MD, PhD, FMedSci, FSB, FRCP, FRCPEd

Dutch neurologists recently described the case of a 63-year-old female patient presented at their outpatient clinic with a five-week history of severe postural headache, tinnitus and nausea. The onset of these symptoms was concurrent with chiropractic manipulation of the cervical spine which she had tried because of cervical pain.

Cranial MRI showed findings characteristic for intracranial hypotension syndrome. Cervical MRI revealed a large posterior dural tear at the level of C1-2. Following unsuccessful conservative therapy, the patient underwent a lumbar epidural blood patch after which she recovered rapidly.

The authors conclude that manipulation of the cervical spine can cause a dural tear and subsequently an intracranial hypotension syndrome. Postural headaches directly after spinal manipulation should therefore be a reason to suspect this complication. If conservative management fails, an epidural blood patch may be performed.

Quite obviously, this is sound advice that can save lives. The trouble, however, is that the chiropractic profession is, by and large, still in denial. A recent systematic review by a chiropractor included eight cases of intracranial hypotension (IH) and concluded that case reports on IH and spinal manipulative therapy (SMT) have very limited clinical details and therefore cannot exclude other theories or plausible alternatives to explain the IH. To date, the evidence that cervical SMT is not a cause of IH is inconclusive. Further research is required before making any conclusions that cervical SMT is a cause of IH. Chiropractors and other health practitioners should be vigilant in recording established risk factors for IH in all cases. It is possible that the published cases of cervical SMT and IH may have missed important confounding risk factors (e.g. a new headache, or minor neck trauma in young or middle-aged adults).

Instead of distracting us from the fact that chiropractic can lead to serious adverse events, chiropractors would be well-advised to face the music, admit that their treatments are not risk-free and conduct rigorous research with a view of minimizing the harm.

45 Responses to Complications after chiropractic manipulations: probably rare but certainly serious

  • I’m almost-homeless now (and probably will be soon) because I wouldn’t let my chiropractor/landlord mess with my spine (which had already been operated). She kicked me out after I was bedridden for two months and fell behind with the rent. I’ve been struggling to stay alive ever since.

    Anyway, got another one for you here. I think, if you haven’t already gotten my point, you will soon,…

    • So Crack, apparently she is not to blame that you are bed-ridden. Why did you let surgeons with needles and knives and power tools and drugs and things mess your spine?

  • I believe that this potential association between manual therapy and IH has also been reported following treatment by physiotherapists (See http://www.archives-pmr.org/article/S0003-9993(07)01457-8/abstract) and is an issue for all manual therapists to consider. IH can also occur spontaneously or after mild trauma and practitioners need to be aware of these issues.

  • Interesting case study. This highlights the importance of Informed Consent and Mandatory Adverse Event reporting that leads to the investigations and research which is needed. Informed consent is already mandatory here in Australia, now for AE reporting across all registration boards and health professions. None of these boards have it:
    http://www.ahpra.gov.au/

  • Yes, EE, we admit that spinal manipulation and chiropractic health care is not risk-free. Some of the most common complications are more energy, more flexibility, sleep better, wake more refreshed, improved posture and feel younger. People will then be able to get off addictive medications so there will be less suicides and unnecessary surgeries. They will then start to exercise more, eat healthier, have more of a positive mental attitude about life and improve their relationships with their families and others. I have seen it thousands of times. Non-drug approaches to health care is not without its risks and responsibilities.

  • EE, just wondering are you aware of the most comprehensive and up to date research on serious complications on Chiropractic? Yes, but OFCOURSE, one case study is far better evidence.

    http://www.ncbi.nlm.nih.gov/pubmed/24239451

    CONCLUSIONS:

    There were no significant changes in blood flow or velocity in the vertebral arteries of healthy young male adults after various head positions and cervical spine manipulations.

    http://www.ncbi.nlm.nih.gov/pubmed/19251066

    CONCLUSION:

    VBA stroke is a very rare event in the population. The increased risks of VBA stroke associated with chiropractic and PCP visits is likely due to patients with headache and neck pain from VBA dissection seeking care before their stroke. We found no evidence of excess risk of VBA stroke associated chiropractic care compared to primary care.

    • “The objective of the study was to investigate the cerebrovascular hemodynamic response of cervical spine positions including rotation and cervical spine manipulation in vivo using magnetic resonance imaging technology on the vertebral artery (VA).”

      THIS DOES NOT SOUND LIKE ” the most comprehensive and up to date research on serious complications on Chiropractic”

      • First is the most up to date and other is the most comprehensive. Still waiting your comments about studies? Why you don’t blog about far better studies an more relevant findings? Big Pharma not paying for that?

        • Jorma Kärtsy cited: http://www.ncbi.nlm.nih.gov/pubmed/19251066 “CONCLUSION: VBA stroke is a very rare event in the population. The increased risks of VBA stroke associated with chiropractic and PCP visits is likely due to patients with headache and neck pain from VBA dissection seeking care before their stroke. We found no evidence of excess risk of VBA stroke associated chiropractic care compared to primary care.”

          Like most chiropractors, you have failed to point out that the study’s authors said that the results had to be “interpreted cautiously…we have not ruled out neck manipulation as a potential cause of some vertebrobasilar artery stroke”.

