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Update: Chiropractic Neck Manipulation and Stroke

Can neck manipulation cause strokes? Most MDs and many chiropractors agree that it can, but some chiropractors disagree. The subject has been covered on SBM before: here, here, here, here, here, here, here, here, and here. We keep returning to the subject not because it is a common problem (it isn’t), but because it is such a devastating one, and because the general public is still not aware of the risk.

A 2012 study published in the International Journal Of Clinical PracticeAssessing the risk of stroke from neck manipulation: a systematic review” concluded:

Conclusive evidence is lacking for a strong association between neck manipulation and stroke, but is also absent for no association.

Despite the uncertainty, they thought the association was strong enough to recommend informed consent be obtained and patients be warned that neck manipulation “may” increase the risk of a rare type of stroke.

A new study in the same journal, “Chiropractic and Stroke: Association or Causation?” applies Hill’s criteria of causation to the evidence and concludes that causality has not been determined. The author is Peter Tuchin, a senior lecturer in chiropractic at Macquarie University in Australia, and a known apologist for chiropractic. I agree with him that the existing evidence is inadequate to conclusively determine causality, but I think it supports a high probability of causality, and the alternate explanations he offers to exonerate chiropractors are questionable. And other factors should be considered, like the many “smoking gun” cases and whether there is any conclusive evidence of benefit to set against the possibility of risk.

Hill’s criteria of causation

Mark Crislip has explained Hill’s criteria here.

Hill’s criteria were applied to the chiropractic subluxation construct with disastrous results for the basic premise of chiropractic:

No supportive evidence is found for the chiropractic subluxation being associated with any disease process or of creating suboptimal health conditions requiring intervention. Regardless of popular appeal this leaves the subluxation construct in the realm of unsupported speculation. This lack of supportive evidence suggests the subluxation construct has no valid clinical applicability.

Tuchin’s study begins by critiquing published reports of chiropractic strokes, objecting that details are not furnished and other causes of stroke are not ruled out. Those are valid criticisms. Indeed, other causes of stroke can never be completely ruled out in any individual case, since vertebral artery dissection (VAD) is known to occur after any hyperextension of the neck, such as painting a ceiling or getting a shampoo at the beauty parlor, and it can even occur spontaneously without hyperextension. Delayed effects cloud the issue: in some of the reported cases, stroke occurred as long as 15 days after spinal manipulation therapy (SMT), postulating a clot that temporarily sealed the tear and later broke loose. That’s why we have to rely on controlled studies, such as the 2001 study that showed VAD was more common after SMT: patients under the age of 45 were 5 times more likely than controls to have visited a chiropractor in the preceding week.

Tuchin addresses each of Hill’s criteria. His explanation is confusing, since he includes comments that are not relevant to the criterion being considered, and he presents the same arguments under more than one criterion.

  1. Strength of association. He acknowledges that the association is there, but he argues that it is not very strong. Here he quibbles that some of the reports were of manipulations done by non-chiropractors, but that is only self-serving damage control that is irrelevant to the question of manipulation causing stroke. He misquotes a German paper as saying “there was a clear evidence that the dissection was present prior to the SMT” whereas it actually says “there was clear evidence or high probability.” [emphasis added] And he doesn’t mention the strong associations in the “smoking gun” cases where a stroke occurred on the chiropractor’s table immediately or shortly after manipulation.
  2. Consistency. He claims the studies are inconsistent, with some showing “a relationship” and others showing only “an association.” He doesn’t explain how a “relationship” is different from an “association;” the dictionary says they are synonyms. The only study he mentions is the Cassidy study (more about that later), which he misrepresents: it actually showed a strong association of SMT and stroke in those under 45. He doesn’t present any studies showing that there is no association. He admits that there is consistency with neck movement causing stroke, but not with SMT. However, SMT involves neck movement; so SMT is necessarily consistent as a cause.
  3. Dose-response relationship. He concludes that a dose-response relationship doesn’t exist. He bases this conclusion on the fact that patients can have many manipulations before the VAD occurs. And the fact that many of the manipulations associated with VAD were done by other non-chiropractic practitioners. This doesn’t make sense to me. I would think dose-response would have to be tested by other means. Perhaps the “dose” relates to the force used or the degree of extension and rotation rather than to who performed the manipulation or how many previous manipulations had been done without incident.
  4. Temporality. Exposure must precede outcome. Here he argues that a clear time-line has not always been established, and he questions whether some patients might have had stroke symptoms before visiting the chiropractor. That is speculation not supported by any evidence.
  5. Plausibility. He argues that the force exerted is not sufficient to cause a tear, and that modern manipulation techniques do not require full cervical spine rotation or extension. It is inconsistent to argue this after he has argued that VAD can occur with any neck movement. I think it is perfectly plausible that even “modern techniques” could result in the same degree of neck movement that is associated with painting ceilings or having a shampoo at a beauty parlor, both acknowledged causes of stroke. I suspect that some chiropractors are using more rotation, extension, and force than the author would like to believe. He doesn’t present any data to support his speculations.
  6. Other explanations ruled out. He argues that VAD can occur spontaneously, and that patients presenting to a chiropractor may have had prior trauma. He argues that prior manipulations without incident suggest that an adverse effect of the last manipulation means something had changed in the patient. (He doesn’t consider that something might have been different about the last manipulation itself, or that perhaps a weakened artery finally gave way after repeated stretching.)
  7. Experimental confirmation. Here he doesn’t address experimental confirmation at all. He only talks about possible precipitating factors. Admittedly, there is no experimental confirmation; but it could be argued that experimental confirmation is next to impossible and is not necessary to establish causality. Hill himself said that his criteria were aids to thinking about causality, not a list of requirements.
  8. Specificity. One in every hundred thousand people has a VAD each year, so he thinks chiropractors could expect to see 10 VADs for every million patients manipulated, even if manipulation didn’t cause the VAD. (I would argue that patients with stroke symptoms are more likely to go to an ER than to a chiropractor.) He also argues that many of the documented tears were not at the location that he thinks would be expected from manipulation, but that doesn’t necessarily mean that SMT was not a factor. We don’t have any data to compare tears after SMT to tears in patients who were not manipulated.
  9. Coherence. He doesn’t think a causal explanation coheres with existing theory and knowledge, in contrast to many others (including other chiropractors) who think it does. He offers an alternative hypothesis: that patients who were already symptomatic from a VAD sought chiropractic care, and manipulation may have dislodged an already existing clot. This is pure speculation not supported by any data. And it points out that chiropractors are not able to judge when manipulation is contraindicated.

His arguments boil down to these:

  • Chiropractors didn’t do it: it was other practitioners who were less well trained who did the suspect manipulations. (But there are plenty of reports involving chiropractors.)
  • SMT didn’t cause it: it was due to one of those other things that can cause VAD. (No evidence to support that claim.)
  • Patients went to a chiropractor because they were already having symptoms of a stroke. (No supporting evidence, and a good reason to avoid neck manipulation.)

He places considerable emphasis on the Cassidy study. He says it “concluded that patients present to either a chiropractor or GP with neck pain because of their stroke already being present.” The Cassidy study does not say what he thinks it says. See Mark Crislip’s critique of that study. The idea that patients were already experiencing symptoms of a stroke was not a conclusion of the study, but merely a hypothesis of the authors that was not supported by their data.

The symptoms of a vertebral artery stroke are headache and focal neurological signs. Facial pain with numbness is the most common neurologic consequence. Other common neurologic signs are dizziness or vertigo, dysarthria or hoarseness, loss of pain and temperature sensation in the trunk and limbs, loss of taste, hiccups, nausea and vomiting, problems with vision, difficulty swallowing, and unilateral hearing loss.

