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Kaiser Rejects Neck Manipulation

Despite quackademia, anti-vaccine propaganda, and other discouraging trends, the news is not all bad. A major HMO has taken a decisive action in support of science-based medicine. 

Kaiser Permanente Mid Atlantic States and Mid-Atlantic Permanente Group recently announced the elimination of neck manipulation from their chiropractic coverage. The revised policy states,

Given the paucity of data related to beneficial effects of chiropractic manipulation of the cervical spine and the real potential for catastrophic adverse events, it was decided to exclude chiropractic manipulation of the cervical spine from coverage. 

Their decision was applauded by some  but was predictably attacked by chiropractors.

The American Chiropractic Association (ACA) promptly responded with a letter to Kaiser outlining “the extensive data that supports cervical spinal manipulation as both beneficial and safe.” I have not yet been able to find a copy of that letter online. I don’t doubt that they presented data to support their beliefs. I do doubt that they presented a balanced view of the entire body of published evidence, the body of evidence that Kaiser relied on in making its decision. When the BCA (British Chiropractic Association) tried to defend itself against Simon Singh’s criticism, it provided a list of allegedly supporting studies but these were readily demolished in the blogosphere. Several previous posts on SBM including this one by a chiropractor have examined the evidence for neck manipulation and concurred with Kaiser that there is a “paucity of data related to beneficial effects of chiropractic manipulation of the cervical spine” and a “real potential for catastrophic adverse events.” That’s what the science says. It is encouraging that Kaiser followed the science.

The ACA also released the following statement, signed by ACA President, Dr. Rick McMichael :

The American Chiropractic Association is aware that Kaiser Permanente Mid Atlantic States and Mid-Atlantic Permanente Medical Group have revised their Chiropractic Manipulation Medical Coverage Policy to exclude cervical Chiropractic Manipulative Treatment (CMT) from coverage.  This restriction, if allowed to stand, will be harmful to chiropractic patients and doctors. We have contacted Kaiser to express our grave concern over this change, and we await its reply. ACA will expend every effort to encourage Kaiser to reverse this new restriction, and we will keep our members and the profession informed along the way.  

Chiropractors are not doing well. 20-25% of chiropractors leave the field within 10 years of graduation. Their average income has dropped from $97,892 annually in 1992-1993 to only $48,900 in 2002-2003.

The new Kaiser policy threatens their livelihood, especially the livelihood of the many practitioners who use neck manipulation on virtually all patients regardless of the presenting complaints. So of course they will protest and will try everything possible to convince Kaiser to change its mind. Such lobbying has been effective in previous cases.

In 2007, United Healthcare decided to stop reimbursing chiropractic care for children and for headaches. A joint letter from various chiropractic organizations chastised them:

Attached is an analysis which demonstrates that the above policy is not only flawed but more importantly, poses a threat to the health of children, adolescents and those individuals suffering with headache pain who may be insured or otherwise covered under United Healthcare programs and policies. We view your recent policy determination to be a material denial of essential benefits and coverage paid for by employers and other insureds. The broad stroke elimination of these important benefits is, in our view, not only unconscionable but is an abrogation of the promises made to cover chiropractic services to employees, individuals and their dependants.

The chiropractors contended that they are “uniquely qualified to address all types of childhood and adolescent ailments [not true].” They provided their evidence that chiropractic treatment was effective for headache [not convincing]. They said a number of other things that those of us on SBM would disagree with. United Healthcare backed down and rescinded the policy.

Kaiser made a good, science-based decision that will protect patients and also save money. They are to be commended. I hope they will stick to their guns and withstand the pressure that will be exerted against them by non-science-based chiropractors and health consumers. I hope other insurance and health care organizations will follow suit. In another action earlier this year, Saskatchewan deleted chiropractic subsidies from its health budget to save $10 million.   

Note: this policy change does not restrict patients’ rights to choose any treatment they want. It does not prevent chiropractors from doing neck manipulation; it only means that patients will have to pay for it out of pocket. Their approach seems entirely reasonable for a large organization that is trying to reduce costs for everyone by refusing to pay for treatments of questionable efficacy and safety.

Posted in: Chiropractic

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133 thoughts on “Kaiser Rejects Neck Manipulation

  1. Draal says:

    Here we go again. ObamaCare choosing profit over our health. (sarcasm)

  2. rwk says:

    Big Deal Harriet. There’s about a $10 difference between manipulation
    codes of 1-2 or 2-3 regions of the spine.
    So it probably won’t save many that are being murdered by chiropractors.
    Because 440 people die a year from smoking in bed most of the rest of us are forced to breathe flame retardants and other petrochemicals
    every night.
    Maybe that should be your next crusade Harriet.
    By the way, many medical doctors have threatened to leave the field
    once Obama care starts to squeeze them.

  3. moderation says:

    Good news. Hopefully this will be the first step on the slippery slope of elimination of coverage of all bogus chiropractic manipulation. As a former employee I know Kiaser has its issues, but I have always admired their systematic and scientific approach to establishing medical guidelines in consultataion with their physicians.

  4. Josie says:

    Chiropractic confuses me.
    I don’t understand why they can’t just market themselves as practitioners of ‘doing stuff that feels good’

    In the same way that a nice oily resort massage feels good, I thought getting my back cracked felt pretty good.

    Going from ‘feels good’ to ‘cures whatever ails you’ is a pretty big leap and that’s what I don’t understand.

    In my opinion something does not need to be medicinal to be worthwhile. I certainly don’t think my evening meals are medicinal, but preparing the food and then enjoying it certainly feels good and enriches my ‘life experience’.

  5. CarolM says:

    Yeah I used to get an “adjustment” once in a blue moon when I had a stiff neck or shoulder. Seemed to do something, make my neck feel warm and glowy and break up the pain cycle earlier than usual.

    But, as a cure for Everything? Umm, no. And to be added as an insurance mandate in my state was nothing short of outrageous. And boy, do they ever lobby.

  6. rwk says:

    Josie,most people visit a chiropractor because they want to feel good
    for whatever reason.Many times people present after the medication,physical therapy,placebo effect or natural course of the condition fails to resolve the problem.
    I don’t need a RCT to make that statement. I don’t like fellow chiropractors that claim to cure whatever ails you. I haven’t seen any
    site that claims to cure anything.
    So,please give us an example and Harriet and I will get all over them.

  7. lizditz says:

    I have no issue with chiropractic for low back pain.

    I have a huge issue with chiropractors marketing chiropractic as effective for treating (for example) ADHD or autism and the whole fields of “chiropractic neurology” http://www.acnb.org/

    Chiropractic Neurology is defined as the field of functional neurology that engages the internal and external environment of the individual in a structured and targeted approach to affect positive changes in the neuraxis and consequent physiology and behavior.

    and “chiropractic pediatrics” http://icpa4kids.com/index.php.

    Our mission is to provide education, training, and support research on chiropractic care in pregnancy and throughout childhood because all children need chiropractic care.

  8. minne peds says:

    @ rwk

    Most people get a massage to feel good, or a hot tub, or for that matter a martini. Yet no one would argue that insurance companies should foot the bill. Paraphrasing Harriet from above, this will not stop chiropracters or chiropractic patients from neck manipulation. It will only stop the insurance company from paying for what is essentially a feel good procedure.

    you know of no site which claims to cure anything?
    seriously?

    Google would beg to differ. Some claims are shrouded with wishy washy language but ther are plenty that discuss asthma, acne, MS and on and on.

  9. Maz says:

    @ rwk

    about 5 seconds on google led me to two sites that tout chiropractic as a treatment for a disease that is can’t possibly treat.

    The first is asthma:
    http://www.chiro.org/research/ABSTRACTS/Asthma.shtml

    Next is IBS:
    http://www.erinelster.com/ConditionsDetail.aspx?ConditionID=15

    Of course, if you do a bit of googling yourself, I’m sure you can find sites that claim to cure a whole host of diseases.

  10. Josie says:

    rwk-

    as a couple others have already said and even a quick check of previous blog entries here at SBM will show a plethora of examples where chiropractic claims to be treatment for just about anything …that ails you.

    If you still want an example from me personally, here you go:

    I saw a chiropractor for about a year after I was in a car accident –and yes it did, in my opinion, help with my sore neck and it seemed to help limber up my back. It felt good.

    During that time I got to know some of the other clients. One in particular was a lady who said she had Irritable Bowel Syndrome. She was coming to the chiropractor so he could treat her for the condition.

    How does chiropractic even begin to treat a disease of the gut through so called adjustments?…seems like a leap to me.

  11. rwk says:

    @minne peds
    sorry but some nsurance companies do pay for massage. If you’re a
    health care worker you should know that. If you don’t, google
    cpt codes for massage therapy or soft tissue massage and see what
    professions use them.
    Joint manipulation of any region is more than a feel good procedure.
    I said simply, most people present to chiropractors because of pain,
    injury,stiffness or immobility. In other words to feel good.
    You’re right.There are cure claims out there. I think those are renegades though. Of the 60,000 or so chiropractors in the US many
    just have bad web sites done by the same company. I’d bet many don’t
    even read their web sites.
    They claim to treat or help the conditions you mention,not cure.

  12. nybgrus says:

    “… many just have bad web sites done by the same company. I’d bet many don’t even read their web sites.”

    That is supposed to make it OK to be marketing this stuff? And somehow paint chiropractors in anything but a terrible light? I don’t care what business you are in, not reading your own web site is an atrocious apathy.

    Additionally, getting into the semantics of “cure” or “treat/help” these conditions is a straw man. If you wish to claim that chiropractics “helps” or “treats” conditions such as asthma or IBS or MS then you are essentially saying chiropractics does nothing in particular since you claim and language is necessarily relegated to the realm of a spa day. Getting in a good stretch, having a nice deep tissue massage, maybe a soak in a jacuzzi or a sauna would all “help” you feel more relaxed and “help” your [insert ailment here]. But at least then, you know you are getting the benefits of a nice spa day. With these chiropractors (including the ones so apathetic about their practice they can’t be bothered to make sure their websites are accurate) there is a perception that they are medical professionals and patient expectation of a chiropractic “treatment” is on par with that of a medical doctor (or at least certainly more than what a spa “treatment” is).

