MD, PhD, FMedSci, FSB, FRCP, FRCPEd

In 2010, I have reviewed the deaths which have been reported after chiropractic treatments. My article suggested that 26 fatalities had been published in the medical literature and many more might have remained unpublished.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. Whenever I write about the risks of spinal manipulation, chiropractors say that I am irresponsible and alarmist. Yet I believe I am merely doing my duty in alerting health care professionals and the public to the possibility that this intervention is associated with harm and that caution is therefore recommended.

Fortunately, I am not alone, as a new report from China shows.This review summarised published cases of injuries associated with cervical manipulation in China, and to describe the risks and benefits of the therapy.

A total of 156 cases met the inclusion criteria. They included the following problems: syncope = 45 cases , mild spinal cord injury or compression = 34 cases, nerve root injury = 24 cases, ineffective treatment or symptom increased = 11 cases ; cervical spine fracture = 11 cases, dislocation or semiluxation = 6 cases, soft tissue injury = 3 cases, serious accident = 22 cases including paralysis, death and cerebrovascular accident. Manipulation including rotation was involved in 42.00%, 63 cases). 5 patients died.

The authors conclude that “it is imperative for practitioners to complete the patients’ management and assessment before manipulation. That the practitioners conduct a detailed physical examination and make a correct diagnosis would be a pivot method of avoiding accidents. Excluding contraindications and potential risks, standardizing evaluation criteria and practitioners’ qualification, increasing safety awareness and risk assessment and strengthening the monitoring of the accidents could decrease the incidence of accidents” (I do apologize for the authors’ poor English).

It is probable that someone will now calculate that the risk of harm is minute. Chinese traditional healers seem to use spinal manipulation fairly regularly, so the incidence of complications would be one in several millions.

Such calculations are frequently made by chiropractors in an attempt to define the incidence rates of risks associated with chiropractic in the West. They look convincing but, in fact, they are complete nonsense.

The reason is that under-reporting can be huge. Clinical trials of chiropractic often omit any mention of adverse effects (thus violating publication ethics) and, in our case-series, under-reporting was precisely 100% (none of the cases we discovered had been recorded anywhere). This means that these estimates are entirely worthless.

I sincerely hope that the risk turns out to be extremely low – but without a functioning reporting system for such events, we might as well read tea-leaves.

172 Responses to Spinal manipulation: a treatment to die for?

  • “I sincerely hope that the risk turns out to be extremely low – but without a functioning reporting system for such events, we might as well read tea-leaves.”

    Due to a lack of reliable methods to screen for patients who might be predisposed to suffering a vertebral (or carotid) artery dissection, it’s surprising that manipulation of the cervical spine hasn’t been banned:
    http://www.bmj.com/content/344/bmj.e3679/rr/591678

    With regard to the absence of a functioning reporting system, that may take a while to rectify in the US where chiropractors enjoy a loophole exempting them from reporting adverse events:
    http://www.ebm-first.com/chiropractic/risks/1842-letter-from-britt-harwe-president-chiropractic-stroke-awareness-group-csag.html

    In the UK things aren’t much better with chiropractors claiming “fear of retribution, being too busy, and insufficient clarity on what to report” as reasons why the Chiropractic Patient Incident Report and Learning System (CPIRLS) is hugely under-utilised:
    http://www.ebm-first.com/chiropractic/uk-chiropractic-issues/1888-british-chiropractic-association-members-attitudes-towards-the-chiropractic-reporting-and-learning-system-a-qualitative-study.html

    Bearing in mind that 90% of neck manipulations are unnecessary, and that informed consent procedures are often ignored, my money’s on “fear of retribution” (loss of income) as being the main reason why chiropractors aren’t interested in determining the true incidence of complications arising from neck manipulation.

    It’s a scandalous state of affairs for a regulated health profession.

    • I am a chiropractor. Each and every patient who comes to see me gets an examination done and risk assessment is an integral part of it. As far as I understand it majority of Chiropractors do this. We get taught diagnostic techniques and orthopedic tests as part of our studies.

      More and more research is being published about Chiropractic and I believe we are more evidence based than medicine is. We have more research on spinal adjustments, effects of adjustments etc. than majority of the currently used drugs.

      Our risk is lower than over the counter NSAIDS.

      Yes there are risks which have been blown out of perportion. If every case of adverse drug reaction were to be published and scrutinised we would never hear the end of it.

      Personally I have been practicing for over 10 years and have not heard of a single case of stroke from anyone in my profession I am in contact with. Honestly I think some of these strokes were in evolution even before they saw the Chiropractor. Meaning they would have happened anyway.

      As for the studies mentioned in the article, sorry but they are just stupid references unrelating to chiropractic and risk.

    • As a fellow Primary Care Physician, I must first state that as an M.D. you’re not doing your job. And I must also state that what you are doing is nothing more than merely poorly done biased research. If we are to advance health care, which it is not at the current moment, it is sick care and disease management (if we can even call it that). You need to educate yourself and read Hippocrates Shadow.

      You all seem to love to play in the unrealistic, evidence-based “unscientific” realm. You love to play in the land of theories and hopes, insufficient, unreliable and the ill-conceived. If perhaps you played around in the real world, and got your heads out of pieces of paper and electronic forms of written “research” and “articles” and instead did the work yourself you would find Chiropractic as a highly credulous profession. You love to dabble in the world of tunnel vision. Every second people die from overdoses of drugs. Every few minutes people die from the PROPERLY prescribed drugs as well. History has show billions upon billions are spent in lawsuits on drugs that didn’t just cause a person some paint and discomfort (the only real “risk” in Chiropractic), the drug lawsuits are about drugs which killed and destroyed families.

      And in addition if you went and read these articles yourself and educated yourself instead of listening to the cry of helplessness given by your fellow incredulous peers, who are very realistically biased, you would see that there very little research on deaths and problems and those that do exist, are so poorly constructed, INCOMPLETE!!!, and pathetic asinine excuses for “research”. I will gladly scientifically and realistically break down these research articles you claim of, as I have already done so in an unbiased manner. Because its quite beautiful you see, when you perform research as it is supposed to be done, and you don’t conclude erroneous and false claims and put horribly incredulous spins on already poor research, the beauty is that you see the truth.

      You should get off your chairs, get out from behind an electronic keyboard and screen, and never again talk about that which you have no knowledge. He who “knows” and does not do, does not know.
      You will see in the real world, people are not only saved by Chiropractic, they’re cured and healed because the body heals itself, not drugs.
      So stop being scared and afraid that you’re wrong, because you are. You need to go out in the real world, and follow around several chiropractors for a few weeks each. Maybe then you’ll realize that you were brainwashed and misled by the same industry that is openly brutalizing and killing people (drugs, chemotherapy). It’s quite sad.

      • apart from personal attacks and insults, do you have some real arguments?

        • At this point in the discussion, I think readers should be reminded that ad hominem attacks are signs of victories of reason over unreason
          http://edzardernst.com/2012/12/ad-hominem-attacks-are-signs-of-victories-of-reason-over-unreason/

          • @ John Deer

            As I said to Kelly Reed above (on 18th February), are you saying that the incidence of life-threatening injuries and fatalities caused by chiropractic spinal manipulation should be determined and corrected only after conventional medicine has put its house in order?

            John Deer wrote: “…paint [sic] and discomfort (the only real “risk” in Chiropractic)”

            That is not true. See http://www.ebm-first.com/chiropractic/risks.html

            John Deer wrote: “You will see in the real world, people are not only saved by Chiropractic, they’re cured and healed because the body heals itself, not drugs.”

            Chiropractic doesn’t cure anybody. At best, spinal manipulation (offered by chiropractors, but not true ‘chiropractic’) offers a small amount of short-lived pain relief for people suffering from low back pain, and even then it isn’t superior to standard conventional treatments which are cheaper, more convenient, and safer.

            I would venture that it would be time well spent if your were to take a slow read through an essay written by the late professor of psychology, Barry Beyerstein, entitled Social and judgmental biases that make inert treatments (including real chiropractic) seem to work. In it, he addresses many of the reasons for alternative medicine’s popularity. Some of the areas he looks at, and which seem relevant to this discussion, are: the will to believe, logical errors, judgmental shortcomings, the low level of scientific literacy among the public at large, psychological distortion of reality, self-serving biases and demand characteristics, diseases that may have run their natural courses, diseases that are cyclical, spontaneous remission, the placebo effect, allegedly cured symptoms that were probably psychosomatic to begin with, symptomatic relief versus cure, consumers hedging their bets, derivative benefits, and misdiagnosis (either by self or by a physician). Full article here http://web.archive.org/web/20110723060336/http://www.crhp.net/article1.html

  • @ Blue Wode

    “Bearing in mind that 90% of neck manipulations are unnecessary”

    So, by that statement 10% of neck manipulations are necessary. Can you define what are the conditions when neck manipulation is necessary?

