MD, PhD, FMedSci, FRSB, FRCP, FRCPEd

The above title was used for a Statement for Healthcare Professionals From the American Heart Association/American Stroke Association

I have taken the liberty to quote its abstract in full:

Purpose—Cervical artery dissections (CDs) are among the most common causes of stroke in young and middle-aged adults. The aim of this scientific statement is to review the current state of evidence on the diagnosis and management of CDs and their statistical association with cervical manipulative therapy (CMT). In some forms of CMT, a high or low amplitude thrust is applied to the cervical spine by a healthcare professional.

Methods—Members of the writing group were appointed by the American Heart Association Stroke Council’s Scientific Statements Oversight Committee and the American Heart Association’s Manuscript Oversight Committee. Members were assigned topics relevant to their areas of expertise and reviewed appropriate literature, references to published clinical and epidemiology studies, morbidity and mortality reports, clinical and public health guidelines, authoritative statements, personal files, and expert opinion to summarize existing evidence and to indicate gaps in current knowledge.

Results—Patients with CD may present with unilateral headaches, posterior cervical pain, or cerebral or retinal ischemia (transient ischemic or strokes) attributable mainly to artery–artery embolism, CD cranial nerve palsies, oculosympathetic palsy, or pulsatile tinnitus. Diagnosis of CD depends on a thorough history, physical examination, and targeted ancillary investigations. Although the role of trivial trauma is debatable, mechanical forces can lead to intimal injuries of the vertebral arteries and internal carotid arteries and result in CD. Disability levels vary among CD patients with many having good outcomes, but serious neurological sequelae can occur. No evidence-based guidelines are currently available to endorse best management strategies for CDs. Antiplatelet and anticoagulant treatments are both used for prevention of local thrombus and secondary embolism. Case-control and other articles have suggested an epidemiologic association between CD, particularly vertebral artery dissection, and CMT. It is unclear whether this is due to lack of recognition of preexisting CD in these patients or due to trauma caused by CMT. Ultrasonography, computed tomographic angiography, and magnetic resonance imaging with magnetic resonance angiography are useful in the diagnosis of CD. Follow-up neuroimaging is preferentially done with noninvasive modalities, but we suggest that no single test should be seen as the gold standard.

Conclusions—CD is an important cause of ischemic stroke in young and middle-aged patients. CD is most prevalent in the upper cervical spine and can involve the internal carotid artery or vertebral artery. Although current biomechanical evidence is insufficient to establish the claim that CMT causes CD, clinical reports suggest that mechanical forces play a role in a considerable number of CDs and most population controlled studies have found an association between CMT and VAD stroke in young patients. Although the incidence of CMT-associated CD in patients who have previously received CMT is not well established, and probably low, practitioners should strongly consider the possibility of CD as a presenting symptom, and patients should be informed of the statistical association between CD and CMT prior to undergoing manipulation of the cervical spine.

In my view, this is an important statement to which I have little to add – however, I hope that the readers of this post will have comments, criticisms, observations, opinions, etc.

84 Responses to Cervical Arterial Dissections and Association With Cervical Manipulative Therapy

    • thank you. and the crucial sentence from the full text is this one: “the
      current best available evidence suggests that CD, especially
      VAD, may be of a low incidence but could be a serious complication
      of CMT”

  • Thanks for the article – very interesting

    Do you think a prospective cohort study can be done on CD?

  • How can it be done and for how much?

  • Well written. Very important topic!
    Informed consent is mandatory here which includes the stastistics as stated above. It is a mandatory common law requirement and it is checked every year by the registration board and professional indemnity insurers.
    I couldn’t agree more in regards to the statement on a thorough history and examination. My patient initial questionairre has a whole section on it! Also agree on the necessity of more research!
    I had a patient years ago who had a positive vertebral artery test on the initial consultation, Said I would call an ambulance immediately, he refused, I eventually bullied him into allowing me to take him myself to the local emercency 5 minutes away. He collapsed with a heart attack as we walked into the emergency waiting room. I informed the doctors of the positive VAT. Next day the hospital called to thank me for the heads up in regards to the vertebral arteries as imaging showed blockages in all of them except one! An anaesthetic could have killed him! Interestingly there was no red or yellow flags in the history.