          IMO, the full text of the following brief critique of the problems with that paper [Cassidy, JD et al, Risk of vertebrobasilar stroke and chiropractic care: results of a population-based case-control and case-crossover study. J Manipulative Physiol Ther. 2009 Feb;32(2 Suppl):S201-8.] needs to be made available online, so here it is:

          “Several hundred published cases have drawn our attention to an association between chiropractic spinal manipulation and vascular accidents [e.g. 1]. Extension and/or rotation of the neck puts strain on the vertebral artery which, in predisposed individuals, may dissect [1]. This theory would provide a biologically plausible mechanism for these adverse events. But neither anecdotal data or a plausible theory alone can establish causality. Proponents of chiropractic therefore claim that the association is, in fact, not causal and should therefore not deter us from recommending neck manipulation.
          This argument has found support from a Canadian case control study [2]. It is now frequently cited by proponents of chiropractic who claim that chiropractic spinal manipulation is entirely safe. Here I will provide a brief critique of the new evidence [2] and try to put it into a clinical context.

          Cassidy’s case control study
          The paper in question [2] provides a retrospective case-control study and case-crossover analysis. The authors, two of whom are chiropractors, used the data from 818 hospitalised stroke patients, and matched them, for the case-control analysis, with 3164 control subjects. For the cross-over analysis, they compared them to data from the same patients from previous time periods. Usage of chiropractic services primary care physicians was extracted from health billing records.
          The results indicate that, compared to exposure to treatment by physicians, there was no excess risks of chiropractic therapy. According to proponents of chiropractic, these findings suggest that many stroke patients have a history of consulting chiropractors because they consult these practitioners for their neck pain and headache [2], which can, of course, be precursors of a stroke. According to this theory, the chiropractic treatment would not be a cause but an innocent bystander of the vascular accident.

          A critical assessment
          The study by Cassidy et al [2] is no doubt interesting but it also has several flaws which must be taken into account. Its authors acknowledge this fact and state: “Our results should be interpreted cautiously … we have not ruled out neck manipulation as a potential cause of some vertebrobasilar artery stroke.” [2] Unfortunately this advice is rarely heeded by those who argue that this evidence demonstrates the safety of chiropractic neck manipulation. Particular concerns relate to the following issues:

          • Non-hospitalised stroke cases, transient cerebral ischaemia, stroke patients residing in long-term care facilities and patients not covered by the Ontario Health Insurance Plan or patients not reimbursed for consulting a chiropractor were all excluded from the analyses. It is conceivable that these exclusions had a significant influence on the results.
          • The authors included all strokes that incurred within 30 days of the index date. This could have weakened an already weak signal: most strokes associated with chiropractic occurred soon after treatment [1]. Sub-analysis of the Cassidy data seem to confirm this; the odds ratio for a stroke within one day of chiropractic is 12.0 compared to 3.1 for the 30 day period [2].
          • Most strokes occur spontaneously and relate to the elderly population. The Cassidy analyses [2] included all age groups. This might have further diluted the weak signal. Sub-analysis of the Cassidy data confirm that the odds ratios for patients below the age of 45 years are consistently higher than those for patients beyond that age.
          • Cassidy et al took their evidence for a stroke from discharge notes. Such notes are notoriously unreliable and no data were provided to show how accurate these data were. This may even be more relevant for vertebrobasilar strokes, the type of stroke relevant in relation to chiropractic neck manipulation [1].

          Conclusion
          Apart from a plethora of anecdotal data [1], at least two further case-control studies suggest a causal association between chiropractic manipulation and vascular accidents [3,4]. The analysis by Smith et al [4] made an attempt to control for the possibility of bias through pre-existing neck pain and concluded that manipulation was a risk factor independent of that variable.
          The Cassidy study [2] is a valuable contribution to the debate about chiropractic’s safety but is by no means a compelling proof for the harmlessness of chiropractic neck manipulation. In fact, the balance of the currently available evidence would seem to point in the opposite direction.
          The most benign interpretation of the totality of the evidence is therefore as follows. There is an association between chiropractic and vascular accidents which not even the most ardent proponents of this treatment can deny. The mechanisms that might be involved are entirely plausible. Yet the nature of this association (causal or coincidental) remains uncertain.
          The cautionary principle, demands that, until reliable evidence emerges, we must err on the safe side. Considering also that the evidence of any benefit from chiropractic neck manipulations is weak or absent [5], I see little reason to advise in favour of upper spinal manipulation.”

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

          Link: http://www.chirowatch.com/stroke/2010%20vascular%20accidents%20after%20chirosm%20-%20myth%20or%20reality.pdf

          More critical comment on the Cassidy study here:
          http://www.ebm-first.com/chiropractic/risks/491-chiropractic-and-stroke-evaluation-of-the-paper-risk-of-vertebrobasilar-stroke-and-chiropractic-care-results-of-a-population-based-case-control-and-case-crossover-study-spine-2008-feb-15334-suppls176-83-cassidy-jd-boyle-e-c.html

  • Think Jorma hits the nail. Why need to give publication to studies this study?

  • SkepdicProf,

    Who SAID she was to blame for my being bed-ridden?

  • Blue wode

    Do you have any other critical evalutions of the study by Cassidy et al.? Why only critic is Ed?

