Jul 02 2010
Not to worry! Chiropractic Board says stroke not a risk of cervical manipulation.
Back in January, the Connecticut Board of Chiropractic Examiners held a four-day hearing to decide whether chiropractors must, as a part of the informed consent process, (1)warn patients about the risk of cervical artery dissection and stroke following neck manipulation and (2) give patients a discharge summary listing the symptoms of stroke.1 On June 10th, the Board of issued a written opinion that stroke or cervical artery dissection is not a risk of cervical spine manipulation, so no warning is necessary. Presumably, although it is not specifically mentioned in the decision, no discharge summary is required because, if there is no risk of a stroke after neck manipulation, what would be the point?
Background
Janet Levy and Britt Harwe are two Connecticut women who suffered strokes resulting from neck manipulation by chiropractors. That’s not just their lay opinion, it’s the opinion of their respective treating physicians, right there in the medical records.
Each decided that some good should come of their unfortunate situations, so each formed a non-profit and began warning patients of the risk of stroke following manipulation. Victims of Chiropractic Abuse, Levy’s organization, put giant ads on the sides of busses in Bridgeport, CT., much to the chagrin of the folks at the University of Bridgeport. Within the hallowed halls of the University (Go Purple Knights!) is a College of Chiropractic, a College of Naturopathic Medicine, and the Acupuncture Institute. The chiropractors demanded that the ads be taken down, which got exactly nowhere.
Some chiropractors also began harassing Levy and Harwe, calling them Nazis and KKK members, for example, and threatening their personal safety and that of their families.(What is it with the pseudoscience crowd and calling people Nazis? Perhaps, having used up their entire supply of imagination creating their nostrums, they are reduced to these tired tropes.) The FBI recommended Levy and Harwe have one of the harassers arrested, which they did, and that calmed things down for a while.
Levy and Harwe knew that most chiropractors were not warning patients on their own, so they pushed for a state law requiring them to do so. After a great deal of effort they got before the state legislative Public Health Committee with the help of Sen. Len Fasano. At the committee hearing a compromise was reached between the proponents for a required warning and the chiropractic faction.
Sen. Fasano described this agreement in his testimony at the hearing before the Chiropractic Board:
I proposed legislation to the Public Health Committee, which legislation sought that some sort of informed consent be given by chiropractors to patients upon the … manipulation of the neck.
There were numerous discussions on both sides of that legislation, if I may, and it was sort of determined that perhaps the best way of handling this would be what we call a Take Away Form, where, for the first time that you [are] treated [with] the manipulation of a neck, the chiropractor would give you a Take Away Form, which discussed the risks and, also, symptoms, should you have some issues with respect to a stroke. These are the things you look at, and you should seek treatment right away.
However, it was impressed upon Senator Harris, [who] is Chairman of the Public Health Committee and myself, as the proponent, that rather than putting [it] in a state statute, the better way of doing this is to allow this Board [of Chiropractic Examiners] to govern itself, and, as a result, the matter was not pressed forward at the senate ….
Both sides agreed that a Take Away once a year upon the manipulation of the neck is reasonable, however, we did not put [it] in [a] state statute, because we believe it was better governed by the policing body [i.e., the Board].
(From Levy, I learned that she lived up to her part of the agreement, which was to take down her ads and not speak out against chiropractic while the matter was before the Board for consideration.)
Upon questioning by one of the attorneys, Sen. Fasano reiterated his understanding that “the chiropractors and the victims were coming to this Board in unison to ask for a Declaratory Ruling.” Sen. Fasano confirmed that this was Sen. Harris’s understanding as well. But by the time of the hearing, it was clear to Sen. Fasano that the chiropractors had no intention of living up to their end of the bargain and that they were dead set against any sort of discussion of the risks with patients and against giving patients a list of stroke symptoms to take home.
The Hearing
The hearing began with a bang on January 5th when the Connecticut Chiropractic Association and the Connecticut Chiropractic Council made a motion to disqualify the only public member of the Board participating in the proceeding, Jean Rexford, because they thought she might be in cahoots with one of the stroke victim organizations. This allowed the lawyers to warm up their vocal cords. By the end of almost 30 pages of transcript on this topic alone they were in fighting form. The chiropractors lost round one and Rexford remained to become the only dissenting vote in the Board’s ruling.
I attended the first two days of the hearing and it was clear to everyone from the get-go that the chiropractors would fight tooth and nail against a rule requiring any disclosure of risk. It was one of those “kumbayah” moments in chiropractic history when a temporary truce is declared in their internecine war and chiropractic organizations of all stripes circle the wagons.
This was no better exemplified than by the fact that J. David Cassidy, D.C., Ph.D., Dr.Med.Sc., lead author of the study, “Risk of Vertebrobasilar Stroke and Chiropractic Care,” Spine 33 (2008) S176-S183 [the “Cassidy study”] was required, in order to testify, to appear as a representative of the International Chiropractors Association (ICA), the organization of the super-straight-Daniel-David- Palmer- Innate-Intelligence chiropractors. I’ll bet he doesn’t put that on his C.V.
Here’s the testimony of George Curry, D.C., Chairman of the Board of ICA’s state affiliate, the Connecticut Chiropractic Council, describing the ICA’s beliefs:
Chiropractic science, as taught in the chiropractic curriculum in an accredited chiropractic college, involves the scientific aspects of the study of the human body and the science of detection and correction of the vertebral subluxation complex.
The art refers to the particular technique that a Doctor of Chiropractic would choose to reduce or correct a subluxation, and the philosophy is the where by [sic] or rationale that someone would investigate the spine as a cause of ill health.
The very basis upon which the profession was founded was that the body is a self-healing, self-regulating mechanism and has inherent recuperative powers, and that if those recuperative powers are interfered with, then it could cause of a loss of health.
Dr. Cassidy should hope and pray that this hearing transcript never, ever gets into the hands of an attorney who is preparing to cross-examine him.
Dr. Cassidy was plopped down into the middle of the hearing as a witness for the chiropractors, even though no one had listed him as a witness, as was required, prior to the hearing. This is why he had to pretend to be speaking for the ICA, as they were allowed to substitute him for the previously listed ICA witness. Apparently, we had done enough damage that the chiropractors felt they needed to bring in the man himself to defend his study.
The problems with the Cassidy study were explained on SBM in an excellent post by Dr. Crislip (which, this being Dr. Crislip, also discusses hangings, The Who v. Motorhead, and being over age 50). The study’s hypothesis is that the association between chiropractic care and stroke can be explained by patients going to the chiropractor for headache and neck pain caused by a pre-stroke vertebral artery dissection. In other words, the pre-existing dissection causes the stroke, not the chiropractor’s twisting the patient’s neck. Dr. Crislip slices and dices the study nicely to show how this conclusion is not supported by the data.
So what did the chiropractors say, under oath, about the need for informed consent regarding neck manipulation and stroke? To quote one chiropractic witness (which is pretty much to quote them all, as their testimony on this point varied little): “There is no scientific evidence of a cause and effect relationship between a chiropractic neck treatment and a subsequent stroke.” That’s right — “no scientific evidence.”
Irony of ironies! The profession that has studiously avoided the scientific method for over 100 years suddenly discovers the value of science. A sort of jailhouse conversion, if you will.
And how did they know this? The Cassidy study. Even though the Cassidy study says, right there on page S181, that “[o]ur results should be interpreted cautiously and placed into clinical perspective. We have not ruled out neck manipulation as a potential cause of VBA strokes.” (Emphasis added.)
In another big dose of irony, decades of case reports of stroke following neck manipulation introduced into evidence were dismissed by one chiropractor, who testified that these constituted mere anecdotal evidence. This from the profession for which anecdotal evidence, dressed up as “clinical experience,” repeatedly trumps scientific plausibility.
I was permitted to give testimony before the Board as a “lay witness” on behalf of the non-profit Campaign for Science-Based Healthcare. My testimony consisted of channeling the post by Dr. Crislip and another post by Dr. Hall about how chiropractors and their trade associations were misrepresenting the study’s results to the public.
I also quoted from two neurology texts which addressed the anatomical aspects of cervical manipulation and artery dissection, both concluding that manipulation could indeed cause dissection:
The extracranial VA (vertebral artery) is also susceptible to traumatic injury because of its encasement in the bony part of the cervical canal. Either spontaneously or after minor trauma from neck manipulation, the VA may be injured, and dissection with luminal compromise and clot embolization may occur. This is a common cause of stroke, especially in younger patients without other vascular risk factors.
Samuels, Office Practice of Neurology (2nd ed. 2003), 372. (Emphasis added.)
Dissection of the extracranial carotid and vertebral arteries accounts for approximately 80% to 90% of all cervicocephalic dissections…. The vertebral artery is most mobile, and most susceptible to mechanical injury, at the C1-C2 level, as it leaves the transverse foramen of the axis and abruptly turns to enter the intracranial cavity …. The C1-C2 site is involved in one half to two thirds of all vertebral artery dissections and in 80% to 90% of rotation-related dissections.
Mohr, Stroke: Pathophysiology, Diagnosis, and Management (4th ed. 2004), 1059. (Emphasis added.)
Also testifying for “our side” was the indefatigable Canadian pediatrician and chiropractic critic, Dr. Murray Katz. If you are not familiar with Dr. Katz’s work, suffice it to say that chiropractors like Dr. Katz every bit as much as anti-vaxers like Dr. David Gorski. He undermined the Cassidy study’s methodology and hammered on the susceptibility of the vertebral and carotid arteries to injury from manipulation.
Three survivors of stroke after manipulation and three relatives of patients who died also testified. You could hear a pin drop.
The most compelling aspect of their testimony was how remarkably similar each story was to the others:
- the nonsensical reasons for having neck manipulation (sore shoulder, “maintenance care,” lower back pain);
- the youth of the victims, all under 45 years old, one only 20 years old;
- symptoms of stroke appearing within minutes to hours after manipulation;
- clueless chiropractors who had no idea what was going on while their patients were experiencing stroke symptoms, and who gave their patients ridiculous advice (toxins were being released, take Advil) or did nothing at all instead of sending them straight to the hospital;
- the patients’ and emergency doctors’ frustrations at not being able to figure out the source of the patients’ symptoms — the patients were not connecting symptoms with manipulation because they had not been informed of the risk of stroke;
- the “aha!” moments of hospital doctors when they learned their patients had undergone chiropractic manipulation;
- the lingering neurological deficits of the patients who survived and the devastation suffered by the victims and their families.
There could have been no better summation for the victims and their allies than the testimony of Douglas Fellows, M.D., chairman of Diagnostic Imaging and Therapeutics at the University of Connecticut Health Center, a member of the Connecticut Medical Examining Board, and himself a former physical therapist who had used cervical manipulation in his practice. He appeared in support of the Medical Examining Board’s previously filed statement urging that patients be informed of the risk of stroke following manipulation.
Dr. Fellows confirmed the Medical Board’s opinion that vertebral artery dissection can be caused by cervical manipulation. He also testified that, although the risk of stroke and death were remote in the procedures he performs as an interventional radiologist, he always tells patients of this possibility. In response to a question from a Chiropractic Board member — which contained the assertion that “we haven’t established any causality. At most, we’ve established a temporal relationship” — he replied:
We don’t know what the risk is, as far as the percentage risk, but it’s the harm that we worry about, the potential, the devastating effect of paralysis or death, and that’s what we do [referring to warning his patients of the risk of stroke from certain procedures, even thought the risk is remote].
The Decision
Although the Board had previously voted 4-1 against the necessity of a warning, the written “Declaratory Ruling Memorandum of Decision” was not issued until June 10th.
In its decision, the Board correctly stated that, under Connecticut law, “[t]he materiality of a risk is determined by weighing the benefits of a procedure, against the frequency and severity of the potential harm.” But, this being chiropractors, who simply discard facts not fitting their paradigms, that was the last mention of “benefits” and “severity.” From then on, the decision focused solely on “frequency.”
The Board relied heavily on the Cassidy study in making its decision that “the evidence is sufficient to establish that a stroke or cervical arterial dissection is not a risk or side effect of a joint mobilization, manipulation or adjustment of the cervical spine performed by a chiropractor.”2 It is worth repeating that the study itself states “[w]e have not ruled out neck manipulation as a potential cause of some VBA strokes.” However, the Board explained this away by noting that “Dr. Cassidy credibly testified ‘this is a study that raises real doubt about the association being a risk …’” In fact, according to Dr. Cassidy’s testimony, he’s become so doubtful he has absolved himself from a previous admission that he caused a patient’s stroke by manipulating her neck.
The Board went on to explain that “[s]tatistically, what scant evidence exists of the incidence of stroke following a … manipulation … of the cervical spine was found primarily in persons under age 45. As provided in the Rothwell study, ‘it remains to be explained why an association between chiropractic manipulation and [vertebrobasilar accident] was observed only in the young. If an association were to exist, one would expect that it would exist regardless of age.’”
If only the Connecticut Board of Chiropractic Examiners had read Science-Based Medicine before issuing its ruling!
Dr. Crislip, who has answered many questions here recently, had an answer to this very question months ago in his SBM post on the Cassidy study.
In the over 45 age group, strokes due to chiropractic could be lost in the sea of strokes due to other reasons, and since we do not know if there were a dissection or blood clot as a cause of strokes, it is hard to conclude that there were no extra strokes from chiropractic. The study was not powered to determine the rare event of a chiropractic event against the background to usual stokes in the elderly. The mean age in this study was 63 ….
Young people should not have any stroke. In the young, vertebral artery dissection is a common cause of a rare event. It is also the worry from chiropractic neck manipulation. If you could find an effect of chiropractic, it would be in the young. And they do. The people who have an increase in stroke are those under age 45. And it is a big association: odds ratios from 3 to 12.
The association is most noticeable in the first 24 hours after seeing a chiropractor. Usually if you rip an artery it is symptomatic right away. Again, we do not know if these people had dissection or not. We only know they had stroke of some sort, within a day after seeing a chiropractor. One would predict that if there were an association between chiropractic and stroke you would most easily find it in the young and the effect would be most noticeable in the first day or so after the chiropractic visit.
And this article confirms this association.
I even cited to Dr. Crislip’s post in my brief and provided a link! So much for Board’s self-proclaimed “careful and thorough review of all of the testimony and documentary evidence.”
And speaking of said “careful and thorough review,” the decision did not explain how Board managed to avoid the basic anatomy of the human neck, which strongly suggests that twisting it forcefully is really not a good idea.
The Board did allow that “the evidence is sufficient to establish that spinal manipulation on persons who are having an acute stroke or cervical arterial dissection is not within the standard of care.” Well, that’s certainly a relief!
The Board also said that a chiropractor who wanted to “discuss these issues” [presumably, the non-existent stroke risk] with a patient could do so without being in violation of the standard of care.
So, even though the Cassidy study says that patients with headache and neck pain can be presenting with vertebral artery dissection, and that there is no screening procedure to determine whether patients presenting with headache or neck pain are at risk of VBA stroke, chiropractors should feel free to manipulate the neck without warning of the risk of stroke. Why didn’t the Board decide that the evidence they find so compelling dictated the much safer option of not using manipulation on anyone with headache or neck pain?
Post-hearing
What does this ruling mean?
Unfortunately, young people will continue to have debilitating strokes and some will die following cervical manipulation.
But the fight was not for naught. Many TV viewers saw scary videos of necks popping at the hands of chiropractors during media coverage of the hearing. Awareness of the risk of stroke was raised — not everyone believes the chiropractors when they deny it. “Our side” got great press.
Janet Levy can resume her bus ads in Bridgeport. Sen. Fasano will again introduce legislation making chiropractors inform their patients of risk. It failed this year but he vows to re-introduce it next year. And Levy has just filed suit in Connecticut against two state chiropractic organizations citing them for, among other things, failure to warn patients of the risk of stroke following manipulation.
The Board’s declaration that there is no risk of cervical artery dissection and stroke following manipulation is a finding of fact and not binding on the courts. As is their ruling that informed consent does not require a warning. Under Connecticut law, whether a warning of risk is required is determined by the “reasonable patient” standard, that is, what would a reasonable patient consider important in making his decision whether to undergo a particular procedure. One of the very purposes of the reasonable patient standard is to prevent practitioners from setting low standards and then claiming they’ve abided by their profession’s standard of care. Imagine the chiropractor sued for failure to warn who erroneously thinks he’s been inoculated against malpractice claims by following the Board’s ruling. Surprise!
As a matter of fact, the hearing transcript and videotape are now in the hands of plaintiffs’ personal injury attorneys, who will mine it for useful information. A couple of years ago the American Justice Society (formerly known as the Association of Trial Lawyers of American) started a chiropractic interest group (that is, interest in suing chiropractors for personal injury). The section collects and distributes such information for AJS members.
The chiropractors may have won this battle, but they could be losing the war.
Notes
- The Petition for Declaratory Ruling filed by the Connecticut Chiropractic Association, which set this proceeding into motion, used the term “cervical artery dissection” in describing the risk of cervical manipulation at issue before the Connecticut Board of Chiropractic Examiners. The Board also used the term “cervical artery(ies)” in its ruling and otherwise during the proceeding, as did some of the other participants. “Cervical artery” is an imprecise term as there is no such anatomic structure. Apparently, its use refers collectively to the vertebral and carotid arteries.
- At least I think that is the Board’s decision, as it is repeated several times and is made “Finding of Fact” number 3 in the Memorandum of Decision. But the Board also states a couple of times, once in its actual “Order” at the end of the written decision, that the “evidence is insufficient to conclude that stroke or cervical artery dissection is a risk or side effect of” cervical spine manipulation. Deciding that the evidence is sufficient to establish there is no risk is quite a different thing than deciding the evidence is insufficient to establish there is a risk.
