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133 thoughts on “Kaiser Rejects Neck Manipulation

  1. mark says:

    @ nwtk2007

    “We’ll see what a medical radiologist has to say about the MRI images presented with the paper.”

    Are you going to show the images to a general radiologist? If so, why? The editors, reviewers, and readers are neuroradiologists- radiologists who are subspecialised in neuroimaging. What will the opinion of someone who is not a specialist in this field add?

  2. mark says:

    @ nwtk2007

    “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.”

    No, it’s not bad. The description of the case is very clear and easy to follow. There is no issue with the quality of the writing.

    This does matter because you appear to be using the issue of language to try and discredit the authors.

  3. nwtk2007 says:

    I’m sorry Mark, but it is bad and poorly written. I’ve shown it to several others including a layman and an NNP who all agree that it is confusing. But as I’ve said and as you would say, its fairly obvious what they wanted to say and it doesn’t matter as to the contents of the article.

    I was wondering though, are the authors neuroradiologists or neurologists. I didn’t see any distinction in the article. I get the impression they are neurologists. Simple enough to e-mail and ask I guess.

    1. Harriet Hall says:

      nwtk2007 says “I’ve shown it to several others including a layman and an NNP who all agree that it is confusing.”

      It’s nice that your friends want to agree with you. However, they are the only ones who do. We have shown it to the commenters on SBM and so far every single one has said that the meaning is clear and that your interpretation is unfathomable. I showed it to a layman and told him what you said and he laughed out loud.

      I think it’s time for you to say what you really think happened in this case. Do you think there was no VAD? Do you think a VAD occurred prior to the cervical manipulation and simply failed to show on the initial MRI? How do you explain the symptoms on the table and the outcome? Do you think the imaging studies were mis-read? Do you think all the editors, reviewers and readers of this NEURORADIOLOGY journal are incapable of interpreting the images?

  4. ntwk2007

    I have no idea what you showed or what you asked, but the language is clear. You are inventing an issue that does not exist.

  5. ntwk2007

    If you want to scrutinize the authors’ qualifications, you can e-mail them here:
    christoph.preul AT med.uni-jena DOT de
    felix.joachimski AT med.uni-jena DOT de

    Unfathomable is a good word.

  6. daedalus2u says:

    The scientific literature is a communication from one scientific expert to another scientific expert. It is not meant to be understood by lay people without the background to understand it.

    The question is what do scientific peers think it means, and to a person they support the meaning that Harriet imputes to the writing.

    That you do not understand the plain meaning of the language is a problem with your understanding, not the language. It means you are not a peer. If you want to understand it, then it seems pretty clear that you need more experience reading the peer reviewed literature.

  7. JMB says:

    I’d like to make an analogy to provide a perspective on the issue of MRI vs MRA for diagnosing vertebral artery dissection in the reported case.

    Take a letter sized white piece of paper and color it red. Now take a letter sized white piece of paper and take a blue felt tip pen and place a blue dot on it. Take a third piece of letter sized white paper and don’t place any mark on it. Now place a camera on a tripod and photograph each sheet of paper first through partly opened window shutters, then through an unshuttered window. When you look at the pictures taken through the shuttered (but partly open shutters) window, will you be confident in saying that the picture either shows the red letter, or not? If you are looking at a picture that shows a white paper through the shutters, would you be confident in saying there is no blue dot? When you are expected to reliably identify the red, white and blue you will prefer the gold standard — taking the picture through the unshuttered window. But, even though the pictures through the shuttered window are not the gold standard, they are reliable in determining whether the picture shows the red letter.

    A standard MRI is not the gold standard for vertebral artery assessment, but because of flow voids from flowing blood in the vertebral arteries, it is sufficient to rule out the artery dissections resulting in the infarcts in the case study (the blood was flowing freely through the vertebral arteries on the initial exam).

    I wonder if somebody will now argue about the gold standard for the red, white, and blue.

  8. mark says:

    @ nwtk2007

    “I was wondering though, are the authors neuroradiologists or neurologists.”

    I think they are neurologists but I’m not sure why it matters.

    Most neurologists I’ve had dealings with would say that no-one can interpret neurological imaging as well as a neurologist. But they would use longer words than this… and then cite some obscure syndrome with lots of hyphenated names as supporting evidence.

  9. nwtk2007 says:

    Unified, elitest obstanance. You can dish it out but you sure can’t take it.

    I’ve already said it looks like a good example for VAD caused by CMT, vaguely proven by non-gold standard MRI performed prior to CMT as compared to gold standard MRA taken after CMT. I have also said that the case would have been clearer if the original MRI had also been repeated. It wasn’t and thus it is not more than another smoking gun, as Harriett referred to it earlier in this thread.