    How about other study which confirm that ed’s mechanical vertebral artery strain theory is not happening?

    • Jorma Kärtsy wrote: “Do you have any other critical evalutions of the study by Cassidy et al.? Why only critic is Ed?”

      Here you go:
      http://www.sciencebasedmedicine.org/chiropractic-and-stroke-evaluation-of-one-paper/

      Do you have any comment to make on the criticisms of the Cassidy study which I have now provided via three links?

      Jorma Kärtsy wrote: “How about other study which confirm that ed’s mechanical vertebral artery strain theory is not happening?”

      That was a pilot study. We’re talking here about serious injuries and their prevention through the application of the precautionary principle: http://en.wikipedia.org/wiki/Precautionary_principle

      BTW, it looks like you haven’t read this part of the content of my link to “more critical comment on the Cassidy study”:

      Quote
      The evaluation also notes the following regarding neck manipulation force: “…in a good hanging, the victim should not strangle to death (1). A good hanging should be set up such that there is a fall just far enough so that the first and second vertebral bodies are separated, breaking the neck and quickly killing the victim. You do not want them to fall too far, as the head may come clean off and that is aesthetically unpleasant. Most people who die these days from hanging do not get a ‘good’ hanging; they suffocate at the end of a rope, a particularly gruesome way to die. The vertebral artery is often damaged in suicidal hanging (2); “The vertebral artery was shown to be injured quite frequently (rupture, intimal tear, sub-intimal hemorrhage), namely in one quarter of all cases, and indeed in more than half taking into account the perivascular bleeding.” This easy injury is in part due to mechanical reasons “The vertebral arteries appear to be particularly susceptible to injury in trauma of the cervical spine because of their close anatomical relationship to the spine” (3). A passive hanging (no drop) gives about 686 Newton’s of force around the neck for a 70 kg human. In chiropractic, “the mean force of all manual applications (is) 264 Newton’s and the mean force duration (is) 145 milliseconds (8)”. So a chiropractic neck manipulation, for a short period of time, can provide 38% the force of a hanging. And a bad hanging at that.”

      Here’s the link (again):
      http://www.ebm-first.com/chiropractic/risks/491-chiropractic-and-stroke-evaluation-of-the-paper-risk-of-vertebrobasilar-stroke-and-chiropractic-care-results-of-a-population-based-case-control-and-case-crossover-study-spine-2008-feb-15334-suppls176-83-cassidy-jd-boyle-e-c.html

  • I mean do you have any other reference to other peer reviewed journals?

    You provide low quality skeptic blog links. It’s as usefull as I would promote subluxation theory with reference of blog of some wacky straight Chiropractor.

    Any single research paper is not perfect, but at the moment the best evidence available says there is not causal effect with manipulation and VBA. And also neck manipulation with exercise is the best treatment option available for mechanical neck pain.

    http://www.ncbi.nlm.nih.gov/pubmed/18204386

    And also combination is more effective (and far more safe) than pain killers

    http://www.ncbi.nlm.nih.gov/pubmed/22213489

    I’m waiting high quality journal references e.g. Bone and Joint Task force or… And something from our friend Ed is not ok. Someone else, thank you!

  • As for criticism on the Cassidy study, Jorma, did you yourself read and understand the whole study, and still missed the flaws?
    For example it looked at discharge billings. They seem NOT to have included patients who died or otherwise were not discharged. They do not even mention them, so we do not know the number of exclusions. The text is not clear on this matter (except that recently dead persons or long-term care residents were excluded from the controls). It seems fair to suppose that the fatality rate among cervical artery strokes is rather high, and so too may the rate of severe sequelae demanding long-term care for survivors be. So one can’t help suspecting that an unknown but significant number of cases were conveniently excluded from the Cassidy study.
    Further, Cassidy & al did not look at the patient records or charts, only billings. So we do not know the hierarchy of simultaneous diagnoses and subdiagnoses. Presumably, the bills would contain the diagnoses giving the best insurance reimbursement. As the authors themselves point out, “A major limitation of using administrative data are misclassification bias, and the possibility of bias in assignment of VBA-related diagnoses.”
    Worse still, they only included cases with two out of six ICD-9 diagnose codes related to cervical artery strokes, viz. 433.0 (Occlusion or stenosis of basilar artery) and 433.2 (Occlusion or stenosis of vertebral artery). They don’t disclose why they chose to not include the following four codes: 433.1 (Occlusion or stenosis of carotid artery), or 433.3 (Occlusion or stenosis of multiple and bilateral precerebral arteries), or 433.8 (Occlusion or stenosis of another specified precerebral artery), or 433.9 (Occlusion or stenosis of an unspecified precerebral artery). How many of these were there? We are not told.
    Did all chiropractors who found a stroke patient on their table (and correctly perceived it as such) actually charge for that session? One may wonder about the ratios of under-reporting stroke among chiros and doctors, respectively.
    Cassidy did not provide a disclaimer that he needed the purported results of this study, as he himnself had had a stroke victim on his table in connection with neck manipulation.
    I have many more objections to the Cassidy study, but they would make this comment almost as long as Cassidy’s report itself.