199 Responses to “Not to worry! Chiropractic Board says stroke not a risk of cervical manipulation.”
Great post.
This explains the billboard I saw in or outside of Hartford last week as I was passing through on Interstate 84. It said something like, “Chiropractic can cause a stroke.” Being an avid reader of SBM, I was glad to see it but wondered where it came from and who paid to put it up. Now I know.
Great post, thanks!
I have one nit to pick: Cassidy (and DCs in general) does not have a legitimate doctorate and does not merit that honorific (‘doctor’). I am more confrontational than many others; but calling him ‘doctor’ makes it sound like he may represent a legit difference of opinion with real, health professionals.
Thanks for your service.
Excellent post.
Jann Bellamy wrote: “To quote one chiropractic witness (which is pretty much to quote them all, as their testimony on this point varied little): “There is no scientific evidence of a cause and effect relationship between a chiropractic neck treatment and a subsequent stroke.” That’s right — “no scientific evidence.” Irony of ironies! The profession that has studiously avoided the scientific method for over 100 years suddenly discovers the value of science. A sort of jailhouse conversion, if you will.”
It’s interesting to note that the above concern was also highlighted in paragraph 146 (p.55) of the Statement of Claim filed by tetraplegic Canadian chiropractic victim, Sandra Nette, in her multi-million dollar lawsuit:
Quote:
“Incredibly, and, acting in bad faith, the College [Alberta College and Association of Chiropractors] attacked the new and surprisingly high number of vascular accidents associated with chiropractic services that were published medical literature and reported in the media by demanding a level of evidence it has never demanded of itself. It maintained that the causal link between strokes and chiropractic adjustment remained unproven.”
http://www.casewatch.org/mal/nette/claim.pdf
For those wishing to watch the online recordings of the January 2010 Connecticut State Board of Chiropractic Examiners Public Hearing on Informed Consent for Chiropractic Procedures, they can be viewed via this link: http://www.ctn.state.ct.us/ondemand.asp?search=chiropractic
I don’t know if anyone else caught this?
“In its decision, the Board correctly stated that, under Connecticut law, “[t]he materiality of a risk is determined by weighing the benefits of a procedure, against the frequency and severity of the potential harm.”
Weighing the benefits of a procedure?
But there are not any benefits only risk!
Happy Camper:
“Weighing the benefits of a procedure?
But there are not any benefits only risk!”
PM Well, chiropractic care may elicit placebo-type benefits, and the “no benefits” argument rarely seems to prevail while patients are claiming otherwise and some kinds of clinical study show substantial patient satisfaction. Chiropractic always gets the benefit of the doubt.
Another tack- chiropractic’s own scientific papers show no advantage of neck manipulation over safer treatments such as massage.
Taking that into account, even the faintest potential for serious risk should forbid the practice, except possibly as a late resort for well-informed patients who are not responding to other measures.
@pmoran
I know, I know
My best friend swears by chiropractic for his back problems. I think most people use chiropractic only for back problems not realizing that a physical therapist or sports massage would help more without risk or the trappings of pseudoscience, and be cheaper in the long run.
I found this video
http://vids.myspace.com/index.cfm?fuseaction=vids.individual&videoid=2679124
Do chiropractors do something that I wouldn’t do while giving my girlfriend a shoulder/neck rub? A stroke is a scary thought!
And smoking cigarettes does not cause lung cancer. The tobacco industry says so.
There was a famous case here almost a decade ago. A physician I know lost his father, also a physician, to a stroke after a manipulation by a chiropractor. Here’s one of the stories:
http://chealth.canoe.ca/channel_health_news_details.asp?news_id=3669&channel_id=0
In this case, chiropractors were not denying the risk of stroke, but defended it as causing fewer deaths than anti-inflammatories. Funny, how often do I see patients taking anti-inflammatories on the advice of their chiropractors? After almost every visit, patients report that their chiro recommended Robax Platinum or Advil after their manipulations for a few days. Of course, the patients always said that the manipulation is what made them better…. despite being in pain for several days afterwards.
One wonders whether the complainants are hoping that the chiropracters will ignore British precedent and sue for defamation. Although I do note that Connecticut doesn’t have a SLAPP law.
Who knows? Maybe we could end up with two good things for the price of one.
The appeal to evidence by the chiropractic board actually further shows just how much they misunderstand the process of applying evidence to medical practice.
The issue of stroke after neck manipulation is best thought of as a rare and serious complication of a procedure. Rare events are not well captured by randomized prospectively obtained evidence as trials powered to determine treatment efficacy are not typically powered to detect rare events. In general terms a 1 in 10,000 risk of death would be potentially significant especially for a treatment that involved repeated exposure or was very common, but such an event could potentially be missed in a trial powered to prove efficacy, even if the trial was very large. Retrospective case control series for common diseases are also unlikely to answer a causation/correlation question and stroke, even in those under 45 is common enough to make the background noise of such a study difficult to cope with.
For most drugs and treatments post marketing or post application surveillance is how rare but serious complications and side effects are detected. That is, when the product is applied to the population unusual and serious events are reported either to the manufacturer or more commonly to a government agency.
A good example from medicine is the antibiotic telithromycin, a promising and heavily marketed drug that proved to have very serious but very rare side effects detected after release to the marketplace and resulting in much restricted use of the drug. Telithromycin was initially marketed as a first line agent for a number of infections, and currently it would be difficult to find a doctor (other than an infectious disease specialist) who routinely uses it.
The threshold to warn patients about rare but potentially serious side effects is the question ‘would a regular prudent person want this information?’. Mainstream medicine does in fact use and rely on anecdote to detect rare events associated with our treatments. The threshold for proof of treatment efficacy relies on well conducted and controlled research, but suspicion of significant side effect is another matter entirely, and when there is reasonable suspicion of a significant side effect patients should be warned in advance, even if definitive proof does not yet exist.
A couple months ago, while visiting my parents, I learned the details of my uncle’s death which occurred years ago while I was living abroad country. All I had known those years was that he had died of a stroke and that he hadn’t wanted to go to the hospital. Now I learned the stroke occurred as he was being driven home from a chiropractic appointment. (He lived in central Wisconsin and the chiropractor was in Upper Michigan.) When the stroke occurred, he indicated to his wife that he wanted to be taken back to the chiropractor’s office — and he died on the way. None of the relatives had any suspicion that the stroke might have been the result of a chiropractic neck adjustment.
Thanks for the informative post. I hope the billboard campaign takes off.
@ (Doctor) Joe,
Let’s not perform any more medical or chiropractic procedures
that can cause stroke or death. OK?
@ LindaRosaRN
Can you prove your last post?
rwk said “Let’s not perform any more medical or chiropractic procedures that can cause stroke or death.”
That would be a pretty stupid reaction, like saying let’s ban cars because traffic accidents kill people. Instead, let’s not perform any more medical or chiropractic procedures that are more likely to harm than to help, and let’s let patients know when there is a risk of death from any treatment so they can make an informed choice.
@ Harriet Hall
I was being facetious. Now to be serious.
How many people actually read those multipage medical
consent forms before they have a procedure nowadays.
Maybe chiropractors should adopt complex forms like those used
by medics that are quickly scanned by the patient and signed .
And since it wouldn’t be the usual SBM rag without an ad hominem,
I’ll throw one in:
http://www.scribd.com/doc/25785402/DEATH-DUE-TO-MEDICAL-INTERVENTION
In 20 years, I’ve not killed ,stroked or disc herniated anyone,
how about you?
rwk,
That’s not an ad hominem, that’s a tu quoque logical fallacy based on a misconception. See my article on “Death by Medicine” at http://www.sciencebasedmedicine.org/?p=136
You say “I’ve not killed ,stroked or disc herniated anyone.” How do you know for sure? Do you have a comprehensive, systematic method of followup? I’ve heard more than one anecdote where a stroke patient never went back and told the chiropractor. And even if you’ve never personally seen these complications, that doesn’t mean the risk doesn’t exist. I’ve been driving for decades without an accident, but that doesn’t mean I won’t have one tomorrow.
And as for those complicated consent forms, at least the fact that they have to sign a form lets the patient know there is a risk. Many chiropractors lead their patients to think there is no risk at all.
“Maybe chiropractors should adopt complex forms like those used by medics that are quickly scanned by the patient and signed .”
Of course they should. Then why are you so afraid of them? Let patients know what the risk-benefit ratio is. That reference you gave has so many errors, I wouldn’t know where to begin. About the only partially correct statement is the first one.
“In 20 years, I’ve not killed ,stroked or disc herniated anyone,how about you?”
Can you prove that you haven’t? You probably have. You, and luckily for you the patient also, are just not aware of it.
@Harriet Hall
Do you have a comprehensive, systematic method of followup?
Yes, unlike many medical establishments that don’t call back or follow up.
@ weing
If a chiropractor tells a patient he might have a stroke following
cervical manipulation ( I’d say) he or she is likely to decline.
If a medical doctor tells a patient they have to have a procedure,
( in my experience) they’re likely to go through with it. How many
doctors or nurses explain to the patient all the possible risks vs benefits involved? In my experience, few.
I was taught in school to do informed consent and for what it’s worth do provocative testing before manipulating someone’s neck.
That idea gets driven home at most state assn. sponsored risk
management CME courses,once a year.
Prove me wrong.
Prove that provocative testing removes the risk.
“If a chiropractor tells a patient he might have a stroke following cervical manipulation ( I’d say) he or she is likely to decline.”
That’s called weighing the risk vs the benefit.
“If a medical doctor tells a patient they have to have a procedure,( in my experience) they’re likely to go through with it.”
They are aware of the risks and benefits. That’s what counts. Some will refuse the procedure or the medication. It’s their quarter.
“How many doctors or nurses explain to the patient all the possible risks vs benefits involved? In my experience, few.”
I tell the patient about the important risks. Telling them all the possible risks is not feasible.
# rwk – “How many people actually read those multipage medical
consent forms before they have a procedure nowadays.”
Well, me, for one. My son has had three minor outpatient, two inpatient surgeries. All of which had one page consent forms which I read. Each time the nurse (outpatient) or NP (inpatient) went over the form with me as well as covering pre-op and post-op care. Once there was medical terminology I didn’t understand, which the NP explained. In all cases the surgeon had already verbally discussed the more significant risks/benefits with us and answered questions before the meeting with the Nurse/NP to go over the consent form which included rarer complications.
Really, I have no idea why you wouldn’t read such a consent form on a pre-arranged procedure. I could see that an emergency procedure may be a different matter.
I will admit that I did not completely read our mortgage paperwork, though.
Every doctor who has performed a procedure on me has either personally explained the risks and benefits or had someone such as a nurse explain it to me. For more serious procedures, I generally got risks/benefits explained to me by both the physician and one or more nurses.
Perhaps you have merely had incompetent doctors.
In my experience, patients will tend to accept medical advice, as you say — but they will accept it no matter what kind of “doctor” gives it. Few patients discriminate between an MD and DC. Why is it that you are so convinced that explaining risks of chiropractic manipulation will drive away all your customers, but equally convinced that no explanation of risks/benefits can ever possibly be meaningful in medicine? Do you think patients are mindless automata when seeing doctors but nervous nellies when seeing chiropractors?
This may not be your intent, but the way you frame your objections sound as if you are more concerned about losing business than about your patients’ safety.
BTW, what Hall was referring to (with respect to followup) was not mere phone calls. She was referring to studies that follow patients for weeks or even years in a consistent manner. Obviously no doctor follows up with their patients that way, but it is expected that for any new drug or surgical technique or whatever, this sort of rigorous followup will be done for a representative sample of the patient population. Just calling people up on the phone isn’t exactly controlled or consistent, and is not going to give you the sort of data you need to really understand the risks and benefits of your procedures.
But then, maybe that’s okay for you. Maybe all you really care about is patient satisfaction, not patient outcomes, and in that case perhaps a followup phone call really is adequate. But I would prefer my doctors see me as a patient rather than a customer.
“I was taught in school to do informed consent and for what it’s worth do provocative testing before manipulating someone’s neck.”
Why, if there’s so risk of stroke from VAD?
PM
i.e. “no risk”.
rwk on 04 Jul 2010 at 6:18 pm wrote “@ (Doctor) Joe,
Let’s not perform any more medical or chiropractic procedures
that can cause stroke or death. OK?”
Although I have a legitimate doctorate (as opposed to a DC) I don’t appreciate that honorific except in settings where it is clear that I am a scientist, not medical person. I always invited my students to call me Joe, rather than mister, doctor or professor; and I invite you to do the same.
Some of your colleagues don’t appreciate the acknowledgment that your ilk cause strokes: http://www.dynamicchiropractic.com/mpacms/dc/article.php?id=53030 That article is about chiros who promise not to snap your neck.
I note that in the case of Sandra Nette (linked, above, by Blue Wode) she arrived at the hospital unable to communicate. When her husband arrived, the neurologist, noting the bilateral VAD, asked “Chiropractor, right?” Yes, bilateral artery dissection is chiropractic’s unique, signature contribution to health (rather, damage to it).
@rwk, what do you think you do by twisting/snapping necks that cannot be achieved, more safely, otherwise? I suspect the risk/benefit ratio is dominated by the ‘benefit’ being zero; which leads to an unacceptably large number (division by zero, emphasizing risk).
@ Joe,
First of all I don’t care what you or anybody else calls me. Noe of us
are any better or higher up than anyone else. You’ve decided that
some doctorates are more honorific than others.
Second, referring to manipulation as “snapping necks” just shows
your level of knowledge of what not just chiropractors do.
Have you read any current technique books nor any directives from
chiropractic associations that say go ahead and twist,snap or ( you
forgot to say) crack necks?
Did I mention by the way that I snap or twist necks?
So, this blog just ends up being an argument, usually one sided.
You’re as guilty of ad hominem tu quoque and other diversions as anyone else (by the way Harriet Hall is there a difference ?).
I just received a link to a youtube video showing a chiropractor practicing in his office. It appears this is a promotional video for the chiropractor. In it you will see neck and other “adjustments,” treatment of children, “adjustments” using the Activator method (that’s the metal gadget that the chiropractor is poking people with), what appears to be leg length testing (a chiropractic diagnostic technique) and some sort of arm shaking — don’t know what that is.
http://www.youtube.com/watch?v=NuUM70kmUSg&feature=related
Here is an actual cervical adjustment, also from youtube:
http://www.youtube.com/watch?v=y_3si7-Pn1A&feature=related
rwk,
Please enlighten us. What are your indications for manipulating necks? Why do you do neck manipulation rather than gentle mobilization? Why do you think you can reduce risk by provocative testing?
If you think our information is one-sided, you are welcome to present the other side. But only if you can provide supporting evidence.
“I was taught in school to do informed consent —”
So, what are you here for, rwk?
You seem to be allowing that neck manipulation can cause strokes, and you say you were taught about the need for informed consent.
Yet you are carrying on as though it an impertinence to despise those chiropractors who pretend there is no problem.
I suspect you are an older chiropractor, trained in the days when the chiropractic profession itself accepted without reservation that neck manipulation can cause stroke.
Well I’m glad I saw this because even though I loathe chiropractic and all their marketing gimmicks, I did used to like an “adjustment” now and then for extreme neck and shoulder tension. One old gal would put me on a series of worthless machines like the Spino-O-Lator while I waited my turn. All I wanted was the massage and neck pop. The tightness seemed to dissipate quicker that way, though it may have been an illusion.
I would go once a year maybe, and never sign up for continuing treatments which I thought were a ripoff. And chiro for infants? Egads. I recognized the old chiro establishment as oldtime health food & vitamin nuts and alt-med quacks, which were plentiful in SoCal (and my family).
Eventually I stopped going because exercise in general seemed to keep the tension at bay…though a month ago I considered it once again.
But I always thought it suspicious that the neck release “adjustment” seemed to be the bottom-line cure for *everything* but how could that be so?
@Harriet Hall and pmoran
I said “I was taught in school to do informed consent and for what it’s worth do provocative testing before manipulating someone’s neck”.
You’re making inferences that aren’t there.
I said for what it’s worth. It has been shown that tests like George’s
deKleyn’s and all the others have failed to show predictive value.
What are your indications for manipulating necks?
-chronic neck pain, joint dysfunction,decreased ROM
Why do you do neck manipulation rather than gentle mobilization?
I never said I do neck manipulation rather than gentle mobilization.
There’s a time for each. It’s best to not take clinical risks.
Why do you think you can reduce risk by provocative testing?
I never said that either. They were taught in school but subsequently showed
little predictive value as I said above.
rwk,
OK, I’m beginning to understand you better. But I still have a lot of questions.
Do you think any chronic neck pain is an indication for manipulation?
Do you think some chronic neck pains might be due to something that would be worsened by manipulation?
When do you think neck mobilization is superior to gentle mobilization? A Cochrane review found them to be equally effective and found that they only worked in conjunction with exercise.
Do you believe neck manipulation can cause strokes?
What do you tell patients before you manipulate them?
I just watched your testimony to the Board in January. It’s nice to put a face to a blogger, I think you do good work. I do something similar, except I dig into the research put out by the medical profession. I think it’s good to have critics, it makes those of us who work in woo sharper. Speaking of sharp, I had some questions about your testimony after reading this blog post.
(From http://ct-n.com/ondemand.asp?ID=5034)
Commissioner Paul Powers: Do you agree or disagree with this statement? Some complications are so extremely rare that they need not be routinely mentioned. However, if asked a direct question concerning the possible occurrence of a complication, the doctor must answer truthfully.
Jan Bellamy: Yes.
Jay Malcynsky: Do you believe there are circumstances where if there is a risk they should inform the patient irrespective of whether the patient asks first?