    • I was part of those 11.1% many years ago (dislocated neck vertebra), so there are conditions where treatment in that area is appropriate and even neccessary. As opposed to the unspecific, unfounded, and vague claims of Chiros, I might add.

      Originally I am German, just like someone else here (Hello, Edzard!), and live somewhere else now since 2 years or so.
      And yes, I know this is only anecdotal, but serves to show how high standards can be when you do things right:

      In the physiotherapy practice in Germany where I was in treatment, only two (yes, TWO!) folks were allowed to relocate neck vertebrae and similar things; out of over 20 highly skilled and experienced physiotherapists there. Edzard, you might even know the guy – Dr.Klaus Eder. At least back then, I never noticed any quackery in his practice, only trained “physiotherapists, masseurs, and balneotherapists” (that was the official title of their education) .
      Even with a condition that clearly mandated this intervention, they were reluctant to do it, and took the time to explain exactly why they were so, and to inform me about possible risks and dangers.

      Note how this was one specific condition that very clearly called for one specific intervention, how I was informed about the risks involved, and how doing the actual treatment was limited to a few individuals.

      Now, when I compare this to what I read here, both from Edzard and the Chiroquacktors commenting, I simply do not see any similar standards in Chiropractic; not to mention any basis in reality :)

  • Isn’t it up to chiropractors to tell us that?

  • @ A N Other
    Actually, the real figure is 11.1%, and even then it is being generous (although not towards chiropractors):

    Quote
    “When the RAND (Research and Development) organization published its review of the literature on cervical spine manipulation and mobilization in 1996, it concluded that only about 11.1% of reported indications for cervical spine manipulation were appropriate…Since about 90% of manipulation in the United States is done by chiropractors (1) who use spinal manipulation as a primary treatment for a variety of health problems, neck manipulation is more problematic among chiropractors than among physical therapists and other practitioners who use manipulation only occasionally in the treatment of selected musculoskeletal problems…Manipulation of the upper cervical spine should be reserved for carefully selected musculoskeletal problems that do not respond to such simple measures as time, massage, exercise, mobilization, longitudinal traction, or over-the-counter medication…There is evidence to indicate that cervical spine manipulation and/or mobilization may provide short-term pain relief and range of motion enhancement for persons with subacute or chronic neck pain.(1) There is no credible evidence, however, to indicate that neck manipulation is any more effective for relieving mechanical neck disorders than a number of other physical treatment modalities,(9) and it is clear that adverse reactions are more likely to occur following manipulation than mobilization.(10)…All things considered, manual rotation of the cervical spine beyond its normal range of movement is rarely justified. The neck should *never* be manipulated to correct an asymptomatic “chiropractic subluxation” or an undetectable “vertebral subluxation complex” for the alleged purpose of restoring or maintaining health or to relieve symptoms not located or originating in the neck. There is no evidence that such subluxations exist. When a painful, actual subluxation (partial dislocation) occurs, manipulation might occasionally be helpful but is most often contraindicated.(13) …A physical therapist trained in the use of both manipulation and mobilization for musculoskeletal problems would be less likely to use manipulation inappropriately than a chiropractor who routinely manipulates the spine for “the preservation and restoration of health.”(15)…According to the Association of Chiropractic Colleges (ACC), “Chiropractic is concerned with the preservation and restoration of health, and focuses particular attention on the subluxation. A subluxation is a complex of functional and/or structural and/or pathological articular changes that compromise neural integrity and may influence organ system function and general health.”15 Chiropractors who are guided by this vague paradigm (more of a belief than a theory) often manipulate the full spine of every patient for “subluxation correction”. Few chiropractors specialize in the care of back pain and other musculoskeletal problems, and only a few have renounced the chiropractic vertebral subluxation theory…Whatever the incidence of stroke per number of neck manipulations might be, this risk is greater *per patient* among chiropractic patients who may be manipulated many times for “health reasons” and who may be manipulated regularly for “maintenance care.” Chiropractors who renounce vertebral subluxation dogma and specialize in the care of back pain will use manipulation more appropriately. Unfortunately, there is no official or legal definition limiting chiropractors to treatment of musculoskeletal problems, making it difficult to find a properly limited chiropractor.(17)
    Ref: http://www.sciencebasedmedicine.org/?p=1037

    @ A N Other

    With regard to that last sentence in bold, would you please answer the following question:

    Q. How would someone looking for a local chiropractor via the list of registered chiropractors on a regulator’s website be able to determine which registered chiropractors were reputable (properly limited) and which were disreputable (subluxation-based)?

    • @ Blue Wode

      Isn’t that a question the GCC should answer?

    • @BlueWode
      You forgot to add the bit that the RAND corp concludes ….. “The frequency with which indications occur in a population is unknown and therefore the rate of inappropriate manipulation/mobilization being rendered to patients cannot be determined at this time.’

      By continuing to promote the RAND study to support your assertion of inappropriate cervical manipulation/mobilisation is misleading and not supported by the authors conclusions.

      • @ anon

        In the knowledge that (1) many chiropractors manipulate their patients’ necks for unethical reasons (the correction of mythical chiropractic subluxations); (2) home exercise advice is as good as, but cheaper and more convenient than SMT for neck pain; and (3) no established and reliable chiropractic adverse event reporting systems exist, would you agree that all chiropractors should be applying the precautionary principle in the interests of patient safety?

        IOW, there is very little justification for manipulation of the cervical spine under any circumstance.

        • Blue Wode,

          Are you certain that home exercise alone is as effective? There is some pretty good evidence to suggest that the best results are with a combination of exercise and manual therapy. And are you certain that exercise for neck pain is more cost-effective? THis recent systematic review says the we dont really know http://link.springer.com/article/10.1007%2Fs00586-012-2272-5?LI=true

          We can’t even be certain that exercises create any less risk for patients than manual therapy. Attached is a link to a recent paper examining negligence claims against physical therapist in NZ. Exercises where a greater source of adverse events than manual therapy. http://www.ncbi.nlm.nih.gov/pubmed/22711215.

          I think chiropractors who conduct a thorough history, physical examination, orthopaedic and neurological assessment and spinal assessment, rule out potential red flags etc, form a working diagnosis and then determine that spinal manipulation is an option for treatment (and the patient is willing), can feel confident that spinal manipulation is a safe (and safer than some common alternatives) and equally effective treatment for people with neck pain.

          • your first link is not about effectiveness but about cost-effectiveness!!!
            your 2nd link shows that Adverse effects associated with physios are mostly related to exercise BECAUSE THAT’S WHAT PHYSIOS PREDOMINANTLY DO! considering that they do relatively little manipulation, the fact that complaints to manipulation rank a very close second, speaks volumes. i think you have just provided evidence against yourself.
            you write that “chiropractors who … determine that spinal manipulation is an option for treatment (and the patient is willing), can feel confident that spinal manipulation is a safe (and safer than some common alternatives) and equally effective treatment for people with neck pain.”
            WOULD IT NOT BE NICE, IF CRITICAL ANALYSTS OF THIS AREA COULD ALSO FEEL “CONFIDENT”?

          • anon wrote: “There is some pretty good evidence to suggest that the best results are with a combination of exercise and manual therapy.”

            Let’s say that future robust research confirms the above to be the case. In the chiropractic scenario, how would someone looking for a manual therapist who was a chiropractor *know* to choose one who was reputable (properly limited)? And if they were aware of the enormous number of disreputable (subluxation-based) registered chiropractors who are in practice, where on a regulator’s website could they find a registered reputable chiropractor?

            Anon wrote: “We can’t even be certain that exercises create any less risk for patients than manual therapy. Attached is a link to a recent paper examining negligence claims against physical therapist in NZ. Exercises where a greater source of adverse events than manual therapy. http://www.ncbi.nlm.nih.gov/pubmed/22711215

            Don’t chiropractors prescribe exercises? Don’t they have data on injuries attributed to the exercises they prescribe? I’d be interested to see it.

            Anon wrote: “I think chiropractors who conduct a thorough history, physical examination, orthopaedic and neurological assessment and spinal assessment, rule out potential red flags…can feel confident that spinal manipulation is a safe”

            How can they rule out potential red flags when there are no reliable screening methods for patients who are at risk of VAD or CAD?

            BTW, are philosophy/subluxation based chiropractors not red flags in themselves? If not, why not?

          • Edzard,
            You’ve misunderstood. Perhaps I didn’t make my point very clear. The first link WAS meant to be about cost-effectiveness. It was in response to BlueWode’s assertion that exercise therapy is cheaper. It wasn’t meant to support effectiveness.
            However, here is a recent RCT comparing the various modalities with exercise at home. http://journals.lww.com/spinejournal/Abstract/2012/05150/Supervised_Exercise_With_and_Without_Spinal.2.aspx In this RCT home exercise alone didn’t perform as well. And another http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3373326/ This bring into question BlueWodes assertion that it is as effective. The cost effectiveness is a null issue if home exercise is not very effective.