  • Thank you Olle, very informing post. Do you have reference for that claim of author’s stroke victim? He is actually full time researcher.

    http://www.uhnresearch.ca/researchers/profile.php?lookup=833

    Hope you can appreciate that VBA after manipulation is not the easiest one to research and Chiros are really working with this important subject. Have e.g. manipulative Physios done any research on topic? Any relevant studies?

    Think question is after all: What we know about causal relation with manipulation and VBA and do we have any other better research done on this matter?

    There is other good Chiro study of safety of neck manipulation.

    http://www.ncbi.nlm.nih.gov/pubmed/17906581

    Someone send me better research and I will change my mind of this subject because of evidence. I’m waiting, no Ed’s papers, please.

    • Jorma Kärtsy wrote: “Do you have reference for that claim of author’s stroke victim?”

      Here you are
      http://www.youtube.com/watch?v=xkZQlrQMJ-k&feature=related

      Jorma Kärtsy wrote: “There is other good Chiro study of safety of neck manipulation.”
      http://www.ncbi.nlm.nih.gov/pubmed/17906581

      It’s not a good study. I’ve lifted this from a comment I’ve just made on another post here:

      QUOTE
      “Still on the subject of ethics, it’s worth noting that J E Bolton went on to claim in early 2008 [in the study] that, in the UK alone, there were an estimated *four* million manipulations of the neck carried out by chiropractors each year.
      http://onlinelibrary.wiley.com/doi/10.1211/fact.13.1.0020/full
      Yet, six months earlier, in October 2007, in a letter to the Journal of the Royal Society of Medicine, she claimed that the figure was “estimated to be well over *two* million cervical spine manipulations” in the UK each year.
      http://jrsm.rsmjournals.com/content/100/10/446.1.full
      IMO, the discrepancy in the above two figures is evidence of a desperate attempt to play down the risks of chiropractic by deliberately over-estimating numbers.”

      Even although Jorma Kärtsy won’t like it, it’s also worth highlighting Professor Ernst’s comments on the study:

      QUOTE
      “In my view, the most confusing aspect about the results of this survey is the fact that the incidence of minor adverse events is so low. Previous studies have repeatedly shown it to be around 50%. The discrepancy requires an explanation. There could be several but mine goes as follows: the participating chiropractors were highly self-selected. Thus they were sufficiently experienced to select low-risk patients (in violation of the protocol). This explains the low rate of minor adverse events and begs the question whether the incidence of serious adverse events is reliable. Studies of this nature are very difficult to conduct such that we can trust the results. One of the problems is that one has to rely on the honesty of the participating therapists who could have a very strong interest in generating a reassuring yet unreliable picture about the safety of their intervention.”

      Link: http://onlinelibrary.wiley.com/doi/10.1211/fact.13.1.0020/full

    • “Do you have reference for that claim of author’s stroke victim?” — Well, at least he said so himself. Loudly and clearly. In the Connecticut hearings. You are aware of them, I hope?
      “Someone send me better research and I will change my mind of this subject because of evidence.” — If you are at all sensitive to scientific evidence, you would have changed your mind already. It is difficult to comprehend why we need this discussion in the first place.
      • There is very little but *anecdotal* evidence since ca 100 years for the alleged benefit of chiropractic intervention. A very clear trend has emerged, however: the better the study the slighter the benefit, if any. And no biologically plausible mechanism of action has been put forward.
      • In contrast, there is a plethora (sic!) of reports of the adverse effects of spinal manipulation, most of which is performed by chiropractors. A significant number of these are strokes occurring during or immediately after neck HVLA manipulation.
      What more do you really need, in order to want to play safe until more is known? When reports on serious adverse effects of a drug accumulate, further use of that drug is halted until more is known. Safety first.
      But chiropractors keep manipulating necks, vigorously denying that there could be even a remote association between a stroke and neck manipulation. Instead, all of a sudden and very unlike their previous low demands for scientific evidence of beneficial effect, they now demand very far-reaching scientific *proof* that there were no preexisting weakness in the precerebral arteries that “caused” the strokes! They say, happily, as e.g. Cassidy (2008): “Activities leading to sudden or sustained rotation and extension of the neck have been implicated, included motor vehicle collision, shoulder checking while driving, sports, lifting, working over-head, falls, sneezing, and coughing.” (page S176)
      But the fact that you are happily excluding HVLA neck adjustment from this list of otherwise very non-traumatic neck movements as possible causes of cervical artery strokes is very frustrating for us in the medical profession.

      • @Olle

        Sorry, took a while. Didn’t notice your message.

        I’m not aware of Conncecticut hearings. Think it’s good to hear full story and not 37 seconds clip from Chiropractic stroke channel from Youtube.

        I’m afraid of hearing same old medical view of Chiropractic: no benefit (or maybe slight placebo effect in sunnyu day) and very high risk. I see risk-benefit ratio better in manual therapy. In clinical point of view I’m see lot of people who don’t respond or tolerate medical approach so this might be true especially in my subgroup of patients.

        In Finland Chiropractic been in country almost 100-years and there is not ant single serious adverse reactions related to treatment according Patientförsäkringscentralen of Finland in 2013. Naturally, safety first, but should be see before banning upper cervical manipulation that first serious adverse reaction happens in this country?

        You wrote:”No biologically plausible mechanism of action has been put forward”.
        Please, have a have look again. There e.g. special issue of Journal of Electromyography & Kinesiology in October 2012.

