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125 thoughts on “Neck Manipulation: Risk vs. Benefit

  1. OZDigger says:

    Hi Harriet,

    please provide me wit the risk/benefit analysis results for the treatment of neck pain with NSAIDS?
    Please provide me with the risk/benefir analysis figures for the long term use of NSAIDS or for that matter, anti-biotics?

  2. Harriet Hall says:

    OZDigger,

    I’m sad to see you are still repeating the same logical fallacies:

    (1) tu quoque
    (2) red herring
    (3) false dichotomy (manipulation and NSAIDS are not the only treatment options).
    (4) changing the subject entirely (antibiotics??!!)

    NSAIDS and antibiotics are irrelevant to the subject under discussion (the risk/benefit ratio of neck manipulation).

    You inadvertently wrote, “please provide me wit” – I only wish I could! :-)

  3. nwtk2007 says:

    Interesting. So Harriet, you are saying there is no risk/benefit analysis of NSAIDS: both short term and long term use?

    Irrelevant? Maybe. But what about perspective?

    Humor me. What are the analysis of such? Have they ever been calculated? Were there ever any evaluations done? In terms of lives saved and deaths, benefit vs risk, what is the true analysis of NSAIDS, particularly ibuprofen? I’ll trust you.

    Any references?

    Just asking. I got an ulcer from using ibuprofen for my shoulder and back pain. Nearly put me under. Now with proper exercise and stretching, not to mention CMT, I have no problems with either unless I drink too much and fall asleep on my back. Even then the back problem is short lived. (Had it since I was 12)

  4. Harriet Hall says:

    nwtk2007 said, “So Harriet, you are saying there is no risk/benefit analysis of NSAIDS: both short term and long term use?”

    No, I said nothing about NSAIDS because that topic is irrelevant to the topic under discussion. I won’t respond to this kind of baiting and misdirection.

    You not only failed to understand why OZDigger’s arguments were logical fallacies, but you committed the same logical fallacies and then tried to put words in my mouth.

    These tactics are beneath contempt. You have both removed yourselves from the realm of rational discussion.

  5. pmoran says:

    Ozdigger and Nobs, you need to talk to your own medical insurance organisations, if you want to use the “it wasn’t us, M’lud” defence. There is no real question that DCs have caused strokes.

    And it doesn’t matter how small the risk is if patients are not being advised of it and neck manipulation is also being used as the first line of treatment for conditions that either would have settled themslves or respomded to safer modalities.

    This is what risk/benefit means.

    According to a 2005 Cochrane review NSAIDs have unclear benefits for neck pain, so they are not a good first choice either.

  6. nwtk2007 says:

    If an insurance company says CMT causes strokes then they do it because it was ruled to be so in some “legal” circle somewhere, somehow. But legal circles do not determine actual reality. In fact, if you have ever been in a court room where the issues are medical, you would honestly and fervently say that there is little truth to be found there, at all.

    When the mechanisms of these VAD’s and strokes are examined objectively, one must, at least I have, come to the conclusion that any connection between the stroke and CMT is coincidental at best. That is why I don’t give in to your risk vs benefit argument. If there is no risk, then the benefit can be very small indeed. And even if there is a slight, slight risk, which I would concede to (and I mean slight) then I would say the benefit is still greater in most cases.

    As to these “logical fallacies”, well, I think they are especially that to you because they lie within the medical world, of which you are a part. You have made the same argument against the chiros, implying that they fail to see the risk because it is a part of their bread and butter, so to speak.

    What you miss is perspective. Actually I don’t think you miss it, you just avoid it, but that is simply a part of your humanity.

  7. nobs says:

    HH claims: “There is little or no benefit from neck manipulation”

    Harriet- You insist on making these broad-brush statements that I know, that you know, are misleading at best, and dishonest at worst. You claim to be “evidence-based” yet you ignore, and/or misrepresent any science/evidence-based evidence that does not fit your dogma. The peer-reviewed, indexed, cites are available……And I also know that you know how to access them.,,,,,,,If in fact, you- DO- wish to truthfully represent the current body of science-based/evidence-based knowledge…..