            My second link was in response to BlueWodes comments about adverse events reporting. My point was that adverse events under-reporting is not unique to the chiropractic field nor to just the manual therapies.

        • Technically adverse event reporting does exist its called Malpractice, and DC’s have the lowest rates of malpractice of major healthcare providers. The majority of their malpractice claims come from “sexual misconduct” largely due to the fact that it is a profession where the doctor uses his hands on the patient.

          • MedDC said:

            Technically adverse event reporting does exist its called Malpractice, and DC’s have the lowest rates of malpractice of major healthcare providers. The majority of their malpractice claims come from “sexual misconduct” largely due to the fact that it is a profession where the doctor uses his hands on the patient.

            Wait. You want us to rely on who gets sued and how often as a good indication of the occurrence and severity of AEs?

          • if this is what you think, you have a lot to learn

          • To edzard and Henness: Rely on? no there must and should be a better method. However, the fact remains that the industries who provide the insurance to chiropractors would be the most interested and aware of the adverse events as it affects their bottom line. If there are more adverse events, the insurance premiums rise, profits increase. So as a barometer of safety, malpractice claims certainly fit. Yet not accurate.

            Please, is it more risky to undergo general surgery? (average malpractice insurance annual cost of $28,000-$50,000), General practitioners ($6,000-11,000) Or chiorpractic ($1,500-$3,000)
            Let the learning begin.

          • MedDC said:

            Rely on? no there must and should be a better method.

            Indeed. But what are you and/or other chiros doing about it? If you are at all concerned about the well-being of your customers what are you doing to establish a comprehensive AE monitoring system? Why is there not one in place already?

            However, the fact remains that the industries who provide the insurance to chiropractors would be the most interested and aware of the adverse events as it affects their bottom line.

            I really wouldn’t know how the insurance industry might work, how they look at risk and decide premiums and I’m not sure what different knowledge you have about them to come to any conclusion about any of this either. However, do you not agree that relying on how the insurance industry works is a pretty poor way of determining what is and isn’t safe in chiropractic?

            If there are more adverse events, the insurance premiums rise, profits increase. So as a barometer of safety, malpractice claims certainly fit. Yet not accurate.

            The leap of ‘logic’ in your first sentence is astounding. All you might be able to say is: “If there are more claims made against chiropractors, insurance premiums rise”, but can you see and understand why that is utterly different to what you said? And why would profits increase?

            Please, is it more risky to undergo general surgery? (average malpractice insurance annual cost of $28,000-$50,000), General practitioners ($6,000-11,000) Or chiorpractic ($1,500-$3,000)

            Yes it is. That doesn’t mean that chiropractic is safe, nor that insurance premiums are a suitable proxy for safety.

            Let the learning begin.

            Indeed.

      • Would you be comfortable with a pharmaceutical company asserting that a drug can be marketed as safe until skeptics can prove that it is dangerous? I wouldn’t. I think it’s up to chiropractors to provide evidence that cervical manipulation is (a) necessary in the number of cases where they apply it and (b) generally safe. It does not look to me as if they have done either. In act, the chiropractic industries comes across as being in denial about this.

        • That happens already, all the time. does Vioxx ring any bells? 60,000 deaths before it was pulled in 2004. Pharmacuticals are in it for money not to get people healthier. Their focus is on sickness care. If a drug isnt working or is dangerous they ask the pharmacists to create a derivative of the previous drug in an attempt to alter the interactions instead of pulling it because they already paid for the advertising. Vioxx was a pain killer recognized by the FDA to cause cardiovascular disease, stokes and heart attacks. And all of this page is clamoring over 26 potential deaths from a service that seeks to replace pain killers for musculoskeletal conditions. Seriously from the perspective of patient health and safety as well as Public Health, the use of chiropractic spinal manipulation for musculoskeletal conditions is clearly the safer alternative therapy! All major credible Medical institutions acknowledge this FACT. professional skeptics are the main hold outs.
          “Risks
          By Mayo Clinic staff
          Chiropractic adjustment is safe when it’s performed by someone trained and licensed to deliver chiropractic care. Serious complications associated with chiropractic adjustment are overall rare, but may include:

          A herniated disk
          Compression of nerves in the lower spinal column (cauda equina syndrome), which can cause pain, weakness, loss of feeling in your legs, and loss of bowel or bladder control
          A certain type of stroke (vertebral artery dissection) after neck manipulation
          Don’t seek chiropractic adjustment if you have:

          Severe osteoporosis
          Numbness, tingling or loss of strength in an arm or leg
          Cancer in your spine
          An increased risk of stroke
          An unstable spine.”
          They forgot to add AAA abdominal aortic aneurysm as a contraindication.

          • stop foaming from the mouth and get rational

          • In response to :
            Edzard says:
            “stop foaming from the mouth and get rational”
            That is the extent of your reply then? Im sorry but I am seeing how Chiropractic is addressing some of the concerns you raise first hand. The reduction of the use of unscientific theories and techniques Applied Kinesiology for example is being phased out. It used to be a 5 credit hr class, now its only 2. Subluxation is not what is diagnosed, its facet syndrome, myalgia’s, and other pain causing muskuloskeletal conditions. Are there still chiros holding on to subluxation and other ‘pseudo-scientific’ ideologies sure. But its changing that is for sure.

            What I stated was not only rational but factual. Im sorry you don’t like it.

    • I just laugh at point 10… a normal adjustment is less than 45deg in majority of the techniques, well within the limit of normal rotation.

      Testing range of motion in the neck causes more strain on the spine than most chiropractic adjustments.

      Obviously the person who wrote this does has never been to a chiropractor.

      • why do yoy think that only chiros can identify risk?
        “normal adjustment”??? what is that? how was this measured? has it any relevance to the clinical situation?

  • @ A N Other

    The GCC evades answering it by referring to its Standard of Profiency and Code of Practice and saying that all UK chiropractors must abide by it. One would think that chiropractors, when they originally sought regulation by statute in the UK, would have ensured that their field of practice was defined and limited in the interests of patient protection. But perhaps not surprisingy, instead of that becoming binding in law, they managed to secure “promoting the profession” as one of the main parts of the GCC’s remit (thankfully it’s now been removed). Anyway, the situation remains that very few patients realise that when they enter a chiropractic clinic they are in great danger of being ensnared by quackery, being financially exploited, and put at risk of experiencing life-threatening complications.

    I think we know why chiropractors aren’t shouting from the rooftops in an attempt to get their regulator do something about it.

  • Ok Prof Ernst please provide evidence that anybody involved in that study was a chiropractor. If you can’t then your argument is a strawman. Nothing more.

    • you do not seem to know what a strawman is.
      moreover this post is about spinal manipulation, not chiro. should you do something about your paranoia?

      • Technically “fedup” is correct in regards to what a straw man is and its relation to the article, however in a back door way. Evidence should be produced. While the Edzard seems to not be targeting Chiro’s, he still is through the examination of spinal manipulation by providing multiple comments to link spinal manipulation (“the mainstay treatment of chiropractors”) to chiropractors more than any other doctors (which is true). And by using the negative results of spinal manipulation preformed by practitioners other than chiropractors to provided evidence against the safety of chiropractic manipulative therapy. Straw man.
        The conclusion of Ernst’s systematic review should have been. In short to properly evaluate the saftey and efficacy of spinal manipulation a long term study using trained Chiropractors (no others) in a hospital setting would be ideal to provide adequate, unbiased, reporting of adverse effects.

        • You are arguing in circles and in serious danger of a case of self-induced cranioproctosis.

          Spinal manipulation is the mainstay treatment of chiropractors. Linked to this there are several known serious problems including:
          1. Use of spinal manipulation to “treat” disease that has no plausible connection with the spine
          2. Use of empirically unverifiable “spinal subluxation” as a diagnosis, when it seems that no two chiropractors will diagnose the same “subluxation”
          3. Promotion of anti-vaccination and other anti-science conspiracies
          4. Promotion of endless courses of treatment for individuals showing no present symptoms (so-called “maintenance”)
          5. Use of full-spine X-rays for no evidentially supportable reason
          6. Sequelae of manipulations of questionable necessity, including vertebral artery dissection

          Worryingly, the chiropractic industry does not seem to accept that most of these are issues at all, and some parts of it vigorously defend the vitalist and discredited notion of innate.

          The chiropractic industry needs to put its house in order, expel the foolishness about “subluxations”, stop using X-rays to diagnose soft tissue injury, drop the antivax … but then of course they would become members of the evidence-based physiotherapy community. As long as they got the necessary additional training.

