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Neck Manipulation: Risk vs. Benefit

While manipulation of any kind has the potential to cause injury, stroke caused by neck manipulation is of greatest concern. Risk must always be weighed against benefit when upper neck manipulation is considered. Risk of stroke caused by neck manipulation is statistically low, but the risk is serious enough to outweigh benefit in all but a few rare, carefully selected cases.

When the RAND (Research and Development) organization published its review of the literature on cervical spine manipulation and mobilization in 1996, it concluded that only about 11.1% of reported indications for cervical spine manipulation were appropriate and that stroke and other serious complications occurred about 1.46 times per one million neck manipulations.1 In the same year, after examining 183 cases of vertebrobasilar stroke that occurred from 1934 through 1994 following neck manipulation, the National Chiropractic Mutual Insurance Company (NCMIC) concluded that “It has to be accepted that VBS [vertebrobasilar stroke] following SMT [spinal manipulative therapy] does occur.”2

Since about 90% of manipulation in the United States is done by chiropractors1 who use spinal manipulation as a primary treatment for a variety of health problems, neck manipulation is more problematic among chiropractors than among physical therapists and other practitioners who use manipulation only occasionally in the treatment of selected musculoskeletal problems.

Estimates on the incidence of stroke caused by cervical spine manipulation range from one in 400,000 to one in 5.8 million manipulations, depending upon who is doing the survey. A chiropractor-authored review of malpractice data provided by the Canadian Chiropractic Protective Association, for example, concluded that a chiropractor will be made aware of an arterial dissection only once per 5.85 million cervical manipulations.3 This stroke-manipulation ratio is widely quoted by chiropractors, despite the fact that court-litigated cases do not reflect the total number of manipulation-related strokes, most of which are unreported or undetected.

Backing away from observations that neck manipulation is a cause of stroke, a 2006 report published by NCMIC Chiropractic Solutions concluded that “The incidence of stroke in the population as a whole is no different (2 per 100,000 persons annually) than among those who received manipulation treatment of the neck,” adding that “The best scientific evidence available has shown no causative relationship between appropriately applied spinal manipulation and stroke events.”4 Many studies, however, have linked chiropractic upper neck manipulation with stroke.5,6

Recent reports produced by chiropractors argue that the incidence of stroke among persons who have had neck manipulation is “…to the same order of magnitude as that occurring in the general population,”4 and that there is “…no evidence of excess risk of VBA [vertebrobasilar artery] stroke associated with chiropractic care compared with primary care.”7 But these reports fail to distinguish strokes caused by trauma to the vertebral arteries of young healthy people from the type of strokes that occur among predisposed persons, especially the elderly. No consideration is given to the possibility that many strokes caused by neck manipulation may go unreported. When patients seek medical care for paralytic symptoms caused by release of a blood clot that was formed days or weeks earlier by neck manipulation, for example, a connection between neck manipulation and stroke may not be made. Such strokes may then be reported by primary care physicians who are unaware of preceding trauma caused by neck manipulation, thus sparing chiropractors of any blame.

The most recent chiropractor-headed study of the association between chiropractic visits and vertebrobasilar artery stroke, based on billing records, concluded that strokes associated with chiropractic neck manipulation occur because patients with headache and neck pain caused by vertebrobasilar dissection seek chiropractic care for relief of symptoms: “The increased risks of VBA stroke associated with chiropractic and PCP [primary care physician] visits is likely due to patients with headache and neck pain from VBA dissection seeking care before their stroke.”7 In other words, the report implies that a chiropractor is not to be blamed for making an incorrect diagnosis and then manipulating the neck of a patient who presents the symptoms of a stroke in progress. It goes without saying, however, that it is the responsibility of the chiropractor to recognize symptoms of stroke before manipulating the patient’s neck, especially if the chiropractor practices independently or portrays himself or herself as a primary care physician. But you cannot depend upon the diagnostic acumen of a chiropractor who believes that he or she can improve health by adjusting the spine. Physicians and therapists who refer patients to chiropractors must be cautious in selecting patients for referral, and they must take responsibility for the diagnosis when making such referrals.

Clearly, patients with acute head and neck pain that might be the result of stroke or arterial dissection should not have their necks manipulated. Elderly persons who might be susceptible to stroke because of diseased vertebral arteries should not be subjected to the risk of neck manipulation. The fact that spontaneous vertebral artery dissection can occur in susceptible persons of all ages does not excuse neck manipulation as a cause of traumatic dissection but rather underscores another reason for avoiding such treatment whenever possible.

Appropriate Neck Manipulation

Manipulation of the upper cervical spine should be reserved for carefully selected musculoskeletal problems that do not respond to such simple measures as time, massage, exercise, mobilization, longitudinal traction, or over-the-counter medication. Because of the tortuous route of the vertebral arteries where they thread through the transverse processes of the first cervical vertebra and then make a sharp turn to travel behind the atlas and enter the skull through the foramen magnum, head and neck rotation forced by manual manipulation should not exceed 45 or 50 degrees if kinking or traumatic dissection of these arteries is to be avoided.8,5 Rotating the head to rotate the cervical spine would force excessive rotation in the occiput-atlas-axis area where the vertebral arteries are most vulnerable and where there are no intervertebral discs and no interlocking joints to limit rotation.  Rotation past 45 degrees might cause kinking of the ipsilateral vertebral artery while rotation past 50 degrees might cause kinking of the contralateral vertebral artery.8 Rapid manual rotation of the head might also cause damage by overcoming the arteries’ normal elasticity, causing tears and blood clots in the intimal lining of the vertebrobasilar arteries. The slow stretching of mobilization within a normal range of movement may be less damaging to arteries than the high-velocity low-amplitude manipulation required to rotate the cervical spine beyond its normal range of motion or to move joints into the paraphysiologic space to produce cavitation.

It seems likely that in rare cases where there is significant discomfort or loss of mobility caused by binding or fixation of a vertebral joint or by entrapment of a synovial membrane or a cartilaginous fragment, manipulation might be the treatment of choice. There is evidence to indicate that cervical spine manipulation and/or mobilization may provide short-term pain relief and range of motion enhancement for persons with subacute or chronic neck pain.1 There is no credible evidence, however, to indicate that neck manipulation is any more effective for relieving mechanical neck disorders than a number of other physical treatment modalities,9 and it is clear that adverse reactions are more likely to occur following manipulation than mobilization.10 (When manipulation is performed, a joint is moved farther than normally possible in an active movement. Passive mobilization moves a joint through its normal range of motion.) Inappropriate cervical spine manipulation may force excessive movement and worsen symptoms related to cervical disc herniation or spondylosis, producing such complications as radiculopathy or myelopathy.11 At least one study has suggested that manual therapy in the form of mobilization is more effective and less costly for treating neck pain that physiotherapy or care by a general practitioner.12 And there is reason to believe that less risk is associated with mobilization than with manipulation.10 There is no justification, however, for use of neck mobilization or manipulation as a treatment for general health problems.

All things considered, manual rotation of the cervical spine beyond its normal range of movement is rarely justified. The neck should never be manipulated to correct an asymptomatic  “chiropractic subluxation” or an undetectable “vertebral subluxation complex” for the alleged  purpose of restoring or maintaining health or to relieve symptoms not located or originating in the neck. There is no evidence that such subluxations exist. When a painful, actual subluxation (partial dislocation) occurs, manipulation might occasionally be helpful but is most often contraindicated.13

The bottom line is that while there might an occasional need for appropriate, properly controlled neck manipulation in the treatment of an uncomplicated musculoskeletal problem that results in loss of mobility, there is no credible support for the use of such treatment based on the chiropractic vertebral subluxation theory. Consultation with an orthopedist or a neurologist should be part of a consensus that determines the need for neck manipulation, weighing benefit against risk. Persons with certain structural or vascular abnormalities, or who might be taking blood thinners or other medications that would increase risk of bleeding, would be advised not to undergo neck manipulation for any reason.

When a sudden onset of neck pain occurs, it is absolutely essential that an attempt be made to  rule out a pre-existing vertebral artery dissection before neck manipulation is done, lest manipulation releases an embolus that will travel to the brain. Sudden, severe headache might also be an indication that stroke is occurring or is about to occur. When neck pain or headache is sudden and severe, neck manipulation should not be considered until a neurologist has tested the patient for symptoms of arterial dissection or stroke. Such a careful approach would be problematic among chiropractors who base diagnosis and treatment upon detection and correction of a “vertebral subluxation complex.”14

Chiropractors vs. Physical Therapists

Since it may be difficult or impossible to determine beforehand who might have weak or diseased vertebral arteries or who might be vulnerable to vertebral artery dissection or stroke that could be caused or aggravated by upper neck manipulation, rotational neck manipulation should be a measure of last resort. A physical therapist trained in the use of both manipulation and mobilization for musculoskeletal problems would be less likely to use manipulation inappropriately than a chiropractor who routinely manipulates the spine for “the preservation and restoration of health.”15

According to the Association of Chiropractic Colleges (ACC), “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.”15 Chiropractors who are guided by this vague paradigm (more of a belief than a theory) often manipulate the full spine of every patient for “subluxation correction.” Few chiropractors specialize in the care of back pain and other musculoskeletal problems, and only a few have renounced the chiropractic vertebral subluxation theory.

An indication that science-based chiropractic is outweighed by subluxation-based chiropractic is evident in the recent demise of the National Association for Chiropractic Medicine (NACM). (Personal correspondence with Ron Slaughter, MS, DC, August 8-09.) The NACM, founded in 1984, required its members to renounce the chiropractic vertebral subluxation theory as part of a plan to develop a science-based musculoskeletal specialty that could become a part of mainstream medicine, with emphasis on manipulation and other physical treatment methods. Only a few hundred chiropractors joined the organization. Failure of the NACM certainly does not speak well for the chiropractic profession, which continues to resist reform that would uniformly limit chiropractors in a properly defined specialty.

While physical therapists, physiatrists, osteopaths, and orthopedists sometimes manipulate the neck for a carefully selected musculoskeletal problem, chiropractors who are guided by the ACC’s subluxation paradigm may routinely manipulate the neck,  thus subjecting the patient to unnecessary risk.16 Whatever the incidence of stroke per number of neck manipulations might be, this risk is greater per patient among chiropractic patients who may be manipulated many times for “health reasons” and who may be manipulated regularly for “maintenance care.” Chiropractors who renounce vertebral subluxation dogma and specialize in the care of back pain will use manipulation more appropriately. Unfortunately, there is no official or legal definition limiting chiropractors to treatment of musculoskeletal problems, making it difficult to find a properly limited chiropractor.17

There is little doubt that most chiropractors are skillful manipulators. And many chiropractors do a good job treating back pain. But until chiropractors are uniformly specialized in treatment methods and scope of practice, and chiropractic associations openly denounce the nonsense that permeates the profession, chiropractors cannot be recommended across the board. Hit-and-miss reliability among chiropractors makes it necessary for physicians and other health professionals to stay on the safe side and recommend physical therapists rather than chiropractors.

Forty-two states permit direct access to the services of physical therapists, some of whom may include use of manipulation among their treatment modalities. A physical therapist who offers neck manipulation without requiring a physician’s prescription must be prepared to take  responsibility for the diagnosis and the treatment outcome. Because of the dangers associated with neck manipulation, therapists who perform such manipulation should work closely with medical specialists to determine if benefit outweighs risk.

Since physical therapists use mobilization more often than manipulation, and use much less neck manipulation than chiropractors who routinely manipulate the spine, there may be less injury and a lower incidence of stroke associated with physical therapy than with chiropractic treatment. For example, a review of 177 cases of injury caused by manipulation of the cervical spine (MCS), reported in 116 articles published between 1925 and 1997, revealed that “Physical therapists were involved in less than 2% of the cases, and no deaths have been attributed to MCS provided by physical therapists.”18

References

1. Coulter ID, Hurwitz EL, Adams AH, et al. The Appropriateness of Manipulation and Mobilization of the Cervical Spine. Santa Monica, CA; RAND; 1996.