    HH continues- “and even if there is benefit it is not clearly superior to other treatments.”

    C’mon Harriet- Seriously—-do you think that no one here will recognize the fallacy of this declaration? One does not not have to be “superior” to be of benefit. They are not mutually exclusive. One does not cancel the other. You know(or should know) that. I will be generous, and ascribe this fundamental fallacy flaw in your argument to your blinding bias.

    Addtionally- “Superior” to “WHAT” Harriet? You have conviently omitted/failed to identify/list the “other treatments” that you are claiming to be “superior”. For what conditions? Please compare the risk/benefit ratio of your “superior” treatments.

  8. Diane Jacobs says:

    nwtk2007-> “And even if there is a slight, slight risk, which I would concede to (and I mean slight) then I would say the benefit is still greater in most cases.”

    What benefit? Pain reduction? Improvement in range of motion? Thicker wallet for you? Inducing the ubiquitous placebo response?

    All those can be had without cranking necks around and endangering neck arteries.

  9. nobs says:

    # pmoranon 07 Sep 2009 at 4:16 am
    Ozdigger and Nobs, you need to talk to your own medical insurance organisations, if you want to use the “it wasn’t us, M’lud” defence. There is no real question that DCs have caused strokes.

    And it doesn’t matter how small the risk is if patients are not being advised of it and neck manipulation is also being used as the first line of treatment for conditions that either would have settled themslves or respomded to safer modalities.

    This is what risk/benefit means.

    According to a 2005 Cochrane review NSAIDs have unclear benefits for neck pain, so they are not a good first choice either.

    I am not quite clear as to how I became invoked here- but thank-you pmoran for your thoughtful queries.

    pm-”There is no real question that DCs have caused strokes. ”

    Actually, this is not a fact, although most posters here are presenting it as so. Association does not prove causation. At this point, it is a hypothesis that has been neither proven nor disproven…….Scientifically.

    However, as more and more studies are conducted, the risk/benefit ratio is clearly evidencing chiropractic care(which may or may not include HVLA- [there are non-HVLA manipulations] as being the best “first choice”, safest treatment option.

    pm-”And it doesn’t matter how small the risk is if patients are not being advised of it “

  10. nobs says:

    Sorry pm- I accidentally hit submit before completion.

    pm-”And it doesn’t matter how small the risk is if patients are not being advised of it ”

    You are correct on this, and if the proselytizations of posters here were one’s only source of (mis)information, one would certainly be led to this erroneous conclusion. Let me assure you that “informed consent’ is covered in DC education curriculum, and is mandated, standard procedure in DC pracrtice.

  11. pmoran says:

    Nobs: “Association doees not prove causation.”

    You realise that the same principle applies to chiropractor’s mostly anecdotal evidence of benefits from spinal manipulation for neck pain?

    I say again that (some) chiropractors are asking for ridiculous levels of evidence when it comes to risk. It is not enough that patients with no relevant symptoms have their neck “adjusted” and are suddenly seriously impaired neurologically, and that there are a lot more cases who develop symptoms later consistent with the known evolution of VAD, nor that the anatomy clearly predisposes to such a risk.

    You cannot ignore this through the mere POSSIBILITY that a few cases may have had a VAD in progress, a notion that itself has never been demonstrated to the standard that chiropractors have concocted for their present purposes.

    Yet we are expected to accept rather weak evidence of equivalence to other likely placebos such as laser therapy, and a lot of “because I said so” in relation to the benefits. What a double standard!

    Even the potential for serious risk outweighs uncertain benefits. But like Homola, I accept that there may be a place for neck manipulation, just not as the first line of treatment for a lot of dubious indications.

  12. nwtk2007 says:

    Apparently no one has anything of substance forth coming and neither side will budge. I personally think Homola has an agenda that involves income and only partially believes what he writes. I could be wrong but there again, nothing more forth coming of any worth.

    My opinion stands as does yours.

    So at the risk of being insulted or “last worded”, shall we call it a draw?