  • This is almost certainly THE most important issue in the whole debate about manipulation and should be a priority research issue for all the physical therapy professions. 38 years of practice has proven to me anyway that the vast majority of neck problems can be improved quickly and WITHOUT resorting to manipulation. Physical therapy providers need to broaden their therapeutic scope and use manipulation last and ONLY when all else fails and there is no clinical evidence of cervical arterial weakness. Identifying the latter requires a high degree of clinical suspicion, high clinical education and physical examination, access to appropriate imaging, and of course a distinctly less blasé approach by manipulators.
    Excellent post!

  • That should have read ‘high quality’ education…

  • Well, I’m skeptical about this so-called “scientific statement”. What is so scientific about it? This has to be the first time in the history of the AHA and the ASA that they felt it necessary to issue a warning to every provider and patient about a procedure that is likely a “rare occurrence” and there is no definitive connection and “it cannot be said with certainty that neck manipulation causes strokes”. Of the 800,000 strokes that occur each year of all kinds, none can be attributed to spinal manipulation. But there might be a small “statistical” association. But there may not be. But maybe there is. Or not. Best to warn every human in case there is. But there may not be.

    Best advice when it comes to spinal manipulation and non-drug approaches to health is to just steer clear of the osteopath and medical/big pharm industry who take a few electives in this and never met a drug they didn’t like. Steer clear also of the physio trades who take a weekend course once a year, go back to their job and practice by trying their hand with rough, non-specific and imprecise manipulations on the unsuspecting public on Monday morning. But they hope they get a raise by increasing their knowledge.

    I do like one of the MD’s name on this “statement”, Jose Biller. The name Biller is very appropriate to the medical industry- create wealth not health.

    It is plain to see that this whole “scientific statement”, whatever that means, was a favor to the radical, anti-chiropractic extremists, so therefore, it fails the smell test.

    • are you sure that it is not YOU who has failed the ‘smell test’ with this comment?

      • “are you sure that it is not YOU who has failed the ‘smell test’ with this comment?” — EE

        Really, Edzard? So now you are relying on insults? I would expect this of Bjorn, being stuck out there in the middle of nowhere. But I expected more from you. This really is below your station, IMO.

        The AHA’s so-called “scientific statement” is a gift to the those insane, life-long chiropractic-haters who walked away empty-handed in Connecticut a few years ago. They had nothing “official” or legitimate to back up their nuttiness. Now, someone did them a favor.

        BTW, among the list of allopaths is one lone chiropractic doctor, Preston Long. Now why in the world would his name be there? I guess his qualifications, other than failing to appear at the Connecticut hearings, is his hatred for his own profession. A very anemic C.V., IMO.

    • Beware all dedicated disciples of the great Lord Palmer!
      The “radical, anti-chiropractic extremists” are crawling out of their institutional holes all over the world and assembling hordes of evil evidence to defame our most precious manipulation.
      Even their names are evil signs of their Big pharma origins. Let us unite in denial and ridicule and fight the destructive scientific statements that may jeopardise our practice building by taking away the right to wring our income out of the necks of the worried-well without telling them about their one in a million chance of ending up like Wallenberg!!

  • In reply to SkepdocProf:
    Mandatory Informed Consent! Any risk MUST be discussed with the patient. Non-negotiable, its the patients chioce not yours!

    In reply to Björn Geir:
    Thanks for citing Sam Homola and Preston Long. Critics within the profession are vital and should be appreciated and lauded!

  • Unfortunately all too true!
    I have some issues with you at times, but on the whole I agree with much of what you say!
    Chiropractic needs to mature/grow up and embrace the critics!

  • Here is evidence based reply to statement:

    http://www.youtube.com/watch?v=zCp_KDXet9g&feature=youtu.be

    Could you Edzard comment on this?

    P.S. This is also for you Björn, no any reading needed.

    • Actually you happened to refer to a sermon presenting a massive collection of reading material.
      But as you telepathically guessed, today I am lazy and want to spend today celebrating my wifes birthday.

      Interesting tape. At least phenomenologically.
      Of course chiropractors preach passionately in praise of Lord Palmer at their secular conventions.
      Perhaps some day, the Palmer-disciples will assemble a tape similar to this one, in honour of their 10 most influential preachers:
      http://youtu.be/kyD3c4x8J00

      This lady will surely make the shortlist. Maybe Jorma and some other of our friends here will too?