Bellamy: Yes.
Ok, I get that. It makes sense. Have you thought more about the threshold question Commissioner Powers asked you? Because earlier there was this exchange:
Powers: Are there any mandated levels that a specific percentage risk of something would require a warning… that disclosure has to happen?
Bellamy: I’m not aware of any and I would say that probably not because risk is always compared to benefit.
So what I’m confused about is that Powers essentially asked you if you agreed with the status quo of informed consent and the recommendations national associations within chiropractic have given in regards to the issue of written and oral informed consent since the time I’ve been aware of the issue- which is about 10 years. You said you did. Malcynsky then followed up by asking if there were certain complications to treatment that should be especially highlighted by the doctor during the process, and you thought so. Yet to Powers you said you didn’t think there would need to be a threshold. My question is the same that Powers has- no other profession has been asked to do this, to be ordered by law to specifically cite a complication during informed consent. So where would you start, the condition severity or the threshold? I calculated the frequency will happen once every 10 to 30 practice years depending on the studies you cited (1 in 400,000, 1 in 1.3 M) figuring 180 patient visits a week, 2 weeks of vacation, and averaging 3-4 adjustments to the spine per visit. Everyone, you included, agreed there has to be a marker somewhere that makes sense- I think the Board and the State of CT reached that conclusion based on the best evidence and testimony provided, so I’m not sure why all the vitrol in response to what happened. You did your best, an agreement was reached, and people were informed. Learn from your experience and move on.
Also, I’d be careful about posting stuff like this:
“My testimony consisted of channeling the post by Dr. Crislip and another post by Dr. Hall about how chiropractors and their trade associations were misrepresenting the study’s results to the public… I even cited to Dr. Crislip’s post in my brief and provided a link! So much for Board’s self-proclaimed “careful and thorough review of all of the testimony and documentary evidence.”
Because during your testimony…
Mary Alice Moore-Leonhardt: How did (you) gather and select the literature that is included in the report that’s being presented to the Board for its review?
Bellamy: Some of the research I already had in my possession from other research I had done. The remainder if I recall correctly I know it involved the literature searches of the medical literature on PubMed.
PubMed, huh? With your background you should have known better than that, because this is probably going to follow you in future cases. Saying Crislip and Hall were covered under your statement of “other research” is going to be a bit thin. If you personally want to create shifts in policy, you’re going to need to stay credible. Katz has blown his so badly by becoming radicalized that the very people he wants to change will now never really listen to anything he has to say, regardless of its validity. I think that’s sad because he’s probably a bright guy, and like I said, I think your training has provided you with good investigative skills too. If this is something you want to continue to do effectively- testify to governing bodies associated with CAM professions to enact change- please carefully consider your personal associations and public statements.
And I’d like to add another question:
What is “joint dysfunction?” Is that the same thing as the chiropractic “subuxation” or any of it’s many synonyms: “vertebral subluxation complex,” “spinal lesion,” etc.
“# Harriet Hallon 04 Jul 2010 at 10:25 pm
Prove that provocative testing removes the risk.”
Prove that cervical manipulation IS a risk.
rwk on 05 Jul 2010 at 4:59 pm wrote “@ Joe, … No[n]e of us are any better or higher up than anyone else. You’ve decided that some doctorates are more honorific than others.”
No, an honorific is a form of address that recognizes earned status; such as general, doctor, ambassador etc. I have decided that some doctorates are legitimate and others are not. A DC is not a legitimate, academic degree, that’s a fact. Your “schools” are not affiliated with legitimate, academic institutions.
Sorry to rattle your New Agey wishful thinking- some of us are better than others. My understanding of anatomy and physiology, as poor as it is, is better than that of anyone who spends years (and money) studying the chiropractic subluxation.
“# Joe on 06 Jul 2010 at 12:00 pm
A DC is not a legitimate, academic degree, that’s a fact. Your “schools” are not affiliated with legitimate, academic institutions. ”
Really Joe ??????
The US Dept. of Education, Veteran’s Administration, hundreds of hospitals, all 50 states in the union and every regional college accrediting agency feel that chiropractic education is “legitimate”.
nobs said “Prove that cervical manipulation IS a risk.”
That has been proven to the satisfaction of most scientific thinkers and even many chiropractors. We don’t (and can’t) have a perfect prospective RCT, but we have other convincing data and many “smoking gun” cases where patients collapsed on the chiropractor’s table.
And chiropractic colleges may be accredited, but that doesn’t mean chiropractic is a legitimate academic discipline. No chiropractic college has ever been accepted as part of a university (except for Sun Myung Moon’s church-affiliated university in Bridgeport.)
My concern is not with the “doctor of chiropractic” designation, but with those chiropractors who only call themselves “doctor” and deliberately mislead patients who assume they are MDs.
“# Harriet Hallon 06 Jul 2010 at 12:42 pm
nobs said “Prove that cervical manipulation IS a risk.”
That has been proven to the satisfaction of most scientific thinkers and even many chiropractors. We don’t (and can’t) have a perfect prospective RCT, but we have other convincing data and many “smoking gun” cases where patients collapsed on the chiropractor’s table.”
Thank-you for your opinion Harriet—-however that was not my question. Perhaps my query was not clear:
“Prove that cervical manipulation IS a risk.”
Afterall, is that not what this discussion is supposed to be about?…….or is it about something else?
drjohnedwards: “So where would you start, the condition severity or the threshold? I calculated the frequency will happen once every 10 to 30 practice years depending on the studies you cited (1 in 400,000, 1 in 1.3 M) figuring 180 patient visits a week, 2 weeks of vacation, and averaging 3-4 adjustments to the spine per visit.”
No, no, no. Where you start is in deciding whether ANY risk is tolerable i.e. does neck manipulation have unique effectiveness for any condition?
If that can be shown, are its advantages over the other options sufficient to justify its use as a first line of treatment, or should it be reserved for cases that don’t respond to other methods? If the latter, what should be the guidelines?
After that, you are on surer ground for deciding how patients are informed, but context remains important. “You might (very rarely) die” would be considered important informed consent information by most patients seeking treatment for tension headaches or those being asked to undergo maintenance chiropractic treatments.
@pmoran
Thank you, very thoughtful response.
>are its advantages over the other options sufficient to justify its use as a first line of treatment, or should it be reserved for cases that don’t respond to other methods? If the latter, what should be the guidelines?
Good question. I suppose it depends on a couple of factors: 1) What weight to we give to qualitative studies measuring patient perceptions of treatment vs. previous experiences with the condition, and 2) how we define conservative treatment- by level of invasiveness in the body, or by level of acceptance by the governing community. Is it reasonable to measure invasiveness by risk of complication per application, and should we include mass effect of chronic (or on-going) use?
>“You might (very rarely) die” would be considered important informed consent information by most patients seeking treatment for tension headaches or those being asked to undergo maintenance chiropractic treatments.
You know what, I’m going to start doing this tomorrow. I read a post on this earlier about woo practitioners being more concerned with their pocketbook than their patients’ safety, and I don’t think that’s really so. I will start with providing this list and report back at the end of the week to tell those interested how it goes: http://www.livescience.com/environment/050106_odds_of_dying.html
@drjohnedwards:
I think your first question has been answered nicely by Dr. Moran. I with what he says. I don’t believe there is any “threshold” percentage of risk which can be used as a guide. The question is not risk alone, but risk v. benefit v. other treatments (and their risks v. benefit) and I think that I made that clear in my answers to Dr. Powers. If I left the impression with you or anyone else that I advocate a threshold number that is not what I meant. To Dr. Powell I was simply stating that, in the abstract, not every risk needs to be disclosed but certainly if the patient asks about it, then the physician must discuss it. I think Dr. Fellowes spoke eloquently on this point and I would urge you to review his testimony.
I do not take my testimony to agree with the “status quo of informed consent” advocated by chiropractors nor is that what I meant, and I am not sure how you came to that conclusion. If that is what Dr. Powers was asking, I assume he would have said so directly.
As to what other profession has been ordered to inform patients of a specific risk, I have not researched that issue. It appeared to be the consensus of the chiropractors who spoke at the hearing that this was the first such case. The problem is that there is a sufficient risk of vertebral and carotid artery dissection and stroke from chiropractic manipulation that patients should be informed of same, and the chiropractors are not doing that. As Dr. Fellowes pointed out (and he specifically said he thought there was evidence pointing both ways) it’s not the percentage of risk but the devastation — the incapacity and death, that mandates the warning in this case. I would add to that, as I did in my testimony and filed documents, the lack of demonstrated benefit of cervical manipulation. I would also point at that, as testified to by Sen. Fasano, the chiropractors were in agreement that a “Take Away Form” warning of the risk would be appropriate. To paraphrase a much-used political comment, they were for it until they were against it.
As to Ms. Moore Leonhardt’s question, I took it to mean a reference to the brief I filed, which cited numerous journal articles, hence her use of the word “literature.” In any event, I disagree that the posts of Drs. Hall and Crislip were “thin.” I thought they did an excellent job and used their comments as a base from which to construct my oral testimony.
I do not agree, for the reasons stated in the post, that the Board’s decision was “based on the best evidence and testimony provided.”
@nobs on 06 Jul 2010 at 12:30 pm wrote “The US Dept. of Education, Veteran’s Administration, hundreds of hospitals, all 50 states …”
Actually, no. Accreditation only means that the school exists as described in its literature and is financially sound. See the article, linked below, about accreditation of a school of astrology. That is not a legitimate program, either.
http://64.233.169.104/search?q=cache:53OEGhaHbjIJ:query.nytimes.com/gst/fullpage.html%3Fres%3D9F02E3D71F31F93BA1575BC0A9679C8B63+astrology+accreditation&hl=en&ct=clnk&cd=1&gl=us&client=firefox-a
Once again I see the anti-chiro non-SBM opinions fly. Just to see how this raging epidemic of chiro stroke is at present, how many chiro-caused strokes have happened since Ms Nette’s alleged chiro-caused stroke occured?
“Just to see how this raging epidemic of chiro stroke is at present, how many chiro-caused strokes have happened since Ms Nette’s alleged chiro-caused stroke occured?”
You hit the nail on the head exactly. We do not know. Since patients are not even aware of the possibility, they do not put the two together. Let’s raise patients’ awareness, track the incidence and we can then answer this question.
Further to what weing said: dead people can’t answer questions. There is a case where a woman found her young husband dead. It was from a stroke; she did not know he had been to a chiro till she went through his wallet and found the appointment slip. Lack of information couples with lack of awareness to leave us in the dark regarding risk.
Besides that, nwtk2007, why don’t you supply us with the information showing the neck-snap is so important that it outweighs the possibility of such serious harm.
ntk:”Once again I see the anti-chiro non-SBM opinions fly. Just to see how this raging epidemic of chiro stroke is at present, how many chiro-caused strokes have happened since Ms Nette’s alleged chiro-caused stroke occured?”
Fewer, I hope. More sensible chiropractors will be thinking long and hard about how and when they manipulates necks. If not adept at massage, or at keeping a straight face while using low-level lasers, they might even consider buying one of those dinky little clicking gadgets to do the “adjustment.
We expect generally similar outcomes regardless of treatment choice.
It is not merely the medically responsible thing to do. Every case that occurs from now on will harden public opinion, increase damages awarded by the courts and hence insurance costs, and put further pressure on your regulators.
Three comments: one that we don’t know, one that they die and no one knows, one that chiro’s will or should be more careful, yet not one single documented case since the Nette incident.
I truly love the absolute association of the woman who found her husband dead and found an appointment slip in his wallet. Not a receipt for services or even a mention of follow up with the chiro? Where did you hear this one Joe?
The bias is just as strong as ever. From the alarm raised in the past, one would think that if it were even a fraction as prevelant as you would make us believe, there would have been at least one verified incident of a stroke truly caused by a chiropractor manipulating a cervical spine, rather than some anecdotal “I heard about one case where… da, ta da, blah, blah” story that is supposed to suffice for good evidence of that “smoking gun” so fondly referred to here.
pmoran – “Every case that occurs from now on…”
What cases? There have to be some don’t you think? If it’s not happening, then surely there isn’t a true correlation. It’s been a couple of years, yes? And none? No more?
Gentlemen, please.
So you are saying that we shouldn’t try to find out? You do realize that if you don’t know what to look for, you will probably never find it. Maybe you don’t know that.
@nwtk2007 on 09 Jul 2010 at 7:01 pm
The man’s widow found the slip showing he had been to the chiro shortly before she found him dead of a stroke.
Still no word from you on why you have to snap a neck like that, in the first place.
And, yes, there are cases where the chiro connection is clear http://whatstheharm.net/chiropractic.html Why do you think Nette’s neurologist recognized the work of a chiro before it was confirmed for him?
@ nwtk2007:
“non-SBM”? I don’t think so.
There are verified cases of chiropractic cervical manipulation causing a stroke. I mention two in the post and others are in evidence presented at the hearing. As for actual incidents since the Nette case, as there is no sytematic collection of the data we can’t learn of these incidents until they are reported as case studies or someone sues.
As for effectiveness of cervical manipulation, which you have yet to address, in the same issue of Spine in which the Cassidy study appears, you will find the conclusion that manipulation is no more effective than other conservative treatments for what they term Grade I and II neck pain and is not recommended at all for Grade III and IV neck pain. In fact, Cassidy is one of the authors of this article. Guzman J, Haldeman S, Carroll LJ, Carragee, EJ, et al., “Clinical Practice Implications of the Bone and Joint Decade 2000-2010 TAsk Force on Neck Pain and Its Associated Disorders,” Spine 2008 (33): S199-S213. It has not been shown effective for any other condition. Ernst E, “Chiropractic: A Critical Evaluation,” J Pain Sympt Man 2010 (34) 544-562. As you well know, chiropractors use cervical manipulation for all sorts of conditions that have nothing to do with neck pain.
As for evidence of causation, you are incorrect in stating there is none. Miley ML, Wellik KE, Wingerchuk DM, Demuerschalk BM, “Does Cervical Manipulative Therapy Cause Vertebral Artery Dissection and Stroke?” The Neurologist 2008 (14) 66-73.
Joe, you know as well as I that there is only one case in that list where the person actually had the sroke on the chiro table. All the rest occured a good time after the chiro manipulation. You assume based upon your bias.
In the case you anecdotalized us with above, you haven’t even a notion of what was treated by the chiro. He might have been gong for a back condition which what I would suspect since there is no follow up regarding the chiro as a possible cause other than the found slip.
We all know that the number of individuals who go to their MD/PCP with the signs of an ongoing stroke who then have one is equal with those who have been seen by a chiro.
Once again, if it were as prelevant as this blog would imply, there would have been many more cases over the past couple of years.
As to “snapping” the neck, joint mobilization and manipulation is a method of restoring motion to the joints of the neck. The “snap” is simply a cavitation which sometimes occurs and sometimes doesn’t. I continue to treat hundred of new patients each year and find that in the cases where I employ manipulation the patients response to care is much greater. I see it all the time, day in and day out. It isn’t published as clinical trial but the data is there in the thousands of files of the thousands of patients I have treated. All injuries of course.
It doesn’t take a rocket scientist to see that when exposed to it on a day to day basis. And not one single stroke in the bunch.
By the way, Nette’s neurologist is just as biased as you guys. That one is easy.
“Once again, if it were as prelevant as this blog would imply, there would have been many more cases over the past couple of years.”
I think you mean prevalent. I don’t know what prelevant means. I thought this blog was saying that we don’t know the prevalence. You need data for that. If patients are unaware of a possible connection, they will not make it. Why do you think that when a new drug is tested patients report everything that happens to them? Are you afraid of chiropractic procedures held up to the same scrutiny for safety as well as efficacy? Sounds like you are.
NTK: “pmoran – “Every case that occurs from now on…”
What cases? There have to be some don’t you think? If it’s not happening, then surely there isn’t a true correlation. It’s been a couple of years, yes? And none? No more?”
PM: Think again. If we were to stop seeing any cases “associated” with neck manipulation, it suggests a change in chiropractor behaviour, and that there was a true causal correlation. It’s all an unlucky coincidence, remember?
As others have pointed out, we cannot yet know. No one keeps track. We presumably have to await another high profile case that your malpractice insurers were not able to settle out of court — or another neurologist getting fed up with this largely senseless source of mortality and morbidity and publishing more cases.
Thanks for being the grammar gooroo weing. Makes all the difference. Really.
No cases, no incidents. Its that simple.
It just ain’t happening. Do you honestly think your efforts and theirs has actually altered how chiros manipulate spines? Get real.
What ever your argument might be, there is absolutely no evidence that chiropractic manipulation of the neck causes stroke. None. At least by the sbm standards. If you can’t admit it, then you aren’t a true sbm supporter. It appears that sbm is good as long as it supports your bias and “beliefs”.
Just keep up the smoking gun theory and your own anecdotes. Quite un-sbm if you ask me.
“What ever your argument might be, there is absolutely no evidence that chiropractic manipulation of the neck causes stroke.”
We don’t want argument, we want data. That’s the point. Collect the data and we’ll see if you is correct. Why are you afraid to do even that? Who knows? Your practice might be vindicated. Or are you like homeopaths and don’t need data, studies, and the like. Making a claim is good enough.
NTK: “We all know that the number of individuals who go to their MD/PCP with the signs of an ongoing stroke who then have one is equal with those who have been seen by a chiro.”
PM We don’t know that at all. Chiropractors are treating the Cassidy study as though it had the force of a top quality, prospective, randomised controlled trial. Yet even its authors allow that it does not prove anything (“We have not ruled out neck manipulation as a potential cause of some VBA.”).