Note that that neck pain is not even on the list. And although headache usually precedes the neurologic signs, many patients don’t seek care until the neurologic signs have developed; and I would guess that those signs would be more likely to send them to the ER than to the chiropractor. In fact, the Cassidy study found a strong association between visiting a chiropractor and having a stroke in the next 24 hours for patients under the age of 45 (odds ratio = 12).

Is neck manipulation beneficial?

A 2007 study purported to show that the benefits outweighed the risks for patients undergoing chiropractic care for neck pain. It was a prospective study, but there was no control group. They found that 2/3 of patients were improved at 3 and 12 months, but how many untreated patients would also have improved by then? 56% of patients reported adverse events and 13% reported these to be severe.

74-79% of patients with non-specific neck pain typically recover in a year, and even patients with cervical radiculopathy improve over time with only conservative treatments such as use of a collar and physical therapy.

Another study found a benefit of exercise combined with manipulation/mobilization but also of exercise alone.

A 2010 Cochrane systematic review found that mobilization was as effective as manipulation.

A 2004 Cochrane systematic review found that mobilization and manipulation were not beneficial alone, but were equally beneficial when used in conjunction with exercise.

It seems plausible that gentle mobilization techniques would be less likely to cause a vertebral artery tear than high velocity low amplitude (HVLA) manipulation techniques. This study showed that mobilization is less likely to cause adverse reactions in general.

In short, there is no evidence-based reason to prefer manipulation techniques to mobilization with exercise. In the absence of proven benefit, even a hypothetical risk is unacceptable.

“Smoking gun” cases

There are plenty of reported cases where patients suddenly developed stroke symptoms when a practitioner manipulated their neck. Until these cases are compiled, investigated, and explained otherwise, it is reasonable to assume a cause/effect relationship. Tuchin argues that it seems impossible for a thrombus to instantly form, dislodge, and travel to the cerebral cortex to cause a stroke within seconds of receiving SMT; but I would argue that if an existing clot were dislodged, symptoms would be almost immediate. Also, a tear can cause bleeding between the layers of the arterial wall, creating a hematoma that rapidly expands to directly occlude the artery.

What is most worrisome is that some of those patients got neck manipulations for symptoms in other parts of the body unrelated to the neck, or even for no symptoms at all (maintenance adjustments as a preventive health measure). A majority of patients consulting a chiropractor for any reason will be subjected to neck manipulation. Children get neck manipulations for problems like ear infections. Upper cervical (NUCCA) practitioners only treat the top vertebra of the neck in every patient. The whole premise of upper cervical chiropractic is nonsensical.

Conclusion

Tuchin correctly concludes that the evidence that SMT causes strokes is not definitive and is not supported by all of Hill’s criteria of causation. But he tries to make his case with fallacious arguments and questionable claims rather than with scientific data, and the whole article smacks of apologetics for chiropractic. While the existing evidence is not definitive, it supports the strong probability of a causal relationship, especially considering the many “smoking gun” cases. Since neck manipulation has not been demonstrated to be effective, even the suspicion of a risk is reason enough to reject the treatment. Alternatives like gentle mobilization, physical therapy, and exercise are better choices. And while everyone agrees that SMT is contraindicated in the presence of a VAD, chiropractors have demonstrated their inability to predict which patients are at risk. The safest course is to avoid neck manipulation altogether.

Posted in: Chiropractic

Leave a Comment (49) ↓

49 thoughts on “Update: Chiropractic Neck Manipulation and Stroke

  1. Stephen H says:

    I’m puzzled. Tuchin claims that “patients went to a chiropractor because they were already having symptoms of a stroke”. So… how many of those chiropractors diagnosed the stroke? If they failed to diagnose it, why? How can they claim to be medical practitioners and fail to notice that they were about to treat a stroke victim?

    The words “petard” and “hoist”, along with “by his own”, come to mind.

  2. windriven says:

    Like Stephen H, I was struck by the claim that chiropractic patients presented with symptoms of stroke begging the question: did the quack miss the diagnosis or did he think that twisting the patient’s neck would bean effective treatment? In other words, was the quack stupid or drunk?

    If that is the best defense that chiropractic can muster …

    1. Carl says:

      These quacks apparently can’t tell the difference between a healthy person and someone who is 30 seconds away from death, and yet they want to be primary care doctors.

    2. EBM says:

      You are not arguing on a high enough level to be taken serious. Please read through how to argue properly. These are cases that quite common are mistaken for musculoskeletal complaints, by both doctors and chiropractors and physios. You’re argument is only meant to make fun of one of the professions.

      1. Harriet Hall says:

        My point stands that if there is diagnostic confusion and the possibility of VAD exists, it is dangerous to manipulate the neck.

        I have never studied how to argue properly. Please present your own arguments about neck manipulation and stroke, so I can learn from your example.

        1. Michael S says:

          As a current chiropractic student, I have studied a lot about this very popular argument. The real outcome is that the chiropractic professional organizations have increased standards of how to better screen for VAD risk before adjusting. Medicine is not about “smoking guns” and proving things wrong, it is about adjusting the state of the art in lieu of current research and information for patient safety. The point I believe the profession is trying to make is that the risk factor does not originate with manipulation, it originates from poor vascular tissue health. You should be arguing that primary care doctors should spend more time health coaching on how to prevent this tissue damage.

          1. Harriet Hall says:

            1. How are you taught to screen for VAD?
            2. What do you think causes the tissue damage and how can it be prevented?
            3. Even if future cases could be prevented by coaching, don’t you agree that we should try to minimize the danger now?

  3. Chris Hickie says:

    When you see chiropractors wearing stethoscopes like real physicians do, it’s probably fools people into thinking that someone who thinks cracking one’s back is a cure for A to Z is somehow clinically trained for something like a stroke (or for that matter knowing when not to mess with someone’s neck). I’m still waiting to see an actual explanation that makes any sort of sense as to of how “manipulation” does anything for ear infections.

    1. Kevin says:

      I would think that syncope from neck palpation would be a contraindication for neck manipulation. Apparently not for this chiro:

      http://youtu.be/_4AkLs6s9H8

    2. it does not do anything for ear infections. Some chiropractic school actually teach the right things to their students. It could possibly be the angle at which the head is tilted, and the pressure at he joint that is put forth to manipulate it.

  4. oldmanjenkins says:

    Tuchin is doing what is to be expected, confirmation bias. He is a firm believer is this quackamedic treatment and therefore no matter what evidence you present he will move the goal post or find in a negative a positive. It is amazing to me that even though science has moved forward with new discoveries and things from 100 years ago were either discredited, or with better understanding and technologies better interventions were found, chiropractic is still holding on to the same discredited “theories” from its creator. They live by the motto “this is the way it has always been done and therefore this is the way it we will continue to do it.” That’s a religion and not science.

  5. Carl says:

    “there was a clear evidence that the dissection was present prior to the SMT” [...] doesn’t mention the strong associations in the “smoking gun” cases where a stroke occurred on the chiropractor’s table immediately or shortly after manipulation

    This sounds like a joke from a mafia movie. “It wasn’t no murder… he got stabbed 20 times in the back just as he was dying of natural causes.”

    He concludes that a dose-response relationship doesn’t exist. He bases this conclusion on the fact that patients can have many manipulations before the VAD occurs.