      • As so many other branches of alternative medicine, the culture and congregation of chiropractic bear strong resemblances to those of a religious movement. Not only are chiropractors, as so well demonstrated in the discussions here, prone to religious-like fervor when their beliefs are under attack. Their founding father, D.D. Palmer himself was very clear in his understanding of himself and his intentions . In this letter his eminence reveals his divine self-image:

        I occupy in chiropractic a similar position as did Mrs. Eddy in Christian Science. Mrs. Eddy claimed to receive her ideas
        from the other world and so do I. She founded theron a religioin, so may I. I am THE ONLY ONE IN CHIROPRACTIC WHO
        CAN DO SO.

        (the capitalisation is not mine)

        • @ Björn Geir

          DD Palmer addressed, at length, ‘The Moral and Religious Duty of a Chiropractor’ in his 1914 book, The Chiropractor:
          http: philosophyofchiropractic,com/wp-content/uploads/2012/04/DD-Palmer-quote-THE-MORAL-AND-RELIGIOUS-DUTY-OF-A-CHIROPRACTOR.pdf [Link disabled by admin due to suspected malware]

          Read and weep.

          Snippet:
          “By correcting these displacements of osseous tissue, the tension frame of the nervous system, I claim that I am rendering obedience, adoration and honor to the All-Wise Spiritual Intelligence, as well as a service to the segmented, individual portions thereof—a duty I owe to both God and mankind. In accordance with this aim and end, the Constitution of the United States and the statutes personal of California confer upon me and all persons of chiropractic faith the inalienable right to practice our religion without restraint or hindrance.”

    • Towards the end of the link posted by Jorma Karsty she informs us that “association is not causation” “just because one thing happens after another it doesn’t mean it was caused by that intervention”

      How ironic! If more manual therapists had that in mind they might find their interventions not as positive as they thought.
      Even when all the evidence concludes that “association is not causation” with spinal manipulation Chiropractors seem to cherry pick when this message is appropriate.

    • Thinking_Chiro wrote: “Physio’s response to the AHA statement!
      http://www.physiospot.com/sponsors/aaompt-responds-to-american-heart-association-cervical-manipulation-paper/#sthash.BRrm6VSL.uxfs
      Interesting!”

      Yes, very interesting. Notably, they say that they are “committed to educating the public about the appropriateness of neck manipulation” and then go onto say that:

      QUOTE
      “Guidelines for manual therapy treatment of the cervical spine have been available for the last 2 decades to assist practitioners in clinical decision making. In 2012, a clinical reasoning framework was developed by the International Federation of Orthopaedic Manipulative Physical Therapists to provide guidance for the assessment of patients for the likelihood of stroke in advance of cervical manipulation. Identified risk factors associated with an increased risk of stroke include history of trauma to the cervical spine, history of migraine-type headache, hypertension, cardiac or vascular disease, diabetes, blood clotting disorders, history of smoking, and recent infection.”

      Surely they must know that there are no reliable methods available to screen for patients who might be at risk of stroke prior to neck manipulation?

      Now contrast the above with the following comments on the AHA/ASA statement from Science Based Medicine neurologist, Steven Novella:

      QUOTE
      “I do think they are understating the probability of a causal relationship, however, probably because they were overly influenced by the Cassidy study, which they should not have been given its fatal flaws…Medicine is a game of risk vs benefit, and so considering the risk is not enough. What is the benefit of CMT for the specific conditions it is used to treat? The evidence for the benefit of CMT is less than the evidence that it causes VAD. A Cochrane review of CMT for neck pain and headache concluded: Done alone, manipulation and/or mobilization were not beneficial; when compared to one another, neither was superior. So CMT does not work, but perhaps may have some benefit when added to medical management, and even then it is no better than the gentler mobilization. Therefore, since CMT (if it works at all) is not superior to mobilization, and may involve a rare but serious risk of VAD and stroke, it seems to me it is unethical to perform CMT for neck pain or headache rather than mobilization….The current review is further evidence that CMT should be eliminated as a medical procedure.”

      Ref: http://www.sciencebasedmedicine.org/a-statement-on-cervical-manipulation-and-dissections/

  • Some of Palmers researchers. They are making a large invest in research!
    http://www.palmer.edu/Research/FacultyandStaff/
    http://www.palmer.edu/Research/GrantsandProjects/
    Food for thought!