    So please, don’t defend pseudoscience marketing for profit by claiming ignorance and using wishy-washy wording to make it OK.

  13. SkepticalLawyer says:

    20-25% of chiropractors leave the field within 10 years of graduation. Their average income has dropped from $97,892 annually in 1992-1993 to only $48,900 in 2002-2003.

    Well, that explains why the salesman at the Sleep Number mattress store no longer practiced chiropractic. Now he’s just using his “expertise” in backs and back pain to sell beds.

  14. marcus welby says:

    Most of the comments here ignore the fundamental equation at issue in this post: that there is real risk of serious harm–stroke and death–from a procedure with no demonstrated benefit over placebo. Kaiser has used solid reasoning to withdraw from covering such treatments, while saving some money on a useless procedure, they also avoid possible legal liability and prevent harm to their covered enrollees. Let us hope other insurers will conclude the coverage of cervical chiropractic adjustment is to be eliminated. Money and lives will be saved.

  15. Jon Newman says:

    (Some) Physical therapists utilize cervical manipulation. Does anyone know if neck manipulation is non-covered in general, or is the language specific to chiropractors?

  16. Toiletman says:

    I was confused first when I read the headline because I did not know that company and because Kaiser means emperor in my motherlanguage so my first impression was “The (Japanese? emperor rejects neck manipulation”. Atleast I had a good laugh.

  17. Blue Wode says:

    It’s interesting to note that the conclusion of a new RCT, published this month, seems to support Kaiser Permanente’s decision:

    Quote
    “Neck manipulation is not appreciably more effective than mobilization. The use of neck manipulation therefore cannot be justified on the basis of superior effectiveness.”

    A Randomized Controlled Trial Comparing Manipulation With Mobilization for Recent Onset Neck Pain
    http://www.ncbi.nlm.nih.gov/pubmed/20801246

  18. Jon Newman says:

    In answer to my own question:

    If the following is an accurate description of the policy then the language is specific to chiropractic. Although, they do note that the CPT codes are not inclusive and that additions/deletions may occur.

    https://www.mapmgonline.com/portal/documents/chiropracticmanipulation.pdf

  19. marcus welby says:

    There is a good reason to make this policy exclusive to chiropractic. Gentle neck manipulation or mobilization, as used by physical therapists and massage therapists in this country, does not have a record of causing strokes and death, and is used for musculoskeletal neck pain complaints. Chiropractors in this country and elsewhere in the world as well, along with some MDs in Germany also utilize a high velocity “neck cracking” which is dangerous and is often used to treat any complaint, including bed wetting, autism, low back pain, shoulder pain, headaches, what have you. That is the risky procedure used by chiropractors for questionable diagnostic reasons and health maintenance which has never been shown to be any more beneficial than placebo and which has serious dangers. It is appropriate that it be delisted by insurers or banned.

  20. Joe says:

    This study http://www.ptjournal.org/cgi/content/full/79/1/50 shows that chiros surpass all others in causing serious damage following neck manipulation. Also, the link provided by Blue Wode (above) gives us reason to believe that chiros are not more effective than PTs at neck “manipulation” (despite the chiro claims to superiority).

    Furthermore, despite the claims of superiority, chiros often lump together research by PTs with research by chiros to support the safety and efficacy of the chiros claims about manipulation. See, for example, see the review http://www.chiroandosteo.com/content/18/1/3 by Bronfort et al. As Marcus Welby has observed (above) and the article in the PT Journal (linked in first paragraph) shows, the two are not the same. In fact, one explanation for the difference in safety is that PTs are more selective and better at neck manipulation.

    Finally, there is the question of what chiros mean by ‘manipulation’. There is no control, whatsoever, on their technique. Historically, they spoke of ‘adjustment’ which meant a ‘dying strain’ (pun intended). You can still see that on their YouTube ads; but it can also mean ‘mobilization’ such as applied by masseurs, or useless (probably harmless) clicks or taps by mechanical probes. Still, I think one has to go with the bottom line and get rid of the procedure altogether (as Kaiser did).

  21. Jann Bellamy says:

    In talking about manipulation it is important to remember that when physical therapists manipulate a joint they do so to relieve pain and increase joint mobility, and that some chiropractors use manipulation for the same reason. Of course, manipulation as a legitimate physical therapy is not appropriate if the risks outweigh the benefits, which apparently is the case with cervical manipulation.

    However, only chiropractors manipulate or “adjust” to eliminate the chiropractic subluxation, which does not exist. Thus, sometimes they use cervical manipulation because that is where they “find” the “subluxation.” Manipulation to reduce the chiropractic subluxation is NEVER appropriate no matter what the presenting symptoms are or where the manipulation is done.

  22. rwk says:

    Thank you Jann Bellamy for making the first fair comment here.
    Mightas Welby,Blue Wad and Joe are very ignorant as to what really goes on in the real world and obviously are not medically trained but have an unfounded grudge against chiropractic. They can read the information
    gleaned from studies available on the internet but can’t put it in proper perspective.
    Any newcomers here may wish to take that into account and read
    Joe’s first URL which is old and contains outdated thought. His second URL actually contains statements by those researchers mentioned supporting cervical manipulations under certain conditions.
    Blue Wad’s example is actually favorable to cervical manipulation
    even though not by much.
    According to Marcus Welby anything a chiropractor does is deleterious.
    He or she should read Joe and BW’s URL examples and then comment.
    I object to any statements that all chiropractors do the same things.

  23. Blue Wode says:

    rwk wrote: “I object to any statements that all chiropractors do the same things”

    That’s one of the main problems with chiropractic. There is no standardisation.

  24. marcus welby says:

    To understand why chiropractors cling to the risky and dangerous high velocity neck cracking procedure which can and does sometimes tear the vertebral artery (or even carotid artery) as it leaves the bony confines of the second cervical vertebra, then makes its tortuous turns to enter the skull, (recoginizing that half of the roughly 90 degrees of cervical spine rotation occurs at that vulnerable location between C-1 and C-2), I offer the following: although gentle neck mobilization and gentle slow velocity manipulation along with massage has essentially no dangers, chiropractors often prefer the high velocity dangerous techinque because it elicits an audible “pop” within cervical articular joints as nitrogen gas is suddenly released from solution by the created vacuum. One can observe this process readily by looking at marketing videos by chiropractors on You Tube. The impressive “pop” leads the unsophisticated patient to the conclusion that something important has happened and that something must have been out of place or “needed and adjustment”. An unfortunate side effect of this “pop” is the occasional (one in thousands of neck crackings..no one knows how often, since chiropractors do millions of these procedures annually but officially deny there is any risk) vertebral artery tear and then dissection, with the stage set for blood clotting, embolic stroke, and even death. Non-chiropractors do not generally use this dangerous high velocity procedure, although there have been reports of a group of Korean or Vietnamese manicurists in NYC who picked up the neck cracking procedure and added it routinely to nail procedures on unsuspecting customers as an added “benefit”.

  25. Joe says:

    Jann Bellamy on 01 Sep 2010 at 5:05 pm wrote “[W]hen physical therapists manipulate a joint they do so to relieve pain and increase joint mobility, and that some chiropractors use manipulation for the same reason. Of course, manipulation as a legitimate physical therapy is not appropriate if the risks outweigh the benefits, which apparently is the case with cervical manipulation.”

    Your second sentence is the key. Chiros are not trained in PT and do not know proper treatments, as evidenced by their frequent use of neck manipulation. A person needing PT is better-off seeing a professional PT, not a pretender or wannabe.

    @rwk on 02 Sep 2010 at 2:43 am

    I second what Blue Wode said (on 02 Sep 2010 at 2:59 am), and I even illustrated it with respect to neck manipulation in my previous post (on 01 Sep 2010 at 3:56 pm ); you should have read it before commenting on it.

    If the article in J Phys Ther that I cited is outdated, just cite the update. Please, legitimate journals only- JMPT and the like are not reliable.

    As for my second reference (chiroandosteo), it illustrates that chiros refer to neck manipulation by legitimate health professionals (e.g., PTs) to support their own claims.

  26. nwtk2007 says:

    Considering how this must happen so often and, as you say, “does sometimes” happen, I wonder who is hiding all those cases of CMT induced stroke or CMT induced VAD? You would think that at least one case would have made it to the news with so many out to publicize it.

  27. marcus welby says:

    nwtk2007: you just don’t get it, do you. “Make it to the news?” What kind of nonsense is that? The world’s literature documents hundreds of cases of vertebral artery stroke and death due to chiropractic (and in the German literature, MD) high velocity neck manipulation. I have spoken personally with a number of stroke victims due to chiropractic neck manipulation, or their family members if they failed to survive. Neck manipulations done for shoulder pain, low back pain, coccyx pain, headaches. Immediate seizures on the treatment table or while attempting to drive home afterward. One victim in our community recently began to have serious neurologic symptoms on the treatment table following chiropractic neck cracking within seconds and was admitted to the stroke service the same day by the stroke neurologist at our hospital. Nearly every neurologist and ER physician now has seen cases.

  28. nwtk2007 says:

    Marcus, you are so making this up. Just scan this blog alone and you’ll see that you are greatly exaggerating by, literally, orders of magnitude. Just making it up and writing here doesn’t make your made up facts true and anyone who has followed this topic, if honest, would tell you the same thing.

    Spoken personally? I seriously doubt it. It is you who just doesn’t get it. In science we do not lie and we do not stretch what little actual evidence there might be.

    Even the Sandra Nette crowd would admit to that.

  29. Joe says:

    @nwtk2007 on 02 Sep 2010 at 11:57 am wrote “Even the Sandra Nette crowd would admit to that.”

    I did not think you could stoop so low as to insult Ms. Nette. You are disgraceful.

  30. nwtk2007 says:

    Define insult Joe.

  31. Blue Wode says:

    Harriet Hall wrote: “The American Chiropractic Association (ACA) promptly responded with a letter to Kaiser outlining “the extensive data that supports cervical spinal manipulation as both beneficial and safe.” I have not yet been able to find a copy of that letter online.”

