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Upper Neck Manipulation: Caveats for Patients and Providers

sam-adjusting

Chiropractors often deny that neck manipulation can be a primary cause of stroke by injuring vertebral arteries. But according to Jean-Yves Maigne, M.D., head of the Department of Physical Medicine at the Hôtel-Dieu Hospital in Paris, France:

It is now a well established fact that cervical thrust manipulation can harm the vertebral artery. This accident was formerly regarded as very rare, although severe, and related to atherosclerosis. Clinical tests were proposed to detect patients at risk. The problem is now better known. It is no longer attributed to atherosclerosis…but to a dissection of a vertebral artery, a clinical entity observed in younger patients (20-45 years). It remains very rare, but mild symptoms appear to be not so infrequent. Finally, the predicting tests seem to be deprived of any value.1

In 1997, the French Society of Orthopaedic and Osteopathic Manual Medicine (SOFMMOO), following presentations by anatomists, neurologists, radiologists, and practitioners in the field of French Manual Medicine, adopted the neck-manipulation proposals made by Dr. Maigne.1 “Acknowledging the fact that prevention is out of reach,” said Dr. Maigne, “the aim of these recommendations is to reduce the number of (not to say to suppress) rotational cervical thrust manipulations in a targeted population. This population consists mainly in females of less than 50 years old. Five recommendations were developed, in addition to classic contraindications of spinal manipulative therapy.”

The recommendations of the SOFMMOO, dealing with cervical manipulation in general and allowing the use of neck manipulation in special cases, are worth considering since they were reviewed by medical specialists in different disciplines and approved by licensed practitioners who use manual therapy, long before the stroke-neck-manipulation furor reached its peak in the United States.

Recommendations of the SOFMMOO

Recommendation #1: Seeking any undesirable effect following previous manipulative neck treatment such as nausea, headache, dizziness or vertigo. They could testify of a previous dissection with a favorable spontaneous outcome. This is an absolute contraindication to further cervical thrust manipulation.

Recommendation #2: No thrust manipulation for recent (i.e. acute) neck pain (less than 3-4 days), because it may be a symptom of a spontaneous dissection of the vertebral artery.

Recommendation #3: Neurologic exam mandatory before any cervical thrust (same reason as #2: the risk of a current dissection).

Recommendation #4: No cervical thrust in rotation in females less than 50 years. No cervical thrust in rotation in males less than 50 years at the first visit (but allowed at the second visit if the first treatment was not efficient). Instead of rotational thrust, it is highly recommended to use mobilizations, MET (muscle energy techniques), soft tissue cervical techniques and upper thoracic spine thrust manipulations (which certainly act on the cervico thoracic muscles).

Recommendation #5: Only physicians with a University Diploma passed at least one year before should be allowed to perform cervical manipulations. This latter recommendation should be adapted to the context of foreign countries. The idea is that a physician should not be allowed to thrust a neck without at least one year of full practice. Such an interval of time may allow him or her to feel comfortable and confident with other techniques (thoracic and lumbar spine).1

Why is upper cervical manipulation dangerous?

Extreme rotation of the atlas on the axis (at the atlantoaxial joint) stretches the vertebral artery.

Extreme rotation of the atlas on the axis (at the atlantoaxial joint) stretches the vertebral artery.

Extreme rotation of the atlas on the axis (at the atlantoaxial joint) stretches the vertebral artery.

Although the incidence of stroke (and other complications such as injury to the carotid artery) caused by neck manipulation may be low, as indicated by the number of such strokes reported in insurance and hospital records, it seems likely that many strokes associated with neck manipulation are not recognized and reported as such. The symptoms of minor cases of dissection may be so slight and temporary that recovery takes place without recognition or treatment; some may be asymptomatic because of adequate collateral circulation. Regardless, the risk of stroke associated with neck manipulation cannot be denied. Case reports of post-manipulation strokes clearly suggest cause and effect, making it necessary to question use of neck manipulation except in very special cases that have multi-disciplinary approval.

It is generally accepted that neck manipulation is most dangerous when there is thrust-type manipulation with rotation in the upper cervical area.

The atlantoaxial joints (connecting the 1st and 2nd cervical vertebrae─the atlas and the axis) in the upper cervical area of the spine, where the greatest amount of rotation takes place, are most vulnerable to injury since there are no intervertebral disc fibers and no interlocking joints to limit rotation. The atlanto-occipital joints (forming the articulation between the atlas and the skull), designed primarily for flexion-extension (nodding of the head), fit together like cups sitting in saucers and are also without disc fibers and interlocking joints. Normally, during active cervical rotation, all of the cervical vertebrae move together, a little movement in each joint, allowing about 80 degrees of rotation right and left. The atlantoaxial joint, capable of about 50 degrees of rotation, is the only joint in the cervical spine where movement can occur alone, allowing excessive rotation when there is passive upper cervical rotation forced by a manual head contact or by specific contact on the atlas vertebra.

Because of the tortuous route of the vertebral arteries in the upper cervical area where they thread through the transverse processes of the atlas (1st cervical vertebra) and then make a sharp turn to travel behind the atlas and enter the skull through the foramen magnum (the opening at the bottom of the skull), extreme rotation of the skull or the atlas may place stress on the vertebral artery and the vertebrobasilar arteries that supply the brain with blood. Passive upper neck rotation forced by manual manipulation should not exceed 45 or 50 degrees if stroke-causing kinking or traumatic dissection of vertebral arteries is to be avoided. A head contact should not be used to force rotation of the neck. Sudden stretching of an atherosclerotic or fragile vertebral artery during a rapid manual rotation of the head might cause vertebral artery damage by overcoming the artery’s compromised elasticity, causing tears and bleeding in the intimal lining of the artery, releasing clots that may travel to the brain.

There is, of course, a vertebral artery on each side of the neck, threading up through the transverse processes of cervical vertebrae from C6 to C1. Extreme rotation of the atlantoaxial joint in either direction stretches both arteries to some degree, more on one side or the other, depending upon the direction of rotation.

Injury to weak or diseased vertebral arteries can occur as a result of such common activities as a beauty parlor shampoo or looking around to back a car out of a garage. But dissection of a healthy vertebral artery in a young person occurs as a result of trauma, such as that which might be caused by the high-velocity thrust of cervical manipulation that forces sudden, extreme rotation of the upper cervical vertebrae, primarily at the atlantoaxial joint. Needless to say, even though it is difficult or impossible to determine beforehand who has weak or defective vertebral arteries, spontaneous dissection does not excuse dissection caused or aggravated by unnecessary or inappropriate neck manipulation. Unfortunately, many chiropractors routinely manipulate (adjust) the neck to correct “subluxations.” Some are “upper cervical specialists” who believe that realigning the atlas will remove pressure on the brain stem and realign vertebrae from the neck down, often requiring a specific manipulative contact (a “chiropractic adjustment”) that forces isolated and abnormal movement of the atlas.

Mobilization of the cervical spine within a normal range of movement may be less damaging to vertebral arteries than the high-velocity low-amplitude thrust that moves joints past their normal range of movement. Of course, persons predisposed to stroke because of fragile or diseased vertebral arteries may sustain injury to a vertebral artery during cervical spine mobilization as well as during manipulation; patients should always be informed of such risk. The added risk of unnecessary thrust manipulation borders on malpractice. A 2010 Cochrane Database Systematic Review (January 20:1) reported that cervical manipulation was no more effective than mobilization in relieving neck pain. Obviously, whenever appropriate, the safer of two treatment methods should receive priority.

In special cases, manipulation that produces cavitation (movement of joints into the paraphysiologic space where slight separation of joint surfaces occurs, often producing a popping sound) might be more effective than mobilization in restoring mobility and improving range of motion in previously injured joints. With proper manipulative contact, mid and lower cervical vertebrae can be rotated to produce cavitation or separation of joint surfaces without rotating the atlantoaxial joints. It’s possible to produce cavitation in the upper cervical joints without exceeding 50 degrees of rotation if certain manipulative-traction techniques are used. But except in very rare cases, I suspect that risk would outweigh benefit.

Contraindications for manipulating the neck

It seems unlikely that upper cervical manipulation could be totally banned, as some stroke-prevention advocates have proposed, since there may be rare problems involving the atlanto-occipital and atlantoaxial joints that could benefit from special manipulative techniques that do not involve excessive rotation. In the absence of a complete ban on the use of upper cervical manipulation, there are some contraindications to be considered. It goes without saying that sudden appearance of neck pain for no known reason, persistent undiagnosed neck pain, or neck pain immediately following injury should not be treated with manipulation, nor should disc herniation or nerve root impingement. Signs of vascular insufficiency, such as dizziness or fainting that occur during active or passive rotation or extension of the neck, or carotid artery bruits (noise caused by turbulent blood flow, often associated with atherosclerosis) heard on auscultation, would certainly be a red flag. Undetected vertebral artery fragility entails some degree of risk in any kind of neck manipulation, requiring that such treatment be used only as a last resort and only with informed consent.

Once the cause of neck pain has been diagnosed (ruling out structural abnormality, pathology, and vascular insufficiency), some types of uncomplicated mechanical-type neck pain might benefit from manipulation. Some diagnoses will strictly prohibit manipulation of the cervical spine. Rheumatoid spondylitis, for example, primarily affects the cervical spine and can cause atlantoaxial instability or true atlas subluxation that should not be manipulated. In rare cases, congenital absence of the odontoid process (a dowel-like projection of the axis that guides rotation of the atlas) will greatly weaken the atlantoaxial joint, making it more vulnerable to injury. Abnormalities in the upper cervical area may be associated with hidden nerve and vascular problems, such as an Arnold-Chiari malformation in which there is hypermobility (ligament weakness) in the atlanto-occipital and atlantoaxial joints with extension of cerebellar brain into the spinal canal. Arnold-Chiari may be associated with syringomyelia, a fluid-filled, vascular-rich cyst in the spinal cord that can be disturbed by manipulation. Basilar invagination, caused by softening of bone at the base of the skull, allows upward movement of the axis odontoid process into the foramen magnum, narrowing this opening at the base of the skull and encroaching upon the brain stem. Obviously, manipulation of upper cervical structures is a potentially dangerous procedure, requiring serious consideration and careful screening to rule out disease, genetic bone disorders, and other relevant problems.

Most neck problems can be treated better by time, massage, traction, exercise, and physical therapy modalities than by thrust manipulation. When neck manipulation is considered for treatment of an ongoing neck problem that has not responded to mobilization and conventional treatment methods, an x-ray exam should be done to rule out pathology and bony malformations before the manipulation is done. An MRI might be needed to find such conditions as an Arnold-Chiari malformation, depending upon the patient’s symptoms.

“Subluxation”: The most common reason for unnecessary neck manipulation

A diagnosis of “chiropractic subluxation,” alleged to be a cause of a great variety of ailments (requiring that every patient have neck manipulation), is a red flag and a major contraindication for neck manipulation since it can lead to excessive, inappropriate, and unnecessary manipulation, posing a risk of stroke. A subluxation diagnosis attached to an organic problem automatically precludes a correct diagnosis. Although a real orthopedic subluxation (not the same as an imaginary, asymptomatic chiropractic subluxation) can cause mechanical-type neck pain, it is not uncommon for chiropractors to report that subluxations are involved in every type of neck pain. A common neck crick (muscle spasm), for example, the kind a healthy person wakes up with in the morning, is usually a self-limiting condition that will resolve in several days with or without treatment if there is not a history to indicate a pre-existing problem caused by disease or injury. Chiropractors who inform their patients that subluxations cause neck cricks commonly take credit for curing this problem, leading the patient to believe that ongoing treatment is needed to keep subluxations from recurring and to prevent the development of illness, even when there are no symptoms. I always advised my patients to leave their neck alone if it is not bothering them and to avoid treatment by chiropractors who routinely manipulate (adjust) the neck to correct “subluxations.”

Although informed consent should be obtained from every patient who submits to neck manipulation, informed consent does not justify unnecessary neck manipulation and its concomitant risks.

References

Vautravers P, Maigne JY. Cervical spine manipulation and the precautionary principle. Joint Bone Spine. 2000;67:272-6. Accessed July 6, 2014 .


sam-bio

Sam Homola is a retired chiropractor who has been expressing his views about the benefits of appropriate use of spinal manipulation (as opposed to use of such treatment based on chiropractic subluxation theory) since publication of his book Bonesetting, Chiropractic, and Cultism in 1963. He retired from private practice in 1998. His many posts for ScienceBasedMedicine.org are archived here.

Posted in: Chiropractic

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131 thoughts on “Upper Neck Manipulation: Caveats for Patients and Providers

  1. PTJason says:

    Awesome awesome post! I’m a PT and always advise against upper cervical manipulations and get informed consent for any upper cervical treatment. Just yesterday I had someone in who had dizziness with extension and some concerning neuro signs. Of course, when I tested him he had a negative VBI test. He had been seeing a chiropractor for neck pain and I had to counsel in no uncertain terms against any upper cervical manipulations.

    People don’t understand how vulnerable of an area C1-2 is. People don’t understand that that area doesn’t really get “out” and need to be put “in.” People don’t understand that some of their neck pain might be from being manipulated in the first place. There is a lot of education that needs to happen to counter these prevailing attitudes.

  2. Graham says:

    There are other groups than chiropractors who perform ‘neck cracking’. Some martial arts group also do this. I was part of a large group (200ish) when the head instructor (8th dan) demonstrated it – and then we all did it on each other.
    Looking back (pun fully intended), omg.

    More recently I have had massage therapists want to do this to me. I politely refuse now.