    Some of their researchers in PubMed!
    http://www.ncbi.nlm.nih.gov/pubmed/?term=pickar+jg
    http://www.ncbi.nlm.nih.gov/pubmed/?term=DeVocht+jw
    http://www.ncbi.nlm.nih.gov/pubmed/?term=Gudavalli+mr
    http://www.ncbi.nlm.nih.gov/pubmed/?term=Hondras+ma
    http://www.ncbi.nlm.nih.gov/pubmed/?term=Onifer+sm
    http://www.ncbi.nlm.nih.gov/pubmed/?term=Reed+wr
    http://www.ncbi.nlm.nih.gov/pubmed/?term=Vining+r

    I have noted increasing research out of Palmer being published in top peer reviewed medical journals like Trials, BMC, Journal of Electromyography and Kinesiology, JMPT, Brain Research, Neuroscience, Experimental Neurology, American Journal of Medical Science, Journal of Neuroscience Methods, Spine, Cochrane Database Systematic Review, Pain, C&MT, Clinical Orthopedics and Related Research, Manual Therapy, Journal of Applied Physiology and Journal of Neurophysiology.
    Interesting!

  • How about all biomechanical studies which show no causation. Do we have superhuman non-mechanical force to cause artery dissection then?

    Björn glad to hear you. You are so agitated all the time.

  • It is also being discovered now that this whole “scientific statement” is a gift to the chiropractic-hating extremists who left Connecticut empty-handed a few years ago. This “paper”, it is thought by many, to be in exchange for huge donations to a medical institution. This is all being looked into now.

    • …and it’s been discovered that SKEPDOCPROF is an alien from mars – but, of course, as for his speculations, there is no evidence for mine.

      • Hey! These math questions to get in here are getting harder!

        “and it’s been discovered that SKEPDOCPROF is an alien from mars – but, of course, as for his speculations, there is no evidence for mine.”

        Ha-ha, very funny, EE! Glad to see that you have managed to maintain some sense of humor given your travails.

        But seriously, EE, the woman who spent a bundle o’ dough in Connecticut terrorizing the population with false warnings on billboards and buses for years and left empty-handed in a huff to her home in Palm Beach, has been raising hundreds of thousands of dollars for the neurology department of the university the past few years. The recipient of her “generousity” and guest of honor at these opulent galas just happens to be… the second lead author of this so-called “scientific statement”. Plenty of photo ops on the web when you plug in the names.

        IMO, it is just payback for the past failures in Connecticut. The incriminating data is all available on the web and is being dutifully recorded. I suspect the head neuro doc will have to explain, what appears to me, to be a gross impropriety. His university and the AHA will be forced to look into it and do something about it sooner or later. It may take a while, but it took a while in Connecticut, too. We are persistent. We prevailed.

  • Thank you Thinking_Chiro for physiotherapy response to AHA statement:

    http://www.physiospot.com/sponsors/aaompt-responds-to-american-heart-association-cervical-manipulation-paper/

    Could anyone tell me why they don’t refer excellent papers of our CAM expert Edzard?

  • In Reply to Blue
    The physio statement essentially said the same thing as the chiro’s, pointing out the same deficiencies in the AHA statement.
    Your cherry picking Blue, what about these statements of the physio’s, if a chiro uttered them your response would be totally different.

    “We believe the scientific statement released yesterday, while stating that the incidence of cervical manipulative therapy-associated carotid dissection is not well established, and probably low, is significantly limited in its scope and context and may place unnecessary fear in the public of an effective low risk treatment intervention.”
    If a chiro said this you would go ballistic! Especially the last line!

    “To date, many scientific studies support cervical manipulation for the treatment of head and neck pain of mechanical origin. One systematic review in the Journal of Rheumatology from 2007 reviewed 88 randomized controlled trials and concluded that exercise combined with manipulation or mobilization demonstrated both pain relief and functional improvement in adults with acute, subacute, or chronic mechanical neck disorders. A study in the medical journal Spine5 concluded that manipulative therapy and exercise can reduce the symptoms of headaches of cervical origin and that the effects are long lasting.”
    You would be tearing this to pieces discrediting the trials reviewed as of small size, biased and of limited value.

    “The Scientific Statement developed by the AHA regarding the risks of cervical and neck manipulation must be considered in context of the relative and comparative risks of manipulation.” The risks of cervical manipulation are much lower than the use of other interventions such as the use of anti-inflammatory drugs, injections and surgery explained Rowe. “Many medications, particularly anti-inflammatory and surgery for the treatment of neck pain or headaches have much larger risks than manipulation.” In addition, a 2007 AHA scientific statement10 indicated that for patients with a prior history of or at high risk for heart disease, certain pain relievers known as COX-2 inhibitors could increase risk for heart attack, stroke, and high blood pressure. Also, a 2013 study in Spine11 found that patients who had cervical spine surgery were at significant risk of cardiac and breathing problems as well as gastrointestinal, neurological, blood cell, and urinary tract complications. In addition, there was a greater risk of death after cervical spine surgery among patients older than 65 who had a history of heart problems.”
    Your response to this if a chiro had written it would be to scream “Straw Man” and “Tu quoque” and “Ad Hominem”.