    You may be interested to know that World Chiropractic Alliance has also responded to Kaiser. You can read its complete letter, along with research references, at the end of the article in this link:
    http://www.thechiropracticjournal.com/news14.php?M=september&Y=2010

    It’s disappointing to observe that chiropractors tend to condemn the evidence for neck manipulation causing stroke as anecdotal when, in many cases, it’s exactly that sort of evidence which they rely on to promote their services – i.e. many chiropractors, as well as their regulators and professional associations, seem to find it acceptable to promote anecdotal or weak evidence where it supports chiropractic treatment, but where similar, or more robust, evidence suggests that serious complications (e.g. stroke) can result from it, they are known to be quick to dismiss it.

    As highlighted by Sandra Nette’s statement of claim, could the reason be economic predation?

  32. nwtk2007 says:

    Love your objectivity Blue Wode. Interesting that you have such a “mission” to save the world from chiropractic on so many blogs for such a long time. But not biased against chiropractic. Right.

    To put it simply, there is practically no evidence that CMT causes stroke or VAD. I find it disappointing that so many SBM’ers aren’t willing to condemn the evidence for CMT causing stroke and VAD as anecdotal.

  33. Blue Wode says:

    nwtk2007 wrote: “To put it simply, there is practically no evidence that CMT causes stroke or VAD.”

    There is a kernel of truth in that, but in the light of numerous case reports associating CMT with serious adverse events, you still cannot escape the fact that a responsible risk/benefit assessment for CMT will show it to be largely unfavourable when there are other equally effective, cheaper, more convenient, and safer options available. Such an assessment would also include chiropractic spinal manipulation for back pain for the reason given in the quote below which is lifted from a critique of the recent UK NICE guidelines for low-back pain:

    Quote
    “…serious complications occur mostly (not exclusively) after upper spinal manipulation. So the guideline authors felt that they could be excluded. This assumes that a patient with lower back pain will not receive manipulations of the upper spine. This is clearly not always the case.
    Chiropractors view the spine as an entity. Where they diagnose ‘subluxations’, they will normally manipulate and ‘adjust’ them.* And ‘subluxations’ will be diagnosed in the upper spine, even if the patient suffers from back pain. Thus many, if not most back pain patients receive upper spinal manipulations. It follows that the risks of this treatment should be included in any adequate risk assessment of spinal manipulation for back pain.”

    http://tinyurl.com/y8dmwcs

    [Ref: Ernst, E. Spinal manipulation for the early management of persistent non-specific low back pain - a critique of the recent NICE guidelines, Int J Clin Pract, 18th August 2009. Reprints available from author.]

    * Ref: Ernst E. Chiropractic: a critical evaluation. J Pain Sympt Man 2008; 35: 544–62.

    I would concede that there *might* be a case for using manipulation judiciously – i.e. very rarely, and only after having gained fully informed consent from the patient. However, due to the aforementioned lack of chiropractic standardisation, it’s likely that very few patients would ever be fortunate enough to encounter chiropractors who practiced in such an ethical manner.

  34. pmoran says:

    “nwtk2007 wrote: “To put it simply, there is practically no evidence that CMT causes stroke or VAD.”

    There is a kernel of truth in that, —- ”

    ————————————————————
    Well, it is a matter of degree, certainly, but has it has come to pass that a very rare event having a strong temporal association with a highly plausible and consistently implicated potential cause is “practically no evidence”?

  35. Joe says:

    That is rich! Nitwit2007 spent a lot of time and money studying the completely fictional spinal subluxation and the bogus claims of chiropracty. Now, suddenly, s/he demands better evidence for something.

  36. canuck says:

    “Kaiser made a good, science-based decision that will protect patients and also save money.”

    I have been sitting on the sidelines reading the dogmatic back and forth for sometime on the topic of chiropractic (this and other related posts) and this latest statement couldn’t be farther from the truth. Here is what the science says, and this is only a small sampling:

    •Vernon et al (2008) Systematic Review “There is moderate- to high-quality evidence that subjects with chronic neck pain not due to whiplash and without arm pain and headaches who are randomized to receive a single session of spinal manipulation demonstrate immediate improvements”
    •Sloop et al (1990) Double Blind CT compared a single session of manipulation to diazepam in a double blinded controlled trial and “showed no significant differences between manipulation and control groups, though both tests favored manipulation.”
    •Vernon et al (1990) Pilot Study – 4 subjects given a single mobilization (control) and 5 a single manipulation of cervical spine for chronic mechanical neck pain. “In the group receiving a manipulation the mean increases in pressure pain threshold ranged from 40-56% with an average of 45%. In the control group no change in any of the pressure pain thresholds was found. These results were ….found to be statistically significant.”
    •Martinez-Segura et al (2006) RCT of 77 subjects subjected to manipulation or mobilization (control). “A single cervical HVLA manipulation was more effective in reducing neck pain at rest and in increasing active cervical range of motion than a control mobilization procedure in subjects suffering from mechanical neck pain.”
    •Cassidy et al (1992) RCT of 100 subjects – half given single session of SMT, the other half a single MOB(control). “Study demonstrates that a single manipulation is more effective than mobilization in decreasing pain in patients with mechanical neck pain. Both treatments increase range of motion in the neck to a similar degree. Further studies are required to determine any long-term benefits.”
    •Howe et al (1983) Pilot Study – “Manipulation produced a significant immediate improvement in symptoms in those with pain or stiffness in the neck, and pain/paraesthesia in the shoulder, and a nearly significant improvement in those with pain/paraesthesia in the arm/hand. Manipulation also produced a significant increase in measured rotation that was maintained for three weeks and an immediate improvement in lateral flexion that was not maintained”
    •Hurwitz et al (2002) RCT showed “cervical spine mobilization is as effective as manipulation in reducing neck pain and related disability among chiropractic patients. In addition, they show that neither heat nor EMS, alone or in combination with manipulation or mobilization, appreciably improves clinical outcomes, although heat may be of short-term benefit for some patients. Given the comparable outcomes and the risk of serious complications resulting from cervical spine manipulation, chiropractors may obtain equally effective results with less risk of adverse effects by treating neck-pain patients with mobilization rather than manipulation. However, manipulation may be more effective than mobilization for specific clinical indications.”
    •Yurkiw and Mior (1992) – compared two SMT techniques in 14 patients and found “Both treatments yielded clinical improvement”.
    •Koes et al (1991) Systematic review found “eighteen studies (51%) showed favorable results for manipulation. In addition five studies (14%), reported positive results in one or more subgroups.”
    •McCrory et al (1996) Systematic review – “Compared to amitriptyline use, chiropractic is shown to produce slightly lesser effects during the treatment period, but markedly superior results afterward in the treatment of tension-type headache.” “Manipulation appeared to result in immediate improvement in headache severity when used to treat episodes of cervicogenic headache when compared with an attention-placebo control. Furthermore, when compared to soft-tissue therapies (massage), a course of manipulation treatments resulted in sustained improvement in headache frequency and severity.
    •Hurwitz et al (1996) – SMT more effective than mobilization or manual therapy methods in treating some subacute or chronic neck pain. SMT, mobilization and manual therapy are all superior to medical care.
    •Koes et al (1992) and (1993) – SMT versus physical therapy, medical treatment and placebo showed greater improvements in the SMT group
    •Verhoef et al (1997) – SMT improved neck mobility and decreased neck pain
    •D’Sylva et al (2010) – SMT, mobilization and soft tissue therapy provide decreased neck pain compared to short wave diathermy. SMT, mobilization and soft tissue therapy plus exercise and advice show increased benefit versus exercise and advice alone for neck pain. SMT and mobilization show decreased pain and increased function for cervicogenic headache versus control in intermediate and long term
    •Gemmell et al (2010) – SMT, mobilization and activator technique all three showed significant long term benefits for subacute neck pain versus control
    •Gross et al (2010) Low Quality Evidence – 9-12 treatments of SMT are superior to 3 for pain relief and reducing disability for cervicogenic headache, Moderate Quality Evidence – SMT and mobilization are equally effective in the short and intermediate term in providing pain relief and improved function, Very Low to Low Quality Evidence – the SMT of the thoracic spine can decrease neck pain when provided alone or as an adjunct to other therapies, Very Low to Low Quality Evidence – that certain mobilization techniques are superior to others

    This list which is far from complete should clearly demonstrate that there is documented benefit to SMT of the cervical spine for reducing at least certain types of mechanical neck pain and headaches and that there is no “paucity” of research on the matter as claimed. I find it quite objectionable that SBM advocates (and others) continue to say that there is ‘NO benefit’ to SMT of the cervical spine demonstrated in the research. Please understand, I am not careless enough to miss the various qualifiers that people add to spin the message such as “no long term benefits”, “no superior benefits” or “published in acceptable journals” and even some of these don’t stand up to scrutiny. As well, I will not fall into the trap in believing that the RCT or systematic review of RCT’s are the end all and be all of science. Certainly they have their strength but we have all seen RCT’s and reviews that have as many issues as the source studies they exclude or include. Further, since something like only 37% of all medical interventions are subject to the rigors of an RCT it would be hypocritical to demand anything more of others. Last, relying on a systematic review that only includes double blinded RCT’s in a study of chiropractic is already heavily biased. At this point, I need to comment on the relative ease and hypocrisy at which either side promotes or condones source studies depending on their bias.

    Back to benefits, some of the above studies of SMT cited are of admittedly poor quality and I have heard many of the arguments downplaying several of them and would agree with some of it. I also agree with many of the posters that the level and quality of chiropractic research overall is fairly inadequate and underwhelming to say the least. That said, all the arguments about quality etc. cannot wipe away the entire body of research and thus the claim of ‘no benefit’ or limited benefit. Also, the paucity of the research on the issue has also been largely misapplied in my opinion. Absence of reliable evidence does not mean reliable evidence of absence.

    Tackling risk, I think several people have summed up the risk fairly nicely, poorly framed arguments, dogma and unchained bias and generalizations aside, on both sides. Temporal association of upper cervical manipulation with VBA dissection has certainly been demonstrated. Causation on the other hand is unknown but certainly there are many plausible explanations for and against. Temporal associations have been used by various groups for or against a cause and this group has been on either side of the discussion depending on the topic. Dare I even bring up thimerosol?