The study involves a complex retrospective interpretation of the data, and the suggested conclusions depend upon the 30 odd patients who had a stroke after attending chiropractors being an identical population to the 400 odd who attended MDs in the 30 days before their index date.
That is obviously not going to be the case. I imagine some of the cases attending doctors will have had to have been picked up off the floor at some stage, and thus be far less likely to have been taken to chiropractor. Patients experiencing an unexplained, unusual, occipital headache or neck ache for the first time would be more likely to consult a doctor first up than a chiropractor, especially if they were also experiencing neurological symptoms.
In fact, Table 7, if I am interpreting it correctly, suggests that even where headache or cervical symptoms are experienced this perticular population is up to six times more likely to see an MD/PCP than a chiropractor. Should the association of stroke with MD visits have been adjusted by this amount when making the comparisons that are said to exonerate DCs? I suspect so.
Even without that, it can be questioned whether such the data shows equal “risk” for DC and MD visits with a precision that excludes neck manipulation as an occasional cause of VAD. That is all that is being claimed, and the authors of the paper allow that it is still possible.
The study confirms what all other studies have shown and the anecdotal material suggests, that young people attending chiropractors are much more likely to have a stroke than those who do not. That is unarguable. I allow that some of that association with DC visits will be due to patients attending with symptoms of a preexisting stroke and the chiropractor not recognising that. Others are obviously not.
No new cases. Difficult to argue with that don’t you think?
“No new cases. Difficult to argue with that don’t you think?”
Sorry. You need systematic data gathering to look for these. You will never find them otherwise. Just saying there are no new cases, doesn’t cut it. Raise patient awareness of the possibility, so they will at least report it. If you are so sure of yourself, there is no need to fear vindication.
Yes, dream on, nwtk. But do watch those necks!
# weing on 10 Jul 2010 at 6:58 pm
“What ever your argument might be, there is absolutely no evidence that chiropractic manipulation of the neck causes stroke.”
We don’t want argument, we want data. That’s the point. Collect the data and we’ll see if you is correct. Why are you afraid to do even that? Who knows? Your practice might be vindicated. Or are you like homeopaths and don’t need data, studies, and the like. Making a claim is good enough”
Actually weing, we “is” been collecting data for decades. Science is, afterall, an epistemological theory..Don’cha know?
Are you making the “claim” that there is PROOF of “manipulation of the neck causes stroke”? Or just when it involves a “visit to to a DC”? It appears that you come from a position that this has been proven—-? Really?
Please provide YOUR data. Please do not provide an argument…..just provide the reference cites to the sources that prove your claim…… “we want data”.
Thank-you in advance.
Its a bit difficult to find data to prove that cmt doesn’t cause strokes when there are no cases to prove otherwise. But, maybe that IS the proof.
I would think that in the real sbm world that those who claim cause could provide the cases and data to prove their point.
And moran, I watch literally hundreds of necks each and every week. Based on my experience and my patients response to care I can very confidently say that cmt is the most therapeutic modality I can employ to have patients recover from sprain/strain injuries.
Considering that there are effective, safer, cheaper, and more convenient options available to patients than chiropractic neck manipulation (e.g. exercise), I can’t help feeling that some chiropractors are putting their own interests ahead of their patients when they resort to such a potentially lethal intervention. Whether those interests are financial, emotional, or related to less time and effort being required (or all three) is anyone’s guess, but the fact remains that chiropractors who continue to use neck manipulation no longer have any excuses for not understanding why they leave themselves open to accusations of being unethical:
Quote
“The most benign interpretation of the totality of the evidence is [therefore] as follows. There is an association between chiropractic and vascular accidents which not even the most ardent proponents of this treatment can deny. The mechanisms that might be involved are entirely plausible. Yet the nature of this association (causal or coincidental) remains uncertain. The cautionary principle, demands that until reliable evidence emerges, we must err of the safe side. Considering also that the evidence for any benefit form chiropractic neck manipulations is weak of absent, I see little reason to advise in favour of upper spinal manipulation.”
Ernst, E. Vascular accidents after chiropractic spinal manipulation: Myth or reality?, Perfusion 2010; 23:73-74
http://tinyurl.com/37ejj22
“Actually weing, we “is” been collecting data for decades. Science is, afterall, an epistemological theory..Don’cha know?”
References, please.
“Based on my experience and my patients response to care I can very confidently say that cmt is the most therapeutic modality I can employ to have patients recover from sprain/strain injuries.”
That’s all you got? Only anecdotal data?
weingon 11 Jul 2010 at 1:13 pm That’s all you got? Only anecdotal data?
Certainly not, he also has the pronouncements of (1895) green-grocer DD Palmer, and his son BJ. Does evidence get any stronger than that?
The basic science does not support the notion that HVLA SMT practiced by chiropractors is responsible for these stroke cases. The relationship is coincidental not causal.
Here is the relevant portion copied from the abstract which also follows:
“Stresses and strains on the vertebral artery during chiropractic spinal manipulation of the neck were always much smaller than those produced during passive range of motion testing and diagnostic procedures.”
———————————–
Journal of Bodywork and Movement Therapies
Volume 14, Issue 3, July 2010, Pages 280-286
Invited Review:
The biomechanics of spinal manipulation
Walter Herzog PhD
a Faculty of Kinesiology, University of Calgary, Calgary, AB T2N 1N4, Canada
Summary
Biomechanics is the science that deals with the external and internal forces acting on biological systems and the effects produced by these forces. Here, we describe the forces exerted by chiropractors on patients during high-speed, low-amplitude manipulations of the spine and the physiological responses produced by the treatments. The external forces were found to vary greatly among clinicians and locations of treatment on the spine. Spinal manipulative treatments produced reflex responses far from the treatment site, caused movements of vertebral bodies in the “para-physiological” zone, and were associated with cavitation of facet joints. Stresses and strains on the vertebral artery during chiropractic spinal manipulation of the neck were always much smaller than those produced during passive range of motion testing and diagnostic procedures.
Keywords: Spinal biomechanics; Chiropractic; Manipulative therapy; Vertebral artery; Stroke; Internal forces
Hey Joe.
If you’re the dopey looking fat guy on WAMC then what right
do you have to critique any medical profession let alone chiropractic?
Why don’t you visit a chiropractic college or read a modern technic book. You have nothing constructive to add to this”discussion” except
insults. What are your credentials to evaluate any of this?
Weing, Joe, you boys are so untrue to the spirit of this blog.
SBM Rule #19: Chiro threads always invite the Internet tone patrol.
Sad, really, when there are so many other spots on the webs that might benefit from their services.
“Weing, Joe, you boys are so untrue to the spirit of this blog.”
Rrrright. It’s we who don’t need data. I’ll just continue to balance humors to restore the patient to health.
“And moran, I watch literally hundreds of necks each and every week. Based on my experience and my patients response to care I can very confidently say that cmt is the most therapeutic modality I can employ to have patients recover from sprain/strain injuries.”
I am sure you believe that. It doesn’t prove that cmt has any unique benefits over other physical methods .
The proof of personal experience fallacy.
nwtk2007,
The GCC’s Investigating Committee:
And furthermore…
@rwk on 11 Jul 2010 at 9:41 pm wrote “Hey Joe.
If you’re the dopey looking fat guy on WAMC then what right
do you have to critique any medical profession let alone chiropractic?”
That ‘Joe’ on WAMC is quite bright; your grade-school comments on his appearance notwithstanding. It really is despicable to “out” someone when you are so wrong.
“What are your credentials to evaluate any of this?”
My credentials are sufficient, and from academic institutions. You simply cannot argue substance.
Let’s also not forget that the Cassidy study itself found an association between cervical manipulation and stroke, once they looked in the best place to find it (patients under 45 in the first 24 hours).
There’s more than ample evidence to demonstrate, at an absolute minimum, a plausible potential for risk. Given that, it is not necessary to demonstrate precisely how large that risk is, *unless* it can be shown that there is some benefit of the procedure that is sufficient to outweigh even that plausible potential – which chiropractors have signally failed to do.
If what you boys say is true, where are all the new cases. Nothing in chiropractic has changed. There are just as many cervical manipulations occurring each and everyday as there were before this issue was trumped up to idiotic levels.
Where are the cases? There are none. None. If you think there is such a link, where are the cases and why aren’t they getting the publicity of the previous cases?
Whats up with that guys?
If they are out there you should be ablew to find them in order to support your argument.
ntwk2007: what Scott said, again: “There’s more than ample evidence to demonstrate, at an absolute minimum, a plausible potential for risk.”
Given this,
1) Patients should be told that there is a plausible potential for risk and that the size of the risk is still unknown. This is the information we have and it’s unethical not to share it.
2) If there is a risk of serious outcomes from a procedure (any procedure, not just chiropractic procedures), a practitioner should not perform it unless the possible risk is balanced by a sufficiently large demonstrated benefit that cannot be offered through less-risky methods.
3) Why would a practitioner want to perform a procedure that has a demonstrated plausible potential for risk and no demonstrated unique benefit?
4) Why aren’t you participating in randomized prospective studies that could actually demonstrate that there is no risk to neck manipulations and/or and that there is benefit to neck manipulations that cannot be found elsewhere? This would shut everyone here up quite nicely.
As has been REPEATEDLY explained, without careful surveillance new cases won’t necessarily be recognized. Which means that:
Is an utterly meaningless argument.
So why does it all of the sudden require “carefull” sueveilance to find these cases. When the public outcry from the anti-chiro’s was so loud there were so many alledged cases popping up out of the woodwork. You guys acted like it was a pandemic happening. Now, no new cases are showing up.
Why aren’t you guys doing your carefull surveilance and uncovering the cases that one would think are occuring based upon the level of alarm the anti-chiro’s sounded. I don’t really know how to do such carefull sirveilance thus you, who are so familiar with such things, could do this and uncover those cases which could help to support your position.
Once again, as to the benefit of cmt, there has been presentation of studies in the past and these have been dismissed without even a good read or analysis. I said it before that I wouldn’t waste my time presenting evidence when it is summarily dismissed in such fashion.
The fact remains that there should be new cases popping up if there is any true connection.
In a major review of injury from neck manipulation, most of the cases come from chiropracty: http://www.ptjournal.org/cgi/content/full/79/1/50 Others are more selective, and more skilled, in manipulation.
nwtk2007 on accountability: “The fact remains that there should be new cases popping up if there is any true connection.”
So prove there isn’t a connection. Participate in prospective research. It shouldn’t be that hard.
That is just too funny Allison. You want me to prove a lack of a connection between cmt and stroke. Are you hearing yourself?
I don’t think I’ll bother qualifying that with a response.
And Joe, who is it that is more skilled at manipulation than a chiro? To imply that any other would be id patently silly and would also warrant no response to qualify it to any degree.
A pity, as it’s exactly what needs a response from chiropractors.
“That is just too funny Allison. You want me to prove a lack of a connection between cmt and stroke. Are you hearing yourself?”
What’s wrong with that? Drug companies have to do that all the time.
“who is it that is more skilled at manipulation than a chiro? ”
Based on this post, you guys are extremely skilled at manipulating the legislative process.
It’s true, it’s not possible to prove a negative. I can’t prove that Russel’s teapot does not exist.
But given that there is reasonable probablilty that CMT can cause stroke, it’s both perfectly possible (and ethically required) to conduct a prospective, randomized study and size it in such a way that an effect larger than X would be captured.* That way you can tell your clients that “There is a 1/1,000 chance of stroke from this procedure” or “There is a 1/1,000,000 chance of stroke from this procedure,” or “There’s a theoretical possibility but if it’s real then stroke occurs in fewer than 1/1,000,000,000 CMT manipulations because we haven’t been able to detect it even with very powerful studies.”
Wouldn’t you love to be able to say that?
______________
*Which is different from Russel’s teapot, because there is no reasonable probabilty that Russel’s teapot exists. And that is what SBM is all about.
One last attempt to get you to think again about your argument, ntwk.
Firstly, if the association between stroke and cervical manipulation is all coincidence, why would there not be just as many strokes occurring either with and without chiropractic care?
Secondly, how can you possibly know that there are “no more cases”? They rarely reach the public eye, unless via the law courts. Your malpractice insurers don’t usually release their data (I suggest you ask them — some old, leaked insurer data suggested more stroke claims per year than even I expected).
The medical profession that has known for years that neck manipulation and other kinds of neck trauma are risk factors for vertebral artery stroke. Fresh cases are not likely to be published unless they contributed something new to the understanding of such events.
nwtk2007 and the rest. Did you not have anything to say about my previous post?
Here is what the biomechanical evidence says:
“Stresses and strains on the vertebral artery during chiropractic spinal manipulation of the neck were always much smaller than those produced during passive range of motion testing and diagnostic procedures.”
The basic science says coincidental not causal.
@Doc on 13 Jul 2010 at 12:53 am
Where is your previous post? Where is the data?
Doc:“Stresses and strains on the vertebral artery during chiropractic spinal manipulation of the neck were always much smaller than those produced during passive range of motion testing and diagnostic procedures.”
That’s rather counter-intuitive. It begs more information on exactly what procedures were being compared and how on earth “stresses and strains” on the vertebral artery were measured.
It is also possible that anatomical variants make some people more prone to vertebral artery damage.
This is Doc’s previous post:
http://www.sciencebasedmedicine.org/?p=5897&cpage=1#comment-54329
And this is the PubMed link that Doc (oddly) omitted:
http://www.ncbi.nlm.nih.gov/pubmed/20538226
There are verified cases of chiropractic cervical manipulation causing a stroke. I mention two in the post and others are in evidence presented at the hearing.
As for evidence of causation, you are incorrect in stating there is none. Miley ML, Wellik KE, Wingerchuk DM, Demuerschalk BM, “Does Cervical Manipulative Therapy Cause Vertebral Artery Dissection and Stroke?” The Neurologist 2008 (14) 66-73.
@Alison, Thanks, I don’t know how I failed to see it after I used the “find” function.
The paper by Herzog (cited by doc, and references therein) does not refer to measurements under clinical conditions; rather, it refers to cadaver studies.
An obvious problem with Herzog’s model is that he uses stretching of the artery (free of the body) to the point where it undergoes wholesale failure as the ‘standard’ strain needed to cause a stroke. In other words, he pulls on the ends of the artery till it loses its structural integrity at 150% normal length and calls the necessary force the amount needed to be medically relevant. That is clearly absurd. The clinical damage is localized in the artery as naturally twisted around bony processes.
Another problem begins with his description of the chiropractic procedure (SMT) involving turning the head till it naturally stops (the normal range of motion, ROM), and then applying more twisting force. Unless I am reading it wrong, he then reports the strain due to SMT is less than the strain involved in reaching the ROM!?
The data are what they are; but do they have any clinical relevance? I doubt it.
Perhaps I missed something; but Herzog’s work is far from a definitive, clinical study.
Anyone tempted to deny the risk of vertebral artery dissection and stroke from neck cracking by chiropractors should watch one of the You Tube videos on the procedure, as posted above by Jann Bellamy earlier, see post at 5 July at 5:31 PM. Knowing what the vertebral artery does anatomically and knowing that half the cervical spine rotation occurs between C-1 and C-2 (facts), the demonstration of what chiropractors do in neck cracking is scary and revolting. Watch the video and decide for yourself. Multiple instances of unsuspecting folks sustaining strokes and in some cases death as a result of neck cracking are extant in the medical literature (not the chiropractic literature). Most ER doctors, neurologists, neurosurgeons and those who treat stroke victims are now aware of this risk. Since the neck cracking procedure has no demonstrated benefit beyond placebo, and the small but serious risk of adverse outcome or death is well documented, there is no reason to ever perform this procedure. The stroke symptoms may occur immediately on the chiropractic treatment table or may be delayed as much as a month or two, when the clot which formed on the torn vertebral artery embolizes into the brain. Risk is probably one in several thousand neck twistings, but since there are far less risky treatments available with equal or better effectiveness, the procedure should never be done. Chiropractors have defensively avoided any study which might show the exact frequency of this tragic treatment complication. Sad.
Alison, Joe, Marcus and the rest, try as you might you are just reaching for straws and coming up empty handed.
The AMA will probably fire you but at least there are unemployment and COBRA benefits until you find work … maybe in 2012.
In the mean time look in the mirror after you watch this video, you will see the a person that this speaker talks about.
http://www.ted.com/talks/michael_shermer_the_pattern_behind_self_deception.html
Bluster doesn’t cut it here, Doc.
There is evidence from many sources of a strong temporal and statistical association of stroke with neck manipulaton (NM). It is highly plausible that the association is causal, given that this is the only area in the body where arteries have cope with an axial twist through 180 degrees range (or possibly more during manipulation) over a very short distance while anchored in bone at one end. Herzog’s studies cannot be regarded as mimicking this.
The chiropractic profession was itself once so certain of this risk as to advise certain provocative tests prior ot the performance of NM.
The novel notion that the strokes are coincidental, and due to patients presenting to chiropractors with early symptoms of stroke, is supported by weak evidence and it cannot explain all cases.
If you have something specific that you wish to debate further, then we are listening.
“http://www.ted.com/talks/michael_shermer_the_pattern_behind_self_deception.html”
Hey, watch the last 2 minutes of that video.
Hilarious!
…..here’s the last two minutes of that video:
http://www.youtube.com/watch?v=bpSF4EQ18Ns
Translation of Doc’s last post:
“You’re wrong because I say so. I can’t provide any actual reasons you’re wrong, but I say so, so it’s true. Here, listen to me whine and make empty threats, because that’s all I have to offer.”
I find it amazing how the anti-chiro bias can blind the SBM group to such a degree such that they ignor their own “belief” in the precepts of science based thinking.
The evidence either way is scant at best. The mechanism, as purported here is, if anything, iffy.