    If getting the same thing done two weeks in a row was the same as getting a double dose, we’d all have broken necks from the accumulation of times we turned our heads slightly to the left.

    Also, if you’re reading this, Tuchin, I can clear up that other thing you were confused by: priapism means 4 hours continuously, not a lifetime total.

    One in every hundred thousand people has a VAD each year, so he thinks chiropractors could expect to see 10 VADs for every million patients manipulated, even if manipulation didn’t cause the VAD.

    Maybe I am confused here, but wouldn’t that only make sense if a visit to the chiropractor lasted 365 days non-stop? After all, it’s 1/100,000 per year, not per hour (or however long a chiropractic jam session takes).

    If 1/1 people (ie, everyone) has a VAD each year, and they went to a chiropractor once per month all year, wouldn’t you expect a chiropractor to see a VAD on the same day as a neck twist for 1/30 of his patients, not 1/1?

    1. ChristineRose says:

      Not necessarily. If the chiro has 3 patients that are destined to have an event and all three of them rush to the office just before the event because they have some sort of pre-stroke premonition then there would be a correlation without cause.

      As pointed out in the article, there’s not a convincing reason to believe in pre-stroke events that cause people to rush to a chiropractor for a neck manipulation but that seems to be the argument.

  6. Andrew L says:

    I find it amazing that chiropractors can deny this risk. It is extremely plausible that a forceful manipulation of the neck could cause VAD. We occasionally see traumatic aortic dissections caused by a similar mechanism causing a tear in the artery. Since my fellowship year in 2010 I have taken care of 3 pts who have had VAD after cervical manipulation. One was elderly male who still had residual symptoms years later. His occurred immediately upon leaving the chiropractors office. If one wants to say he is in a high risk population- eldest male with coronary artery disease, fine give that a pass. But how about the two women in their 20′s that experienced VAD after a visit to the friendly neighborhood chiropractor. That is a very low risk population for such a condition. As an anesthesiologist that basically sees a patient alert and awake for 5-10 minutes I find this number to be alarmingly high! It leads me to believe that VAD is drastically under reported.

  7. Harriet, have you considered writing a letter to the editor critiquing this article? I think it might be warranted.
    Peter is certainly not unreasonable and would be open to constructive criticism.
    I think he is understating the adherence to older (and unsafe) techniques being used by clinicians in this article – just because they are taught “safer” techniques in university, doesn’t mean they can’t pick up bad habits or be shown by an older practitioner saying “my patients prefer this, use this technique or I won’t let you see any patients.” It’s only an anecdote, but I’ve seen it happen first hand. Also, is he familiar with how chiropractic technique is taught across the world?
    Some would argue whether it is important or not whether the cervical manipulation is being performed by a chiropractor or not. It may just be semantics. However it could be important if there is a different standard of training in the delivery of cervical manipulation.
    The final two paragraphs sit just fine with me. However, I think he should have perhaps highlighted the imperative for caution when delivering cervical manipulation. Not only to take a thorough clinical history for causes of VAD (and other contra-indications) but if there is even a reasonable clinical suspicion.
    To me it is horrifying to think that a clinician could be taking a poor history, but hey some chiropractors allocate as little as 15 minutes to a new patient visit before adjusting.

  8. Andrey Pavlov says:

    Tuchin argues that it seems impossible for a thrombus to instantly form, dislodge, and travel to the cerebral cortex to cause a stroke within seconds of receiving SMT; but I would argue that if an existing clot were dislodged, symptoms would be almost immediate. Also, a tear can cause bleeding between the layers of the arterial wall, creating a hematoma that rapidly expands to directly occlude the artery.

    This seems like a very poor argument to me. Inducing an intimal tear, even a small one of just a few millimeters, exposes a significant amount of basement collagen which is extremely thrombogenic. In fact, collagen based platelet aggregation studies have replaced ristocetin as the preferred modality to test the ability of platelets to form a thrombus (along with arachodonic acid and ADP). The point being is that the thrombus begins to form nearly instantaneously when exposed to collagen.

    Furthermore, this initial thrombus is disorganized. It takes subsequent formation of fibrin via the coagulation cascade the stabilize the thrombus. Thus, that initial rapid formation is more likely to dislodge rapidly with minimal further disruption of the site. Additionally, dislodgement is even more likely considering that typically when an artery is actually torn through there is a significant pressure differential between the artery lumen and the connective tissue surrounding the artery externa, which would essentially push the thrombus into place. There is no such pressure differential in an intimal dissection, so the vector of force from the arterial pressure would be parallal to the path of the artery rather than orthogonal.

    It is also a fact that after a cervical manipulation the individual would tend to move in some way – either lifting or adjusting their heads, standing up, or having further SMT. If one SMT ended up creating the tear, then within seconds we would expect a loose thrombus to form, with no forces preventing the thrombus from dislodging, and then any subsequent movement would be trivially easy to embolize the thrombus.

    That is for a small intimal tear. If it is large enough then a false lumen could form, trapping thrombus/hematoma which could then later dislodge or expand (via the Law of Laplace) to create an occlusive false lumen leading to delayed symptoms.

    Either way it is entirely plausible that SMT – particularly HVLA – could lead to VAD. Based on fundamental principles I would actually expect more cases to present acutely rather than delayed which is also consistent with the data we do have.

    Tuchin’s ideas are in general, and specifically here, out of touch with reality and not informed by basic principles of physics and the known mechanisms of thrombus formation.

  9. EBM says:

    You should read through the research again. It is concerning that you don’t know that neck pain is one of the most common first symptoms of vad/icad.

    1. Harriet Hall says:

      @EBM,
      “neck pain is one of the most common first symptoms of vad/icad.”
      You are right. I looked for more studies on the presenting symptoms of VAD, and neck pain is more common than I had realized. It is usually at the top of the neck where it connects to the skull, so there might be some confusion about whether to call it head or neck pain. Neck pain is less common than headache; and dizziness is more common than either head or neck pain. http://www.ncbi.nlm.nih.gov/pubmed/22931728 What would the average chiropractor do if a patient presented with only dizziness, or with dizziness plus head or neck pain? And if patients present with neck pain, manipulation would endanger those whose neck pain was due to a VAD. So if chiropractors can’t rule out VAD, they shouldn’t do neck manipulations.

  10. DG says:

    This is a more common event than has been reported. I have seen or heard of a number of cases in clinical practice. Chiropractors should never be allowed to do neck manipulations. Period. Full stop. End of story.

    1. do you understand the full effect of drugs that are prescribed by MDs repeatedly and repeatedly…. honestly y’all are not much better…..There are good DCs, just like there are good MDs. Some chirps are quacks, just like some MDs are quacks. I won’t disagree w/ the VAD discussion but its pretty obvious to rule it out when it presents to your office, but its supposed to be combined with a full detailed Hx from their first visit.

      1. Harriet Hall says:

        Um… the problem is not so much being able to recognize the symptoms of a stroke as to prevent causing one with neck manipulation.

        1. you don’t cause a stroke with a cervical adjustment if you know what you are doing… normally there is already a clot formed when a stroke happens, and it dislodges. look up the ratio of VADs to cervical adjustments. Then while we are on the subject of ratios look up the ratio of successful back surgeries, and what they define as successful.

          1. and in the Hx you can find out answers to questions that would steer you away from doing a HVLA adjustment to that patient and then you would decide what other treatment would be best for the patient.

            1. Harriet Hall says:

              There is no way “answers to questions” can predict the risk of a stroke with neck manipulation. If you can cite any references for your claim, please do.