2. Terrett AGT. Vertebrobasilar Stroke Following Manipulation. West Des Moines, IA: National Chiropractic Mutual Insurance Company; 1996.

3. Haldeman S, Carey P, Townsend M, Papadopoulos C. Arterial dissections following cervical manipulation: the chiropractic experience. Can Med Assoc J 2001;165(7):905-6.

4. Triano J, Kawchuk G. Current Concepts in Spinal Manipulation and Cervical Arterial Incidents. Clive, IA: NCMIC Chiropractic Solutions; 2006.

5. Terrett AGT. Current Concepts in Vertebrobasilar Complications Following Spinal Manipulation. West Des Moines. IA: NCMIC Chiropractic Solutions; 2001.

6. Ernst E. Adverse effects of spinal manipulation: a systematic review.  J R Soc Med 2007;100:06-0100.1-9.

7. Cassidy JD, Boyle E, Cote P, et al. Risk of vertebrobasilar stroke and chiropractic care: results of a population-based case-control and case-crossover study. Spine 2008;33(No. 4S):S176-83.

8. Magee D. Orthopedic Physical Assessment. Philadelphia, PA: W.B. Saunders Company; 1987.

9. Gross AR, Hoving JL, Haines TA, et al. Manipulation and mobilization for mechanical neck disorders. Cochrane Database of Systematic Reviews 2004, Issue 1. Art. No: CD004249.DOI: 10.1002/14651858.CD004249.pub2.

10. Hurwitz EL, Morgenstern H, Vassilaki M, et al. Frequency and clinical prediction of adverse reactions to chiropractic care in the UCLA neck pain study. Spine 2005;30(13):1477-84.

11. Malone DG, Baldwin NG, Tomecek FJ, et al. Complications of cervical spine manipulation therapy: 5-year retrospective study in a single-group practice. Neurosurg Focus 2002;13(6):1-7.

12. Korthals-de Bos, Ingeborg BC, Hoving Jan L, et al. Cost effectiveness of physiotherapy, manual therapy, and general practitioner care for neck pain: economic evaluation alongside a randomised controlled trial. Br Med J April 26, 2003.

13. Homola S. Chiropractic: history and overview of theories and methods. Clin Orthop Relat Res 2006; Number 444:236-42.

14. Homola S. Can chiropractors and evidence-based manual therapists work together? An opinion from a veteran chiropractor. J Man Manipulative Ther 2006;14(2):E14-E18.

15. Christensen MG, Kollasch MW, Ward R, et al. Job Analysis of Chiropractic. Greeley, CO; National Board of Chiropractic Examiners; 2005.

16. Homola S. Is the chiropractic subluxation theory a threat to public health?@ The Scientific Review of Alternative Medicine 2001;3(1):45-53.

17. Homola S. Finding a Good Chiropractor. Arch Fam Med 1998;7(Jan/Feb):20-3.

18. Di Fabio RP. Manipulation of the cervical spine: Risks and Benefits. Phys Ther 1999;79:50-75.

Note: Portions of this article have been published in The Scientific Review of Alternative Medicine (Vol. 2, 2007, published in 2009) and Skeptical Inquirer (Vol. 33, No. 4, 2009).

Posted in: Chiropractic

Leave a Comment (125) ↓

125 thoughts on “Neck Manipulation: Risk vs. Benefit

  1. halincoh says:

    Very well done Sam.

    I am an internist. I am a pediatrician as well. I am also a D.O., but I did my residency an a NJ affiliate hospital of New York’s Columbia’s College of Physicians and Surgeons. I am a hybrid two times over. From time to time I will use manual medicine in my practice. I view it as immediate type of physical therapy. I claim no hocus pocus. I never bought into the fringe elements of osteopathic manipulation but I like being able to use my hands as well as my stethescope. I only use myofacial or muscle energy techniques and I use them only as an adjunct to treating myofascial pain. Some days I never use it. Some days I use it on a couple of patients. I consider it when patients ask me for it, but only if I think it is reasonable.

    I have never, ever used cervical, low amplitude , high velocity manipulation. Why? Because I read the literature.

    Thank you so much for presenting this so clearly and thank you also for presenting the chiropractic paradigm. It was enlightening.

  2. Joe says:

    I appreciated this article; but I have some questions.

    You write “Manipulation of the upper cervical spine should be reserved for carefully selected musculoskeletal problems that do not respond to such simple measures as time, massage, exercise, mobilization, longitudinal traction, or over-the-counter medication.” Is there reliable evidence that manipulation is effective after all those alternatives have been tried? Is there evidence that chiros follow that dictum? Also, “manipulation” is too vague- there are videos on YouTube where the chiro seems to be straining to cause bi-lateral VAD (chiropractic’s gift to humanity). I don’t think there is any evidence that the violent procedure does anything that safer procedures (which I acknowledge you advocate) don’t do. One must go with the common denominator- any chiro is likely to cause a stroke that is not balanced by a potential benefit.

    Your reference #1, a RAND publication, is not peer-reviewed- do we have any evidence that medical experts agree with the notion that 11.1% of chiro neck manipulation (whatever “manipulation” means) is legitimate? More particularly, I am given to understand that most chiro customers get a neck-snap; what number of them fall under that 11% rule? In other words, if 2 in 100,000 snaps cause strokes, and 99,999 thousand snaps are not therapeutically justified- that’s a lot of risk for no benefit.

    That is what I think is missing in your article- evidence of benefit; especially justifying the risk.

  3. Diane Jacobs says:

    I would like to thank the author for this blogpost. People here may or may not be aware of this petition against neck manip, started in Australia by someone who incurred VAD, but I think it belongs attached here in this thread. It’s been on the internet for years. I’ve had it bookmarked since 2004, and occasionally check in to see how many signatories there are.

    One of the interesting things I learned in corresponding with its author is that neck manip is commonly done by barbers in many countries all round the western Asian rim. The petition expressly mentions barbers and chiropractors, asks for legislation to require warning signs be placed in waiting areas.

    The petition has attracted its fair share of trolls, but also comments from many genuine-seeming people who claim to have had neck injuries or strokes, or who know someone who died after a neck manip, etc.

    Diane Jacobs

  4. Sam Homola says:

    Most conditions treated with spinal manipulation are self limiting. And while such treatment may provide symptomatic relief in some cases, I do not know of any evidence that upper neck manipulation is an absolutely necessary treatment for any condition.

    Leaving open the possibility that there might be cases in which risky neck manipulation might be necessary and more effective than safer neck mobilization, I always advise that care be taken not to exceed certain limits and that the treatment be subjected to approval by appropriate medical specialists.

    When chiropractors use neck manipulation to “restore and maintain health” by adjusting “subluxations,” I would consider the treatment to be 100% unnecessary. It has been my observation that few chiropractors limit their treatment to the musculoskeletal-related neck problems that fall into RAND’s 11.1% group as being appropriate. The consensus expressed by medical researchers at this time seems to be that there are no conditions for which upper neck manipulation can be used to provide more benefit than risk. The RAND report was careful to note that “additional scientific data about the efficacy of cervical spine manipulation are needed.”

    So far, this data as not been provided. For this reason, I usually advise against submitting to neck manipulation. When the common denominator for neck manipulation is a “subluxation complex,” the slim risk of stroke far outweighs any benefit.

  5. nwtk2007 says:

    Harriett, you are baiting with a paper with nothing but absolute, total anectotal “evidence” which has been dismissed over and over again.

    I thought you were above that.

    Get real.

    I have seen one and only one case where the stroke actually happened on the table after cervical manipulation, and that is unsubstantiated.

    In the last few years there have been no “new” cases.

    Get over this. You are obsessing and biased in your need to denigrate chiropractic. Why not correct the 500 deaths everyday due to medical errors and the 40% or so mis-diagnosed (by MD’s) strokes in progress instead of trying to save the world from the “risk” of something that is essentially harmless but biting into the medical profession’s pocketbook.

    Why don’t you go into politics. They do the same sorts of things. You really don’t realize the power of the printed word and the abuse that can be reeked with it. People see things in print and think they are true, else it would not be in print.

    Get it? You abuse your “blog post” responsibility here.

  6. Harriet Hall says:

    I am intrigued. When I wrote about this subject last year http://www.sciencebasedmedicine.org/?p=94 I got 324 comments including many attacks by chiropractors who said I didn’t know what I was talking about. So far Sam’s article has generated only 3 comments and they are all favorable.

  7. nwtk2007 says:

    You deleted one; the one where I accused you of baiting by printing this article by Mr Homola and which pointed out that except for one single instance, all of these chiro caused accounts of stroke are anectodal and unwitnessed, which compares highly favorably with the 40% “mis-daignosed by MD’s” strokes in progress.

    We also know that the onset of the stroke brings the patient to the doctor, both MD and DC who then, equally, both MD and DC, fail to recognize a stroke in progress.

    Has there even been one “anecdotal” account of such a chiro caused stroke in the last couple of years?

  8. Joe says:

    Harriet Hall on 30 Aug 2009 at 1:13 pm “I am intrigued. When I wrote about this subject last year http://www.sciencebasedmedicine.org/?p=94 I got 324 comments including many attacks by chiropractors …”

    I noticed the same thing. You may be in a unique position as someone who thinks chiros can salvage their business (I am not so favorably disposed); yet, you have a talent for, how can I put it politely(?), annoy the urine out of them. There, I didn’t (impolitely) write “piss” rather than urine.

    And I appreciated S. Homola’s response. Thanks.

  9. Joe says:

    Apparently I have a comment awaiting moderation, and nwtk had some in limbo when I submitted mine.

    nwtk2007 on 29 Aug 2009 at 10:59 pm “I have seen one and only one case where the stroke actually happened on the table after cervical manipulation …”

    First, if you studied and understood anatomy and physiology you would know the stroke does not have to be immediate. Second, your anecdote is useless. Third, the neck-snap has no proven benefit beyond safer procedures. Aside from that, Mrs. Lincoln, how did you like the play … ?

    nwtk2007 on 30 Aug 2009 at 3:18 pm “We also know that the onset of the stroke brings the patient to the doctor …” Or chiropractor.

    So, why do you snap the necks of people with symptoms of an impending stroke? Doctors stopped bleeding people when it was clear there was no benefit, and it killed people.

  10. Harriet Hall says:

    Unreal! Sam Homola, a fellow chiropractor, writes an article and instead of responding to him, nwtk2007 attacks ME!

  11. Harriet Hall says:

    A clarification: nwtk2007′s first comment was not visible when I posted my first comment. I did not delete it. Sometimes comments get held up for “approval” by an editor, which is essentially automatic.

  12. OZDigger says:

    An interesting article Sam. However, it is another example of cherry-picking the references to suit your argument, without looking at the whole picture.

    Please provide me with the reference for the following statement, (including, cost benefit analysis of the use of NSAIDS and dangers of Vioxx).

    “Manipulation of the upper cervical spine should be reserved for carefully selected musculoskeletal problems that do not respond to such simple measures as time, massage, exercise, mobilization, longitudinal traction, or over-the-counter medication”.
    Also, please provide me with the references to justify those treatment regimes you advocate (above).

    I have read many books on Spinal Manual Therapy, written by Osteopaths (Stoddard), Physiotherapists (Grieve and MacKenzie) and medical practitioners (Fisk). I have watched medical manipulation under anesthetic by Orthopaedic Surgeons. I have seen patients manipulated by Opthalmologists (Frank Gorman) for visual field defects and I have seen physiotherapists manipulate people on sports fields after accidents. For you to claim (unreferenced) that these practitioner groups are better qualified than chiropractors to assess and provide spinal manual therapy, this not only defies logic, but it also puts them in an invidious position of responsibility.
    Professions such as Physiotherapy in Australia have only recently adopted SMT and are doing less hours academically in learning how to “do it” than chiropractors. Yet, you hold their qualifications as greater than the chiropractors. Medical practitioners training in SMT, or in fact neuro-musculo-skeletal medicine is known to be less than chiropractors. To have patients assessed by less qualified practitioners, than the one providing the treatment, is obtuse.