    I hate to give the World Chiropractic Alliance credit, as in my opinion they are a group of chiropractors who represent a large portion of the fringe which the SBM crowd (and EBM chiropractors) love to hate, but the link cited by Harriet to their letter to Kaiser actually has a good summary of the research related to the risk profile for SMT, provided you get past some of the irksome statements made within the body of the letter. Looking at the evidence, this risk/benefit profile is certainly not out of line given many other forms of accepted medical options which are currently being reimbursed by Kaiser. The only reason we are debating this is because it is chiropractic.

    I have heard the argument many times that if modern medicine finds something that has an unacceptable risk/benefit ration that its use is discontinued. I am however skeptical. Taking perhaps the most common treatment for neck pain in the medical model, namely NSAID use, there is limited evidence in the research to demonstrate purported benefit. Second, the risk associated with their use is many factors higher for serious adverse events and death than that of SMT. The second most common treatment option is muscle relaxants which have even less effectiveness and more side effects. Anyone, calling on upper cervical SMT practitioners to stop should more loudly be calling on the use of NSAIDs to also cease if they had any integrity. Similarly, looking at other treatment options there is no evidence to support the use of intra-articular steroid injections or radiofrequency neurotomies for neck pain, but these are still utilized and again have much higher risk ratios than SMT. Epidural and nerve root injections also do not demonstrate long term effectiveness. Cervical disc arthroplasty also has no supportive evidence for use in any patient without radicular pain and even then results are seemingly limited. Neck pain educational advice and doing nothing have evidence to show they are not effective either. I could go on, and I am not saying any of these treatment regimes are necessarily better or worse than others, or engaging in an argumentum ad hominem. More so I am trying to highlight the options available to someone with neck pain and their corresponding research and risk/benefit ratios. I have no issue with the argument about applying risk/benefit ratios to methods of care with one caveat – that it is applied equally to all forms of treatment. For the reasons above and many other’s, Kaiser’s decision is certainly not science based and is likely more political than anything else. I have seen nothing offered otherwise and would be curious to see some detail behind the rationale.

    Looking at the Kaiser decision en face, I find it suspect that chiropractors as a group are singled out rather than all practitioners of SMT to the cervical spine, assuming that that is what in fact Kaiser intends. If the research truly and clearly showed ineffectiveness or unacceptable risk for cervical manipulation (which I believe it does not), a universal ban of all SMT regardless of provider would seem more appropriate versus singling out the group that is probably the most highly trained and skilled in manipulation of this area. Arguably, portions of this group may be the most laissez faire about the risks associated with SMT as they use it everyday without observable serious side affects (hairdressers, martial arts practitioners etc. excluded), however, this does not constitute an outright prohibition in my mind. Further, it also seems reasonable that Kaiser’s reimbursement plan likely does not pay providers for providing primary care in treating someone’s AIDS, asthma, cancer, IBS etc. with cervical or any SMT as inferred. Though I am not intimately familiar with it nor have ever tried and subsequently attempted to collect for these procedures this is my guess. Perhaps I am wrong and I am sure there are exceptions, but these egregious acts in my mind have little to do with the rationale for this move by Kaiser and attempts to link the two is misleading. Perhaps someone in the business can shed some light. I would be curious to know more.

  37. canuck says:

    “Chiropractors are not doing well.”

    Chiropractors are doing just fine. Certainly 20-25% are leaving the State of California which is where that stat seemingly came from, but there was no follow-up on why, where they went etc. The salary income comes from a select Ontario survey and it is my understanding that in 2004 the income was somewhere on the average of $104K.

    Some posters have also commented about economic predation and I think that the typical chiropractor does not even make the short list when compared to the profiteering and pandering etc. that many in and outside the medical establishment see and have to deal with on a daily basis. I have seen this first hand and continue to see it. Understand, I am sure there is no profession that is immune from profit motives (most working are not in it for the sheer joy and could or would forego any money), but painting with a broad brush is unfair and unjustified by either side.

    Just saying and nothing herein supports any chiropractor for manipulating someone’s neck without evidence for doing so (research aside) or engaging in any practice outside the law or scope of practice.

  38. canuck says:

    Saskatchewan cut chiropractic from their budget and thus realized a budget savings of $10 Million. The real cost of health care and savings have not been realized and the vast quantity of research out there shows that this move will be detrimental as chiropractic has consistently shown to be economically advantageous when compared to other health care options.

    Any statements that Kaiser is saving money by doing this are only short term. They will have to pay more money to have these same insured’s get treated for their neck pain or headache somehow else if the trend confirmed by all reliable economic studies continues.

  39. canuck says:

    In a comment awaiting moderation I mistakenly attributed a link to the WCA letter to Harriet – it was actually Blue Wode.

    My apologies…

  40. James Fox says:

    Chiro’s exist to treat subluxations in their patients. There is no evidence that subluxation’s exist and every reason to believe that they were made up by one particular person many years ago. Therefore Chiro’s have no real reason to exist or ply their trade. And on top of that Chiro’s seem to regularly engage in a particular treatment that has a known history of causing strokes resulting in disability and even death. It seems to me that the discussion is all about a made up disease that fits all manner of patient complaints and a made up and potentially dangerous treatment. Perhaps when the issue gets boiled down to its essential components more people will see that the emperor has no clothes and then perhaps funding from governmental and private health care plans will dry up and put the quacks out of business.

  41. rwk says:

    @James Fox<
    every poster here needs to do their homework before posting or
    else they get eaten alive.
    You haven't done yours.
    "every reason to believe that they were made up by one particular person many years ago."
    Wrong.
    The subluxation was already known as the osteopathic lesion 20
    years before. So similar you could say it was copied. Palmer even
    sat in on osteopathic classes.
    Dope!

  42. Joe says:

    rwk on 07 Sep 2010 at 2:46 pm wrote “… every poster here needs to do their homework before posting …”

    Apparently, you do not.

    At the time, osteopathy was as quacky as chiropracty is today. A nonexistent condition (e.g., chiropractic subluxation) remains nonexistent regardless of who first imagined/named it.

    That is why chiro is a cult, you cleave to the ideas of the founder regardless of what we have learned since then.

    rwk: “Dope!” ? How much time and money did you spend studying the nonexistent subluxation? How dopey is that?

    Or, can you provide legitimate citations to the fact that chiro-subs exist? I think not, you were easily duped. Citations to your trade magazines and newsletters don’t count.

  43. James Fox says:

    @RWK

    “every reason to believe that they were misappropriated and later embellished by one particular person many years ago.”

    There, fixed. Wouldn’t want to have my nits pic.., errr, I mean be eaten alive.

  44. pmoran says:

    Canuck, I’ll allow that neck manipulation could be of significant help for a subgroup of patients with chronic musculoskeletal neck pain. That would justify a trial of one or more neck manipulations in well-informed patients who have not responded to safer measures. That would be entirely in accord with normal medical practice, although some might argue that the evidence even for this is too weak.

    The point is that this is all you’ve really got with the most favourable possible assessment of the available evidence. The millions of OTHER neck manipulations performed by chiropractors, some of them exploring the depths of crackpottery, cannot in any way be justified on a risk versus benefit basis.

    You are right that similar concerns apply to some medical practices with doctors being insufficiently aware of the risks of what they prescribe (because, just like chiropractors they very rarely see them), or not applying modern standards of informed consent. So? Are these malpractices not similarly publicised and condemned?

    (It doesn’t matter for practical medical purposes whether you regard the risks as wholly proven or merely possible. The evidence is sufficient to arouse concern, and certainly sufficient to modify or even wholly suspend the use of a drug if such cases were being reported to VAERS.)

  45. rwk says:

    @joe
    First of all there really is no word called chiropracty. I’ve heard a few
    know it all Brits use it because it sounds right.

    “you cleave to the ideas of the founder regardless of what we have learned since then.”

    Did I ever say I used or endorsed the S word?
    I think not.

    I spent 3.0 hours at NCC ( now NUHS) studying the history of
    chiropractic. No one ever forced me to embrace it.
    Some schools did and still do.
    You should know that if you did slightly more than just read Blue Wads blogs.
    Before I waste my time referencing citations, what is your definition
    of a chiropractic subluxation ?

  46. Dr Benway says:

    Did I ever say I used or endorsed the S word?
    I think not….

    Before I waste my time referencing citations, what is your definition of a chiropractic subluxation ?

    Why bother talking about the “S word” if you don’t believe in it?

  47. Joe says:

    @ pmoran on 07 Sep 2010 at 5:25 pm wrote “Canuck, I’ll allow that neck manipulation could be of significant help for a subgroup of patients with chronic musculoskeletal neck pain.”

    A problem with your suggestion is that, as Blue Wode and I have observed (above), there is no standardization for what a chiro refers to as an “adjustment.” It can range from gentle mobilization that one can get from a masseuse (or even a health professional) to a dying strain intended to elicit the classic popping sound.

  48. Joe says:

    rwk on 07 Sep 2010 at 7:31 pm wrote “… Did I ever say I used or endorsed the S word?”

    According to the Association of Chiropractic Colleges http://www.chirocolleges.org/paradigm_scope_practice.html

    “Chiropractic is Concerned with the preservation and restoration of health, and focuses particular attention on the subluxation.

    “A subluxation is a complex of functional and/or structural and/or pathological articular changes that compromise neural integrity and may influence organ system function and general health.”

    If you eschew subluxations you are not doing chiropractic. But that is okay, once you are licensed you are free to do just about anything that gets you money. After all, when one is playing at healthcare it doesn’t really matter what one does.

    Based on the official definition, nobody has ever been able to explain exactly what they think a subluxation is. Moreover, many avoid the word; but substitute another to invoke the same, nonexistent entity.

  49. nwtk2007 says:

    I love listening to your biased banter Joe Wisdom. Amazing your inability to see beyond black and white.

    You’re talking semmantics once again. But thats OK.

    Even using the medical definition of “subluxation”, one can easily see that a fixated joint can and will subluxate to some degree while in its limited motion. The degree to which it might or might not is small and subtle but in terms of mechanics, must be so. Even if the joint is only partially subluxated for a fraction of a second or for a longer period of time, it would still be a subluxation for that period of time, effecting sensory input from that joint to some degree.

    Additionally, to think that fixated joints don’t effect organ systems is, again, a bit short sighted. A muscle is an organ as is a bone. A joint and its associated tissues is also an organ or would be considered a part of an organ system.