There are so many things that can occur to cause blood clot formation in the vertebral arteries which could easily be the actual cause of these strokes. I find it interesting that it is believed that a clot can form but not become dislodged for hours to days and even weeks. If true, then any stroke could be attributed to just aboput anything. Bias here, selects CMT as the cause.
Neurologists and MD’s in the ER have a habit of the same type of bias. Upon finding out if any stroke victim has seen a chiro with in the past month or two, will automatically attribute the cause to CMT. This is a broad statement but is, in fact, what has occured where the neurologist and ER doc has attributed a stroke to CMT. To be perfectly honest, they haven’t a clue and are simply guided by bias.
As for proof of cause, the burden is on the accusers. Fact is, in real truth, they haven’t even proven a significant correlation outside of tid bits of “studies” which simply would not pass the SBM standards of significance with out their anti-chiro bias.
Chiro’s cannot go out and find data to prove a lack of correlation except to say, where are the cases, which you now say rarely make it into the public arena. This is simply untrue. If the strokes are said to be caused by CMT, then the data is out there and it would have been publisised to some degree. If all you can offer is that the cases are not brought to the public eye, then you have nothing to base your “belief” on.
I would point out that the first step in ridding ones self of a bias is to admit that you have one.
NWTK2007: most strokes due to chiropractic neck cracking occur within 24 hours, many occur on the treatment table with immediate seizures and in some cases eventuating in death either immediately or within hours. Fortunately about half of these VAD strokes recover in time nearly completely. Some result in profound neurologic deficit. Some result in first symptoms while the patient is driving home after the neck cracking or within a few days but up to a month or two later. All have demostrable vertebral artery or less commonly carotid artery damage in the neck and the usual site is the vertebral artery dissection between C-2 and the skull, just where knowledge of the anatomy would predict it would occur from any viewing of what chiropractors and some MDs (especially in Germany and elsewhere in Europe) do, which is obviously dangerous. The burden should be not on accusers, but in such an instance when no valid benefit of this obviously documented occasionally dangerous procedure has been shown, the burden is on those who insist on continuing to perform such to act to protect the public and cease.
Dr Welby,
You are making statements previously made by members here which have been proven to be incorrect or flat out ficticious.
You might have heard this misinformation elsewhere, but there is little truth to it.
There are several very lengthy articles and discussions you can look at on this web site and see the same false claims made and debunked, so to speak.
Additionally, there is documented evidence of the benefit of CMT that has been presented here, but in almost all cases, summarily dismissed without so much as a discussion or analysis; in many cases criticised by some who later admitted that they didn’t even read it. Thus it is a waste of time to present the evidence for the benefits of CMT and also a waste of breath to say there are none.
nwtk,
What are you on about? You are unwilling to accept that what you do carries risk and refuse to even to gather data to see if it does and how much of a risk if it does. That is supposed to be the science based approach? Another point, I thought the strokes were caused by dissection of the vertebral artery and not by clot formation as you are purporting. Now I gotta go back to converting paper to electronic charts.
weing, I don’t know if you remember all the discussion over the past two to three years on this blog, but to suffice briefly, even Dr Hall has admitted that the evidence for CMT causing stroke amounts to little more than a “smoking gun”, as she and a few others have put it.
I am now saying that in light of the lack of new cases of stroke being allegedly associated with CMT, this “smoking gun” is, at the very least, highly over rated.
As to stoke and VAD, they are indeed, two different things, but ultimately, stroke is caused by blockage of a blood vessel to some portion of the brain, usually a blood clot. If the VAD results in a clot that becomes dislodged, then a stroke would be the end result. If the VAD results in rupture and bleed out then the result is a bit different but ultimately the same, deminishment of blood flow to some part of the brain.
If the VAD causes occlusion of the lumen of the vessel, a stroke can result. No clot dislodges or even forms intraluminally.
When I brought up the “smoking gun” cases I didn’t mean that was the only evidence we had. Even the Cassidy study showed a correlation in patients under the age of 45, confirming earlier data. And there is a plausible mechanism because of the unique kink in the vertebral artery at the level of manipulation and the awkward way the artery is stretched at the extremes of rotation. The evidence is convincing except to those who make their living doing this dangerous procedure, often for totally bogus indications.
Systematic reviews have shown no advantage of neck manipulation over gentle mobilization, and little evidence of efficacy. The reports chiropractors cite to support their beliefs are less convincing than the reports of stroke following manipulation. We apply the same standard of evidence to any claims.
Either way, the end result would be the same. It was your buddy, Marcus Welby, in a previous statement who first mentioned the idea of a blood clot forming on a damaged vessel and later mobilizing as an embolus.
For you to say that no clot forms or dislodges is a bit presumptuous I think, but as I said, the end result would be the same.
Also, if the damage is done and the stroke can occur weeks or months afterwards, then there is absolutely no way to pin point the cause to CMT. There are just too many possible mechanisms by which the same type of damage could occurr.
In the study which seemed to indicate that the stroke incidence is more likely in the lower age group, one would have to at least consider the possibility that the younger age group is involved in activities which might lend themselves to being other likely causes of the damage to the artery; sports, etc.
Once again, there is just no evidence, what so ever, of any connection of CMT to stroke. Simply none.
nwtk2007: It seems hopeless getting you to admit what we have observed, that chiropractic neck manipulation is too dangerous to perform ever. I have discussed episodes of stroke with victims in wheelchairs, and talked with the survivors after the death of victims of neck manipulation. I personally have discussed this occurrence with a number of ER physicians who were on site when confronted with victims, with neurologists and neurosurgeons with likewise experience, seen VAD arteriograms with the dissection exactly where one would anticipate injury from neck manipulation, and read multiple accounts in the U.S, Canadian, and european medical literature. Some neurologists have told me of victims with permanent neurologic damage caused by chiropractic family members. Some chiropractic textbooks I have perused council against neck manipulation stating the risk is not worth it. See for instance Chiropractic Technique by Peterson and
Bergman, 2nd Edition, page 119, “Although this condition is extremely rare, chiropractic doctors should give serious consideration to receiving informed consent before applying cervical manipulation.” Same text Chapter 4 has references 110 and 111 by AGJ Terrett et al who evidently recommended that rotational manipulation of the upper cervical spine be abandoned in favor of lateral flexion adjustments. As to evidence-based data showing chiropractic neck manipulation is effective beyond the placebo effect, the Cochrane reviews and other recognized authorities are devoid of evidence to support your views.
Since you seem unwilling to consider this evidence, I will not post further on this subject here.
I found these articles that indicate there is an association. Unless you have data other than anecdotes, you are like the guy who talks about denying the existence of the alleged 1 in a hundred year flood over the past 40 years.
Dziewas R, Konrad C, Drager B, et al. Cervical artery dissection–clinical features, risk factors, therapy and outcome in 126 patients. J Neurol. Oct 2003;250(10):1179-84. [Medline].
Haldeman S, Kohlbeck FJ, McGregor M. Stroke, cerebral artery dissection, and cervical spine manipulation therapy. J Neurol. Aug 2002;249(8):1098-104. [Medline].
Smith WS, Johnston SC, Skalabrin EJ, et al. Spinal manipulative therapy is an independent risk factor for vertebral artery dissection. Neurology. May 13 2003;60(9):1424-8. [Medline].
Stevinson C, Honan W, Cooke B, Ernst E. Neurological complications of cervical spine manipulation. J R Soc Med. Mar 2001;94(3):107-10. [Medline].
Norris JW, Beletsky V, Nadareishvili ZG. Sudden neck movement and cervical artery dissection. The Canadian Stroke Consortium. CMAJ. Jul 11 2000;163(1):38-40. [Medline].
Rubinstein SM, Peerdeman SM, van Tulder MW, Riphagen I, Haldeman S. A systematic review of the risk factors for cervical artery dissection. Stroke. Jul 2005;36(7):1575-80. [Medline].
Saeed AB, Shuaib A, Al-Sulaiti G, Emery D. Vertebral artery dissection: warning symptoms, clinical features and prognosis in 26 patients. Can J Neurol Sci. Nov 2000;27(4):292-6. [Medline].
No, actually, the burden of proof is on chiropractors to demonstrate the procedure safe and effective. It cannot be ethically offered otherwise.
Scott, we believe we have demonstrated the procedure safe and effective. The lack of any new ginuine or alleged cases is further evidence of that.
weing, I have looked at the first of the papers you listed. It is just a re-iteration of the previous CMT/stroke studies we have previously discussed, listed as references. I do find it interesting that they mention other possible causes like, for example nose blowing and hiccups. Interesting don’t you think. If the stroke can occur up to months after the CMT, are you suggesting that the victim didn’t blow their nose or have the hiccups in all that time and that the stroke couldn’t have been related to that?
The list of other possible causes is probably no where near complete either.
Strike one on that list.
nwtk,
I made this new drug, turbocor. Works great for whatever ails you. No toxicities whatsoever. I haven’t tested it for toxicities because the burden of proof is on you to show that it is toxic.
The intellectual dishonesty on display here is mind-boggling.
1. How many times has it been explained to you that your claimed lack is meaningless? Without you responding in any way?
2. The “evidence” chiropractors have to demonstrate the procedure safe and effective is far, far, far, less than that demonstrating the risk. Yet you claim the former adequate the latter nonexistent.
You are both being obtuse.
If it isn’t happening the it isn’t caused by CMT. You say you can’t find new cases and that I should somehow prove there aren’t any. Get real. I have searched and searched in all the ways I know of and there are none to be found. If you wish to dispute my finding of no new cases, ginuine or otherwise, then find them and prove me wrong.
Does that help?
Or, just accept the fact that there are no new cases as I have been unable to find any and leave it at that. If it isn’t happening then it isn’t happening, thus, since CMT is ongoing, probably to a much higher degree than ever, then there must be no connection.
You say it isn’t tested? How would you propose it be tested? If a million or 10 million manipulations have occurred the past year and no new cases have occured, then I would say that is the test, so to speak. The cases shoudl be there, happening regularly, if there is, indeed, the connection that you claim.
For the 100,000,000,000th time. Just because cases are not reported does not mean they are not happening, because without systematic investigation and wide awareness they will not be reliably recognized.
You have repeatedly refused to address any of the evidence presented that the risk is very real, instead continuing to parrot the same completely worthless, repeatedly destroyed claim.
An identical argument:
“John Smith fell to his death when his parachute failed to open. Ergo we know that parachuting can kill.”
“No it can’t. Find me somebody whose parachute failed to open in the last month, or it proves that he must have died from some other cause.”
A few more details.
If you wish to make the claim that it isn’t happening and use that as the basis of your argument, then YES you must prove that it isn’t happening! YOU’RE making the claim that it isn’t happening. YOU have to demonstrate said claim if you want it to show up.
Only a reasonable argument if there is a strong probability that you would have found any cases that happened. There is no reason to believe that, because such cases are not necessarily identified or reported.
The rest of your post is completely predicated on the assumption that you’ve proven no cases have occurred, when in fact you’ve provided no credible evidence to that effect.
Scott, I have addressed most of what you have presented in past threads on this very blog. I’ll get back to the other “studies” presented earlier today. I have addressed one already.
As to no new cases, if you are so smart and knowledgable, then find’em. I can find none. Your parachute analogy is weak at best. Its been a great deal of time. Shall I come back in another years, with still no new cases, and present the same argument?
I understand that I havn’t proven there are no new cases. duh. But since there are none, and if you can’t find any, nor can I, then you must beging to feel at least a bit of a need to rethink your cmt/stroke connection.
The fact that there was so much earlier on about it and thus some alleged cases, was due to the great publicity with the Nette case. Now that that has gone away, it just seems there is nothing new to be found, nothing new being reported and thus, maybe nothing happening.
There is a medical data base and there are journals where case studies are published. Why arent there any new articles and case studies being reported?
nwtk2007 said “There is a medical data base”
No there isn’t. There is no way to track these patients.
“Why arent there any new articles and case studies being reported?”
Perhaps because it isn’t news any more. Just because there are no new articles doesn’t mean it isn’t happening.
I have to break in again, with nwtk2007 still desperately attempting to defend the indefensible. In a hallway conversation this week with an anesthesiologist, he related his experience in a critical care unit on a 2 week rotation during residency recently in an Indianapolis hospital affiliated with IU. He saw 3 patients admitted with strokes due to chiropractic neck cracking. These occurrences are no longer news and no longer justify case reporting, which is weighted toward the unusual occurrence. Chiropractors think the incidence is low because they are unaware of the admissions to the hospital for strokes unless they personally are sued. They do not warn their patients of the risk and as repeatedly demonstrated, the ER team at the hospital may waste valuable time while the patient is unconscious trying to figure out the cause of the serious neurologic catastrophe, instead of proceeding to vascular imaging and anticoagulation therapy.
He said, she said. What a bunch of bull.
If I related every story I “heard” from a doctor, then I could say, without a doubt, that all of those 500 deaths per day due to medical mistakes and errors are just coincidental and have nothing to do with incompetence.
So people provide the cases you’ve been demanding and you ignore them. Nice.
And since I somehow missed your prior post:
This has no relationship whatsoever to anything posted in the thread…
Try to pay attention this time. If you wish to use as the basis of your argument that there are no new cases, then you must provide evidence establishing to a reasonable degree of confidence that there ARE no new cases. Simply saying it doesn’t make it so when it’s be repeatedly explained why the methods you’ve mentioned using are unreliable, and you have declined to address the points raised.
No, not in the least. New evidence causes a need to rethink; absence of evidence from an investigation that would be EXPECTED to provide no evidence does not.
Scott – “So people provide the cases you’ve been demanding and you ignore them. Nice.”
Sir, there is absolutely nothing new presented in this thread that has not been presented and addressed earlier in other threads.
All of the studies presented simply cite earlier references and, in fact, point out other possible causes.
I truly love the idea that I should be able to prove that something hasn’t happened recently when, if you are so sure, you could simply present the new cases and for at least a moment, give us something relevant to look at.
As to prior posts, they are readily available on this web site.
At any rate, there is currently no evidence that any new strokes have occured in the past year or two due to CMT other than a bunch of he said, she said stories.
If you’re genuinely THAT ignorant and determined to avoid all facts, then I guess I’m done here.
I think the pro-chiro crowd here may have been misinformed regarding evidential standards.
Yes, “standards” with an “s.” There’s more than just one.
The standard for “claim x is worthy of study,” is much lower than the standard for, “claim x has been proven.”
Analogy: the evidence needed for getting a search warrant is much less than that needed for a conviction. The former requires only probable cause while the latter requires “beyond a reasonable doubt.”
Young people shouldn’t have strokes within 24 hours of a neck manipulation. One case alone is sufficient “probable cause” for further study.
Dr Benway, I think the pro-chiro crowd here can appreciate the “standards” of evidence much more than is admitted by the anti-chrio crowd here. The anti-chiro crowd has presented many, many more anecdotal “stories” than has the pro-chiro crowd.
As to your suggestion that a person shouldn’t have a stroke within 24 hours of a neck manipulation, I would just suggest that in every single case of stroke within any time period after CMT, there is no evidence of any inquiry, what so ever, of other possible causes. The anti-chiro bias of those reporting these stokes “caused” by CMT prevents them from doing adequate history. There is no evidence of inquiry into the activities of the stroke victim 2 to 3 weeks prior to the stroke which could possibly be the actual culprit.
Do you think the person reporting the cause as being CMT actually asked the victim if they had, within the past several weeks, participated in any contact sports, participated in yoga, been in an MVA, even one where there was actually no property damage or apparent injury, had any type of fall, been startled to such a degree that they might have turned their head suddenly, had a bad case of the hiccups, sneezed forcefully, etc, etc?
The sheer number of other possible causes boggles the mind, it truly does. What do these medical professionals attribute the cause of stroke to in the absence of any history of chiropractic care?
My point is that the evidence for CMT being the actual cause of these alleged cases of CMT induced stroke is nebulus at best. My guess is that there are, indeed, ongoing studies into this on both sides of the fence. My guess is that over the past few years there has just been so little true evidence to support the idea of CMT induced stroke, that we may never hear about these studies. Note, I said “may” never hear about them.
Also, to suggest that new cases are not being reported because it is not “news worthy” anymore, is patently absurd. I doubt that the emotion of the Nette case has been lost, not the determination of the ones who believe they have suffered at the hands of chiropractors. To put it simply, the “victims of CMT” have simply stopped coming forward, or there just aren’t any.
The Nette case was stopped by the judge because of the complexity of the suit. Nothing has prevented her from continuing her case against the one doctor regarding her specific incident. She might actually be doing this but I haven’t heard of it. I see nothing to suggest that the “news worthiness” of these alleged cases has been lost. It could also be that they are finding there is no evidence to support their cases.
nwtk2007 wrote: “The Nette case was stopped by the judge because of the complexity of the suit. Nothing has prevented her from continuing her case against the one doctor regarding her specific incident. She might actually be doing this but I haven’t heard of it.”
FYI, Sandra Nette’s malpractice suit against Gregory John Stiles is still active and is to proceed. See update (2) here:
http://www.ebm-first.com/chiropractic/sandra-nette-v-stiles-et-al.html
nwtk2007:
“Do you think the person reporting the cause as being CMT actually asked the victim if they had, within the past several weeks, participated in any contact sports, participated in yoga, been in an MVA, even one where there was actually no property damage or apparent injury, had any type of fall, been startled to such a degree that they might have turned their head suddenly, had a bad case of the hiccups, sneezed forcefully, etc, etc?”
You may not realize it, but you just admitted the plausibility of CMT causing stroke. Think about it.
Good. I’m glad she is going forward with it. It is a good venue to put a lot of this to rest and especially to bring out the fact that there is little to no evidence that CMT causes strokes.
