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Not to worry! Chiropractic Board says stroke not a risk of cervical manipulation.

Back in January, the Connecticut Board of Chiropractic Examiners held a four-day hearing to decide whether chiropractors must, as a part of the informed consent process, (1)warn patients about the risk of cervical artery dissection and stroke following neck manipulation and (2) give patients a discharge summary listing the symptoms of stroke.1 On June 10th, the Board of issued a written opinion that stroke or cervical artery dissection is not a risk of cervical spine manipulation, so no warning is necessary. Presumably, although it is not specifically mentioned in the decision, no discharge summary is required because, if there is no risk of a stroke after neck manipulation, what would be the point?

Background

Janet Levy and Britt Harwe are two Connecticut women who suffered strokes resulting from neck manipulation by chiropractors. That’s not just their lay opinion, it’s the opinion of their respective treating physicians, right there in the medical records.

Each decided that some good should come of their unfortunate situations, so each formed a non-profit and began warning patients of the risk of stroke following manipulation. Victims of Chiropractic Abuse, Levy’s organization, put giant ads on the sides of busses in Bridgeport, CT., much to the chagrin of the folks at the University of Bridgeport. Within the hallowed halls of the University (Go Purple Knights!) is a College of Chiropractic, a College of Naturopathic Medicine, and the Acupuncture Institute. The chiropractors demanded that the ads be taken down, which got exactly nowhere.

Some chiropractors also began harassing Levy and Harwe, calling them Nazis and KKK members, for example, and threatening their personal safety and that of their families.(What is it with the pseudoscience crowd and calling people Nazis? Perhaps, having used up their entire supply of imagination creating their nostrums, they are reduced to these tired tropes.) The FBI recommended Levy and Harwe have one of the harassers arrested, which they did, and that calmed things down for a while.

Levy and Harwe knew that most chiropractors were not warning patients on their own, so they pushed for a state law requiring them to do so. After a great deal of effort they got before the state legislative Public Health Committee with the help of Sen. Len Fasano. At the committee hearing a compromise was reached between the proponents for a required warning and the chiropractic faction.

Sen. Fasano described this agreement in his testimony at the hearing before the Chiropractic Board:

I proposed legislation to the Public Health Committee, which legislation sought that some sort of informed consent be given by chiropractors to patients upon the … manipulation of the neck.

There were numerous discussions on both sides of that legislation, if I may, and it was sort of determined that perhaps the best way of handling this would be what we call a Take Away Form, where, for the first time that you [are] treated [with] the manipulation of a neck, the chiropractor would give you a Take Away Form, which discussed the risks and, also, symptoms, should you have some issues with respect to a stroke. These are the things you look at, and you should seek treatment right away.

However, it was impressed upon Senator Harris, [who] is Chairman of the Public Health Committee and myself, as the proponent, that rather than putting [it] in a state statute, the better way of doing this is to allow this Board [of Chiropractic Examiners] to govern itself, and, as a result, the matter was not pressed forward at the senate ….

Both sides agreed that a Take Away once a year upon the manipulation of the neck is reasonable, however, we did not put [it] in [a] state statute, because we believe it was better governed by the policing body [i.e., the Board].

(From Levy, I learned that she lived up to her part of the agreement, which was to take down her ads and not speak out against chiropractic while the matter was before the Board for consideration.)

Upon questioning by one of the attorneys, Sen. Fasano reiterated his understanding that “the chiropractors and the victims were coming to this Board in unison to ask for a Declaratory Ruling.” Sen. Fasano confirmed that this was Sen. Harris’s understanding as well. But by the time of the hearing, it was clear to Sen. Fasano that the chiropractors had no intention of living up to their end of the bargain and that they were dead set against any sort of discussion of the risks with patients and against giving patients a list of stroke symptoms to take home.

The Hearing

The hearing began with a bang on January 5th when the Connecticut Chiropractic Association and the Connecticut Chiropractic Council made a motion to disqualify the only public member of the Board participating in the proceeding, Jean Rexford, because they thought she might be in cahoots with one of the stroke victim organizations. This allowed the lawyers to warm up their vocal cords. By the end of almost 30 pages of transcript on this topic alone they were in fighting form. The chiropractors lost round one and Rexford remained to become the only dissenting vote in the Board’s ruling.

I attended the first two days of the hearing and it was clear to everyone from the get-go that the chiropractors would fight tooth and nail against a rule requiring any disclosure of risk. It was one of those “kumbayah” moments in chiropractic history when a temporary truce is declared in their internecine war and chiropractic organizations of all stripes circle the wagons.

This was no better exemplified than by the fact that J. David Cassidy, D.C., Ph.D., Dr.Med.Sc., lead author of the study, “Risk of Vertebrobasilar Stroke and Chiropractic Care,” Spine 33 (2008) S176-S183 [the “Cassidy study”] was required, in order to testify, to appear as a representative of the International Chiropractors Association (ICA), the organization of the super-straight-Daniel-David- Palmer- Innate-Intelligence chiropractors. I’ll bet he doesn’t put that on his C.V.

Here’s the testimony of George Curry, D.C., Chairman of the Board of ICA’s state affiliate, the Connecticut Chiropractic Council, describing the ICA’s beliefs:

Chiropractic science, as taught in the chiropractic curriculum in an accredited chiropractic college, involves the scientific aspects of the study of the human body and the science of detection and correction of the vertebral subluxation complex.

The art refers to the particular technique that a Doctor of Chiropractic would choose to reduce or correct a subluxation, and the philosophy is the where by [sic] or rationale that someone would investigate the spine as a cause of ill health.

The very basis upon which the profession was founded was that the body is a self-healing, self-regulating mechanism and has inherent recuperative powers, and that if those recuperative powers are interfered with, then it could cause of a loss of health.

Dr. Cassidy should hope and pray that this hearing transcript never, ever gets into the hands of an attorney who is preparing to cross-examine him.

Dr. Cassidy was plopped down into the middle of the hearing as a witness for the chiropractors, even though no one had listed him as a witness, as was required, prior to the hearing. This is why he had to pretend to be speaking for the ICA, as they were allowed to substitute him for the previously listed ICA witness. Apparently, we had done enough damage that the chiropractors felt they needed to bring in the man himself to defend his study.

The problems with the Cassidy study were explained on SBM  in an excellent post by Dr. Crislip (which, this being Dr. Crislip, also discusses hangings, The Who v. Motorhead, and being over age 50). The study’s hypothesis is that the association between chiropractic care and stroke can be explained by patients going to the chiropractor for headache and neck pain caused by a pre-stroke vertebral artery dissection. In other words, the pre-existing dissection causes the stroke, not the chiropractor’s twisting the patient’s neck. Dr. Crislip slices and dices the study nicely to show how this conclusion is not supported by the data.

So what did the chiropractors say, under oath, about the need for informed consent regarding neck manipulation and stroke? To quote one chiropractic witness (which is pretty much to quote them all, as their testimony on this point varied little): “There is no scientific evidence of a cause and effect relationship between a chiropractic neck treatment and a subsequent stroke.” That’s right — “no scientific evidence.

Irony of ironies! The profession that has studiously avoided the scientific method for over 100 years suddenly discovers the value of science. A sort of jailhouse conversion, if you will.

And how did they know this? The Cassidy study. Even though the Cassidy study says, right there on page S181, that “[o]ur results should be interpreted cautiously and placed into clinical perspective. We have not ruled out neck manipulation as a potential cause of VBA strokes.” (Emphasis added.)

In another big dose of irony, decades of case reports of stroke following neck manipulation introduced into evidence were dismissed by one chiropractor, who testified that these constituted mere anecdotal evidence. This from the profession for which anecdotal evidence, dressed up as “clinical experience,” repeatedly trumps scientific plausibility.

I was permitted to give testimony before the Board as a “lay witness” on behalf of the non-profit Campaign for Science-Based Healthcare. My testimony consisted of channeling the post by Dr. Crislip and another post by Dr. Hall about how chiropractors and their trade associations were misrepresenting the study’s results to the public.

I also quoted from two neurology texts which addressed the anatomical aspects of cervical manipulation and artery dissection, both concluding that manipulation could indeed cause dissection:

The extracranial VA (vertebral artery) is also susceptible to traumatic injury because of its encasement in the bony part of the cervical canal. Either spontaneously or after minor trauma from neck manipulation, the VA may be injured, and dissection with luminal compromise and clot embolization may occur. This is a common cause of stroke, especially in younger patients without other vascular risk factors.

Samuels, Office Practice of Neurology (2nd ed. 2003), 372. (Emphasis added.)

Dissection of the extracranial carotid and vertebral arteries accounts for approximately 80% to 90% of all cervicocephalic dissections…. The vertebral artery is most mobile, and most susceptible to mechanical injury, at the C1-C2 level, as it leaves the transverse foramen of the axis and abruptly turns to enter the intracranial cavity …. The C1-C2 site is involved in one half to two thirds of all vertebral artery dissections and in 80% to 90% of rotation-related dissections.

Mohr, Stroke: Pathophysiology, Diagnosis, and Management (4th ed. 2004), 1059. (Emphasis added.)

Also testifying for “our side” was the indefatigable Canadian pediatrician and chiropractic critic, Dr. Murray Katz. If you are not familiar with Dr. Katz’s work, suffice it to say that chiropractors like Dr. Katz every bit as much as anti-vaxers like Dr. David Gorski. He undermined the Cassidy study’s methodology and hammered on the susceptibility of the vertebral and carotid arteries to injury from manipulation.