          2. MadisonMD says:

            you don’t cause a stroke with a cervical adjustment if you know what you are doing

            Pray tell us how a consumer would know if his/her chiro knows what she is doing? My conclusion is that if neck manipulation is done, then she does NOT know what she is doing since there is no evidence of benefits and risks are extremely bad, albeit rare.

            look up the ratio of VADs to cervical adjustments

            Umm.. Harriet has done that. Actually more than once if you follow the links. The conclusion? I could hardly say it better than Harriet herself. After listing the symptoms of vertebral artery stroke:

            Note that that neck pain is not even on the list. And although headache usually precedes the neurologic signs, many patients don’t seek care until the neurologic signs have developed; and I would guess that those signs would be more likely to send them to the ER than to the chiropractor. In fact, the Cassidy study found a strong association between visiting a chiropractor and having a stroke in the next 24 hours for patients under the age of 45 (odds ratio = 12).

            1. Saints1868 says:

              have you ever been to a chiro before? and please tell me how the consumer knows what there MD is doing? b/c i been to lots that have no clue and give horrible advice to there patients, along with medications that they do not need. Like i have said before MDs have quacks and chiros have quacks… everyone has bad people in there profession looking to make a buck off of false claims.

              1. MadisonMD says:

                No, I haven’t been to a chiro before. I know some chiropractors personally and it actually pains me because I know they are good people.

                Sure there are good chiros and bad, good doctors and bad. However, there is a major fundamental difference between the field of medicine and of chiropractic:

                (a) Medical practice is taught on the basis of biomedical science. There is a scientific basis to standard medical interventions that the benefits outweigh risks. Clinical practice and guidelines are altered in response to new scientific findings. Quality initiatives hold physicians accountable to practice guidelines. Medical practice changes rapidly on the basis of new research.

                (b) Chiropractic is fundamentally based on the unscientific belief of D.D. Palmer. Some chiropractors have rejected his teachings; others have not. Many are against standard medical practice such as vaccines– and there are no guidelines or quality care initiatives against such advice. Most recommend treatments are ineffective or unlikely to be effective. Many of the claims–such as those about whiplash and colic– are, in the words of one observer, “bogus.” Little has changed in chiropractic over the past century and there are few standards of care or quality initiatives.

                Yes, a few chiropractors accept that vertebral subluxations do not exist, that spinal manipulation does not have therapeutic effects on the nervous system, and that it–like physical therapy– can be of only limited benefit in select cases of musculoskeletal back pain. Some don’t use applied kinesiology and some avoiding recommending or selling supplements. I hope you are one…. but I’m afraid you’ll have trouble making ends meet if you limit yourself to scientific practice.

              2. WilliamLawrenceUtridge says:

                Again, the argument is nonsensical. You’re saying “because doctors aren’t perfect, chiropractors can be as dangerous as they want and don’t need to prove that spinal manipulation works”. That’s stupid, and you’re kind of an idiot for repeating it.

          3. Harriet Hall says:

            You may think you know what you are doing and yet be wrong. Medieval bloodletters thought they knew what they were doing. There is no evidence that pre-existing clots are the sole cause of stroke with neck manipulation (see Mark Crislip’s critique of the Cassidy study). If there is a clot present, there is no test you can do in the office that will tell you it is there. VAD can occur simply from hyperextending the neck for a shampoo in the beauty parlor; so how can you think neck manipulation couldn’t cause a tear? We are well aware that VAD with neck manipulation is rare. The ratio of successful back surgeries is irrelevant and a tu quoque fallacy.

      2. WilliamLawrenceUtridge says:

        What does the effectiveness, lack thereof, and adverse effects have to do with the risks and effectiveness of chiropractic? If chiropractic is ineffective and dangerous, it has nothing to do with the safety and efficacy of drugs.

        Or, for that matter, stretching and exercises for neck pain – which are safe and effective.

        Please don’t pretend your argument is anything but a distraction.

      3. WilliamLawrenceUtridge says:

        What does the prescribing habits of doctors have to do with the risk of cervical artery dissection by chiropractors? Are you saying chiropractors don’t have to prove that spinal manipulation is safe and effective until all of medicine is proven safe and effective? How is that rational?

  11. ahavoc says:

    I mostly crack my neck myself, because there’s pressure and it’s uncomfortable until I do. Are you saying that every time I crack my own neck I’m at risk of a stroke? If so better call CNN and put out a warning because there’s a lot of people that do this everyday. My chiropractor will adjust my neck and then the need for me to crack it goes away until I do something which causes my neck to go out again. All a medical doctor’s ever done is throw meds at me that either make me sick or incapacitate me, making it impossible for me to do all the things I have to do on a daily basis, (work, family, responsibilities), and provide no relief.

    Did you know that 100% of the time people get sick after seeing a medical doctor? Some sooner, some later. Did you know that there’s a certain percent of patients who experience VAD after seeing a medical doctor? Did you know that 100% of the time, people die after seeing a medical doctor? Some sooner, some later, some because of.

    Statistics may be used to prove a lot of things. Mitigating circumstances abound. What I need to see and read is the exact type of manipulation pre-VAD. What cervical area is indicated? Is it the same cervical manipulation each time? The same technique? Did the patient present with pre-VAD symptoms prior? Was there a predisposition in those that experienced the VAD? Did all of the patients present with the same complaint? Out of the millions of patients that see chiropractors and have neck manipulations, in what percentage has VAD been the outcome?

    If this is a true concern, then a cross training should occur to help the chiros better recognize the possibility of what’s being presented, (pre-VAD symptoms), and not in condescending manner . But make no mistake about this, I’ve gotten more help from my chiropractor than I have ever gotten from a physician, and so have a lot of others. People are going to continue going to chiropractors whether you all like it or not. My suggestion is that, (dare I say it), medical doctors and chiropractors work together and stop fighting each other. (Hope springs eternal.) I’d go to a practice that had an MD and a Chiro in a heartbeat.

    1. I mostly crack my neck myself, because there’s pressure and it’s uncomfortable until I do. Are you saying that every time I crack my own neck I’m at risk of a stroke?

      Most neck adjustments are harmless and can have some benefit for relieving pain conditions. Your margin for error however is small in that area – if you do it wrong or apply too much force, you could injure the vertebral artery or fracture a vertebra.

    2. William says:

      @ ahavoc
      Thanks for keeping it real.

    3. WilliamLawrenceUtridge says:

      Are you saying that every time I crack my own neck I’m at risk of a stroke?

      Yes, that’s pretty much what is being said. Fortunately the risk is low.

      My chiropractor will adjust my neck and then the need for me to crack it goes away until I do something which causes my neck to go out again.

      At any point did your chiropractor tell you “by the way, there’s a small, but real chance that this will cause a stroke”? Did he offer you alternatives like stretching before moving to vertebral manipulation? My physio, for my back pain, could do a manipulation. He’s trying exercises and stretching first (and my back feels pretty good now).

      CAM proponents often demand disclosure of vanishingly rare consequences of vaccination, or point to these vanishingly rare events as if they were a smoking gun demonstrating how harmful medicine is. Well, here is the CAM side of things – CAM is normally inert, but rare side effects are real, and should be disclosed.

      All a medical doctor’s ever done is throw meds at me that either make me sick or incapacitate me, making it impossible for me to do all the things I have to do on a daily basis, (work, family, responsibilities), and provide no relief.

      My doctor wrote me a prescription for physiotherapy, after doing some tests and asking some questions to make sure it wasn’t cancer or arthritis.