  3. Thor says:

    Thanks for another important post on this topic. During my career as a neuromuscular massage therapist mainly dealing with pain and dysfunction cases, I worked closely, yet independently, with several chiropractors (and a PT, and an osteo). The chiros were all “subluxationists” (the osteo was woo-filled to the brim; only the PT used appropriate, evidence-based modalities). It certainly would have been wonderful (refreshing) , to say the least, to have made your acquaintance. Remarkably, I have never met a chiropractor who doesn’t practice and promote pseudo-science of varying degrees, yet I know they exist.
    You embody a much-needed approach to this discipline, and SBM is lucky to have you on board.

    1. Peter S says:

      What finally cured me of trying chiropractic was when a chiropractor I had been seeing (naturally, he promised it would take many visits to help me) suggested I wear a titanium necklace. And he was not some neighborhood schmo either — he was the chiropractor for a major, nationally-recognized sports team.

      1. simba says:

        The one I heard is that “If your back’s been bad for 10 years, it’s not going to be fixed in 10 visits. It could take as long again to fix it…”

      2. Thor says:

        Congratulations on your “healing”.
        Not surprising to hear at all, regardless of his status. Sadly, the whole team is being conned, though perhaps not intentionally. It seems that once the door of the mind gets opened to false belief, it becomes primed to resonate and accept all kinds of nonsense, including CAM. Then comes promulgation and practice— the business of quackery, ‘a la SSR. Sadly, most consumers of CAM are unknowing and well-intentioned victims. The athletes, for example, think they are getting extra-special care.

        1. Peter S says:

          Of all the crap out there promoted by chiropractors, Matrix Energetics by Richard Bartlett (here, incredibly, being advocated by an actual MD, Dave Ou of Atlanta, may be the worst.

          “Matrix Energetics® was developed by Richard Bartlett, D.C., N.D. about 10 years ago and it is based upon the principles of quantum physics.. He has taught it to tens of thousands of people over the last few years. Dr. Ou was initially skeptical about how well it would work but was interested since it was been supported by leaders that he respected in holistic medicine. Dr. Ou offers Matrix Energetics as a complementary approach within his medical practice. Patients have reported positive results when incorporating Matrix Energetics as part of their overall health care plan.

          What happens during a session?

          A session lasts 10-20 minutes. The patient lies, sits or stands comfortably while Dr. Ou gently touches various points around the body. Many patients report feeling warm or very relaxed.

          How does it work?

          There is ongoing research in this area. EEGs and EKGs suggests that when a practitioner starts to work, his brain waves and heart rhythm begin to become synchronized. Furthermore, the patient’s brain and heart also begin to become synchronized with the practitioner’s. There is growing research demonstrating that this synchronization increases the body’s ability to heal itself. One mechanism drawing from acupuncture research is that blood flow to the parts of the brain that regulate healing may increase.”

          1. Thor says:

            Whooo! Yeah, that’s out there for chiropractic but quickly saw why—NfrigginD. This uber-quack is a chiropractic naturopathist, for God’s sake, so it’s not that surprising. His mind has been completely inundated by the CAM spectrum at large. But Ou? The bastard.

            1. MTDoc says:

              Well, he may have legitimate parents, but still be full of shit.

            2. Peter S says:

              Ou is a cornucopia of junk science –in addition to Matrix Energetics he embraces Dietrich Klinghardt, Nutri-Energetic Systems (which says it measures human biofields with a hand held device and prescribes so-called nfoceuticals (energized drops of water) to correct them, Simon Yu (dental cavitations are the source of all illness), Ritchie Shoemaker and his neurotoxin theories, and who knows what else. Come one, call all, Dr. Ou is in.

            3. Peter S says:

              The good Dr. Ou, himself.

              http://www.drdaveou.com/

              1. Thor says:

                Oy vey. What doesn’t he do? He, as the ultimate doctor, can heal every ailment know to mankind. How insidious, using the MD, which gives legitimacy to the whole sordid affair. They are some of the worst kinds of CAM practitioners and have potential for great harm.

              2. Peter S says:

                Doctors like this always seem to get reviews at both extreme ends of the spectrum on review sites. For example, for Ou, one review says he is the best doctor ever and the next one says this:

                I just need to preface a verbatim quote from Dr. Ou during one of my doctor visits. I asked him how much longer I had for our visit and he said, “It’s up to you, I charge by the minute.” So now I will start from the beginning. I came to Dr. Ou for an alternative treatment to my illness because I was tired of traditional medicine and wanted to try something different. I was hopeful that I would finally get the help I needed. I was sadly disappointed. I went through test after test and I could never get any answers. He was telling me I “probably” have “lyme disease.” Or that I have mold in my house which is causing all my symptoms. Well, I definitely do not have mold and that’s a fact. I got the Lyme disease test done which was inconclusive. He still insisted I have more tests done while I spend even more money. All the while I had not insurance and I was working a part time job. He was extremely condescending and disrespectful. He seemed annoyed that I had questions. I thankfully have found some wonderful doctors that have helped me tremendously. I warn anyone considering going to Dr. Ou, you will spend a lot of money for no results.

                http://www.vitals.com/doctors/Dr_Dave_Ou/reviews#ixzz396PxlGv7

      3. WilliamLawrenceUtridge says:

        Athletes are not exactly recognized for their acumen in their health care choices, nor for their failure to understand jewelry is not a substitute for practice, no matter how fucking ugly.

  4. Mark Jessop says:

    I am a Chiropractor and read this article with interest. I consider myself to be an evidence informed Chiropractor and as such do not believe in all that subluxation nonsense and manipulation to be a cure all for disease known to man.
    I do however use manipulation and I do perform cervical manipulation on a regular basis when I feel it is clinically justified- for neck pain and cervicogenic headaches.
    I think advising against all upper cervical manipulation is ridiculous. I also think just presuming it is safe to perform is just as ridiclous.
    It is not just the vertebral artery- lets not forget about the carotids which supply more of the brain! There are no tests to predict if cervical manipulation is safe!! But what we can do is look at the case history and look for clues as to if the neck pain this patient is experiencing is in fact due to a dissection of an artery. Eg any dizzyness (feeling of being unsteady and falling to one side rather than room spinning) tiredness is a very big one, headache like none they have experienced before etc… Look at the patients medical history and family history for clues. Is there a big family history of strokes at a young age if so be more cautious.
    Soemtimes clues from the case history suggest that performing an examination is contraindicated. The VBAI test is useless as it doesnt tell us if it is safe to perform cervical SMT but can cause further damage if done on a patient undergoing a dissection. I never perform it.
    On EVERY patient before I manipulate their Cx spine I take blood pressure and perform a cranial nerve exam. Same as for every patient who has back pain with radiation into their legs I would check dermatomes/myotomes/reflexes.
    If a patient is suffering neck pain and has a past history of trauma THAT is the risk factor. NOT cervical manipuation. Giving that patient mobilisations/ home range of motion exercises will be just as dangerous (if not more as more time will be spent at end range)
    It is not a dangerous intervention but can be on certain individuals. What we need to do is is take a thorough case history to find out who these individuals are. An intervention is about risk/benefit and other alternatives to SMT such as painkillers also carry a risk!
    BUT when manipulation is performed it has to be clinically justified and not performed 3 x per week for 2 months to prevent premature ejaculation and/or erectile dysfunction.
    The reference cited for this article is 14 years old. That is old and more research has been done since then. Cassidy et al showing risk of stroke is increased if pt has consulted a Chiropractor however also increased if visited MD suggesting neck pain was a symptom of stroke. Hertzog work showing strains on arteries in neck are greater in everyday ROM than they are in a cervical manipulation.
    Like I said I am Chiro and want to do what is best for my patients. I do not want to cause a dissection- I would be devestated. I read with interest lots of information on SMT and stroke and if if was shown to cause a dissection I WOULD stop using it. The guidelines in this document are very out of date. The recent IFOMPT 2012 are much better.
    I get frustrated when Chiropractors dont look at the evidence but also get frustrated when people just say dont visit a Chiro because they will give you a stroke.
    Mark

    1. Thor says:

      But, there is only scant evidence that cervical thrust adjustments alone help pain, and then only minimally and temporarily, and only a bit more that they help cervicogenic headache. With the potential for harm it can unexpectedly impose on recipients, despite your protocols, erring on the side of caution and not even performing them would seem to be a more reasonable approach.

      1. Mark Jessop says:

        You are right there is minimal evidence that it helps alone. But there is minimal evidence for everything with regards to neck pain. I never just do a cervical manipulation. I would always supplement my manipulation with massage, exercise, advice, education and self management strategies.
        I don’t think the evidence suggests that erring on the side of caution and not doing these techniques would actually help. If all Cervical manipulation were to be banned and everyone stopped performing them tomorrow these events would still happen. I think a more reasonable approach would be everyone who sees patients with neck pain be aware of the risk factors and perform a thorough case history before even doing an examination or treatment. End range ROM exercises are just as bad if not worse than a Cx manipulation. Especially McKenzie type retraction/extension exercises (which I also still give certain patients following a thorough case history if I deem it appropriate)

        1. Thor says:

          You underscore my point. If you ALWAYS supplement “neck cracking” with massage, exercise, etc., you have no real way of determining if the adjustment itself was effective.
          By “these events” I assume you mean strokes. If so, you may be right (still, no evidence for this). But, there are other adverse events that can be directly attributable to thrust adjustments, such as traumatizing tissues causing varying degrees of pain/dysfunction, some of which can last a long time, if not permanently.

    2. Jann Bellamy says:

      What does “evidence informed” mean? Is that the same as “evidence based?” If not, how are the two terms different? If so, why use a different term?

      1. Thor says:

        I was puzzled by the term, as well. The first thing that popped into my mind was that being informed about evidence doesn’t necessarily carry over to actually basing a practice on evidence. Most woo-practitioners get informed somewhere along the line but choose not to accept this information.

    3. WilliamLawrenceUtridge says:

      Like I said I am Chiro and want to do what is best for my patients. I do not want to cause a dissection- I would be devestated.

      How do you know you haven’t already caused a dissection? If a patient ceases to show up, does that mean they dropped your practice or dropped dead?

  5. brewandferment says:

    Is there any evidence of permanent neck damage besides the results of vertebral dissection? Even if one doesn’t seem to have occurred or was one of the minor dissections mentioned?

    What about degenerative injuries?

  6. tgobbi says:

    Peter S. “And he was not some neighborhood schmo either — he was the chiropractor for a major, nationally-recognized sports team.”

    Which carries about as much weight as being president of the Flat Earth Society.

  7. tgobbi says:

    Chiropractor Jessop: “On EVERY patient before I manipulate their Cx spine I take blood pressure and perform a cranial nerve exam. ”

    Please explain (in layman’s terms, if possible) how chiropractors perform this cranial nerve exam.

    1. Mark Jessop says:

      There is not a magical way Chiropractors perform this exam (as far as I’m aware) but I perform a pretty standard Cranial nerve examination screen.

      CN 3,4,6- Have pt visually follow my finger whilst I write a letter H and then test for convergence by moving it towards the patients nose.
      CN 2- Test the visual fields and use an opthalmoscope to look into for papilledema in patients with a headache
      CN 2 and 3- pupil response to light (shine light into eye and see if pupils om both sides constrict)
      CN 5 lightly touch face to check sensation on all divisions of the trigeminal nerve
      CN 7 – Get the patient to raise eyebrows, close the eyes tightly and smile
      CN 8 rustle fingers in pts ear to see if they can hear
      CN 9 and 12- Stick tongue out and llok for deviation, say “Ahhhh” and observe elevation of the palate
      CN 11- test muscle strength of upper traps and SCM’s

      I also listen to patients speech, ask questions regard to swallowing. I dont bother testing CN1 (smell as it is outside of the brainstem)

      Hope this helps,
      Mark

  8. Charles says:

    Sorry for being dumb, but I routinely (multiple times/day) crack my neck – is this along the lines of what we’re talking about? It feels so good but I don’t want to damage myself in any sort of permanent manner.

    1. KayMarie says:

      I haven’t seen a report from self cracking causing this. It is a rare event, but very serious.

      Personally, I stopped cracking my neck as I got older and now I find it doesn’t really need to crack so much anymore, or at least won’t crack with light pressure anymore. I just do some neck stretches and shoulder rolls when I feel tension in my neck, now.

      I don’t know if you can generate the same force with self manipulation that another person can do and you may have more feedback of a pain sensation that says stop that now which someone doing it to you wouldn’t feel so you may stop faster.

    2. Thor says:

      You and probably countless others do this. Like cracking fingers. It’s simply an acquired habit, but not necessary. While doing basic stretches (ROM), the neck usually self adjusts anyway. Try weaning yourself of this as we don’t really know what harm is caused, if any, by constant self-cracking. Expedited wear and tear on the joints seems plausible.

      1. KayMarie says:

        Well according to the winner of the coveted Ig Nobel prize it doesn’t seem to add any wear and tear to crack your knuckles.

        http://www.scientificamerican.com/article/crack-research/

        1. Harriet Hall says:

          That study only showed that one person did not develop arthritis. I have heard orthopedic specialists speculate that repeated cracking of the back might stretch the ligaments and make back pain more likely to recur. I don’t think that’s ever been tested, but it does seem possible.

          1. KayMarie says:

            There are some papers with larger sample sizes (but most are retrospective) that show at least for hands it doesn’t seem to add to wear and tear.

            I don’t know that cracking a joint would be more likely to stretch a ligament than anything else that may push a joint past the range of movement it would do by muscle contraction alone (like forcing a stretch too far too often or an injury). I know a fair number of my joints crack and pop with normal range of movement, so don’t really need to put strain on the ligaments.