Three survivors of stroke after manipulation and three relatives of patients who died also testified. You could hear a pin drop.

The most compelling aspect of their testimony was how remarkably similar each story was to the others:

  • the nonsensical reasons for having neck manipulation (sore shoulder, “maintenance care,” lower back pain);
  • the youth of the victims, all under 45 years old, one only 20 years old;
  • symptoms of stroke appearing within minutes to hours after manipulation;
  • clueless chiropractors who had no idea what was going on while their patients were experiencing stroke symptoms, and who gave their patients ridiculous advice (toxins were being released, take Advil) or did nothing at all instead of sending them straight to the hospital;
  • the patients’ and emergency doctors’ frustrations at not being able to figure out the source of the patients’ symptoms — the patients were not connecting symptoms with manipulation because they had not been informed of the risk of stroke;
  • the “aha!” moments of hospital doctors when they learned their patients had undergone chiropractic manipulation;
  • the lingering neurological deficits of the patients who survived and the devastation suffered by the victims and their families.

There could have been no better summation for the victims and their allies than the testimony of Douglas Fellows, M.D., chairman of Diagnostic Imaging and Therapeutics at the University of Connecticut Health Center, a member of the Connecticut Medical Examining Board, and himself a former physical therapist who had used cervical manipulation in his practice. He appeared in support of the Medical Examining Board’s previously filed statement urging that patients be informed of the risk of stroke following manipulation.

Dr. Fellows confirmed the Medical Board’s opinion that vertebral artery dissection can be caused by cervical manipulation. He also testified that, although the risk of stroke and death were remote in the procedures he performs as an interventional radiologist, he always tells patients of this possibility. In response to a question from a Chiropractic Board member — which contained the assertion that “we haven’t established any causality. At most, we’ve established a temporal relationship” — he replied:

We don’t know what the risk is, as far as the percentage risk, but it’s the harm that we worry about, the potential, the devastating effect of paralysis or death, and that’s what we do [referring to warning his patients of the risk of stroke from certain procedures, even thought the risk is remote].

The Decision

Although the Board had previously voted 4-1 against the necessity of a warning, the written “Declaratory Ruling Memorandum of Decision” was not issued until June 10th.

In its decision, the Board correctly stated that, under Connecticut law, “[t]he materiality of a risk is determined by weighing the benefits of a procedure, against the frequency and severity of the potential harm.” But, this being chiropractors, who simply discard facts not fitting their paradigms, that was the last mention of “benefits” and “severity.” From then on, the decision focused solely on “frequency.”

The Board relied heavily on the Cassidy study in making its decision that “the evidence is sufficient to establish that a stroke or cervical arterial dissection is not a risk or side effect of a joint mobilization, manipulation or adjustment of the cervical spine performed by a chiropractor.”2 It is worth repeating that the study itself states “[w]e have not ruled out neck manipulation as a potential cause of some VBA strokes.” However, the Board explained this away by noting that “Dr. Cassidy credibly testified ‘this is a study that raises real doubt about the association being a risk …’” In fact, according to Dr. Cassidy’s testimony, he’s become so doubtful he has absolved himself from a previous admission that he caused a patient’s stroke by manipulating her neck.

The Board went on to explain that “[s]tatistically, what scant evidence exists of the incidence of stroke following a … manipulation … of the cervical spine was found primarily in persons under age 45. As provided in the Rothwell study, ‘it remains to be explained why an association between chiropractic manipulation and [vertebrobasilar accident] was observed only in the young. If an association were to exist, one would expect that it would exist regardless of age.’”

If only the Connecticut Board of Chiropractic Examiners had read Science-Based Medicine before issuing its ruling!
Dr. Crislip, who has answered many questions here recently, had an answer to this very question months ago in his SBM post on the Cassidy study.

In the over 45 age group, strokes due to chiropractic could be lost in the sea of strokes due to other reasons, and since we do not know if there were a dissection or blood clot as a cause of strokes, it is hard to conclude that there were no extra strokes from chiropractic. The study was not powered to determine the rare event of a chiropractic event against the background to usual stokes in the elderly. The mean age in this study was 63 ….

Young people should not have any stroke. In the young, vertebral artery dissection is a common cause of a rare event. It is also the worry from chiropractic neck manipulation. If you could find an effect of chiropractic, it would be in the young. And they do. The people who have an increase in stroke are those under age 45. And it is a big association: odds ratios from 3 to 12.

The association is most noticeable in the first 24 hours after seeing a chiropractor. Usually if you rip an artery it is symptomatic right away. Again, we do not know if these people had dissection or not. We only know they had stroke of some sort, within a day after seeing a chiropractor. One would predict that if there were an association between chiropractic and stroke you would most easily find it in the young and the effect would be most noticeable in the first day or so after the chiropractic visit.

And this article confirms this association.

I even cited to Dr. Crislip’s post in my brief and provided a link! So much for Board’s self-proclaimed “careful and thorough review of all of the testimony and documentary evidence.”

And speaking of said “careful and thorough review,” the decision did not explain how Board managed to avoid the basic anatomy of the human neck, which strongly suggests that twisting it forcefully is really not a good idea.

The Board did allow that “the evidence is sufficient to establish that spinal manipulation on persons who are having an acute stroke or cervical arterial dissection is not within the standard of care.” Well, that’s certainly a relief!

The Board also said that a chiropractor who wanted to “discuss these issues” [presumably, the non-existent stroke risk] with a patient could do so without being in violation of the standard of care.

So, even though the Cassidy study says that patients with headache and neck pain can be presenting with vertebral artery dissection, and that there is no screening procedure to determine whether patients presenting with headache or neck pain are at risk of VBA stroke, chiropractors should feel free to manipulate the neck without warning of the risk of stroke. Why didn’t the Board decide that the evidence they find so compelling dictated the much safer option of not using manipulation on anyone with headache or neck pain?

Post-hearing

What does this ruling mean?

Unfortunately, young people will continue to have debilitating strokes and some will die following cervical manipulation.

But the fight was not for naught. Many TV viewers saw scary videos of necks popping at the hands of chiropractors during media coverage of the hearing. Awareness of the risk of stroke was raised — not everyone believes the chiropractors when they deny it. “Our side” got great press.

Janet Levy can resume her bus ads in Bridgeport. Sen. Fasano will again introduce legislation making chiropractors inform their patients of risk. It failed this year but he vows to re-introduce it next year. And Levy has just filed suit in Connecticut against two state chiropractic organizations citing them for, among other things, failure to warn patients of the risk of stroke following manipulation.

The Board’s declaration that there is no risk of cervical artery dissection and stroke following manipulation is a finding of fact and not binding on the courts. As is their ruling that informed consent does not require a warning. Under Connecticut law, whether a warning of risk is required is determined by the “reasonable patient” standard, that is, what would a reasonable patient consider important in making his decision whether to undergo a particular procedure. One of the very purposes of the reasonable patient standard is to prevent practitioners from setting low standards and then claiming they’ve abided by their profession’s standard of care. Imagine the chiropractor sued for failure to warn who erroneously thinks he’s been inoculated against malpractice claims by following the Board’s ruling. Surprise!

As a matter of fact, the hearing transcript and videotape are now in the hands of plaintiffs’ personal injury attorneys, who will mine it for useful information. A couple of years ago the American Justice Society (formerly known as the Association of Trial Lawyers of American) started a chiropractic interest group (that is, interest in suing chiropractors for personal injury). The section collects and distributes such information for AJS members.

The chiropractors may have won this battle, but they could be losing the war.

Notes

  1. The Petition for Declaratory Ruling filed by the Connecticut Chiropractic Association, which set this proceeding into motion, used the term “cervical artery dissection” in describing the risk of cervical manipulation at issue before the Connecticut Board of Chiropractic Examiners. The Board also used the term “cervical artery(ies)” in its ruling and otherwise during the proceeding, as did some of the other participants. “Cervical artery” is an imprecise term as there is no such anatomic structure. Apparently, its use refers collectively to the vertebral and carotid arteries.
  2. At least I think that is the Board’s decision, as it is repeated several times and is made “Finding of Fact” number 3 in the Memorandum of Decision. But the Board also states a couple of times, once in its actual “Order” at the end of the written decision, that the “evidence is insufficient to conclude that stroke or cervical artery dissection is a risk or side effect of” cervical spine manipulation. Deciding that the evidence is sufficient to establish there is no risk is quite a different thing than deciding the evidence is insufficient to establish there is a risk.

Posted in: Chiropractic, Politics and Regulation

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199 thoughts on “Not to worry! Chiropractic Board says stroke not a risk of cervical manipulation.

  1. SkepticalLawyer says:

    Great post.

    This explains the billboard I saw in or outside of Hartford last week as I was passing through on Interstate 84. It said something like, “Chiropractic can cause a stroke.” Being an avid reader of SBM, I was glad to see it but wondered where it came from and who paid to put it up. Now I know.

  2. Joe says:

    Great post, thanks!

    I have one nit to pick: Cassidy (and DCs in general) does not have a legitimate doctorate and does not merit that honorific (‘doctor’). I am more confrontational than many others; but calling him ‘doctor’ makes it sound like he may represent a legit difference of opinion with real, health professionals.

    Thanks for your service.

  3. Blue Wode says:

    Excellent post.