    I am pleased you quoted Prof. Allan Terrett of Australia. His book “Current Concepts in Vertibrobasilar Insufficiency”, is very good and is matched by Dr. Randy Becks book “Functional Neurology for Practitioners of Manual Therapy”. What you failed to mention, is the rate of reporting of VBI’s to chiropractors that really were attributed to other practitioner groups. This is a good study in itself.

    Poor referencing seems endemic with anti-chiropractic literature, see the New Zealand Medical Journal, August 21, 2009.

    From an bio-ethical point of view your article is poorly referenced and lacks credibility as it does not look at the whole picture of SMT, how it is done and who provides it.

  13. Harriet Hall says:

    OZDigger,

    I think you mis-read what Sam Homola wrote. He did not claim that other providers are as skilled as chiropractors in performing SMT, but that chiropractors are more likely to use it inappropriately. And nowhere does he discuss cost benefit analysis or advocate the use of NSAIDS or Vioxx.

  14. nobs says:

    OZ—”An interesting article Sam. However, it is another example of cherry-picking the references to suit your argument, without looking at the whole ”

    YES OZ- Dr. Homola’s Article is old, outdated, misleading, and most assuredly “cherry-picked”. Most of it has been debunked via replies to Harriret’s editorials.

    However, aside from that, I also find the SBM site to curiously cherry-pick…….Very Curious indeed.

    HMMMMM……..Without comment, I submit the following, also authored by Dr. Homola:

    Secrets of Naturally Youthful Health and Vitality by Homola Samuel

    Celebrity Body Book: A Body-improvement Guide for Men and Women by Peter Lupus and Samuel Homola (Hardcover – April 1980)

    Guide to Radiant Health and Beauty: Mission Possible for Women by Peter Lupus and Samuel Homola

    Doctor Homola’s Life Extender Health Guide: Secrets That Help You Live Longer by Samuel Homola

    Dr. Homola’s Macro-Nutrient Diet for Quick Permanent Weight Loss by Samuel Homola

    Doctor Homola’s Natural Health Remedies by Samuel Homola

    Doctor Homola’s Fat Disintegrator Diet by Samuel Homola

  15. OZDigger says:

    Hi Harriett
    OTC’s include NSAIDS and well as Asprin and Paracetemol. The inherent dangers of these medications should have been discussed by Sam. As he did say….

    “measures as time, massage, exercise, mobilization, longitudinal traction, or over-the-counter medication”.

    Sam seems to believe that the only form of treatment that Chiropractors use is manipulation and others use mobilization. Reviewing the other practitioners I have mentioned will show that these practitioner groups do use high velocity and rotatory manipulation (I challenge Sam to read the books and look at the videos and tell me he can tell the difference) and there are just the same dangers as this.

    Please do not belabor the point of inappropriate use of therapy by chiropractors. You are on very dangerous ground on this topic in the light of recent complications from the inappropriate use of medications. I am sure you can think of several examples.

    Perhaps Sam or you could reference …”that chiropractors are more likely to use it inappropriately”.

  16. Harriet Hall says:

    To all of you supporters of chiropractic: this is a science-based medicine website. You are quick to criticize and to change the subject but have not provided any convincing scientific evidence for your claims. This systematic review of systematic reviews concludes that “we have found no convincing evidence from systematic reviews to suggest that SM is a recommendable treatment option for any medical condition. In several areas, where there is a paucity of primary data, more rigorous clinical trials could advance our knowledge.”
    http://jrsm.rsmjournals.com/cgi/content/full/99/4/192

    We are not biased against chiropractors; we are biased against treatments that are not based on credible evidence. Where is your evidence?

  17. Sam Homola says:

    When it comes to offering advice to those who trust me and want answers to questions about health problems, I must admit that I am biased. In matters so important, I first read representative literature and then draw my own conclusions about whether I think a theory or treatment method is plausible or not; then I look for the most credible studies I can find to support what I think is a sensible, rational view—in concert with my own opinion based on 43 years of experience as a practicing chiropractor. I must admit that I discount most of the hundreds of poorly-done studies written by chiropractors and published in journals that are peer-reviewed by chiropractors. I feel compelled to trust my own judgment in drawing conclusions based on what I have learned, always depending upon science and reason for guidance. When I make an unreferenced statement, you may assume that I am offering my opinion.

    More than 90% of manipulation in the United States is done by chiropractors, the majority of whom base use of their treatment on the questionable chiropractic vertebral subluxation theory. It’s not unreasonable to assume that manipulation is more likely to be used inappropriately by chiropractors than by other practitioners who use manual therapy. According to McDonald, et al, (How Chiropractors Think and Practice, Ohio Northern University, 2003), 81.1% of 687 chiropractors who responded to a random survey thought that the term “vertebral subluxation complex” should be retained by the chiropractic profession and that vertebral subluxation is a significant contributing factor in 62% of visceral ailments. The majority (89.8%) thought that the a spinal adjustment should not be limited to musculoskeletal conditions.

    Obviously, a “chiropractic adjustment” based on the vertebral subluxation theory is not the same as generic spinal manipulation. Use of spinal manipulation by chiropractors as a primary treatment method is more problematic than use of such treatment among other practitioners who include of spinal manipulation in their treatment armamentarium. This is not say that there are not some good chiropractors. When I find a chiropractor whom I feel is science based and properly limited, I offer him or her my support.

  18. OZDigger says:

    Hello Harriett

    I have not made any claims. I have asked for references (peer review journals are good, David Colquhoun should know) for some of the comments Sam has made.
    Nor do I believe I have changed the subject. However, as the old saying goes, “What is good for the goose, is good for the gander”. So you are as obliged to
    1). Not change the topic.
    2). Reference the articles properly.
    3). Be credible, plausible and reliable.
    4). Be ethical in your comments.
    5). Be scientific and if you are going to quote references and authors, please quote those who are credible, plausible and reliable and not authors who, in peer reviewed journals, have already been eviscerated. Please do not use propaganda.

    “we are biased against treatments that are not based on credible evidence”.

    Is the quote of the century. It will come back to haunt you as you do not and have never followed that dictum.

  19. Sam Homola says:

    When it comes to offering advice to those who trust me and want answers to questions about health problems, I must admit that I am biased. In matters so important, I first read representative literature and then draw my own conclusions about whether I think a theory or treatment method is plausible or not; then I look for the most credible studies I can find to support what I think is a sensible, rational view—in concert with my own opinion based on 43 years of experience as a practicing chiropractor. I must admit that I discount most of the hundreds of poorly-done studies written by chiropractors and published in journals that are peer-reviewed by chiropractors. I feel compelled to trust my own judgment in drawing conclusions based on what I have learned, always depending upon science and reason for guidance. When I make an unreferenced statement, you may assume that I am offering my opinion.

    More than 90% of manipulation in the United States is done by chiropractors, the majority of whom base their treatment on the questionable chiropractic vertebral subluxation theory. It’s not unreasonable to assume that manipulation is more likely to be used inappropriately by chiropractors than by other practitioners who use manual therapy. According to McDonald, et al, (How Chiropractors Think and Practice, Ohio Northern University, 2003), 81.1% of 687 chiropractors who responded to a random survey thought that the term “vertebral subluxation complex” should be retained by the chiropractic profession and that vertebral subluxation is a significant contributing factor in 62% of visceral ailments. The majority (89.8%) thought that the a spinal adjustment should not be limited to musculoskeletal conditions.

    Obviously, “chiropractic adjustment” of a selected vertebra based on the vertebral subluxation theory is not the same as generic spinal manipulation designed to improve mobility. Use of spinal manipulation by chiropractors as a primary treatment method is more problematic than use of such treatment among other practitioners who include of spinal manipulation in their treatment armamentarium. This is not say that there are not some good chiropractors. When I find a chiropractor whom I feel is science based and properly limited, I offer him or her my support.

  20. Sam Homola says:

    Between publication of my book “Bonesetting, Chiropractic, and Cultism ( published in 1963) and my book “Inside Chiropractic” (published in 1999), I wrote many books on how to improve general health, none of which promoted the chiropractic subluxation theory.

  21. Harriet Hall says:

    OZDigger,

    You accused Sam of cherry-picking the literature. It seems to me you should defend that accusation by showing us what a non-cherry-picked review of the literature says. I thought Prof. Ernst’s systematic review of systematic reviews pretty much avoided the cherrry-picking problem.

  22. nobs says:

    Harriet- I must disagree(based on my observartions on this site, and upon your editorials in particular), that there is indeed a bias “against chiropractors”.

    You opine: “this is a science-based medicine website” and “Where is your evidence?” I have personally provided you with solid, indexed, evidence refuting many of your “boiled down” conclusions/opinions. You choose to ignore, dismiss, obfuscate, and even assume personal affronts when presented with evidence that refutes your bias.

    At any rate, You opine above: -”Where is your evidence?”

    I present the following academic, science-based, evidence-based, refutation of your cited hallowed reference:

    -Review conclusions by Ernst and Canter regarding spinal manipulation refuted-

    “In the April 2006 issue of the Journal of Royal Society of Medicine, Ernst and Canter

    authored a review of the most recent systematic reviews on the effectiveness of spinal

    manipulation for any condition. The authors concluded that, except for back pain, spinal

    manipulation is not an effective intervention for any condition and, because of potential

    side effects, cannot be recommended for use at all in clinical practice. Based on a

    critical appraisal of their review, the authors of this commentary seriously challenge the

    conclusions by Ernst and Canter, who did not adhere to standard systematic review

    methodology, thus threatening the validity of their conclusions. There was no systematic

    assessment of the literature pertaining to the hazards of manipulation, including

    comparison to other therapies. Hence, their claim that the risks of manipulation outweigh

    the benefits, and thus spinal manipulation cannot be recommended as treatment for any

    condition, was not supported by the data analyzed. Their conclusions are misleading and not

    based on evidence that allow discrediting of a large body of professionals using spinal

    manipulation.
    ………..
    The conclusions by Ernst and Canter were definitely not based on an acceptable quality

    review of systematic reviews and should be interpreted very critically by the scientific

    community, clinicians, patients, and health policy makers. Their conclusions are certainly

    not valid enough to discredit the large body of professionals utilizing spinal

    manipulation.”

    The entire paper can be read here:

    http://www.chiroandosteo.com/content/14/1/14

  23. weing says:

    The authors declare that they have no competing interests. The fact that several of them are affiliated with chiropractic institutions and may in fact be chiropractors makes that claim incredible and intellectually dishonest. Therefore, any conclusion reached by them is tainted.

  24. Harriet Hall says:

    The “evidence” you now offer is not a study and does not offer any evidence. It is an opinion clearly labelled in the journal as “commentary.” It looks to me like sour grapes and damage control from true believers. Chiropractors don’t like what Ernst found. They have not offered their own systematic review of systematic reviews.
    These other articles (by chiropractors) also criticized Ernst’s revew: http://jrsm.rsmjournals.com/cgi/content/full/99/6/277-a and http://jrsm.rsmjournals.com/cgi/content/full/99/6/278

    The authors replied at http://jrsm.rsmjournals.com/cgi/content/full/99/6/279.

    I haven’t seen any criticism of his methods from anyone in the mainstream scientific medicine community.

    Ernst is a highly respected academic – a professor of complementary medicine who started out believing in many alternative treatments and trying to evaluate the evidence behind them: he changed his mind about numerous treatments based on the evidence (or lack thereof). He has critiqued acupuncture, homeopathy and other alternative methods using the same standards. I think his work is credible, and most of the science-based community agrees with me. Chiropractors, homeopaths, and acupuncturists disagree – but what else could they do? They have to defend their livelihood any way they can.

    At least Ernst has a track record of following the evidence and changing his mind. In fact, his earlier writings were more favorable towards chiropractic. In his book wth Simon Singh, Trick or Treatment, he only discourages visiting chiropractors who employ quackery or who claim to treat non-musculoskeletal conditions. He gives advice for patients who are seeing chiropractors for back problems. It seems to me that Ernst is solidly grounded in science-based medicine – something that can only be said about a tiny minority of chiropractors. I support those chiropractors.