        Chiropractors are not excluding happily HVLA neck adjustment from this list of otherwise very non-traumatic neck movements as possible causes of cervical artery strokes. If this were the case, why all this research activity in late years.

        • Jorma Kärtsy wrote: “I’m not aware of Conncecticut hearings. Think it’s good to hear full story and not 37 seconds clip from Chiropractic stroke channel from Youtube.”

          Here you go:
          http://www.ebm-first.com/chiropractic/latest-news/1547-online-recordings-of-the-january-2010-connecticut-state-board-of-chiropractic-examiners-public-hearing-on-informed-consent-for-chiropractic-procedures-.html

        • In Finland Chiropractic been in country almost 100-years and there is not ant single serious adverse reactions related to treatment according Patientförsäkringscentralen of Finland in 2013. Naturally, safety first, but should be see before banning upper cervical manipulation that first serious adverse reaction happens in this country

          I think you omitted some words there Jorma.
          You probably meant to say that “…there is not a single serious adverse reaction on record according to Patientförsäkringscentralen…” (Patientförsäkringscentralen is Swedish and means literally: “The patient insurance central”)

          I suspect that, as in other nordic countries, chiro’s are by law health-care providers who are required to keep records of their treatments, right?
          Would it not be a great idea to require Finnish chiropractors to enter a centralised electronic record of every treatment session (tax-man would at least love that ;) ). It would be rather easy to find grants to finance a centralised register and this would be great help for chiropractors in their outcome audits.
          They could gather a lot of good material to prove their therapy is efficacious. If properly set up it would be only a few clicks on the computer screen for every session.

          In my work we enter a lot of information into a computer in the OR about every procedure we perform (we do 1100 gastric bypass per year in a single theatre) into a central electronic register in Sweden (the SOREG register). This is done real time and provides us with a great way of proving that we are doing a good and safe service. That is why I know this is very doable and very rewarding ;)

          I know that chiro´s have little time for extra workload. My chiro (I tried that once), a very busy man, had a turnaround time of only a couple of minutes for repeat manipulations. But it would not be much information you would need to enter and all could be done with standardised, clicks in checkboxes. I would think it could be done in only 5-10 seconds.

          Then the Patient Insurance Central could monitor strokes or other cerebral events that are admitted to hospitals and see immediately if the victim had been manipulated within the preceding day(s) and even whether it was cervical or not. If, during say five to ten years, there was no apparent correlation between cervical manipulation and subsequent strokes that could not be due to chance alone, then we could stop having this uncertainty about the safety of cervical manipulation. I am sure EU would be willing to finance such a venture. They are granting incredible amounts of money for projects of far less public health interest.

          One could actually also do this retrospectively. Find the (not so many) cases of suspect strokes and VB-occlusions in hospital records for ten or even twenty years retrospectively in one or two large university hospitals in areas with a stable population, say Vaasa and Oulu, and go through the preceding days records at the local chiro’s that the victims could have seen. A nice epidemiology project for medical students, right? This would generate a real blockbuster article whatever the outcome would be.

          Or do Finnish chiro’s perhaps not keep useful records?

          • @Björn

            I’m surprised to see happy smiley faces. Keep it up!

            Patient insurance central records includes all serious adverse reactions claims made by patients. If someone visits in Chiro and get stroke after he/she is hospitalised and you should find these cases easily from nationwide retrospective patient insurance central record. There is e.g. around 8000 claims made by patients in 2013. Public awareness of possible stroke after neck manipulation is very well known here, so it can’t be the reason of clean record. You can order records also in swedish.

            http://www.pvk.fi/sv/Statistik/

            Thank you for your research idea. I’m more interested of research of rehabilitation. Major problem is not in my mind possible rare adverse reactions but more how to prevent episodic pain to become chronic and burden individual and society. The effective strategy could be the real blockbuster study.

            Chiro’s keep record by law. I have my own VERYVERY USEFUL records on private medical centre, where I ALWAYS AND EVER diagnose subluxation, manipulate neck on both sides (or in other words put lights on!) with more than 90 degrees of rotation and treat people less than two minutes (-;

            Hope you understand that I’m little suspicious that someone can possible practise that way in a competitive environment of modern healthcare. There is also more competition in Sweden.

          • @Jorma
            Oh-dear. It seems like you do not understand at all the natural history and pathogenesis of the grave but rare complications we are talking about here. Perhaps it comes from your lack of medical training. It may even require a measure of training in vascular surgery to really grasp how arterial injury happens and behaves andhow it can have a time-lag before symptoms set in.