    Jann Bellamy wrote: “To quote one chiropractic witness (which is pretty much to quote them all, as their testimony on this point varied little): “There is no scientific evidence of a cause and effect relationship between a chiropractic neck treatment and a subsequent stroke.” That’s right — “no scientific evidence.” Irony of ironies! The profession that has studiously avoided the scientific method for over 100 years suddenly discovers the value of science. A sort of jailhouse conversion, if you will.”

    It’s interesting to note that the above concern was also highlighted in paragraph 146 (p.55) of the Statement of Claim filed by tetraplegic Canadian chiropractic victim, Sandra Nette, in her multi-million dollar lawsuit:

    Quote:
    “Incredibly, and, acting in bad faith, the College [Alberta College and Association of Chiropractors] attacked the new and surprisingly high number of vascular accidents associated with chiropractic services that were published medical literature and reported in the media by demanding a level of evidence it has never demanded of itself. It maintained that the causal link between strokes and chiropractic adjustment remained unproven.”
    http://www.casewatch.org/mal/nette/claim.pdf

    For those wishing to watch the online recordings of the January 2010 Connecticut State Board of Chiropractic Examiners Public Hearing on Informed Consent for Chiropractic Procedures, they can be viewed via this link: http://www.ctn.state.ct.us/ondemand.asp?search=chiropractic

  4. Happy Camper says:

    I don’t know if anyone else caught this?

    “In its decision, the Board correctly stated that, under Connecticut law, “[t]he materiality of a risk is determined by weighing the benefits of a procedure, against the frequency and severity of the potential harm.”

    Weighing the benefits of a procedure?

    But there are not any benefits only risk!

  5. pmoran says:

    Happy Camper:

    “Weighing the benefits of a procedure?

    But there are not any benefits only risk!”

    PM Well, chiropractic care may elicit placebo-type benefits, and the “no benefits” argument rarely seems to prevail while patients are claiming otherwise and some kinds of clinical study show substantial patient satisfaction. Chiropractic always gets the benefit of the doubt.

    Another tack- chiropractic’s own scientific papers show no advantage of neck manipulation over safer treatments such as massage.

    Taking that into account, even the faintest potential for serious risk should forbid the practice, except possibly as a late resort for well-informed patients who are not responding to other measures.

  6. Happy Camper says:

    @pmoran

    I know, I know

    My best friend swears by chiropractic for his back problems. I think most people use chiropractic only for back problems not realizing that a physical therapist or sports massage would help more without risk or the trappings of pseudoscience, and be cheaper in the long run.

  7. Ian says:

    Do chiropractors do something that I wouldn’t do while giving my girlfriend a shoulder/neck rub? A stroke is a scary thought!

  8. weing says:

    And smoking cigarettes does not cause lung cancer. The tobacco industry says so.

  9. Bogeymama says:

    There was a famous case here almost a decade ago. A physician I know lost his father, also a physician, to a stroke after a manipulation by a chiropractor. Here’s one of the stories:

    http://chealth.canoe.ca/channel_health_news_details.asp?news_id=3669&channel_id=0

    In this case, chiropractors were not denying the risk of stroke, but defended it as causing fewer deaths than anti-inflammatories. Funny, how often do I see patients taking anti-inflammatories on the advice of their chiropractors? After almost every visit, patients report that their chiro recommended Robax Platinum or Advil after their manipulations for a few days. Of course, the patients always said that the manipulation is what made them better…. despite being in pain for several days afterwards.

  10. overshoot says:

    This explains the billboard I saw in or outside of Hartford last week as I was passing through on Interstate 84. It said something like, “Chiropractic can cause a stroke.” Being an avid reader of SBM, I was glad to see it but wondered where it came from and who paid to put it up. Now I know.

    One wonders whether the complainants are hoping that the chiropracters will ignore British precedent and sue for defamation. Although I do note that Connecticut doesn’t have a SLAPP law.

    Who knows? Maybe we could end up with two good things for the price of one.

  11. aaronupnorth says:

    The appeal to evidence by the chiropractic board actually further shows just how much they misunderstand the process of applying evidence to medical practice.

    The issue of stroke after neck manipulation is best thought of as a rare and serious complication of a procedure. Rare events are not well captured by randomized prospectively obtained evidence as trials powered to determine treatment efficacy are not typically powered to detect rare events. In general terms a 1 in 10,000 risk of death would be potentially significant especially for a treatment that involved repeated exposure or was very common, but such an event could potentially be missed in a trial powered to prove efficacy, even if the trial was very large. Retrospective case control series for common diseases are also unlikely to answer a causation/correlation question and stroke, even in those under 45 is common enough to make the background noise of such a study difficult to cope with.

    For most drugs and treatments post marketing or post application surveillance is how rare but serious complications and side effects are detected. That is, when the product is applied to the population unusual and serious events are reported either to the manufacturer or more commonly to a government agency.

    A good example from medicine is the antibiotic telithromycin, a promising and heavily marketed drug that proved to have very serious but very rare side effects detected after release to the marketplace and resulting in much restricted use of the drug. Telithromycin was initially marketed as a first line agent for a number of infections, and currently it would be difficult to find a doctor (other than an infectious disease specialist) who routinely uses it.

    The threshold to warn patients about rare but potentially serious side effects is the question ‘would a regular prudent person want this information?’. Mainstream medicine does in fact use and rely on anecdote to detect rare events associated with our treatments. The threshold for proof of treatment efficacy relies on well conducted and controlled research, but suspicion of significant side effect is another matter entirely, and when there is reasonable suspicion of a significant side effect patients should be warned in advance, even if definitive proof does not yet exist.

  12. LindaRosaRN says:

    A couple months ago, while visiting my parents, I learned the details of my uncle’s death which occurred years ago while I was living abroad country. All I had known those years was that he had died of a stroke and that he hadn’t wanted to go to the hospital. Now I learned the stroke occurred as he was being driven home from a chiropractic appointment. (He lived in central Wisconsin and the chiropractor was in Upper Michigan.) When the stroke occurred, he indicated to his wife that he wanted to be taken back to the chiropractor’s office — and he died on the way. None of the relatives had any suspicion that the stroke might have been the result of a chiropractic neck adjustment.

    Thanks for the informative post. I hope the billboard campaign takes off.

  13. rwk says:

    @ (Doctor) Joe,
    Let’s not perform any more medical or chiropractic procedures
    that can cause stroke or death. OK?

    @ LindaRosaRN
    Can you prove your last post?

  14. Harriet Hall says:

    rwk said “Let’s not perform any more medical or chiropractic procedures that can cause stroke or death.”

    That would be a pretty stupid reaction, like saying let’s ban cars because traffic accidents kill people. Instead, let’s not perform any more medical or chiropractic procedures that are more likely to harm than to help, and let’s let patients know when there is a risk of death from any treatment so they can make an informed choice.

  15. rwk says:

    @ Harriet Hall
    I was being facetious. Now to be serious.
    How many people actually read those multipage medical
    consent forms before they have a procedure nowadays.
    Maybe chiropractors should adopt complex forms like those used
    by medics that are quickly scanned by the patient and signed .
    And since it wouldn’t be the usual SBM rag without an ad hominem,
    I’ll throw one in:

    http://www.scribd.com/doc/25785402/DEATH-DUE-TO-MEDICAL-INTERVENTION

    In 20 years, I’ve not killed ,stroked or disc herniated anyone,
    how about you?

  16. Harriet Hall says:

    rwk,

    That’s not an ad hominem, that’s a tu quoque logical fallacy based on a misconception. See my article on “Death by Medicine” at http://www.sciencebasedmedicine.org/?p=136

    You say “I’ve not killed ,stroked or disc herniated anyone.” How do you know for sure? Do you have a comprehensive, systematic method of followup? I’ve heard more than one anecdote where a stroke patient never went back and told the chiropractor. And even if you’ve never personally seen these complications, that doesn’t mean the risk doesn’t exist. I’ve been driving for decades without an accident, but that doesn’t mean I won’t have one tomorrow.

    And as for those complicated consent forms, at least the fact that they have to sign a form lets the patient know there is a risk. Many chiropractors lead their patients to think there is no risk at all.

  17. weing says:

    “Maybe chiropractors should adopt complex forms like those used by medics that are quickly scanned by the patient and signed .”

    Of course they should. Then why are you so afraid of them? Let patients know what the risk-benefit ratio is. That reference you gave has so many errors, I wouldn’t know where to begin. About the only partially correct statement is the first one.

    “In 20 years, I’ve not killed ,stroked or disc herniated anyone,how about you?”

    Can you prove that you haven’t? You probably have. You, and luckily for you the patient also, are just not aware of it.

  18. rwk says:

    @Harriet Hall
    Do you have a comprehensive, systematic method of followup?

    Yes, unlike many medical establishments that don’t call back or follow up.

    @ weing
    If a chiropractor tells a patient he might have a stroke following
    cervical manipulation ( I’d say) he or she is likely to decline.
    If a medical doctor tells a patient they have to have a procedure,
    ( in my experience) they’re likely to go through with it. How many
    doctors or nurses explain to the patient all the possible risks vs benefits involved? In my experience, few.

    I was taught in school to do informed consent and for what it’s worth do provocative testing before manipulating someone’s neck.
    That idea gets driven home at most state assn. sponsored risk
    management CME courses,once a year.
    Prove me wrong.

  19. Harriet Hall says:

    Prove that provocative testing removes the risk.

  20. weing says:

    “If a chiropractor tells a patient he might have a stroke following cervical manipulation ( I’d say) he or she is likely to decline.”

    That’s called weighing the risk vs the benefit.