          • 1.Vaccinations have increased dramatically in the past 20 years. Inquiry should be made.
            2.Subluxation is taught but is not used as a diagnosis, with the exception of Medicare patients in the US. Medicare only pays chiropractors to treat subluxations. The new term which is physiologically correct is segmenatl dysfunction. Which results in the measurable loss of range of motion of that joint. Spinal manipulation restores range of motion.
            3. Treatment must maintain progress to receive reimbursement from Medicare. Maintenace therapy
            4. Full spine xrays on patients with no prior imaging are recommended to asses risk for Abdominal aortic aneurysm, scoliosis and other contraindications for treatment. (the use of full spine xrays for “spinal analysis” has no evidence for use)
            5. Agreed Spinal manipulation does not ”Treat” any disease.
            6. Sequelae? whatever i know what you meant. And while there is a lot of apparent confusion arround this topic. Cervical manipulation does raise a patients risk of stroke, especially when that patient has risk factors for strokes. And to be clear a Vertebral artery dissection is when one of the two arteries that wind through the back of the neck to the brain starts to tear. The lining of the artery bleeds and forms a blood clot. This clot can easily enter the brain and cause a fatal stroke. Cervical manipulation may release this blood clot and cause a stroke. As for incidence, its very low but never the less a possibility.

            This said, i can not attest to Chiropractic conducted outside of the USA.

            Oh lastly. necessary training? I hope that you realize that we study all information necessary to be qualified as Doctors and portal of entry physicians. The only lack in education i can see is in pharmacology/toxicology we only get a few hours of that. Other than that its Guyton & Hall Physiology books, Goldman Cecil Medicine, Robbins patholgy, all of our core clinical sciences are the same as MD’s with the exceptions of pharmacology and immunology. The rest includes biomechanics, diagnostic imaging (sooo much dx Img) probably our best subject) Labratory diagnosis, geriatrics etc.
            I know that it seems silly to explain all this but honestly I am very tired of people who don’t know what we study to become a Doctor of chiropractic. If anyone disagrees with the similarities in core medical course material please be detailed in your explanation of why Chiropractic medical knowledge is inferior.

        • MedDC says:

          While the Edzard seems to not be targeting Chiro’s, he still is through the examination of spinal manipulation by providing multiple comments to link spinal manipulation (“the mainstay treatment of chiropractors”) to chiropractors more than any other doctors (which is true). And by using the negative results of spinal manipulation preformed by practitioners other than chiropractors to provided evidence against the safety of chiropractic manipulative therapy. Straw man.

          No. A straw man happens when someone misrepresents an opponent’s position by arguing against a proposition their opponent has not put forward, implicitly attributing to their opponent a view they do not hold. The position that Edzard is arguing against here is stated quite clearly:

          Whenever I write about the risks of spinal manipulation, chiropractors say that I am irresponsible and alarmist.

          He then goes on to provide evidence that spinal manipulation can dangerous, thereby proving that he is not irresponsible and alarmist.

          However, I agree there is an implicit argument that goes like this:

          P1. Chiropractic involves manipulation of the spine
          P2. Spinal manipulation can be dangerous
          C: Therefore chiropractic can be dangerous

          It’s a valid proposition but if the evidence for P2 was produced by non-chiros, then chiros may reasonably contend that it is deceptive because the chiro approach to spinal manipulation is different to that of non-chiros. This could be fedup’s position but he doesn’t make that argument (if he did, of course, he would find himself in Jesgol’s position of being required to explain the difference). Instead he says,

          please provide evidence that anybody involved in that study was a chiropractor

          I’m sure fedup knows that chiropractic is a barely recognised therapy in China. There are very few chiropractors and it seems likely that most if not all of the injuries were caused by non-chiros. Edzard mentions Chinese traditional healers with reference to the study, but no chiros. So far, so good for the contention that chiros do it differently, even if they can’t explain exactly how.

          But, unfortunately for the chiros, Edzard does not rely on the one Chinese study to support his premise that SM can be dangerous. His very first link was to a review of deaths after specifically chiropractic spinal manipulation. Therefore the conclusion that chiropractic can be dangerous is a reasonable one.

          What the further evidence – ie both the 2002 paper and the Chinese one – supports is the proposition that spinal manipulation carries risks whoever carries it out.

          It’s a no-win situation for all breeds of Spine Wizard.

      • LOL paranoia? I think if you check your post you associated this study to chiropractic not me.

  • It seems to me that this is a issue of perspective. The CDC reports, in the US alone, 800,000 stroke and Heart disease deaths annually. This report alleges 26 fatalities, that is .003%. While any unnecessary death is too many, should we not focus on preventing a substantial segment of unnecessary deaths. This year 15, in Michigan alone, have died from bad steroids. Could we focus on those from improperly used OTC medication, 10,000 annually, or prescription medical interactions, 30,000 each year.

    As with other studies on the subject many of these deaths have been as a result of untrained or under-trained personnel. A properly administered Chiropractic adjustment to decrease interference in the function of the central nervous system will improve function.

    • Kelly Reed said:

      As with other studies on the subject many of these deaths have been as a result of untrained or under-trained personnel. A properly administered Chiropractic adjustment to decrease interference in the function of the central nervous system will improve function.

      How do I find a properly trained chiro?

    • i think you ignore my argument of under-reporting. we assume and hope that these cases are very rare – but how can we possibly know, if there is no functioning system of adverse-effect reporting as for medications and other medical treatments.
      my main message is not that there have been xy cases, my main messase is that there might be an association, chiros know about it but do far too little to generate more reliable data. this is not responsible, in my view.

    • Kelly Reed wrote: “While any unnecessary death is too many, should we not focus on preventing a substantial segment of unnecessary deaths?”

      Kelly, are you saying that the incidence of life-threatening injuries and fatalities caused by spinal manipulation should be determined and corrected only after conventional medicine has put its house in order?

    • My background isn’t in medicine, it is in aerospace development, and Kelly Reed’s suggestion that a 0.003% fatality rate should be ignored because other unrelated risks are higher had my eyebrows climbing for the skies. I don’t know what the normal accepted fatality rates are in medicine, or perhaps I should more properly say in chiropractic, but in aviation (and in other safety critical areas of engineering) we are mandated by international standard to consider _all_ risks in a system, in combination rather than individually, and to demonstrate life-critical risks do not exceed Safety Integrity Level 4, i.e. have a combined risk level of no greater than 1 in 10 to the power 9/hour – in other words a risk factor of quite literally 1 in a billion. I’ve personally spent time investigating a individual risk at roughly that order of magnitude in order to determine whether additional risk mitigation measures were needed, and I’d rather hope any medical technique being applied to my less-than-stable spine had been developed to similarly rigorous professional standards!

  • Funny, because 193 of the 441 words in your article refer to a case of xy studies. Details of which are omitted, and it’s not certain whether you have taken the information from the full article or the abstract. Is your blog based on the abstract of the article in question?

  • I read the article on dangerous neck manipulations with interest — both as a GP, and as a doctor.

    I have visited a chiropractor, on and off, for about 4 years to help with my back. The manipulations — which actually feel quite gentle to me — seem to help reduce stiffness (just about always) and pain (more than half the time). We have come to an agreement that I do not wish to hear the “explanations” for what is being done, as they are based on an irrational language that cannot be understood. Overall, I rate the treatment quite highly as a way to unstiffen a painful back prior to, and alongside, an exercise program.

    BUT. I have two concerns. The first is that necks are much more delicate than lumbar spines. Although some form of manipulation of the neck may, on occasion, be really helpful, it is not clear what criteria would need to be satisfied to ensure that it was safe. I x-ray all necks before sending to physiotherapy; I simply don’t know if this would be enough prior to chiropractic, or even if a normal MRI scan would ensure minimal risk.

    The second concern is the sloppy language itself. Manipulation of the musculoskeletal system for musculoskeletal conditions is at least not illogical, but what about manipulation for other conditions? A feeling of physical wellbeing does help emotional conditions, but the benefits are likely to be short-lived — something which might concern a self-funding patient. Manipulation for asthma, colitis etc might help a bit, but could be very dangerous if it were used instead of treatment. In these cases, it is not an alternative treatment, or even a complementary treatment, it is just something pleasant to have done, in much the same way as drinking a cup of tea is comforting.

    I have to say that I find the concept of a General Chiropractic Council (analogous to the GMC) rather strange. I cannot really understand why chiropractic, osteopathy and physiotherapy cannot be regulated together. For sure, they use different intellectual models, but I am not sure that my vertebrae appreciate these nuances.

    • If i may offer an explanation of why chiropractic manipulation works to reduce pain? simply put a (call it what you will, cry babies) immobile/fixated/subluxated joint is generally a painful one. By unlocking the fixation and freeing the range of motion of that joint produces mechanorecption(neural recognition of motion) by the nervous system which is inhibitory to nociception (pain). done.
      PS subluxations do not cause disease, they cause dis-ease, every chiropractor knows that. or they should.

      • Also to have chiropractic, osteopathy and physiotherapy regulated together would be fantastic.

      • can you demonstrate to critical thinkers that this is more than chiro BS?