  25. nobs says:

    Harriet replies: “I haven’t seen any criticism of his methods from anyone in the mainstream scientific medicine community.”

    Really? “mainstream scientific medicine community”? Exactly what does that mean?

    Mainstream scientic medicine community- as in?:
    Chalmers Research Group, Evidence-based Practice Center,
    Departments of Pediatrics, Epidemiology and Community Medicine,
    University of Ottawa, 401 Smyth, Ottawa ON, K1H8L1, Canada
    or
    Institute for Research in Extramural Medicine, Vrije Universiteit Medical Centre, The Netherlands
    or
    Texas Back Institute, 6300 W. Parker Road, Plano Texas 75093, USA
    or
    Department of General Practice and Nursing Home Medicine, LUMC Medical Centre, Leiden, The Netherlands

  26. Joe says:

    Ernst has a blog (free registration required) and one post is titled Quackbuster or critical analyst? http://www.pulsetoday.co.uk/story.asp?sectioncode=20&storycode=4123323&c=1 For some reason, comments were “off” on that thread; but on his subsequent post I cited some examples where I thought he was overgenerous. The point is, he is not out to do a hatchet job on CAM (in general) or chiro (in particular). Like Harriet says about the SBM bloggers, Ernst just follows the data.

  27. weing says:

    I have patients that go to chiropractors for lower back pain, others prefer physical therapy. I really haven’t seen any difference, but I consider my experience just anecdotal.

  28. Harriet Hall says:

    nobs answers with quibbles about one sentence I wrote and ignores all the rest. The list nobs cites is from the opinion piece he cited. There are several chiropractors on the list and the piece was published in a chiropractic journal. I haven’t seen any criticism of Ernst’s article in mainstream medical journals.

  29. OZDigger says:

    Writing in the BMJ in 1999, Dr Gordon Waddell, a leading UK orthopaedic surgeon and back pain authority, described Ernst as offering “inter-professional confrontation under the guise of scientific objectivity.”
    Waddell G. Chiropractic for low back pain. Evidence for manipulation is stronger than that for most orthodox medical treatments [Letter to Editor]. Br Med J. 1999;318:262.

    Harriett, for you to rely upon Edzard Ernst as a reference, is grasping at straws. Here is just one example of how he is considered, published in a “mainstream medical journal”. Gordon Waddell’s book on low back pain is, in my opinion, one of the best ever written. “The Back Pain Revolution” is valid, non-confrontational and easy to read. You you read it someday, for a real understanding of how much is known (or not) about low back pain. More importantly, it exposes why the medical model of low back pain is flawed, inappropriate and outdated.

  30. Harriet Hall says:

    I previously told OZDigger “You accused Sam of cherry-picking the literature. It seems to me you should defend that accusation by showing us what a non-cherry-picked review of the literature says.”

    Instead, he offers ad hominems against Edzard Ernst in the form of a letter to the editor (!) of the BMJ expressing one man’s opinion and he reccommends the same man’s book which in OZDigger’s opinion is one of the best ever written.

    I have not read that book, but the reviews indicate it recommends an interdisciplinary biopsychosocial approach to back pain, not a chiropractic or a manipulative approach.

    At any rate, the reputations of Waddell and Ernst are really beside the point. The question is whether manipulation is effective and safe. Both Homola and Ernst have shown evidence that it is only mildly effective for back pain and not for other indications, and is associated with risks. If their evidence is wrong, please show us why – don’t just offer opinions.

  31. OZDigger says:

    Hi Harriett

    Please reread my post. Your reply is nonsense and a mis-interpretation of what I wrote.
    Homola and Ernst are not authorities on back pain. Waddell is!!! As pointed out to you in previous post, there is quite a bit of literature out there that eviscerates both these authors.
    Just look at the Meade study published in the British Medical Journal, as well as the results from the multi-disciplinary Bone and Joint Decade recommendations for the treatment of Neck Pain. The NICE study in the U.K. also is a good advocate for chiropractic care to be covered by the U.K. National Health Service.
    Waddells book is worth the read, yes it does recommend biopsychosocial approaches to LBP. That is good, isn’t it?
    These citations have been recommended tok you in the past. You should take the time to read them.

  32. Harriet Hall says:

    NICE is not as credible as rigorous systematic reviews. Its recommendations are questionable. See http://www.dcscience.net/?p=1516

    Ernst’s article specifically commented on such guidance recommendations, suggesting that they should be amended to reflect the actual state of the evidence.

    Weren’t the Meade study and other studies included in the systematic reviews that Ernst systematically reviewed? Isn’t a review of ALL the published evidence more meaningful than citing isolated studies that support your beliefs?

    Biopsychosocial approaches are indeed good. But a book recommending them is not evidence that Sam cherry-picked the literature about the benefits and risks of manipulation. It seems to me that you are doing some cherry-picking of your own, citing references that support manipulation.

    Waddell is an authority? Are you recommending that we accept the opinion of authorities rather than examining the evidence?

  33. pmoran says:

    Ozdigger, why would we read a book when we all have direct access to the scientific literature on the matters under dispute? I believe even I have seen most of the studies relevant to the effectiveness of neck manipulation and its relationship to stroke. If you have important material that you think we may have missed tell us what it is.

    And for your information, since you seem not to have read that paper yourself, the Bone and Joint decade is very muted in its endorsemant of manual therapies of neck pain, regarding them as about equal to five or six non-manipulative approaches including laser therapy and massage. These others possibly perform only marginally better than placebo, if at all, when you take into account the difficiltues in blinding studies of such interventions.

    That publication also blithely dismisses the question of stroke by reference to a single study which did not even directly establish which patients had their necks manipulated and which did not. It also ignored many simple observations that make it extremely unlikely that specific strokes preceded manipulation.

  34. OZDigger says:

    It is a nonsense to quote the blogsite by David Colquhoun dcscience etc. For an idea of the poor quality of his referencing and writing, please look at the most recent edition of the New Zealand Medical Journal. Your quest for science and peer reviewed literature, though commendable, is let down by the people you hold as sacrosanct

  35. Harriet Hall says:

    OZDigger,

    Who says I hold anyone sacrosanct? You just don’t get it, do you? I am not promoting people as authorities (Isn’t that what you were doing for Waddell?); I am citing their writings when I think they are well-reasoned and based on good science. The NZMJ published an article by Colquhoun that I thought was quite reasonable. In a LETTER TO THE EDITOR, a LAWYER hired by chiropractors complained that it was “defamatory”and threatened a lawsuit. The journal’s editor replied quite reasonably, ending with this statement: “The Journal has a responsibility to deal with all issues and not to steer clear of those issues that are difficult or contentious or carry legal threats. Let the debate continue in the evidence-based tone set by Colquhoun and others. I encourage, as we have done previously, the chiropractors and others to join in, let’s hear your evidence not your legal muscle.”

    Colquhoun was the one who wrote in an evidence-based tone; the chiropractors sicced a lawyer on him instead of offering evidence to contradict what he wrote. Colquhoun comes out of this smelling much better than the chiropractors.

    I will say to you what the editor said, “Let’s hear your evidence.” Enough of ad hominems, generalizations, and opinions!!

  36. OZDigger says:

    Harriett,

    you have obviously not read the most recent edition of the NZMJ, 21 August, 2009. David Colquhoun quoted a fictitious reference. Not only was the data incorrect, it was unverifiable and from a journal that does not exist. It was sloppy and shonky research by Colquhoun. The fact that it was published in the NZMJ (a peer reviewed journal) makes this a serious issue. It renders his argument to be rubbish. It puts the editor in an invidious situation of realizing that he has published something in good faith, that was patently inaccurate and difficult to retract.

  37. pmoran says:

    http://www.nzma.org.nz/journal/121-1278/3158/

    Ozdigger, is this the article you refer to? Which reference purports to be a journal reference but is “fictitious” and contained non-existent and unverifiable data?

  38. pmoran says:

    The Eidtor’s response can be found here:

    http://www.dcscience.net/ff%20nzmj%20ed%20lawyers%20CAMt.pdf

    In it he states:

    “The Journal has a responsibility to deal with all issues and not to steer clear of those issues that are difficult or contentious or carry legal threats. Let the debate continue in the evidence-based tone set by Colquhoun and others.

    I encourage, as we have done previously, the chiropractors and others to join in, let’s hear your evidence not your legal muscle.”

  39. nobs says:

    Harriet posts:”Weren’t the Meade study and other studies included in the systematic reviews that Ernst systematically reviewed?

    NO HARRIET- The Meade studies were NOT included in Ernst’s flawed review.

    Harriet continues: “Isn’t a review of ALL the published evidence more meaningful than citing isolated studies that support your beliefs?”

    NO HARRIET- Ernst’s review is NOT a review of “ALL the published evidence”. Are you suggesting it is? The authors chose to only summarize reviews published after 2000 without providing a rationale or assessing the impact of this censored, truncated approach. Based on the inclusion and exclusion criteria, the review excluded at least three eligible reviews, and included at least one review not considered systematic. The review did not reference the eight excluded studies to enable readers to verify the judgments made.

    Earlier,Harriet posts:”Where is your evidence?” –I cite scientifically and statisically sound evidence….

    Then Harriet moves the goalpost with: “I haven’t seen any criticism of his methods from anyone in the mainstream scientific medicine community.” Again, I provide cites from(what I can only assume Harriet considers)the “mainstream scientific medicine community.”….

    Then, without answering my request for her definition of “mainstream scientific medicine community”, she moves the goalposts once again with “I haven’t seen any criticism of Ernst’s article in mainstream medical journals.” UMMMM- that is blatently erroneous. There are no less than 5 in jrsm alone. Additionally, ‘Chiropractic and Osteopathy’(my original evidence source) is a peer-reviewed, pubmed-indexed, journal(as opposed to…..umm…let’s say….a blog?)…..

    NOW- I suspect you will most likely move the goalposts again.

  40. Harriet Hall says:

    nobs,
    See http://www.nzma.org.nz/journal/121-1279/3208/content.pdf for the letter from the lawyer and the editor’s response. Neither the lawyer nor the editor mentions anything about a fictitious reference. What are you talking about?

    The people criticizing Ernst and Colquhoun are mainly chiropractors. You cite the BMJ – did you see this from the BMJ’s editor? http://www.bmj.com/cgi/content/full/339/jul08_4/b2783

    But all this quibbling is really beside the point. Instead of moving the goalposts, let’s get back to the original goalposts: is neck manipulation effective and safe?

    Numerous recent reviews by science-based writers have reached similar conclusions: that manipulation is somewhat effective for low back pain but not more effective than other treatments, and that it is not effective for most of the other things chiropractors claim. The evidence for the effectiveness of neck manipulation is much shakier than the evidence for low back pain. All studies of manipulation are hampered by the impossibility of doing a double blind study, so the contribution of a placebo response may be significant. And almost everyone, even chiropractors, agrees that there is a small risk of stroke with neck manipulation: the only disagreement is whether that risk is significant and whether neck manipulation can still be justified.

    You (or was it OZDigger?) accused Sam Homola of cherry-picking. If you think you there is convincing evidence that he and all those other writers missed, please present it.

    I doubt if you will be any more successful than the recent attempt of the BCA to refute Simon Singh. They presented their best evidence: 18 studies that were promptly demolished. See http://jackofkent.blogspot.com/2009/07/bmj-plethora-has-been-demolished.html and click on the link to the BMJ editorial itself.

  41. nobs says:

    Harriet posts to me:
    “nobs,
    See http://www.nzma.org.nz/journal/121-1279/3208/content.pdf for the letter from the lawyer and the editor’s response. Neither the lawyer nor the editor mentions anything about a fictitious reference. What are you talking about?The people criticizing Ernst and Colquhoun are mainly chiropractors. You cite the BMJ – did you see this from the BMJ’s editor?http://www.bmj.com/cgi/content/full/339/jul08_4/b2783

    ????What???? My posts have nothing to do with the above that you appear to want credit to me.