      Statistics may be used to prove a lot of things. Mitigating circumstances abound. What I need to see and read is the exact type of manipulation pre-VAD. What cervical area is indicated? Is it the same cervical manipulation each time? The same technique? Did the patient present with pre-VAD symptoms prior? Was there a predisposition in those that experienced the VAD? Did all of the patients present with the same complaint? Out of the millions of patients that see chiropractors and have neck manipulations, in what percentage has VAD been the outcome?

      Those sound like great questions. Don’t you think that they should have been studied by chiropractors before neck manipulation was used for over a century? Physiotherapists made a point of waiting until there was proof for spinal manipulation having benefit before adopting it. It only took a century for someone to test it.

      People are going to continue going to chiropractors whether you all like it or not. My suggestion is that, (dare I say it), medical doctors and chiropractors work together and stop fighting each other. (Hope springs eternal.) I’d go to a practice that had an MD and a Chiro in a heartbeat.

      For what? For muscle pain? Fair enough (I just hope your pain isn’t caused by something other than something mechanical). But why a chiropractor rather than a physiotherapist? And what do you think of chiropractors who claim to be able to cure cancer, or allergies, or diabetes? What do you think of chiropractors who want to be primary care providers? What about chiropractors who not only recommend nutritional supplements but sell them in their office (and expensive ones at that)?

      There are different flavours of chiropractors, at least two (straights and mixers). Mixers are basically physiotherapists who focus on the back and have some questionable practices and training. Straights are lunatics who think they can cure and treat serious diseases by manipulating the spine. Be careful when discussing chiropractors because the two types are often mixed.

      Plus the usual caveats that almost nothing they do is tested in controlled trials, or has any research base.

  12. ahavoc says:

    At any point did your chiropractor tell you “by the way, there’s a small, but real chance that this will cause a stroke”? Did he offer you alternatives like stretching before moving to vertebral manipulation?
    My chiro did ask me if I would agree to neck manipulation. He ascertained if I had done any research, (yes), so yes he asked me. My chiro shows me stretches and exercises to do always, but what’s going on in my back or neck, usually makes it extremely difficult to do anything until it’s adjusted, so adjustment first, then doing the stretches and exercises afterwards in order to improve. It’s a partnership. My chiro got me back into the gym and working out. He also helped design a program of exercises, (Professor Stuart McGill is his guru), specifically for me and my issues.
    CAM proponents often demand disclosure of vanishingly rare consequences of vaccination, or point to these vanishingly rare events as if they were a smoking gun demonstrating how harmful medicine is.
    I don’t need CAM to tell me about this. My reaction to the flu shot almost kills me, literally. The last time I needed an antibiotic I had to go through five before I found one that didn’t cause projectile vomiting and simultaneous diarrhea within an hour of taking it. Is it any wonder why I’d want to try something that doesn’t cause those kind of symptoms first?
    Well, here is the CAM side of things – CAM is normally inert, but rare side effects are real, and should be disclosed.
    First, my chiropractor considers himself to be a scientific chiropractor. We send each other links to papers on NCBI and other sites. He’s not big on vaccination. I, after researching and going through countless debates with myself, am on the fence, but it’s more because of past reactions to vaccinations as I mentioned earlier.
    I agree that rare side effects should be disclosed, but do you disclose all of the possible side effects of all the meds and vaccinations you prescribe to every single patient? Do you have a valid discussion about every possible side effect? Do you research the meds prior to prescribing, taking into consideration everything that’s going on with your patient? Or do you hand out whatever freebie the drug rep has left? Perhaps you feel that as long as any and all risks and side effects are listed and attached by the pharmacist to the bottle bag, the patient will be all set?
    All a medical doctor’s ever done is throw meds at me that either make me sick or incapacitate me, making it impossible for me to do all the things I have to do on a daily basis, (work, family, responsibilities), and provide no relief.
    My doctor wrote me a prescription for physiotherapy, after doing some tests and asking some questions to make sure it wasn’t cancer or arthritis.

    For my back it was muscle relaxers, and they didn’t help. And that’s what’s been prescribed by three different medical doctors over 25 years. (Had a slip and fall, and two rear-enders.)
    Those sound like great questions. Don’t you think that they should have been studied by chiropractors before neck manipulation was used for over a century? Physiotherapists made a point of waiting until there was proof for spinal manipulation having benefit before adopting it. It only took a century for someone to test it.
    Wait, did medical science wait for studies before deciding that physicians should wash their hands between patients? If something helps someone, do you not do it even if you know it will help because you need a study? If neck manipulation has been used for over a century, how much longer should a study last before confirming that there are benefits to it? Standard and Priority reviews on new drugs still indicate that John Q. Public is the real guinea pig in medicine, so cast not the first stone.
    For what? For muscle pain? Fair enough (I just hope your pain isn’t caused by something other than something mechanical).
    The medical community, in its lack of wisdom, has actually given me a few umbrellas, one of them being the diagnosis of Autoimmune Syndrome. This means I don’t feel well a lot. My old allergist / immunologist shrugged his shoulders and told me there wasn’t anything to be done. I dropped all the meds that guy put me on, and felt better. This was on my own, not something my chiro did. (Hadn’t met him yet). My chiropractor helps me in a variety of ways. He helped me to change my diet, do correct stretches and exercises, the positive use of massage and adjustments, and I actually feel better. Lately people have mentioned I don’t look so “puffy”. Modern medicine is only 100 years old and prior to that, herbs and foods were used for thousands of years to help people, as you well know. These “natural” therapies haven’t suddenly stopped working because of the invention of the test tube. My chiro discusses nutrition and yes, nutritional supplements. I’d rather take turmeric than ibuprophen, use honey on burns, quecertin rather than benedryl. If I didn’t have to take levo for my Hashimoto’s I’d stop that as well. Oh yeah, my Hashi’s can only be treated, it can’t be cured, because again, medical science doesn’t cure these days, it seems it can only treat, and it can’t figure out what is going on in the autoimmune department at all. Trust me, I’ve been researching it for 30 years.
    But why a chiropractor rather than a physiotherapist?
    Why not? I’ve been to physiotherapists and I get more and longer lasting relief from my chiropractor.
    And what do you think of chiropractors who claim to be able to cure cancer, or allergies, or diabetes?
    I think there’s a sucker born every minute. You can’t stop idiots from being idiot, whether they’re selling or buying.

    What do you think of chiropractors who want to be primary care providers?
    I’d love my chiro to be my primary. All primary means to me is someone who helps coordinate all medical care for a patient and makes sure all health providers are on the same page in regards to the patient’s choice of treatment. Doesn’t mean I don’t have a doctor or that I don’t consult my doctor, it’s just that I prefer to try to do what I can with nutrition, exercise and supplements prior to going for prescription meds. My chiro has sent me to my doctor when I’ve been reluctant to go.
    What about chiropractors who not only recommend nutritional supplements but sell them in their office (and expensive ones at that)?
    Doesn’t mean I have to buy those supplements. My chiro has actually said where I could get some of the supplements provided by the office at a cheaper store. But I also research before getting anything. What about doctors who hand out free sample meds that the drug rep has left, then written the prescription for the new med, and the patient goes to the pharmacy and ends up having to pay $200+?
    There are different flavours of chiropractors, at least two (straights and mixers). Mixers are basically physiotherapists who focus on the back and have some questionable practices and training. Straights are lunatics who think they can cure and treat serious diseases by manipulating the spine. Be careful when discussing chiropractors because the two types are often mixed.
    Sorry, I disagree. My chiro is a scientific chiropractor. He holds research very high. There are good chiros and bad chiros just as there are good doctors and bad doctors. I’ve experienced the good and the bad of both, and I feel lucky that I’ve got two good ones.