    “Incidents of stroke associated with cervical manipulation of the spine are rare.In a 2002 review12 of 64 cases of cerebrovascular ischemia, or lack of blood flow to the brain, associated with cervical spine manipulation, researchers concluded that strokes after manipulation appear to be unpredictable and should be considered a rare complication of this treatment approach. In addition, a 2010 systematic review in the scientific journal Manual Therapy13 found no strong evidence linking the occurrence of adverse events to cervical manipulation and/or mobilization.”
    And your response to this?

    • Thinking_Chiro wrote: “And your response to this?”

      In a word, disappointing. I think that physiotherapists are failing to adopt a cautious attitude. However, at least their use of neck manipulation is generally more judicious than that of chiropractors. See Fig 2 here:
      http://ptjournal.apta.org/content/79/1/50.long

      I would also refer you to here: http://www.sciencebasedmedicine.org/compare-and-contrast/
      Reports of deaths after chiropractic treatment “about three times the number of deaths from trovafloxacin, an excellent antibiotic abandoned in the U.S. as too dangerous”.

      And to here: http://www.sciencebasedmedicine.org/a-statement-on-cervical-manipulation-and-dissections/

      “There is no question that if this [neck manipulation] was a medication with similar problems being reported there would be strong advisories being circulated, if not an actual withdrawal from the marketplace, there being no clear, uniquely useful place for cervical manipulation in medicine. At most cervical manipulation should be considered as a late resort in fully informed patients with neck pain not responding to other measures. The only barrier to a more rational approach is the heavy investment of chiropractic in the procedure.”

      The final sentence in the above quote is particularly pertinent. Given that neck manipulation is a faster procedure than mobilisation, could it be that those chiropractors who perform it, who aren’t part of the evangelistic ‘upper cervical’ subluxation crowd, are simply being lazy? What other reason could there be?

  • Yes, the physio and osteopath trades are also upset by this so-called “scientific statement”. Can’t be helped. The authors see it as necessary collateral damage. Their skills at spinal manipulation, however, are severely deficient. The osteos are offered a few electives which they don’t take anymore in favor of drug-based treatments so they can be accepted almost like regular MDs later on after graduation so they can more likely be employed in the allopathic/pharma industry.

    The physio trades take a weekend seminar once a year, then go back to their job on Monday to “give it a try” on real people that their employer provides to them. Very crude. This obviously is very dangerous. They mean well. Not a good idea. No. Don’t misunderstand me, they can sometimes be very helpful with their other PT chores. Many chiropractic and orthopedic doctors employ these PT technicians.

    Only chiropractic doctors study spinal manipulation for four years at a chiropractic university, so qualify to provide very skilled specific, controlled and precise adjustments that the others can’t. While the osteos and physios are good at other things, never let them practice spinal manipulation on you.

    • the proper teaching of nonsense will still result in nonsense.

    • @Skepdocprof..you are so naive in your approach. Have you investigated how long osteopaths study for and what their curriculum consists of? You obviously haven’t. You should probably pull that chiropractic carrot out of your arse and stop putting other manual therapists under the same umbrella. The key word is manual therapist. Most chiropractors, osteopaths and physiotherapists all use similar techniques especially when it comes to spinal manipulation and high velocity low amplitude thrusts. Obviously their effectiveness is dependent on their training. Joint manipulations are not taught over a weekend or a day. Where you have got the idea from is beyond me. So to say that osteopaths and physiotherapists are good at other things and to never let them practice spinal manipulation is rather arrogant of you.

      • “Most chiropractors, osteopaths and physiotherapists all use similar techniques especially when it comes to spinal manipulation and high velocity low amplitude thrusts.” YM Wrong!

        Thanks, YM. Looks like I’ve activated a few of your short circuits! I respect all viewpoints, even wrong ones like yours. Yes, only chiropractic doctors study spinal manipulation full-time for four years at a chiropractic university and then receive their doctorate degree.