    HH- “But all this quibbling is really beside the point. Instead of moving the goalposts, let’s get back to the original goalposts: is neck manipulation effective and safe?”

    May I remind you that it was YOU that chose to use Ersnt’s paper in this thread, and susequently made assertions based on this flawed paper.

    HH-” All studies of manipulation are hampered by the impossibility of doing a double blind study, …….”

    Impossibility???? Really??? It may be more difficult, but certainly not impossible. An interesting study here:

    http://www.archives-pmr.org/article/S0003-9993(08)01628-6/abstract

    A True Blind for Subjects Who Receive Spinal Manipulation Therapy

    Gregory N. Kawchuk, DC, PhDa, Rick Haugen, MD, FRCPCb, Julie Fritz, PhD, PT, ATCc

    Objective
    To determine if short-duration anesthesia (propofol and remifentanil) can blind subjects to the provision or withholding of spinal manipulative therapy (SMT).

    HH:”…..so the contribution of a placebo response may be significant.

    That is a dismissive assumption.

    HH-”You accused Sam Homola of cherry-picking. If you think you there is convincing evidence that he and all those other writers missed, please present it.”

    Perhaps you need to review my posts above citing and including evidence from the “mainstream scientific medicine community”, Which BTW, you continue to ignore my request from you as to what you mean by that.

    HH: “I doubt if you will be any more successful than the recent attempt of the BCA to refute Simon Singh. They presented their best evidence: 18 studies that were promptly demolished. See http://jackofkent.blogspot.com/2009/07/bmj-plethora-has-been-
    demolished.html and click on the link to the BMJ editorial itself.”

    And this has what to do with your opine of “let’s get back to the original goalposts”?

    HMMMMM- ??? Looks like the “original goalposts” are moving again.

  42. Harriet Hall says:

    Sorry, that was OZDigger who claimed Ernst used a false citation. I get the two of you confused. Where is OZDigger, by the way – did he give up?

    The link you provided is to a method for single-blinding. Double blinding is impossible, since the provider always knows what he is doing.

    Back to the original goal posts: what evidence can you offer to show that Sam Homola’s article is inaccurate?

  43. nwtk2007 says:

    Harriet,

    I wouldn’t argue with you that the evidence for the efficacy of CMT is weak (not non-existent) and that there is the inherent difficulty with providing a placebo treatment which then precludes a true double blinded study.

    But I would ask if there are any true, non-anecdotal examples of CMT causing stroke outside of one that I know of, where a patient had a stroke on the table, which even then could be questionable if the patient were in the process of having the stroke in the first place.

    If a patient goes to the hospital or other provider and is diagnosed as having or having had a stroke and any mention of chiropractic is in the patient’s history, then the provider will conclude that the stroke was caused by the chiropractor.

    The fact of the stroke is an objective finding but the link with the history is opinion and thus purely anecdotal. And with some saying that the stroke could occur as much as three weeks post CMT (there is no possible way that could be known or proven) then I am surprized it doesn’t get reported as occuring much more ofter.

    I know that some chiropractors and their organizations believe there is a risk but they could be wrong also.

    Both sides of this argument cherry pick the research and fail to present both sides with the same zeal and gusto. And lets face it, the anti-chiro zeal is significant. I wonder at that in light of the incredible number of people harmed by medical mistakes and errors, literally thousands every year.

    Why have the reports of strokes caused by CMT deminished over the last few years? Why aren’t there more people coming forward with their stories of their stroke being caused by CMT now that it is such a publicized issue? I don’t think there are fewer people going to the chiropractor.

  44. Harriet Hall says:

    “Why have the reports of strokes caused by CMT deminished over the last few years?”

    I’m not aware that they have. Do you have a reference?

    There are plenty of smoking gun cases documented by the Chiropractic Stroke Awareness group, Victims of Chiropractic Abuse and others. What’s the Harm website http://www.whatstheharm.net/chiropractic.html has an impressive list. And of course there’s Sandra Nette, whose class action lawsuit has been joined by people who would not otherwise have come forward to complain.

    I agree that definite proof is unlikely and that it is difficult to put a number on the risk, but the circumstantial evidence is impressive, the proposed mechanism makes sense, and it is perverse to pretend there is nothing to worry about, especially since the evidence for benefit from neck manipulation is so weak.

  45. OZDigger says:

    I am here!!!!
    This is the NZMJ reference,
    http://www.nzmj.com/journal/122-1301/3756/
    Is this reference correct?
    Frank Frizelle

    “I (the author) have attached all my personal communications with Colquhoun. They demonstrate this is not a citation error. Prof Colquhoun believes the origin of the quote doesn’t matter because Long was quoting from a Canadian Neurologists’ report (this is also incorrect). As you can see he fails to provide any evidence at all to support the existance of the “J Quality Health Care.” This would not be an issue at all if he had admitted it came from a blog site—but I guess the link would have eroded the credibility of the quote.
    Colquhoun ‘s belief that my forwarding this complaint is me “resorting to threats” is the final nail in the coffin. If he had any leg to stand on where is the threat?
    This may seem pedantic but it surely reflects a serious ethical breach. Is it acceptable to make up a reference to try and slip any unsupported statement into a “scientific” argument and thereby give it some degree of credibility? ”

    This is just some of the article. Colquhoun used a false reference, then a blogsite, using incorrect evidence to validate a spurous argument. It put the editor of the NZMJ in a difficult position considering the “legal muscle”, comment.

    Basically Harriett, your comments about chiropractic and strokes have been extensively eviscerated, you are inconsistent and bio ethically unsafe in your argument.

  46. pmoran says:

    I can’t open the Ozdigger link. If Colquhoun has misrepresented Long it still does not make a lot of primary evidence regarding the neck manipulation/stroke link go away.

    When a patient presents with unrelated symptoms and has a stroke immediately after neck manipulation, and is shown to have bilateral vertebral artery dissections on imaging, only chiropractors with a large investment to protect could possibly cling to the miniscule odds that it is all a terrible coincidence.

    And this kind of case is just some of the evidence.

  47. Harriet Hall says:

    Back to the original goal posts: what evidence can you offer to show that Sam Homola’s article is inaccurate?

  48. Blue Wode says:

    OZDigger wrote on 31 Aug 2009 at 7:38 pm: “Homola and Ernst are not authorities on back pain. Waddell is!!! As pointed out to you in previous post, there is quite a bit of literature out there that eviscerates both these authors. Just look at the Meade study published in the British Medical Journal…”

    Yes, just look at it:
    http://www.dcscience.net/?p=1718

  49. OZDigger says:

    Harriett, if you need answers to this statement, you obviously have not bothered to read or comprehend anything that has been written. Next topic, please.

  50. nwtk2007 says:

    pmoran,

    If the stroke is already in progress, then the “miniscule odds” comment is a non-sequetor. If the stroke is as much as a few days to two or three weeks after the alleged causative CMT, then there is really no concrete link between the two and any number of factors could be involved. And usually the patients are getting treatment for neck pain and in many cases for associated headaches, which, as previously pointed out, are just as often not diagnosed by all doctors, MD and DC alike.

    The bilateral nature of the arterial tear is also not a link to manipulation. For one thing, on full rotation one of the vertebral arteries is pinched, the other is only mildly stretched, if that. With two different things occuring on the bilateral sides, how could the tears be linked. (Two different mechanisms producing the same tear at the same time?) More than likely, some other event is the causative action which would place similar stresses on the arteries bilaterally. And even if the manipulation is done bilaterally, then there truely are miniscule odds of a similar tear occuring on bilateral sides in consecutive order. In other words, a tear on the right side followed immediately by a tear on the left? I think not.

    How is Mr Homola’s article inacurate? It is based upon records of strokes alleged to be caused by CMT, virtually none of which were witnessed to have actually happened at the point of CMT application. The entire idea could very well be a sham, perpetrated aven by the chiropractic community upon itself in their effort to appear to be working to help stop these alleged events.

  51. pmoran says:

    “If the stroke is already in progress, then the “miniscule odds” comment is a non-sequetor.”

    It’s weird that you don’t seem to get the point.

    In many (agreed not all) there is no reason to suspect that a stroke was in progress before the manipulation — no reason at all. These are often healthy young people who had no neurological symptoms before having their necks manipulated but developed them soon after.

    So there are plenty of reasons to blame the manipulation, including the worrying anatomy, the frequency of the association, and the temporal nature of the association.

    You said “The bilateral nature of the arterial tear is also not a link to manipulation. For one thing, on full rotation one of the vertebral arteries is pinched, the other is only mildly stretched, if that. With two different things occuring on the bilateral sides, how could the tears be linked. ”

    Injury could be through either stretching or pinching. It is also possible that people who get injured in this way have an anatomical predisposition. Human anatomy has numerous minor variations and studying a few subjects cannot answer all questions.

  52. Harriet Hall says:

    “With two different things occuring on the bilateral sides, how could the tears be linked.” Perhaps because the practitioner did bilateral manipulations? He twisted one way and tore one artery, then twisted the other way and tore the other artery.

    And OZDigger, I’m still waiting for convincing evidence that neck manipulation is beneficial.

  53. OZDigger says:

    Hi Harriett

    I would suggest you read all the previous posts on this subject and previous ones you have contributed too. This would save me and anyone else having to repeat themselves ad nauseum.
    Try reading books by Grieve (Physiotherapist), Jull (Physiotherapist), Beck (Chiropractor), Biederman (Prthopaedic Surgeon), Stoddard (Osteopath), Lieberman (Chiropractor), Fisk (Medical Practitioner), Halderman (Chiropractor, medical practitioner and neuro-physiologist), just to name a few. You seem to rely upon the internet for your information, rather than primary sources.
    Next topic please, your past comments have always been profoundly eviscerated by sound, logic peer reviewed literature.

  54. Harriet Hall says:

    OZDigger,

    Books are not primary sources. They are secondary sources and they are not peer reviewed. In scientific literature, a primary source is the original publication of a scientist’s new data, results, and theories.

    I could cite an even larger number of books that conclude that spinal manipulation is next to useless. Systematic reviews of published literature have not shown that neck manipulation is superior to other treatments for any condition, but perhaps they missed all the pertinent studies and perhaps you can direct us to a better quality systematic review based on studies that are larger and better designed and more rigorous than anything previous authors were able to find. I’m waiting, patiently but hopelessly.

    You say my comments have always been profoundly eviscerated by sound, logic peer reviewed literature. I could say the same of your comments, but I’m more polite and am trying to stick to the subject under discussion rather than making vague ad hominem attacks. In fact, I’m even considerate enough to notice how your name is spelled. :-)

  55. nwtk2007 says:

    pmoran – “In many (agreed not all) there is no reason to suspect that a stroke was in progress before the manipulation — no reason at all.”

    If they went to the doctor for headache or neck pain or even just plain feeling bad (or any single symptom of a stroke in progress), there is reason to think the stroke might have been in progress. If they are there for “maintenance”, then you are correct.

    pmoran – “So there are plenty of reasons to blame the manipulation, including the worrying anatomy, the frequency of the association, and the temporal nature of the association.”

    The worrying anatomy is a strong reason AGAINST bilateral tearing as I explained above. Frequency is like 1 in 1 to 5 million. Temporal nature is actually the same thing but if by that you mean the propinquity of the CMT procedure and the stroke occurrence, then that is also questionable if the stroke is in progress (no propinquity at all), or one to three weeks down the road after a CMT procedure.

    pmoran – “Injury could be through either stretching or pinching.”

    The physics of the mechanism (pinching vs stretching) suggests that the odds of both happening at the same time would, itself, be meniscule.

    pmoran – “It is also possible that people who get injured in this way have an anatomical predisposition.

    This could also be true and probably is. The patient might even be vit C deficient and have weak connective tissues. I agree with you here. But I doubt if it would be expressed in a bilateral tear due to the mechanics of the mechanism of the tear.

    pmoran – “Human anatomy has numerous minor variations and studying a few subjects cannot answer all questions.”