    I know its probably irritating to have a simple chiro point out the flaws in this study. I know.

  10. Dawn says:

    This is hysterical. I read, first, what nwtk2007 had written and was shocked at the sentence…until I read Harriet’s comment where she posted the full sentence.

    So, nwtk2007, since you are having trouble with the sentence, let’s re-word it for you.

    Original:

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

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

    Does that make what the authors wrote, who are probably not native English speakers, clearer to you?

    To be honest, I work with a lot of ESL people, so the sentence was perfectly understandable to me. Obviously, you need to work with more people from non-English speaking Europe and Asia. This helps with understanding things that may not be as clearly spoken or written to those of us who are native English speakers. (And if I spoke/wrote ANY other language as well as my ESL friends/coworkers speak/read English, I would be thrilled…)

  11. nwtk2007 says:

    The authors were presenting a case of VAD induced stroke caused by CMT, not a case of stroke proven by MRA studies as a result of VAD.

    How about, “Here, we present a case of a young woman with posterior circulation strokes secondary to VAD caused by CMT.”

  12. Dawn says:

    @nwtk2007: I don’t agree, totally. I agree that the authors are saying her VAD was caused by CMT, but you can’t ignore the fact that she had MRI documentation of normal arteries prior to, and VAD documented by MRI after CMT. You do need, in your sentence, to address the fact of the documentation.

  13. nwtk2007 says:

    How about ” …… caused by CMT, proven by MRI performed both pre- and post-CMT.”

    At least the purpose of presenting the case is then seen as related to the CMT possibly causing the VAD and not just a case of posterior strokes secondary to VAD.

    1. Harriet Hall says:

      nwtk2007: The purpose of presenting the case was perfectly clear in the context. It is ridiculous to take one sentence out of context and expect it to comprehensively explain everything that is already explained in adjacent sentences. Here are the entire first two paragraphs of the article:

      “There is an established epidemiologic association between
      chiropractic maneuvers and cervical artery dissection [1, 2].
      In spite of clinical evidence, however, proof that spinal
      manipulative therapy can be the actual cause for dissection
      is still a matter of debate. It has been argued that chiropractic
      maneuvers are performed for neck pain that may have
      been caused by preexisting dissection of a cervical artery,
      and hence the manipulation may coincide with, rather than
      cause, the vessel lesion [3–5].
      Here, we present the case of a young woman with posterior
      circulation strokes due to magnetic resonance imaging-
      (MRI-)proven bilateral vertebral artery dissection. Clinical
      evidence strongly supports the notion that the dissection
      occurred during the maneuver, since an MRI scan prior to
      the manipulation showed a protruded intervertebral disk,
      and intact cervical vessels.”

      Your perseveration and deliberate misunderstanding of the language is beginning to make you sound like Th1Th2. It’s time for you to stop now. The article is a valid addition to the already substantial evidence showing that neck manipulation can cause stroke, and nothing about your misguided quibbling will change that.

  14. Dawn says:

    Probably more readable.

  15. nwtk2007 says:

    Quibling? I’ve admitted to the partial validity of the article. Maybe you should at least concede to the fact that the first MRI amounts to little more than a spot check of the vertebral arteries condition prior to the CMT.

    I, for one, also wonder how the authors could suggest that MRI be used as a pre-CMT device when it didn’t reveal any abnormalities and yet the VAD still occured. If they meant MRA instead should be used to screen patients prior to CMT, then I can only assume the authors must also suspect the VAD was and usually is in progress prior to CMT. Otherwise, why recommend it to screen patients for CMT?

  16. Harriet Hall says:

    The first MRI was not just a “spot check” but a demonstration that blood was flowing freely through unobstructed vertebral arteries. Did you understand JMBs explanation?

    The suggestion to use MRI “more frequently” pre-manipulation was just that: a suggestion, not offered with any evidence that the practice would reduce the incidence of stroke. I took it to mean that they were advocating more precise diagnosis of the cause of neck pain before indiscriminately manipulating necks. And it was a suggestion in a neuroradiology journal that strongly supports imaging studies. I don’t think you can read anything more into it, certainly not a suspicion that a VAD is usually in progress. It might just as well mean that they thought it would help document other cases where manipulation caused strokes. I don’t think anyone is suggesting that MRI or MRA should be used to screen every patient with neck pain. It is expensive, not always available, and involves potentially dangerous injection of contrast.

  17. mark says:

    @ nwtk2007

    “I can only assume the authors must also suspect the VAD was and usually is in progress prior to CMT.”