            Funny thing, since I stopped using my hands to force the neck to crack those joints seem less prone to making cracking noises either on their own or on the rare occasion I just felt like I needed a good crack out of them and tried to do it.

            1. Thor says:

              The joints of the neck are more intricate than those in the hands, not only structurally, but neurologically and vascular.
              Simply pulling on a phalange and creating a “pop” seems less involved anatomically, and less invasive, than forcing facet joints and vertebral bodies to “crack”, twist, and turn in a fairly forceful manner.
              Also, gently taking a joint past it’s normal range of motion through stretching is different than high-velocity thrust maneuvers.

              1. KayMarie says:

                I’m not sure if self cracking of the neck causes the same stresses a chiropractor would put on it or not.

                My knuckles don’t pop from a pull they pop from being bent way over, but your mileage may vary.

                If I’m getting damage from my upper back vertebra cracking because I breath, then I’m in real trouble. Sometimes all it takes to get a lot of noise from my back is change sitting positions slightly and take just a bit deeper breath than my usual.

                But as I said earlier I didn’t give up cracking my neck because I was worried I might stretch a ligament. Once I read about the stroke issue(having way too many stokes in my family history as well as other arterial hardening issues) I figured it wasn’t worth the risk. Even if i couldn’t put as much pressure on things up in there as someone doing it to me could do.

              2. Kris says:

                Aggressive stretching of the neck for healthy, or moderate stretching in a weak neck can cause the same problem. I know of a patient that had a stroke during a scalene stretch ( neck muscle)

  9. Kathy says:

    Completely off-topic but I’ve no idea where to place it: Clay Jones is also cited in this article from New Scientist.

    http://www.newscientist.com/article/dn25980-antivaccine-movement-turns-on-vit-k-shots-for-babies.html#.U9tYbPkabVY

  10. Nigel says:

    Quick question for Mark Jessop, would your exam exclude a 24yr old female with a history of thoracic pain but otherwise well?

    Like the one that presented to my clinic suffering with expressive dysphasia the day after a neck manipulation, she was admitted to the Stroke unit, but if the procedure had not been undertaken???

    1. Mark Jessop says:

      I have no idea if my exam would have excluded that particular case, it is impossible to say. There are no clear cut, its safe, its not safe answers. I would have made a judgement call based upon my findings from the history and examination. What I am saying is that the evidence suggests a cervical manipulation is no more risky than taking an NSAID or giving the patient a home ROM exercise. From the very limited information you have given me I would say that if she had presented with just thoracic pain and my examination nothing wrong with the neck I would not have manipulated her neck. Does this mean she will not have had a stroke?
      This is a very emotive subject but I feel case reports of anecdotal evidence like this one are no help and just used to fuel the fire. Case reports are low on the hierarchy of evidence and much larger scale scale studies and better available evidence is available.
      We know these events happen, Im not going to deny that but we know they are very rare which makes studying very hard. We do not know that Cx manipulation causes them and we do know they occur even in cases when neck manipulation has not been performed.

      1. Harriet Hall says:

        “We do not know that Cx manipulation causes them and we do know they occur even in cases when neck manipulation has not been performed.”

        I think we do know with reasonable certainty that neck manipulation causes some strokes. A controlled study showed that patients under the age of 45 with basilar strokes were 5 times as likely to have seen a chiropractor in the previous few days. A study of neurologists suggested that there is widespread under-reporting of manipulation-related strokes. And there are plenty of “smoking gun” cases where the patient immediately felt pain with manipulation and developed stroke symptoms on the chiropractor’s table. Chiropractors may not be aware of how often these strokes occur, because patients may lose confidence in them and simply stop seeing them. I have personally heard of patients who had a stroke after manipulation and never told their chiropractor about it. And on the other hand, I read about one case where 3 family members kept going back to the same chiropractor until all 3 had had strokes after manipulation. In the absence of more complete knowledge, I think there is a good argument for accepting that neck manipulation can cause strokes and for following Sam Homola’s advice.

      2. WilTaylor says:

        You are wrong . If you for example are taking an NSAID for chronic pain at moderate to high doses for one year (ie Arcoxia) for every 33 patients this would lead to on average one death in the 33 patients. See BMJ 2011 Juni NSAID Safety. This would also suggest that non fatal heart attacks or strokes may occur in every 10 to 15 patients in the NSAID(Arcoxia) group. I have not seen it this nearly this high for Cervical SMT. Although the frequency of SMT provided to taking an NSAID is different.

        1. Harriet Hall says:

          I question those statistics. There is a risk from NSAIDS, but other sources haven’t found it to be nearly that great.
          But the risk of NSAIDS is not pertinent to a discussion of the risks of neck manipulation. It is not fair to compare taking an NSAID at high doses for a year to neck manipulations as if those were the only two alternatives for patients with neck pain. There are plenty of other options including watchful waiting, heat, physical therapy, and exercise. A Cochrane review found gentle mobilization as effective as manipulation, and found that neither was effective alone, but only when combined with exercise.

          1. Wil Taylor says:

            Harriet here is the link regarding those statistics ” http://www.bmj.com/rapid-response/2011/11/03/numbers-needed-treatharm “.
            An eminent neuropathologist stated to me via email who sees VBI cases, ” most causes of VBI are idiopathic or with minimal trauma and prolonged laughter when drinking with secondary coughing might be enough for the latter. Have seen a couple of cases of stroke related to golf but I haven’t regarded as clearly associated. Fortunately very rare,” Does that mean we ban golf, I do not think so. Maybe a more judicious use for Cervical SMT is not unresonable until risk is clearly defined. But this is a complicated area, It may for example be the long term use by some of these patients concurrently use NSAIDS as this can contribute to endothelial dysfunction ? ref “http://www.annclinlabsci.org/content/35/4/347.long”. Could this mean the patient more at risk of a VBI after NSAID use and subsequently playing golf or seeing ther chiropractor or having prolonged laughter who knows. Maybe it would be better to say to chiropractors, we are concerned that this risk is not clearly defined in regards to VBI and Cervical SMT. Would you consider commonly using alternative non cavitation methods or alternative therapeutic methods in this area. Furthermore consider only using Cervical (cavitation) SMT sparingly only when other measures fail. It is a reality that there are many methods that chiropractors employ if alternatives are needed. Finally, with regards to Cochane review. I like Cochrane but it is not the beginning or the end of medical opinion on any particular subject. For example NICE guidelines can differ from Cochrane review. Which one is right ? Well thats another long discussion for another time.

            1. WilliamLawrenceUtridge says:

              Golf isn’t a purported medical treatment which is sold as having essentially zero risks. Golf has recognized benefits. Cervical manipulation has few to no benefits and much better, safer options as alternatives, including just watchful waiting. The two aren’t comparable.

              1. wil taylor says:

                Actually golf is essentially sold as having zero risk, because I have never been asked to complete or sign an informed consent form before I hit off the first tee. As to the recognized health benefits of golf, maybe as you rightly state there may be other healthy activities besides golf that do not involve vigorous rotation of the trunk and neck during the golf swing. Seriously though, they are comparable in the sense they are both may be associated with VAD.

              2. WilliamLawrenceUtridge says:

                But again – golf isn’t a medical treatment. What is medically recommended is some form of exercise. Golf is one example. It’s not like doctors prescribe golf, it’s merely one suggestion among many to make patients get in a bit of walking. Personally I think it’s a terrible game and a stupid waste of space and time, but whatever. And it has fewer risks than many other forms of exercise such as hockey, tennis, skiing, etc.

      3. WilliamLawrenceUtridge says:

        This is a very emotive subject but I feel case reports of anecdotal evidence like this one are no help and just used to fuel the fire. Case reports are low on the hierarchy of evidence and much larger scale scale studies and better available evidence is available.

        The real irker here is that anecdotes must be relied upon because the entire profession has failed to study the issue before widespread implementation. In the past when surgeons have undertaken surgical procedures without study, they are now held up as examples of their embarrassing and unscientific past, and used to emphasize the point that new techniques and medications require study before widespread adoption.

        Chiropractic is now over a century old and still hasn’t validated many of its fundamental precepts, or developed a good sense of risk versus benefit. And that’s not even counting the outright nutjobs who think they can adjust the spine without touching it, prescribe homeopathy or claim they can treat actual disease.

        Seriously, chiropractors need to get their own house in order before they criticize medicine.*

        *Mark didn’t do so in this case, but it is a trait of many if not most CAM practitioners and chiropractors to claim safety and effectiveness of their own practices by pointing to medicine’s flaws.

  11. The best available scientific evidence at this point in time does not support the hypothesis that cervical manipulation causes dissections. Here is the largest epidemiological study to evaluate the relation between stroke and chiropractic or medical care. It found that people with these kinds of strokes were as likely to have seen an MD or a DC. Thus the person is most likely presenting to either doctor with the early symptoms of the stroke and their treatment does not effect the eventual outcome.

    Cassidy JD, Boyle E, Côté P, He Y, Hogg-Johnson S, Silver FL, et al. Risk of vertebrobasilar stroke and chiropractic care: results of a population-based case-control and case-crossover study. Spine. 2008 Feb 15;33(4 Suppl):S176–83.

    http://www.ncbi.nlm.nih.gov/pubmed/18204390

    This is called protopathic bias.

    Unfortunately many patients with strokes are not diagnosed.

    Newman-Toker DE, Moy E, Valente E, Coffey R, Hines AL. Missed diagnosis of stroke in the emergency department: a cross-sectional analysis of a large population-based sample. Diagnosis. 2014;1(2).

    A good free full text article that discusses the science of this issue is

    Murphy DR. Current understanding of the relationship between cervical manipulation and stroke: what does it mean for the chiropractic profession? Chiropr Osteopat. 2010 ed. 2010;18:22.

    http://www.chiromt.com/content/18/1/22

    Biomechanical research has shown that cervical manipulation does not even come close to stretching the arteries an amount that would harm them and daily activity causes greater stretch.

    1. Symons B, Herzog W. Cervical artery dissection: a biomechanical perspective. J Can Chiropr Assoc. 2013 Dec;57(4):276–8.
    2. Herzog W, Tang C, Leonard T. Internal Carotid Artery Strains During High-Speed, Low-Amplitude Spinal Manipulations of the Neck. J Manipulative Physiol Ther. 2012 Nov 6.
    3. Herzog W, Leonard TR, Symons B, Tang C, Wuest S. Vertebral artery strains during high-speed, low amplitude cervical spinal manipulation. J Electromyogr Kinesiol. 2012 Apr 5.
    4. Symons B, Wuest S, Leonard T, Herzog W. Biomechanical characterization of cervical spinal manipulation in living subjects and cadavers. J Electromyogr Kinesiol. 2012 Mar 6.
    5. Herzog W. Response to letter to editor by Drs. Haynes and Vincent. J Electromyogr Kinesiol. 2012;22(6):1018.
    6. Wuest S, Symons B, Leonard T, Herzog W. Preliminary report: biomechanics of vertebral artery segments C1-C6 during cervical spinal manipulation. J Manipulative Physiol Ther. 2010 May;33(4):273–8.
    7. Austin N, DiFrancesco LM, Herzog W. Microstructural damage in arterial tissue exposed to repeated tensile strains. J Manipulative Physiol Ther. 2010 Jan;33(1):14–9.
    8. Symons BP, Leonard T, Herzog W. Internal forces sustained by the vertebral artery during spinal manipulative therapy. J Manipulative Physiol Ther. 2002 Oct;25(8):504–10.

    And finally another series of studies on dogs with man made injuries to the vertebral arteries found that manipulation was incapable of expanding the size of those injuries. Thus suggesting that manipulation doesn’t worsen a dissection.

    1. Kawchuk GN, Jhangri GS, Hurwitz EL, Wynd S, Haldeman S, Hill MD. The relation between the spatial distribution of vertebral artery compromise and exposure to cervical manipulation. J Neurol. 2008 Mar;255(3):371–7.
    2. Wynd S, Anderson T, Kawchuk GN. Effect of cervical spine manipulation on a pre-existing vascular lesion within the canine vertebral artery. Cerebrovasc Dis. 2008;26(3):304–9.
    3. Kawchuk GN, Wynd S, Anderson T. Defining the effect of cervical manipulation on vertebral artery integrity: establishment of an animal model. J Manipulative Physiol Ther. 2004 Nov-Dec;27(9):539–46.

    None of this is to say that there are not people who have had dissections after seeking chiropractic care. But cause and effect are not established.

    This week a case report was published about a patient who had a stroke in a chiropractors office, before the doctor manipulated the patient’s neck

    1. Mattox R, Smith LW, Kettner NW. Recognition of Spontaneous Vertebral Artery Dissection Preempting Spinal Manipulative Therapy: A Patient Presenting With Neck Pain and Headache for Chiropractic Care. J Chiropr Med.; 2014 Jun;13(2):90–5.

    1. Harriet Hall says:

      The Cassidy study actually confirms the findings of the earlier study showing that chiropractic is associated with stroke in the under-45 age group. See Mark Crislip’s excellent analysis of the Cassidy study at:
      http://www.sciencebasedmedicine.org/chiropractic-and-stroke-evaluation-of-one-paper/

      Perle is biased: he teaches at a chiropractic school, and he has cherry-picked articles that support his beliefs, mainly from the chiropractic literature.
      If cause and effect have not been established, they have not been ruled out either; so the most prudent approach is to be concerned and to follow Sam Homola’s recommendations.