    On this I also agree with you. There simply aren’t enough cases with the temporal association to be able to say that CMT causes strokes. Obviously it can’t be eliminated but you can’t study something to show it doesn’t do something. I think I said that right.

  56. nwtk2007 says:

    Harriet – ““With two different things occuring on the bilateral sides, how could the tears be linked.” Perhaps because the practitioner did bilateral manipulations? He twisted one way and tore one artery, then twisted the other way and tore the other artery.”

    It is the consecutive nature of the tears that is the problem with the bilateral CMT procedure. Even if the rotation could cause a tear, the odds would be against a tear occurring on the very next rotation to the opposite side. In other words, it would be against the odds (there would be a low probability) for the two sides to be damaged at the very same time after the exact same number CMT procedures. That would be kind of like two tires blowing out after the exact same number of miles down the road. It ain’t happening.

  57. nwtk2007 says:

    So as I said before, “How is Mr Homola’s article inacurate? It is based upon records of strokes alleged to be caused by CMT, virtually none of which were witnessed to have actually happened at the point of CMT application.”

    And, the mechanism is questionable and not very plausible.

  58. pmoran says:

    NTWK, The fact is that a bilateral injury occurred, so there is no point in arguing that it can’t happen.

    It is becoming clear that chiropractors want the risks of neck manipulation to be proved to a level somewhat beyond very high probability, while asking for the benefits to be accepted on much less, or on no truly scientific evidence whatsoever, should they wish to use neck manipulation for general health purposes and other highly implausible reasons.

    That is just not on. We know that other methods work as well as primary care for neck pain. It is a serious indictmnent of the chiropractic profession that so many of its members seem unable to grasp the need for at least some caution, as Dr Homola is advising.

    It also reverses usual medical custom, which is sensitive to risk when of serious injury and death. Note how the VAERS system for detection of drug adverse effects relies on entirely anecdotal case reports, yet the information received is the subject of advice to doctors.

  59. nwtk2007 says:

    A bilateral injury has occurred yes. I am saying it is highly unlikely that it was caused by CMT.

    And there is no indictment of chiro in my argument. The indictment is of the cultish zeal of the “science based” anti chiro biased movement. I do not see you applying SBM in the same fashion across the board here.

    Why can’t you see that the supposed correlation does not mean causation in this case? You can’t refute the physics and probabilities which I have now enlightened you on. They are the facts. This “cause” by CMT is a fabrication, grossly amplified by the anti-chiro bias of the SBM family.

    You also really can’t be saying that chiropractors throw caution to the wind can you? You would think we all go out and head lock our patients, yanking as hard as we can to get it to “pop”. You really must be kidding.

  60. weing says:

    nwtk2007,
    If I aim a gun at you and pull the trigger and they find a bullet lodged in your chest shortly thereafter, will you agree with my defense that correlation does not equal causation?

  61. nwtk2007 says:

    Weing, your analogy is utterly non-applicable. That would, of course, be a witnessed event. If, however, I went to the hospital the doctors there would in no way be able to offer an opinion as to who did the shooting.

    When a person goes to the hospital two to three weeks or even a few hours after seeing their chiropractor, it cannot be assumed that the cause of the stroke was the CMT.

    If a person goes to the ER having a stroke and hasn’t been to the chiro in the past, then what is the assumption as to the cause? Hair cut? Sports injury? A quick flinch of the head when a car tooted their horn? Drying their hair after a shower? Too thick a pillow? The coffee they had? The cigarette they had? The failure to take their Bp meds for the past week? Their 70 to 80 extra pounds of weight they are carrying? The thud they received when the guy at the gas station bumped into them by accident? The slip and fall to the floor yesterday when the kitchen flood was wet? Etc. Etc.

    Your analogy proves my point about bias opinion overriding SBM thinking.

  62. Joe says:

    nwtk2007 on 02 Sep 2009 at 11:24 am “Weing, your analogy is utterly non-applicable. That would, of course, be a witnessed event. If, however, I went to the hospital the doctors there would in no way be able to offer an opinion as to who did the shooting.

    When a person goes to the hospital two to three weeks or even a few hours after seeing their chiropractor, it cannot be assumed that the cause of the stroke was the CMT.”

    Your “analogy” is tortured. There are many examples of people who left the chiropractor’s office (or did not get far) in an ambulance.

    As for delayed stroke after VAD, I suggest you study anatomy and get back to us.

  63. Harriet Hall says:

    nwtk2007 said “When a person goes to the hospital two to three weeks or even a few hours after seeing their chiropractor, it cannot be assumed that the cause of the stroke was the CMT.”

    No, it can’t. But when a study shows that vertebrobasilar stroke patients under the age of 45 are 5 times as likely as controls to have visited a chiropractor in the previous week, it sure makes you wonder!

    Add that to all the “smoking gun” cases where asymptomatic patients collapsed on the table, and it’s hard to rationalize the evidence away – but I’m sure you will manage to do so.

  64. pmoran says:

    “You also really can’t be saying that chiropractors throw caution to the wind can you? You would think we all go out and head lock our patients, yanking as hard as we can to get it to “pop”. You really must be kidding.”

    Actually I would be very encouraged if chiropractors (and others) would show SOME indications of caution with necks. That is the first objective so far as I am concerned.

    I must have got the wrong impression from the assertions that we are completely misunderstanding a field in which we hold some expertise, even inventing a problem to aid the further persecution of the chiropractic profession.

  65. nwtk2007 says:

    joe – “There are many examples of people who left the chiropractor’s office (or did not get far) in an ambulance.

    As for delayed stroke after VAD, I suggest you study anatomy and get back to us.”

    Where are these examples you speak of. I looked on the websites and don’t see examples such as you describe. More than one, or two? or three? I will review the sites that have examples to see if, indeed, there are many. As to the anatomy, I have given you the short version as to why it is unlikely that CMT would cause bilateral VAD. My guess is Joe, you didn’t read it as you have in the past been guilty of commenting on that which you have not read.

    Harriett – “But when a study shows that vertebrobasilar stroke patients under the age of 45 are 5 times as likely as controls to have visited a chiropractor in the previous week, it sure makes you wonder!”

    I agree that on the surface this sounds compelling, but how do you know that people under the age of 45 who have not had stroke don’t go to the chiro 5 times as often. I personaly think that the younger aged group are 5 times more likely to go to the chiro for headaches and neck pain anyway. Were the control groups assymptomatic or did they also have S/S I described above? A control group of non-symptomatic people is not a good control group for this study.

    In fact, I wold imagine that the total number of patients under 45 who treat in a chiropractors office out number the ones over 45 by at least that amount.

    pmoran – “I must have got the wrong impression from the assertions that we are completely misunderstanding a field in which we hold some expertise, even inventing a problem to aid the further persecution of the chiropractic profession.”

    If you refer to the anatomical positioning and it’s “contribution” to VAD, then you could be right, or the expertise is not there to the extent that you imagine, and it is being misunderstood who the anatomy is significant in VAD. Where in my description of the mechanics am I incorrect?

  66. Harriet Hall says:

    nwtk2007,

    You don’t have to look very hard to find smoking gun cases. As I said before, there are plenty of them documented by the Chiropractic Stroke Awareness group, Victims of Chiropractic Abuse and others. What’s the Harm website http://www.whatstheharm.net/chiropractic.html has an impressive list. You didn’t bother looking. And of course there’s Sandra Nette, whose class action lawsuit has been joined by people who would not otherwise have come forward to complain.

    Your rationalization for the under-45 stroke study doesn’t make any sense to me. You seem to be assuming the patients went to a chiropractor for symptoms of an impending stroke, but we aren’t told why the patients who saw chiropractors saw them – it could have been for maintenance adjustments or symptoms below the neck. The number of older people seeing a chiropractor is irrelevant. The study showed that people under 45 with a basilar stroke were 5 times as likely as controls to have seen a chiropractor in the previous week. This was a controlled study with only one variable, and the difference was statistically significant.
    You are working very hard to find rationalizations to support your prejudice. I don’t think you have been successful.

  67. nwtk2007 says:

    I am sorry Harriett, I disagree. I looked at the sites you posted and will do so again. Almost none of the strokes occurred on the table and had a definite link to the CMT. Read them for yourself.

    Also, this small number of occurrences, when not absolutely linked to CMT, can not be significant to CMT. Not even smoking gun level.

    I am also not rationalizing your cited study. You simply refuse to see the alternative interpretation of the data because you want it to reveal something. I have mentioned to you the most significant confounding factor which is not accounted for in your conclusion as to the signficance of the under 45 age group.

    I think it is you who are rationalizing a prejudice. To me, you might as well be arguing the dangers of radiation in MRI.

  68. Harriet Hall says:

    Anecdote alert.

    I met a woman (not listed on the websites) who saw a chiropractor for shoulder pain and did not give him permission to manipulate her neck. He unexpectedly manipulated her neck anyway, and she immediately developed pain and dizziness before even getting up from the table. She had a stroke and almost died. She still walks with a cane and has other sequelae.

    I suppose you can think of some rationalization to explain this away too. Yes, it could have been just sheer chance that she happened to see the chiropractor on the very day and at the very moment that she would have had a spontaneous stroke anyway. If you are like the Red Queen and practice believing 6 improbable things before breakfast, you might believe that.

    Even most chiropractors have accepted that there is a small risk of stroke from neck manipulation. Your refusal to admit that it is more likely than radiation from an MRI is sheer perverseness. I don’t think there is any more to be said.

  69. nwtk2007 says:

    Harriett, if I presented an anecdote about a kid I manipulated back in 1996 who stopped bed wetting as a by product of his back problem being solved, your SBM buddies here would rape me, almost literally. I can present many more doctors with similar stories. I personally know mine is true and thus I would have no reason not to believe them.

    I could tell you about my patients whose Bp problem has been greatly lessened after being treated for their neck injury and again, your SBM buddies would attack without remorse, and relentlessly I might add.

    I can present a great many anecdotal stories about the Bp changes than there are total documented stories such as your friend who had a stroke.

    The pendulum swings both ways. And, the more I analyze the stories and the mechanics of the neck/CMT procedures, the more I think it is highly unlikely to be even remotely close to the frequency you describe (as cited in your references).

  70. Harriet Hall says:

    nwtk2007, you asked for examples: I gave you one. I did not depend on anecdotes to make my point, but on the cited published studies.

    I want to ask you something that I probably should have asked in the first place. What kind of evidence would it take to convince you that neck manipulation can cause stroke? Could any study be done that would answer all your objections?

    And if it doesn’t cause stroke, why haven’t chiropractors done a study to to demonstrate that and defend themselves? The NCCAM would gladly fund such a study.

    PS. My name is Harriet, but so many people insist on adding an extra T that I have become almost frustrated enough to change my name. :-)

  71. pmoran says:

    Ah, yes, ntwk, your anecdotes are indeed suggestive evidence of a treatment effect, but they can be given all due consideration and still leave considerable doubt as to what actually happened.

    YOUR anecdotes lose force once we start examining the plausibility of some of your claims in terms of mechanisms, and consider other at least equally likely explanations such as spontaneous cures and placebo responses.

    Then there is the difficulty in demonstrating any substantial effect of spinal adjustments over placebo in clinical trials of many conditions despite chiropractic confidence in them, and our own extensive experience of esteemed medical doctors and professors having unjustified confidence in treatment methods that proved inactive (over sham) when properly tested.

    All that gets set against your anecdotes. Yet rarely explained thus.

    Harriet’s story is also suggestive of a causal event — strongly suggestive for most people. What considerations enable you to dismiss it?

  72. nwtk2007 says:

    You speak of plausibility. I have discussed the mechanism of VAD caused allegedly by CMT and given plenty of reason to doubt it’s plausibility based upon the mechanics of the anatomy in question. Do you deny the likelihood of bilateral VAD occurring with rotation to be similar to the likelihood of two tires blowing out on the exact same mile or rotation?

