelling evidence that chiropractic treatment is effective for any other conditions? Whatever happened to “first do no harm”?

    You wrote: “Your evidence supporting the conclusion that “One can only conclude that the reason why so many chiropractors fail to obtain fully informed consent is that it works against their financial interests.” is exceptionally weak at best, being a transcript of the plaintiff’s attorney’s closing arguments.”

    If not financial, then what other (valid) reasons do you suggest there could be for non-disclosure of risks?

    You wrote: “I’m not familiar with the functioning or actions taken by the regulatory board of UK chiropractors, and I’m all read-out for today. Just quickly looking at the quote you posted and considering what myself and others have been trying to design as an automatic reporting option for outcomes and adverse reactions here in Canada, it’s not something you can throw together overnight.”

    Chiropractors, world-wide, have known about the risks associated with their procedures for decades. With regard to an acceptable amount of time for setting up a reporting procedure, to borrow a phrase from you, how much is enough? Bear in mind that the British Chiropractic Association has already attempted to set up a reporting system which it hoped to see used throughout Europe by 2006, and it appears to have failed (i.e. there’s been a complete absence of PR about it).

    You wrote: “Something to maybe consider for those who cast stones at my profession … medicine enjoyed general acceptance and funding during it’s growing stages towards more EBM … forgive us if we are a little slow seeing as we have little such support.”

    If chiropractic became evidence based, it would simply start duplicating the services already provided by physiotherapists and osteopaths. Why would any chiropractor want to risk diluting his/her income by crowding that market?

  91. Calli Arcale says:

    If you’re prescribed a prescription medication, it’s always accompanied by a patient information leaflet outlining the benefits, side effects (rare or otherwise) and contra-indications of the treatment. What is the *reliable* equivalent regarding chiropractic treatment?

    Agreed. Prescription medicine leaflets even list things not proven to have any relationship to the medicine itself, but which were reported in the clinical trials, though they generally point this out. (Nausea is a pretty ubiquitous side-effect, largely because nausea occurs so often anyway that it’s bound to happen by chance while some of the study participants are on the drug.)

    That said, it’s probably unreasonable to expect all patients to actually read the monograph accompanying their prescription. For one thing, they only get that after they’ve already gotten the prescription filled, which means they’ve already paid money for the drug and would need a new appoint (and copay, assuming they’re insured) in order to express any concerns with their doctor. That’s a larger barrier to acting on the information in the leaflet than many people appreciate. So the process used with prescription pharmaceuticals is still imperfect, and could definitely do with improvement.

    I do think that informed consent procedures could be improved. It’s a delicate balance — informing your patient of enough risks without totally scaring him or her away from even contemplating the benefits. Consider appendectomy. Comes with some pretty scary side-effects, but the alternative is generally a nasty death, so a person scared off by the risk of abdominal surgery is in a real pickle. But at the same time, it would be wrong to minimize the risks. The patient needs to understand the stakes in order to make a good decision, and while surgeons generally do a good job of this (probably because everybody takes more notice when something involves cutting a person open), I think it gets overlooked too easily in a lot of other disciplines. Chiropractic doesn’t visibly screw around with anything critically important. Not like, say, surgical repair of a herniated disk, where the surgeon is messing around with sharp implements very close to the spinal cord. It’s easy to see the risk of the surgery, but it’s not so easy to see the risk of a chiropractic adjustment.

    If chiropractic became evidence based, it would simply start duplicating the services already provided by physiotherapists and osteopaths. Why would any chiropractor want to risk diluting his/her income by crowding that market?

    You might as well ask why osteopaths go into obstetrics. (My second baby was delivered via c-section, which meant the obstetrician on call did it, and it happened to be their one osteopathic OB. I was disappointed that my regular doctor couldn’t do it, but the family practice doctors don’t get to perform c-sections at that hospital.) Don’t MDs have a lock on that market? Why get into it?

    Truthfully, I’m not sure myself. Evidence-based osteopaths are nearly indisinguishable from MDs. Yet they seem to do okay. I guess it’s a bit like the difference between a physicist who starts out with the BA and a physicist who starts out with a BS. They both get enough education in physics to do fine, but one has a liberal arts degrees.

    If chiropractors become evidence based, they will not replace osteopaths; osteopaths are generally able to prescribe medicines and even perform surgery (presuming they have the appropriate surgical qualifications; as with MDs, not all do). They would provide some competition to physiotherapists and osteopaths, as they already do, but as their scope is more limited, I think they would do okay. Low back pain is a widespread complaint; it’s the price we as a species pay for bipedalism. They’d be able to find customers, and they’d have a competitive advantage in being able to significantly undercut the prices of MD office visits. It would mean fewer chiropractors would be able to stomach the more unethical practice-building methods, but I think that would be a good thing. Medicine, any kind of medicine, should be about helping people rather than personal enrichment.

  92. Blue Wode says:

    On 04 Mar 2009 at 9:13 am Calli Arcale wrote: “…it’s probably unreasonable to expect all patients to actually read the monograph accompanying their prescription. For one thing, they only get that after they’ve already gotten the prescription filled.”

    Once would assume that the MD would have already determined that the benefits of the prescription medication would outweigh any serious risks. However, as it appears that the benefits of chiropractic neck manipulations don’t outweigh the risks (especially since equally effective, safer and cheaper options are available), it follows that the technique cannot be justified. If chiropractors do use it, then they should definitely *always* inform patients about the potential risks beforehand.

    On 04 Mar 2009 at 9:13 am Calli Arcale wrote: “ Evidence-based osteopaths are nearly indisinguishable from MDs.
    -snip-
    If chiropractors become evidence based, they will not replace osteopaths; osteopaths are generally able to prescribe medicines and even perform surgery.”