        I have very high respect for osteopaths, especially in the U.S. They go to osteopath school, not as difficult to get in as real medical school. But they get out and do the things that real allopathic MDs do like drug-based care and surgery. And they are very good at it, too! So they become just like real doctors. But here in the U.S. they are offered only a few electives in spinal manipulation but have no time to take them. They focus on drugs and things that will get them an internship and residency in a hospital if they are let in by the medical industry.

        “Obviously their effectiveness is dependent on their training.” Finally, YM, you got something right!

        The physio trades don’t study this other than an intro in their limited technical schools. They, too, are very good at what they do helping rehab people with some serious issues. I refer to them. Many are given employment by chiropractic doctors. They are very dependent on referrals. As I said earlier, only chiropractic doctors train for four years full-time at a chiropractic university providing drug-free health care.

        “Joint manipulations are not taught over a weekend or a day. Where you have got the idea from is beyond me.” wrong again, YM.

        Well, YM, I have gotten this from the University of Oklahoma:
        http://www.ah.ouhsc.edu/rehab/documents/Spinal%20Manipulation%20Courses%202%20and%203%20Mar%202013.pdf

        and

        http://www.ah.ouhsc.edu/rehab/documents/Oklahoma_2014_Spinal_Manipulation_brochure.pdf

        Here they are having a few beers during their weekend “seminar” then back to work on Monday morning to give it a try on the unsuspecting public:

        https://www.facebook.com/pages/Spinal-Manipulation-Gibbons-Tehan/230596113746257

        So you see, YM, it is not a good idea to let anyone other than a chiropractic doctor provide spinal manipulation. So maybe it is you who has something shoved up your arse, to use your own term. I would never stoop that low. 😉

      • “Most chiropractors, osteopaths and physiotherapists all use similar techniques especially when it comes to spinal manipulation and high velocity low amplitude thrusts.” YM Wrong!

        Thanks, YM. Looks like I’ve activated a few of your short circuits! I respect all viewpoints, even wrong ones like yours. Yes, only chiropractic doctors study spinal manipulation full-time for four years at a chiropractic university and then receive their doctorate degree.

        I have very high respect for osteopaths, especially in the U.S. They go to osteopath school, not as difficult to get in as real medical school. But they get out and do the things that real allopathic MDs do like drug-based care and surgery. And they are very good at it, too! So they become just like real doctors. But here in the U.S. they are offered only a few electives in spinal manipulation but have no time to take them. They focus on drugs and things that will get them an internship and residency in a hospital if they are let in by the medical industry.

        “Obviously their effectiveness is dependent on their training.” Finally, YM, you got something right!

        The physio trades don’t study this other than an intro in their limited technical schools. They, too, are very good at what they do helping rehab people with some serious issues. I refer to them. Many are given employment by chiropractic doctors. They are very dependent on referrals. As I said earlier, only chiropractic doctors train for four years full-time at a chiropractic university providing drug-free health care.

        “Joint manipulations are not taught over a weekend or a day. Where you have got the idea from is beyond me.” wrong again, YM.

        Well, YM, I have gotten this from the University of Oklahoma:
        http://www.ah.ouhsc.edu/rehab/documents/Spinal%20Manipulation%20Courses%202%20and%203%20Mar%202013.pdf

        and

        http://www.ah.ouhsc.edu/rehab/documents/Oklahoma_2014_Spinal_Manipulation_brochure.pdf

        Here they are having a few beers during their weekend “seminar” then back to work on Monday morning to give it a try on the unsuspecting public:

        https://www.facebook.com/pages/Spinal-Manipulation-Gibbons-Tehan/230596113746257

        So you see, YM, it is not a good idea to let anyone other than a chiropractic doctor provide spinal manipulation. So maybe it is you who has something shoved up your arse, to use your own term. I would never stoop that low. 😉

  • So here is their “damning” non-evidence from the lead authors:

    “Treatments involving neck manipulation may be associated with stroke, though it cannot be said with certainty that neck manipulation causes strokes”

    “Although a cause-and-effect relationship between these therapies and CD has not been established and the risk is probably low…”

    “The association between cervical artery dissection and cervical manipulative therapies was identified in case control studies, which aren’t designed to prove cause and effect. ”

    “However, it’s not clear whether other factors could account for the apparent relationship.”

    “The relationship between neck manipulation and cervical artery dissection is difficult to evaluate.”

    http://med.miami.edu/news/neck-manipulation-may-be-associated-with-stroke

    Bottom-line:
    Let’s warn every provider, patient and human on the planet just in case we are right, which we are not saying we are!

