Compare and Contrast

I have been in Infectious Diseases for almost 25 years. I have two major jobs: I see inpatient consults and I chair the Infection Control program. I have been involved in quality improvement, especially as it relates to hospital acquired infections, for my entire career. It has been an interesting quarter century. Year after year we have driven down infection rates and other kinds of mortality and morbidity in hospitalized patients. Everyone recognizes that medicine is difficult and dangerous and its biggest problem is medicine is practiced by humans, who, I would venture to observe, are prone to mistakes and any number of cognitive errors.

It has not been a easy journey. People hate change and there has not always been certainty as to the best options to choose to solve a problem, a problem that continues today. For example, how best to treat a patient with potential methicillin resistant Staphylococcus aureus colonization (MRSA). Should we screen everyone? Screen high risk patients? Surgical patients? Do we decolonize, with the long term consequence of accelerating antibiotic resistance? Do we place everyone with MRSA in isolation, with the known decrease in care that patients in isolation may have? Everything we do has potential downsides and unintended consequences. No good deed ever goes unpunished.

When I was a resident every PVC (preventricular contractions) in cardiac patents was suppressed as we thought PVC’s were the sentinel event that led to ventricular tachycardia and death. So patients received IV lidocaine and we often sent patients home on quinidine or other antiarrhythmics. Subsequent studies demonstrated that antiarrhythmics may have killed more people than they saved, and doctors no longer suppress every PVC in the ICU. Medicine changes, one hopes for the better, offering old geezers like me the opportunity to ‘reminisce’ about the old days, when I tied an onion to my belt, which was the style at the time. Now, to take the ferry cost a nickel, and in those days, nickels had pictures of bumblebees on ‘em. Give me five bees for a quarter, you’d say. Now where were we? Oh yeah: the important thing was I had an onion on my belt, which was the style at the time.

Sorry. I digress. A couple of months ago I had a patient with severe malaria that needed IV quinidine (the dextrorotatory diastereoisomer of quinine, but that is obvious) and there was none in the pharmacy; we had to get some shipped in by our dealer, er, distributor. In medicine, if it discovered that what was thought to be a beneficial intervention turns out to cause more harm than good, the intervention is abandoned.

When To Err is Human was published, it caused quite a brouhaha. Depending on whose numbers you want to believe, 44 to 98 thousand Americans died each year from medical errors. I did not have issues with the numbers. There are about 5700 hospitals in the US, so that would be about one death every month and a half. Knowing what I did about infections and other complications in the hospital, that did not seem like an unreasonable estimate. A bit high, perhaps, but in the ballpark of my understanding of reality.

That is old data, and no longer applicable. Due, in part, to To Err is Human, the last decade has led to innumerable studies evaluating the causes of infections and complications in hospitals and the best approaches to decrease them. My institutions have invested huge time and effort to implement these quality improvements with great success.

When I started in Infection Control, the infection data was considered protected. The thought was that institutions would be more likely to collect and evaluate data about infections if there were not discoverable by lawyers. The downside was, as I was informed, if I informed anyone about the data, it would no longer be protected, and the institutions would be open to expensive lawsuits. This century my institutions are much more transparent about disseminating information about our practice. I thought I would have a conniption the first time I saw the infection data for the ICU posted in the ICU for all too see. It turns out, like so many deeply held convictions, that keeping the data protected was a bad idea. Transparency has not led to an increase in lawsuits but it has led to a decline in all manner of hospital associated complications. Our staff takes a great deal of pride in their work. They took the data as a personal affront and worked to improve all aspects of patient care. When they saw harm potentially occurring, practice changed for the better.

So there are three reactions to new data in medicine that demonstrates that a given medical practice may cause harm.

First, the data and the conclusions are challenged, as they should be. All studies are open to analysis and improvement. In medicine we continuously try to improve care, and that requires good information.

Second, further studies are done to confirm and refine the problem and other studies are done to see how practice can be improved.

The third is practice change, which is often slower than we like. But change we do. I am old enough that I often bore the residents with how it used to be in the old days. Medicine today is drastically different than 20 years ago, and many logs better.

The most impressive example of improvement in the last 20 years is hand hygiene. Hand washing adherence 20 years ago was an embarrassment. Part of the problem was the time it took to wash hands; I have heard that if a nurse spent her time appropriately washing her hands, 80% of his shift would be spent at the sink.