  12. Dr. Hall is correct I teach at the University of Bridgeport in the College of Chiropractic and yes I have my biases but one of them is not on this issue. I have changed as the evidence changed. See:

    http://www.dynamicchiropractic.com/mpacms/dc/article.php?id=52115
    http://www.dynamicchiropractic.com/mpacms/dc/article.php?id=54678

    However, as the evidence has mounted that there is not a cause and effect but only as association between stroke and chiropractic Dr. Hall’s bias against chiropractic has made it impossible for her to change her mind.

    The criticism from Dr. Crislip is well hollow. It is very interesting to note that those who criticize this study have done so in every medium except for the only one that counts, in the biomedical literature and specifically as a letter to the editor of the journal it was published in Spine. It appears to be that Science Based Medicine doesn’t do one thing well, that is contribute to the….science.

    Dr. Hall is also correct that, as I noted, Cassidy et al do find there is an association between chiropractic care and stroke as have other studies found before it. However, the unique thing about this study is that they also looked at the association between stroke and seeking care with a medical physician. They found that the odds of having a stroke after seeing a DC and after seeing a MD were identical. Also to Dr. Crislip’s point about the potential problems with the diagnosis they did a sensitivity analysis which found that their results wouldn’t have changed if there were errors in the diagnosis because the errors would be randomly distributed between both the chiropractic and medical arms of the study.

    Finally if I have cherry picked the literature please show me the biomechanics literature that refutes what I have presented?

    As to cherry picking Dr. Homola hasn’t really done that, he’s only picked a raisin, dried old fruit from 2000. I really respect his long history of speaking out about problems within the chiropractic profession from within the profession when most wouldn’t and being vilified for it. This is something I have been doing for ten years, so I’ve got a way to go to catch up with his record of honest criticism. As a friend said of me said about me and this applies to Dr. Homola too, we walk around the profession with targets on our back. However, in this case he’s behind the times.

    1. Windriven says:

      Let us assume for a moment that the incidence of stroke in those seeking care from a physician and those seeking care from a chiropractor is the same. I am not ceding that, but we’ll assume it for conversation’s sake.

      The physician can be expected to provide meaningful diagnosis and therapy for a broad range of conditions while a chiropractor can competently diagnose and treat lower back pain. Therefore the comparison is flawed. The risk-benefit ratios are not comparable.

      1. But apparently medical physicians can’t provide a competent management for back pain especially if they have an interest in that kind of case.

        Buchbinder R, Staples M, Jolley D. Doctors with a special interest in back pain have poorer knowledge about how to treat back pain. Spine. 2009 May 15;34(11):1218–26–discussion1227.

        There is a clear need for people whose primary function is the diagnosis and management of spinal pain given its position as having a very high burden of disease world wide.

        On global burden of disease
        1. Hoy D, March L, Woolf A, Blyth F, Brooks P, Smith E, et al. The global burden of neck pain: estimates from the Global Burden of Disease 2010 study. Ann Rheum Dis. BMJ Publishing Group Ltd and European League Against Rheumatism; 2014 Jul;73(7):1309–15.
        2. Hoy D, March L, Brooks P, Blyth F, Woolf A, Bain C, et al. The global burden of low back pain: estimates from the Global Burden of Disease 2010 study. Ann Rheum Dis. 2014 Apr 30;73(6):968–74.

        On need for primary spine care practitioner:

        1. Erwin WM, Korpela AP, Jones RC. Chiropractors as Primary Spine Care Providers: precedents and essential measures. J Can Chiropr Assoc. 2013 Dec;57(4):285–91.
        2. Kosloff TM, Elton D, Shulman SA, Clarke JL, Skoufalos A, Solis A. Conservative Spine Care: Opportunities to Improve the Quality and Value of Care. Population Health Management. 2013 Dec;16(6):390–6.
        3. Hartvigsen J, Foster NE, Croft PR. We need to rethink front line care for back pain. BMJ. 2011 ed. 2011;342:d3260.
        4. Nelson CF, Lawrence DJ, Triano JJ, Bronfort G, Perle SM, Metz RD, et al. Chiropractic as spine care: a model for the profession. Chiropr Osteopat. 2005 Jul 6;13:9.

        1. Blue Wode says:

          Stephen M. Perle wrote: “apparently medical physicians can’t provide a competent management for back pain”

          Apparently chiropractors can’t either:

          QUOTE
          “Chiropractors view the spine as an entity. Where they diagnose ‘subluxations’, they will normally manipulate and ‘adjust’ them (11). And ‘subluxations’ will be diagnosed in the upper spine, even if the patient suffers from back pain. Thus many, if not most back pain patients receive upper spinal manipulations. It follows that the risks of this treatment should be included in any adequate risk assessment.”

          Ref: Spinal manipulation for the early management of persistent non-specific low back pain — a critique of the recent NICE guidelines, Edzard Ernst, Int J Clin Pract (18th August 2009). Reference (11) is Ernst E. Chiropractic: a critical evaluation. J Pain Sympt Man 2008; 35: 544–62. Page 6 of the paper mentions a report that indicates that only 11% of all cervical manipulations are “appropriate” and gives the reference Coulter I, Hurwitz E, Adams A, et al. The appropriateness of manipulation and mobilization of the cervical spine. Santa Monica, CA: RAND, 1996:18e43.

        2. Windriven says:

          “But apparently medical physicians can’t provide a competent management for back pain especially if they have an interest in that kind of case.”

          Am I to feel chastened by this? Even if true, and I certainly am not convinced, the cost versus benefit of chiropractic is even worse than the risk/benefit.

          I’ll ask you the question that I have asked other chiropractors: what does chiropractic bring to the armamentarium that a well qualified PT doesn’t?

          1. The cost benefit ratio is really quite good if we look at objective data rather than your subjective opinion.

            1. Kosloff TM, Elton D, Shulman SA, Clarke JL, Skoufalos A, Solis A. Conservative Spine Care: Opportunities to Improve the Quality and Value of Care. Population Health Management. 2013 Dec;16(6):390–6.
            2. Keeney BJ, Fulton-Kehoe D, Turner JA, Wickizer TM, Chan KCG, Franklin GM. Early predictors of lumbar spine surgery after occupational back injury: results from a prospective study of workers in Washington State. Spine. 2013 May 15;38(11):953–64.
            3. Michaleff ZA, Lin C-WC, Maher CG, van Tulder MW. Spinal manipulation epidemiology: systematic review of cost effectiveness studies. J Electromyogr Kinesiol. 2012 Oct;22(5):655–62.
            4. Elton D, Kosloff T. Conservative Care: Ensuring the Right Provider for the Right Treatment. Optum Health; 2012 Jan pp. 1–37.
            5. Martin BI, Gerkovich MM, Deyo RA, Sherman KJ. The Association of Complementary and Alternative Medicine Use and Health Care Expenditures for Back and Neck Problems. Med Care. 2012.
            6. Herman PM, Poindexter BL, Witt CM, Eisenberg DM. Are complementary therapies and integrative care cost-effective? A systematic review of economic evaluations. BMJ Open. 2012;2(5).
            7. Paskowski I, Schneider MJ, Stevans J, Ventura JM, Justice BD. A hospital-based standardized spine care pathway: report of a multidisciplinary, evidence-based process. J Manipulative Physiol Ther. 2011 ed. 2011 Feb;34(2):98–106.
            8. Liliedahl RL, Finch MD, Axene DV, Goertz CM. Cost of care for common back pain conditions initiated with chiropractic doctor vs medical doctor/doctor of osteopathy as first physician: experience of one Tennessee-based general health insurer. J Manipulative Physiol Ther. 2010 ed. 2010 Nov-Dec;33(9):640–3.
            9. Nelson CF, Metz RD, LaBrot T. Effects of a managed chiropractic benefit on the use of specific diagnostic and therapeutic procedures in the treatment of low back and neck pain. J Manipulative Physiol Ther. 2005 Oct;28(8):564–9.
            10. Nelson CF, Metz RD, LaBrot TM, Pelletier KR. The selection effects of the inclusion of a chiropractic benefit on the patient population of a managed health care organization. J Manipulative Physiol Ther. 2005 Mar;28(3):164–9.
            11. Legorreta AP, Metz RD, Nelson CF, Ray S, Chernicoff HO, Dinubile NA. Comparative analysis of individuals with and without chiropractic coverage: patient characteristics, utilization, and costs. Arch Intern Med. 2004 Oct 11;164(18):1985–92.

            1. Windriven says:

              Bullsh!t. Once you move beyond LBP it is division by zero. Including LBP it is division by 1.0XX.

              I’ll ask you the question that I have asked other chiropractors: what does chiropractic bring to the armamentarium that a well qualified PT doesn’t?

              1. WilliamLawrenceUtridge says:

                Allow me to note a conspicuous lack of reply to your question, despite being repeated twice…

    2. Harriet Hall says:

      I don’t have access to the full Cassidy study at the moment. Did it not show a relationship between recent chiropractic visits and stroke in those under 45 that was several times greater than the correlation with recent MD visits? Or am I remembering wrong? When this is combined with the results of earlier studies showing a risk in those under 45, why is that not sufficient reason to avoid neck manipulations in cases where manipulation is not known to be superior to other treatments?

      Biomechanics studies can’t rule out risk to a minority of patients, and there is no reliable way to pick out patients who might be at higher risk. It seems to me that even though correlation doesn’t prove causation, this correlation constitutes a serious cause for concern. Chiropractors who want to manipulate necks and objective outside observers will naturally reach different conclusions from the same data.

      1. Blue Wode says:

        For interested readers, the full text of the Cassidy study can be read here:
        http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2271108/pdf/586_2008_Article_634.pdf

        Professor Edzard Ernst’s criticism of it can be read here:
        http://www.chirowatch.com/Stroke/2010%20Vascular%20accidents%20after%20chiroSM%20-%20myth%20or%20reality.pdf

        And various other criticisms of it can be read here:
        http://tinyurl.com/bp7dkn3

        Lots of flaws.

        1. Dr. Hall it is best not to comment about a scientific paper without having the paper in hand. Your memory is wrong. The odds of having a stroke in individuals under age 45 after seeing a chiropractor was statistically identical to seeing a MD. That’s the whole point. The two previous case control studies only looked at the odds of a stroke after seeing a chiropractor. Cassidy used even the same methodology as Rothwell et al with the addition of searching the database for MD visits prior to the stroke. There were other methodological improvements but the basics were the same.

          Rothwell DM, Bondy SJ, Williams JI. Chiropractic manipulation and stroke: a population-based case-control study. Stroke. 2001;32(5):1054–60.

          Regarding the criticism I’ll say it again the way to critique a paper in the literature is to write a letter to the editor (LTE). It is one of THE fundamental differences about scientific literature. It tags the critique to the paper as all letters to the editor are included in the PubMed record for the original paper. It is the problem with books. To write a critique of Velikovsky’s Worlds in Collision, Carl Sagan wrote a chapter in his book Broca’s Brain. But a person who looked up Velikovsky in a card catalog would never see a link to Sagan to see what is wrong with Velikovsky.

          For example when Dr. Ernst wrote a paper about deaths after chiropractic that stimulated 6 different LTEs. A contientious reader of the literture could then read the original paper and see the critiques and the responses to judge then the value of the original paper.

          http://www.ncbi.nlm.nih.gov/pubmed/20642715

          If one looks at the PubMed record for Cassidy one finds one LTE

          http://www.ncbi.nlm.nih.gov/pubmed/18204390

          Thus the critiques sound more like unhappy people than science and given that this is “science based medicine” I shall only comment on the science.

          Relative to the biomechanics one can’t have it both ways. One can’t say it is too much force and then when the data show it isn’t too much say biomechanics isn’t so important.

          1. Blue Wode says:

            Stephen M. Perle wrote: “…Dr. Ernst wrote a paper about deaths after chiropractic that stimulated 6 different LTEs. A contientious reader of the literture could then read the original paper and see the critiques and the responses to judge then the value of the original paper.”

            IMO, Professor Ernst’s LTE response to the critiques of his paper was the most interesting:
            http://www.deepdyve.com/lp/wiley/response-to-critiques-of-deaths-after-chiropractic-08HB17Yykg

            Full text of the original paper here:
            Deaths after Chiropractic: A Review of Published Cases
            http://mcdanielchiro.com/clients/4846/documents/Deaths_After_Chiropractic_…pdf

            1. I think his response is interesting. I won’t give my take on it. But to my point the interested reader can read his paper, the critiques, his response and then think about the validity of the paper in light of the critiques and responses. As I said it is fundamental the nature of science. Peer-review and then open to public comment in a way that the conscientious reader can see the paper, its critique and response.

              Contentious research often engenders many many LTE, responses and further rounds of same. Cassidy et al did not which is a good indication of how scientists in the field, epidemiologists view the validity of the study.

              IF “Science Based Medicine” really wants to do…science and thinks…science is important then rather than just being gadflies on the Internet posting their critiques where no one will find them when searching for science – through PubMed I’d suggest LTE.

              However, given the fact that so many in the public learn their “science” from Wikipedia or their favorite web site then I guess some will come here and actually believe that the title of this blog honestly presents what the blog does, science. Much like the National Vaccine Information Center, who to the ignorant seems to be a provider of valid unbiased information on vaccines. We know they aren’t just as we know that SBM’s critiques aren’t always valid and unbiased.

              1. Blue Wode says:

                Stephen M. Perle wrote: “…it is fundamental the nature of science. Peer-review and then open to public comment in a way that the conscientious reader can see the paper, its critique and response. Contentious research often engenders many many LTE, responses and further rounds of same. Cassidy et al did not which is a good indication of how scientists in the field, epidemiologists view the validity of the study.”

                Bearing in mind the following, could the European Spine Journal have a dodgy peer review process that reduced the responses to the Cassidy paper to only one LTE?