    “If a medical doctor tells a patient they have to have a procedure,( in my experience) they’re likely to go through with it.”

    They are aware of the risks and benefits. That’s what counts. Some will refuse the procedure or the medication. It’s their quarter.

    “How many doctors or nurses explain to the patient all the possible risks vs benefits involved? In my experience, few.”

    I tell the patient about the important risks. Telling them all the possible risks is not feasible.

  21. # rwk – “How many people actually read those multipage medical
    consent forms before they have a procedure nowadays.”

    Well, me, for one. My son has had three minor outpatient, two inpatient surgeries. All of which had one page consent forms which I read. Each time the nurse (outpatient) or NP (inpatient) went over the form with me as well as covering pre-op and post-op care. Once there was medical terminology I didn’t understand, which the NP explained. In all cases the surgeon had already verbally discussed the more significant risks/benefits with us and answered questions before the meeting with the Nurse/NP to go over the consent form which included rarer complications.

    Really, I have no idea why you wouldn’t read such a consent form on a pre-arranged procedure. I could see that an emergency procedure may be a different matter.

    I will admit that I did not completely read our mortgage paperwork, though.

  22. Calli Arcale says:

    If a chiropractor tells a patient he might have a stroke following
    cervical manipulation ( I’d say) he or she is likely to decline.
    If a medical doctor tells a patient they have to have a procedure,
    ( in my experience) they’re likely to go through with it. How many
    doctors or nurses explain to the patient all the possible risks vs benefits involved? In my experience, few.

    Every doctor who has performed a procedure on me has either personally explained the risks and benefits or had someone such as a nurse explain it to me. For more serious procedures, I generally got risks/benefits explained to me by both the physician and one or more nurses.

    Perhaps you have merely had incompetent doctors.

    In my experience, patients will tend to accept medical advice, as you say — but they will accept it no matter what kind of “doctor” gives it. Few patients discriminate between an MD and DC. Why is it that you are so convinced that explaining risks of chiropractic manipulation will drive away all your customers, but equally convinced that no explanation of risks/benefits can ever possibly be meaningful in medicine? Do you think patients are mindless automata when seeing doctors but nervous nellies when seeing chiropractors?

    This may not be your intent, but the way you frame your objections sound as if you are more concerned about losing business than about your patients’ safety.

    BTW, what Hall was referring to (with respect to followup) was not mere phone calls. She was referring to studies that follow patients for weeks or even years in a consistent manner. Obviously no doctor follows up with their patients that way, but it is expected that for any new drug or surgical technique or whatever, this sort of rigorous followup will be done for a representative sample of the patient population. Just calling people up on the phone isn’t exactly controlled or consistent, and is not going to give you the sort of data you need to really understand the risks and benefits of your procedures.

    But then, maybe that’s okay for you. Maybe all you really care about is patient satisfaction, not patient outcomes, and in that case perhaps a followup phone call really is adequate. But I would prefer my doctors see me as a patient rather than a customer.

  23. pmoran says:

    “I was taught in school to do informed consent and for what it’s worth do provocative testing before manipulating someone’s neck.”

    Why, if there’s so risk of stroke from VAD?

    PM

  24. pmoran says:

    i.e. “no risk”.

  25. Joe says:

    rwk on 04 Jul 2010 at 6:18 pm wrote “@ (Doctor) Joe,
    Let’s not perform any more medical or chiropractic procedures
    that can cause stroke or death. OK?”

    Although I have a legitimate doctorate (as opposed to a DC) I don’t appreciate that honorific except in settings where it is clear that I am a scientist, not medical person. I always invited my students to call me Joe, rather than mister, doctor or professor; and I invite you to do the same.

    Some of your colleagues don’t appreciate the acknowledgment that your ilk cause strokes: http://www.dynamicchiropractic.com/mpacms/dc/article.php?id=53030 That article is about chiros who promise not to snap your neck.

    I note that in the case of Sandra Nette (linked, above, by Blue Wode) she arrived at the hospital unable to communicate. When her husband arrived, the neurologist, noting the bilateral VAD, asked “Chiropractor, right?” Yes, bilateral artery dissection is chiropractic’s unique, signature contribution to health (rather, damage to it).

    @rwk, what do you think you do by twisting/snapping necks that cannot be achieved, more safely, otherwise? I suspect the risk/benefit ratio is dominated by the ‘benefit’ being zero; which leads to an unacceptably large number (division by zero, emphasizing risk).

  26. rwk says:

    @ Joe,
    First of all I don’t care what you or anybody else calls me. Noe of us
    are any better or higher up than anyone else. You’ve decided that
    some doctorates are more honorific than others.
    Second, referring to manipulation as “snapping necks” just shows
    your level of knowledge of what not just chiropractors do.
    Have you read any current technique books nor any directives from
    chiropractic associations that say go ahead and twist,snap or ( you
    forgot to say) crack necks?
    Did I mention by the way that I snap or twist necks?
    So, this blog just ends up being an argument, usually one sided.
    You’re as guilty of ad hominem tu quoque and other diversions as anyone else (by the way Harriet Hall is there a difference ?).

  27. Jann Bellamy says:

    I just received a link to a youtube video showing a chiropractor practicing in his office. It appears this is a promotional video for the chiropractor. In it you will see neck and other “adjustments,” treatment of children, “adjustments” using the Activator method (that’s the metal gadget that the chiropractor is poking people with), what appears to be leg length testing (a chiropractic diagnostic technique) and some sort of arm shaking — don’t know what that is.

    http://www.youtube.com/watch?v=NuUM70kmUSg&feature=related

    Here is an actual cervical adjustment, also from youtube:

    http://www.youtube.com/watch?v=y_3si7-Pn1A&feature=related

  28. Harriet Hall says:

    rwk,

    Please enlighten us. What are your indications for manipulating necks? Why do you do neck manipulation rather than gentle mobilization? Why do you think you can reduce risk by provocative testing?

    If you think our information is one-sided, you are welcome to present the other side. But only if you can provide supporting evidence.

  29. pmoran says:

    “I was taught in school to do informed consent —”

    So, what are you here for, rwk?

    You seem to be allowing that neck manipulation can cause strokes, and you say you were taught about the need for informed consent.

    Yet you are carrying on as though it an impertinence to despise those chiropractors who pretend there is no problem.

    I suspect you are an older chiropractor, trained in the days when the chiropractic profession itself accepted without reservation that neck manipulation can cause stroke.

  30. CarolM says:

    Well I’m glad I saw this because even though I loathe chiropractic and all their marketing gimmicks, I did used to like an “adjustment” now and then for extreme neck and shoulder tension. One old gal would put me on a series of worthless machines like the Spino-O-Lator while I waited my turn. All I wanted was the massage and neck pop. The tightness seemed to dissipate quicker that way, though it may have been an illusion.

    I would go once a year maybe, and never sign up for continuing treatments which I thought were a ripoff. And chiro for infants? Egads. I recognized the old chiro establishment as oldtime health food & vitamin nuts and alt-med quacks, which were plentiful in SoCal (and my family).

    Eventually I stopped going because exercise in general seemed to keep the tension at bay…though a month ago I considered it once again.

    But I always thought it suspicious that the neck release “adjustment” seemed to be the bottom-line cure for *everything* but how could that be so?

  31. rwk says:

    @Harriet Hall and pmoran

    I said “I was taught in school to do informed consent and for what it’s worth do provocative testing before manipulating someone’s neck”.

    You’re making inferences that aren’t there.

    I said for what it’s worth. It has been shown that tests like George’s
    deKleyn’s and all the others have failed to show predictive value.

    What are your indications for manipulating necks?
    -chronic neck pain, joint dysfunction,decreased ROM

    Why do you do neck manipulation rather than gentle mobilization?
    I never said I do neck manipulation rather than gentle mobilization.
    There’s a time for each. It’s best to not take clinical risks.

    Why do you think you can reduce risk by provocative testing?
    I never said that either. They were taught in school but subsequently showed
    little predictive value as I said above.

  32. Harriet Hall says:

    rwk,

    OK, I’m beginning to understand you better. But I still have a lot of questions.
    Do you think any chronic neck pain is an indication for manipulation?
    Do you think some chronic neck pains might be due to something that would be worsened by manipulation?
    When do you think neck mobilization is superior to gentle mobilization? A Cochrane review found them to be equally effective and found that they only worked in conjunction with exercise.

    Do you believe neck manipulation can cause strokes?
    What do you tell patients before you manipulate them?

  33. drjohnedwards says:

    I just watched your testimony to the Board in January. It’s nice to put a face to a blogger, I think you do good work. I do something similar, except I dig into the research put out by the medical profession. I think it’s good to have critics, it makes those of us who work in woo sharper. Speaking of sharp, I had some questions about your testimony after reading this blog post.
    (From http://ct-n.com/ondemand.asp?ID=5034)
    Commissioner Paul Powers: Do you agree or disagree with this statement? Some complications are so extremely rare that they need not be routinely mentioned. However, if asked a direct question concerning the possible occurrence of a complication, the doctor must answer truthfully.
    Jan Bellamy: Yes.
    Jay Malcynsky: Do you believe there are circumstances where if there is a risk they should inform the patient irrespective of whether the patient asks first?
    Bellamy: Yes.

    Ok, I get that. It makes sense. Have you thought more about the threshold question Commissioner Powers asked you? Because earlier there was this exchange:

    Powers: Are there any mandated levels that a specific percentage risk of something would require a warning… that disclosure has to happen?
    Bellamy: I’m not aware of any and I would say that probably not because risk is always compared to benefit.