Jann, I never denied the plausability. Also, anything is possible, but some things are not probable.
Ok let’s imagine some woman in her 20s gets a basilar artery stroke a few hours after a chiropractor cracks her neck.
Her doctor asks about other risk factors over the past several days, and yes, she did have hiccups two days ago. She did hear a loud noise that startled her one day ago. She also fell down while playing soccer one day ago. And she sneezed one hour before the stroke.
So that all means… what? The neck cracking is off the hook? No need to worry about it as a risk factor?
Same girl, same situation except the stroke occurs a few hours after going to her PCP for the same reason the other one went to the chiro. The doctor asks the same questions. She is of that younger group who is more active in all arena’s simply because she is young. (I refer here to a previously discussed study.)
Is CMT off the hook? In this case yes.
What it means Dr Benway is that in both cases, the cause of the stroke is unknown.
ntwk: “Do you think the person reporting the cause as being CMT actually asked the victim if they had, within the past several weeks, participated in any contact sports, participated in yoga, been in an MVA, even one where there was actually no property damage or apparent injury, had any type of fall, been startled to such a degree that they might have turned their head suddenly, had a bad case of the hiccups, sneezed forcefully, etc, etc?”
Is it now your argument that all these things can cause stroke, but neck manipulation, a potentially much more stressful event, can’t? Or are you admitting that it (also) can, as temporal and statistical associations peculiar to CMT indeed suggest?
nwtk, I also totally reject your frequent accusations of undue bias.
We doctors would be remiss by our own most minimal standards if we were not pushing for all those using CMT (not only DCs) to react to this risk, or the strong potential for risk if you prefer.
Given the practical hurdles in trying to ban neck manipulation altogether and the possibility that there may be a small subgroup of patients who may benefit from it, I personally would be quite happy if chiropractors and others using it showed some signs of setting reasonable evidence-based guidelines as to how and when it was performed, along with an average standard of informed consent.
It is the apparent utter rejection by some chiropractors of the need for — well, anything — that is provoking more violent reactions. We can see strong financial biases behind that.
nwtk2007, what if we knew the incidence of basilar artery stroke in all persons under, say, 40 years of age.
Wouldn’t we learn something, if we did a prospective study of all persons under 40 getting their neck cracked over the next year, monitoring for any basilar artery vascular events?
By looking for harmful effects, it has been found that Amaryl used in the treatment of diabetes increases the risk of heart attack by 43% (I prefer absolute risk, but that’s not important here).
No one would have made the link if they didn’t specifically look for it. It now seems that the manufacturers tried to hide this fact, which is only slightly worse than not looking for adverse effects in the first place.
“By looking for harmful effects, it has been found that Amaryl used in the treatment of diabetes increases the risk of heart attack by 43% (I prefer absolute risk, but that’s not important here).”
Do you have a reference for that? I was aware that the sulfonylurea drugs, like glipizide and glyburide, more or less double the risk, but not about glimepiride.
nwtk2007, the anti-chiro crowd here think like homeopaths when it comes to CMT of the neck and stroke.
It’s that CMT of the neck and not all those other things you mentioned that the neck does daily which caused the stroke to occur later even though CMT of the neck is so bio-mechanically “diluted” compared to all those other things the neck does daily that not even a molecules (worth of force) can found. The blood vessels have a mystical memory of CMT imparted on them.
At least that’s what I think James Randi would have said about this SBM crowd
.
So CMT of the neck is like, not moving your neck very much?
I thought you guys were crackin’ necks.
@Dr Benway on 18 Jul 2010 at 9:14 pm wrote “So CMT of the neck is like, not moving your neck very much?”
In some cases, yes. There are no standards in chiro. Dr. Hall found one case of a chiro in Washington state who did not even touch her customers when she “adjusted” their necks. Others use mechanical, tapping devices that do essentially nothing. Some use gentle mobilization such as is sometimes recommended by health professionals.
On the other hand, you can find videos on YouTube which are painful to watch.
I am here looking for any help I can get, I don’t even know what I need, please read… I am writing this on behalf of my girlfriend.
On July 11th of this year my girlfriend had a stroke and was rushed to the emergency room because of it. They had no idea what had happened other than “her neck ‘popped’ while drying her hair” at which point she immediately became dizzy, numb on one side, etc. etc. I’ll save the details, but after two CT scans and a MRI they determined that she had suffered a stroke. The stroke was caused by a clot that had formed due to vertebral artery dissection. She was then immediately taken to a stroke center for treatment. Luckily they were very quick about all of this or she would be much worse off than she is now.
She spent 5 days recovering in neuro-intensive care and just began rehabilitation this past Saturday. She is doing better and better every day. At this point she has double vision, trouble swallowing anything that is even close to water thickness, and must regain functionality of her right leg, among other things.
The reason why I am posting here is this: She visited the Chiropractor only days before this happened. After leaving she complained of neck pain. She woke up with a horrible headache the morning of the event. Upon reading her notes/chart (not sure what they call it) each doctor has made clear what they believe was the the cause of this… Care to guess what they have unanimously said? I think you know where I’m going here.
At this point the prognosis is that she will make a full recovery. However, no one can be certain of the event’s long term impact on her life. As well, NO ONE should have to go through this, ever… She was NOT made aware of the risks.
Lastly, she is 30 years old!!!
Please help… Thank you.
@mrbasher on 20 Jul 2010 at 4:57 pm
Try:
http://www.chiropracticstroke.com/
http://www.vocact.com/
http://www.chirobase.org/07Strategy/chirovic.html
Best luck
Mrbasher: fortunately, about half of VAD stroke victims recover nearly fully with anticoagulant treatment and time. Sounds like she is getting good care.
Thank you for your responses…
Just a little more info, although I will not disclose the name of the hospital or doctors here…
When asked whether or not she was in danger of having another stroke, one neurologist stated that her stroke was caused by physical trauma and not issues with her general health. Because of this, baring a change in health, she should not be at risk of another stroke after anticoagulant treatment.
The “lead” doctor (not sure what they are called) which was doing rounds with a large group of other doctors came by the first morning we were there and upon hearing the that she had been to the chiropractor only days earlier stated very matter-of-factly that it wasn’t surprising. As they left, I asked the doctor what he meant and he stated that we were in a “stroke center” and that if you have a stroke and you live anywhere near here, this is where you’d come. He went on to say that while going to the chiropractor does not mean you will end up with a stroke, the vast majority of young people that come in had just seen the chiropractor and had not had any other physical trauma.
Thanks for listening.
nwtk2007,
You’re repeatedly asked for examples… Wish granted.
Thanks
You’ll have to forgive me for not believing a word you say and that I strongly suspect that you are a certain blogger who goes by many aliases and is well known for such fiction.
I’ll have to admit that the “not knowing what the “lead” doctor is called” is a nice touch over your previous posts on the other blogs.
Get real.
I can understand how you might have run into someone doing what you describe… Especially if you often get into these types of debates on other blogs. However, I assure you that I am not this other person you speak of.
I came across this site while doing research into whether or not the stroke could have actually been caused by her chiropractor. I did not believe it myself, especially given their apparent certainty. As well, I had never ever heard of something like this happening, so I decided to do some looking on my own.
Be callus if you wish, maybe you do not intend to be… But rest assured, as much as I wish it had not, this DID just happen… For whatever reason all signs point to chiropractic manipulation as the source. I’m not a doctor of anything, just a computer guy that wants his girlfriend to be happy again and live a normal life. So you’ll have to forgive me if I don’t know what the “lead” doctor is called.
This is the most “real” thing that has even happened in my life… I can’t imagine it being any more so. You’re true colors have apparently come out in full force here… Are all of your statements based purely on assumption and past experience?
Lastly, I don’t care if you think it’s true or not… I came here asking for help. I did not even realize you had asked for examples until I went back and read through all of the comments… After reading your posts, I found myself wishing I could edit my first post to say “Here’s an example” but I could not. You assumed the worst, something it sounds most chiropractors should as well.
@mrbasher
We hope your girfriend will have a complete and rapid recovery.
@nwtk2007
Just a lesson in SBM. If mrbasher was dishonest, what harm has that done to you? If mrbasher is honest, what harm have your attacks done to him. Perhaps your profession does not take the Hippocratic oath? SBM is about more than randomized clinical trials and relative risk estimates.
@mrbasher, Another good source of information for you is http://www.ebm-first.com/chiropractic/risks.html Particularly note the most recent review of chiropractic harm under the title “Deaths after chiropractic: a review of published cases.”
JMB,
If mrbasher is dishonest then he is attempting to harm the profession and using the tactics of so many anti-chiro individuals, that the ends justify the means. It has been done countless times by the anti-chiro trolls on many blogs. I place it right up there with commenting on research without even reading it.
If honest then he shouldn’t be hurt in the least. He came here with an agenda for much more than “help” for his “girlfriend”. That much is obvious. On its face value, this is nothing but a story, possibly contrived, representing bait for those of us who continue to see very clearly that there is little, if any, evidence that CMT causes strokes.
As to this fictional account, what is this “pop” that the girlfriend heard while drying her hair? It must have been quite a “pop” to be heard above the noise of a hair dryer. The fictional fact that she had been seen by a chiro recently can, in no form or fashion, be linked to that. It is claimed that she left the chiro complaining of neck pain. Was that the reason she went to see the chiro? What is the history of her neck pain beyond what has been provided here?
There is much to ask about this fictional account. Why not bring it up to the level of something real. Mrbasher is in no danger of violating HIPPA and, I would suspect that if the MD’s truly felt that the stroke was caused by CMT that they would take steps to bring this out in some form or fashion.
I’ll stand by my suspicion that this is fictional until proven otherwise.
@nwtk2007
Again, you assume far too much…
I did not come here looking for a fight or to “stoke the fire.” As well, I did not even realize this was some type of anti-chiro blog… Must I continue to reiterate that I was and still am, in the process of doing research on this whole thing? You’re not helping “your side” either…
You “sir” are the one attempting to stoke the fire by doubting the reality of this situation and attempting to discredit someone who has done nothing more than ask for help. Why it is so difficult for you to believe this has happened is beyond me… However, I do not find it necessary to “prove” anything to you or anyone else here.
If you had taken this opportunity to actually help me in this situation by providing whatever knowledge you may have on the subject, I would have appreciated your input. Instead you have simply dismissed the possibility that this even happened. Again, doing “your side” no favors. Please forgive me for starting to actually “take a side” in all of this based partially on your input here.
You’re asking me to prove something over the internet which is a ridiculous request, especially since this JUST happened. As well, I’m not providing anyone with any specific information at this point because I don’t know what the implications of doing that might be and certainly not to someone like yourself.
I will, for whatever reason answer your questions:
She went to the chiro for neck/upper back pain, as she had previously on occasion. Nothing too horrible really, just your typical pain from sitting in front of a computer screen all day. However, this time her neck hurt after leaving and upon calling to ask the chiro about it was told to make another appointment, which she did. I must point out that the pain she was feeling after he last visit was in the exact same location as the VAD. He stroke happened prior to her scheduled visit.
The “pop” as she describes it very well may not have been heard but felt/perceived… I don’t know for certain. I never stated that she was using a hair dryer at the time and I haven’t asked her that. All she has said thus far is that she bumped that part of her neck with her hand and heard a pop, followed by the stroke. (and no, I doubt she karate chopped herself in the neck hard enough to cause a stroke) I do not think she heard a literal popping sound but a clot going into your brain stem might very likely cause any number of strange sensations, including a pop sound/feeling.
Lastly nwtk2007, I urge you to go back and reread my posts… I have not at any point attempted to discredit chiropractors. I told of our situation in the process of asking for help and only after your responses have I eluded to my increasing distrust in the profession. YOU are making my posts into something they were not intended to be and I can only guess as to why. Frankly I am amazed and I feel you should be ashamed.
To those that have tried to help, thank you. I’m not going to debate any of this with anyone here because admittedly I don’t know what I’m talking about outside of my current situation. Thanks again.
mrbasher,
you are now becoming inconsistent in your information. Firstly, you did not mention a hair dryer but you did sat that she heard the “pop” while drying her hair. I guess she might have been towel drying it, as girls do, forcefully turning their head to one side, draping the hair over the shoulder and squeezing the hair with a towel. I have two daughters and have watched this activity in them and a few girl friends as well over the years. It is a bit violent. One even used the air from the outside A/C unit, running a brush thru her hair and flipping her head in all manner of ways. If this had been going on for years, how could you possibly not see that this might be the very thing that might have gradually, over years and years, caused the damage that lead to the stroke in the first place.
Anyway, secondly, you say that the pop could be the sound of a blood clot going into the brain stem. I guess you’ve brushed up on your anatomy a bit since not even knowing what the “lead” doctor might be called. Just a computer guy?
As to your intent in the first post, you end it with:
“Upon reading her notes/chart (not sure what they call it) each doctor has made clear what they believe was the the cause of this… Care to guess what they have unanimously said? I think you know where I’m going here.”
Certainly the intent is clear here as to what it is you are implying. This statement is, if anything, an indirect accusation of a sort. I also find it a bit unbelievable that you would have spoken to each doctor that has “read her note/chart”. You are not a relative and thus the doctors would have had to have had a signed release from your “girlfriend” for them to even address her case with you. HIPPA laws are very particular about protecting the health information of the patient. And doctors are very leary of discussing this health information in the presence of anyone not clearly designated to be allowed in on such discussions.
Lastly, you say you are looking for help. What sort of help in particular?
I find that the more you post here, the more unbelievable your story becomes.
I don’t really see how I am becoming inconsistent… You seem to be arguing the semantics of how I’ve relayed the apparent “pop.” I don’t know if it was heard, felt, imagined, etc. It doesn’t matter and I fail to see why you are concentrating on that.
You are correct, I did end with that statement… I will admit, I did read the article before posting and wrote that paragraph based upon my perceived correlation between it and the events she experienced. However, while I did not perceive the article as bashing the profession, I felt it safe to assume people could guess based upon the contents of the article. Poor choice of words on my part I suppose.
As for my knowledge regarding all of this, while I may not be a medical professional, I am certainly capable of simple tasks such as reading and listening. I spent 5 days by her side in intensive care… If it were someone you loved, don’t you think you’d absorb as much of what was said as possible? Ask as many questions as possible? Do research so you can understand what’s happening? If I’d ever heard someone say what the main doctor that was doing rounds was called I’d have called them that here, but I didn’t hear that. In fact if I knew, you’d just use that against me anyhow so whatever.
I don’t know how HIPPA works or even what it is apart from what you have stated here. However, I spoke to every doctor that visited her directly and was always in her presence when doing so…
The help I am looking for is simply more information in order to determine whether or not this could have been caused by her chiropractor.
I know of the hair flipping thing you speak of and have seen previous girlfriends doing that… I agree it seems a bit excessive. However, I have never seen my current girlfriend doing those things. I still haven’t said whether or not she was using a hairdryer or a towel at the time because I don’t know and will have to ask.
I just don’t get why you are being like this, otherwise I’d stop responding. It doesn’t make any sense to me… You have no idea if it happened or not, it shouldn’t matter to you either way, and yet you have decided to continue doubting the fact that it actually happened. Not only that but you’re tearing apart each post searching for a way to discredit me. I don’t need to be discredited, I never had any credit to begin with and neither do you, given that we are posting on the internet. This is a terrible thing that has happened to her whether the chiropractor caused it or not and I don’t really appreciate your assumption that it didn’t happen. You gain nothing in doing what you are other than the reputation for being jerk. How can you not see that? You apparently don’t believe in Karma.
One more thing… Sorry for the double post…
If you want to refute the possibility that it was caused by her chiropractor, I have no problem with that. However, that is not what you are doing. You are denying entirely, based solely on you’re “gut” that it even happened.
I’ve given you good reasons to consider as more likely cause than any chiro treatment, based upon what little info you have given.
For example, if the hair drying caused a pop, and she has been doing this for years now, isn’t it more likely that the damage which led to the stroke had accumulated over those years and was, in fact, finally caused by the hair drying, and not the chiropractic treatment? It could even have been damage from this activity, the hair drying, that caused the symptoms for which she initially went to the chiro for in the first place.
@nwtk2007 on 23 Jul 2010 at 5:12 pm wrote “I’ve given you good reasons to consider as more likely cause than any chiro treatment, based upon what little info you have given.”
You have been given a lot of information about chiros causing strokes and you either cannot understand or do not want to. Either way, it does not bode well for you.
On the other hand, mrbasher has expert opinion of real doctors at a stroke center.
I’ll leave it as an intellectual exercise for you to choose, and explain, whom he should believe.
nwtk’s thesis of accumulated damage in a blood vessel of someone who is 30 from hair drying doesn’t jive with current medical knowledge. Accumulated damage due to mechanical trauma is seen in tendons, ligaments, and cartilage… all of which are relatively avascular. Blood vessels heal much more rapidly after damage. When mechanical damage to arteries occurs, we see it much more commonly in areas where vessels branch, in patients with lipid disorders, patients who smoke, and patients with prolonged hypertension. Accumulated damage to arteries is more commonly seen in the age group of 45+, even in those with risk factors.