    What do you think about that, Thinkin’ Chiro?

  • The AHA statement is certainly vague and open to misinterpretation. Even when they said the things SkepdocProf cited above.
    Physio’s and Chiro’s have both stated the importance of informed consent no matter how rare the risk. Though chiro’s have not said “no strong evidence linking the occurrence of adverse events to cervical manipulation and/or mobilization.” We would be crucified and accused of burying our heads in the sand if we did!

    • …chiro’s have not said “no strong evidence linking the occurrence of adverse events to cervical manipulation and/or mobilization.”
      ARE YOU SURE?
      I know dozens of such statements.

    • Thinkin’ Chiro, no one is arguing with you about informed consent. It is required in every state in the U.S. I do it. We all do it. You do it. But they wave the stroke issue around like college boys wave panties at a college panty-raid (from Edzard’s era I would guess). They stormed into Connecticut like the Gestapo and failed to produce any evidence whatsoever, so they were sent packing in disgrace. The board even cited, in the official record with the approval of the Assistant Attorney General (not a chiropractic doctor) that one of their so-called star-witness “expert”, a Canadian circumcision MD delivered testimony that was totally unreliable!

      What came out of the hearings was that this questionable group is not interested in the safety of the public (400,000 or 800,000, it is still a huge number, die every year in the U.S. alone from preventable medical errors according to the medical journals) but rather they demonstrated that they want to do as much damage to non-drug approaches to health care, just like EE and his following. But they never met a drug they didn’t like!

      The same people re-emerged now and somehow influenced well-known people, who influenced the AHA to produce this this statement as payback that still says that there is no evidence. 800,000 Americans get a stroke each year and none can be attributed to proper spinal manipulation by a chiropractic doctor or the types by the medical or physio technician trades. Several hundred thousand die from strokes, and again, none attributable to spinal manipulation.

      Of course, known factors are drugs, surgery, burgers, scones with clotted cream, fries, looking at your medical bills, watching the news, learning new ways our lawmakers are spending our money, being overweight and bald and not exercising (BTW EE, lifting teacups at 4 pm daily doesn’t count as exercise)

      So you see, Thinkin’ Chiro, keep up the informed consent, very nice, let people know that their tuchas might be a little sore the next day, or muscles might react because things are inflamed and may flare-up, etc., so put some ice on it, but just because you want a pat on the head from EE and a little rub on your tummy along with a few crumbs of his scone that falls off the china and he lets you lick up off the floor, doesn’t mean you are required to tell people their head might explode and die if the prestigious neurologists and the prestigious AHA can’t even provide any proof of your murderous tendencies.

      Just sayin’.

      • so you are from mars after all!

      • “Results from this survey suggest a patient’s autonomy and right to self-determination may be compromised when seeking chiropractic care. Difficulties and omissions in the implementation of valid consent processes appear common, particularly in relation to risk. Practitioners felt that a serious adverse event occurred so infrequently that this, coupled with a lack of convincing evidence regarding the risk associated with certain treatment, rendered the routine discussion of major risk unnecessary.” [http://www.ncbi.nlm.nih.gov/pubmed/17693332]

        • Well, EE, according to the AHA and Dr. Sacco, there is no proof. If a leading neurologist can’t come up with proof, despite his yearly $400,000 donations to his department as a result of opulent galas (this is being investigated as we speak), then how can you:

          “Treatments involving neck manipulation may be associated with stroke, though it cannot be said with certainty that neck manipulation causes strokes”

          “Although a cause-and-effect relationship between these therapies and CD has not been established and the risk is probably low…”

          “The association between cervical artery dissection and cervical manipulative therapies was identified in case control studies, which aren’t designed to prove cause and effect. ”

          “However, it’s not clear whether other factors could account for the apparent relationship.”

          “The relationship between neck manipulation and cervical artery dissection is difficult to evaluate.”

          http://med.miami.edu/news/neck-manipulation-may-be-associated-with-stroke

          However, in the medical industry, there is proof of widespread mayhem and lack of honesty:

          “Doctors are often not completely honest with their patients regarding their diagnosis or prognosis, or in the event of an iatrogenic incident. However, most doctors will respect a patient’s right to refuse treatment. Informed consent practices vary substantially and are largely determined by locally accepted policy and accepted by doctors working in those areas.”

          http://www.ncbi.nlm.nih.gov/pubmed/9885876

          • nobody ever said that there is PROOF – I see that you did not follow my advice to read up about the precautionary principle in health care nor did they teach you about it in chiro school. pity!