    So what I’m confused about is that Powers essentially asked you if you agreed with the status quo of informed consent and the recommendations national associations within chiropractic have given in regards to the issue of written and oral informed consent since the time I’ve been aware of the issue- which is about 10 years. You said you did. Malcynsky then followed up by asking if there were certain complications to treatment that should be especially highlighted by the doctor during the process, and you thought so. Yet to Powers you said you didn’t think there would need to be a threshold. My question is the same that Powers has- no other profession has been asked to do this, to be ordered by law to specifically cite a complication during informed consent. So where would you start, the condition severity or the threshold? I calculated the frequency will happen once every 10 to 30 practice years depending on the studies you cited (1 in 400,000, 1 in 1.3 M) figuring 180 patient visits a week, 2 weeks of vacation, and averaging 3-4 adjustments to the spine per visit. Everyone, you included, agreed there has to be a marker somewhere that makes sense- I think the Board and the State of CT reached that conclusion based on the best evidence and testimony provided, so I’m not sure why all the vitrol in response to what happened. You did your best, an agreement was reached, and people were informed. Learn from your experience and move on.
    Also, I’d be careful about posting stuff like this:

    “My testimony consisted of channeling the post by Dr. Crislip and another post by Dr. Hall about how chiropractors and their trade associations were misrepresenting the study’s results to the public… I even cited to Dr. Crislip’s post in my brief and provided a link! So much for Board’s self-proclaimed “careful and thorough review of all of the testimony and documentary evidence.”

    Because during your testimony…
    Mary Alice Moore-Leonhardt: How did (you) gather and select the literature that is included in the report that’s being presented to the Board for its review?
    Bellamy: Some of the research I already had in my possession from other research I had done. The remainder if I recall correctly I know it involved the literature searches of the medical literature on PubMed.

    PubMed, huh? With your background you should have known better than that, because this is probably going to follow you in future cases. Saying Crislip and Hall were covered under your statement of “other research” is going to be a bit thin. If you personally want to create shifts in policy, you’re going to need to stay credible. Katz has blown his so badly by becoming radicalized that the very people he wants to change will now never really listen to anything he has to say, regardless of its validity. I think that’s sad because he’s probably a bright guy, and like I said, I think your training has provided you with good investigative skills too. If this is something you want to continue to do effectively- testify to governing bodies associated with CAM professions to enact change- please carefully consider your personal associations and public statements.

  34. Jann Bellamy says:

    And I’d like to add another question:

    What is “joint dysfunction?” Is that the same thing as the chiropractic “subuxation” or any of it’s many synonyms: “vertebral subluxation complex,” “spinal lesion,” etc.

  35. nobs says:

    “# Harriet Hallon 04 Jul 2010 at 10:25 pm

    Prove that provocative testing removes the risk.”

    Prove that cervical manipulation IS a risk.

  36. Joe says:

    rwk on 05 Jul 2010 at 4:59 pm wrote “@ Joe, … No[n]e of us are any better or higher up than anyone else. You’ve decided that some doctorates are more honorific than others.”

    No, an honorific is a form of address that recognizes earned status; such as general, doctor, ambassador etc. I have decided that some doctorates are legitimate and others are not. A DC is not a legitimate, academic degree, that’s a fact. Your “schools” are not affiliated with legitimate, academic institutions.

    Sorry to rattle your New Agey wishful thinking- some of us are better than others. My understanding of anatomy and physiology, as poor as it is, is better than that of anyone who spends years (and money) studying the chiropractic subluxation.

  37. nobs says:

    “# Joe on 06 Jul 2010 at 12:00 pm

    A DC is not a legitimate, academic degree, that’s a fact. Your “schools” are not affiliated with legitimate, academic institutions. ”

    Really Joe ??????

    The US Dept. of Education, Veteran’s Administration, hundreds of hospitals, all 50 states in the union and every regional college accrediting agency feel that chiropractic education is “legitimate”.

  38. Harriet Hall says:

    nobs said “Prove that cervical manipulation IS a risk.”

    That has been proven to the satisfaction of most scientific thinkers and even many chiropractors. We don’t (and can’t) have a perfect prospective RCT, but we have other convincing data and many “smoking gun” cases where patients collapsed on the chiropractor’s table.

    And chiropractic colleges may be accredited, but that doesn’t mean chiropractic is a legitimate academic discipline. No chiropractic college has ever been accepted as part of a university (except for Sun Myung Moon’s church-affiliated university in Bridgeport.)

    My concern is not with the “doctor of chiropractic” designation, but with those chiropractors who only call themselves “doctor” and deliberately mislead patients who assume they are MDs.

  39. nobs says:

    “# Harriet Hallon 06 Jul 2010 at 12:42 pm
    nobs said “Prove that cervical manipulation IS a risk.”

    That has been proven to the satisfaction of most scientific thinkers and even many chiropractors. We don’t (and can’t) have a perfect prospective RCT, but we have other convincing data and many “smoking gun” cases where patients collapsed on the chiropractor’s table.”

    Thank-you for your opinion Harriet—-however that was not my question. Perhaps my query was not clear:

    “Prove that cervical manipulation IS a risk.”

    Afterall, is that not what this discussion is supposed to be about?…….or is it about something else?

  40. pmoran says:

    drjohnedwards: “So where would you start, the condition severity or the threshold? I calculated the frequency will happen once every 10 to 30 practice years depending on the studies you cited (1 in 400,000, 1 in 1.3 M) figuring 180 patient visits a week, 2 weeks of vacation, and averaging 3-4 adjustments to the spine per visit.”

    No, no, no. Where you start is in deciding whether ANY risk is tolerable i.e. does neck manipulation have unique effectiveness for any condition?

    If that can be shown, are its advantages over the other options sufficient to justify its use as a first line of treatment, or should it be reserved for cases that don’t respond to other methods? If the latter, what should be the guidelines?

    After that, you are on surer ground for deciding how patients are informed, but context remains important. “You might (very rarely) die” would be considered important informed consent information by most patients seeking treatment for tension headaches or those being asked to undergo maintenance chiropractic treatments.

  41. drjohnedwards says:

    @pmoran
    Thank you, very thoughtful response.
    >are its advantages over the other options sufficient to justify its use as a first line of treatment, or should it be reserved for cases that don’t respond to other methods? If the latter, what should be the guidelines?
    Good question. I suppose it depends on a couple of factors: 1) What weight to we give to qualitative studies measuring patient perceptions of treatment vs. previous experiences with the condition, and 2) how we define conservative treatment- by level of invasiveness in the body, or by level of acceptance by the governing community. Is it reasonable to measure invasiveness by risk of complication per application, and should we include mass effect of chronic (or on-going) use?
    >“You might (very rarely) die” would be considered important informed consent information by most patients seeking treatment for tension headaches or those being asked to undergo maintenance chiropractic treatments.
    You know what, I’m going to start doing this tomorrow. I read a post on this earlier about woo practitioners being more concerned with their pocketbook than their patients’ safety, and I don’t think that’s really so. I will start with providing this list and report back at the end of the week to tell those interested how it goes: http://www.livescience.com/environment/050106_odds_of_dying.html

  42. Jann Bellamy says:

    @drjohnedwards:

    I think your first question has been answered nicely by Dr. Moran. I with what he says. I don’t believe there is any “threshold” percentage of risk which can be used as a guide. The question is not risk alone, but risk v. benefit v. other treatments (and their risks v. benefit) and I think that I made that clear in my answers to Dr. Powers. If I left the impression with you or anyone else that I advocate a threshold number that is not what I meant. To Dr. Powell I was simply stating that, in the abstract, not every risk needs to be disclosed but certainly if the patient asks about it, then the physician must discuss it. I think Dr. Fellowes spoke eloquently on this point and I would urge you to review his testimony.

    I do not take my testimony to agree with the “status quo of informed consent” advocated by chiropractors nor is that what I meant, and I am not sure how you came to that conclusion. If that is what Dr. Powers was asking, I assume he would have said so directly.

    As to what other profession has been ordered to inform patients of a specific risk, I have not researched that issue. It appeared to be the consensus of the chiropractors who spoke at the hearing that this was the first such case. The problem is that there is a sufficient risk of vertebral and carotid artery dissection and stroke from chiropractic manipulation that patients should be informed of same, and the chiropractors are not doing that. As Dr. Fellowes pointed out (and he specifically said he thought there was evidence pointing both ways) it’s not the percentage of risk but the devastation — the incapacity and death, that mandates the warning in this case. I would add to that, as I did in my testimony and filed documents, the lack of demonstrated benefit of cervical manipulation. I would also point at that, as testified to by Sen. Fasano, the chiropractors were in agreement that a “Take Away Form” warning of the risk would be appropriate. To paraphrase a much-used political comment, they were for it until they were against it.

    As to Ms. Moore Leonhardt’s question, I took it to mean a reference to the brief I filed, which cited numerous journal articles, hence her use of the word “literature.” In any event, I disagree that the posts of Drs. Hall and Crislip were “thin.” I thought they did an excellent job and used their comments as a base from which to construct my oral testimony.

    I do not agree, for the reasons stated in the post, that the Board’s decision was “based on the best evidence and testimony provided.”