    1. WilliamLawrenceUtridge says:

      My chiro did ask me if I would agree to neck manipulation. He ascertained if I had done any research, (yes), so yes he asked me.

      If doctors expected me to do the research for my own drugs and medical procedures, and expected me to be the one to digest and process it, and to do my own due diligence in general, I would ask why I bothered going to a doctor when apparently all that medical school nonsense isn’t needed because I can just find it out on the internet. I don’t consider “uh, so, did you do your own research?” to be an adequate form of informed consent.

      Do you have a valid discussion about every possible side effect? Do you research the meds prior to prescribing, taking into consideration everything that’s going on with your patient? Or do you hand out whatever freebie the drug rep has left?

      I expect my doctor to do this, I expect him to tell me what kinds of reactions are serious (particularly ones that are apparently banal but could be deadly). My doctor writes me prescriptions for generic medications, which I pick up in a pharmacy (this may be biased because I have a government-funded health plan, so neither I, nor my fellow countrymen, need to rely on pharma handouts; perhaps if the US government did the sane and humane thing and set up a real health plan, poorer citizens wouldn’t have to rely on the generosity of drug companies or choose to go without food that week).

      Wait, did medical science wait for studies before deciding that physicians should wash their hands between patients? If something helps someone, do you not do it even if you know it will help because you need a study? If neck manipulation has been used for over a century, how much longer should a study last before confirming that there are benefits to it? Standard and Priority reviews on new drugs still indicate that John Q. Public is the real guinea pig in medicine, so cast not the first stone.

      Are we talking about medicine, or chiropractic? Are you saying chiropractic doesn’t have to test its interventions until medicine is perfect? Or do we just have to wait until a century has passed, then it gets a free pass? Semmelweis’s seminal studies occurred in 1847, basically before the Flexner report and the existence of scientific medicine. Also note that the polio vaccine, despite being desperately needed, was tested with proper control groups before it was used widely. Scientific medicine tests even desperately needed medications before selling.

      The real issue is whether a treatment helps someone, and for the most part, including spinal manipulation, that is still an open question.

      What is your solution other than post-marketing surveillance for rare drug effects? Should we drive up the cost of drug production by a couple hundred million more dollars, thus incentivizing more Big Pharma malfeasance, by insisting clinical trials of ten thousand people or more? Real medicine is hard and imperfect, and that has absolutely nothing to do with the fact that chiropractic care has incredibly inadequate safety and efficacy research on it.

      Modern medicine is only 100 years old and prior to that, herbs and foods were used for thousands of years to help people, as you well know. These “natural” therapies haven’t suddenly stopped working because of the invention of the test tube. I’d rather take turmeric than ibuprophen, use honey on burns, quecertin rather than benedryl.

      They also didn’t start working because Andrew Weil started spouting off about them. Herbs are dirty drugs, of uncertain potency, uncertain pharmacokinetics, uncertain contents (seriously, read that article then tell me how great your herbs are; do you have the capabilities to determine what’s actually in your pills in some sort of home DNA-barcoder?) and for the most part you are simply trusting the hoary wisdom of ages (that brought you things like “bloodletting”, and “inquisitions”, and homeopathy) and when tested it, they were either ineffective, or in some cases turned out it had dangerous adverse effects.

      Are you sure about honey by the way?

      I think there’s a sucker born every minute. You can’t stop idiots from being idiot, whether they’re selling or buying.

      What do you think about the fact that some chiropractic colleges systematically teach the idea that chiropractic manipulation can cure cancer?

      I’d love my chiro to be my primary. All primary means to me is someone who helps coordinate all medical care for a patient and makes sure all health providers are on the same page in regards to the patient’s choice of treatment.

      …and again, what about the chiropractors who think they can cure cancer or asthma? Your chiropractor may be decent, but the massive amount of straights out there, the crazies, are not. They are deluded and dangerous. Your chiropractor doesn’t have the ability to parse medications, and apparently don’t appreciate the danger of cervical manipulation.

      What about doctors who hand out free sample meds that the drug rep has left, then written the prescription for the new med, and the patient goes to the pharmacy and ends up having to pay $200+?

      The issue of pharma samples is complicated; yes, it can influence prescribing practices. But it also helps increase uptake of new (and sometimes superior) medications. It provides physicians with samples that they can in turn provide to patients who would otherwise go untreated. And hey, as you say, the patient doesn’t have to spend the money, do they? Just like your chiropractor’s supplements, with one tiny distinction.

      The sins of one profession do not make up for, or discount, the sins of another. Chiropractic as a profession contains a large number of practitioners systematically trained to believe they can cure cancer, they can prescribe drugs with a couple weekends of training, that they know more about nutrition than doctors, that vaccination is a health risk, and more. That needs to change, because they are a danger to public health.

  13. William M. London says:

    It’s important to keep in mind that Hill’s criteria (as presented by Hill) are rules of thumb, not rigid decision rules. There is more than enough evidence to suggest that chiropractic neck treatment can have severe consequences even if they are infrequent. The evidence for benefit of chiropractic neck treatment is weak. The potential for harm exceeds the potential for benefit.

  14. Dan Meyers says:

    Chiropractors are not medical doctors in any sense of the word. At very best they are semi-qualified masseuses. At worst they are extremely dangerous individuals.

    Below is a link to a great article on chiropractors AKA: fake doctors, AKA: con-men AKA: medical charlatans. It’s based on a book written by an ex-chiropractor and lists the “20 THINGS YOUR CHIROPRACTOR DOESNT WANT YOU TO KNOW.

    It’s amazing that with the availability of so much information people still buy into what these play-doctors say. The horror stories on the net of the damage these people have caused are everywhere. It’s most upsetting to me when they call themselves Doctors (MD) instead of what they are – “doctors of chiropractic” (DC) with a 2-year virtually worthless degree. I have actively embarrassed quite a few in my years and will continue to do so!

    Here is the article:

    http://edzardernst.com/2013/10/twenty-things-most-chiropractors-wont-tell-you/

    1. WilliamLawrenceUtridge says:

      At best they are semi-qualified physiotherapists, that’s (IMO) the profession they are closest to. Also, Dr. Hall has written about Long’s book here.

  15. Dan Meyers says:

    Twenty Things Most Chiropractors Won’t Tell You – Published Friday 18 October 2013

    The following is a guest post by Preston H. Long. It is an excerpt from his new book entitled ‘Chiropractic Abuse—A Chiropractor’s Lament’. Preston H. Long is a licensed chiropractor from Arizona. His professional career has spanned nearly 30 years. In addition to treating patients, he has testified at about 200 trials, performed more than 10,000 chiropractic case evaluations, and served as a consultant to several law enforcement agencies. He is also an associate professor at Bryan University, where he teaches in the master’s program in applied health informatics. His new book is one of the very few that provides an inside criticism of chiropractic. It is well worth reading, in my view.

    Have you ever consulted a chiropractor? Are you thinking about seeing one? Do you care whether your tax and health-care dollars are spent on worthless treatment? If your answer to any of these questions is yes, there are certain things you should know.

    1. Chiropractic theory and practice are not based on the body of knowledge related to health, disease, and health care that has been widely accepted by the scientific community.