    I’m just saying. Now does the altered funtion of a joint effect other organ systems? Maybe, maybe not. The reduction of headaches thru CMT would be difficult to explain were it not for the altered joint having an effect on other organs and organ systems.

    By the way, what is a “nonexistent entity”?

  50. pmoran says:

    nwtk: “The reduction of headaches thru CMT would be difficult to explain were it not for the altered joint having an effect on other organs and organ systems.”

    Yeah, well, that brings subluxation theory up to the status of the theories of the homeopath, or of the TCM acupuncturist, or of the Reiki practitioner. They, along with dozens of others believe “it (my theory) must be true because my patients say they are better.”

    But headaches “get better” for far too many mundane reasons: placebo influences, spontaneous resolutions, patient reporting biases and other non-specific influences of medical attentions (reassurance, relaxation, “time out” etc ).

    You cannot work backwards from such fragile clinical observations into reliable science. That is the only economical explanation for so much unsubstantiated medical theory.

    That, incidentally, is not the same thing as saying that the attentions are of no value at all to patients.

  51. nwtk2007 says:

    There have been plenty of studies listed here in this blog showing the positive effects of CMT for headaches versus many drugs. Not just “my patient feels better”.

    I guess its just difficult, when immersed in the drug culture, to see that physical/mechanical changes can have dramatic effects on living systems. In the case of CMT or any other manipulation or mobilization, the effects might be very slight to non-existent to great, depending upon the physical state of the individual.

    How is it that mechanical stress can induce bone remodeling to thicken bone? How is it that repetitive contraction of muscle tissues induce muscle building processes? Why does rubbing the skin induce the basal cells to divide more rapidly to thicken the area?

    The mechanical effects of movement on joints will also have their effects. Its inevitable. Joints that don’t move properly tend to atrophy as well as their associated ligaments, tendons and muscles. You don’t use it, you lose it. Movement induces trophic function as well to the associated structures. Its difficult to say what the increased proprioceptive input to the CNS has on other systems and their function? Slight as it might be, I’m sure there are effects that go beyond your homeopathic parallel.

  52. pmoran says:

    nwtk: “There have been plenty of studies listed here in this blog showing the positive effects of CMT for headaches versus many drugs. Not just “my patient feels better”.”

    =============================================
    When of reasonable quality those studies raise interesting questions about what may suffice as medical care for some conditions, but they say nothing specific for subluxation theory.

    The drugs usually used in such comparisons are themselves known to work only marginally better than placebo (e.g. antidepressants).

    In consequence it is very possible that in such studies true treatment effects from either method are being overwhelmed by the superiority of hands-on placebo treatments over pill placebos, and the other influences I have mentioned: patient reporting biases possibly aggravated by the way subjects are chosen, and probable non-specific benefits of the additional medical contact necessary for CMT sessions.

    Can, then, CMT “serve as medicine” in most resepcts? Possibly. But it is not necessary to invoke subluxation theory to explain why it seems to work. And there are treatments that probably perform about as well without the risk of either VAD or drug side effects.

  53. Joe says:

    nwtk2007 on 08 Sep 2010 at 8:09 pm wrote “There have been plenty of studies listed here in this blog showing the positive effects of CMT for headaches versus many drugs.”

    Cite those, and be sure they refer to chiro as opposed to massage and genuine, medical interventions.

    nwtk2007 on 08 Sep 2010 at 8:09 pm wrote “How is it that …”

    Appeal to ignorance, if you understand that. How is it that I found a nickel under my pillow after I lost a childhood tooth? Surely, there must be a tooth fairy.

    nwtk2007 on 08 Sep 2010 at 8:09 pm wrote “Slight as it might be, I’m sure there are effects that go beyond your homeopathic parallel.”

    No. Your business is based on anecdote and that is the basis for homeopathy.

  54. nwtk2007 says:

    Sorry Joe, I’ll not re-cite the studies again. If I recall you were able to criticize them even without having read them; by your own admission I might add. At least your dishonesty is honestly presented.

    Indeed, your comment here attests to the waste of time that would be. I’ll continue to be entertained by them, your comments, on chirotalk and topix.

  55. pmoran says:

    nwtk: “There have been plenty of studies listed here in this blog showing the positive effects of CMT for headaches versus many drugs. Not just “my patient feels better”.”
    =============================================

    Such studies may be telling us something important about real world medicine, but they are of neutral significance for subluxation theory.

    They lack double-blinding. Hence they are unable to isolate from the other influences I have mentioned as mimicking treatment effects. These include augmented placebo responses from hand-on kinds of medical care, patient reporting biases, possibly aggravated by the way subjects were chosen for the studies, and non-specific benefits from the additional medical interactions that CMT sessions entail.

    Also remember that many medical treatments work only marginally better than placebo, so that there may not be much to beat — i.e. both treatments are mainly placebo.

    Similar studies are being produced by acupuncturirsts and homeopaths. They produce predictable results, whenever conventional medical care has limited efficacy and the “alternative” treatment has greater novelty or intensity.

  56. rwk says:

    @nwtk2007
    while you at it with Joe, remember he thinks there is no standardization in chiropractic. All physical therapists do the same
    thing for every condition, right Joe? All medical doctors and surgeons
    follow the same protocols and standardized procedures,right Joe?
    Medical standards of care have options. Some practitioners are better than others.

  57. pmoran says:

    The third attempt to get this through –.

    nwtk: “There have been plenty of studies listed here in this blog showing the positive effects of CMT for headaches versus many drugs. Not just “my patient feels better”.”
    =============================================

    Those studies may raise interesting questions about medicine in the real world, but they say nothing directly about subluxation theory.

    Lacking double blinding, they cannot separate from all the other influences affecting patients’ responses to medical care, including augmented placebo responses to hands-on kinds of medical attention, biased patient reporting (“he tried so hard”), and non-specific benefits from additional medical and social contact during treatment sessions.

    Note also that many drug treatments have only marginal activity over placebo, e.g. antidepressants, so there is not much to beat if you are actually comparing two near-placebos in two very different styles of treatment program.

    Acupuncturists and homeopaths are producing similar results in “real-world” studies. It seems inevitable whenever the drugs chosen for the comparisons have minimal effect and the alternative “treatment” has greater novelty or intensity.

    I don’t dismiss these studies as having no relevance at all for medical practice. We can be pretty sure that the theories behind them are bunk, yet still see ways in which these practitioners may help many patients.

  58. Jerry says:

    Can anyone clarify a few things for me please.

    First, and at least here in California, Kaiser’s chiropractic benefits are provided through American Specialty Health (ASHP). So was the removal of benefits directly from Kaiser, or from ASHP?

    If directly removed by Kaiser, does ASHP hold a position regarding the change?

    Lastly, Joe, regarding an adjustment, you stated that “It can range from gentle mobilization that one can get from a masseuse (or even a health professional) to a dying strain intended to elicit the classic popping sound.”

    I am not aware that spinal manipulation is written into the scope of practice for any massage or physical therapist, or for any other health care profession other than chiropractors or osteopaths. (Other than a total dislocation being treated by a licensed medical professional.)

    Would you mind clarifying you statement please, as to whom you feel to be qualified, and in which professions, to perform spinal manipulations?

    Thank you

  59. pmoran says:

    Should read –

    “Lacking double blinding, they cannot separate (whatever it is that CMT does) from all the other influences affecting patients’ responses to medical care, including augmented placebo responses to hands-on kinds of medical attention, biased patient reporting (“he tried so hard”), and non-specific benefits from additional medical and social contact during treatment sessions.”

    Still learning. I made the mistake of putting “whatever it is that CMT does” in >< brackets.

  60. nwtk2007 says:

    pmoran, you are very much stuck on the term “subluxation” and “subluxation theory”.

    Simply put, it is the concept that altered joint biomechanics can effect other organ systems. How ever some might have taken this to the nth degree and tried to claim something thats not, the basic idea is sound, supported by both science and research.

    The additonal complexities that you have pointed out are valid points, yes, but do not negate this basic concept.

    As to insurance companies denying coverage based upon their notion that CMT is “dangerous” and without benefit, please don’t for a second pretend to think that they actually believe this. They make their decisions totally based upon money and their ability to make money, period.

    As was pointed out earlier, this decision might just backfire on them when those who can’t get the chiro’s help go to the medical folks who are very likely to run up much higher bills.

  61. Cowy1 says:

    If affecting altered joint biomechanics is your MOA, how is popping my knuckles any different than a chiropractor popping my back? Sometimes my knuckles get stiff and I crack ‘em because it feels good; is that somehow supplementing “insert organ system here” to work better?

  62. Joe says:

    rwk on 09 Sep 2010 at 6:07 pm wrote “while you at it with Joe, remember he thinks there is no standardization in chiropractic. All physical therapists do the same thing for every condition, right Joe? All medical doctors and surgeons follow the same protocols and standardized procedures,right Joe?”

    Jerry on 09 Sep 2010 at 6:44 pm “I am not aware that spinal manipulation is written into the scope of practice for any massage or physical therapist …”

    When I was a college professor, I used to proclaim that there is no such thing as a stupid question. Apparently, I was wrong.

  63. Joe says:

    nwtk2007 on 10 Sep 2010 at 9:20 am wrote”They [meaning chiropractors] make their decisions totally based upon money and their ability to make money, period.” Fixed it for you.

  64. nwtk2007 says:

    Joewisdom,

    I’d appreciate it if you would not change or alter what I have said. Someone might actually believe you. I clearly, very clearly was saying that the insurance companies make their decisions based upon their ability to make money. Changing or abusing what someone has said is simply childish.

    Additionally, I am currently and have been a college professor since 1983 and can tell you that there certainly are stupid questions as well as stupid comments. If you said there is no stupid questions then you were/are in the same company as the ones who ask the idiotic, non-sequetor, accusing questions and make the idiotic comments.

    Funny how consistent you are from one blog to another.

  65. pmoran says:

    “Simply put, it (the subluxation)is the concept that altered joint biomechanics can effect other organ systems. How ever some might have taken this to the nth degree and tried to claim something thats not, the basic idea is sound, supported by both science and research.”