  43. Joe says:

    @nobs on 06 Jul 2010 at 12:30 pm wrote “The US Dept. of Education, Veteran’s Administration, hundreds of hospitals, all 50 states …”

    Actually, no. Accreditation only means that the school exists as described in its literature and is financially sound. See the article, linked below, about accreditation of a school of astrology. That is not a legitimate program, either.

    http://64.233.169.104/search?q=cache:53OEGhaHbjIJ:query.nytimes.com/gst/fullpage.html%3Fres%3D9F02E3D71F31F93BA1575BC0A9679C8B63+astrology+accreditation&hl=en&ct=clnk&cd=1&gl=us&client=firefox-a

  44. nwtk2007 says:

    Once again I see the anti-chiro non-SBM opinions fly. Just to see how this raging epidemic of chiro stroke is at present, how many chiro-caused strokes have happened since Ms Nette’s alleged chiro-caused stroke occured?

  45. weing says:

    “Just to see how this raging epidemic of chiro stroke is at present, how many chiro-caused strokes have happened since Ms Nette’s alleged chiro-caused stroke occured?”

    You hit the nail on the head exactly. We do not know. Since patients are not even aware of the possibility, they do not put the two together. Let’s raise patients’ awareness, track the incidence and we can then answer this question.

  46. Joe says:

    Further to what weing said: dead people can’t answer questions. There is a case where a woman found her young husband dead. It was from a stroke; she did not know he had been to a chiro till she went through his wallet and found the appointment slip. Lack of information couples with lack of awareness to leave us in the dark regarding risk.

    Besides that, nwtk2007, why don’t you supply us with the information showing the neck-snap is so important that it outweighs the possibility of such serious harm.

  47. pmoran says:

    ntk:”Once again I see the anti-chiro non-SBM opinions fly. Just to see how this raging epidemic of chiro stroke is at present, how many chiro-caused strokes have happened since Ms Nette’s alleged chiro-caused stroke occured?”

    Fewer, I hope. More sensible chiropractors will be thinking long and hard about how and when they manipulates necks. If not adept at massage, or at keeping a straight face while using low-level lasers, they might even consider buying one of those dinky little clicking gadgets to do the “adjustment.

    We expect generally similar outcomes regardless of treatment choice.

    It is not merely the medically responsible thing to do. Every case that occurs from now on will harden public opinion, increase damages awarded by the courts and hence insurance costs, and put further pressure on your regulators.

  48. nwtk2007 says:

    Three comments: one that we don’t know, one that they die and no one knows, one that chiro’s will or should be more careful, yet not one single documented case since the Nette incident.

    I truly love the absolute association of the woman who found her husband dead and found an appointment slip in his wallet. Not a receipt for services or even a mention of follow up with the chiro? Where did you hear this one Joe?

    The bias is just as strong as ever. From the alarm raised in the past, one would think that if it were even a fraction as prevelant as you would make us believe, there would have been at least one verified incident of a stroke truly caused by a chiropractor manipulating a cervical spine, rather than some anecdotal “I heard about one case where… da, ta da, blah, blah” story that is supposed to suffice for good evidence of that “smoking gun” so fondly referred to here.

    pmoran – “Every case that occurs from now on…”

    What cases? There have to be some don’t you think? If it’s not happening, then surely there isn’t a true correlation. It’s been a couple of years, yes? And none? No more?

    Gentlemen, please.

  49. weing says:

    So you are saying that we shouldn’t try to find out? You do realize that if you don’t know what to look for, you will probably never find it. Maybe you don’t know that.

  50. Joe says:

    @nwtk2007 on 09 Jul 2010 at 7:01 pm

    The man’s widow found the slip showing he had been to the chiro shortly before she found him dead of a stroke.

    Still no word from you on why you have to snap a neck like that, in the first place.

    And, yes, there are cases where the chiro connection is clear http://whatstheharm.net/chiropractic.html Why do you think Nette’s neurologist recognized the work of a chiro before it was confirmed for him?

  51. Jann Bellamy says:

    @ nwtk2007:

    “non-SBM”? I don’t think so.

    There are verified cases of chiropractic cervical manipulation causing a stroke. I mention two in the post and others are in evidence presented at the hearing. As for actual incidents since the Nette case, as there is no sytematic collection of the data we can’t learn of these incidents until they are reported as case studies or someone sues.

    As for effectiveness of cervical manipulation, which you have yet to address, in the same issue of Spine in which the Cassidy study appears, you will find the conclusion that manipulation is no more effective than other conservative treatments for what they term Grade I and II neck pain and is not recommended at all for Grade III and IV neck pain. In fact, Cassidy is one of the authors of this article. Guzman J, Haldeman S, Carroll LJ, Carragee, EJ, et al., “Clinical Practice Implications of the Bone and Joint Decade 2000-2010 TAsk Force on Neck Pain and Its Associated Disorders,” Spine 2008 (33): S199-S213. It has not been shown effective for any other condition. Ernst E, “Chiropractic: A Critical Evaluation,” J Pain Sympt Man 2010 (34) 544-562. As you well know, chiropractors use cervical manipulation for all sorts of conditions that have nothing to do with neck pain.

    As for evidence of causation, you are incorrect in stating there is none. Miley ML, Wellik KE, Wingerchuk DM, Demuerschalk BM, “Does Cervical Manipulative Therapy Cause Vertebral Artery Dissection and Stroke?” The Neurologist 2008 (14) 66-73.

  52. nwtk2007 says:

    Joe, you know as well as I that there is only one case in that list where the person actually had the sroke on the chiro table. All the rest occured a good time after the chiro manipulation. You assume based upon your bias.

    In the case you anecdotalized us with above, you haven’t even a notion of what was treated by the chiro. He might have been gong for a back condition which what I would suspect since there is no follow up regarding the chiro as a possible cause other than the found slip.

    We all know that the number of individuals who go to their MD/PCP with the signs of an ongoing stroke who then have one is equal with those who have been seen by a chiro.

    Once again, if it were as prelevant as this blog would imply, there would have been many more cases over the past couple of years.

    As to “snapping” the neck, joint mobilization and manipulation is a method of restoring motion to the joints of the neck. The “snap” is simply a cavitation which sometimes occurs and sometimes doesn’t. I continue to treat hundred of new patients each year and find that in the cases where I employ manipulation the patients response to care is much greater. I see it all the time, day in and day out. It isn’t published as clinical trial but the data is there in the thousands of files of the thousands of patients I have treated. All injuries of course.

    It doesn’t take a rocket scientist to see that when exposed to it on a day to day basis. And not one single stroke in the bunch.

  53. nwtk2007 says:

    By the way, Nette’s neurologist is just as biased as you guys. That one is easy.

  54. weing says:

    “Once again, if it were as prelevant as this blog would imply, there would have been many more cases over the past couple of years.”

    I think you mean prevalent. I don’t know what prelevant means. I thought this blog was saying that we don’t know the prevalence. You need data for that. If patients are unaware of a possible connection, they will not make it. Why do you think that when a new drug is tested patients report everything that happens to them? Are you afraid of chiropractic procedures held up to the same scrutiny for safety as well as efficacy? Sounds like you are.

  55. pmoran says:

    NTK: “pmoran – “Every case that occurs from now on…”

    What cases? There have to be some don’t you think? If it’s not happening, then surely there isn’t a true correlation. It’s been a couple of years, yes? And none? No more?”

    PM: Think again. If we were to stop seeing any cases “associated” with neck manipulation, it suggests a change in chiropractor behaviour, and that there was a true causal correlation. It’s all an unlucky coincidence, remember?

    As others have pointed out, we cannot yet know. No one keeps track. We presumably have to await another high profile case that your malpractice insurers were not able to settle out of court — or another neurologist getting fed up with this largely senseless source of mortality and morbidity and publishing more cases.

  56. nwtk2007 says:

    Thanks for being the grammar gooroo weing. Makes all the difference. Really.

    No cases, no incidents. Its that simple.

    It just ain’t happening. Do you honestly think your efforts and theirs has actually altered how chiros manipulate spines? Get real.

    What ever your argument might be, there is absolutely no evidence that chiropractic manipulation of the neck causes stroke. None. At least by the sbm standards. If you can’t admit it, then you aren’t a true sbm supporter. It appears that sbm is good as long as it supports your bias and “beliefs”.

    Just keep up the smoking gun theory and your own anecdotes. Quite un-sbm if you ask me.

  57. weing says:

    “What ever your argument might be, there is absolutely no evidence that chiropractic manipulation of the neck causes stroke.”

    We don’t want argument, we want data. That’s the point. Collect the data and we’ll see if you is correct. Why are you afraid to do even that? Who knows? Your practice might be vindicated. Or are you like homeopaths and don’t need data, studies, and the like. Making a claim is good enough.

  58. pmoran says:

    NTK: “We all know that the number of individuals who go to their MD/PCP with the signs of an ongoing stroke who then have one is equal with those who have been seen by a chiro.”

    PM We don’t know that at all. Chiropractors are treating the Cassidy study as though it had the force of a top quality, prospective, randomised controlled trial. Yet even its authors allow that it does not prove anything (“We have not ruled out neck manipulation as a potential cause of some VBA.”).

    The study involves a complex retrospective interpretation of the data, and the suggested conclusions depend upon the 30 odd patients who had a stroke after attending chiropractors being an identical population to the 400 odd who attended MDs in the 30 days before their index date.

    That is obviously not going to be the case. I imagine some of the cases attending doctors will have had to have been picked up off the floor at some stage, and thus be far less likely to have been taken to chiropractor. Patients experiencing an unexplained, unusual, occipital headache or neck ache for the first time would be more likely to consult a doctor first up than a chiropractor, especially if they were also experiencing neurological symptoms.