    Most chiropractors believe that spinal problems, which they call “subluxations,” cause ill health and that fixing them by “adjusting” the spine will promote and restore health. The extent of this belief varies from chiropractor to chiropractor. Some believe that subluxations are the primary cause of ill health; others consider them an underlying cause. Only a small percentage (including me) reject these notions and align their beliefs and practices with those of the science-based medical community. The ramifications and consequences of subluxation theory will be discussed in detail throughout this book.

    2. Many chiropractors promise too much.

    The most common forms of treatment administered by chiropractors are spinal manipulation and passive physiotherapy measures such as heat, ultrasound, massage, and electrical muscle stimulation. These modalities can be useful in managing certain problems of muscles and bones, but they have little, if any, use against the vast majority of diseases. But chiropractors who believe that “subluxations” cause ill health claim that spinal adjustments promote general health and enable patients to recover from a wide range of diseases. The illustrations below reflect these beliefs. The one to the left is part of a poster that promotes the notion that periodic spinal “adjustments” are a cornerstone of good health. The other is a patient handout that improperly relates “subluxations” to a wide range of ailments that spinal adjustments supposedly can help. Some charts of this type have listed more than 100 diseases and conditions, including allergies, appendicitis, anemia, crossed eyes, deafness, gallbladder problems, hernias, and pneumonia.

    A 2008 survey found that exaggeration is common among chiropractic Web sites. The researchers looked at the Web sites of 200 chiropractors and 9 chiropractic associations in Australia, Canada, New Zealand, the United Kingdom, and the United States. Each site was examined for claims suggesting that chiropractic treatment was appropriate for asthma, colic, ear infection/earache/otitis media, neck pain, whiplash, headache/migraine, and lower back pain. The study found that 95% of the surveyed sites made unsubstantiated claims for at least one of these conditions and 38% made unsubstantiated claims for all of them.1 False promises can have dire consequences to the unsuspecting.

    3. Our education is vastly inferior to that of medical doctors.

    I rarely encountered sick patients in my school clinic. Most of my “patients” were friends, students, and an occasional person who presented to the student clinic for inexpensive chiropractic care. Most had nothing really wrong with them. In order to graduate, chiropractic college students are required to treat a minimum number of people. To reach their number, some resort to paying people (including prostitutes) to visit them at the college’s clinic.2

    Students also encounter a very narrow range of conditions, most related to aches and pains. Real medical education involves contact with thousands of patients with a wide variety of problems, including many severe enough to require hospitalization. Most chiropractic students see patients during two clinical years in chiropractic college. Medical students also average two clinical years, but they see many more patients and nearly all medical doctors have an additional three to five years of specialty training before they enter practice.

    Chiropractic’s minimum educational standards are quite low. In 2007, chiropractic students were required to evaluate and manage only 15 patients in order to graduate. Chiropractic’s accreditation agency ordered this number to increase to 35 by the fall of 2011. However, only 10 of the 35 must be live patients (eight of whom are not students or their family members)! For the remaining cases, students are permitted to “assist, observe, or participate in live, paper-based, computer-based, distance learning, or other reasonable alternative.”3 In contrast, medical students see thousands of patients.

    Former National Council Against Health Fraud President William T. Jarvis, Ph.D., has noted that chiropractic school prepares its students to practice “conversational medicine”—where they glibly use medical words but lack the knowledge or experience to deal appropriately with the vast majority of health problems.4 Dr. Stephen Barrett reported a fascinating example of this which occurred when he visited a chiropractor for research purposes. When Barrett mentioned that he was recovering from an attack of vertigo (dizziness), the chiropractor quickly rattled off a textbook-like list of all the possible causes. But instead of obtaining a proper history and conducting tests to pinpoint a diagnosis, he x-rayed Dr. Barrett’s neck and recommended a one-year course of manipulations to make his neck more curved. The medical diagnosis, which had been appropriately made elsewhere, was a viral infection that cleared up spontaneously in about ten days.5

    4. Our legitimate scope is actually very narrow.

    Appropriate chiropractic treatment is relevant only to a narrow range of ailments, nearly all related to musculoskeletal problems. But some chiropractors assert that they can influence the course of nearly everything. Some even offer adjustments to farm animals and family pets.

    5. Very little of what chiropractors do has been studied.

    Although chiropractic has been around since 1895, little of what we do meets the scientific standard through solid research. Chiropractic apologists try to sound scientific to counter their detractors, but very little research actually supports what chiropractors do.

    6. Unless your diagnosis is obvious, it’s best to get diagnosed elsewhere.

    During my work as an independent examiner, I have encountered many patients whose chiropractor missed readily apparent diagnoses and rendered inappropriate treatment for long periods of time. Chiropractors lack the depth of training available to medical doctors. For that reason, except for minor injuries, it is usually better to seek medical diagnosis first.

    7. We offer lots of unnecessary services.

    Many chiropractors, particularly those who find “subluxations” in everyone, routinely advise patients to come for many months, years, and even for their lifetime. Practice-builders teach how to persuade people they need “maintenance care” long after their original problem has resolved. In line with this, many chiropractors offer “discounts” to patients who pay in advance and sign a contract committing them for 50 to 100 treatments. And “chiropractic pediatric specialists” advise periodic examinations and spinal adjustments from early infancy onward. (This has been aptly described as “womb to tomb” care.) Greed is not the only factor involved in overtreatment. Many who advise periodic adjustments are “true believers.” In chiropractic school, one of my classmates actually adjusted his newborn son while the umbilical cord was still attached. Another student had the school radiology department take seven x-rays of his son’s neck to look for “subluxations” presumably acquired during the birth process. The topic of unnecessary care is discussed further in Chapter 8.

    8. “Cracking” of the spine doesn’t mean much.

    Spinal manipulation usually produces a “popping” or “cracking” sound similar to what occurs when you crack your knuckles. Both are due to a phenomenon called cavitation, which occurs when there is a sudden decrease in joint pressure brought on by the manipulation. That allows dissolved gasses in the joint fluid to be released into the joint itself. Chiropractors sometimes state that the noise means that something therapeutic has taken place. However, the noise has no health-related significance and does not indicate that anything has been realigned. It simply means that gas was allowed to escape under less pressure than normal. Knuckles do not “go back into place” when you crack them, and neither do spinal bones.

    9. If the first few visits don’t help you, more treatment probably won’t help.

    I used to tell my patients “three and through.” If we did not see significant objective improvement in three visits, it was time to move on.

    10. We take too many x-rays.

    No test should be done unless it is likely to provide information that will influence clinical management of the patient. X-ray examinations are appropriate when a fracture, tumor, infection, or neurological defect is suspected. But they are not needed for evaluating simple mechanical-type strains, such as back or neck pain that develops after lifting a heavy object.

    The average number of x-rays taken during the first visit by chiropractors whose records I have been asked to review has been about eleven. Those records were sent to me because an insurance company had flagged them for investigation into excessive billing, so this number of x-rays is much higher than average. But many chiropractors take at least a few x-rays of everyone who walks through their door.

    There are two main reasons why chiropractors take more x-rays than are medically necessary. One is easy money. It costs about 35¢ to buy an 8- x 10-inch film, for which they typically charge $40. In chiropractic, the spine encompasses five areas: the neck, mid-back, low-back, pelvic, and sacral regions. That means five separate regions to bill for—typically three to seven views of the neck, two to six for the low back, and two for each of the rest. So eleven x-ray films would net the chiropractor over $400 for just few minutes of work. In many accident cases I have reviewed, the fact that patients had adequate x-ray examinations in a hospital emergency department to rule out fractures did not deter the chiropractor from unnecessarily repeating these exams.