        • Inhibition of nociceptive evoked activity in spinal neurons through a dorsal column-brainstem-spinal loop
          Nayef E. Saadé, 1, Munther S. Tabet2, Nabil R. Banna1, Samir F. Atweh2, Suhayl J. Jabbur2
          a Faculty of Sciences, Lebanese University, Hadath-Beirut, Beirut Lebanon
          b Faculty of Medicine, American University of Beirut, Beirut Lebanon

          • and what does this have to do with the DISEASE/ DIS-EASE notion?

          • In reference to the reply below. “and what does this have to do with the DISEASE/ DIS-EASE notion?” Nothing it was a Post Script comment. But since you asked. Disease ie. asthma, ulcerative colitis, chron’s disease, cannot be cured by correcting subluxations, like many MD’s claim Chiropractors believe. Dis-ease is an old notion from the begnining of chiropractic meaning discomfort, pain, general unwellness. After an adjustment to correct subluxations of the spine Dis-ease is reduced or cured. This is true as anyone who has had a succesful chiropractic adjustment can tell you, they generally fell better after an adjustment. I hope this is known by all who claim to be experts on chiropractic and CAM’s.

          • Dis-ease is an old notion from the begnining of chiropractic meaning discomfort, pain, general unwellness. After an adjustment to correct subluxations of the spine Dis-ease is reduced or cured.

            So no effect on anything specific, then, just generally feeling better? Sounds like the placebo effect at work.

        • Just having some fun with ‘subluxation’ anyway. demonstrate yes.
          Studies preformed by Melzak & Wahl on “Gate theory” have long understood the reflex of mechanoreception over nocieception as stimulation of mechanoreceptors release the inhibitory neuortransmitter GABA at the cord level which actually reduces the conduciton along pain fibers entering the cord as well as the spinothalamic tracts. This is the same reason why when you stub your toe or something your mother would tell you to “rub it, rub it”!

          • personally, i prefer to rub the site of pain than to receive an intervention that is associated with severe complications, including deaths.

        • Studies preformed by Melzak & Wahl on “Gate theory” have long understood the reflex of mechanoreception over nocieception as stimulation of mechanoreceptors release the inhibitory neuortransmitter GABA at the cord level which actually reduces the conduciton along pain fibers entering the cord as well as the spinothalamic tracts. This is the same reason why when you stub your toe or something your mother would tell you to “rub it, rub it”!

          Would you call this a fair explanation of why a chiropractic manipulation reduces pain? you asked to me for proof that it wasn’t ChiroBS and I got a BS response.

    • Dr Daniel Albert said:

      I have to say that I find the concept of a General Chiropractic Council (analogous to the GMC) rather strange. I cannot really understand why chiropractic, osteopathy and physiotherapy cannot be regulated together. For sure, they use different intellectual models, but I am not sure that my vertebrae appreciate these nuances.

      Not so sure about physiotherapy, but certainly agree with the thrust (sorry!) of your argument. I have been trying to find out about the difference between chiro and osteo here, but nothing substantive yet. All that Jesgol has been able to tell me is that they are similar yet somehow different. He said:

      They are separate forms of spinal manip. Typically osteopaths use long level techniques, chiros use short lever. Both aim to achieve the same thing – spinal health. The EU degrees are similar, but not identical.

      …but no specific parameters yet that would allow differentiation.

      • Physical therapists use a graded system for spinal manipulation. Ranging from very small short manual (for the lack of a better word) wiggling of a joint through its ranges of motion (Gade 1), all the way to a Grade 5 which is a chiropractic adjustment. Osteopaths use Grade 5 and Grade 4 like chiro’s, they can prescribe pills too.
        The manipulations are terrifying to watch as a Chiropractor. The few moves i’ve seen preformed involve sheering force on the spine!!! I almost screamed NO to the video. Here’s a link of the wrong way. First off never lift the neck into extension for this move, and never use a counter force against the head! her right hand shouldn’t have moved at all. Truly frightening. http://www.youtube.com/watch?v=0vDoxFIG8Z4

        • MedDC said:

          Physical therapists use a graded system for spinal manipulation. Ranging from very small short manual (for the lack of a better word) wiggling of a joint through its ranges of motion (Gade 1), all the way to a Grade 5 which is a chiropractic adjustment. Osteopaths use Grade 5 and Grade 4 like chiro’s

          So, what are the parameters that differentiate a chiro from an osteo from a physio?

          they can prescribe pills too.

          Not in the UK they can’t.

  • Dr. Ernst, though your question may seem logical, you leave more questions about your own bias in your inquiry. Though you may speculate about whether there are unreported or under-reported cases, you still have no research-based evidence to support your statements. You somehow have avoided the much larger elephant in the room – the significant amount of accidental deaths caused by medical errors, upwards of 100,00 per year in the US alone! Amazing disconnect! (Another reason those numbers of deaths will never be competently addressed).

    • I have no research-based evidence for under-reporting???
      but i do! you only need to read my post again where i cite our case-series; the result showed that under-reporting was 100%

      • How could you make any conclusion other than ‘more research must be preformed’, if underreporting was 100% how did you find any information at all? how could you conclude that manipulation is deadly? citing your own studies doesn’t count. or at least it shouldn’t in respectable journals. Impact factor 2.4

  • I would agree that as with all actions be it prescribing or manipulating we should do as much as we can to prevent negative consequences. Regarding the reporting, I believe that true negative consequences are reported as those people have the need to seek medical care thus circumventing the need for DC reporting. I believe that is the wrong target. I would tend to agree with Dr. Reed that let’s concentrate our efforts where the most damage is done.

    • belief is not good enough! patient safety is too important to allow it resting on belief. we need data. we need chiros to establish systems akin to postmarketing sueveillance in medicine.

  • In my studies of both Medicine and chiropractic the issue of under reporting is huge regardless of healthcare provider. Nobody wants to be responsible for missing the signs of stroke.
    I have a question regarding
    “It is probable that someone will now calculate that the risk of harm is minute. Chinese traditional healers seem to use spinal manipulation fairly regularly, so the incidence of complications would be one in several millions.

    Such calculations are frequently made by chiropractors in an attempt to define the incidence rates of risks associated with chiropractic in the West. They look convincing but, in fact, they are complete nonsense.”

    The numbers add up, as fact with regard to incidence of serious/deadly outcomes to cervical manipulation. For the sake of time: in 2008 there were 133,000 stroke deaths in the US (lets say half died from chiorpractors). There are roughly 30,000,000 chiropractic patients in the US most of them receiving multiple adjustments a year. for arguments sake say that they all received 1 adjustment to the neck. .002% is the death rate. Is under reporting so bad that all stroke deaths were from SMT/CMT? even so at a rate of .004% the incidece of death after manipulation is hardly statistically significant. And offers better/equal results (Bronfort et al 2012) with less serious side effects as compared to OTC and prescription pain killers (the most common medical treatment for neck pain). I know these are rough numbers so please humor me. So I ask. How is that complete nonsense?

    • I guess what I would also like to know is, how can Edzard come to a conclusion such as “The risk of death from cervical manipulation far outweights the benifits” when its not statistically significant? It is too broad of a conclusion for such a small systematic review, espescially when published by only One author. And as a professor of complementary medicine should you not take into consideration the medical approach that parallels chiropractic treatments? I understand the need to promote the development of a adverse reaction reporting system and hopefully EHR’s will start to bridge that gap.

    • “Bronfort 2012″ is not exactly a precise reference but, if we mean the same article, let’s look at its conclusion in ful:” For participants with acute and subacute neck pain, SMT was more effective than medication in both the short and long term. However, a few instructional sessions of HEA resulted in similar outcomes at most time points”( HEA stands for home exercise advice). where do you see that SMT is better than no chiro, i.e. HEA? where do you see anything about risk?
      i think i can rest my case regarding COMPLETE NONSENSE

      • Yes we mean the same Bronfort article, I knew you would reach that concluison. I was citing Bronfort to give credibility that spinal manipulations provides at least some benefit. It provides NO information as to risk, it is not assessing risk but effectiveness. Also it makes no mention of millions of adjustments vs. stroke and adverse effects. And to really split hairs the article states cervical manipulation for neck pain has no usefullness but it does for cervicogenic headaches. who knows the dangers of unsupervised HEA! Falls? bumps and bruises? death?
        I am failing to feel the weight of am answer that lets you rest your case. Please answer, how do you justify your conclusion that the risk outweights the benefit of spinal manipulation (given the rough statistics for incidence of adverse effects) when the sheer volume of adjustments preformed is not taken into account?

        • how do i justify this?
          simple:
          according to the best evidence available (not one trial but a cochrane review), there is no proven benefit of spinal manipulation. in such a situation, any risk would outweigh the benefit – and the risks ar, in fact, considerable: an unknown frequency of serious complications + a ~50% incidence of mild to moderate adverse-effects lasting 1-3 days.