    It is abundantly clear from the article the authors do not suspect that. They suspect the stroke was caused by the manipulation. Drawing any other inference is dishonest.

    So far you’ve unsuccessfully tried to discredit the article by impling the journal is not correctly peer-reviewed, claiming the language is bad, questioning the authors’ qualifications, saying the authors have overinterpreted the images, disputing the validity of the various imaging tests, and trying repeatedly to twist the authors’ words to meanings others find unfathomable.

    What’s next? A big pharma conspiracy theory?

  18. Joe says:

    @mark on 03 Nov 2010 at 3:43 pm wrote “So far you’ve unsuccessfully tried to discredit the article by implying …”

    Isn’t it amazing that someone can go to chiro school and swallow all the nonsense about subluxations and Innate Intelligence, and then suddenly become a “critical thinker” when their treasured notions are undermined? One must wonder why they cannot use that same critical approach on their own business.

    Mark- don’t give them ideas about Big Pharma. We may have to come out in our dark blue (often mistaken for black) helicopters and take you to a re-education camp.

  19. Fred Dagg says:

    The qualifications of the person performing the maneuver are very important. In Germany “chiropractic” is a term often used by medical practitioners who have done courses in spinal manual therapy. ca”Chiropractic” can then be considered a generic term for “Spinal Manual Therapy”. It is not used as a qualification or profession the way it is used in the U.S., Canada, U.K. etc.
    I wonder if any one can actually find out the qualifications of the treatment provider.
    It would be very unusual for someone in Germany to be both an orthopaedic surgeon as well as a chiropractor. (There are many medical practitioners and chiropractors who have both degrees e.g. Scott Haldeman)
    Thus, the authors of the article, as well as a lot of the contributors to the site are falling into the same trap that many other authors e.g. Edzard Ernst (in his most recent article), have done. That is, ascribing a bad result to a profession, rather that the treatment.
    As I read it, it would be more correct for the article to be entitled, “Bilateral Vertebral Artery Dissection After Spinal Manual Therapy”. That is, until the qualifications of the treatment provider are detailed.

    1. Harriet Hall says:

      @ Fred Dagg.
      If “chiropractic” is considered a generic term for SMT, then the title “Bilateral Vertebral Artery Dissection after Chiropractic Maneuver” is a synonym for “Bilateral Vertebral Artery Dissection after SMT” and therefore it says nothing about ascribing a bad result to a profession. In this case apparently it was the individual who did the manipulation who called himself a chiropractor and calls what he did a chiropractic maneuver. It is clear that I, Ernst, and the authors of the present article all think that it is the manipulation that causes these strokes, no matter who did it or what they chose to call it. If SMT is confused with chiropractic, it’s the fault of chiropractors themselves who have laid claim to manipulation as their raison d’etre.

      It is pathetic that defenders of chiropractic are reduced to quibbling about the language instead of addressing the substance of what the article showed.

  20. Fred Dagg says:

    Harriett

    your literary impudence amazes me. You and Ernst’s attacks on the chiropractic profession are nothing short of hysterical, yet you rarely have ever acknowledged that it is “spinal manual therapy” that causes complications rather than “chiropractic, osteopathy, physical therapy or medical manipulation”. Ernst falls into this problem regularly and one only has to look at the errors in his research to see examples of this. Mis-scribing complications of spinal manual therapy to chiropractors instead of other therapists is rife in medical literature. Prof. Allan Terrat from Australia has written on this topic.
    The substance of the article is important, and I am not denying it. However, if you were a true skeptic and a true defender of Science Based Medicine, as you claim, then your first duty would be to look at the article and find faults in it, such as the incorrect use of the term “chiropractic”, and errors of translation, rather than mount an attack on a profession that has been maligned.

    1. Harriet Hall says:

      @Fred Dagg,

      Balderdash! I have pointed out the limited effectiveness and risk of stroke from neck manipulation by anyone who does it; I have acknowledged that chiropractors are not the only ones to blame, but I have also recognized that chiropractic claims SMT as its raison d’etre, that the great majority of SMT is done by chiropractors, and that every smoking gun case I have so far encountered has involved a chiropractor. I have criticized chiropractic for not being science-based, for being founded on a myth (the subluxation). I have criticized chiropractors (and others) for adopting quack diagnostic methods and quack treatments. I have criticized chiropractors (and others) for discouraging immunizations. Nothing I have written has ever come close to any kind of “hysteria.” In fact, I have taken flak from my colleagues for being too “soft” on chiropractic: rather than calling for complete abolishment I have called for reform and limitation of chiropractors’ practices to appropriate short-term treatment of musculoskeletal problems.