Alcohol foam changed that. When we introduced the foam in the hospital, even when compliance was only 20%, we had a 50% drop in hospital infections, and as compliance has increased to 90 to 95%, the infections had a parallel decline. And the effects of alcohol foam improved once I discovered it was not a po agent, to be used like Cheez Whiz. Our biggest problem now is fall prevention. Most falls occur when the patient doesn’t want to bother the nurse and, in the process of moving about the room without help, falls. We are investigating ways to remove gravity from the hospital.

The threshold for changing and abandoning a therapy can be very small. Last century there was a drug called trovafloxacin that caused several hundred cases of hepatitis and a half a dozen deaths when it was being prescribed at a rate of 300,000 new prescriptions a month. Hepatitis was an extremely unusual complication, but the small risk was not worth the potential benefits since there were equally efficacious alternatives.

Compare and contrast medicine and alt med.

Most alt med interventions are, of course, based on eternal truths that cannot be improved or changed. They are often immune to reality induced change. Studies that confirm their eternal truth are always accepted. Studies that show harm or lack of efficacy? Not so much.

Certainly, when complications of alternative medicines are published the data is up for discussion. That is good and as it should be. But that is where the similarities with medicine ends.

There is an ongoing issue of safety in the two most invasive alternative interventions: acupuncture and chiropractic.

There were two reviews concerning chiropractic safety published recently. Safety of chiropractic interventions: a systematic review, which found

A total of 376 potential relevant articles were identified, 330 of which were discarded after abstract or complete article analysis. The search identified 46 articles that included data concerning adverse events: 1 randomized controlled trial, 2 case-control studies, 7 prospective studies, 12 surveys, 3 retrospective studies, and 115 case reports. Most of the adverse events reported were benign and transitory, however, there are reports of complications that were life threatening, such as arterial dissection, myelopathy, vertebral disc extrusion, and epidural hematoma. The frequency of adverse events varied between 33% and 60.9%, and the frequency of serious adverse events varied between 5 strokes/100,000 manipulations to 1.46 serious adverse events/10,000,000 manipulations and 2.68 deaths/10,000,000 manipulations.

CONCLUSION: There is no robust data concerning the incidence or prevalence of adverse reactions after chiropractic. Further investigations are urgently needed to assess definite conclusions regarding this issue.

That is impressive complication rates, although the authors suggest the data to support the rates are not robust, for an intervention that only has at best proven efficacy for low back pain and safer alternatives. Also published recently was Deaths after chiropractic: a review of published cases.

Twenty six fatalities were published in the medical literature and many more might have remained unpublished. The alleged pathology usually was a vascular accident involving the dissection of a vertebral artery.

That is about three times the number of deaths from trovafloxacin, an excellent antibiotic that we abandoned in the U.S. as too dangerous. Of course, we have safer alternatives with equal efficacy.

Also recently published was Acupuncture-related adverse events: a systematic review of the Chinese literature which found

that in total reported on 479 cases of adverse events after acupuncture. Fourteen patients died. Acupuncture-related adverse events were classified into three categories: traumatic, infectious and “other”. The most frequent adverse events were pneumothorax, fainting, subarachnoid haemorrhage and infection, while the most serious ones were cardiovascular injuries, subarachnoid haemorrhage, pneumothorax and recurrent cerebral haemorrhage.

Based on the reported complications of the two interventions, if they were a medical therapy regulated in a manner similar to medications and medical devices, they would certainly have, at a minimum, a black box warning and, in the case of chiropractic, no longer be used. Especially as there are no good indications for chiropractic or acupuncture.

What you do not see in the medical literature or the chiropractic blogs is any concern that harm may be done and investigations into changes in practice that could minimize the morbidity and mortality.

Instead you get The Self Importance of Being Ernst and Death by Chiropractic Another Misbegotten Review

Two essay that show zero interest in considering that chiropractic could potentially cause harm, the latter including the argument that it is real doctors that kill people and in comparison out ‘an order of magnitude greater than the side-effects attributed to spinal manipulation.’ See. If you kill small numbers of people, it is not important. Safety only matters when you kill people in large numbers. In the risk/benefit calculus of medicine, an intervention that has no benefit should cause no harm.