    If you give the spinal joints a very violent wrench you may provoke a hypotensive and bradycardic autonomic reaction. This is a sterotyped reaction to painful trauma and can be more easily provoked by squeezing the testes or pressing on the eye balls.

    Is that the kind of thing you mean? Just what does does “science and research” support in the way of visceral response to trivial non-painful spinal abnormalities, whatever they may be called?

    Your clinical evidence is extremely weak, there is no animal or disease model for such effects, and we don’t see “chiropractic organ effects” in patients with real spinal injuries of any degree.

    It was reasonable for those who inititally observed that manipulationn seemed to help some kinds of back pain to think that they were “putting something back into place” a perfectly sufficient hypothesis. But once the claims get past that you are on ground best not trod, if chiropractic wishes to see itself as part of the medical mainstream, rather than as part of “alternative” medical culture.

  66. nwtk2007 says:

    Difficult to speak to the comments of one so lacking understanding that they would compare CMT with squeezing a testicle or pressing on an eyeball, albeit, there would be reactions to both.

    Would you deny that unabated or free joint motion is better than inhibited joint motion of a fixated or partially fixated joint? Would you argue that there are no responses to joint motion such as dialtion of blood vessels to the asociated structures or deny that sensory input from structures asssociated with freely moving joints is not instrumental in initiation of at least some of the trophic function of the joint and its associated structures?

    The effects of physical/mechanical stimili are subtle and difficult to measure, but it cannot be denied that they exist, however small the effect might be.

    Is a frozen shoulder the only joint in the body that can loose mobility when associated tissues are injured but not the joint itself? Why is it that therapeutic exercise is so effective in these types of injuries. Was the shoulder frozen because of the ligament damage in an A/C joint sprain? Why is the mobilization of the joint beneficial in the healing of this or other shoulder injuries? Is there an effect of scar tissue that must be dealt with? Could there be local impengement of nerves in the area which might result in numbness or tingling to the extremeity?

    These are all questions that go to the “visceral” effects of joint motion. It’s complex for sure and difficult to see in simple terms that studies can demonstrate.

    Spinal joints are much more complex and thus are injuries much more complex in their presentations. Most spinal joints have 2 highly innervated facet joints associated with them, no less than seven ligaments (each of which can be a source of pain and resultant scar tissue build up when injured), and an intervertebral disc which is filled with fluid that is seen as foriegn to the body, embrionic actually, and thus can illicit immune response and all that intails. The local effects on spinal nerves and associated branches can lead to confusing and often poorly diagnosed conditions. Paraspinal splinting, local inflammation, radiculitis, swelling in the facet joints, all work to immobilize and fixate the joint as is also the case in the shoulder joint.

    Motion is the key to it all. The lack thereof might have no effect on other organ systems and then again it might. The lack of motion would surely effect the lymphatic flow which flows directly through the lymph nodes which play a huge role in the immune response, again, differently in some than others. There would certainly be a decrease in venus drainage due to the dependance of venous drainage on motion.

    If you have an overall understanding of the relationships between all of these and many other structures then many senarios can be immagined or conceived. Don’t discount the effects that loss of motion can have on the local organs and systems which operate around the joint.

    It is very complex and, as I said, not easily broken down into something that can be understood based only upon “double blinded” studies or seen as black and white in terms of all that is going on.

    Squeezing testicles and pressing on eyes? No.

  67. Cowy1 says:

    If affecting altered joint biomechanics is your MOA, how is popping my knuckles any different than a chiropractor popping my back? Sometimes my knuckles get stiff and I crack ‘em because it feels good; is that somehow supplementing “insert organ system here” to work better?

  68. pmoran says:

    ntwk: “Difficult to speak to the comments of one so lacking understanding that they would compare CMT with squeezing a testicle or pressing on an eyeball, albeit, there would be reactions to both.”

    ———————————————————–
    Oh, come on! Where did I make such a comparison? I was clearly showing how there can be stereotyped visceral reactions to severe joint stresses, but that there is no compelling evidence for the kind that are required for chiropractic’s “subtle subluxation” theory of visceral illness, or for that matter, any obvious reason why such connections should exist.

    And you have responded with yet more mere speculation,e.g. “Don’t discount the effects that loss of motion can have on the local organs and systems which operate around the joint.”

    That actually goes against all experience. Even very severely restricted joints just don’t affect the function of adjacent viscera. They don’t. Try and find an example.

    The “moon could be made of cheese” is a valid scientific hypothesis only if you require no direct evidence that it is so, and ignore all evidence to the contrary including that making it highly implausible . That is an only slight exaggeration of where we are with the chiropractic subluxation theory.

    I have a thorough knowledge of anatomy and an adequate knowledge of the relevant neurology, so I don’t find this unduly complicated. It is NOT difficult to understand what you and other chiropractors are trying to say.

    It is just not a good fit with the available evidence, as I have tried to explain.

  69. JMB says:

    Since we seem to be in the lecture mood, I’ll throw in my own 2 cent lecture.

    Any joint may have scar tissue. Scar tissue tends to tighten, which can be helpful for stabilizing the joint, or containing the displacement of disc nuclear material (which usually dehydrates at all levels in the spine by age 50). Scar tissue tends to cause pain when it pulled tight during motion of the joint. If the joint is placed in a position of rest, usually the pain decreases significantly. The shoulder is one of the most common sites for adhesive capsulitis because of its large normal range of motion and relatively unrestricted axis of motion. Any scar tissue tightening up the shoulder joint may result in the pain during customary motion. It is more difficult to identify adhesive capsulitis as a common cause for back pain. Most patients with back pain cannot find a position of rest that will eliminate the back pain. The more common causes of back pain include tears of the disc annulus, neuritis of the spinal nerve roots, abnormal motion, and spondylosis (all of which may be interrelated). Joint effusions are a more common cause of joint pain than adhesions IMHO. Joint effusions will cause pain and stiffness that persist in spite of the joint being in a resting position. Popping the knuckles or popping the back may cause leakage of the joint fluid through small tears in the synovium. This could relieve the joint effusion pain originating from the facet joints in the back, or knuckles. Most synovial tears are self repaired within 1 to 2 days, and seldom result in anything other than the relief of joint pressure (sometimes they result in synovial cysts). A hyaline cartilage tear my also result in painful restriction of motion, often with a catch, and pain that tends to be constant. Ligament tears can also be a source of joint pain, but tend to hurt more when stretched. Popping a joint may result in extending a partial tear of hyaline cartilage or capsular ligament to a complete tear. A subsequent complete tear usually hurts less than an initial partial tear (an initial complete tear usually signifies greater force of injury and collateral damage). Now I don’t think that completion of a ligament tear is a common occurrence in spinal manipulation, it may have a higher frequency of occurrence in manipulation of the shoulder. Although it is an uncommon event, it can potentially destabilize a joint that may have had potential to heal sufficiently without intervention. Fibrocartilage tears are significant in many joints (especially the shoulder, hip, knee, wrist, and jaw), but is not an anatomic feature of the facet joint.

    Interference with organ function is usually not seen unless scoliosis is greater than 60 degrees. Kyphosis must also be severe to interfere with organ function. Spinal manipulation does not result in a significant decrease in either severe scoliosis or kyphosis. It likely reduces scoliosis due to muscle spasm (which tends to be less than 20 degrees of scoliosis). Idiopathic scoliosis is generally not associated with pain or organ dysfunction (mechanical alterations can be associated with variations in the usual patterns of disc and facet degenerative disease). It is a mistake to assume physiologic effects observed in a disease process of great severity, will be seen to a lesser degree in a disease process of mild severity. There can be a threshold of severity below which no physiologic effects are seen.

    Muscle spasm may limit depth of inspiration, pain can increase heart rate and or blood pressure. Muscle spasm can restrict circulation through muscle, both blood and lymphatic (through muscle, not other organs). Other than the effects of reducing muscle spasm and pain, I think it is stretching our scientific body of evidence to suggest that spinal manipulation has significant therapeutic benefits in other organ systems. Any local improvement in lymphatic flow is unlikely to have an effect on the nerve roots bathed in CSF, because of the compartmentalization of CSF and lymph.

    In regards to back pain, it is necessary to recognize the differences in anatomy at the different levels of the spine. Interventions that are successful at some levels are not necessarily successful at other levels. There are also different pathologic processes (disc protrusion/extrusion, spondylosis, joint effusions, adhesions, infammatory processes, chemical irritants, mechanical injury, neoplastic processes), with variable degrees of response (sometimes negative) to spinal manipulation. There is no one therapy that can completely address all levels and all processes.

  70. mburke says:

    For a site that claims to be “alarmed at the manner in which unscientific and pseudoscientific health care ideas have increasingly infiltrated academic medicine” and to “examine these claims in the light of science and skepticism,” I am surprised by the amount of unscientific and uninformed discussion I have seen in response to the post about Kaiser’s Mid-Atlantic States HMO eliminating coverage for chiropractic manipulation of the cervical spine. If the editors of this blog were truly concerned that “medicine based on science is the best medicine,” then they would be criticizing Kaiser’s decision.

    Kaiser reportedly cited “the paucity of data related to beneficial effects of chiropractic manipulation related to the cervical spine and the real potential for catastrophic adverse events” as its reasons. I don’t know if they referenced any medical literature as I did not read the Kaiser report itself, and the article on this blog does not mention a scientific basis for Kaiser’s decision.

    However, the evidence in favor of cervical manipulation (in combination with exercise) is strong, and the risk of any adverse event of a catastrophic nature (I’m presuming they meant CVA or stroke) is so low as to be virtually nonexistent, again according to the scientific literature. The evidence I am referring to is, in the first place, a Cochrane Review of cervical manipulation and mobilization and, in the second place, a case-controlled study of all vertebrobasilar occlusion and stenosis strokes in Ontario over a ten year period. If readers are interested in these citations they can email me at mburke@uws.edu.

    By the way, the Mid-Atlantic States Kaiser is the only Kaiser organization to my knowledge to take this drastic and unfounded step. Northwest Kaiser Permanente, of which I am a participating chiropractic provider, has protocol for the appropriate referral of its members to chiropractors for spinal manipulation for various neck and back diagnoses. Some members also have a direct-refer benefit without the PCP gatekeeper.