  13. Harriet Hall says:

    nwtk2007 says, “no one has anything of substance….shall we call it a draw?” No, we shall not. Opinions based on fact and backed up by good evidence are not a draw with opinions based on belief and backed up by rhetoric. Homola’s article was full of substance. The attacks on his article were full of logical fallacies and insults.

    Your accusation that Sam only partially believes what he writes is baseless, highly offensive, and totally inappropriate. If you had any convincing evidence, all you would have to do is present it – you wouldn’t have to resort to nefarious tactics like this.

    As for income, Sam Homola is now retired, and he forfeited a great deal of income during his working life because he didn’t accept unfounded chiropractic beliefs.

    I could retort that it is far more likely that you have an agenda and are saying things you only partially believe as a last-ditch effort to defend your livelihood. But that would be an ad hominem and would not advance the discussion. I will simply say once more that the evidence does not show a favorable risk/benefit ratio for neck manipulation, particularly for the commonly used indications like somatovisceral conditions and maintenance. Nothing you have said changes that.

  14. nwtk2007 says:

    I said it was a risk. I also seriously doubt if you truly believe all you just said as well.

  15. Harriet Hall says:

    nwtk2007,

    When all else fails, accuse your opponents of not believing their own arguments. Is there a name for that?
    This is SO not a draw!

  16. OZDigger says:

    Hi Harriet,

    you persist in making illogical, unfounded and unethical comments in your replies.
    For example, “Sam Homola is now retired, and he forfeited a great deal of income during his working life because he didn’t accept unfounded chiropractic beliefs”.
    How do you know this? Do I or anyone else really want to know about Sam’s financial plight? Is it really your business bringing this up? Can you reference this please?

    This discussion is going around in circles and as I have pointed out to you in the past, from a bio-ethical standpoint your arguments have become unsubstantiated rubbish for the sake of having the last word.
    Think about the four principles of bioethics you wrote so eloquently about several weeks ago, and follow those principles.

  17. OZDigger says:

    Please

  18. pmoran says:

    A “draw”, now?

    Pleading for a draw is another ploy of those in a weak position. There is no serious scientific controversy here, merely some uncertainty as to details in terms of how many strokes and for what medical gain.

    EVen if the arguments were evenly balanced that would still mean that neck manipulation “may” not be of much unique benefit to anyone and it “might” cause stroke.

    It is OK with me if that is the message that is coming across.

  19. Harriet Hall says:

    OZDigger,

    I was not the one who brought up Sam’s financial situation.
    nwtk2007 accused Sam of having “an agenda that involves income.” I was responding to that, showing that Sam’s “agenda” of science and reason had actually diminished his income. I fail to see how my comment is illogical, unfounded or unethical.

    “from a bio-ethical standpoint your arguments have become unsubstantiated rubbish” ??!! Please!!

  20. nobs says:

    HH claims: “There is little or no benefit from neck manipulation”

    Harriet- You insist on making these broad-brush statements that I know, that you know, are misleading at best, and dishonest at worst. You claim to be “evidence-based” yet you ignore, and/or misrepresent any science/evidence-based evidence that does not fit your dogma. The peer-reviewed, indexed, cites are available……And I also know that you know how to access them.,,,,,,,If in fact, you- DO- wish to truthfully represent the current body of science-based/evidence-based knowledge…..

    HH continues- “and even if there is benefit it is not clearly superior to other treatments.”

    C’mon Harriet- Seriously—-do you think that no one here will recognize the fallacy of this declaration? One does not not have to be “superior” to be of benefit. They are not mutually exclusive. One does not cancel the other. You know(or should know) that. I will be generous, and ascribe this fundamental fallacy flaw in your argument to your blinding bias.

    Addtionally- “Superior” to “WHAT” Harriet? You have conviently omitted/failed to identify/list the “other treatments” that you are claiming to be “superior”. For what conditions? Please compare the risk/benefit ratio of your “superior” treatments.

  21. Harriet Hall says:

    nobs,

    My statements merely repeat the results of systematic reviews of the literature. You have not offered a systematic review showing that neck manipulation is superior to other treatments.