If there are concerns in the chiropractic community expressed about these complications, I can’t find them. If there is to improve chiropractic care, I can’t find it. If there is any quality/safety research being done, please rub my nose in it. I would love to know and those involved or aware of such research should trumpet the results for all to read. All the literature and letters to the editor I can find concerns denying there is a problem at all.

At least I could find concerns in the acupuncture literature : ‘A single injury – let alone a fatality – caused by acupuncture is one too many.” Exactly right. If you are practicing prescientific magic, it should have a mortality and morbidity of zero. Again if there is ongoing research into improving the safety of acupuncture, I cannot find it either.

Both seem far more interested in the messenger (Dr. Ernst) and his malevolent intent rather than the message.

It is, I think, a key difference between medicine and its ‘alternatives’. The former takes safety and quality seriously and strives constantly with research and its application to improve care. The alternatives? Nope. Not yet. And probably never.

Addendum. This may be the last post of 2010. I would like to say on behalf of myself and the other authors of SBM (who can disagree in the comments if they desire): Happy New Year. Enjoy 2011 since the world will end in 2012. With one exception, we have a wonderful group of readers and commenters and at times I learn more from the comments that I do preparing my posts. Stay healthy, my friends.

Posted in: Acupuncture, Chiropractic, Science and Medicine

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40 thoughts on “Compare and Contrast

  1. marcus welby says:

    Terrific post which calmly explains one of the fundamental differences between CAM philosophy and medical science. Medicine is constantly attempting to improve its safety and healing ability and recognizes there are many errors which harm patients along with many practices which are ineffective, dangerous, or just placebo effects. Medical science is in continual quest to discover these ineffective or dangerous therapies and eliminate them. CAM is, to this outside observer, on a constant crusade to protect their outmoded superstitious beliefs from any criticism, and uninterested in abandoning their intrenched notions. A truly broad gulf from a safety and intellectual standpoint.

    I found an unusual honest recognition of “possible chiropractic harm” which the author gently suggests chiropractors might wish to avoid:

    In Chiropractic Technique, Second Ed. 2002, by Peterson and Bergmann, Mosby, Chapter 4, Principles of Adjustive Tehnique:

    P. 114: “The anatomy of the cervical spine and the relationship of the vertebral arteries to neighboring structures do make the arteries sussceptible to mechanical compression and trauma….”
    and risk of arterial intimal injury is elaborated subsequently.
    P. 115: “Unfortunately, all of the commonly applied testing procedures alone or in combination do not specifically increase the chance of identifying the patient at risk fro this condition. A history of successful cervical manipulation without complications does not appear to reduce the risk of future complications with manipulation.” And “…there are few historic findings that would alert the clinician to an impending vascular event.”
    p. 119: re: VAD and stroke risk, “Although this condition is extremely rare, chiropractic doctors should give serious consideration to receiving informed consent before applying cervical manipulation.”

    So there IS the rare sober and thoughtful recognition within the chiropractic community, along with Sam Homola and a few others, of risk for serious harm by neck manipulation, along with some cautionary notations. Of course, within the medical science community, as this blog points out, once strokes and death were recognized, analyzed, published, exposed, there would have been moratorium on the procedure or abandonment, in all likelihood. The puzzling lack of brakes on neck manipulation by MDs in Germany, as pointed out by continuing publication of strokes in that country within their neurology literature…caused by neck manipulation performed by orthopedic surgeons as well as chiropractors, is an exception.

  2. nwtk2007 says:

    Medical science continually pats itself on the back for its concern over safety and their ability to change to decrease the dangers of various treatments and medications. I applaud that and believe it to be deserved.

    I find it a bit hypocritical, however, that certain drugs which are clearly responsible for thousands of deaths each year are still readily available to the general public, no matter their education or ability to understand the dangers of their use.

    Chiropractors are aware of the “dangers” of cervical manipulation, however small the risk might be, if there is any at all. But I would ask, at which point and what is the cut off number of deaths that would determine the need for a dangerous drug to be removed from the shelves?

  3. Epinephrine says:

    Could you be more precise about “certain drugs”?
    How many lives are saved by the drugs in question? What benefits are associated with its use? Who is dying, and were they already dying?

    If you are referring to alcohol, I agree that there is a huge issue with the use of alcohol, despite the awareness that it has many harmful effects, including the danger posed to others by those who drive while under the influence. Somehow I doubt that’s the drug you were referring to.