    I also don’t necessarily dismiss Harriet’s anecdotal as you imply. I simply point out that it is just one; that there are many, many more encdotal accounts of the “outside” benefits of CMT for which you say there is no evidence to support. However, since you ask, I would wonder what exactly were the symptoms which brought this person to the chiropractor in the first place.

    Harriet said it was shoulder pain. Do you know how many people come into my clinic almost daily complaining of shoulder pain but are indicating the base of their neck instead? Even when you discuss their condition and explain to them that the injury in in their neck as they themselves have shown physically, they still call it their shoulder. They will literally have their hand on their neck showing me where they are feeling pain and tell me their shoulder is hurting.

    Did her friend have a history of head aches or had she ever been treated previously by this doctor for head aches or neck pain? Had she ever been to this doctor prior to this visit? If so what for? Had she ever been treated by any other doctor for the “shoulder’ pain? When did the “shoulder” pain begin? Was it brought on by some trauma? How long had it been going on? How long after the “event” at the doctor’s office did she go to see someone about the “stroke”? Who diagnosed the stroke? Was it confirmed with imaging? What kind of “stroke” was it? Was it VAD? Which side? Bilateral?

    I have worked with enough doctors (MD, DO, DC alike) to know that their diagnoses and accounts of the patients history and pain are many, many times questionable; often incomplete and inaccurate. The anecdotes of alleged VAD caused by CMT lack any analysis to eliminate other causes of the VAD. As presented, they, for the most part, present with a patient who has been to a chiropractor, has a stroke and the doctor who diagnosed the stroke immediately assumes a causal effect without any further investigation. Patients fail to reveal much about their history and have to be questioned deeply in order to get a true history. They also hide history because they somehow are worried that they will be denied care because they have had the same issues before.

    For example, a person falls in the shower, gets bumped from behind in their car that day or the next, and assumes instantly that their neck and back are hurt by the MVA. It literally doesn’t occur to them that they might have been injured when they fell in the shower and thus it never comes up in the history. Since 99.9999 some odd percent of VAD’s are caused by something other than CMT, it seems reasonable to assume that these alleged VAD’s, caused allegedly by CMT, could also have other causes.

  73. Joe says:

    pmoran on 02 Sep 2009 at 5:56 pm “Actually I would be very encouraged if chiropractors (and others) would show SOME indications of caution with necks. …”

    I agree. However, when chiros do take note, they are accused of “eating their own.” http://www.dynamicchiropractic.com/mpacms/dc/article.php?id=53030

  74. nobs says:

    HH posts: “The link you provided is to a method for single-blinding. Double blinding is impossible, since the provider always knows what he is doing. ”

    BUT Harriet- That does not make a study invalid, or diminish it’s results. Your reply appears you are implying otherwise?

    You declared: “the contribution of a placebo ‘RESPONSE’ may be significant”. (operative word here being “response”).

    While I dispute your arbitrary use of “significant”, this study, using short-duration, low-risk general anesthesia can create effective blinding of subjects to the provision or withholding of SMT. An anesthetic blind for SMT subjects solves many, if not all, problems associated with prior SMT blinding strategies. Although further studies are needed to refine this technique, the potential now exists to conduct the first placebo-controlled randomized controlled trial to assess SMT efficacy.

    After all, this study IS, from “mainstream scientific medicine community”. ……. NO?……Although I can only make that assumption of qualification, since you have ignored my repeated requests to document your working definition of what that means.

    pmoran posts: “I must have got the wrong impression from the assertions that we are completely misunderstanding a field in which we hold some expertise, even inventing a problem to aid the further persecution of the chiropractic profession.”

    That is certainly plausible, perhaps even probable.
    “If one says often enough and has enough money to put billboards up that a chiropractor caused a stroke, then it must be true……Surely if these billboards are up there must be some truth to it, no? …..What is really interesting about this whole campaign against chiropractic care is that the campaign isn’t about cervical manipulation.”

    http://smperle.blogspot.com/2009/03/stroke-of-genius.html

  75. nobs says:

    HH posts: “The link you provided is to a method for single-blinding. Double blinding is impossible, since the provider always knows what he is doing. ”

    BUT Harriet- That does not make a study invalid, or diminish it’s results. Your reply appears you are implying otherwise?

    You declared: “the contribution of a placebo ‘RESPONSE’ may be significant”.

    While I dispute your arbitrary use of “significant”, this study, using short-duration, low-risk general anesthesia can create effective blinding of subjects to the provision or withholding of SMT. An anesthetic blind for SMT subjects solves many, if not all, problems associated with prior SMT blinding strategies. Although further studies are needed to refine this technique, the potential now exists to conduct the first placebo-controlled randomized controlled trial to assess SMT efficacy.

    After all, this study IS, from “mainstream scientific medicine community”. ……. Although I can only make that assumption of qualification, since you have ignored my repeated requests to document your working definition of what that means.

    pmoran posts: “I must have got the wrong impression from the assertions that we are completely misunderstanding a field in which we hold some expertise, even inventing a problem to aid the further persecution of the chiropractic profession.”

    That is certainly plausible, perhaps even probable.
    “If one says often enough and has enough money to put billboards up that a chiropractor caused a stroke, then it must be true……Surely if these billboards are up there must be some truth to it, no? …..What is really interesting about this whole campaign against chiropractic care is that the campaign isn’t about cervical manipulation.”

    http://smperle.blogspot.com/2009/03/stroke-of-genius.html

  76. weing says:

    I checked out your stroke of genius. I think Hitler’s propaganda minister was an adept of this method, so were the flagellants of the 14th century blaming the spread of the bubonic plague on the Jews It does explain the refrain of the chiros that doctors kill people.

  77. Harriet Hall says:

    nwtk2007,

    “Do you deny the likelihood of bilateral VAD occurring with rotation to be similar to the likelihood of two tires blowing out on the exact same mile or rotation?” Yes. I would compare it to the likelihood of two tires blowing out when someone sticks nails in both of them. If neck manipulation in one direction traumatically tears one artery, neck manipulation in the other direction is just as likely to tear the other.

    You didn’t answer my question: “What kind of evidence would it take to convince you that neck manipulation can cause stroke? Could any study be done that would answer all your objections?”

  78. Harriet Hall says:

    nobs,

    The fact that a double blind study is impossible (in manipulation, acupuncture, etc.) does not make a study invalid, but the results of a single blind study are not as credible as a double blind study. Just as an epidemiological study is less credible than a single blind study.

    The idea of anesthetizing patients for a manipulation study bothers me. I wonder how many IRBs would consider that unethical.

  79. nwtk2007 says:

    Harriet, I do think that CMT can, very slightly/possibly cause a stroke, but I think it is way, way, way less likely than you and the others here would like to have people believe. Even rarer still would be the bilateral VAD and definitely NOT caused by the rotation CMT techniques previously described.

    What kind of evidence? Real evidence with a plausible explanation of a mechanism involved. Most definitely there has been no good mechanism proposed thus far, especially for the bilateral VAD.

    But definitely more than a doctors opinion (or a courts) that since a person saw a chiro within the past day to three weeks the CMT must be the only possible explanation for the cause of a stroke.

    Like I said previously, what is the mechanism of cause of the other 99.999% of strokes where the person has not recently been to a chiropractor? An answer to this question could, at least, lead to a possible understanding of how a stroke might (and I mean might) be caused by CMT.

    Then, when I see cases where there is adequate past medical and personal history taken, not just assumed, then I might begin to think it more likely.

  80. nobs says:

    HH replies: “The fact that a double blind study is impossible (in manipulation, acupuncture, etc.) does not make a study invalid, but the results of a single blind study are not as credible as a double blind study. Just as an epidemiological study is less credible than a single blind study.

    “Credibility” is a factor of the question being asked and the design/methodology of that which is being studied, along with with the statisical analysis of the results. A poorly designed, poorly interpreted/staistically skewed double-blind study will never trump(at least scientifically) a well designed, well-concluded single-blind study. The scientific world is replete with poor, uncredible, even bogus, double-blind studies. Let’s not confuse quality with nomenclature.

    HH-”The idea of anesthetizing patients for a manipulation study bothers me. I wonder how many IRBs would consider that unethical.”

    I am amused, but not surprised by this staement…….That you would choose to question the “ethics” of a short-duration, low-risk general anesthesia, whose effects are well-known and used every day……………….as opposed to…….ahhhhhhhem……..an experimental drug with unknown short or long-term adversities.

  81. nobs says:

    weingon posts:
    “# weingon 03 Sep 2009 at 9:42 am
    I checked out your stroke of genius. I think Hitler’s propaganda minister was an adept of this method, so were the flagellants of the 14th century blaming the spread of the bubonic plague on the Jews It does explain the refrain of the chiros that doctors kill people.”

    Please feel free, actually, I encourage you, to post your comment to:

    http://smperle.blogspot.com/2009/03/stroke-of-genius.html

  82. Harriet Hall says:

    nwtk2007 said
    “I think it is way, way, way less likely than you and the others here would like to have people believe.”

    I think you are reading more into what we wrote than what we actually said. Sam’s article cited figures as low as one in 5.8 million adjustments. I have said that the incidence is very small and that we don’t have a handle on what that incidence really is.

    The point is not the magnitude of the risk, but the risk/benefit ratio. Sam said “Risk of stroke caused by neck manipulation is statistically low, but the risk is serious enough to outweigh benefit in all but a few rare, carefully selected cases.”

  83. “PS. My name is Harriet, but so many people insist on adding an extra T that I have become almost frustrated enough to change my name. :-)”

    Maybe you should change your online ID to ‘Harriet Withwuntee’

  84. pmoran says:

    nwtkL “What kind of evidence? Real evidence with a plausible explanation of a mechanism involved. Most definitely there has been no good mechanism proposed thus far, especially for the bilateral VAD.”

    You must be talking from either an ignorance of arterial pathology or mindless obstinacy. The pathology is well-understood.

    Arterial dissection occurs when a there is separation of the intimal layers of a blood vessel from deeper layers, as the result of stretch, pinching, or vessel wall weakness from other pathology and daily traumas.

    Smaller vessels, such as the vertebra concerning us here, may be immediately occluded, if the separation is severe enough. More minor damage may merely partially occlude the vessel producing symptoms from that or from bits of clot forming on the damaged intima and embolising the brain. Or complete thrombotic occlusion may be a later event.

    The rare bilateral cases are only mentioned because they cannot be dismissed a terrible coincidence.

    We should not even have to mention the anatomy that makes such injury possible. It is an accident waiting to happen.

  85. pmoran says:

    Harriet: “The point is not the magnitude of the risk, but the risk/benefit ratio. Sam said “Risk of stroke caused by neck manipulation is statistically low, but the risk is serious enough to outweigh benefit in all but a few rare, carefully selected cases.””

    It seems to be very difficult to get this point across, or even elicit a direct response to it. The attitude seems to be that chiro is generally safer than conventional medicine. But even if that were true in risk/benefit terms with some conditions, that would not justify the carte blanche for neck manipulation that some chiropractors seem to be defending.

    There is also a misunderstanding of “what goes where” in terms of the utilisation of different forms of evidence in medicine. The mere possibility of a serious complication like stroke, as ntwk now reluctantly allows, should prompt modification of prevalent chiropractic behaviour, especially when the benefits of neck manipulation over many other managements are so tenuous.

    It understandable that chiropractors might demand higher forms of evidence with part of their livelihood under this threat. But it’s a risky approach for them. It involves erecting their own ultimately untenable double standard — absolute proof of risk vs loose, mainly anecdotal, evidence for benefits.

    I agree with you that prospective studies of the risk are already unethical.

  86. pmoran says:

    I said: “I agree with you that prospective studies of the risk are already unethical”

    There is an unspoken ” if they involved randomisation of patients to an unkown risk with no proven benefit” in there.

  87. Canucklehead says:

    Interesting analogy of two tires bursting at the same time, very rare occurance indeed. However, how many chiropractors manipulate the upper cervical area into both directions during treatment, I know I’ve had my head tweaked both ways on most visits even though my symptoms were one sided. I’d have thought that bilateral disections would be a smoking gun for manipulation being the root cause.
    Perhaps the analogy should include chiropractors and other high cervical manipulators as potential spike belts?