                QUOTE
                When one submits a letter to the editor they are peer reviewed, as were the original manuscripts,
                http://smperle.blogspot.co.uk/2010/12/self-importance-of-being-ernst.html

                (NB. J. D. Cassidy sits on the European Spine Journal’s Assistant Editorial Board.)

              2. Andrey Pavlov says:

                @Stephen Perle:

                It seems to me that you are trying to say that a criticism is only valid if it is published in some sort of peer reviewed literature. While, yes, that is an excellent place to do things you are basically dismissing the work here by simply saying it wasn’t done as a LTE or something else in that vein.

                You have heard of arXiv? That is where most theoretical and empirical physics papers are published these days. It is not peer reviewed and is essentially a more science-paper version of a blog. Yet it is considered to be the place to go for the latest in theoretical physics.

                My point being that you need to engage with the actual content rather than chastise for not putting said content into a forum or form that you prefer. And you really haven’t said much of anything substantive in that regard. In my estimation that is because you haven’t really much of anything to say in that regard.

                The entirety of your arguments basically boil down to saying that there isn’t enough evidence in your estimation to say that HVLA maneuvers of the c-spine can lead to VA dissection and that anything else said here about the topic is not valid because it is not published as an LTE.

                You also try and conflate an endpoint with different mechanisms without addressing painfully obvious confounders. Just because there are a similar number of VA dissections and strokes in people after seeing an MD vs DC (which I don’t actually agree with, but is irrelevant to my point) doesn’t mean that DC’s aren’t causing VA dissections from manipulations. There are myriad possible interpretations of that (contentious) assertion: it could be that MD’s are also causing strokes from some other means; it could be that MD’s are seeing sicker patients that are more likely to suffer from strokes (population selection bias); it could be MD’s are actually reducing the number of VA dissections and strokes in a group more likely to have them while DC’s are increasing the risk to groups less likely to have them; etc. The point is that your argument hinges on the only possible reason for similar rates between MD’s and DC’s being that DC’s do not actually cause or increase the rate of VA dissection and stroke and that both are merely noting the baseline rate of such events in the general population. But you haven’t established this is the case and the data does not support it to be so.

                In other words, you’ve spent a lot of posts saying very little and necessarily having assumptions that you have not justified in order to be true.

              3. MadisonMD says:

                My point being that you need to engage with the actual content rather than chastise for not putting said content into a forum or form that you prefer. And you really haven’t said much of anything substantive in that regard. In my estimation that is because you haven’t really much of anything to say in that regard.

                My thoughts exactly.

                You also try and conflate an endpoint with different mechanisms without addressing painfully obvious confounders. Just because there are a similar number of VA dissections and strokes in people after seeing an MD vs DC (which I don’t actually agree with, but is irrelevant to my point) doesn’t mean that DC’s aren’t causing VA dissections from manipulations.

                Great minds think alike. Well, the confounders are indeed painfully obvious so maybe this is not evidence of “great minds.”

              4. Andrey Pavlov says:

                Great minds think alike. Well, the confounders are indeed painfully obvious so maybe this is not evidence of “great minds.”

                Yes, I noticed we had basically cross-posted the same thoughts on the matter. Perhaps not evidence of greatness, but at least some that rigorous reality based thought can (and should) lead to the same conclusions.

              5. WilliamLawrenceUtridge says:

                The idea that peer review can only happen in the peer-reviewed press, and that criticisms are invalid only if they appear in a peer-reviewed journal, is a false one.

          2. MadisonMD says:

            Your memory is wrong. The odds of having a stroke in individuals under age 45 after seeing a chiropractor was statistically identical to seeing a MD. That’s the whole point.

            Technically true, but your interpretation is wrong. There is not the statistical power to prove a lack of difference. Here’s Cassidy’s conclusion:

            Our results should be interpreted cautiously and
            placed into clinical perspective. We have not ruled out
            neck manipulation as a potential cause of some VBA
            strokes. On the other hand, it is unlikely to be a major
            cause of these rare events.

            Which is reasonable for the data in the paper, with all the limitations.

            I think Ernst’s conclusion is also fair:

            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 the association (causal or coincidental) remains uncertain.

            Given this, the potential rare potential risk of chiropractic neck manipulation would only seem to be acceptable of the benefits are substantial.

            The rest of your post implies that the number of letters to the editor on a paper somehow provides meaningful information about how reliable that paper is. You can deny it, because you didn’t say this outright, but why do you enumerate letters to the editor? That is odd.

            The conclusions stand on the merits of evidence alone, not the # of letters to the editor, debate on the blogs, etc. It is not unscientific to critique here and your statements enumerating letters of the editor and implying other motives “unhappy people” belies your statement that you only comment on the science.

            I have some additional concerns about the Cassidy study besides lack of statistical power to rule out a difference. See below. It makes me conclude that Cassidy is not the final word on causality.

          3. Harriet Hall says:

            I apologize for my poor memory. I do not apologize for dismissing the Cassidy study because of its poor methodology; it didn’t even try to identify whether patient’s necks were manipulated, and its other many flaws have been discussed elsewhere. The Cassidy study did nothing to change my mind; I rely on earlier studies with better methodology, especially the one showing an association with chiropractic visits in basilar stroke patients under the age of 45. However you choose to interpret the studies, the risk has not been ruled out. The most prudent course is to avoid neck manipulation, especially since it has not been shown to produce better outcomes than other treatments.

            1. Mark Lopes, DC says:

               The most prudent course is to avoid neck manipulation, especially since it has not been shown to produce better outcomes than other treatments.”
              This conclusion is very short sighted. Even if the risk is valid it is very very small by any account. The alternative choices are not necessarily less risky, and the experience of millions of chiropractic patients that have received this care and are content with the results can not be reasonably overlooked. Many patients that have received this care have improved after other care had failed.

              1. Windriven says:

                ” Many patients that have received this care have improved after other care had failed.”

                Citations, please.

              2. Harriet Hall says:

                How do you reconcile those “many patients” with the results of systematic reviews?

              3. MadisonMD says:

                Many patients that have received this care have improved after other care had failed.

                Perhaps so. Agreed that the risk is serious but appears rare. It may be worth taking if the benefits are substantial. But your anecdotes do not provide convincing evidence of therapeutic benefit. If we admitted such evidence, we would probably choose Perkin’s tractors for this type of pain because the anecdotal evidence of benefit is equal with fewer risks.

              4. Andrey Pavlov says:

                This conclusion is very short sighted. Even if the risk is valid it is very very small by any account. The alternative choices are not necessarily less risky, and the experience of millions of chiropractic patients that have received this care and are content with the results can not be reasonably overlooked. Many patients that have received this care have improved after other care had failed.

                The reason to avoid cervical manipulation is that there is no evidence to support the practice. The data available show it is not useful for any indications tested. And other data show that gentle physical manipulation has a role. So there is no benefit and only risk for doing HVLA manipulations of the c-spine. No matter how small the risk is, without a demonstration of benefit that risk is still too much. If the same can be achieved in certain cases using non-HVLA neck manipulation like PT’s do, then that is what should be done. But of course it has nothing to do with subluxations or chiropractic.

              5. WilliamLawrenceUtridge says:

                The alternative choices are not necessarily less risky, and the experience of millions of chiropractic patients that have received this care and are content with the results can not be reasonably overlooked. Many patients that have received this care have improved after other care had failed.

                Millions of patients were bled for thousands of years, and all who wrote about it were very pleased with their recoveries.

                Of course, the ones who died did not.

                Your comment contains the implication of uncertainty – that manipulation may be more risky or less, or more effective or less, compared to alternatives. The fact that you don’t know this is a damning indictment of the chiropractic profession’s lack of ethics in researching their primary form of “treatment”. One would think that after more than a century you might have gotten around to testing whether those millions of adjustments are any better than usual care or mere watchful-waiting.

            2. Peter S says:

              Perkins sounds pretty close to some of today’s quantum physics wackos.

              The tractors consisted of two 3-inch metal rods with a point at the end. Although they were made of steel and brass, Perkins claimed that they were made of unusual metal alloys. Perkins used his rods to cure inflammation, rheumatism and pain in the head and the face. He applied the points on the aching body part and passed them over the part for about 20 minutes. Perkins claimed they could “draw off the noxious electrical fluid that lay at the root of suffering”.

              1. MadisonMD says:

                Yes. And there was very strong anecdotal evidence that Perkins tractors worked!

                This is the same type of evidence of efficacy that Mark Lopes, DC provides. Apparently he believes that this evidence of efficacy of cervical manipulation somehow justifies accepting the rare risk of vertebral artery dissection.

              2. Peter S says:

                That book, exposing quackery and the post hoc ergo propter hoc fallacy, was written in 1850!! How far have we come, really?

            3. wow too many comments to really reply to all but a few

              “(NB. J. D. Cassidy sits on the European Spine Journal’s Assistant Editorial Board.)”
              Hey that’s cool because the paper wasn’t published in Eur Spine J, it was in Spine which not only is a different journal it even has a different publisher.

              Having spoken with Cassidy a month ago he told me that the only time he hears criticism of the study is when he’s talking to groups that are not trained in epidemiology.

              A good example of why this is so is Dr. Madison’s criticism. Cassidy’s caveat is based upon the fact that case control studies can not rule-in nor rule-out causation. To really rule in SMT as a cause of stroke, given the size of the association one would need an RCT with tens of MILLIONS of patients. To rule it out, I think is impossible but then again an RCT with tens of millions of patients means it is impossible, which is why case control methods are the most appropriate method.

              Also Dr. Hall you think the previous studies have better methodology we are talking two studies.

              1. Rothwell DM, Bondy SJ, Williams JI. Chiropractic manipulation and stroke: a population-based case-control study. Stroke. 2001;32(5):1054–60.
              2. Smith WS, Johnston SC, Skalabrin EJ, Weaver M, Azari P, Albers GW, et al. Spinal manipulative therapy is an independent risk factor for vertebral artery dissection. Neurology. 2003 May 13;60(9):1424–8.

              Cassidy used essentially the same methodology as Rothwell so…

              The plausibility of the purported mechanism is challenged by the biomechanical evidence. And given that the purported mechanism is mechanical….

              Andrey Pavlov theoretical physics and biomedical research are different and what is standard in one is not necessarily standard methodology in the other.

              1. Andrey Pavlov says:

                Andrey Pavlov theoretical physics and biomedical research are different and what is standard in one is not necessarily standard methodology in the other.

                And you still fail to address the actual point of the criticisms levied. You have nothing but bluster and denial in an attempt to obfuscate and handwave to say there is nothing there to look at. Nobody said that the data has conclusively established causality. But multiple lines of evidence converge and, yes, the biomechanics are clearly there to support plausibility of mechanism. The fact that you argue it isn’t there is simply the clearest evidence of your bias and the fact that you are holding a conclusion and trying to fit evidence to it rather than following the evidence to the conclusion.

              2. MadisonMD says:

                @SMP:
                I was hoping you would address the substantial questions rather than engage in special pleading. You yourself brought the Cassidy study into evidence here with the interpretation that cervical manipulation does not cause stroke. Now you grudgingly admit that this evidence offers no such proof and is underpowered, yet you hold to your interpretation?

                It is odd to make statements like Cassidy only receives criticism from non-epidemiologists. Somehow that is proof to you that (a) epidemiologists agree that it proves lack of causation; and (b) these epidemiologists are always right. I mean, you keep implying that medical scientists lack the expertise to evaluate the study. Yet you don’t engage the serious critiques of the study seriously. I mean, really, if no statistician has critiqued the study, does that mean to you that the stats are done absolutely correctly? It means to me that perhaps no statisticians are interested in the article enough to read it, or perhaps to offer critique even after reading. So what? Please.

                In addition to the lack of statistical power to demonstrate a lack of difference between stroke after PCP and DC visits, perhaps you would care to address that VBI and dissections cause neurological symptoms in addition to headache and neck pain, which is highly likely to make populations visiting PCP before stroke much different from the population visiting DC before stroke. Someone with neurologic symptoms is far more likely to visit a PCP and is far more likely to actually have a stroke.

                Also you fail to address the central issue regarding whether any of this potential risk is worth taking at all. So ignore all above and focus on this question, if you please:

                What is the evidence of efficacy of cervical manipulation with high velocity movements or rotation beyond normal range of motion for any condition?

              3. Blue Wode says:

                Stephen M. Perle wrote: “…the paper [Cassidy et al] wasn’t published in Eur Spine J, it was in Spine which not only is a different journal it even has a different publisher.

                I know it was published in Spine
                http://www.ncbi.nlm.nih.gov/pubmed/18204390

                but it was also published in Eur Spine J.
                http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2271108/pdf/586_2008_Article_634.pdf

                Am I missing something?

              4. MadisonMD says:

                I know it was published in Spine but it was also published in Eur Spine J.

                Well, I’ll be… that is very very odd. I don’t know of any scientific journals that allow republication in another journal. Isn’t that self-plagiarism?

              5. MadisonMD says:

                Ah, not plagiarism. Looks kosher as the Eur Spine J is marked “republished with permission.”

              6. JD says:

                Having spoken with Cassidy a month ago he told me that the only time he hears criticism of the study is when he’s talking to groups that are not trained in epidemiology.

                Must not be talking to many individuals trained adequately. To me, the problem with this study is more about what can be concluded than the methodology. They did an alright job of explaining the potential limitations and I like that they showed both analysis methods (matched controls and case-crossover). But, you have to agree that this study tells us absolutely nothing about whether spinal manipulation by DC’s is associated with VBA stroke. This tells us that compared to those without VBA stroke (or compared to time periods further from the VBA stroke) individuals with stroke had greater odds of seeking care.