          • Thank you, that was a much better answer. The newest cochrane review also upheld the stance of no proven benefit however, it did include 6-8 new studies that are prompted research for of a more controlled nature. Chiropractic research is still in its infancy as it is difficult to reproduce exactly the same adjustment, create a sham adjustment etc. with better research techniques and proper funding we may see the real results of manipulative therapy. SO as a fellow health professional who truly cares about providing the best care possible for patients and as a professor of complimentary medicine why seek to destroy a therapy that has clearly helped many people (otherwise this would have been gone long ago) and instead help to steere the focus of new research, develop guidelines and safety standards? I do believe that an integrated approach to healthcare is the best one. The Spinal manipulation and conservative care should be a first line of defense to surgical and pharmacological interventions which tax the body in a much more severe way.

  • “in its infancy” means unproven, doesn’t it?
    i am/ was prof of COMPLEMENTARY MEDICINE, not complimentary medicine, as you put it. as such my task is to critically analyse rather than to promote – a distinction which, in my experience, is next to unknown in the realm of chiropractic.

  • Med DC: so you are saying dis-ease is a symptom in normal nomenclature. the claim to produce symptomatic relief can and must be proven through clinical trials – just like the claim to cure disease.the distinction between disease and dis-ease is not very meaningful and is merely a ploy by chiros to say “we cannot be measured by the same yard-stick”. double terminology tends to create double-standards which are unhelpful.

    • Dis-ease is a historical chiorpractic notion related to subluxation. There seems to be unending misinterpritation that subluxation has to do with clincial diseases and I am providing background information for its use. Keep in mind this was over 100 years ago. Medicine still used laxatives as a cure-all. The only reason subluxation still exists is because DC’s do not get reimbursed by Medicare in the US without a diagnosis of subluxation. All other insurance companies require documentation of myalgia/myositis, facet syndrome, disc herniation, cervicogenic headache etc. as causes of pain and preferably supported by orthopedic testing, muscle strength testing and neuroligic/sensory testing. sure come chiro’s in practice now reject the new model. Its just going to take time for the change to precipitate, so until then we’ll just have to deal with the semantics.

  • I apologize Complementary Med. And no Infancy means just that. As represented by how few long term studies have been conducted. Also there are only a handfull of quality research articles published that have anything to do with chiropractic and Spinal manipulative therapy. As a matter of fact a good portion of them are from you, at least they are more prominent due to their powerful language. Critical analysis should certainly promote progress, however the progress does not have to be positive, it can go backward. It should not be a used as a guise for soap box sermons passing judgement on something for which real evidence is lacking. (dont worry I’m aware chiropractic is guilty of this too and they are a more serious detriment to the profession) There is a reason why todays young healthcare professionals are more accepting of CAM’s, it works but we don’t know why. Most likely from a combination of physiological, psychological and neurological elements that produce positive results, which are difficult to quantify through research which is inherently mechanistic in its evaluation of a system. With the benefits of chiropractic being largely subjective and qualitative, it is extremely difficult to evaluate its effectiveness.

    • “it works but we don’t know why” = a tripple fallacy favoured by quacks http://edzardernst.com/2013/02/three-fallacies-for-the-price-of-one/ , as pointed out in a recent post.

      • Hence the need for more long terms clinical trials is the point you failed to see. Once again making a straw man argument, and yes I fully understand the use of the term. Jumping to a ‘fallacy’ conclusion is the resort of someone who just knows too little about what they speak. I am no weekend seminar Chiro thank you. The “I don’t care how this therapy works, as long as it helps” clearly does not apply here as I am calling for further scientific inquiry. Please refrain from simpleton responses, it is insulting.

        • MedDC said:

          Hence the need for more long terms clinical trials is the point you failed to see. Once again making a straw man argument, and yes I fully understand the use of the term. Jumping to a ‘fallacy’ conclusion is the resort of someone who just knows too little about what they speak. I am no weekend seminar Chiro thank you. The “I don’t care how this therapy works, as long as it helps” clearly does not apply here as I am calling for further scientific inquiry. Please refrain from simpleton responses, it is insulting.

          Why, after 120-odd years, are chiros still looking for that elusive clear-cut trial that substantiates the claims they frequently make?

          • No, I’m saying the research hasn’t been done at all. There is limited funding for research, there simply isn’t enough money to conduct multiple long term clinical trials. Most of the ‘research’ is case studies. Chiropractic doesn’t have a large corporation that has profits to fund further more extensive research. Any research has really only begun in the past 20 years or so. Honestly, we may never catch up in that department.

          • You’re joking, of course.

            The chiropractic industry is a vast, possibly multi-billion dollar industry. There are ‘universities’ dedicated to churning out chiros; there are trade bodies that represent thousands upon thousands of chiros; there are chiros out there, some of whom may be struggling, but many appear to be highly profitable.

            But to help you understand this, let me ask you three simple questions:

            1. What’s the cost of a good quality, robust trial – one that set out to see what effects chiro had on one specific condition currently treated by chiros?

            2. Until that good evidence materialises – if such a trial did, in fact, produce good evidence for chiropractic – do you think chiros should be treating that condition or even claiming to be able to treat that condition?

            3. If that trial showed conclusively that chiro was not effective for that condition, would you – and all other chiros – stop treating that condition?

            Your answers could be quite illuminating.

        • i find “simpleton” more insulting than reminding you politely that your argument is fallacious.

          • Henness:

            $33 billion spent on chiropractic in 2008. 1.5% of Health care expenditures.
            Cost of a 5-8 year study? Roughly 300-500 thousand dollars. Using MRI’s to evaluate responses to treatment and pain responses in the brains of chronic pain patients.
            The conditions that we treat with great success are muskuloskeletal, I am making this statement based on my Clinical experience and clinical observations of 25 years. (I am a third generation chiropractor). So for muskuloskeletal conditions yes. For gall stones, asthma, GERD, no.

            Yes if a trial is conducted that shows no benefit in any body system for the use of a specific technique that technique should be let go.

          • MedDC said:

            $33 billion spent on chiropractic in 2008. 1.5% of Health care expenditures.
            Cost of a 5-8 year study? Roughly 300-500 thousand dollars. Using MRI’s to evaluate responses to treatment and pain responses in the brains of chronic pain patients.
            The conditions that we treat with great success are muskuloskeletal, I am making this statement based on my Clinical experience and clinical observations of 25 years. (I am a third generation chiropractor). So for muskuloskeletal conditions yes. For gall stones, asthma, GERD, no.

            I don’t think we need to discuss any protocol just yet, but glad you agree funding shouldn’t be an issue. The question is, why isn’t it being done already?

            Yes if a trial is conducted that shows no benefit in any body system for the use of a specific technique that technique should be let go.

            Meanwhile, while we wait for that good evidence, and in the absence of it, do you think it appropriate for chiros to treat or even claim to treat that condition?

  • Just realised you cherry picked the results from that study. Could you please let us know what this means “had other primary diseases” as it equates to over half of the serious side effects. And could you please enlighten us as to the time frame of these serious side effects following SMT. was it 1 hour,1 day or 1 month? For somebody who likes to pick to pieces poor research it seems very strange that you pick certain parts of the conclusion but don’t actually bother to investigate the study methods.

    serious accident was 22 cases (14.70%, including paralysis, death and cerebrovascular accident). In cases of serious accident, 12 cases (54.55%) had the other primary diseases

  • I can’t beleive I missed that aswell, this study covered from 1979 to march 2011. 32 years and , as you said yourself,” Chinese traditional healers seem to use spinal manipulation fairly regularly” and they came up with 156 incidents where over 100 recovered!! Thats 56 injuries in 32 years!! Come on Prof Ernst even you must concede that the numbers here are very very small.

  • From the Post:

    The Professor writes
    “It is probable that someone will now calculate that the risk of harm is minute. Chinese traditional healers seem to use spinal manipulation fairly regularly, so the incidence of complications would be one in several millions.

    Such calculations are frequently made by chiropractors in an attempt to define the incidence rates of risks associated with chiropractic in the West. They look convincing but, in fact, they are complete nonsense.

    The reason is that under-reporting can be huge. Clinical trials of chiropractic often omit any mention of adverse effects (thus violating publication ethics) and, in our case-series, under-reporting was precisely 100% (none of the cases we discovered had been recorded anywhere). This means that these estimates are entirely worthless.”

    Some questions from a Patient and ex user of Chiropratic

    What is the point of commenting if you dont read the post? Or maybe you did. Couid it be your setting up the Professor by cherry picking to complain about cherry picking!

    If all incidents have been recorded you might have an argument. Do you believe they have? if you do then do you have the confidence to set up monitoring and research yourselves to prove your point. if yes, How are you doing this?

    If you don’t believe that the above covers every incident then what is the reason for your comments ? Do you agree that Alt Practitioners gain more if they do nothing?

    How good do you want to be (and be seen to be) as practitioners? Which of the two scenarios best describes your position?

    a)Do You believe that the studies have found all cases or b)that there is under reporting. I genuinely would love to know.