    I did not claim other treatments were superior; I repeated the findings of systematic reviews that neck manipulation is NOT superior to other treatments in effectiveness.

    Mobilization has been shown by a Cochrane systematic review to be equally effective.

    You guys have all conveniently side-stepped one of Sam’s most important points: that chiropractors frequently manipulate for conditions like maintenance and non-musculoskeletal conditions where there is clearly NO evidence of benefit. Even if there were no risk of stroke, it would still be questionable ethics to offer an ineffective treatment and misrepresent it to patients.

  22. nobs says:

    # Harriet Hallon 08 Sep 2009 at 10:40 am

    HH- “My statements merely repeat the results of systematic reviews of the literature. You have not offered a systematic review showing that neck manipulation is superior to other treatments.”

    But Harriet- Are you now moving the goalposts AGAIN?— that the only evidence must be “a systematic review”?
    I have provided objective, science-based evidence that debunks your hallowed “systematic review”. You ignore, and refuse to acknowledge or address it in a scientific-based tone.

    HH- “I did not claim other treatments were superior;”
    Perhaps you need to review your own posts. Instead of reconfiguring the dialog, please review and answer these questions:

    ——(on 07 Sep 2009 at 12:02 pm

    HH continues- “and even if there is benefit it is not clearly superior to other treatments.”

    C’mon Harriet- Seriously—-do you think that no one here will recognize the fallacy of this declaration? One does not not have to be “superior” to be of benefit. They are not mutually exclusive. One does not cancel the other. You know(or should know) that. I will be generous, and ascribe this fundamental fallacy flaw in your argument to your blinding bias.

    Addtionally- “Superior” to “WHAT” Harriet? You have conviently omitted/failed to identify/list the “other treatments” that you are claiming to be “superior”. For what conditions? Please compare the risk/benefit ratio of your “superior” treatments.)—-

    HH- “I repeated the findings of systematic reviews that neck manipulation is NOT superior to other treatments in effectiveness.”

    Even though I have already debunked your “systematic review(s)—That does not invalidate manipulation as being of benefit. GEESH!! I addressed this in previous posts. Please review.

    HH-”Mobilization has been shown by a Cochrane systematic review to be equally effective.”

    Some studies(depending upon how they are constructed), do come to this conclusion. It is a factor of the construction of the study, YOU know that. Specifically Harriet, to enjoin a scientific-based discussion, it is imperitive to identify ‘Which’ study you are specifically referring to. You do not cite your source, which therefore limits any discussion to your opinion/interpretation. Please provide a link to the “review” you refer to above.

    HH-” You guys have all conveniently side-stepped one of Sam’s most important points: that chiropractors frequently manipulate for conditions like maintenance and non-musculoskeletal conditions where there is clearly NO evidence of benefit.”

    Harriet- “Side-stepping”? REALLY?? Harriet- you have very obviously, and conviently “side-stepped”(aka ignore) answering any of my queries to you.

    HH- ” Even if there were no risk of stroke, it would still be questionable ethics to offer an ineffective treatment and misrepresent it to patients.”

    Please elaborate on your accusation of “ineffective treatment”. What is, by your definition, “ineffective treatment”.

    OH—AND—, BTW, while you are at it—- AGAIN, I request that you please provide your definition of “mainstream scientific medicine community” which you first invoked here(-# Harriet Hall on 31 Aug 2009 at 1:02 pm) Exactly what does that mean?
    Despite repeated requests, you continue to “side-step” answering my very basic, academic questions to you.

    Please provide,
    Thank-you in advance

  23. Harriet Hall says:

    I think this discussion has reached the point of no return. I am hereby withdrawing from the discussion and will allow my critics to have the last word – for what it’s worth. :-)

    And I certainly don’t think it has ended in a draw. Readers may judge for themselves.

  24. EricG says:

    no draw, I read every comment….like a science soap opera.

    amidst it all, i read not one shred to convince me that i should go to a chiropractor for anything at all.

    if the burden of proof lays upon those making the claims (i.e. an alternative to “harmful western medicine”) then this surely constitutes an epic fail.

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