                My response: no s**t sherlock. Is it likely that this could be due to the early recognition of something wrong, or other issues which may occur prior to VBA stroke? I would say absolutely. We have to recognize that not all questions can be addressed adequately with designs like this. This is true even when the methodology is flawless. We could go on all day critiquing the methodology, but I think it is absolutely erroneous to use this study as evidence in either direction because the question was not adequately addressed.

                (sorry if this is a repeat of comments below or above, didn’t read very thoroughly)

              7. JD says:

                Also Dr. Hall you think the previous studies have better methodology we are talking two studies.

                Cassidy used essentially the same methodology as Rothwell so…

                I would agree that the methodology used in the Rothwell study was similar, but I would contest that the paper with Johnston from UCSF involved did a better job. At least they asked about the receipt and timing of SMT. A small step above Cassidy, but an important one as we can at least have some idea of what the associations represent.

                In order to address this question ideally, because it is such a rare event and record keeping is likely sub-optimal, this question would likely be best addressed by standing outside of chiropractic offices, enrolling individuals undergoing SMT, and following them up for a month or two. The harsh reality is that I doubt this would be supported by practitioners of SMT.

                I am starting to become convinced that the only way we are going to answer questions, such as this, related to the outcomes of CAM users is by forcing CAM practitioners and mainstream physicians into some sort of high-stakes research gauntlet where both groups have to work together and include all of their names on the publications. Hey, maybe we can use NCCAMS for this? Of course, the potential harms here are pretty great depending on the treatment modality and would likely just confuse the public further. We’d have answers, but maybe a bigger mess on our hands. I digress…

              8. Blue Wode says:

                On August 1, 2014 at 3:01 pm Stephen M. Perle wrote “The best available scientific evidence at this point in time does not support the hypothesis that cervical manipulation causes dissections.”

                Yet on August 3, 2014 at 12:37 pm he wrote: “Cassidy’s caveat is based upon the fact that case control studies can not rule-in nor rule-out causation.” [Cassidy: “Our results should be interpreted cautiously and placed into clinical perspective. We have not ruled out neck manipulation as a potential cause of some VBA strokes.”]

                It begs the question, why aren’t all chiropractors applying the precautionary principle http://en.wikipedia.org/wiki/Precautionary_principle in regard to Cassidy’s caveat?

                For example, in the following broadcast Stephen Perle informs us that the Cassidy paper was responsible for a change in chiropractic informed consent protocols in Canada – i.e. chiropractors were allowed to switch from telling patients there was a risk of stroke to telling them there wasn’t a risk of stroke. See 34:40 in here:
                http://ontheotherhand.podbean.com/e/episode-2-dr-stephen-perle-discusses-chiropractic-and-stroke/

              9. Andrey Pavlov says:

                @JD:

                Very nicely done. I eagerly await Perle’s response.

                My prediction is it will involve little science and much rhetoric.

              10. MadisonMD says:

                ***crickets***

        2. MadisonMD says:

          The Cassidy study is interesting in that the number of strokes is not statistically different between patients who have seen DC versus those who have seen PCP within 30 days. The number of events was small, so despite the effort to include a very large N, it is difficult to make a firm conclusion of no difference in event rate between PCP and DC visits. Besides this statistical issue, I think there are some other issues.

          My major concerns are:
          (1) Different patient populations between MD and DC visits. (a) VBA stroke, in addition to headache and neck pain can cause major neurologic symptoms, include speech impairment, visual loss, ataxia. Patients with these neurologic symptoms are far more likely to present to PCP. Moreover, patients with underlying cardiovascular disease or hereditary disorders which predispose to VBA are likely to see a PCP on a regular basis. Thus, Cassidy compares apples (patients with headache, neck pain and no major underlying disease who are more likely to select DC) with oranges (patients who may additionally have significant neurologic symptoms or underlying disease who are more likely to see PCP). Under these conditions, I would expect to see fewer VBA events after DC visits than PCP visits if there is no causality.

          (2) Patients see PCPs far far more often than DCs. From Cassidy et al:

          Overall, 4% of cases and controls had visited a chiro-
          practor within 30 days of the index date, while 53% of
          cases and 30% of controls had visited a PCP within that
          time (Table 2).

          So seeing a PCP is very very common, and, unlike DC visits, more common amongst the cases than controls. This confirms the idea above that the PCP cases are a sicker population than the PCP controls. Second, it means that you can choose any major medical event and a third of them would have seen a PCP just because many more people see doctors than chiropractors.

          I would not call the paper flawed. It is what it is and provides some evidence that has limitations. Yet I do not find this paper as strong evidence of lack of causation.

          It would seem fair and ethical for DCs to inform patients of small possible risk of serious harm of neck manipulation and to weigh this against objective benefits of such manipulations (Perle, can you address this?) prior to the treatment.

          1. Jann Bellamy says:

            The study also used totally different ICD-9 codes for chiropractors and PCPs in choosing patients for inclusion in its analysis:

            “All reimbursed ambulatory encounters with chiropractors and
            PCPs were extracted for the one-year period before the index
            date from the OHIP database. Neck-related chiropractic visits
            were identified using diagnostic codes: C01–C06, cervical and
            cervicothoracic subluxation; C13–C15, multiple site subluxation;
            C30, cervical sprain/strain; C40, cervical neuritis/
            neuralgia; C44, arm neuritis/neuralgia; C50, brachial radiculitis;
            C51, cervical radiculitis; and C60, headache. For PCP visits,
            we included community medicine physicians if they submitted
            ambulatory fee codes to OHIP. Fee codes for group therapy
            and signing forms were excluded. Headache or neck painrelated
            PCP visits were identified using the diagnostic codes:
            ICD-9307, tension headaches; 346, migraine headaches; 722,
            intervertebral disc disorders; 780, headache, except tension
            headache and migraine; 729, fibrositis, myositis and muscular
            rheumatism; and 847, whiplash, sprain/strain and other traumas
            associated with neck (These codes include other diagnoses,
            and we list only those relevant to neck pain or headache).”

            They then further limited the patients to those with neck pain or headache. This supports MadisonMD’s conclusion that the study compares apples and oranges. Even if narrowed by head or neck pain, you are starting with patients with very different diagnoses. (Some of them bogus, such as “subluxations.”)

            In any event, “neck pain or headache” is not a proper description of a stroke symptom. It is “SUDDEN severe headache with no known cause” according to the National Stroke Association, http://www.stroke.org/site/PageServer?pagename=symp. No PCP is going to code that under “tension headache” or “migraine headache” or “rheumatism.”

    3. WilliamLawrenceUtridge says:

      The criticism from Dr. Crislip is well hollow. It is very interesting to note that those who criticize this study have done so in every medium except for the only one that counts, in the biomedical literature and specifically as a letter to the editor of the journal it was published in Spine. It appears to be that Science Based Medicine doesn’t do one thing well, that is contribute to the….science.

      I’ll merely note that none of the studies you cite appear to have your name appended.

      Oh, and that Dr. Crislip and Dr. Hall’s incomes are not predicated on the success or failure of chiropractic as a profession.

  13. Dcosta says:

    Thank you Dr. Perle. Finally, someone that can interpret the study findings properly and not in a “biased” manner trying to point fingers towards CMT.

    1. Harriet Hall says:

      We may be biased against chiropractic subluxation theory and against some of the things many chiropractors do, like applied kinesiology and discouraging vaccinations; but we are not biased against spinal manipulation therapy. SMT is not uniquely “chiropractic” – it is practiced by DOs, PTs, and some MDs, not just by chiropractors. We are just asking what we ask of any medical therapy: is there good evidence that it is effective, and is there good evidence that the benefits outweigh the possible harms? In this case, there appear to be other treatments that are at least as effective as neck manipulation for most conditions and that appear to be less risky.

  14. Peter S says:

    If there is no such thing as a subluxation, what is the point of a forceful manipulation of the neck?

    1. Ed Zachary says:

      Subluxations do exist. Please see William Ruch’s book: Atlas of Common Subluxations of the Human Spine and Pelvis.

      1. Harriet Hall says:

        As one of the Amazon reviews of that book said,”Pictures are nice, but what about an analysis?”
        One atlas assembled by a chiropractor carries little weight compared to systematic reviews of the literature showing no evidence that the chiropractic “subluxation” exists. Radiologists look at the same x-rays and call them normal.

  15. Wil Taylor says:

    There may not be a clear clinical entity such as a subluxation, spinal dysfunction, spinal fixation or whatever name you put to it and that certainly needs to be looked at more closely. But it would be agreed that the risk of cervical manipulation causing a stroke is similar to turning your head quickly from side to side? Opinions ?

    1. Harriet Hall says:

      Manipulation forcefully moves a joint beyond the normal range of motion; turning your own head involves less force and is restricted to the normal range of motion, and if it starts to hurt, you can stop.

      1. Dr. Hall you have again made a statement without any support in the science. This is “Science Based Medicine” right? The evidence does not support your contention that manipulation forcefully moves a joint beyond the normal range of motion. That was a theory but we have data that this is not the case.

        The first being
        Gal J, Herzog W, Kawchuk GN, Conway PJ, Zhang YT. Movements of vertebrae during manipulative thrusts to unembalmed human cadavers. J Manipulative Physiol Ther. 1997;20(1):30–40.

        A recent study shows that the global motion during cervical manipulation is not as large as normal active range of motion.

        Williams JM, Cuesta-Vargas AI. An investigation into the kinematics of 2 cervical manipulation techniques. J Manipulative Physiol Ther. 2013 Jan;36(1):20–6.

        1. Harriet Hall says:

          Chiropractors are known for “cracking” the spine, producing an audible cavitation by stretching the joint, as in cracking one’s knuckles. Can you crack your knuckles without exceeding the normal ROM? Granted, chiropractors don’t always produce an audible crack, but they do so often enough to have developed a reputation for it in the public mind.

          If the normal ROM is restricted by pain, a sudden chiropractic thrust within the normal ROM takes the joint where the patient would not take it voluntarily because it would hurt. It is at least plausible that this might lead to harm in some cases; I don’t think that possibility has been ruled out.

  16. Wayne DC says:

    Hall states that ‘Turning your head involves less force and is restricted to the normal range of motion… This statement demonstrates a ignorance of the fundamental biomechanics of specific manipulation. A chiropractic adjustment usually takes the head through the range of about 1cm motion.

    1. Peter S says:

      I have no reason to doubt you in general, but in my personal experience, when two different chiros did the rotational thrust on my neck, it was ALL the way to both sides.

    2. MadisonMD says:

      A chiropractic adjustment usually takes the head through the range of about 1cm motion.

      Check out this youtube chiro video between 6:15 and 6:30. Is this one of the cases that is not usual? Should all chiros stop doing these unusual neck manipulations that involve hyper-rotation?

      1. Peter S says:

        That looks much more like what was done to me than a “1 cm” movement.

        1. MadisonMD says:

          Shall I point out that “1cm” is essentially meaningless when we are talking about an angle of rotation? 1cm close to the vertebral axis of rotation would be one hell of an angle.

    3. WilliamLawrenceUtridge says:

      This looks like a “no true Scotsman” argument – “Those aren’t chiropractic adjustments, because they go past a 1cm range of motion.”

      Never mind that the person doing so calls it a chiropractic adjustment, calls themselves a chiropractor, attended a chiropractic college and appends the letters “DC” to their name.

  17. WilTaylor says:

    I would be interested to see what the nnh from rapid head movement causing a vertebral artery dissection vs the nnh of cervical spinal manipulation causing vertebral artery dissection . I suspect they probably wouldn’t be much different but it would be great to clarify this with current data.

    1. MadisonMD says:

      it would be great to clarify this with current data.

      How? A RCT of standardized manipulation versus a standardized “rapid head movement,” with N=100,000 so enough events occur? What current data could address this? What is the basis for your suspicion.

      Anyway, mechanistically it would seem to depend on whether manipulation does or does not include hyper-rotation. I appreciate that the DC’s posting here says it does not– and kudos to them if they aware of the risk of such hyper-rotation. But it is easy to demonstrate that at least some chiros do perform hyper-rotation. See:
      (1) here at 1:49. Interestingly, this chiro admits cervical adjustmants can be “deadly.” (Why would he say that if there is no risk as the DCs here claim. I guess he was just trained wrong in school, right?)
      (2) Here.
      (3) Here at 5:18 at 6:19 to 6:30 Man that last one is particularly severe hyper-rotation. How can you deny that chiros do this?

      … and these were just a few examples from a quick perusal of youtube.

      Incidentally, owls have adaptations that allow safe hyper-rotation. Hyper-rotation is what is dangerous and if all chiros avoided it, then it is likely the risk of adjustment would indeed be minimal.

      1. WilTaylor says:

        The reason for this is that VBIs can occur spontaneously, without evidence of overt head movement and with evidence of cervical spine movement. The (VA dissection) does not need to depend on cervical hyperotation. I would be interested to know of your opinion as to the causes of vertebral artery dissections without evidence of any significant cervical spine movement.

        1. MadisonMD says:

          The (VA dissection) does not need to depend on cervical hyperotation.

          … and lung cancer does not need to depend on tobacco. True but irrelevant to the question at hand.

          1. Well not really – if it happens without any precipitating event how can one tell that an event that occurs prior to a disection is the cause or just ergo hoc propter hoc?

            1. MadisonMD says:

              Have you read Bradford Hill’s paper lately? You are starting to sound like the tobacco industry apologists circa 1970.