    In fact, Table 7, if I am interpreting it correctly, suggests that even where headache or cervical symptoms are experienced this perticular population is up to six times more likely to see an MD/PCP than a chiropractor. Should the association of stroke with MD visits have been adjusted by this amount when making the comparisons that are said to exonerate DCs? I suspect so.

    Even without that, it can be questioned whether such the data shows equal “risk” for DC and MD visits with a precision that excludes neck manipulation as an occasional cause of VAD. That is all that is being claimed, and the authors of the paper allow that it is still possible.

    The study confirms what all other studies have shown and the anecdotal material suggests, that young people attending chiropractors are much more likely to have a stroke than those who do not. That is unarguable. I allow that some of that association with DC visits will be due to patients attending with symptoms of a preexisting stroke and the chiropractor not recognising that. Others are obviously not.

  59. nwtk2007 says:

    No new cases. Difficult to argue with that don’t you think?

  60. weing says:

    “No new cases. Difficult to argue with that don’t you think?”

    Sorry. You need systematic data gathering to look for these. You will never find them otherwise. Just saying there are no new cases, doesn’t cut it. Raise patient awareness of the possibility, so they will at least report it. If you are so sure of yourself, there is no need to fear vindication.

  61. pmoran says:

    Yes, dream on, nwtk. But do watch those necks!

  62. nobs says:

    # weing on 10 Jul 2010 at 6:58 pm
    “What ever your argument might be, there is absolutely no evidence that chiropractic manipulation of the neck causes stroke.”

    We don’t want argument, we want data. That’s the point. Collect the data and we’ll see if you is correct. Why are you afraid to do even that? Who knows? Your practice might be vindicated. Or are you like homeopaths and don’t need data, studies, and the like. Making a claim is good enough”

    Actually weing, we “is” been collecting data for decades. Science is, afterall, an epistemological theory..Don’cha know?

    Are you making the “claim” that there is PROOF of “manipulation of the neck causes stroke”? Or just when it involves a “visit to to a DC”? It appears that you come from a position that this has been proven—-? Really?

    Please provide YOUR data. Please do not provide an argument…..just provide the reference cites to the sources that prove your claim…… “we want data”.

    Thank-you in advance.

  63. nwtk2007 says:

    Its a bit difficult to find data to prove that cmt doesn’t cause strokes when there are no cases to prove otherwise. But, maybe that IS the proof.

    I would think that in the real sbm world that those who claim cause could provide the cases and data to prove their point.

    And moran, I watch literally hundreds of necks each and every week. Based on my experience and my patients response to care I can very confidently say that cmt is the most therapeutic modality I can employ to have patients recover from sprain/strain injuries.

  64. Blue Wode says:

    Considering that there are effective, safer, cheaper, and more convenient options available to patients than chiropractic neck manipulation (e.g. exercise), I can’t help feeling that some chiropractors are putting their own interests ahead of their patients when they resort to such a potentially lethal intervention. Whether those interests are financial, emotional, or related to less time and effort being required (or all three) is anyone’s guess, but the fact remains that chiropractors who continue to use neck manipulation no longer have any excuses for not understanding why they leave themselves open to accusations of being unethical:

    Quote
    “The most benign interpretation of the totality of the evidence is [therefore] as follows. There is an association between chiropractic and vascular accidents which not even the most ardent proponents of this treatment can deny. The mechanisms that might be involved are entirely plausible. Yet the nature of this association (causal or coincidental) remains uncertain. The cautionary principle, demands that until reliable evidence emerges, we must err of the safe side. Considering also that the evidence for any benefit form chiropractic neck manipulations is weak of absent, I see little reason to advise in favour of upper spinal manipulation.”

    Ernst, E. Vascular accidents after chiropractic spinal manipulation: Myth or reality?, Perfusion 2010; 23:73-74

    http://tinyurl.com/37ejj22

  65. weing says:

    “Actually weing, we “is” been collecting data for decades. Science is, afterall, an epistemological theory..Don’cha know?”

    References, please.

  66. weing says:

    “Based on my experience and my patients response to care I can very confidently say that cmt is the most therapeutic modality I can employ to have patients recover from sprain/strain injuries.”

    That’s all you got? Only anecdotal data?

  67. Joe says:

    weingon 11 Jul 2010 at 1:13 pm That’s all you got? Only anecdotal data?

    Certainly not, he also has the pronouncements of (1895) green-grocer DD Palmer, and his son BJ. Does evidence get any stronger than that?

  68. Doc says:

    The basic science does not support the notion that HVLA SMT practiced by chiropractors is responsible for these stroke cases. The relationship is coincidental not causal.

    Here is the relevant portion copied from the abstract which also follows:

    “Stresses and strains on the vertebral artery during chiropractic spinal manipulation of the neck were always much smaller than those produced during passive range of motion testing and diagnostic procedures.”

    ———————————–

    Journal of Bodywork and Movement Therapies
    Volume 14, Issue 3, July 2010, Pages 280-286

    Invited Review:
    The biomechanics of spinal manipulation

    Walter Herzog PhD

    a Faculty of Kinesiology, University of Calgary, Calgary, AB T2N 1N4, Canada

    Summary

    Biomechanics is the science that deals with the external and internal forces acting on biological systems and the effects produced by these forces. Here, we describe the forces exerted by chiropractors on patients during high-speed, low-amplitude manipulations of the spine and the physiological responses produced by the treatments. The external forces were found to vary greatly among clinicians and locations of treatment on the spine. Spinal manipulative treatments produced reflex responses far from the treatment site, caused movements of vertebral bodies in the “para-physiological” zone, and were associated with cavitation of facet joints. Stresses and strains on the vertebral artery during chiropractic spinal manipulation of the neck were always much smaller than those produced during passive range of motion testing and diagnostic procedures.

    Keywords: Spinal biomechanics; Chiropractic; Manipulative therapy; Vertebral artery; Stroke; Internal forces

  69. rwk says:

    Hey Joe.
    If you’re the dopey looking fat guy on WAMC then what right
    do you have to critique any medical profession let alone chiropractic?
    Why don’t you visit a chiropractic college or read a modern technic book. You have nothing constructive to add to this”discussion” except
    insults. What are your credentials to evaluate any of this?

  70. nwtk2007 says:

    Weing, Joe, you boys are so untrue to the spirit of this blog.

  71. Dr Benway says:

    SBM Rule #19: Chiro threads always invite the Internet tone patrol.

    Sad, really, when there are so many other spots on the webs that might benefit from their services.

  72. weing says:

    “Weing, Joe, you boys are so untrue to the spirit of this blog.”

    Rrrright. It’s we who don’t need data. I’ll just continue to balance humors to restore the patient to health. :)

  73. pmoran says:

    “And moran, I watch literally hundreds of necks each and every week. Based on my experience and my patients response to care I can very confidently say that cmt is the most therapeutic modality I can employ to have patients recover from sprain/strain injuries.”

    I am sure you believe that. It doesn’t prove that cmt has any unique benefits over other physical methods .

  74. BillyJoe says:

    The proof of personal experience fallacy. ;)

  75. BillyJoe says:

    nwtk2007,

    The GCC’s Investigating Committee:

    In the context of the relevant law (The Consumer Protection from Unfair Trading Regulations 2008) advertised claims for chiropractic care must be based on best research of the highest standard. This will almost certainly mean randomised controlled trials that produce high or moderate positive evidence.

    And furthermore…

    The other elements of evidence based care as it relates to clinical practice (the preferences of the patient and the expertise of practitioners (including the individual chiropractor her/himself)) are, of themselves, insufficient to support advertised claims.

  76. Joe says:

    @rwk on 11 Jul 2010 at 9:41 pm wrote “Hey Joe.
    If you’re the dopey looking fat guy on WAMC then what right
    do you have to critique any medical profession let alone chiropractic?”

    That ‘Joe’ on WAMC is quite bright; your grade-school comments on his appearance notwithstanding. It really is despicable to “out” someone when you are so wrong.

    “What are your credentials to evaluate any of this?”

    My credentials are sufficient, and from academic institutions. You simply cannot argue substance.

  77. Scott says:

    Let’s also not forget that the Cassidy study itself found an association between cervical manipulation and stroke, once they looked in the best place to find it (patients under 45 in the first 24 hours).

    There’s more than ample evidence to demonstrate, at an absolute minimum, a plausible potential for risk. Given that, it is not necessary to demonstrate precisely how large that risk is, *unless* it can be shown that there is some benefit of the procedure that is sufficient to outweigh even that plausible potential – which chiropractors have signally failed to do.

  78. nwtk2007 says:

    If what you boys say is true, where are all the new cases. Nothing in chiropractic has changed. There are just as many cervical manipulations occurring each and everyday as there were before this issue was trumped up to idiotic levels.

    Where are the cases? There are none. None. If you think there is such a link, where are the cases and why aren’t they getting the publicity of the previous cases?

    Whats up with that guys?

    If they are out there you should be ablew to find them in order to support your argument.

  79. ntwk2007: what Scott said, again: “There’s more than ample evidence to demonstrate, at an absolute minimum, a plausible potential for risk.”

    Given this,

    1) Patients should be told that there is a plausible potential for risk and that the size of the risk is still unknown. This is the information we have and it’s unethical not to share it.

    2) If there is a risk of serious outcomes from a procedure (any procedure, not just chiropractic procedures), a practitioner should not perform it unless the possible risk is balanced by a sufficiently large demonstrated benefit that cannot be offered through less-risky methods.