    • Incidence reporting is quite simple in the west (lets focus on the UK/EU). If a patient suffers at the hands of the chiropractor/osteopath/physio/MD it is reported to the hospital/mortuary who are obligated to investigate the reason for injury/death. Usually this results in an inquiry, investigation and prosecution of the guilty party. So I’m not sure how under reporting of serious cases is possible in our society.

  • Hi there,

    There is again mighty Dr. Ernst against quackery Chiros, who promote their treatment to be falsely safe.

    Let’s see study http://www.ncbi.nlm.nih.gov/pubmed/23316428

    Study says: When spinal manipulation is made by PT is effective and safe. Compare this finding to any of Dr. Ernst studies of safety of Chiropractic SMT. Pretty impressing! What Dr. Ernst says?

    Than you for your great lecture in Orton. We hope get you soon back to tell other interesting facts about CAM.

    Jukka Kolehmainen PT

  • Jesgol: the problem, i think, is yours: you have repeatedly demonstrated that you do not understand what i am writing: i am discussiong neck manipulation!!! why can you not accept this?

  • Hi,
    I’ve not seen anything advising against it as such but there are a host of pre-manip guidelines to ensure safety from Kerry et al. and the MACP;
    http://www.macpweb.org/home/index.php?m=file&f=395
    I think it’s fair to say the treatment would only be considered by physios in very specific situations with low risk of complications.

    • thanks, that’s helpful. it might not convince jesgol but it is a start.

      • @ everyone who has commented so far

        I think everyone should have a thorough read of the link put up by Physiotom (Thanks), because it does highlight some interesting points such as:

        1. Because of a lack of evidence, judgment cannot be made on the risk of physiotherapy-specific treatment. Non-manipulative techniques have been associated with neuro-vascular complications.

        2. The real risk of arterial complications following manual therapy is unknown and impossible to estimate, based on existing data.

        3. Traditional cardinal signs and symptoms of “VBI” following manual therapy are not supported by the literature reviewed.

        I think that all professions who perform manual therapy should look to conduct the appropriate trial (large scale, high quality prospective trials). I think chiropractors have the higher obligation to perform such a trial due to the fact they perform more manipulations but I think that the other professions such as physiotherapists, osteopaths and massage therapists should look to perform such a trial as soon as possible too.

        I also think that when a discussion starts about the safety of spinal manipulation of the cervical spine, all the professions should be referred to rather then just one profession because all the professions do perform manipulation of the cervical spine (to varying amounts). In addition, the article states non-manipulative techniques of the cervical spine (even exercises) have been associated with safety issues and therefore should be regarded with the same skepticism as manipulative techniques of the cervical spine.

      • someone very helpfully just tweeted that the CHARTERED SOCIETY OF PHYSIOTHERAPISTS issued an official recommendation not to use neck manipulations.
        CAN ANYONE PROVIDE THE LINK TO IT?

        • @ Edzard

          I think they could be referring to an article in the Frontline magazine of the CSP, which refers to a study Neil O’Connell et al about cervical manipulation and how it should not be used anymore.

          What do you think about the interesting points i raised in my comment above?

    • I should hope so, :) and the same should be true for chiropractors, and probably osteopaths (we don’t have many osteopaths in Canada). I know the only time I (and every chiropractor I have ever met… hundreds…) perform an adjustment is after a history and examination, and after finding a manipulable lesion (a joint restriction). Even then the thrust is within the normal range of motion.

      A non-chiropractic practitioner, and certainly most patients, would likely underestimate the amount of precaution that DC takes in Canada, especially with screening for the likelihood of stroke.

      After the 2008 study Risk of Vertebrobasilar Stroke and Chiropractic Care: Results of a Population-Based Case-Control and Case-Crossover Study, it has been postulated that stroke victims were in the process of the stroke prior to visiting the chiropractor. Because of this, there is a huge focus on evaluation for early signs of stroke, and to refer appropriately when they are present.

  • You narrowed the playing field. But I’ll keep playing.

    Here is my evidence for the effectiveness of SMT (neck manipulation) for non-specific neck pain.
    http://www.cks.nhs.uk/neck_pain_non_specific/management/scenario_management/management/basis_for_recommendation

    The strong evidence provided by the Bone and Joint Decade 2000–2010 Task Force on Neck Pain concludes:
    “There was an association between chiropractic services and subsequent vertebrobasilar artery stroke in persons under 45 years of age, but a similar association was also observed among patients receiving general practitioner services. This is likely explained by patients with vertebrobasilar artery dissection-related neck pain or headache seeking care before having their stroke.”

    Still wild and unsupported?

  • A lot of the responses to this article seem to take the form of a tu quoque fallacy. If you claim to be from a healing profession, shouldn’t your first priority be to reduce harm?

    Too many chiros I see seem to be more concerned about their bottom-line; an attribute they often seem to wrongly project onto their detractors in place of any reasonable discussion.

  • As a chiropractor, it seems reasonable, almost imperative to have a register of adverse reactions, be they severe (where the chiro may not know if patient goes to hospital) or mild (aggravation of existing condition or a new sprain to an unrelated/a symptomatic area).
    It wouldn’t be too hard & it would allow chiropractors to test their theory once & for all whether what we do is safe.

    • Matt

      There is a reporting system in the UK, but it’s operated by chiros, not the statutory regulator. As far as I’m aware, it’s rarely used, private and publishes no reports.

      You have to wonder why such an obviously essential system is not run by the statutory regulator so that it can properly protect the public.

      • Alan are incident reporting systems for medics, surgeons, physiotherapists and osteopaths etc run by their statutory regulators- I am not aware that this is with in the remit of such bodies.

        • Andy said:

          Alan are incident reporting systems for medics, surgeons, physiotherapists and osteopaths etc run by their statutory regulators- I am not aware that this is with in the remit of such bodies.

          Some are, some aren’t. However, the issue here, as Prof Ernst has shown, is the risks associated with chiro. Do you know how many reports have been logged by CPiRLS, whether those incidents been acted on, what anyone is doing about mitigating any risks identified and why nothing has been reported publicly?

          • Hi Alan can you inform us which ones are and which ones are not administered by the statutory regulator, I do not know the answer to your question but it would be useful to know what other professions do. Thanks.

          • Although the main method of reporting issues is through the practitioner’s statutory regulator, I was thinking as well of systems such as the Yellow Card system and the CQC. But the issue here is that there appears to be a system in place for reporting chiro AEs (only by chiros, of course, not by members of the public), but we have no idea how many incidents have been reported, whether they have been investigated nor whether any action has been taken to mitigate any future occurrence. Don’t you see that as being within the remit of a regulator charged with protecting the public?

  • The mentioned “chinese” study doesn’t mention chiropractic at all, so we don’t really know if these people administering manipulations to the neck are barbers, osteopaths, chiropractors or self-taught lay men?? Leave chiropractors alone people!
    Stop attacking this noble profession. If you don’t like chiropractic delivered by well educated and tested chiropractors in clinical setting, take drugs and go and have surgery. Chiropractors wouldn’t be insured to practice or registered with GCC or other bodies if they could cause death.

  • YOU ARE SO RIGHT.
    I AM FINALLY CONVINCED BY YOUR ELEGANT, CONVINCING ARGUMENT.
    LONG LIVE IRRATIONALITY, LONG LIVE CHIROPRACTIC!!!

  • Somewhere in there i read about “pain fibers”… Those don’t exist!!! There a sensory neurons, that pick up mechanical stimuli, thermal or chemical stimuli… Send this iNFO to the brain and it’s the brain who assesses the info an can give an output in the sense of pain…

    BUT PAINFIBERS DO NOT EXIST!!!!

  • So what i want to say with my last info… To all chiro’s, manual therapists, osteopaths…

    Start by learning pain biology, physiology. Get the facts straight why there is pain before you start busting up necks and backs!

    • I made the about pain fibers, when it is understood you are referencing the nervous system FIBER is an acceptable term for nerve. Yes there are nerves for pain there are two, Neospinothalamic tract and paleospinalthalamic tract. These nerve fibers end in the ventrobasal complex along with the dorsal column-medial lemniscal tract for tactile sensations. If you want more go look up A.Delta fibers and glutamate and pain, Type C nerve fibers and substance P.

      Started and learned Willy. My BS degrees are in Life science and Neuro-psychology. My facts are straight. This is not basic information so I understand if you don’t comprehend. Mechanical, thermal and chemical stimuli excite pain receptors. Fast pain is elicited by mechanical and thermal types of stimuli and all three stimulate slow pain receptors. As for why there is pain. Lets use Muscle spasm as it is the basis of many clinical pain syndromes. Pain is caused in part by the mechanosensitive pain receptors but it might also result from an indirect effect of the muscle spasm to compress the blood vessels and cause ischemia. The spasm also increases the rate of metabolism in the muscle tissue, thus making the relative ischemia even greater, thus creating the ideal conditions for the release of chemical pain-inducing substances.