              You can identify cause the same way you can tell that smoking causes lung cancer even though some lung cancers are not caused by smoking:
              (1) Plausibility. In lung cancer there are known carcinogens in smoke that can cause cancer in other contexts. In neck manipulation, it is known that hyper-rotation can cause vertebral artery dissections in other contexts.
              (2) Correlation, which we have ddressed above. Smokers have more lung cancer than no-smokers. Patients with vertebral-artery dissections/VB strokes are more likely to have seen a chiropractor than those without.
              (3) Temporality. An extended history of smoking typically precedes lung cancer (consistent with mechanism being chronic exposure to carcinogens). A visit to a DC with neck manipulation immediately prior to stroke is common, consistent with the mechanism of acute injury from stretching this blood vessel beyond physiologic limits.

              It remains possible that neck manipulation does not cause these events. However, we have met at least three Bradford-Hill criteria, which is a significant cause for concern. Even if these events are rare–and they appear to be– the consequence, stroke is quite serious.

              I conclude that, unless there is substantial objective benefit of cervical manipulation that provides high velocity motion or hyper-rotation, then it is not justified given the risk. Please provide the evidence of substantial objective benefit for any condition and I will reconsider.

  18. Joel Dykstra PT, Cert MDT says:

    Mark Jessop wrote: “End range ROM exercises are just as bad if not worse than a Cx manipulation. Especially McKenzie type retraction/extension exercises (which I also still give certain patients following a thorough case history if I deem it appropriate)”

    The McKenzie system utilizes an assessment process involving a progression of forces starting with patient-generated forces, progressing to therapist-generated forces, with a goal of getting the segment to end range. The patients response to the forces is repeatedly assessed (change in pain or change in the their ROM). Changes of other signs and symptoms (vascular or neurological) would be apparent as well. If any unfavorable changes present, the force would not be progressed. This is a safer way of loading the structures. Mckenzie-method trained physical therapists (or chiropractors or physicians) would use HV/SA manips as the final force progression if the patient wasn’t able to create elicit a favorable response themselves, or the therapist-generated “overpressure” did not elicit a favorable response. As a result, the use of the manipulation is used more discriminately, and also much less often. We rely on the inherent integrity of the spine and let the nature of the pain-generating-entity reveal itself through distinct pain patterns in response to these loading strategies. (Thorough history and Red flag/contraindication assessment assumed.)

  19. Sam Homola says:

    As to cherry picking Dr. Homola hasn’t really done that, he’s only picked a raisin, dried old fruit from 2000….However, in this case he’s behind the times.”

    The neck manipulation recommendations adopted by a French multidisciplinary group back in 1997 are worth considering since they offer actions and safeguards not yet adopted by chiropractic proponents of neck manipulation. Scientific consensus is more in agreement with the old French guidelines than with current chiropractic contention that neck manipulation is totally safe. Unfortunately, it seems that the official stance of chiropractic spokes persons in the U.S. is to defy logic by continuing to deny that upper neck manipulation might damage vertebral arteries, despite observations by neurologists who report that traumatic vertebral artery dissection has occurred in healthy young persons who presented with symptoms of stroke immediately following neck manipulation. The vulnerability of the atlanto-axial joint to injury and the risk of injury to vertebral arteries associated with extreme rotation of this joint is an observation based on simple, timeless anatomy. It cannot be denied that many chiropractors are unnecessarily rotating the upper cervical spine in a misguided attempt to correct putative chiropractic subluxations, offering risk without benefit. This is not to say, however, that appropriate generic neck manipulation is never indicated.

    1. Harriet Hall says:

      ” in this case he’s behind the times.””

      It’s chiropractic that’s behind the times, not Sam Homola.

        1. Harriet Hall says:

          Interesting! Odds ratio for patients under 45 much greater than previously calculated. It will be interesting to see how Stephen Perle rationalizes the findings of that study away. :-)

        2. JD says:

          That’s very cool. Would be interesting to see this definition of dissection applied in a study that has access to SMT exposure. Taking this approach, weeding out strokes related to atherosclerotic disease using a better case definition with chart review, would be likely to remedy some of the “reverse causation bias,” as it was called.

  20. SH says:

    As a recently graduated french osteopath, I decided not to perform any cervical manipulation. The evidence is just not there to promote this treatment over another. What is needed is more studies on the different types of manipulations, for exemple, what is the incidence of stroke for non rotational thrust manipulation starting at C2 and below, without any contact on the skull ? This would be interesting.

    I dare point out also that these recommendations suggest that only a medical doctor should perform these manipulations (this is more obvious in the french version). Doctor Maigne teach a DIU of manipulative therapy, which has 2 years of teaching and one year of post DIU seminaries. Manipulative therapy is learned during the 2nd year where courses are dispensed once a week. (source: http://www.sofmmoo.com/formation_congres_fmc/diplomes_inter_universitaires/accueil_diu_mmo.htm )

    This is suggesting that people who follow this course are better at manipulation than people who follow a full time 5 years course of manipulation (who are not medical doctors). Either that, or he suggests that non MDs cannot read recommendations. The website also contain videos of rotational upper cervical manipulations (which you can’t access, but it says so in the title).
    FYI the reason rotational thrust manipulation is still widely used is because it is much easier to perform.

    1. SH says:

      Actually I forgot that this was written in 2000. At that point only MDs were allowed to perform manipulation in France.
      Rotation is still bad in manipulation as well as lack of practice.

  21. Crickets – Sorry but I actually have a job and I don’t troll this web site just waiting for a question to answer. Some of you must have more free time than I do. With my semester of classes starting on Monday I’ve been occupied and generally was reading bit here and there and replying with what I recalled of the postings.

    The way the machinegun replies appear on the web site make it very difficult to actually see what’s happening. So I printed this out. 42 pages! Wow. Not my most erudite exposition of the magnitude of the responses to this blog posting but words fail me on that.

    To the substance

    As to lack of statistical power. One will note reading Cassidy et al that no where was their a calculation of “p value” i.e. statistical significance or the probability of Type I error. Likewise power was not calculated. Instead the appropriate methodology was to use 95% confidence intervals. So the criticism isn’t valid as it is inconsistent with conventional epidemiological methodology for case-control studies.

    You assert that because VBI causes headache and neck pain that the population of patients visiting the MDs and the DCs are in some way fundamentally different. This would be a valid criticism if one were investigating the totality of the patients seen by both DCs and MDs. The evidence tells us that DCs predominately see patients with musculoskeletal complaints. However, the study didn’t look at the totality of patients seen by either profession, what was done was to look at cases (those with vertebrobasilar territory stroke) and compare those to controls (average Ontarians). Additionaly there are more cases seeing MDs than seeing DCs. This again does not validate the relative health of the individuals it is just consistent with market penetration. I don’t have data on patient preferences in neck pain but in LBP we know that about twice as many people first see an MD than a DC. The question of co-morbidities is a good one but not one studied in this paper. But one cannot assume more co-mobidities especially because we are dealing with a young population (<45 YOA)

    Further to that point you say cardiovascular disease disease which is a reason many seek care of PCPs this is true but it doesn’t predispose people to VBA. As you note connective tissue disorders are one pathophysiological process that appears to predispose individuals to VBA. But only a minority of people with VBA have connective tissue disorders. It is true that some people with VBA present with more hard neurological symptoms and patient’s like this do present to chiropractors offices. We see case reports by DCs of such cases. Cassidy does not compare apples to oranges, at best that is a hypothesis not supported by any data.

    I think shared decisionion making is appropriate

    As I noted before the best conclusion when the odds of obtaining care with either a DC or MD prior to a stroke, which we know can occur spontaneously and which produces symptoms for which people often seek the care of DCs or MDs is that what we are observing is protopathic bias.

    I would suggest reading the seminal work on protopathic bias by Horwitz and Feinstein:

    Horwitz RI, Feinstein AR. The problem of “protopathic bias” in case-control studies. Am J Med. 1980 Feb;68(2):255–8.

    You ask is this potential risk worth taking at all. This is a good question. The evidence cervical manipulation is effective (rather than efficacious) is in fact not great. It suffers from a recently well-recognized problem with the totality of the body of literature on all treatments of spinal pain syndromes. In fact, because of this universal problem NIH convened an expert panel to develop standards. One hopes that all future RCTs take into account these standards.

    Deyo RA, Dworkin SF, Amtmann D, Andersson G, Borenstein D, Carragee E, et al. Report of the NIH Task Force on Research Standards for Chronic Low Back Pain. 2014 Apr 25;:1–17.

    And while I do understand the problems with using a tu quoque argument the answer is that this is a universal problem not particular to SMT but to ALL interventions for neck pain. Thus applying the standard of saying well there are potential risks to SMT with poor evidence (which doesn’t mean no) of effectiveness then what shall we do? Instead use other treatments with known risks NSAIDs or surgery with equally poor evidence of effectiveness? There is a substantial burden of disease from neck pain.

    Hoy D, March L, Woolf A, Blyth F, Brooks P, Smith E, et al. The global burden of neck pain: estimates from the Global Burden of Disease 2010 study. Ann Rheum Dis; 2014 Jul;73(7):1309–15.

    Shall we take a nihilist approach and say that given the fact that NO treatments whatsoever have reached a level where we can predict with a good degree of certainty that they are clinically effective and in particular to this discussion have NNTs that are much lower than their NNHs shall we do nothing.

    “Sorry Mrs. Jones we have no treatments that systematic reviews have a substantial amount of high quality evidence (low risk of bias) showing that they are clinical effective with an acceptably low risk of side effects – therefore I propose letting you suffer.”

    You ask about rotation beyond normal range of motion. There are no studies I am aware of that show that SMT moves a joint beyond it’s “normal range of motion”. In fact doing so would mean that rather than a discussion about stroke we’d be having a discussion about the fact that a majority of people receiving cervical manipulation would be complaining of sprains, dislocations and fractures, and we don’t see that.

    To the blue faced Celt’s question as per Cassidy et al the inability to rule out risk is a valid caveat. A good scientist, as Cassidy is, notes their study’s limitations. As Cassidy said on the witness stand in CT IF a better designed thus more robust study does in fact find a risk that cannot be attributed to protopathic bias (as Cassidy’s study did) or other forms of bias then one has to change ones assessment of the situation. When such a study is published, if ever, I’ll change my tune as will other evidence-based chiropractors, just like when Cassidy was published I changed my stance then. What chiropractors are or are not telling their patients regarding SMT and stroke we do not know. We do know that all professional associations recommend shared decision making and that includes an open discussion about risks and benefits. As I noted in my article in DC Canadian DCs to let people know about the association where previously they told them about the risk. The reason I speak specifically about Canada and not the US is that the chiropractic profession is a bit more homogeneous in Canada their laws also result in a bit more homogeneity based upon mostly having the same malpractice carrier.

    Dr. Madison writes that he didn’t know about republication in other journals. It is not very common but does happen when the editors of both journals believe a paper is important. Cassidy et al was published also in J Manipulative Physiol Ther. In fact the first paper I ever saw of Cassidy’s was originally published in Can Fam Phys and republished in the defunct Am Chiropr Assoc J Chiropr.

    Dr. Hall notes that her bias is against what I’ll call poor clinical practice behaviors and beliefs of some in the profession. We are in agreement on this however, the strawman argument that attempts to demonize a whole profession isn’t
    germane to the discussion of cervical SMT and stroke.

    Dr. Madison brings up Hill’s paper on causation. (BTW Bradford was his middle name but if you like that convention you can call me Marc Perle)
    1. Plausibility – the biomechanical data shows that it isn’t plausible that movement would cause the VBA. Otherwise we’d see thousands of people who said, “doc I turned my head quickly to the side and then….”
    2. Correlation – got and but also have an explanation for it – protopathic bias resulting in care seeking behavior rather than care causing the VBA.
    3. Temporality – sometimes yes and sometimes 30 days. There are a lot of intervening events and then spontaneous dissections. Here’s a new case report of a stroke that occurs on the chiropractor’s table just BEFORE manipulation. What if the DC was a few minutes faster performing the manipulation. You’d likely call that a smoking gun.

    Mattox R, Smith LW, Kettner NW. Recognition of Spontaneous Vertebral Artery Dissection Preempting Spinal Manipulative Therapy: A Patient Presenting With Neck Pain and Headache for Chiropractic Care. J Chiropr Med. 2014 Jun;13(2):90–5.

    It is true that McKenzie does not use SMT. However many physical therapists do, including those who use McKenzie. There is a time and a place for either intervention one does not replace the other.

    1. Saavedra-Hernández M, Arroyo-Morales M, Cantarero-Villanueva I, Fernández-Lao C, Castro-Sánchez AM, Puentedura EJ, et al. Short-term effects of spinal thrust joint manipulation in patients with chronic neck pain: a randomized clinical trial. Clin Rehabil. 2013 Jun;27(6):504–12.
    2. Puentedura EJ, March J, Anders J, Perez A, Landers MR, Wallmann HW, et al. Safety of cervical spine manipulation: are adverse events preventable and are manipulations being performed appropriately? A review of 134 case reports. J Man Manip Ther. 2012 May;20(2):66–74.
    3. Puentedura EJ, Cleland JA, Landers MR, Mintken PE, Louw A, Fernández-de-Las-Peñas C. Development of a clinical prediction rule to identify patients with neck pain likely to benefit from thrust joint manipulation to the cervical spine. J Orthop Sports Phys Ther. 2012;42(7):577–92.

    I don’t know when I’ll be back to see another 42 pages of comments so maybe more crickets.

    1. Jopari says:

      Not enough time. Yet you somehow printed out 42 pages worth of comments and read it, which, I might add, is pretty much no different.

      The entire viewpoint is that since the cervical manipulation causes harm and isn’t proven to work, we might as well stick to what works which is already proven to have clearly defined efficiency and risks.