    The acceptable risk associated with a drug varies depending on its use – a prophylactic vaccine used in healthy individuals will need to be much safer than an oncology drug, for example. There is no single “cut-off” that is used, the acceptable risk for a drug that is the only shot at survival is much higher than the risk acceptable in a cough syrup. The benefit of having a drug on the market must outweigh the harm caused, though balancing these is tricky.

    As for cervical manipulation, if it offered any benefit it might be worth taking a risk – but I’m not aware of any benefit stemming from cervical manipulation. Without evidence of effectiveness, the acceptable risk should be comaparable to placebo, but there is some evidence that real risk of stroke exist following this type of intervention.

  4. nwtk2007 says:

    NSAIDS – 7000 to 8000 deaths per year.

  5. nwtk2007 says:

    The July 1998 issue of The American Journal of Medicine stated the following:

    “Conservative calculations estimate that approximately 107,000 patients are hospitalized annually for nonsteroidal anti-inflammatory drug (NSAID)-related gastrointestinal (GI) complications and at least 16,500 NSAID-related deaths occur each year among arthritis patients alone. The figures of all NSAID users would be overwhelming, yet the scope of this problem is generally under-appreciated.”

    And again a year later (June 1999) in the prestigious New England Journal of Medicine there is a similar statement:

    “It has been estimated conservatively that 16,500 NSAID-related deaths occur among patients with rheumatoid arthritis or osteoarthritis every year in the United States. This figure is similar to the number of deaths from the acquired immunodeficiency syndrome and considerably greater than the number of deaths from multiple myeloma, asthma, cervical cancer, or Hodgkin’s disease. If deaths from gastrointestinal toxic effects from NSAIDs were tabulated separately in the National Vital Statistics reports, these effects would constitute the 15th most common cause of death in the United States. Yet these toxic effects remain mainly a “silent epidemic,” with many physicians and most patients unaware of the magnitude of the problem. Furthermore the mortality statistics do not include deaths ascribed to the use of over-the-counter NSAIDS.”

    A recent study in Therapeutics and Clinical Risk Management notes that shockingly the number of deaths and hospitalizations from GI bleeding due to NSAIDs has remained unchanged since that 1999 study.

    “Major adverse gastrointestinal events attributed to NSAIDs are responsible for over 100,000 hospitalizations, US $2 billion in healthcare costs, and 17,000 deaths in the US each year. Despite improvements in the available medications to aid in healing and treatment of NSAID-associated complications, the number of hospitalizations and deaths has remained unchanged in the US in the last decade.”

    The dangers of NSAIDs were known even before that 1999 article. In 1991 in the Journal of Rheumatology the authors estimate a large number of deaths each year attributed to NSAID use.

    “Overall death estimates are similarly disquieting. Conservative calculations, counting only excess deaths, indicate that about 7,600 deaths/year in the United States are attributable to NSAID use. The Food and Drug Administration suggests even higher figures, estimating NSAID use accounts for 10,000 to 20,000 deaths/year. These figures are comparable to Hodgkin’s disease or acquired immunodeficiency syndrome and represent a serious problem.”

    Interestingly, there has been no change in the availability of these drugs since these studies came out.

  6. Epinephrine says:

    Hmm, thanks for sourcing some quotes. I’ll have to look at more data to really form an opinion, since I wasn’t aware of this. Of course, when toxicity is largely due to misuse of a drug it’s less likely to result in pulling a drug, and more likely to result in changes to labelling, education campaigns, etc.

  7. marcus welby says:

    For the chiropractic apologist, NWTK, who seems to like to change the subject and point at some problem in medical care, Bextra, Vioxx, and Celebrex were NSAIDS which have been severely restricted or removed from market entirely as a result of epidemiological studies and risk-benefit analysis. Do I wish the FDA were more harsh on Big PharMa? Yes.

  8. nwtk2007 says:

    The degree of “apologistics” is weighted much more heavily upon your shoulders Mr Welby.

    And why does the FDA need to be harsh on Big Pharma? Where is the AMA in this concern? Owned by Big Pharma maybe? Or visa versa?

    Big Pharma represents capitalism at its finest, does it not? Throw in the insurance industry and double whammy.