    In the UK, osteopaths are distinguishable from MDs. The following is lifted from the ‘Bad Backs’ chapter of Rose Shapiros book, ‘Suckers: How Alternative Medicine Makes Fools Of Us All’:

    Quote:
    The UK’s 5,000 or so osteopaths require no scientific medical training and so are more firmly established in the ‘alternative’ camp. Very few are MDs and many combine osteopathy with dubious practices such as naturopathy and cranial osteopathy. They are regulated by statute.

    On 04 Mar 2009 at 9:13 am Calli Arcale wrote: “They [chiropractors] would provide some competition to physiotherapists and osteopaths, as they already do, but as their scope is more limited, I think they would do okay. Low back pain is a widespread complaint…”

    I’m not sure if an evidence-based chiropractic profession would be able to find enough customers. Bearing in mind that most chiropractors already treat low back pain (and that there are other cheaper treatment options available which are just as effective, e.g. exercise, OTC analgesics), it’s interesting to note that a recent article in Chiropractic & Osteopathy, reported that chiropractic’s market share is dwindling:
    http://www.chirobase.org/01General/respect.html

    The following doesn’t indicate a too bright a future for chiropractic either:

    Quote:
    “Although four possible scenarios were given by Dr. Bezold, it’s clear the worst case scenario, Scenario #2: Downward Spiral, is the most accurate now inasmuch he said 15% of DCs have quit the profession. Meanwhile, there has been a 39% drop in chiro education student enrolment from 1969-2002 and, while the use of CAM in general has increased, the largest decrease occurred for chiropractic (9.9% to 7.4%) according to the recent Eisenberg study. Indeed, there’s little to cheer about when faced with the hard facts about this profession.”

    http://chirotalk.proboards3.com/index.cgi?action=display&board=outlook&thread=1112 967697&page=1

    On 04 Mar 2009 at 9:13 am Calli Arcale wrote: “They’d be able to find customers, and they’d have a competitive advantage in being able to significantly undercut the prices of MD office visits.”

    That’s not universally true. For example, here in the UK, most of the population relies on NHS medical care, whereas nearly all chiropractors work in (expensive) private practice.

  93. Calli Arcale says:

    Once would assume that the MD would have already determined that the benefits of the prescription medication would outweigh any serious risks. However, as it appears that the benefits of chiropractic neck manipulations don’t outweigh the risks (especially since equally effective, safer and cheaper options are available), it follows that the technique cannot be justified. If chiropractors do use it, then they should definitely *always* inform patients about the potential risks beforehand.

    Oh, I agree. Don’t get me wrong. Chiropractors should be informing patients of this risk before attempting neck manipulations. I just don’t think the analogy to prescription meds is entirely accurate, since I’m not convinced those warnings actually get read by the patient, and we’re talking about informed patient consent here, not just the doctor knowing what’s best and making a risk/benefit decision for his/her patient.

    And though most doctors do carry out their jobs well, I have known some who did not take much care with that sort of thing. One was a psychiatrist who put me on Ritalin, knowing that I was on Seldane-D (contains pseudephedrine). I fired her after my first episode of arrhythmia, but probably should’ve made a complaint so it was on record. Live and learn.

    For example, here in the UK, most of the population relies on NHS medical care, whereas nearly all chiropractors work in (expensive) private practice.

    Good point about cost; I’m speaking from an American perspective and don’t know enough about how it is in the UK.

    The OTC analgesics are cheaper than chiropractic care, assuming we’re not talking about a pain that is defying OTC analgesics, but I think some of that is really because of the deceptive techniques many chiropractors use to increase business, such as excessive office visits for single problems and “maintenance care”. It is true that their revenue stream will be much smaller if they aren’t providing maintenance care anymore (the main reason why so many chiropractors want to be recognized as primary care physicians), but I think they could make a go of it in an evidence-based way. Sure, they won’t be able to afford a BMW and a house out on Lake Minnetonka (one of the ritzy parts of the Twin Cities), and will instead be on a par with LPNs, but that probably better befits their level of training anyway. I would think that chiropractors, if they were truly evidence-based, would probably only be able to operate in a group practice, especially one which mostly employs MDs and/or DOs, since the general medical care would cover the overhead costs.

    Then, going to see the chiropractor would be similar to going in for a lab-only visit. You wouldn’t have to see a doctor or pay for an office visit. You’d just see the chiropractor and then be on your way.

    One drawback: health care corporations may then start seeing chiropractors as less expensive than certain physiotherapists, or might lay off a DO, transfer the regular caseload to the MDs, and just have the manipulation done by a lower-paid chiropractor. This is what is happening with nursing, and it is a disturbing trend.

  94. daijiyobu says:

    Regarding neck manipulation, chiropractor Dan Golaszewski tells us

    at CBS TV station WYOU in “Holistic Health & Medicine” http://pahomepage.com/content/fulltext/?cid=73371

    that nervous system related complaints can seriously be treated with high cervical neck adjustment, and that the alignment of the middle spine is very important in terms of the function of the pancreas per DM, playing a “huge role.”

    There’s an ND and an LAc there too, for good measure.

    -r.c.

  95. nwtk2007 says:

    Will the medical establishment ever give full disclosure and true informed consent ?

    I doubt it. But those darn chiropractors should! Right.

    Given the true dangers of medicine, why are they not the first to be required to give true and full disclosure in their “informed” consent?

    Consider this – http://ourcivilisation.com/medicine/usamed.htm

    Oh those dangerous chiropractors!

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