When mechanical forces are greater than encountered in everyday activities, there are certain areas that we tend to see arterial damage; the traumatic tears of arteries including dissections. The occurrence of dissection of arteries in the neck following motor vehicle accidents, and chiropractic manipulation is a clinical observation, even though it is uncommon. In both cases, the position of the neck and the force of distraction is considered a mechanism of injury. The vertebral artery extends upward through holes in the bone at each vertebral level. When the cervical vertebral are moved from the neutral position you assume when standing still, some parts of the two vertebral arteries in the neck may be stretched because the relative position of the holes in the bone change. Forceful distraction of the neck will also produce stretching of the vertebral artery. Stretching of an artery can result in tears of the layers of the artery. If the inner layer of the artery, the intima, is torn, dissections and blood clots can occur. Such damage in one of a pair of vertebral arteries can result in neck pain, but not a stroke if there is still adequate blood supply from the other vertebral artery. Now if the dissection (tear in the inner layer) extends up high enough into the brain, or if the blood clot breaks off and floats up to the brain, then arteries without good collateral blood flow may be occluded, and the stroke develops. Intimal dissections can extend, or blood clots may dislodge for several days after an injury. As time passes, the artery heals, the risk decreases. After a few months, it may be hard to tell where the vessel was injured.
The vertebral arteries don’t branch until they are inside the skull, in an area affected very little by movement. The two vertebral arteries supply some of the vessels to the brain stem and cerebellum that do not have good collateral supply. Here is a link to the wikipedia article with some pictures of the anatomic points I have discussed. Hopefully, this will be helpful.
http://en.wikipedia.org/wiki/Vertebral_artery
JMB’s post is explanatory. A little knowledge of the anatomy is useful here. From a biomechanical standpoint, it helps to know that in addition to the vertebral artery leaving the confines of the bone at C-2, then making sharp turns before ascending into the skull, HALF of the neck rotation (roughly 45 degrees of the 90 degrees to either side) occurs between C-1 and C-2 and that is the exact location of the demonstrated tear in the vertebral artery wall when the stroke is investigated by arteriography. Over and over, that is where the damage occurs. Rarely, carotid arteries are injured, but mostly it is this exact location in the vertebral arteries in young people with no prior risk factors and no demonstrated atherosclerotic plaques at time of the imaging study. Anyone who understands these anatomical facts who has watched a video of the high velocity neck manipulation favored by chiropractors, and some MDs in Germany can readily appreciate the risk. Having spoken with a number of victims or their surviving family members, many of the strokes begin immediately following the neck twisting while the patient is on the treatment table, but some occur in the car while driving home or later that night, even up to a month or more later. Chiropractors deny the risk out of either ignorance or a shortsighted sense of economic protection of the profession. No other explanations are understandable.
# mrbasheron 20 Jul 2010 at 4:57 pm
“On July 11th of this year my girlfriend had a stroke……snip……Please help… Thank you.”
mrbasher-
A more likely cause, in this age group, would be this:
ScienceDaily (Oct. 27, 2009) — She was only 30 years old, but she was experiencing the classic symptoms of a stroke. Her speech suddenly became slurred, and her left hand became clumsy while eating.
What triggered her stroke, at such a young age, may have been the birth control pills she was taking. Oral contraceptives nearly double the risk of stroke, according to a review article in MedLink Neurology by three Loyola University Health System neurologists.
http://www.sciencedaily.com/releases/2009/10/091026152820.htm
Let me also direct you to a few other relative and important sources, that you you will find informative:
http://smperle.blogspot.com/
Science, Sometimes- Stroke and Chiropractic
“snip……What is the epidemiology of these strokes? They are rare representing 2% of all ischemic strokes but 10 to 25 percent of strokes in the young and middle aged.(5) These facts are not well known so when someone in who is young or middle aged presents to a hospital with a stroke everyone wants to know why. Given the bias and bad information then the question comes, “did you see a chiropractor within the past month?” This only serves to expand the perceived value of this belief. It is not uncommon to hear someone say that the risk is proven. Proof is a word I tell my students that they can never use when referring to biomedical research. There is either evidence that supports or refutes a particular hypothesis. IF they want PROOF then their career choice should become mathematics not health care.
Or that there is 80 years of science backing this up. Well time to go back to that earlier quote: “the pleural of anecdote is anecdotes not evidence.” There isn’t an 80 year history of science with respect to the association between cervical manipulation and stroke, there is an 80 year history of anecdotes that appears in the scientific literature. The real science behind this issue has a much shorter history. We get a survey of neurologists in 1995 (6) with a very poor response rate and which suffers from referral bias. (7) Plus a survey doesn’t establish cause and effect. There are many studies of cases that have tried to discover the incidence. For example this paper by Haldeman et al which estimated that one chiropractor in 48 would during the course of their practice career would be made aware of an arterial dissection following cervical manipulation. But none of these papers actually evaluated the risk.
There are only three studies that have evaluated the risk of stroke after manipulation. And all three agree there is an association. (9- 11) The first two found a risk (9, 10) and the third (11) finding the same association provided evidence that explains the first two. Cassidy et al (11) used the same data sources as Rothwell et al (9) but Cassidy et al study investigated one thing neither Smith (9) nor Rothwell (10) did and that is they determined the background rate of these strokes. The issue is if the rate of strokes after chiropractic care was greater than the background rate (those that were occurring spontaneously not caused by the manipulation) then we would know what the added risk was due to manipulation. The finding, the rate of strokes in patients under 45 seeking care from their primary care physician was identical to the rate for those who had seen a chiropractor. Thus seeking chiropractic care produced no extra risk for stroke over and above the background rate. It appears that patients about to have a stroke from a dissection of a vertebral artery (the kind blamed on chiropractic for 80 years) seem to go to a doctor (a medical doctor or a chiropractic doctor) and the only reason the association between chiropractic and stroke appeared to be strong and not for PCPs is that no one asks the question in the emergency room, “did you see your MD within the past month?”"snip…”
Here is a link to the Cassidy study:
http://www.ncbi.nlm.nih.gov/pubmed/18204390?dopt=Citation
Ask your girlfriend’s Docs if they have read/are familiar with this study.
weing,
BillyJoe: “By looking for harmful effects, it has been found that Amaryl used in the treatment of diabetes increases the risk of heart attack by 43% (I prefer absolute risk, but that’s not important here).”
weing “Do you have a reference for that?”
Sorry, I did that from memory.
It was Avandia, not Amaryl:
http://www.guardian.co.uk/commentisfree/2010/jul/17/ben-goldacre-diabetes-drug
JMB – “nwtk’s thesis of accumulated damage in a blood vessel of someone who is 30 from hair drying doesn’t jive with current medical knowledge”
I’d like to know how you can conclude this. You need to acknowledge that these same types of strokes occur in an almost equal number of individuals who have not been cervically manipulated. The finding of slightly higher incidence in a younger population is easily understood from the basic knowledge that younger individuals are more active and more likely to be involved in activities which place stresses on the vertebral arteries.
By the way, the vertebral arteries don’t branch but join to form one larger basilar artery which then branches to supply various parts of the lower brain and brain stem, with the exception of a small branch which supplies the upper spinal cord.
JMB – “The occurrence of dissection of arteries in the neck following motor vehicle accidents, and chiropractic manipulation is a clinical observation, even though it is uncommon”
The occurrance of strokes after a great many other events is also a medical observation, although not well investigated. The fact is that with the mention of chiropractic the cause automatically goes to the manipulation. It doesn’t even matter if the chiropractic care was months ago or related to a low back condition, it is still the automatic choice of cause. When there is not previous chiro activity, there is little, if any, investigation into other possible causes.
And Joe, you know as well as I do that opinions are like anal orifi, most everyone has one. You have, in the past, admitted to having given opinions on studies that you haven’t read or it was painfully obvious that you had not read them.
Y’know, I think that ntwk2007 doesn’t exist either. They are a straw-man figment of the imagination of someone who believes in ethical, evidence-based practice who has created the fictitious persona of ntwk2007 to make chiropractors look bad.
mrbasher,
Don’t let the chiropractic apologists snow you. I covered the evidence for chiropractic and stroke at http://www.sciencebasedmedicine.org/?p=94
Dr. Crislip eviscerated the Cassidy study at http://www.sciencebasedmedicine.org/?p=170
Sam Homola (a chiropractor) also addressed this issue at http://www.sciencebasedmedicine.org/?p=1037
The evidence that neck manipulation can cause stroke is strong enough to convince unbiased observers. The only ones who don’t accept the evidence are those who make their living manipulating necks. Since they don’t have good evidence or arguments on their side, they are reduced to despicable tactics like accusing you of lying.
I find it very un-SBM to be unwilling to admit that the true cause of mrbasher’s girlfriend’s stroke is more likely something other than CMT. The supposed fact that she heard a pop while drying her hair is a strong indicator that she has been putting stress on her neck repeatedly over years of this type of activity. As I said, it makes perfect sense and could very well be the initial cause for her to seek chiropractic care in the first place.
This anecdote has so many holes in it as to be not even worthy of consideeration of even a smidgen of evidence that CMT causes strokes. It is only your bias that would prevent you yourself from pointing this out.
And I’m not calling mrbasher a liar or saying that he is lying, I simple don’t believe a word of his story is true and not ficticious. He or you can take that in any way you wish. If it truly is a ficticious story, then he is a liar. Period. I simply say that I don’t believe it to be true.
And Dr Hall, you yourself, in past threads have finally admitted that there is little or no evidence that CMT is a true cause of stroke. In your own words, what there is amounts to only a smoking gun, which I have pointed out, time and again, is not a smoking gun in an equal number of incidents, except for the younger group as has been previously pointed out, can be understood clearly in light of the greater activity levels of that younger group, doing the types of activities that could easily put more strain on the vertebral arteries than manipulation.
It is the cumulative effects of these activites that hides their obvious role in this extremely rare event.
nwt2007 says “you yourself, in past threads have finally admitted that there is little or no evidence that CMT is a true cause of stroke.” That’s a lie, and it’s been alleged before and I’ve denied it before. You just chose to misinterpret my words. I am not relying just on the “smoking gun” cases, and I have made that abundantly clear. There is plenty of other evidence. I only brought up the “smoking gun” cases as something that chiropractors have not even attempted to explain away, because they can’t. There are cases of asymptomatic patients getting their neck manipulated, feeling a pop and immediately developing pain, dizziness and stroke symptoms while still on the table, and imaging shows a tear in the vertebral artery. Even most chiropractors admit that this can happen. Your denialism is becoming tedious. It’s tantamount to saying a post-op infection wasn’t caused by the surgery but was already present or would have developed anyway.
@nobs on 24 Jul 2010 at 8:15 am
You offer a press release about an unpublished study as evidence for what I believe is already known. Tell me, do you think the strokes associated with birth control pills are due to artery dissection?
You also offer the opinion of a chiropractor who selects the lit. he cites and is ignorant-enough to believe the Cassidy study.
I’ll give you the same challenge I gave to the other chiro- when it comes to health, should mrbasher believe a chiropractor or the several health professionals (doctors, at a stroke center, no less) who said the chiro was likely responsible?
I tell you what… If we end up taking this to court, I believe it would then be public record. If that is the case, I will be sure to post the information here in hopes that maybe other people can at least have the opportunity to decide what is best for them, regardless of the perceived odds.
I’m not going to argue any further whether it actually happened, it’s simply a waste of my time which can honestly be better spent.
nwt2007, for your sake, given that your are a chiropractor I wish you and your patients the best of luck with neck manipulations. If drying ones hair as you describe is a more likely cause of vertebral artery dissection than neck manipulations, I wish your daughters the best of luck when doing so.
It is completely outrageous to categorically deny the possibility of this being caused by neck manipulation. You could at the very LEAST admit to me and everyone else here that is is a possibility, despite it’s rarity. You have not done so and I simply cannot understand that. Forgive me, but it seems a bit ignorant. Yes, I have come to the conclusion that it was caused by her chiropractor, but I have not done so based purely on assumptions. I started researching this with absolutely no bias whatsoever… The same cannot be said for you. You need to get that chip off your shoulder and stop assuming that everyone speaking of chiropractic malpractice is taking a shot at you.
Some number of posts ago, you told me to “get real.” You said this with absolutely no knowledge of who I was or whether or not I was telling the truth. Can you not even fathom how ridiculous that looks? How can you expect anyone here, even people in your own profession, to buy into that kind of blind disregard for another human beings apparent anguish. I will go so far as to say your posts are borderline “troll” and because of this I will simply ignore you from here on out, as should the rest of you. Go look in the mirror and ask yourself if you’d done the right thing here, if YOU’VE been “real.”
Goodbye.
It’s interesting to note that the legal profession is now beginning to take the chiropractic neck manipulation and stroke association very seriously. The following link, which has good, comprehensive, medical and legal information on the issue, is dedicated to chiropractic stroke victims:
http://chiropracticstrokevictims.com/
@ mrbasher
I’m sorry to hear about your girlfriend and wish her a full and speedy recovery. It would probably be time well spent if you were to browse the above link.
@mrbasher:
I also wish your girlfriend the best of luck in her recovery.
She has a right to her medical records, so she might want to get a copy. From your description, I imagine the records will show that her dissection was caused by chiropractic manipulation. If not, she might want to find out why that was not included in the diagnosis.
I agree that the website referenced by BlueWode is an excellent place to start your search for an attorney.
@nwtk
I suppose you claim to have studied anatomy with the same rigor as us biased doctors. Perhaps chiropractors deny the risk of vertebral/basilar infarctions because they all ignore the posterior inferior cerebellar artery like you do.
http://en.wikipedia.org/wiki/Posterior_inferior_cerebellar_artery
Please note the symptoms of occlusion of the PICA (the article has errors, but the main points are correct). You will have to follow the link for the symptoms.
Once a vessel, or any other structure in the body, has been torn, it may take only a minor force to complete a tear. Ligaments, tendons, and cartilage heal very slowly, and often incompletely. Therefore, we see many patients in which simply turning while walking produced a big cartilage tear. Blood vessels heal much more rapidly, and usually completely in a 30 year old. That is the problem with the postulated accumulated injury from hair drying. However, a recent injury to the vessel could have put the patient in the precarious situation that common every day activities could have resulted in the stroke. If the injury had been recognized, and the patient anticoagulated, perhaps the stroke would not have occurred.
Strokes have many causes. Only a minority are due to dissection (not all dissection result in stroke). An obvious problem with performing an observational study of all types of stroke, is that no conclusion can be reliably made about the less common varieties of stroke. If you were concluding that strokes could not occur due to decompression sickness, because the incidence of stroke was no different between people who got in the water versus people who saw their primary care physician, then you would obviously be wrong.
Interesting the delay in Nobs post. Good summary of the current research.
nwtk2007 on 25 Jul 2010 at 11:50 am wrote “Interesting the delay in Nobs post. Good summary of the current research.”
How do you know there was a delay?
So, the “good summary” comprises a press release about an unpublished study (as evidence for what I believe is already known). And the opinion of a chiropractor who selects the lit. he cites and is ignorant-enough to believe the Cassidy study.
@nwtk
The fact that that article was published reflects poorly on the peer review process. Not all vertebrobasilar strokes result from dissection. Most strokes occurring from an arterial dissection will develop within a short time frame (typically less than a year, more commonly in the first week). Nearly all arterial dissections are symptomatic, so they should have considered only those patients who reported worsening of pain during the provider visit.
If the author wanted to prove the lack of a causal relationship, then the correlation should have been made between a visit to the chiropractor or PCP within a week before the onset of the stroke, excluding any cases in which patients had visited both the chiropractor and PCP. Instead, the factor considered by the study is whether the patient had seen either provider within a year prior to diagnosis. Furthermore, the presence of a dissection of the vertebral artery causing the stroke should have been verified. Many would have been due to other causes. Since arterial dissections are rarely asymptomatic, they should have considered only those patients in which pain became significantly worse during the visit to the chiropractor or PCP.
Using a more science based selection criteria, the results would likely have been different. The selection of a one year time frame is probably sufficient to obscure any causal relationship.
I thought the usual guide for informed consent before any procedure was providing information that the “reasonable patient” would want to know. Applying that to this example- would a “reasonable patient” want to know that neck manipulation has been linked to stroke? In this case, stroke can be fatal or debilitating, so regardless of how rare it is, a “reasonable patient” would definitely want to know about it. The practitioner’s belief in the strength of the link is not really that relevant- if the condition is very, very rare but serious, you must inform the patient of the risk.
I’m not from the US and I don’t know how your insurance system works, but I would have thought that if mrbuster’s girlfriend was not informed of the risk before the procedure, the chiropractor has not obtained informed consent. The chiropractor’s insurer would likely be interested in settling out of court because the issue is clearcut, and the potential for a court awarding very high costs against the chiropractor must be very high, assuming she was young and healthy before the stroke.
P.S- mrbuster- I hope your girlfriend makes a full recovery quickly. I’d urge you and her to consider visiting the chiropractor afterwards and explain what happened. I suspect that he/she will be devastated to hear what happen, and it may lead to them changing their practice.
I am afraid there is an error in your last post, JMB.
Nobs and ntwk love the Cassidy study, despite the admission of its authors that it does not prove cmt to be safe, so I am sure they will be able to quickly point the error out.
@pmoran
It wouldn’t be my first error. I didn’t pay for the full article. I commented on the methods reported in the summary available from Spine, lww
http://journals.lww.com/spinejournal/Abstract/2008/02151/Risk_of_Vertebrobasilar_Stroke_and_Chiropractic.19.aspx
I see there is an erratum in which a table is cited for stroke 0 to 7 days after visit. Perhaps that is the error you have noted for me.
Granting that I may be wrong about the consideration of temporal relationship, I still have two other concerns about the study. I am still concerned about the method of identifying whether a vertebrobasilar stroke was related to an arterial dissection or other etiology. Perhaps the article discussed whether all cases in patients less than 45 were angiographicly (either standard, CTA, or MRA) confirmed. I also think there has to be caution about the criteria for identifying a patient as having a vertebrobasilar stroke. For scientific evaluation, it should be confirmed by imaging, or at least a neurologist. Perhaps those concerns were addressed in the full article?