  9. marcus welby says:

    Let’s return, NWTK, to your prior charges: clearly medical science is not hiding from the truth and is searching for problematic therapies with risk-management issues needing correction. Note that every one of your journal articles cited regarding mortality and morbidity from NSAIDs is from a published article in a medical science journal, not from chiropractic journals. Note that the German neurology data on VAD and neck manipulation cites neck manipulation by MDs as well as chiropractors as the cause of VAD, strokes and death. The facts are important to be brought out, transparency is paramount, when problems with risk-benefit are identified, corrective action is expected. Most MDs are careful about prescribing NSAIDs in patients on blood thinners or with ulcer histories and are careful about dose and recommendations regarding empty stomach. Many NSAIDs are taken over the counter and some consumers ingest alarming doses of these drugs against recommendations. All of these risks need to be documented and monitored on a continual basis. No argument here. This is what the medical journals were attempting to do.

  10. JMB says:

    Most doctors that prescribe NSAIDS inform the patients of the risks. Patients can then make the informed decision about whether the benefit is worth the small chance of death. Do chiropractors provide information about the risks?

  11. windriven says:


    Powerful drugs sometimes have powerful side effects. But one point of Dr. Crislip’s post was that medicine continuously examines the risk benefit ratio of various therapies. Crislip also made the point rather succinctly that the same calculus doesn’t work in chiroquactic because there IS NO THERAPEUTIC BENEFIT against which to balance the risk.

    Well, no therapeutic benefit disregards the value of a nice massage for lower back pain. But you see the point.

  12. nwtk2007 says:

    I think the point Crislip makes is that medicine continues to make changes to improve the safety of treatments and drugs while CAM does not.

    My question is why doesn’t that effort toward improves safety apply to OTC meds like NSAIDS which are clearly killing people daily? So far, all here have avoided that topic. Medicine pats itself on the back yet ignores this travesty for the past ten and more years.

    Its fun, I’m sure, to attack chiropractic for its fractional risk invloved in manipulation. It certainly detracts from the obvious mayhem of some of these OTC drugs you seem to continually defend.

  13. weing says:

    Believe it or not, but one of the reasons that Celebrex, Vioxx, and Bextra were such a success was that the GI risks were much lower and they could even be used in patients on warfarin. I really can’t find any reliable statistics on cardiac deaths due to Vioxx. If we had them, then we could compare the lives saved from GI bleeds to the lives lost from MIs per year.

  14. weing says:

    “My question is why doesn’t that effort toward improves safety apply to OTC meds like NSAIDS which are clearly killing people daily? So far, all here have avoided that topic. Medicine pats itself on the back yet ignores this travesty for the past ten and more years.”
    So are tobacco and alcohol. Big pharma won that battle. All we can do is educate our patients about the risks.

  15. I am the mother of two small children who like to run full-out in inappropriate places. Let me know when you get that gravity problem worked out!

    Thanks to all of you who write for SBM. I’m looking forward to more in 2011.

  16. daedalus2u says:

    I think Dr Crislip is trying to solve the gravity problem by making light of everything. I think so far his efforts have been no better than placebo. ;)

  17. rwk says:

    SBM fellows,
    Why does no one challenge the following remarks by Mark Crislip?

    It has been an interesting quarter century. Year after year we have driven down infection rates and other kinds of mortality and morbidity in hospitalized patients.


    Numbers of both community-associated and hospital-acquired infections have increased in the past 20 years. From 1990-1992, data from the National Nosocomial Infections Surveillance System for the Centers for Disease Control and Prevention (CDC) revealed that S aureus was the most common cause of nosocomial pneumonia and operative wound infections and the second most common cause of nosocomial bloodstream infections.

    An estimated 95,000 people developed MRSA infections in 2005, according to CDC Hospitalizations due to MRSA infections have doubled in recent years. Between 1999 and 2005, the number of patients hospitalized with MRSA infections went from 127,000 to almost 280,000.vii

    because of progressively shorter inpatient stays over the last 20 years, the rate of nosocomial infections per 1,000 patient days has actually increased 36%, from 7.2 in 1975 to 9.8 in 1995

  18. moderation says:

    Nwk2007: I think your choice of NSAIDs was a poor choice to make your case. As has been said, you have to balance benefit against risk. There may be several thousand deaths a year, but the sheer number of doses (billions?) used a year and the benefit to individuals with arthritis, injuries, etc are balanced against these deaths. How many of these deaths occurred in individuals with underlying disease? How many occurred without physician supervision, as these meds are mostly acquired OTC? And even in those who were under physician supervision, how many were made aware of the risk and chose to be treated anyways for quality of life reasons. Additionally, the benefits of NSAIDs are well known and researched … chiropractic cervical spine manipulation, not so.