      My first duty in evaluating the article is not to look for errors of translation or to look for terminology that be misconstrued by some and might hurt chiropractors’ feelings but to evaluate the scientific content. It appears that your first duty is to defend chiropractic at all costs and your second duty is to attack anyone who spreads information that you perceive as threatening.

  21. Fred Dagg says:

    Hello Harriett
    you tirade is nothing more than hot air.
    I would like to see examples of your criticisms of physical therapists, osteopaths and medical practitioners who practice Spinal Manual Therapy. I would like to see examples the same type of vehemence that you have directed at the chiropractic profession, directed at others.

    My impression is that the minute the word “chiropractic”shows up in any research, you wade in and criticize.
    Please do no assume things about me that are incorrect. The statement…

    “It appears that your first duty is to defend chiropractic at all costs and your second duty is to attack anyone who spreads information that you perceive as threatening”.

    …is a perfect example of a fallacy you wish to pursue. It is incorrect. I look at articles such as this one, and look for correctness. Science is more than just test tubes, computers and technology. Science is more than just sitting in front of a computer and googling anything you want and cherry-picking to suit your argument. It is also words, terminology and an overall correctness. That is why there are people out there who are professional proof readers.

    You have mis-construed the article, seized on the word “chiropractic” in it, and now you have been shown to be wanting in your poor research technique, you are resorting to insults and fallacies.

    Harriett, you have dug yourself into a hole. Stop digging!!!!!!!!

  22. Harriet Hall says:

    @Fred Dagg,

    It was not the word “chiropractic” in this article that attracted my attention. It was the fact that a VAD followed a neck manipulation.

    I have said that SMT is effective for certain patients with low back pain, and I don’t criticize chiropractors, PTs, or DOs for using it appropriately. I do criticize anyone who uses it to correct hypothetical subluxations and who does neck manipulation for inappropriate indications and without informed consent.

    Show how I have “misconstrued” the article and explain what you think really happened in that case.

  23. Fred Dagg says:

    Harriett.
    I have asked you for examples of your criticisms of other health care providers who do SMT. e.g. orthopaedic surgeons who may do Manipulation under Anesthetic, Physical Therapists and Osteopaths. There should be many articles written by you on treatments that are provided by these practitioners that are “unscientific”. You have refused to provide me with examples and changed the topic. Headings such as “chiropractic” should be changed to “Spinal Manual Therapy”, just to be fair. Your tirades should be pan-professional, but they are not.

    Your first duty in reading the article should have been to define the terms used. In this case the term “chiropractic” was used incorrectly. It should have been “Spinal Manual Therapy” as performed by a medical practitioner. You have acknowledged this on this site, but only after significant prompting. If the shoe was on the other foot, would you be as vehement?

    As I said, you are in a hole, dug by yourself. Stop digging!!!!!!!!

  24. Harriet Hall says:

    Fred Dagg said,

    “There should be many articles written by you on treatments that are provided by these practitioners [PT, DO, Orthopedist] that are “unscientific”.

    There are a few. Here are a couple of examples:
    I wrote about the Graston technique, used by PTs, at http://www.sciencebasedmedicine.org/?p=3170
    I wrote about craniosacral therapy, used by osteopaths, at http://www.quackwatch.org/01QuackeryRelatedTopics/cranial2.html
    I don’t think I’ve written anything about orthopedic surgeons, but then my radar hasn’t lit up with any examples of unscientific treatments they are using.

    It is not your place to lecture me on what I “should” do. This is a blog. We are not writing a textbook. We are not obligated to cover every subject or provide a balanced number of articles in each area. My colleagues and I are free to write about whatever happens to attract our interest at the moment. We have written 159 posts on vaccines and only 2 on ophthalmology and 4 on dentistry. We have picked on homeopathy (63), herbs and supplements (76), and acupuncture (53) more than we have picked on chiropractic (40).

    The only “duty” I recognize is to use good critical thinking skills and rigorous scientific principles in evaluating the subjects I write about. I do not accept your criticism. I do not accept that the term “chiropractic” was used incorrectly in this article, because SMT is commonly seen as a “chiropractic” treatment even by chiropractors: they claim to do it better than anyone else and they have tried to prevent PTs from doing it because they see it as their personal province. Some states allow only chiropractors to perform SMT. It is understood that it is the SMT that causes strokes no matter who does it, and I don’t agree that that fact necessarily has to be specifically spelled out every time.

    I don’t have a hissy fit every time someone calls MDs “allopaths,” although the term is inappropriate and meaningless. I don’t protest every time someone uses the term “alternative medicine” because its meaning is generally understood and serves the purpose of communication even though we have repeatedly explained that there is no such thing as “alternative medicine,” just medicine that has been proven to work and medicine that hasn’t. It is disingenuous of you to complain every time someone refers to spinal manipulation as “chiropractic” since manipulation is the essence of chiropractic, even reflected in the etymology “chiro” = “hands on.”