    J. Michael Burke, D.C.
    Associate Professor
    University of Western States
    Portland, Oregon

  71. Mark Crislip says:

    I discussed the Ontario study at length here;

    http://www.sciencebasedmedicine.org/?p=170

    it does not mean what you think it means:

    I quote me

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

  72. Jerry says:

    Joe, I have no interest in the “us verses them” type of comments. I am genuinely interested in your knowledge regarding my question.

    Part of my question was “I am not aware that spinal manipulation is written into the scope of practice for any massage or physical therapist …”

    And again I simply ask, can you inform me in what states is it permissible for a massage therapist to perform manipulation?

    Thank you

  73. Jerry says:

    Josie, on August 31st you wrote…

    “During that time I got to know some of the other clients. One in particular was a lady who said she had Irritable Bowel Syndrome. She was coming to the chiropractor so he could treat her for the condition.”

    I appreciated your comment. As a chiropractor, I sometimes hear from new patients, or patients of other chiropractors, that conditions such as this are being treated by said chiropractor.

    California state law allows a chiropractor to treat conditions of the musculoskeletal structures of the human body.

    Only a fool would claim to cure such other conditions as irritable bowel, acid reflux, etc.

    However, I have had ocassions where patients have reported a change in, or the dissapearance of long standing conditions that are not musculoskeletal in nature, after begining care. Nothing overly dramatic or serious. And nothing I could write a paper on a make a case for.

    My patients who wear hearing aids still wear them. My elderly patient with glaucoma still doesn’t see very well.

    I imagine we are all pleased when a patient gets better, has a better quality of life. And I imagine we are pleased to have a role in that path to wellness.

    However, as I mentioned in my previous message to Joe, I have no interest in arguing amongst professionals. Research speaks. Good research speaks more fluently, and with a gentle tone.

    Regards to all :)

  74. Joe says:

    Blue Wode (who sometimes comments here) has found a recent report of bilateral vertebral artery dissection during a chiro manipulation http://www.springerlink.com/content/028k88286784n763/

    In this case, and MRI was taken shortly before the neck manipulation and the arteries were fine.

  75. nwtk2007 says:

    Interesting article from a “peer reviewed” journal.

    I quote the first sentence on the second paragraph on page one –

    “Here, we present the case of a young woman with posterior strokes due to magnetic resonance imaging …. ”

    In addition, it is doubtful that the arteries can be assessed by an MRI of the cervical spine, but I could be mistaken. Your statement that the “arteries were fine” is probably not supported by the cervical MRI films.

    Not sure I want to pay the 34 dollars for the entire article, but I would be happy to review it with you (should you decide to present it in its entirety; I assume you have it if presenting it as evidence for your position) if you feel it is the significant case you think it is.

  76. Joe says:

    Quoting from the article:

    Our case is unique in that premanipulation
    MRI showing normal vessel anatomy is available.
    Although the cervical arteries have not been depicted
    in their entire course, relevant parts are represented that are
    later affected by the dissection. MRI therefore provides evidence
    that in this patient, the dissection was not just temporally
    coincident with the cervical chiropractic maneuver, but
    was indeed a direct sequel of the procedure.

  77. Harriet Hall says:

    nwtk2007,

    Why do you put “peer reviewed” in quotes? The article was published in the official journal of the German, Swiss, and Austrian Societies of Neuroradiology. It is peer reviewed.

    Why do you partially quote the opening sentence to make it sound like it is saying MRI causes strokes? The complete sentence is “Here, we present the case of a young woman with posterior circulation strokes due to magnetic resonance imaging-
    (MRI-)proven bilateral vertebral artery dissection.”

    Your statement that “it is doubtful that the arteries can be assessed by an MRI of the cervical spine, but I could be mistaken.” only shows your ignorance. You certainly are mistaken. MRI not only CAN assess the arteries, it is the GOLD STANDARD for diagnosing vertebral artery dissection.

  78. nwtk2007 says:

    Incorrect Harriet, MRA might be but not MRI of the cervical spine, as the use in this instance clearly is consistent with.

    The sentence clearly says the VAD is due to the MRI. I assume it was not meant to say that but that is what it says.

    It calls into question the validity of the article as does the statement that “an orthopedist and chiropractor” performed this CMT. Was the person who performed it both or were there two people involved? If so, how did both perform the CMT?

    In reading that, is appears that the CMT was performed as an MUA, in which case the patient would not report feeling a snapping in her neck.

    Forward the article to me at nwtk@yahoo.com and I’ll review it in detail. It certainly implies that a CMT did the deed, but I can’t accept it at face value by the biased faculty here at this website.

    Objectively, it could be the case many here have been “hoping” for.

    1. Harriet Hall says:

      nwtk2007,
      (1) MRI is magnetic resonance imaging. MRA is magnetic resonance angiography, which is a special kind of magnetic resonance imaging. In this case, MRA was used, and the MRA images are included in the article.
      (2) I provided you with the exact quote from the article. It does NOT say the VAD was due to the MRI. It says the patient had a stroke caused by a VAD that was diagnosed by MRI (explained later in the article to be MRA).
      (3) The article says “an orthopedist and chiropractor performed a rotating abrupt chiropractic maneuver.” In the absence of further explanation, I think we can reasonably assume that it was done by one person who identified himself as both an orthopedist and a chiropractor. The relevant information is that a rotating abrupt maneuver was performed. The fact that we don’t know details about the perpetrator is irrelevant.
      (4) If this had been MUA, the article would have said so. It doesn’t. It wasn’t.

      This article is important because it is the best “smoking gun” evidence to date. Documentation of normal arteries, followed by an abrupt maneuver with immediate symptoms, followed by documenton of VAD in the previously normal arteries. Defensive chiropractors can always try to come up with rationalizations, but this kind of evidence is hard to explain away.

  79. Joe says:

    nwtk2007 on 01 Nov 2010 at 12:45 pm wrote “The sentence clearly says the VAD is due to the MRI. …

    It clearly does not.

    nwtk2007 on 01 Nov 2010 at 12:45 pm wrote “In reading that, is appears that the CMT was performed as an MUA [manipulation under anesthesia, Joe], in which case the patient would not report feeling a snapping in her neck.

    So, since she did report feeling snapping in her neck (and severe, throbbing headache) it was clearly not MUA.

  80. Scott says:

    The sentence clearly says the VAD is due to the MRI. I assume it was not meant to say that but that is what it says.

    Please explain. I cannot see how

    Here, we present the case of a young woman with posterior circulation strokes due to magnetic resonance imaging-
    (MRI-)proven bilateral vertebral artery dissection.

    can possibly be misconstrued in that way. I might as well claim that you’re clearly confusing Vertebral Artery Dissection with Value Added Tax because you said

    The sentence clearly says the VAD is due

    and while you don’t pay VAD (therefore it can’t be ‘due’) one would pay VAT (therefore it can).

  81. nwtk2007 says:

    I’ll not quote the article again. It says what it says and anyone can read it. Admit it, it’s poorly edited thus calling into question its “peer reviewed” status. As in, was it really reviewed?

    Harriet said- “The relevant information is that a rotating abrupt maneuver was performed. ”

    I’m sorry, but when so much is left unclear and “vague” then how much of the article can be trusted for validity’s sake or relevance. But I don’t discount it.

    As to the MRI, the initial MRI was not angiography, but a cervical MRI; very limited in its ability to assess the vertebral arteries. I offered that you had said “the MRI was the gold standard” to a radiologist I know who confirmed that clearly it is not. You can say that an MRA is an MRI but to those of us who regularly order them and use them in our patients assessment, we know all too clearly that a cervical MRI would not be ordered to assess the vertebral arteries.

    Before one instantly grabs onto this as evidence of CMT induced VAD, I would think that the SBMer’s here would want to be clear on some of the important details of the article and not just assume that it is valid. As I said, I don’t discount it, I just like to be objective when looking at “evidence”.

  82. nwtk2007 says:

    Scott, I like your reasoning. Gave me a smile.

    An interesting thing to do would be to repeat the original MRI as it was done initially and compare the two. It might have been done but as I said, I don’t have the whole article.

  83. Joe says:

    Why do chiropractors suddenly become critical thinkers when evidence does not please them? They sponge-up endless nonsense in school.

    nwtk2007 on 01 Nov 2010 at 2:51 pm “I’ll not quote the article again.

    Yes, when you are in a hole, stop digging.

  84. nwtk2007,

    If you are a chiropractor, it seems that you would want to read the article in question.

    Why would someone else pay for it and send it to you for free? If I want information relevant to my profession, I pay for it.

  85. Harriet Hall says:

    nwtk2007 said “I would think that the SBMer’s here would want to be clear on some of the important details of the article”

    I am clear. You are not. I have read the entire article and looked at the images. You have not. I can read sufficiently well to know that the sentence I quoted does NOT say that MRI caused VAD. You apparently can not.

    The pre-manipulation MRI clearly showed unobstructed vertebral arteries; the post-manipulation MRA showed the damage. Joe already quoted the authors about the legitimacy of comparing the two studies (see his 11:25 comment earlier today).

    Your approach is hardly objective: you admit that you have not looked at the evidence since you have not seen the article. Your pro-chiropractic bias has led you to lash out inappropriately before you had all the facts. You are digging yourself deeper with every comment.

  86. nwtk2007 says:

    I have the article and the images now and have read the entire article.

    If you don’t want to admit what the sentence says then so be it. The only other conclusion one might reach is that they are presenting a case of a young woman with posterior circulation strokes “because” they have proof on MRI imaging, which makes almost as little sense as saying the strokes are “due to magnetic resonance imaging” which it says. It’s a poor sentence and should have been edited/changed. Just admit it.

    As to the images, I would not base a determination of a vertebral artery’s integrity based upon that. To say that, based upon those images, the vertebral artery was normal is almost baseless. There are no abnormalities in terms of what can be seen, nothing more. Only a repeat of the same type of MRI would be able to verify that their conclusion is valid.

    I read Joes quote and saw the same in the article but I think its a “reach” based on what little is visible on this rather low resolution image is. That’s why angiography is the “gold standard”, not this type of MRI imaging.