    So, you are comparing a treatment with benefits and risks to a treatment with no known benefit, but with risks.

  19. wales says:

    Regarding numbers of medical error deaths as estimated in “To Err is Human”, MC said “That is old data, and no longer applicable.”

    Newer data indicates the problem has gotten worse, not better.

  20. wales says:

    “The HealthGrades study finds nearly double the number of deaths from medical errors found by the 1999 IOM report “To Err is Human,” with an associated cost of more than $6 billion per year. Whereas the IOM study extrapolated national findings based on data from three states, and the Zhan and Miller study looked at 7.5 million patient records from 28 states over one year, HealthGrades looked at three years of Medicare data in all 50 states and D.C. This Medicare population represented approximately 45 percent of all hospital admissions (excluding obstetric patients) in the U.S. from 2000 to 2002.”

    “The HealthGrades study shows that the IOM report may have underestimated the number of deaths due to medical errors, and, moreover, that there is little evidence that patient safety has improved in the last five years”

  21. Mark Crislip says:

    I was not clear. I was using the very personal we, referring to the experience of the hospitals of which I chair the infection control committees.

    the we is work do we at my institutions

  22. WilliamOBLivion says:


    1) As one commenter mentioned NSAIDs are a questionable example because you need to look at the injury/mortality to dose (or patient) ratio, which for NSAIDs is so large as to be stupefying. I’d be willing to bet that in a given year the percentage of westerners that take some sort of OTC NSAID is at least 70%.

    2) Most NSAIDs are consumed outside the advice of medical professionals. In some circles Advil/Ibuprofen is called “Ranger Candy” because of the rate at which soldiers (specifically Rangers and Special Forces types) used to consume it when in the field. Others (like myself) take prescription level doses routinely when experiencing certain types of pain (I have many physical problems ranging from an extra vertebra in my lower back causing pain to various joint problems from a life well lived).

    3) Pharmaceutical companies are CONSTANTLY trying to solve various problems with NSAIDs. We’ve had Aspirin forever (as teas and extracts) and paracetamol/acetaminophen since the late 1800s. Ibuprofen came along in the 1960s, and Naproxen Sodium in the 80s or 90s (depending on where you live) as an OTC drug. Many other Rx only NSAIDs exist, and the pharmaceutical industry continues to try to find newer drugs that have less impact on our livers (acetaminophen) and GI stuff.

    4) In Texas, purportedly, “He needed killing” is still on the books as a justification for killing someone. You take away my NSAIDs and we’ll test that. No, seriously. I am (almost) out of Ibuprofen, and in a place where I have to get it by mail. I stopped taking my regular doses over the weekend so I would have enough to tamp the pain down at work until my shipment gets here. Today is NOT a good day.

    There is a reason that many people OD on NSAIDs, or otherwise wind up with adverse conditions because of them. This reason, often, is “pain”. Pain from work (a relative who was a plumber back when shovels were used as much as backhoes could barely move his arms and shoulders for years), pain from injuries from sports and police/military training. Rheumatoid Arthritis, etc. etc. life hurts and you either die, or suffer. Ibuprofen et. al. reduce that suffering. This comes with a tradeoff. Everything does.

  23. @ Wales, go back and look at the first comment in your SA blog link. It shows why the blog’s suggestion of an increase in medical errors appears inaccurate.

  24. As far as I’m concerned NSAIDS are like aging, may not be great, but consider the alternative.

  25. BenAlbert says:

    Just a quick note, I see someone else also mentioned him but your characterisation of Chiro left out Samuel Hommola whose message on this blogsite and in his book “Inside Chiropractic” was reasonable. He clearly does not recommend the sort of neck manipulation that may lead to vertebral artery dissection and does not believe in subluxation theory.

    -Dr Ben

  26. Joe says:

    MC, you are mistaken, chiros are worried about neck manipulation. It seems some are advertising that they do not apply a dying-strain to the neck, and that has the others worried that they are “eating their own” Yes, some chiros have the audacity to claim they offer safer treatments than others!