  • I personally don’t understand why Dr. Ernst says cervical rotation and ekstensio is bad. Where is proof for that? Where is EBM? In my practise it seems that more rotation and ekstension is exactly what patients neck needs!

    Dear Dr. Ernst don’t like to critisise you, but could you give me study reference, please.

    Jukka Kolehmainen PT

    • the links to the published articles are provided in the text of my post

    • @ Jukka

      As highlighted above by Physiotom above there are good reasons and evidence not manipulate or even mobilise the neck. As a EBM physio you should look to read the document put on this blog by physiotom.

      Most importantly it must be kept in mind that because of the lack of evidence, judgment cannot be made on the risk of physiotherapy-specific treatment. Non-manipulative techniques have been associated with neuro-vascular complications.

      Also i would like state that this article on neck manipulation should make reference to all the professions that do neck manipulation to counter the suspicion of bias and because the risk is present no matter who is doing the manipulation or mobilisation.

  • @ Edzard

    Good to see you agree. Will you now include those professions in future articles about neck manipulations and the associated complications?

    May I even dare to suggest you could include those professions in this above topic.

    • you may suggest what you like.
      in the above post, i have linked to 2 ot my articles which were specifically about chiropractors.
      the chinese paper was about spinal manipulations performed by chinese healers.
      in both cases, i made this very clear.
      do you want me to obfuscate which profession the data relate to in future?

  • @ Edzard

    No need to obfuscate. You just need to present the whole picture and refer to all profession that do neck manipulation, because people who read this website many not be aware that other professions do.

    • @ A N Other

      I think you’re being unfair towards Professor Ernst. He has defended what he’s written more than adequately. He has also, historically, always been very careful to present the whole picture. For example, the following is lifted from the introduction to his masterpiece paper, Adverse effects of spinal manipulation: a systematic review:

      Quote
      “Spinal manipulation or adjustment is a manual treatment where a vertebral joint is passively moved between the normal range of motion and the limits of its normal integrity, though a universally accepted definition does not seem to exist. It is occasionally used by osteopaths, physiotherapists and physicians, and it is the hallmark treatment of chiropractors.”
      http://jrsm.rsmjournals.com/content/100/7/330.long

      IMO, it’s becoming increasingly obvious that Professor Ernst has chiropractors on the run and they’re finding fewer places to hide. What’s more, I expect that growing numbers of people are witnessing the wheels coming off the chiropractic charade as this superb blog slowly builds up steam and keeps lots of pressure on chiropractors as it goes forward.

  • @ Blue Wode

    It is good to see that Professor Ernst has mentioned almost all professions in a previous article about spinal manipulation. However, that doesn’t explain why he has chosen not to in this article. As i said previously i hope to see him correct this mistake in future articles on this topic.

    As i mentioned earlier, i think there is onus on manual therapists (physiotherapists, osteopaths, chiropractors (especially chiropractors), physicians etc.) to conduct the appropriate study to clear up the issue with neuro-vascular complications associated with neck manipulation. Furthermore, the article posted by physiotom pointed out that “Non-manipulative techniques have been associated with neuro-vascular complications”. This opens the issue to a wider section of manual therapists.

    • are you unable to understand my comments?
      i said that i mentiones chiros and traditional chinese healers because the links specifically refer to them.
      you do seem to want me to obfuscate after all. this might be what some chiros do, but not i.

  • MedDC: you wrote above that chiros now receive less instructions in quackery such as applied kinesiology. do you expect me to take you seriously? i find any amount of hours on quackery not acceptable!
    and have you seen the survey data on how many % of US chiros practice homeopathy, craniosacral therapy etc?

  • @ Edzard

    I don’t think you are able to understand my comments either. The links you have chosen refer to chiros and Chinese healers but you could have easily mentioned that other professions do neck manipulation (and have chosen links to studies)and therefore presenting a more complete representation of the issue in hand.

    I am perfectly happy for you to relate the data to the profession but i think that when you write an article about the safety of neck manipulation you have to be clear that it is not safe regardless which profession does it.

    p.s. Also the link to the article Am J Med. 2002 May;112(7):566-71, the abstract states “Reports in any language containing data relating to risks associated with spinal manipulation were included, irrespective of the profession of the therapist”. So one of the articles you link to is a search on all professions.

  • One of the recommendations is :”standardizing evaluation criteria and practitioners’ qualification.”

    I am curious what the qualification of the practitioners was, or if manipulation is even standardized or regulated in China. Although I am not aware of the situation in China, in Malaysia there are “Chinese bone-setters” and other lay practitioners that have far fewer qualifications than a western DC, and presumably this would decrease their ability to examine, assess, diagnose and treat safely.

    I asked one practitioner in Indonesia where he learned his craft and he said “from his boss.”

    With the exception of “monitoring of the accidents” I would think the other recommendations for safe care are well represented in Canada and the US, because of standardized 7-year doctorate programs, and strong communication between the associations and their members. Mind you, there is always room for improvement.

    FUNCTIONAL REPORTING SYSTEM

    So I agree with your article’s final line, regarding a “functional reporting system.” I am certain most DCs do not follow up with their patients as rigorously as I do, and still many patients will inevitably fall through the cracks.

    For functional reporting, the general or ER physician would have to take interest and contact the chiropractor…unless you have a better idea :). I know that most chiropractors really care about their patients, and would be more than happy to discuss the specific treatment they did, and would want to know about their patient’s condition. They are trained to manage such a situation.

    Furthermore, I think it gives the medical physician more to go on than “he cracked my neck.” Such words could describe an adjustment to a C1 left rotation restriction, or right lateral flexion restriction at C6, or maybe a first rib adjustment done in the supine position with an index contact.

    Those details can help a physician better evaluate a potential cause, and the chiropractor should have those details in their chart.

    Furthermore, if there was an accident, a chiropractor could then have his technique analyzed, see if his history and examination were adequate, etc.

  • Med DC: let me try to clear up a fundamental misunderstanding which you seem to perpetuate: you seem to think that i conduct a witch-hunt against chiropractic and keep pointing out that they have improved, are becoming evidence-based, are doing their best etc.
    i do not dispute that this applies to you and many of your collegues. but we both know that it does not apply to a whole lot of other chiros. if you negate this, go on twitter or search chiro websites and see for yourself how deep your profession is into quackery, marketing, misleading the public etc.
    DO YOU NOT THINK THAT IT IS WORTH EXPOSING THIS IN THE INTEREST OF CONSUMERS AND PATIENTS?

    • Thank you for that recognition, Edzard. I do agree that the perpetuation and use of religious ideology in chiropractic create a scenario that denies the inherent risks that come with and over exaggerates the effectiveness of chiropractic adjustments. The groups that perpetuate these views tend to be from outside organizations that are classified as ‘practice management’ groups and attract patients that are fervent ‘believers’ in chiropractic/homeopathy etc. They stress ‘patient education’ of how a chiropractic lifestyle and chiropractic treatment benefits overall health. Which is not a bad thing to promote healthy eating, taking care of one’s own body and mind, however, encouraging unnecessary treatments and forgoing medical advice (vaccinations) is dangerous and detrimental to the profession. Honestly, these groups should not be labeled as Chiropractors, rather wholeistic/ vitalistic practitioners.
      Do you have any opinion of how to generate or what is in place in other professions for adverse event reporting? I see this becoming easier with the implementation of electronic health records.

      • yellow card system! also patients can report adverse effects.

      • It’s got nothing to do with electronic health records.

        But there is already some sort of chiro AE reporting system – it just looks like no one uses it; it certainly doesn’t publish reports and who knows if anyone actually acts on anything reported. Oh, and members of the public don’t have access.

  • here is a quote from the SUDAY STAR TIMES 24/2/13 (NZ)
    “A common chiropractic neck manipulation caused a stroke in a man, a court rules…”

  • Here is a quote from the Manipulation Association of Chartered Physiotherapists (UK)

    “Non-manipulative techniques have been associated with neuro-vascular complications”

  • My wife (38) has mild forward head posture. Even without a clinical term, it is fairly clear from seeing her that her upper back /neck arches forward . Yet, back in Jan, 2014, during a series of visits to a local PT, the PT had my wife laying flat on her face, without a massage chair hole for her face, and was pushing fairly hard on her upper back / neck to seemingly trying to help muscular tightness, and the PT caused 2 slipped disks at C4-C5 and C7-C8. Initially, during the visit, it seemed to bring relief from her issues (her purpose in going was to help her shoulder pain from breastfeeding / carrying a newborn a year before). But that evening, my wife started getting tingling down her arm and fingers, and one leg. The MRI shows the slipped disks. She has had tingling, numbness and weakness ever since.

    I know this article focuses on chiropractors and manipulation, but we can relate to the author’s warning and are now wondering if legal intervention might help 1. with all medical bills resulting from this PT’s mistake, and 2. raise awareness / consequences for chiro and PT who do not diagnose before manipulating. I will now read through other posts to see if legal recourse is recommended or not. Thank you the article.

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