    I’m not the one in a hole. Repeating that doesn’t make it so. Chiropractic has dug itself into a hole away from science and shows few signs of trying to reform itself out of the hole and into the scientific medical mainstream.

    The fact that I didn’t complain about the word “chiropractic” doesn’t mean that I “misconstrued” the case under discussion. “Misconstrue” means to misunderstand or misinterpret. So I’ll ask once more: show how I have misunderstood or misinterpreted the facts and tell us what you think really happened in that case.

  25. marcus welby says:

    Fred Dagg: as an orthopedic surgeon, I am unaware of any MDs who do spinal manipulation in the U.S. Some do in Germany and there is an article recently in their neurology literature documenting a number of VAD strokes in that country with about equal numbers due to chiropractors and those performed by orthopedists. In the U.S. although some physical therapists do spinal manipulation therapy, the high velocity neck manipulation favored by many chiropractors and responsible for the strokes and death seems to be the exclusive realm of chiropractors. Why the German medical authorities still allow orthopedic surgeons to perform this risky procedure with no proven medical benefit is a serious question.

  26. nwtk2007 says:

    This response to a few of my questions to the authors of “Bilateral VAD after Chiropractic Maneuver” –

    “Thank you very much for your interest in this case. To adress your
    questions, let us explain that FJ, SI and OW were among the treating
    neurology team in our Neurologic Intensive Care Unit. A neuroradiologist
    and CP supplied neuroradiologic input.
    Unfortunately, we only managed to obtain the cervical MR images of the
    days before the chiropractic intervention weeks after the patient was
    admitted, when all new imaging had already been done. Thus the MR images
    obtained before and after the intervention differ in orientiation
    (sagittal vs. axial) and sequences (T2 vs. EPI) employed. From the
    neuroradiologist’s viewpoint the vessels are still reasonably well
    depicted, so that one can deduce that the dissection in the
    V3/V4-segment of the vertebral arteries was not present before the
    intervention. One might still argue that a more proximal dissection
    (V2/V3) might have been possible, but this is a rare location for
    dissections – the area of least resistance (where most dissections
    happen) seems to be the atlas coil and distal to it.
    The question whether strokes in dissections are generally predominantly
    embolic or hemodynamic is currently lively debated, probably both
    mechanisms occur. In our case most of the infarctions appear
    morphologically embolic (pro: asymmetric, ovoid), but we cannot rule out
    that the vessel was temporarily occluded and resulted in hemodynamic
    strokes.
    With respect to image quality: We do have scanned copies of the
    original films of the pre-intervention MRI and, of course, digital
    copies of all our own images. The images for the publication were
    carefully selected in terms of the optimal demonstration of the
    pathologies.

    We hope to have answered some of your questions and look forward to
    hearing from you.

    With best regards,
    Christoph Preul

  27. nwtk2007,
    There are so many line breaks in your comment that I literally can’t read it. I’ve removed them and reposted in case anyone else wants to read it.

    Thank you very much for your interest in this case. To adress your questions, let us explain that FJ, SI and OW were among the treating neurology team in our Neurologic Intensive Care Unit. A neuroradiologist and CP supplied neuroradiologic input.

    Unfortunately, we only managed to obtain the cervical MR images of the days before the chiropractic intervention weeks after the patient was admitted, when all new imaging had already been done. Thus the MR images obtained before and after the intervention differ in orientiation (sagittal vs. axial) and sequences (T2 vs. EPI) employed. From the neuroradiologist’s viewpoint the vessels are still reasonably well depicted, so that one can deduce that the dissection in the V3/V4-segment of the vertebral arteries was not present before the intervention. One might still argue that a more proximal dissection (V2/V3) might have been possible, but this is a rare location for dissections – the area of least resistance (where most dissections happen) seems to be the atlas coil and distal to it.

    The question whether strokes in dissections are generally predominantly embolic or hemodynamic is currently lively debated, probably both mechanisms occur. In our case most of the infarctions appear morphologically embolic (pro: asymmetric, ovoid), but we cannot rule out that the vessel was temporarily occluded and resulted in hemodynamic strokes.

    With respect to image quality: We do have scanned copies of the original films of the pre-intervention MRI and, of course, digital copies of all our own images. The images for the publication were carefully selected in terms of the optimal demonstration of the pathologies.

    We hope to have answered some of your questions and look forward to hearing from you.

    With best regards,
    Christoph Preul

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