      Simply because something is low risk does not make it the treatment for something. Just like though acupuncture is relatively harmless, it cannot be said that it helps with menopausal symtoms, because there isn’t any evidence for it. Because there isn’t any evidence for it, we are pretty sure ot doesn’t provide any benefit, or maybe it provides a negligible amount of benefit. Because it is has risks, it shouldn’t be performed unless it has benefits that outweigh the risk. Since it cannot be proven to have benefits larger than risks because of lack of evidence, it’s recommended not to do so.

      Next, when you perform a cervical manipulation, while the joint isn’t dislocated, it is jerked suddenly and/or forcefully towards another direction, unlike when the neck muscle pulls it. Therefore, it also jerks to a very sudden stop or strains the joint. This is definitely harmful, like getting a friend to jerk my forearm outwards until it jams into place is harmful. You’re dealing with the neck, airways, nervous pathways, bloodvessels all pass through here. Caution is of course, recommended.

    2. Jopari says:

      Addressing stuff I missed.
      1) Plausibility, yep, normal muscle movement won’t cause VBA, if chiropractice simulates normal muscle movement, then they shouldn’t exist.
      2) Correlation, wait, wait, wait, are you saying that people with VBA problems go to chiropractors for treatment by cervical manipulation? Beg your pardon, but aren’t the symptoms not what cervical manipulation are purported to treat?
      3) Temporality, now, while we would probably discard that extraordinary case where the patient had it immediately after, saying that it wasn’t from THAT session, we would also check to see if the patient’s stroke is caused by the VBA, and if so, if the patient had previous activity which caused this, has the person had cervical manipulation before? Of course, extraordinary cases will probably be ignored, instead, the normal trend suggests that it is because of cervical manipulations.

    3. JD says:

      As to lack of statistical power. One will note reading Cassidy et al that no where was their a calculation of “p value” i.e. statistical significance or the probability of Type I error. Likewise power was not calculated. Instead the appropriate methodology was to use 95% confidence intervals. So the criticism isn’t valid as it is inconsistent with conventional epidemiological methodology for case-control studies.

      Including an interaction term in conditional models is a pretty “conventional epidemiological method.” I read this question with regard to assessing the difference in associations between DCs and PCPs. You can eyeball it, but having a statistically significant multiplicative interaction to back up one’s assessment of differences in magnitude can be useful.

      Further to that point you say cardiovascular disease disease which is a reason many seek care of PCPs this is true but it doesn’t predispose people to VBA.

      The issue is how VBA stroke was defined. Whenever one is scouring administrative databases, it is important to consider what these cases actually represent. Did they find true dissections leading to VBA stroke, or the rare issues you mention? Do you not agree that this is a better definition that is more pertinent to the question at hand (one that I wish could be applied on the actual data)? http://www.ncbi.nlm.nih.gov/pubmed/25085345

      As I noted before the best conclusion when the odds of obtaining care with either a DC or MD prior to a stroke, which we know can occur spontaneously and which produces symptoms for which people often seek the care of DCs or MDs is that what we are observing is protopathic bias.

      If this is the case (I think we both agree that it is), how in the world does this study provide any support at all that cervical SMT is not associated with VBA stroke? I think the answer is pretty clearly that it doesn’t.

      To me, this boils down to the same old problem with CAM treatments. We don’t know what types of movements DCs may be doing in the office. Many will likely follow the protocols you mention, with movements that may or may not lead to dissection or VBA stroke. But, is it plausible that some (or a good proportion) are not being so careful and would be going too far? Because we have no idea what is happening, mostly due to the fact that those in these areas are generally not very forthcoming, this is a distinct possibility. As for NSAIDs and surgery you mention, at least there is some amount of meaningful regulation and we have enough information to generally gauge risks and benefits. This is absolutely not the case for cervical SMT.

      Why is it such a horrible thing to practice the precautionary principle in a situation like this in a poorly regulated industry, with scant pertinent data? I don’t view this as nihilism, I view this as logical.

    4. MadisonMD says:

      As to lack of statistical power. One will note reading Cassidy et al that no where was their a calculation of “p value” i.e. statistical significance or the probability of Type I error. Likewise power was not calculated. Instead the appropriate methodology was to use 95% confidence intervals.

      You are comparing the following odds ratio (selecting <45yo, 0-3d, headache or cervical visit):
      DC visit (0-3 day): OR= 5; range 1.3 – 18.6 (95% CI)
      MD visit (1-3 day*): OR= 25.6; range 3.1- 209 (95% CI)
      [*Odd, I wonder why intervals are different?]

      From these data you draw the conclusion the results are the same when in fact the odds ratio could reasonably be up to 6-fold higher in DC visits and fall within this CI (or could be higher for MD–we cannot tell). So you can say that 'the appropriate methodology was used,' and I'll agree. But your conclusion that these rates are the same cannot be drawn from these data. Moreover, this does not even address JD’s substantial critique that this study does not show the OR of having a stroke after an MD or DC visit for neck pain, but that the odds of having sought care prior to such a stroke was high for both (in the setting of 10x higher baseline rate of regular MD care than regular DC care).

      You assert that because VBI causes headache and neck pain that the population of patients visiting the MDs and the DCs are in some way fundamentally different. This would be a valid criticism if one were investigating the totality of the patients seen by both DCs and MDs. The evidence tells us that DCs predominately see patients with musculoskeletal complaints. However, the study didn’t look at the totality of patients seen by either profession, what was done was to look at cases (those with vertebrobasilar territory stroke) and compare those to controls (average Ontarians).

      You missed the point that patients with VBA stroke are often going to have neurologic symptoms in addition to headache and neck pain. Because, as you say, DCs predominantly see patients with “musculoskeletal complaints” I conclude that patients with bona fide VBA with neurologic symptoms are likely to see an MD prior to being diagnosed with VBA. In fact, since MDs generally diagnose VBA stroke whereas DCs generally don’t (you agree?), it is very very likely that these patients would have seen an MD prior to being diagnosed with VBA, and many of those MDs will code the visit without specificity (e.g. headache), prior to obtaining the diagnostic test (MRI). Thus the patients with more severe symptoms are pretty much automatically going to seek care from an MD, a prerequisite for the diagnosis. So you are pretty much doing this. And you clearly can make the comparison, if you so wish, but you are not going to get useful conclusions.

      It is true that some people with VBA present with more hard neurological symptoms and patient’s like this do present to chiropractors offices. We see case reports by DCs of such cases.

      Are you seriously claiming that a patient with aphasia, ataxia or visual loss is equally likely to seek care from an MDs or DCs? And as evidence you offer “case reports.” This is laughable. You are sharp enough to know this not a credible argument. More likely you are being disingenuous.

      But one cannot assume more co-mobidities especially because we are dealing with a young population (<45 YOA)

      Well, damn! You don’t think there are sick people with vascular disease younger than 45? In North America? And you don’t think these sick people will suffer a disproportionate number of strokes? The irony is, your response actually confirms my conclusion that MDs are seeing sicker patients than DCs.

      You ask is this potential risk worth taking at all. This is a good question. The evidence cervical manipulation is effective (rather than efficacious) is in fact not great.

      This is of quintessential essence to your profession, and the lack of this knowledge is a blight on DCs. Why? Because these procedures are carried out millions of times per year worldwide over decades and yet you still do not have an answer. I mean, it almost looks like you all don’t want to know the answer. (I am also puzzled that you do not mention what medical problems you think it might be effective for, since headache and neck pain can both occur by numerous distinct clinical entities.)

      I think shared decisionion making is appropriate

      How do you engage in shared decision making when you admit to knowing neither the risk nor effectiveness of a procedure? I suppose you tell them that you don’t really know if it is effective, and that there is an association with stroke but you don’t really know if it is causative?

      You ask about rotation beyond normal range of motion. There are no studies I am aware of that show that SMT moves a joint beyond it’s “normal range of motion”.

      It is circular to argue that DCs haven’t really done studies of SMT and then to additionally state that no studies show that SMT moves a joint beyond normal ROM. Have a look at this video between 6:15 and 6:30, if you please, to see that DCs do this.

      about the fact that a majority of people receiving cervical manipulation would be complaining of sprains, dislocations and fractures, and we don’t see that.

      How would you know you if a majority of them don’t have this without a reporting system? Do you call the ones who don’t return after cervical manipulation to check? Moreover, do you claim it is impossible to hyperextend a joint beyond ROM without causing sprain? Odd, because I’ve done it without sprain on several joints (but not my neck). Oh, and by the way, neck fractures from chiro manipulation, in fact, do occur.

      1. Plausibility – the biomechanical data shows that it isn’t plausible that movement would cause the VBA. Otherwise we’d see thousands of people who said, “doc I turned my head quickly to the side and then….”

      This is silly. When I turn my head, I have proprioceptive and pain sensation which delimit the extent that I am willing to rotate it. Moreover, I do it rather quite slowly, compared to the chiro video above, giving plenty of time for such feedback. When a DC forces rotation of a neck, there is no such feedback and so it can be easily forced beyond these limits. See the video I linked above.

      What you are claiming here is that forced neck rotation cannot cause stroke. In fact, Bow hunter’s stroke is a well described clinical entity that occurs precisely by this mechanism. So, I conclude: Plausibility, check.

      2. Correlation – got and but also have an explanation for it – protopathic bias

      Agreed, yet there no evidence to conclude it is protopathic not causative. That’s why we look for the other criteria here, in fact, and don’t rely on just this one.

      Temporality – sometimes yes and sometimes 30 days. There are a lot of intervening events and then spontaneous dissections.

      Nevertheless, the criterion is met. It would be best to know that the rate of stroke immediately after manipulation (diagnosis within say 48h), but it doesn’t seem that DCs have, er, motivation to collect such data. Do you have Quality Improvement at all as a requirement for board cert or licensing?

      Now for the insubstantial sniveling:

      Dr. Madison writes that he didn’t know about republication in other journals.

      You may have missed this.
      AND

      BTW Bradford was his middle name but if you like that convention you can call me Marc Perle

      And if you don’t have a leg to stand on, Marc Perle, please do resort to petty irrelevant critiques. But if you must, when I teach medical scientists, I always refer to the Bradford-Hill criteria for the simple reason that this is the common convention, and I would hope that future physician scientists would use this convention in the interest of clear communication. The Wikipedia article on Bradford Hill helpfully explains:

      Note that Austin Bradford Hill’s surname was Hill and he always used the name Hill, AB in publications. However, he is often referred to as Bradford Hill.

      This convention is, in fact, useful to avoid mixing him up with good old Archie.

      In sum, you know neither risk of cervical SMT nor effectiveness for any condition… and pretty much admit it. But you sure seem motivated to veil this admission behind bluster and circumstance. Do you veil it from patients as well during “shared decision making?”

    5. WilliamLawrenceUtridge says:

      Hey blah blah, how about instead of chiropractors proclaiming how safe cervical adjustment is, and how superior it is to other forms of treatment – how ’bout you fucking test it in controlled trials a little more before defending it? Chiropractic has been around for over a century and still hasn’t adequately tested its main interventions, because it appears to be a profession of unethical hacks more bent on helping their income stream than patients.

  22. Blue Wode says:

    Published 7th August 2014:

    Cervical Arterial Dissections and Association With Cervical Manipulative Therapy: Statement for Healthcare Professionals From the American Heart Association/American Stroke Association

    http://stroke.ahajournals.org/content/early/2014/08/07/STR.0000000000000016.full.pdf+html

    (full text)

  23. Sam Homola says:

    Thanks, Blue Wode, for providing the full text of the neck manipulation article prepared on behalf of the American Heart Association/American Stroke Association. I do not see how any scientifically-oriented person could disagree with the observations and conclusions outlined in this article.

  24. I’m sure no one will be swayed by any arguments. But Christine Goertz does a great job deconstructing the problems with the AHA statement.

    http://t.co/OlJOmkMlql

    1. Windriven says:

      You’re right. But we would be swayed by evidence. Until then, and with the small exception of LBP, chiros look just like grifters.

  25. Kelly Luckman says:

    Hi, I was very interested in your article regarding the tricks of Chiropractors, as I have just started seeing a Chiro again, the one I saw for 15 years has retired, he was incredible, no tricks, no trying to make more money from me, he adjusted me and I felt amazing. The new one however is the guy with the attitude and the gadgets, the thermo scanner, the 12 sessions for only $60 a visit not $65!, or 24 sessions for only $55 a visit! Also needing to see him 3 times a week for the first 2 weeks, twice a week for the next month after that, warning bells started going off in my head so I started to research and found your article. But the thing that really irked me was the manipulation of my body to show that his treatment was ‘fixing me’. Raising my arm over the head in one way, correcting something then changing the angle of my arm so it could actually go over my head and saying, ‘look! twice as much movement already!’ Well yes, it’s the way you were holding my the first time compared to the second time. No movement or strength in my hips? No worries, just a quick adjustment, change the angle of my leg as you move it and wallah! double the movement! Pushing down on my arm, no resistance, op no worries, a slight adjustment and amazing!!! You didn’t push as hard or in the same place but wow, i can resist!!! And it was all because of the adjustment (not).

    I hope you know what i’m talking about above, I’m not sure if there’s a name for it but after 3 sessions of this I politely declined another treatment. Some people might believe that but as a veteran of chiropractic care, those tricks are completely see through! I just want to be adjusted and feel good, which he did actually help the pain, so why all these other unnecessary mind tricks?!

    Just thought other people might have experienced this, I’ve seen similar body manipulation techniques on those magnet arm band things and hoping to spread the word that it seems to have spread into chiropractic.

    Cheers,

    Kel

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