    The authors did the right thing in having the angiography performed but in order for them to make the conclusion that the manipulation caused the dissection, the original MRI needed to be repeated. They didn’t and thus another “smoking gun” is created. The repeat MRI could have raised this case to something above “smoking gun” status.

    1. Harriet Hall says:

      An old joke: a man’s neighbor asks to borrow his lawnmower and he says he can’t lend it because he has to fix the roof. The neighbor asks if he is going to use the lawnmower to fix the roof and he says no, but when you don’t want to lend something, any excuse will do.

      When you don’t want to admit that neck manipulation can cause a stroke, any excuse will do. Manipulation-related VADs are dismissed with the excuse that the patient might have already had a VAD. In the present article, that excuse is ruled out by a patent artery clearly shown on MRI before the manipulation, by development of symptoms on the table, and by demonstration of a VAD afterwards. So another excuse is offered: there might have already been a dissection elsewhere in the artery that didn’t show up on the first study. Never mind that if that were true, the manipulation would clearly be contraindicated and could have caused the tear to extend and cause a stroke.

      Even if we could document (with some new video imaging procedure) a tear actually occurring as the neck was twisted, defenders of manipulation could still argue that it might have been a congenitally weak artery that just coincidentally happened to start tearing spontaneously the moment the treatment was started, so the treatment was not really responsible. Chiropractic apologists will always have an excuse, and no evidence will ever convince them. They are ingenious at rationalizing anything away.

      Yes, officer, I pointed my gun at him and fired, and there are entrance and exit wounds in his torso, but that doesn’t prove I killed him. My bullet could have missed and an unseen intruder could have fired at the same instant and been the actual killer.

  87. Jann Bellamy says:

    @ Jerry:
    “I am not aware that spinal manipulation is written into the scope of practice for any massage or physical therapist, or for any other health care profession other than chiropractors or osteopaths. (Other than a total dislocation being treated by a licensed medical professional.)”

    Scope of practice is a political decision, not a scientific one. Physical therapists are trained in spinal manipulation but chiropractors have lobbied to keep them from using manipulation in their practices. I have not done a survey of the physical therapy scope of practice but here is an article discussing the subject: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2565606/pdf/jmmt0015-0069.pdf. (N.B.: I am assuming you are talking about spinal manipulation as a manual therapy and not the spinal “adjustment” to reduce the chiropractic “subluxation” which only chiropractors perform because chiropractors are the only ones who believe such “subluxations” exist.)

    “California state law allows a chiropractor to treat conditions of the musculoskeletal structures of the human body.”
    I disagree. My conclusion is that California, like the other 50 states, allows chiropractors a wide scope of practice consisitent with what they are taught in chiropractic schools, which is the detection and correction of the chiropractic “subluxation.” Bellamy J, “Legislative Alchemy: The state chiropractic practice acts,” FACT: 15(3), 2010.

    “Only a fool would claim to cure such other conditions as irritable bowel, acid reflux, etc.”
    Then there are a lot of fools out there practicing chiropractic. I hope you are working within your profession to stop this.

  88. nwtk2007 says:

    Allison,

    I have the article now. Hariet sent it to me personally for which I am grateful.

    And hey, when youre a single income family with two teenage girls, 34 bucks is 34 bucks.

    I knew that if anyone actually had it and truly wanted to discuss it, that they could send a copy. If I had an article and they would have had to pay to get it, I would forward it also.

    And now that I have it, have seen the images and read the article, I have given my thoughts on it as well. I will also be contacting the Journal to ask about the wording in the introduction. I have a hard time believing they actually reviewed it and let it be published in this form.

  89. daedalus2u says:

    The real smoking gun is that it is bilateral. Both arteries on both sides of the neck were both damaged between the MRI showing the were undamaged and the MRI showing they were damaged.

  90. nwtk2007 says:

    I find the obstanance of this “unbiased”, science based group humorous at the least.

    I am fully willing to concede that this is a strong candidate for a case of CMT induced VAD but you are totally unwilling to admit to its weaknesses and inconsistancies. Nor even to your own errors in knowledge. That’s fine. Its all here for a truly unbiased reader to see.

    We’ll see what a medical radiologist has to say about the MRI images presented with the paper. The real question related to those images is how much of the vertebral artery is actually assessed. The condition if the basilar artery prior to CMT is not at issue. The pre-CMT vertebral arteries is.

  91. Joe says:

    nwtk2007 on 02 Nov 2010 at 10:45 am wrote “I find the obstanance of this “unbiased”, science based group humorous at the least.

    You use that word “bias,” I do not think it means what you think it means. I am biased against child abuse, do you think that is a bad thing? I am also biased against chiro because quackery has been my hobby for more than 30 years; that bias is based in knowledge, not an arbitrary position for me to take.

    Then there is your bias for a topic you cannot support with reference to high-quality research. That might be humorous; instead, it is sad.

  92. Scott says:

    If you don’t want to admit what the sentence says then so be it. The only other conclusion one might reach is that they are presenting a case of a young woman with posterior circulation strokes “because” they have proof on MRI imaging, which makes almost as little sense as saying the strokes are “due to magnetic resonance imaging” which it says. It’s a poor sentence and should have been edited/changed. Just admit it.

    One more time.

    Here, we present the case of a young woman with posterior circulation strokes due to magnetic resonance imaging-
    (MRI-)proven bilateral vertebral artery dissection.

    This cannot, possibly, by any stretch of the imagination, be construed to mean anything even vaguely similar to what you’re claiming. When attempting to quote it otherwise, you bloody cut it off midword. Not only completely ignoring the “bilateral vertebral artery dissection” part of the sentence, but cutting “MRI-proven” off into just “MRI.”

    How can you not admit that it’s clear as day – couldn’t possibly be made any clearer, in fact – and that you simply made a gross error in reading it?

    Or, for that matter, how can you not see that continuing with such preposterous lunacy completely undermines any claim you might make to have read and understood anything in the REST of the paper?

  93. Joe says:

    @Scott on 02 Nov 2010 at 1:19 pm

    Here, we present the case of a young woman with posterior circulation strokes due to magnetic resonance imaging-
    (MRI-)proven bilateral vertebral artery dissection.

    I think I get it! I am not an English major; but I think there is a comma (,) missing between “proven” and “bilateral”. That could wreak havoc on the understanding by an English purist. Or not …

  94. nwtk2007 says:

    Scott, its the “due to” portion that is the crux of the matter. And believe me, I’m not an english purist but why deny the obvious here. Its poor writing, should have been edited out, is almost non-related to the papers purpose and gramatically miss states what I assume would be their meaning. (Its pretty obvious what they wanted to say.) My only point with it is that if such a blunder was not caught by the peer who reviewed it or the editor then I have my doubts about how “peer reviewed” it is.

    And Joe, once again, you make my point for me about bias.

  95. Harriet Hall says:

    nwtk2007,

    Don’t be ridiculous! The patient had a stroke. It was DUE TO bilateral vertebral artery dissections. The dissections were demonstrated with a type of magnetic resonance imaging, MRA. You are just grasping at straws to try to salvage your untenable position. While you are quibbling about your interpretation of language, you might take into account that the article was published in the official journal of the German, Swiss, and Austrian Societies of Neuroradiology, and English is not a native language in any of those countries. Infelicities of English phrasing are to be expected and excused.

    By the way, I have not claimed that the study has no flaws; I have only said it is the best evidence to date.

  96. Joe says:

    nwtk2007 on 02 Nov 2010 at 2:26 pm wrote “… And Joe, once again, you make my point for me about bias.”

    I am glad you acknowledge your point is biased; be it ignorance of science or language. However, I must add that I prefer not to disparage your misunderstanding of English language because many contributors do not speak English as their first language and I hope to encourage their participation.

  97. nwtk2007 says:

    You’re a crack up Joe, proof positive that the eye can only see what the mind thinks it knows.

  98. Scott says:

    I think I get it! I am not an English major; but I think there is a comma (,) missing between “proven” and “bilateral”. That could wreak havoc on the understanding by an English purist. Or not …

    No, a comma would be strictly wrong there. It says, very clearly and correctly, exactly what they meant.

    Scott, its the “due to” portion that is the crux of the matter.

    Indeed. It was due to “MRI-proven bilateral vertebral artery dissection.” There is NO OTHER POSSIBLE WAY to read this than that “MRI-proven” is an adjective modifying “bilateral vertebral artery dissection.” (The parenthetical being an absolutely standard way to introduce the acronym and meaning that “MRI-” and “magnetic resonance imaging-” are interchangable.)

    And believe me, I’m not an english purist but why deny the obvious here.

    Indeed, why ARE you doing your very best to prove you can’t comprehend simple English?

    Its poor writing, should have been edited out,

    Why? Because someone bound and determined to deliberately misconstrue the plain English can manage to find a way to do so by selective deletion? That’s true of any sentence.

    is almost non-related to the papers purpose and gramatically miss states what I assume would be their meaning. (Its pretty obvious what they wanted to say.)

    It is exactly the paper’s point and is 100% grammatically correct.

    Do you at least admit that it was grossly wrong of you to cut of your original quote in midword? And if you don’t, why do you think anyone should take you seriously? You’re proving that you’re willing to delete words in order to make the sentence say what you want!

    In all seriousness, your claim is effectively equivalent to stating that Nixon famously admitted to being a crook. The quote being “I am … a crook”. Except you’re not even having the decency to include the ellipsis.

  99. nwtk2007 says:

    Oh please Scott, even the rest of the paragraph is weird. The next sentence says that “the evidence strongly supports the notion that the dissection occurred during “the” maneuver.”

    Terrible. They haven’t even established that this “young woman” was treated by a “maneuver”, yet they reference it as a past tense topic.

    Sorry. Its bad and thats all.

    At best I’ll allow for the language barrier but I doubt if they are that english challenged and surely the editor would not be.

    It doesn’t matter. Really.

    The crux of the evidence is that the standard cervical MRI done prior to the “maneuver” is adequate to say that the vertebral artery was normal prior to the manuever. (I’m being redundant to assist you for clarity’s sake.)

    It would be interesting to see the actual radiologists reports. I have a feeling there might be a bit of embellishment on the part of the persons involved with this paper. Are the authors neurologists or radiologists by the way?

Comments are closed.