  88. nwtk2007 says:

    canucklehead – “I’d have thought that bilateral disections would be a smoking gun for manipulation being the root cause.”

    For the bilateral VAD to occur, both sides have to be damages. Rotation to one dierction pinches one side and stretches the other. Are you suggesting that both the pinching and the stretching are damaging the bilateral arteries simultaniously? Doubtful, two different mechanisms of injury occurring at the very same time in a situation such as this. The other possibility is rotation to one direction would damage one side and the opposite rotation would damage the other, essentially simultanious, but more accurately consecutively. Again, this is not likely and this is where the two tire analogy is relevant.

    The bilateral VAD is just the opposite of the smoking gun for rotationally caused damage.

    pmoran, I do not “reluctantly allow” for the possibility, I have always said there is that slight possibility, but I think it is much slighter (if that is a word) than you would have people to believe. As to the benefit of CMT, that is also weak (again not as weak as you would have people believe) unless you see it in action everyday.

    I also stand by my position on the “evidence” of CMT caused strokes seen on the wedsites previously indicated as being not well investigated and sensationalized.

    I would also re-ask, what is the cause of the 99.999% of all the other strokes and VAD’s that occur when a person has not been to the chiro for some CMT? In the absence of previous CMT, do the doctors question the patient to see if, indeed, there is some physical event or mechanism that might have caused the stroke? You will probably say yes, and if so, give some examples.

  89. pmoran says:

    “I would also re-ask, what is the cause of the 99.999% of all the other strokes and VAD’s that occur when a person has not been to the chiro for some CMT? ”

    We are talking specifically about VAD, actual arterial damage, as has now been demonstrated by imaging in many or most of the cases cases under discussion.

    Your question is a diversion. Regardless of what causes other strokes there does seem to be a strong association of VAD with neck manipulation, in both timing and frequency.

    It is also not so rare as you seem to think German neurological centres encountered over thirty cases with this association over a three year period. We can allow that some of these patients were unlucky enough to have been manipulated by someone who did not recognise the early symptoms of VAD (which is worrying enough) and still be concerned at what looks like a lot of unnecessary morbidity.

    Yes, it would be akin to doctors causing injury or death through the over-prescritption of NSAIDs. but the unique benefits of NSAIDs for some conditions are much clearer and no one is disputing the risk.

  90. Harriet Hall says:

    pmoran pointed out that it is difficult to get the risk/benefit point across or to elicit a response. Yes, it is still being ignored.

  91. nwtk2007 says:

    Harriet, it is not being ignored, it is just a waste to get into that again as any and all evidence for benefit is disregarded for the most part and despite the presentation of supporting studies, it continues to fall on deaf ears.

    I have demonstrated that the risk vs benefit ratio is almost totally on the side of benefit since I have shown you the extremely unlikelihood of risk. I would estimate it at less than even the 1 in 5 million number when realistically viewed for it’s plausibility.

    You talk about risk and you can’t seem to even distinguish between the causes of stroke, so how could you realistically discuss the risk?

    And yes, pmoran, there is actually damage when a stroke occurs; the question is of cause, which more and more clearly points away from CMT. Opinions about cause do not constitute cause.

  92. OZDigger says:

    What amazes me, when reading this post and others on this site, is the absolute monocular vision contributors such as Harriet, Joe. pmoran, Val, Gorski et al. have.
    While the United States health care system is in disarray, through the fault of the medical establishment and insurance companies, the contributors keep on insisting that CAMS, acupuncture, chiropractic, osteopathy, etc., are not scientific. This is rubbish and nonsense.
    At present, scientific medicine has brought us a $2.3billion law suit against Pfizer, for marketing drugs for “off-label use”, the U.S. spends more per capita on health-care, yet 45 million people are uninsured and have no real access to health care. Compared to the U.K., Germany, Holland and Australia, this is abysmal. I am sure there are many other examples.
    Yet Harriet et al. seem to want to ignore this and become obsessed about smaller things. Take a look at the big picture members of SBM editorial group. Take the plank out of your own eyes before attempting to remove the small splinters from other health-care providers.
    Look at what “scientific medicine” that you support has bought us, Vioxx, Thalidomide, obscene plastic surgery, etc. and compare that to what other health care providers are able to do.
    You comments are not plausible, they are not reliable and they are not credible. They do not fulfill a bio ethical model of integrity. As such, sort out your own profession before taking aim at others. I wonder what you are trying to hide??????????????

  93. pmoran says:

    Ozdigger: “— absolute monocular vision contributors such as Harriet, Joe. pmoran, Val, Gorski et al. have,”

    Ozdigger, I am my own man.

    How many times on this blog have I stated that skeptics are not entitled on the present evidence to state that alternative methods are of no value to those using them (mainly because of placebo responses and other non–specific benefits of medical attentions)?

    I have therefore argued, at the risk of alienating people I respect and regard as friends that such methods may need to be tolerated to some degree within present-day medical systems while ever the conventional system methods lacks entirely effective and safe solutions for all medical problems.

    I have also suggested that skeptics routinely exaggerate the risks of CAM and are mistaken in assuming that CAM use is all about poor scientific education and understanding.

    There are, however, matters that don’t lend themselves to compromise, such as certain scientific claims and exaggerated claims regarding the effectiveness and scope of some of the methods. For example, I have no tolerance of cancer cure claims, because they should be very easy to demonstrate if true.
    .
    In relation to the present argument, the problem is getting chiropractors to look at neck manipulation in risk/benefit terms. They admit there is a risk, but do not want to consider the implications of this for chiropractic practice or condemn fellows who may be engaged in entirely unjustified tretaments.

    And do think again about the argument that it is OK to kill or injure people so long as everyone does it (sometimes).

  94. Harriet Hall says:

    When someone is losing a debate and has run out of credible evidence and rational arguments, he can either (1) be courageous and concede defeat, (2) withdraw quietly from the field and hope no one notices, or (3) he can take the cowardly approach and attack and insult his opponents and try to change the subject, even trying to blame them for the very things he himself is guilty of. Sometimes that might work, but readers here are sophisticated enough to spot the logical fallacies.

  95. Joe says:

    @OZDigger on 03 Sep 2009 at 11:53 pm “What amazes me, when reading this post and others on this site, is the absolute monocular vision contributors such as Harriet, Joe. pmoran, Val, Gorski et al. have.”

    Mr/s. Digger, you should not tar the others (health professionals) by lumping them with me. It is no secret that I am a chemist.

    But, you are right- I do have a focused point of view. I want the data- not your fretful, whinging, mewling, tearful arguments. If you question me on chemistry, I can cite the original research; when you are challenged about your quackery, all you do is pule about it.

    Are you never embarrassed by demonstrating your ignorance?

  96. nobs says:

    pmoran- you DO appear to be among, perhaps even, the ONLY, truly skeptical(as opposed to pseudoskeptical) poster here.

    Thank-you.

    AND- as of late, many(I am resisting saying ‘most’) links have been to blog sites as “evidence”(????) as opposed to ‘scienced-based’ links.

    Just for kicks and giggles, but also out of curiosity, I intentionally linked a post to a blog—– the reply invoked Hitler and Jews!! WOW!!

    pmoran posts:

    “It is also not so rare as you seem to think German neurological centres encountered over thirty cases with this association over a three year period…..”

    FIRST- It is duly noted by me that you, very correctly, note the “ASSOCIATION” aspect, and realize that association does not confer causation.

    SECOND-This study is often flouted here. I have REPEATEDLY posted on the FACTS of this study. Despite my posting the facts of the study, it goes ignored, or purposefully(maybe even dutifully?) distorted—- only to be repeated(often dishonestly) again, and used as “evidence” against “chiropractic” care.

    The facts of the study you refer to can be found here:
    http://www.chiro.org/Professional_Regulation/
    http://smperle.blogspot.com/2009/03/stroke-of-genius.html
    http://www.ncbi.nlm.nih.gov/pubmed/16511634?dopt=Abstract

    I trust you will objectively read these. Thank-you in advance.

    PM- “We can allow that some of these patients were unlucky enough to have been manipulated by someone who did not recognise the early symptoms of VAD (which is worrying enough) and still be concerned at what looks like a lot of unnecessary morbidity.”

    I addressed/documented/linked this- ‘recognition of early sx of VAD’- on one of Harriet’s editorials here. I linked to indexed publications documenting that in most/all cases(in the study) the patient had previously been to a MD or ER ***BEFORE*** seeking chiropractic consultation. Apparently that was for naught, since the same, tired, debunked argument continues to be posted…..again…..and again….sigh…..

    Hopefully moving on-

    Let’s remove the evaluation of the extremely low risk(if it does indeed exist-it is only a hypothesis at this point) of HVLA high neck manipulation, and compare it, side by side, to medical interventions for the same condition- neck pain.

    Please allow me to direct you to the following:
    A risk assessment of cervical manipulation vs. NSAIDs for the treatment of neck pain.
    http://www.ncbi.nlm.nih.gov/pubmed/8583176?dopt=Abstract

    -Footnote-
    Some here choose to ignore the facts and dishonestly and intentionally misreprsent DCs as only employing HVLA.

  97. OZDigger says:

    Harriet and Joe. You are wrong. I have not lost the argument, I see that you are tortuously going around and around in the same circle, without looking a bit beyond it at your own professional problems.
    (pmoran, I apologize for putting you in the same group).
    I would suggest you endeavor to engage in ïnter-disciplinary dialogue”, rather than insisting you are always correct.

  98. Harriet Hall says:

    Even after his logical fallacies are pointed out, OZDigger employs them once more to insult his opponents and deflect the discussion to a different subject (our own professional problems).

    We have been offered a few studies supporting neck manipulation, but studies can be found to support anything. Systematic reviews have given little support to the effectiveness of neck manipulation for any condition, and there is no credible evidence that it is effective for somatovisceral problems or health maintenance. And it is a fact that many chiropractors use neck manipulation for just such totally inappropriate indications.

    Inter-disciplinary dialog? Between science-based medicine and something else? No thank you. That’s not just moving the goal posts, that’s changing the playing field and the name of the game.

  99. OZDigger says:

    Interesting Harriet, but you are still going around in circles and now changing the goal posts. Who mentioned “somatovisceral problems”?. That is not the discussion at present, and if you want to make it a topic, then ethically, you must then talk about the “medical management ” of somato-visceral problems. You have avoided this, thus do not fulfill the criteria of the the bioethical model of Beauchamp et al.
    Apart from this, I would suggest that your biggest problem in your argument is the lack of continuity in medical care for a multitude of conditions. This occurs between practitioners within hospitals, between countries and even within the same HMO’s. As I said before, sort out your own problems, before attempting other practitioner groups.

  100. Harriet Hall says:

    Sam Homola’s article may not have used the word “somatovisceral” but it certainly alluded to that kind of inappropriate treatment including “maintenance” adjustments. The subject was definitely between the original goalposts.

    OZDigger is STILL using the same logical fallacies. There is no “ethical” requirement to cover apples in a discussion of oranges. If John Doe is on trial for stealing a car, it won’t do his defense lawyer a bit of good to argue that Joe Blow stole a truck. The prosecutor would shout “Irrelevant.” Information about Joe Blow is only pertinent to Joe Blow’s trial.

    And talk about moving goalposts: where on earth did “lack of continuity of care” come from?

    I will say this once more, as clearly as I can, smack dab between the original goal posts of the article. There is little or no benefit from neck manipulation and even if there is benefit it is not clearly superior to other treatments. Chiropractors frequently use manipulation for inappropriate reasons where there is no conceivable benefit. There is a small but very serious risk. The pro-chiropractic commenters have not presented any convincing evidence that would make an unbiased reader reject anything in Sam’s article.

    That is what was under discussion. Sam was not comparing the risks of manipulation to the risks of other treatments, especially not to treatments that have been shown to offer benefits.

    OZDigger is just digging himself deeper and deeper.

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