    BTW, the “Acupuncture-related adverse events” link is wrong.

  27. nwtk2007 says:

    Did I see a blurb in the news last week that Kaiser was covering CMT again?

  28. Arch01 says:

    Thank you for stating the importance of transparency in medicine.

  29. TruthStorm says:

    Why is there such a focus on chiropractic implied harm, when modern medicine is determined to be the third leading cause of death, originally published in the AMA Journal. I have been treated by chiropractic for years and never had any bad affect, nor have I met anyone who has. How about some focus on the benefits to the immune system of chiropractic? There is plenty of evidence for that, but only comes from their journal studies, and for some reason some people seem to find that unacceptable.

  30. Harriet Hall says:

    TruthStorm, there is not “a focus on chiropractic implied harm” but a focus on comparing the risk/benefit ratio of any treatment based on the scientific evidence. Modern medicine is not “determined” to cause death – that’s a ridiculous accusation! Modern medicine is determined to prevent death and improve life whenever possible. Effective treatments all have side effects, and modern medicine accepts a certain level of risk in order to attain proven benefits. I explained this in a previous post:

    The alleged benefits of chiropractic on the immune system boil down to a few studies showing that blood test results show some kind of change after spinal manipulation. There are no credible studies showing any clinical benefit to patients.

    You might want to review our topic-focused reference page at

    I have a copy of an “evidence-based” chiropractic textbook on somatovisceral effects of chiropractic. There is nothing in it that would constitute credible evidence by the standards of this blog.

  31. mortna says:

    I agree there is not to much to support the efficacy of chiropractic treatment and I used to think spinal manipulation to the neck involved substantial risks to patients with neck pain but was struck by this articles design – and conclusion

    The supposed significance of this article is debated by Dr Stephen Perle.

    I took the liberty of posting an excerpt from Dr Perle below as I would like to have his views scrutinized. I find it hard to dismiss the article by Cassidy et al. as it appear very well designed. I am aware of several case studies describing associations between neck manipulation and stroke but as they are only suggestive I have difficulties accepting them and the same time rejecting the article by Cassidy et al.

    Excerpt from Dr Perle (

    “There are only three studies that have evaluated the risk of stroke after manipulation. And all three agree there is an association. (9- 11) The first two found a risk (9, 10) and the third (11) finding the same association provided evidence that explains the first two. Cassidy et al (11) used the same data sources as Rothwell et al (9) but Cassidy et al study investigated one thing neither Smith (9) nor Rothwell (10) did and that is they determined the background rate of these strokes. The issue is if the rate of strokes after chiropractic care was greater than the background rate (those that were occurring spontaneously not caused by the manipulation) then we would know what the added risk was due to manipulation. The finding, the rate of strokes in patients under 45 seeking care from their primary care physician was identical to the rate for those who had seen a chiropractor. Thus seeking chiropractic care produced no extra risk for stroke over and above the background rate. It appears that patients about to have a stroke from a dissection of a vertebral artery (the kind blamed on chiropractic for 80 years) seem to go to a doctor (a medical doctor or a chiropractic doctor) and the only reason the association between chiropractic and stroke appeared to be strong and not for PCPs is that no one asks the question in the emergency room, “Did you see your MD within the past month?””


  32. Harriet Hall says:

    The Cassidy study does not show what you and Perle seem to think it shows. Please see Dr. Crislip’s commentary at:

  33. Costner says:

    Truthstorm (aka: Lowell Hubbs): “Why is there such a focus on chiropractic implied harm, when modern medicine is determined to be the third leading cause of death”

    This silly notion that “modern medicine” (a rather vauge choice of words) is the third leading cause of death has been proven to be factually incorrect time and time again.

    I am sorry Mr. Hubbs, but if you are going to continue to repeat the same dishonesty, people will continue to call you out on it. I showed evidence to dispel your myth in the past but you conveniently ignored it. Ignoring facts doesn’t change them Mr. Hubbs… it just proves to those around you that you are closed minded and more than willing to repeat statements even after they have been proven to be inaccurate.