            You think you can rely on the fact that because you have never heard of a patient of yours getting a stroke after your manipulations, that it is not a real and serious risk. There you are seriously mistaken. That there are no records in the official system of such occurrences is no guarantee of absence either. The current systems will not pick these things up without active monitoring of time-shifted occurrences and database coupling. As it happens I have quite some experience with medical registries official and private and their problems and shortcomings in epidemiological monitoring and research.
            VB occlusion is certainly a very rare occurrence but catastrophically serious. The artery is very well protected by bones and tissues but it is very easy to understand the mechanism of injury by rotatory manipulation and illustrations of this very plausible mechanism are abundant. The risk is definitely real and there are thousands of reported, more or less likely cases as has been repeatedly pointed out here and elsewhere. You choosing not to believe this is your problem and your patients.
            A patient of yours who would get an intimal lesion from rotatory manipulation would not occlude the vessel immediately unless the lesion was extreme and dissecting. Such cases have been described though. He or she would most likely go home and never return to you. You would probably never realize what happened. When disaster strikes after a time lag of several hours the artery occludes as a thrombus builds up. It may require a propensity for thrombosis (increased risk for blood clots) but this is rather common. When that happens the patient will be in no shape to report that shortly before, maybe even the day before or more, he/she was being manhandled by you.
            These patients are not in any shape to give a history of recent activities. They are usually lying unconscious in a respirator. VB occlusion can result in anything from transient ischemic symptoms to death and anything in between. Afterward, should they recover, they will not remember what happened some time before and after the stroke. This is why there are no records in the present systems showing a correlation. That is why I wrote a proposition of a system of active monitoring. What I was saying is that you would need to have active, independent monitoring for years to catch such complications. You would have to centralise the chiropractors record keeping (which I suppose many of them would not like?)
            Statistics only contain what is entered and they only show what you look for.
            One serious complication to a cervical manipulation that has not been proven useful is enough to make it a serious matter.
            Some patients with VB occlusion suspected to be caused by cervical manipulation have ended up with locked-in syndrome which is perhaps the most terrible fate one can imagine.
            Cervical manipulation has not been shown to be a useful therapy for anything, least of all the idiotic notions that chiro’s have about it being useful for improbable conditions like ear problems, allergies and other nonsensual delusional theories.
            Your cognitive dissonance is shining bright and clear Jorma.

            And BTW… your smiley is the wrong way around.

  • So any research not showing causality and high risk is not good and promoting other opinion is always other way around. Maybe we can say we don’t know? It could be very interesting to read better research on subject by other professions because Chiro research is always not good.

    Now it could be time for Edzard to let me know:

    Why you are not writing risks of manipulative physiotherapists?

    There is more manipulative physios in Europe than Chiros and their education is not standartised and they haven’t carried on almost any research on this subject.

  • So logic is – two person perform similar maneuver, but outcome of other is carrying 900% higher risk depending on first name of person. I applaud for this scientific view.

    Thank you!

    • @ Jorma Kärtsy

      Spinal manipulation is the hallmark intervention of chiropractors. They use it far more frequently than other manual therapists, and as previously explained, less judiciously. Therefore it follows that chiropractors will be responsible for most complications arising from its use. See Fig.2 here:
      http://ptjournal.apta.org/content/79/1/50.full

    • No. The (subjective) observation is that 90% of those with complications after spinal manipulation were receiving those manipulations from chiropractors. There are various explanations of that (chiropractors manipulating the spine differently; chiropractors using manipulation where physiotherapists don’t use it; …), the profession’s name isn’t one of them (nor is the therapist’s first, middle or last name).

  • @Blue Wode

    So, more manipulations = more adverse events. Total agreement on first time. Nowadays, there is (at least in Nordic countries) more physios manipulation and I’m little worried about their short and varied education for manipulative skills and lack of education about pathology and research. It’s just my opinion that they are who we should worry about in coming years.

    Reference paper is fifteen years old. It’s way better than EBM-blog and EE’s papers but a bit old.

    @Vicky

    I see you don’t have background on hands on therapy. Your various explanations could be theoretically true but not really there. It’s like me telling you Chiro’s just do it better. There is all kind of professionals out there in any profession. I’m personally sorry if your local Chiro is not the brightest star of christmas tree.

    You must be good in research so, please, tell why the latest research suggests manipulation to be better treatment option on neck pain compared to medication? Do medication have less risk compared to manipulation on treatment of neck pain? Do you see ethical and professional problem when patients are informed of potential risks of neck manipulation and have potentially the best risk benefit ratio treatment on neck pain? Should we give Chiro’s bad name if they perform 90% of manipulations?

    http://www.ncbi.nlm.nih.gov/pubmed/22213489

    http://www.medicine.ox.ac.uk/bandolier/booth/painpag/nsae/nsae.html

    • Jorma Kärtsy wrote: “…please, tell why the latest research suggests manipulation to be better treatment option on neck pain compared to medication?”

      That paper doesn’t say what you think it says. Here’s Professor Ernst’s critical assessment of it:

      QUOTE
      “…Within hours of the publication of this new US study [1], the world of chiropractic celebrated it as a vindication of chiropractic spinal manipulation. Its aim was to “to determine the relative efficacy of spinal manipulation therapy (SMT), medication, and home exercise with advice (HEA) for acute and subacute neck pain in both the short and long term”. Because neck pain is such a common problem which is often difficult to treat, this study did indeed seem important.
      The researchers recruited 272 patients suffering from nonspecific neck pain since 2 to 12 weeks, subsequently they treated them for 12 weeks with either SMT, medication, or HEA. The primary outcome was pain which was measured at 2, 4, 8, 12, 26, and 52 weeks. The results suggested that SMT had a significant advantage over medication after 8, 12, 26, and 52 weeks, and HEA was superior to medication at 26 weeks. No clinically important differences were found between SMT and HEA at any time. The authors concluded that, “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”.
      At first glance, this seems to be a rigorous piece of research. At closer scrutiny, however, the flaws of this study become fairly obvious. Here are the ones that strike me as particularly important. The medication group was treated in a different setting than the other two groups. The drugs administered were not clearly defined, and no information was provided about the dosage or the length of the drug therapy. Six patients of the medication group received no treatment at all. Thus any comparisons between patients receiving medication and the other two groups are problematic, to say the least.
      Similar problems exist regarding the comparison between the SMT and the exercise group. There was no adequate control for non-specific effects. It is obvious that the therapeutic encounter and “tender loving care” (TLC) can be beneficial for patients who suffer from neck pain. The SMT group enjoyed an average of 15 hands-on sessions of TLC while the exercise group had just 2 sessions of instructions. For this reason alone, the comparison between these two groups tells us next to nothing about the specific effects of chiropractic SMT.
      I therefore fear that this study merely shows that TLC and non-specific effects can strongly influence symptoms such as pain. If we consider the high costs of regular SMT versus the negligible expense of HEA, the latter would probably turn out to be preferable. If we finally factor in the potential for harm, the balance decidedly tilts towards HEA. Exercise is virtually risk-free, whereas SMT results in transient adverse effects in about 50% of all patients [2]; in addition, it is associated with several hundred severe complications including deaths [3].
      My conclusion is simple: Chiropractic, or more accurately, the uncritical promotion of this approach, can therefore be a pain in the neck.”

      References
      (1) Bronfort G, Evans R, Anderson AV, Svendsen KH, Bracha Y, Grimm RH. Spinal manipulation, medication or home exercise with advice for acute and subacute neck pain. A randomised trial. Ann Intern Med 2012; 156:1-10.
      (2) Stevinson C, Ernst E. Risks associated with spinal manipulation. Am J Med 2002; 112:566-570.
      (3) Ernst E. Deaths after chiropractic: a review of published cases. Int J Clin Pract 2010; 64(8):1162-1165.
      Chiropractic: a treatment for neck pain or a pain in the neck?

      Link: http://web.archive.org/web/20120505100932/http://www.thetwentyfirstfloor.com/?p=3800

  • @Blue Wode

    Bone and Joint Decade Neck Task Force for neck pain conclusion is very similar to findings of study

    http://www.ncbi.nlm.nih.gov/pubmed/18204386

    Let Vicky answer, it’s not national women’s day anymore but we should show some resepect anyway.

    • Jorma Kärtsy wrote: “Bone and Joint Decade Neck Task Force for neck pain conclusion is very similar to findings of study http://www.ncbi.nlm.nih.gov/pubmed/18204386 Let Vicky answer, it’s not national women’s day anymore but we should show some resepect anyway.”

      There’s plenty of room for all to comment on this blog as and when they like it.

      As for the Bone and Joint Decade findings…

      “…the Bone and Joint decade is very muted in its endorsement of manual therapies of neck pain, regarding them as about equal to five or six non-manipulative approaches including laser therapy and massage. These others possibly perform only marginally better than placebo, if at all, when you take into account the difficulties in blinding studies of such interventions.
      That publication also blithely dismisses the question of stroke by reference to a single study [the notorious study by Cassidy et al which has been critiqued in the comments above] which did not even directly establish which patients had their necks manipulated and which did not. It also ignored many simple observations that make it extremely unlikely that specific strokes preceded manipulation.”

      Ref. Comment 33 from an MD here:
      http://www.sciencebasedmedicine.org/neck-manipulation-risk-vs-benefit/

  • @Jorma, on what do you base your opinion that medication is more dangerous than neck manipulation?

  • @Olle, very much appreciate your neutral approach.

    It’s not just my opinion in mechanical neck pain. I don’t mean neck manipulation, more manual therapy combined with exercise.

    http://www.ncbi.nlm.nih.gov/pubmed/18204386

    Think you are aware risks of e.g. NSAIDs. Here MDs always give patients muscle relaxants, opioids, pregabalin etc. And everything for simple mechanical neck pain. Hope would see one day data about adverse reactions of these very common combinations.

    In that perspective, what do you think of Chiropractic vs. medical risk-benefit ratio in mechanical neck pain?

    • Let’s see:
      Chiropractic: benefits can only be measured reliably if you stick your fingers in your ears, close your eyes and sing lalala.
      NSAIDS: relieve pain. Yes, if you take relatively massive doses of them on a regular basis, they cause harm, but not until after they have made patients’ lives a lot more liveable.

      The choice is: are you going to spend massive amounts of money on some nincompoop who swindles you with a demonstrably dangerous placebo, and possibly die as a result, or are you going to spend candy-bar type amounts of money on products that work and possibly die as a result if you use enough of hem for long enough, all while having a demonstrably better life in the meantime?

      It all boils down to the essential question: are you a reality-denier?

      • Thank you for your opinion. You should marry B. Geir you would make a perfect match.

        • Your attempt at sarcastic humour is not elevating our rating of your analytical prowess, Jorma.
          We are waiting in awe for your answer to Olle’s question, which he repeated below.

  • @Bart B., please, aggressive and/or derogative attacks will achieve nothing, regardless of their contents or directions. :)

    @Jorma, I asked about YOUR opinion, because I can’t have a dialogue with everyone. I am curious about the methods of acquiring and accumulating knowledge: How, in your opinion, do we know if there are risks involved in using e.g. NSAIDs?