    3) Why would a practitioner want to perform a procedure that has a demonstrated plausible potential for risk and no demonstrated unique benefit?

    4) Why aren’t you participating in randomized prospective studies that could actually demonstrate that there is no risk to neck manipulations and/or and that there is benefit to neck manipulations that cannot be found elsewhere? This would shut everyone here up quite nicely.

  80. Scott says:

    If what you boys say is true, where are all the new cases. Nothing in chiropractic has changed.

    As has been REPEATEDLY explained, without careful surveillance new cases won’t necessarily be recognized. Which means that:

    Where are the cases? There are none. None. If you think there is such a link, where are the cases and why aren’t they getting the publicity of the previous cases?

    Is an utterly meaningless argument.

  81. nwtk2007 says:

    So why does it all of the sudden require “carefull” sueveilance to find these cases. When the public outcry from the anti-chiro’s was so loud there were so many alledged cases popping up out of the woodwork. You guys acted like it was a pandemic happening. Now, no new cases are showing up.

    Why aren’t you guys doing your carefull surveilance and uncovering the cases that one would think are occuring based upon the level of alarm the anti-chiro’s sounded. I don’t really know how to do such carefull sirveilance thus you, who are so familiar with such things, could do this and uncover those cases which could help to support your position.

    Once again, as to the benefit of cmt, there has been presentation of studies in the past and these have been dismissed without even a good read or analysis. I said it before that I wouldn’t waste my time presenting evidence when it is summarily dismissed in such fashion.

    The fact remains that there should be new cases popping up if there is any true connection.

  82. Joe says:

    In a major review of injury from neck manipulation, most of the cases come from chiropracty: http://www.ptjournal.org/cgi/content/full/79/1/50 Others are more selective, and more skilled, in manipulation.

  83. nwtk2007 on accountability: “The fact remains that there should be new cases popping up if there is any true connection.”

    So prove there isn’t a connection. Participate in prospective research. It shouldn’t be that hard.

  84. nwtk2007 says:

    That is just too funny Allison. You want me to prove a lack of a connection between cmt and stroke. Are you hearing yourself?

    I don’t think I’ll bother qualifying that with a response.

    And Joe, who is it that is more skilled at manipulation than a chiro? To imply that any other would be id patently silly and would also warrant no response to qualify it to any degree.

  85. Scott says:

    That is just too funny Allison. You want me to prove a lack of a connection between cmt and stroke. Are you hearing yourself?
    I don’t think I’ll bother qualifying that with a response.

    A pity, as it’s exactly what needs a response from chiropractors.

  86. weing says:

    “That is just too funny Allison. You want me to prove a lack of a connection between cmt and stroke. Are you hearing yourself?”

    What’s wrong with that? Drug companies have to do that all the time.

    “who is it that is more skilled at manipulation than a chiro? ”

    Based on this post, you guys are extremely skilled at manipulating the legislative process.

  87. It’s true, it’s not possible to prove a negative. I can’t prove that Russel’s teapot does not exist.

    But given that there is reasonable probablilty that CMT can cause stroke, it’s both perfectly possible (and ethically required) to conduct a prospective, randomized study and size it in such a way that an effect larger than X would be captured.* That way you can tell your clients that “There is a 1/1,000 chance of stroke from this procedure” or “There is a 1/1,000,000 chance of stroke from this procedure,” or “There’s a theoretical possibility but if it’s real then stroke occurs in fewer than 1/1,000,000,000 CMT manipulations because we haven’t been able to detect it even with very powerful studies.”

    Wouldn’t you love to be able to say that?

    ______________
    *Which is different from Russel’s teapot, because there is no reasonable probabilty that Russel’s teapot exists. And that is what SBM is all about.

  88. pmoran says:

    One last attempt to get you to think again about your argument, ntwk.

    Firstly, if the association between stroke and cervical manipulation is all coincidence, why would there not be just as many strokes occurring either with and without chiropractic care?

    Secondly, how can you possibly know that there are “no more cases”? They rarely reach the public eye, unless via the law courts. Your malpractice insurers don’t usually release their data (I suggest you ask them — some old, leaked insurer data suggested more stroke claims per year than even I expected).

    The medical profession that has known for years that neck manipulation and other kinds of neck trauma are risk factors for vertebral artery stroke. Fresh cases are not likely to be published unless they contributed something new to the understanding of such events.

  89. Doc says:

    nwtk2007 and the rest. Did you not have anything to say about my previous post?

    Here is what the biomechanical evidence says:

    “Stresses and strains on the vertebral artery during chiropractic spinal manipulation of the neck were always much smaller than those produced during passive range of motion testing and diagnostic procedures.”

    The basic science says coincidental not causal.

  90. Joe says:

    @Doc on 13 Jul 2010 at 12:53 am

    Where is your previous post? Where is the data?

  91. pmoran says:

    Doc:“Stresses and strains on the vertebral artery during chiropractic spinal manipulation of the neck were always much smaller than those produced during passive range of motion testing and diagnostic procedures.”

    That’s rather counter-intuitive. It begs more information on exactly what procedures were being compared and how on earth “stresses and strains” on the vertebral artery were measured.

    It is also possible that anatomical variants make some people more prone to vertebral artery damage.

  92. And this is the PubMed link that Doc (oddly) omitted:
    http://www.ncbi.nlm.nih.gov/pubmed/20538226

  93. Jann Bellamy says:

    There are verified cases of chiropractic cervical manipulation causing a stroke. I mention two in the post and others are in evidence presented at the hearing.

    As for evidence of causation, you are incorrect in stating there is none. Miley ML, Wellik KE, Wingerchuk DM, Demuerschalk BM, “Does Cervical Manipulative Therapy Cause Vertebral Artery Dissection and Stroke?” The Neurologist 2008 (14) 66-73.

  94. Joe says:

    @Alison, Thanks, I don’t know how I failed to see it after I used the “find” function.

    The paper by Herzog (cited by doc, and references therein) does not refer to measurements under clinical conditions; rather, it refers to cadaver studies.

    An obvious problem with Herzog’s model is that he uses stretching of the artery (free of the body) to the point where it undergoes wholesale failure as the ‘standard’ strain needed to cause a stroke. In other words, he pulls on the ends of the artery till it loses its structural integrity at 150% normal length and calls the necessary force the amount needed to be medically relevant. That is clearly absurd. The clinical damage is localized in the artery as naturally twisted around bony processes.

    Another problem begins with his description of the chiropractic procedure (SMT) involving turning the head till it naturally stops (the normal range of motion, ROM), and then applying more twisting force. Unless I am reading it wrong, he then reports the strain due to SMT is less than the strain involved in reaching the ROM!?

    The data are what they are; but do they have any clinical relevance? I doubt it.

    Perhaps I missed something; but Herzog’s work is far from a definitive, clinical study.

  95. marcus welby says:

    Anyone tempted to deny the risk of vertebral artery dissection and stroke from neck cracking by chiropractors should watch one of the You Tube videos on the procedure, as posted above by Jann Bellamy earlier, see post at 5 July at 5:31 PM. Knowing what the vertebral artery does anatomically and knowing that half the cervical spine rotation occurs between C-1 and C-2 (facts), the demonstration of what chiropractors do in neck cracking is scary and revolting. Watch the video and decide for yourself. Multiple instances of unsuspecting folks sustaining strokes and in some cases death as a result of neck cracking are extant in the medical literature (not the chiropractic literature). Most ER doctors, neurologists, neurosurgeons and those who treat stroke victims are now aware of this risk. Since the neck cracking procedure has no demonstrated benefit beyond placebo, and the small but serious risk of adverse outcome or death is well documented, there is no reason to ever perform this procedure. The stroke symptoms may occur immediately on the chiropractic treatment table or may be delayed as much as a month or two, when the clot which formed on the torn vertebral artery embolizes into the brain. Risk is probably one in several thousand neck twistings, but since there are far less risky treatments available with equal or better effectiveness, the procedure should never be done. Chiropractors have defensively avoided any study which might show the exact frequency of this tragic treatment complication. Sad.

  96. Doc says:

    Alison, Joe, Marcus and the rest, try as you might you are just reaching for straws and coming up empty handed.

    The AMA will probably fire you but at least there are unemployment and COBRA benefits until you find work … maybe in 2012.

    In the mean time look in the mirror after you watch this video, you will see the a person that this speaker talks about.

    http://www.ted.com/talks/michael_shermer_the_pattern_behind_self_deception.html

  97. pmoran says:

    Bluster doesn’t cut it here, Doc.

    There is evidence from many sources of a strong temporal and statistical association of stroke with neck manipulaton (NM). It is highly plausible that the association is causal, given that this is the only area in the body where arteries have cope with an axial twist through 180 degrees range (or possibly more during manipulation) over a very short distance while anchored in bone at one end. Herzog’s studies cannot be regarded as mimicking this.

    The chiropractic profession was itself once so certain of this risk as to advise certain provocative tests prior ot the performance of NM.

    The novel notion that the strokes are coincidental, and due to patients presenting to chiropractors with early symptoms of stroke, is supported by weak evidence and it cannot explain all cases.

    If you have something specific that you wish to debate further, then we are listening.

  98. BillyJoe says:

    “http://www.ted.com/talks/michael_shermer_the_pattern_behind_self_deception.html”

    Hey, watch the last 2 minutes of that video. :D
    Hilarious!

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