If I were to design a population study, I would select those patients who experience a sharp increase in pain during the visit to either type of provider, and who had angiographicly demonstrated vertebral artery dissection.
In conventional science based medicine, we will use case reports to decide what to include in informed consent (however, informed consent does vary considerable from provider to provider). We will even use them to decide whether to obtain more tests. Of course, that does lead to inefficiencies to perform so many tests for the benefit of so few (but what a benefit to those few). EBM will do away with that.
There is one other question about the methodology of Cassidy’s study. If the study did consider the time frame from 0 to 7 days, then the visit to the PCP physician on day 0 may have been the visit that the diagnosis of a possible vertebrobasilar stroke was made, and the patient sent to the hospital. So the methodology would have to show some consideration of whether the patient was admitted to the hospital after the visit on day zero, before or after some other therapy was instituted.
JMB, interesting points about the methodology of the Cassidy study. But either way it might have been done, truly linking the stroke to CMT vs a visit to the PCP is futile. The patients went to the chiro or PCP for the same complaints. I would ask, also, if the PCP chould have been able to diagnose the apparent risk of oncoming stroke.
Mark, about informed consent, do you think the informed consent on bottles of ibuprofen clearly indicate the risk? If the warning on the bottle clearly stated that ibuprofen was the number two cause of peptic ulcer, would it be a more effective informed consent. Likewise, if it indicated that ibuprofen was considered by the medical community to be resposible for the deaths of a few thousand people each year, would that also make it a more credible informed consent, considering the call for improved informed consent for something not proven and only scantly indicated as CMT and the risk of stroke?
Personally, I’d be in favor of having OTC drugs made to include all the same warnings as their prescription-only counterparts. So yes, ibuprofen’s packaging (or an insert) should indicate that it is a risk factor for peptic ulcer. That it doesn’t showcases the deficiencies in the system.
When I had my last upper endoscopy, I was informed of even very rare risks. The same was true when I received my 2009 H1N1 vaccination. My prescription medications all include lists of adverse effects, including those which are very rare, but particularly highlighting the serious ones. I think that at a minimum, such language should also be used by chiropractors (or their assistants) as they prepare to perform cervical manipulation.
To me, this seems like a no-brainer. Chiropractors seem to be mainly worried that people will stop going to see them if they are aware of risks. But informed consent hasn’t stopped people getting much more dangerous elective surgical procedures performed, so I hardly think people with splitting headaches are going to stop getting their spines adjusted after being informed that there are possible risks. I mean seriously; if you get a bad enough headache, you’d put a bullet in your foot if you thought it would help; patients will certainly accept the risk of stroke to treat their headaches. So your business will not suffer. But, when those rare adverse effects happen, patients will be well enough informed that they can get to an ER and have it treated in time. And we (meaning society) will be able to better understand how often the adverse effects happen and whether or not techniques need to be altered or, if it proves particularly dangerous, abandoned altogether.
@nwtk2007
The onus is on the prescriber or practitioner to obtain informed consent before prescribing a medication or performing an intervention. So if a person sustained a peptic ulcer while taking ibuprofen and the practitioner hadn’t warned the person of that risk, their position would be indefensible. Just like a doctor who does not obtain informed consent before performing a procedure or a chiropractor who does not obtain informed consent before manipulating a neck.
Again, what potential risks need to be discussed is determined by what a reasonable patient would want to know. If the risks are serious- such as a stroke, or death etc, then they should be discussed, even if they are only theoretical or very rare.
So who is the “onus” on when a person self prescribes based upon TV marketing of OTC meds which are so dangerous, like ibuprofen?
I have no problem telling a “resonable” patient that there are some out there who believe there is a risk of stoke with CMT, how ever slight the risk might be. Don’t you think the true risks associated with ibuprofen should also be made known? All OTC meds for that matter?
And shouldn’t it be painfully clear in light of the fact, and I say fact, that so many lack the education and basic knowledge to truly assess the risk of these things they are willing to pop into their mouths so indescriminately?
nwtk2007 still doesn’t understand why tu quoque is a logical fallacy. You can complain all day about NSAIDS, but that does nothing to exonerate neck manipulation. And telling the patient “there are some out there who believe there is a risk of stoke with CMT” is just the kind of self-serving weasel-wording that many chiropractors are using to pretend that they are getting informed consent when they are really trying to influence the patient. MDs don’t minimize the risks of NSAIDS by saying “there are some out there who believe there is a risk of death from NSAIDS.”
@ nwtk2007
I’m not sure where you are going with the ibuprofen/OTC analogy. Obviously, if something is self-prescribed the issue of a practitioner obtaining informed consent is irrelevant. I agree with you about the difficulties of communicating risks to individuals who chose to self-prescribe. As Calli Arcade says, you can have the information in the packaging or insert, but as you point out, the person may not read or understand it.
However, coming back to the issue, which is about a practitioner obtaining informed consent before a procedure. I agree with Harriet that you would need to be very careful phrasing your words in that way. The test for informed consent is providing information that the patient needs to know. If a practitioner used that phrase, and a patient later formally questioned whether informed consent had been obtained, I suspect most formal authorities would say that it hadn’t. The practitioner would then find him/herself in an indefensible position if a stroke did occur after the procedure.
I’m not tu quoque’ing. I’m compairing the need and the level of urgency of the informed consent related to the risks of CMT vs the risks of ibuprofen. I’m not saying that since the informed consent for ibuprofen risk is insufficient that the chiros shouldn’t have to be sufficient in their informed consent as relates to the risks of CMT. Not saying that at all.
I’m just comparing the two. One is a proven killer and harmer of people, without doubt, however rare it might occur. The other is of questionable risk and if actually a risk, much rarer than the risk of the other.
Just compairing and wondering why the level of urgency for informed consent isn’t just as comparable.
I also wouldn’t say that chiro’s weasal word the risk. By SBM standards, there is simply no concrete evidence that CMT causes stroke. None. Just stories and questionable studies where the data can be interpreted in many ways, where the “link” between the two is highly questionable and insufficiently investigated by the one who provides the “opinion” that a CMT has caused a stroke.
nobs explained a good bit of this earlier on and I’ll not reitterate it again and again.
Informed consent is fine, I have no problem with it. It won’t effect the business or peoples choice of one treatment over another as relates to chiropractic. But I am willing to bet that if the death statistics associated with ibuprofen and its level of risk associated with gastric ulcer were presented in anything by “fine print” on a little piece of paper annoyingly folded up almost too tightly to unfold, the sales of ibuprofen would plummet. As it is right now it is comparable to the disclaimers read at lightning speed at the end of many radio advertisements.
If the chiro’s informed consent were presented in such a way, the outcry of many of the SBM’ers here would be incredible.
Call it tu quoque or what ever, it doesn’t matter. Out cry for informed consent related to the risks of CMT by many medical professionals is tantamount to the proverbial pot calling the kettle black.
One more thing, I’m thinking that if a doctor causes harm to a patient, even if there is informed consent as to the risks, he/she is still in an indefensible position. The lay-public simply lacks the education and the understanding to make informed decisions related to most things health and medically related. In any malpractice proceeding, the informed consent would be the very first thing a plaintifs attorney would dispense with. Juries can be convinced of many things which do not jive with “assumed” justice and/or justifyable actions.
“By SBM standards, there is simply no concrete evidence that CMT causes stroke.”
And there never will be, if the standard you demand is multiple prospective randomised controlled trials of a size large enough to demonstrate what is admittedly a very small, but serious, risk in patients with no solid justification for the procedure.
That is not the same thing as “no evidence” .
There are the regularly occurring “smoking gun” cases which first drew attention to the problem and that you seem unable to grasp the significance of with such an extremely rare condition in the young, and the strong statistical associations in every study that has looked for them, including the Cassidy study.
Only some of that association could be due to patieints with early symptoms of VAD attending chiropractors. Some of the smoking gun cases had no relevant symptoms.
What’s more, Cassidy’s own figures show that a patient with a “headache or cervical” problem is at least four times more likely to see a PCP than DC. Allowing for that would completely eliminate the supposedly similar association of stroke with PCP visits. I cannot see where that has been allowed for. Can you?
nwtk2007: NSAIDs provide benefit beyond placebo for a number of conditions and relieve pain far more than placebo or they would not have been able to be prescribed and sold for that purpose. Chiropractic neck manipulation has not been shown to be better than placebo by evidence based medical standards, and on rare occasions kills or maims. Practically every MD who has studied this issue, which now includes almost all ER physicians, neurologists, neurosurgeons, stroke physicians of any type, those who come in contact with stroke victims and also understand the distinct anatomy of the C-1/C-2 articulation and the vertebral artery, knows the connection between chiropractic neck manipulation and stroke is real and a danger. None of those MDs, I would venture to say, would countenance advising anyone to have a chiropractic neck manipulation. Anyone who understands the anatomy and has a sense of biomechanics who has watched a chiropractic neck manipulation as shown on some of the You Tube chiropractic advertising videos listed above, would consider recommending such a procedure…no benefit beyond placebo, small but real risk of stroke or death. True informed consent is the bare minimum which should be demanded of the profession. Chiropractors keep hanging their hat on the Cassidy study, lead by a chiropractor who admitted at one time he had caused a stroke in a patient but now evidently retracts that admission, has multiple flaws, shows an association in young people between chiropractic neck manipulation and stroke (that is where the primary risk exists…so including a bunch of older folks in the study population dilutes this relatively rare event so much as to make it appear stroke is less likely), did not search for diagnostic codes for Vertebral Artery Dissection (the primary pathologic cause for the stroke following neck manipulation), examined not one patient (just discharge diagnoses) and still admitted strokes were a 4 fold risk in young people if their neck had been manipulated. The Cassidy study should be recognized for what it is…
I tell all patients who insist on seeing a chiropractor: ” just don’t let them touch your neck.” And I am serious.
What if we look at this at a higher level?
Is it possible that if done correctly 100% of the time, there would be no chance of dissection?
Is it possible that if not done correctly, a chiropractor could cause a dissection?
Should a chiropractor be expected to do whatever is necessary to avoid the risk of causing a dissection?
I do not believe anyone is saying that CMT = dissection/stroke, in fact I haven’t seen this stated on even the most biased sites I have seen. Everything I have read is attempting to point out an associated risk, which seems obvious… even to the lay-person. You won’t catch me cracking my own neck anymore either, for the very same reason.
I’ll tell you what I do see… I see chiropractors giving the following defense, repeatedly: “It could have been anything.” Which is entirely true… However, “anything” does not exclude CMT. Unless of course, chiropractors do it right 100% of the time… Do they?
Mr. Basher: as one who has followed this issue closely for years, the answer is that the risk of vertebral artery dissection and then serious neurologic harm or death is on the order of one in thousands of neck crackings. However, there are over a million of these done annually in the U.S. and Canada, I am informed. Many chiropractors use this procedure to treat every condition which presents itself to their office: I have seen permanent neurologic injury from neck cracking to treat tailbone pain and shoulder pain and low back pain, and death from neck cracking to treat some of the same conditions. Sometimes seizures occur on the treatment table and most develop symptoms within 24 hours, but because a clot can occur at the site of the torn artery, delay of up to a month or more does occur. It is not a matter of the procedure being done properly, since the chiropractors wish to elicit the “pop” of sudden negative pressure within neck vertebral joints resulting in nitrogen gas appearing, like cracking one’s knuckles. A slow and safe neck manipulation which some chiropractors and most physical therapists use, would not produce the impressive “pop” which makes the patient think something important has happened and that something must have been out of place.
Put another way, a safe neck manipulation would be performed slowly and gently and would be described better as gentle immobilization. Akin to massage therapy, which is safe. Chiropractors, as seen on this blog, seem unwilling to admit there is any risk, nor to warn patients of that risk. Those MDs who treat stroke victims know better. In my opinion, the high velocity neck maneuver favored by many chiropractors and also practiced by many MDs in Germany should never be performed for any reason. No demonstrated benefit. No plausible reason why it would help anyone. Rare risk of stroke or death.
Mr Welby, I am not believing what I am reading. I am beginning to think you might be as ficticious as mrbasher. You certainly sound much the same as I have experienced in reading other blogs where failed chiro’s pretend to be doctors, pt’s and nurses who repeat the same jargon and have, in some instances, been exposed as ficticious imposters. At the very least some of your comments are exact copies of many on these blogs I mention.
marcuswelby – “as one who has followed this issue closely for years, the answer is that the risk of vertebral artery dissection and then serious neurologic harm or death is on the order of one in thousands of neck crackings. ”
If you have, indeed followed this issue for years, then you would be more acurate. Even if the alleged stroke were caused by CMT, the risk has been estimated from one in a million to one in ten million.
marcuswelby – “However, there are over a million of these done annually in the U.S. and Canada, I am informed.
What a bogus attempt to be taken seriously and to be seen as genuine. Informed where? In the coffee shop? At the barber shop? Do you mean you have read it?
marcuswelby – ” I have seen permanent neurologic injury from neck cracking to treat tailbone pain and shoulder pain and low back pain, and death from neck cracking to treat some of the same conditions. ”
Yeah right. Where? When? More fiction from the coffee shop? If, indeed, you are a doctor, did you report it? What became of it?
marcuswelby – “Sometimes seizures occur on the treatment table and most develop symptoms within 24 hours, but because a clot can occur at the site of the torn artery, delay of up to a month or more does occur.”
What a bunch of fiction. You know this to be fact? How do you know it?
marcuswelby – “Those MDs who treat stroke victims know better.”
Really? Are you one of those? If you hear the word chiropractor, do you investigate any further at all?
The way you speak of it just cries “fiction”. And that’s pretty much the way I have seen it argued in most places. I’ve seen this or I’ve seen that.
I’ll stick with the studies discussed here and leave it at that. I left this blog for a year because there just wasn’t anything more coming up about it. It’s still the same. The court cases are public record and will eventually either go away or be decided. My guess is there will be no definative studies ever nor any agreement with any resultant studies that might be performed.
If the risk is as it is discussed here, then there will be new law suits and many more real cases appearing in the news. We’ll see.
nwtk2007 said “The way you speak of it just cries “fiction”.
The way nwtk2007 speaks just cries “desperate rationalizations trying to defend a lost cause.” Apparently he won’t believe neck manipulation can cause a stroke until he is confronted with some kind of “perfect” evidence. And yet he seems to think new lawsuits and cases in the news would constitute acceptable evidence. Does he really? How many lawsuits and news stories does it take to add up to evidence? Why aren’t the existing ones sufficient? The rest of us are concerned enough about patient safety to accept the existing evidence.
Marcus Welby: “I’ll tell you what I do see… I see chiropractors giving the following defense, repeatedly: “It could have been anything.” Which is entirely true… However, “anything” does not exclude CMT.”
Actually that’s not “entirely true”. I’ve been meaning to point out that the several case control studies should control for the “anything”, meaning the other possible triggering events of VAD that chiropractors like to raise.
In any case, it is ridiculous for them to be claiming that sneezing and drying the hair can cause stroke, but neck manipulation can’t.
Why not continue to twist my position. I have pointed out that there is literally no solid evidence that CMT causes these strokes and that repeatedly, the other possible causes are ignored or not considered.
I don’t expect perfect evidence, just objective assessment of it. Failure to consider the other possible causes that have been mentioned, even when there is no CMT performed, is to me, unscientific thinking.
In the words of pmoran, it is “ridiculous” NOT to think that activities which are even more violent in their neck motions would not be possible causes.
Total BIAS. Not science based thinking.
nwtk2007,
Didn’t you understand pmoran’s point? The controlled studies constituted “considering that there could be other possible causes.”
“Why not continue to twist my position. I have pointed out that there is literally no solid evidence that CMT causes these strokes and that repeatedly, the other possible causes are ignored or not considered.”
That is PRECISELY the position that gives us concern, if it is guiding chiropractic’s response to the matter. The “other possible causes” is ridiculous, considering the details of many of the cases that occur while still on the chiropractor’s table, or in a doctor’s office, as in one local case.
But be it on your own head. Ignoring the matter can only add to a generally low regard for the professionalism of many chiropractors.
Arterial dissection is a recognized complication for any procedure involving an intra-arterial catheter. The majority can be recognized at the time of catherization, and treated with anticoagulant therapy to minimize the risk of infarction from the dissection. The occurrence of dissection during a procedure is not considered a breach of the standard of care (unless it happens much more frequently than the norm). What is considered a breach of the standard of care is the failure to recognize and treat the complicating dissection.
If chiropractors get hung up on the issue of scientific proof, they may miss the opportunity in the rare patient that suffers a vertebral artery dissection to minimize the risk of stroke, or minimize the deficit resulting from the stroke. Early intervention can improve the outcome. Don’t worry about scientific proof when the patient is in front of you exhibiting the symptoms of a vertebral artery dissection or stroke, just get the patient to the hospital for confirming tests and anticoagulants. Nowhere in SBM is there an axiom that says, “Don’t treat if there is no evidence from Randomized Clinical Trials.”
Is it better for the chiropractor’s profession to argue that scientific evidence does not exist… or that there is anecdotal evidence that it may occur rarely following cervical manipulation, so it is important for chiropractors to learn the symptoms of arterial dissection and vertebrobasilar stroke so that early intervention can minimize the long term sequela.
In view of the rational contributions here which clearly indicate an unfavourable risk/benefit profile for neck manipulation, it’s disappointing to see a new article in Chiropractic & Osteopathy that strongly suggests that stroke after neck manipulation is coincidental:
http://www.chiroandosteo.com/content/18/1/22
Interesting read… Looks like Kaiser Permanente picked a side: http://www.chiroeco.com/chiropractic/news/10075/52/American-Chiropractic-Association-responds-to-new-Kaiser-policy-excluding-cervical-manipulation/