  • @Olle

    My opinion is based on experience and information.

    I see subgroup of patients who don’t respond and/or tolerate pharmacological approach on treatment, so my experience might be very different than yours and my direct everyday experience is showing NSAIDs etc. not very usefull.

    Do you have direct experience of adverse reactions of neck manipulation?

  • Jorma said “My opinion is based on experience and information. I see subgroup of patients who don’t respond and/or tolerate pharmacological approach on treatment, so my experience might be very different than yours and my direct everyday experience is showing NSAIDs etc. not very usefull.”
    —Thank you, Jorma. Does that imply that you are unaware of our human shortcomings regarding memory, cognitive bias, lack of objectivity, and inevitability of self-deception? Am I correct to infer that your belief in chiropractic treatment also is founded on your personal “experience and information”? That is called “anecdotes” and is, sadly, too subjective to be trustworthy.
    Modern scientific methods were developed exactly in order to avoid the traps involved in all that. With correctly applied scientific methods, we don’t have to rely on personal experience that “might be very different” from one another, but on facts that are as hard and objective as possible, and consequently applicable to anyone, regardless of personal experience. As a result, for example, blood-letting and many other strange treatments, although strongly believed in and loved for centuries, were abandoned in favour of therapies which showed probability of having a positive effect with least possible risks or side effects. All old and new therapies were and are constantly being assessed and reevaluated in the light of accumulating results of an ever increasing amount of studies. We cannot trust anecdotes.
    Treatment effects can be assessed through well-designed studies with proper control groups (any comparison saying “better than…” needs something to fill the slot after “than…”, otherwise it is useless), and preferably randomised and blinded to both experimenter and subjects, so-called RTCs (Randomized Controlled Trials).
    However, unexpected adverse effects can’t, obviously, be included in the study design of an RCT, but they have to be meticulously described and reported in the scientific literature. In this case, although each such report is an “anecdote”, the accumulation of them is indeed “data” to look carefully into. Underreporting is a cardinal sin. Usually it is difficult or even impossible to exactly identify the cause of the adverse effect, but if the association is strong, the safety-first principle dictates that the implicated treatment be halted until more data collects and the suspicion can be confirmed or refuted.
    This is the situation for NSAIDs and their reported adverse effects, in case you didn’t know, Jorma. But so many well-designed RCTs also show that they are better than placebo in so many conditions, so then it is up to the care-giver and patient to balance the hoped-for benefits against the possible adverse effects. Often enough, the balance is in clear favour of the NSAID, but the contraindications are well known and warned against.
    Incidentally, this is also the situation for chiropractic. I.e., the alleged *benefits* are collections of anecdotes! The published RTCs so far show no or very little beneficial effects of, say, neck manipulation, the better the study, the less the effect. And reports of adverse effects are also accumulating, and can’t, of course, be assessed in RCTs. Some of these adverse effects are very serious, even fatal. There are several hundred published reports on serious adverse effects (stroke) associated with neck manipulation. Everybody knows that an “association” is no proof of “causation”, but that applies equally well to the alleged benefits of neck manipulation. So the risk/benefit balance reaches asymptotic values, and in the eyes of the medical profession, the only conclusion is that the implicated treatments must be halted until more is known. I.e., neck manipulation has to be halted, and then there will be no chance to know more to confirm or refute the suspicion. But at least no more patient will have to die under the suspicion that neck manipulation caused it.

    • @ Ollie – “—Thank you, Jorma. Does that imply that you are unaware of our human shortcomings regarding memory, cognitive bias, lack of objectivity, and inevitability of self-deception? Am I correct to infer that your belief in chiropractic treatment also is founded on your personal “experience and information”? That is called “anecdotes” and is, sadly, too subjective to be trustworthy.”

      The simple solution to that is to keep a daily pain/treatment journal. Much more effective than modern scientific methods for the individual case. Research and evidence is great to get a starting point, so as not to reinvent the wheel – but for individual treatment it falls short. In the end, personal anecdote is all that matters in terms of individual treatment.

    • @Olle

      Firtst you give a lesson of subjectivity and then you give extremist opinion that neck manipulation must be banned.

      I would ask from other camp how we can trust on NSAIDs RCT’s done by Big Pharma?

      Are you aware of any RCT’s comparing neck manipulation, exercise and NSAIDs in threatment of mechanical neck pain?

      And I did reply your questions and you didn’t mine so again to keep dialogue alive: Do you have direct experience of adverse reactions of neck manipulation?

  • Couldn’t agree more Jm, I’ve known people that have trusted their MD’s their WHOLE lives and have now kidney / liver damage from being on pain medication for the whole of it also.

    Others have (thankfully) gone to see a DC, BUT not after trusting the mainstream medical industry and had damaged liver and kidneys from being on painkillers for many years, only to have a COMPLETELY different view of DC’s after actually VISITING them. They don’t have to go for the REST OF THEIR LIVES either, just enough to fix the problem, sometimes yes they have to revisit as things come out of place again or something else gets injured (or even the same thing) but that is life.

    I’ve heard such good things about DC’s (and some MD’s also as so many people say, finding a good MD is like finding a needle in a hay stack, I believe the same thing to be true with a DC) and seen people get off their pain meds BECAUSE of them.

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