    Chiropractors also use x-ray examinations inappropriately for marketing purposes. Chiropractors who do this point to various things on the films that they interpret as (a) subluxations, (b) not enough spinal curvature, (c) too much spinal curvature, and/or (d) “spinal decay,” all of which supposedly call for long courses of adjustments with periodic x-ray re-checks to supposedly assess progress. In addition to wasting money, unnecessary x-rays entail unnecessary exposure to the risks of ionizing radiation.

    11. Research on spinal manipulation does not reflect what takes place in most chiropractic offices.

    Research studies that look at spinal manipulation are generally done under strict protocols that protect patients from harm. The results reflect what happens when manipulation is done on patients who are appropriately screened—usually by medical teams that exclude people with conditions that would make manipulation dangerous. The results do not reflect what typically happens when patients select chiropractors on their own. The chiropractic marketplace is a mess because most chiropractors ignore research findings and subject their patients to procedures that are unnecessary and/or senseless.

    12. Neck manipulation is potentially dangerous.

    Certain types of chiropractic neck manipulation can damage neck arteries and cause a stroke. Chiropractors claim that the risk is trivial, but they have made no systematic effort to actually measure it. Chapter 9 covers this topic in detail.

    13. Most chiropractors don’t know much about nutrition.

    Chiropractors learn little about clinical nutrition during their schooling. Many offer what they describe as “nutrition counseling.” But this typically consists of superficial advice about eating less fat and various schemes to sell you supplements that are high-priced and unnecessary.

    14. Chiropractors who sell vitamins charge much more than it costs them.

    Chiropractors who sell vitamins typically recommend them unnecessarily and charge two to three times what they pay for them. Some chiropractors center their practice around selling vitamins to patients. Their recommendations are based on hair analysis, live blood analysis, applied kinesiology muscle-testing or other quack tests that will be discussed later in this book. Patients who are victimized this way typically pay several dollars a day and are encouraged to stay on the products indefinitely. In one case I investigated, an Arizona chiropractor advised an 80+-year-old grandma to charge more than $10,000 for vitamins to her credit cards to avoid an impending stroke that he had diagnosed by testing a sample of her pubic hair. No hair test can determine that a stroke is imminent or show that dietary supplements are needed. Doctors who evaluated the woman at the Mayo Clinic found no evidence to support the chiropractor’s assessment.

    15. Chiropractors have no business treating young children.

    The pediatric training chiropractors receive during their schooling is skimpy and based mainly on reading. Students see few children and get little or no experience in diagnosing or following the course of the vast majority of childhood ailments. Moreover, spinal adjustment has no proven effectiveness against childhood diseases. Some adolescents with spinal stiffness might benefit from manipulation, but most will recover without treatment. Chiropractors who claim to practice “chiropractic pediatrics” typically aim to adjust spines from birth onward and are likely to oppose immunization. Some chiropractors claim they can reverse or lessen the spinal curvature of scoliosis, but there is no scientific evidence that spinal manipulation can do this.

    16. The fact that patients swear by us does not mean we are actually helping them.

    Satisfaction is not the same thing as effectiveness. Many people who believe they have been helped had conditions that would have resolved without treatment. Some have had treatment for dangers that did not exist but were said by the chiropractor to be imminent. Many chiropractors actually take courses on how to trick patients to believe in them.

    17. Insurance companies don’t want to pay for chiropractic care.

    Chiropractors love to brag that their services are covered by Medicare and most insurance companies. However, this coverage has been achieved though political action rather than scientific merit. I have never encountered an insurance company that would reimburse for chiropractic if not forced to do so by state laws. The political pressure to mandate chiropractic coverage comes from chiropractors, of course, but it also comes from the patients whom they have brainwashed.

    18. Lots of chiropractors do really strange things.

    The chiropractic profession seems to attract people who are prone to believe in strange things. One I know of does “aura adjustments” to treat people’s “bruised karma.” Another rents out a large crystal to other chiropractors so they can “recharge” their own (smaller) crystals. Another claims to get advice by “channeling” a 15th Century Scottish physician. Another claimed to “balance a woman’s harmonics” by inserting his thumb into her vagina and his index finger into her anus. Another treated cancer with an orange light that was mounted in a wooden box. Another did rectal exams on all his female patients. Even though such exams are outside the legitimate scope of chiropractic, he also videotaped them so that if his bills for this service were questioned, he could prove that he had actually performed what he billed for.

    19. Don’t expect our licensing boards to protect you.

    Many chiropractors who serve on chiropractic licensing boards harbor the same misbeliefs that are rampant among their colleagues. This means, for example, that most boards are unlikely to discipline chiropractors for diagnosing and treating imaginary “subluxations.”

    20. The media rarely look at what we do wrong.

    The media rarely if ever address chiropractic nonsense. Reporting on chiropractic is complicated because chiropractors vary so much in what they do. (In fact, a very astute observer once wrote that “for every chiropractor, there is an equal and opposite chiropractor.”) Consumer Reports published superb exposés in 1975 and 1994, but no other print outlet has done so in the past 35 years. This lack of information is the main reason I have written this book.

    References

    1. Ernst E, Gilbey A. Chiropractic claims in the English-speaking world. New Zealand Medical Journal 123:36–44, 2010.

    2. Bernet J. Affidavit, April 12, 1996. Posted to Chirobase Web site.

    3. Standards for Doctor of Chiropractic Programs and Requirements for Institutional Status. Council on Chiropractic Education, Scottsdale, Arizona, Jan 2007.

    4. Jarvis WT. Why becoming a chiropractor may be risky. Chirobase Web site, October 5, 1999.

    5. Barrett S. My visit to a “straight” chiropractor. Quackwatch Web site, Oct 10, 2002.

    6. Romano M, Negrini S. Manual therapy as a conservative treatment for idiopathic scoliosis: A review. Scoliosis 3:2, 2008.

    1. mousethatroared says:

      I appreciate the sentiment, but next time, could you please quote an excerpt from the article with a link. When I come back to comments to read updates, I’ll have to scroll past that whole article every time I hit the comments page.

  16. As a chiropractic student that has finished the majority of his classes and entering clinic we are taught to screen for a VAD by asking a series of questions and after those questions if there is any doubt of a stroke, any at all we call 911 to get that patient out of our office.

    1. windriven says:

      From a post under your name above:

      “have you ever been to a chiro before? and please tell me how the consumer knows what there MD is doing? b/c i been to lots that have no clue and give horrible advice to there patients, along with medications that they do not need. Like i have said before MDs have quacks and chiros have quacks… everyone has bad people in there profession looking to make a buck off of false claims.”

      And now you say:

      “As a chiropractic student that has finished the majority of his classes”

      I guess I have to ask, based on your grammar, spelling, and struggles with sentence structure: how the hell did you ever graduate high school much less make it most of the way through chiropractic school?

      But we’ll let that slide for now. Tell us instead what drew you to chiropractic and what it is you believe chiropractic brings to patient care. What great benefit will you bring to your fellow man? Does chiropractic cure MRSA? Does it save 800 gram babies? Does it remove toxins from the blood supply of those with kidney failure? Repair or replace incompetent valves? Bring an end to the embarrassment of explosive flatulence? Just wondering…

    2. WilliamLawrenceUtridge says:

      At what point are you given the scientific evidence base for the safety and efficacy of cervical spinal manipulation to treat neck pain? What controlled trials do you refer to, where chiropractic is compared to stretching and exercises, or even watchful waiting?

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