  34. mortna says:

    Harriet many thanks for the link. Dr Crislips’s commentary was wonderful. Yet, I failed to see any further comments on the point made by qetzal:

    “Yes, the association increases in the young, but it increases equally for both chiro and PCP visits. As far as I can tell, the authors are completely correct to say their study “found no evidence of excess risk of VBA stroke associated chiropractic care compared to primary care””.

    I am now aware several of the methodological flaws pointed out by Dr Crislip but I fail to see the significance of the increased (12) risk of vertebrobasilar dissection in the young group seeking chiropractic treatment, if a similar increase (11.2) is seen in young people after PCP visits.

    Please correct me if the numbers quoted above are wrong and/or if I otherwise have missed the plot.

  35. Harriet Hall says:


    Please read Dr. Crislip’s article again. He explains that the Cassidy study actually confirmed a strong association of stroke with chiropractor visits in the under 45 age group. The odds ratio in the first 24 hrs was 12. Table 3 provides the smoking gun.

  36. mortna says:

    Thank you for your swift response Harriet.

    Ok, I have had a second look at the table so let me rephrase my question somewhat: If an odds ratio of 12 for the first 24 hrs after “any visit” to a chiropractor provides the smoking gun, what does an odds ratio of 11.21 for the first 24 hrs after “any visit” to a PCP imply?

    I agree pasients seeking their PCP for “any visit” are potentially more likely to have a more serios hidden condition (i.e. stroke) than “patients” seeing their chiropractor for their regular check-up when potentially asymptomatic.

    Please elaborate on this point if I’m still in the dark.

  37. Harriet Hall says:


    The Cassidy study confirmed previous findings of an association between vertebrobasilar artery stroke and chiropractic visits in those under 45 years of age.

    The odds ratio for PCPs is a separate issue and we don’t know what it means. The assumption that patients sought care for pre-existing symptoms of stroke was not justified by the data. The data collection method did not permit any conclusions about that or even about neck manipulation.

    So far no study has directly assessed the relationship between presenting symptoms, neck manipulation vs. other interventions, and stroke. That is the kind of study we need. Chiropractors themselves have been concerned about the stroke/neck manipulation connection, but they haven’t yet studied it in any meaningful way.

    In the recent hearings in Connecticut, a chiropractor testified that he had once thought he was responsible for a stroke that his patient suffered after neck manipulation, but he changed his mind after the Cassidy study. I don’t think he was justified in changing his mind based on those inadequate data.

  38. mortna says:

    Thank you again Harriet.

    I see your point. However in this study didn´t the PCP group serve as another control group for the DC group? If so, the odds ratio for the PCP group could not reasonably be regarded a separate issue. Reading the whole paper it seems the authors thought a group seeking care is best compared to anther group seeking care based on the principle of matching.

    Further, in reading dr Crislips response over again I´m puzzled by his comment that neck pain is a not common symptom for vertebral artery dissection as several scientific studies suggest that it is.

    1. Harriet Hall says:


      What we really want to know is whether neck manipulation is a risk factor for stroke. The data from several studies, the many “smoking gun” case histories, and the presence of a credible mechanism suggest that it is. If previous visits with PCPs are associated with stroke, that is an entirely separate question. If pre-existing neck pain predicts these strokes and prompts visits to any provider, that would be useful to know, but this study doesn’t illuminate us. The study didn’t even address neck manipulation, only visits to chiropractors – which might have involved activator or other treatments without manipulation. And for all we know, a few of the visits to PCPs could have involved neck manipulation, particularly if the PCP was a DO. The study may serve a psychological function for chiropractors by reinforcing their beliefs but it is really useless as far as helping us understand what is going on. It certainly does not show that neck manipulation can’t cause strokes. I think most chiropractors would hesitate to manipulate the neck of someone who was having a stroke in progress; and if there is no reliable way to differentiate those patients from patients with musculoskeletal neck pain, doesn’t that mean that chiropractors ought to be reluctant to manipulate any patient with neck pain?

  39. nobs says:


    This Dr. Cassidy’s testimony from the Connecticut hearings. He discusses the study and addresses in detail the above questions. Enjoy

    BTW- You note:

    “Further, in reading dr Crislips response over again I´m puzzled by his comment that neck pain is a not common symptom for vertebral artery dissection as several scientific studies suggest that it is.”

    IMO- That must be a typo. Neck pain and headache is indeed common, and is indeed, THE most common symptom(s) of VAD…… and …….is what prompts a patient to seek care.

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