        • I suspect that a chiro who doesn’t properly inform his/her customer of the risks might be guilty of an offence under s6 of the The Consumer Protection from Unfair Trading Regulations 2008:

          6. (1) A commercial practice is a misleading omission if, in its factual context, taking account of the matters in paragraph (2)—

          (a)the commercial practice omits material information,
          (b)the commercial practice hides material information,
          (c)the commercial practice provides material information in a manner which is unclear, unintelligible, ambiguous or untimely, or
          (d)the commercial practice fails to identify its commercial intent, unless this is already apparent from the context,
          and as a result it causes or is likely to cause the average consumer to take a transactional decision he would not have taken otherwise.

          A test case would be interesting…

  • Individuals definitely have, but within research articles? Will have to read through my mendeley library folder on Adverse Events. Have 51 articles in it, 5 are yours!

  • SkepdocProf wrote: “[Informed consent] is required in every state in the U.S. I do it. We all do it. You do it.”

    Do you really? How, exactly, can someone consent in an informed manner when opacity is the clearly the overall mode of chiropractors? For example:

    QUOTE
    “We just came across a fancy patient information form that was given to a patient after an assessment by a clinician. The form just blew our minds (but not in a good way) because it seemed to be the perfect clinical tool for generating ongoing pain and disability, and all by the simple process of ramping up the fear. So, just for fun, we thought we’d take you through it…Page 2 “Your nervous system controls everything”… The terrifying consequences of subluxations…The “Spinal Decay Report” Oh my goodness my spine is crumbling!…What is wrong with giving patients detailed information? Absolutely nothing but ultimately information should be accurate and empower the patient to make good decisions. The problems here are legion.”
    Ref: http://www.ebm-first.com/chiropractic/various-concerns/1755-misinformed-consent-what-not-to-tell-a-patient-with-back-pain.html

    More…

    QUOTE
    “Consider a woman consulting a chiropractor for neck pain, which is a common reason for people to seek chiropractic care, and chiropractors claim that it can be effectively treated with spinal manipulation. The relevant facts regarding such a case are as follows:
    • Treatment would be elective, i.e. the patient could, without serious risks, postpone her treatment decision.
    • Other treatments exist, some of which, like exercise, are virtually risk-free [5].
    • The risk of not having any treatment at all is minimal.
    • Chiropractic treatment of neck pain has not been demonstrated to be effective or more effective than competing therapies [6].
    Manipulation of the upper spine is associated with material and significant risks. About half of all patients will experience transient discomfort or pain, and in a (probably small but essentially unknown) number of cases, it may cause arterial dissection with potentially serious sequelae [7]. ‘A significantly more thorough standard of disclosure is needed where the treatment is elective and…the law may require disclosure of all known risks …’ [8]. Thus chiropractors must advise patients with neck pain that the risk–benefit balance of upper spinal manipulation is not demonstrably in favour of this approach and that other, less risky and effective treatments (e.g. exercise) exist [9]. Many patients would be alarmed by these facts and decline treatment. As most chiropractors are self-employed, full informed consent is overtly against their own financial interest. Consequently chiropractors might rarely provide such information (to date no data are available). Yet the mere fact that the patient might become upset by hearing the information, or might refuse treatment, is not sufficient to act as a justification for non-disclosure of information [3]. ‘Therapeutic privilege’ could be the solution and, in fact, seems to be current clinical practice. It means that chiropractors limit disclosure of risks in the belief that this is in the patient’s best interest. However, therapeutic privilege only applies where ‘treatment is so necessary to maintain the life or health of the patient and the consequences of failing to carry it out are so clearly disadvantageous’ [8].”
    Ref: http://rheumatology.oxfordjournals.org/content/43/5/666.2.full

    SkepdocProf wrote: “They stormed into Connecticut like the Gestapo and failed to produce any evidence whatsoever, so they were sent packing in disgrace.”

    I think readers will find the following interesting regarding Connecticut chiropractors, the Connecticut State Board of Chiropractic Examiners, and the Connecticut Chiropractic Informed Consent hearings:

    The hearings resulted in a 4-1 vote against a requirement for chiropractors to gain informed consent from patients regarding the risks of treatment. The four members who voted against the ruling were chiropractors, with the dissenting vote coming from Jean Rexford, executive director of the Connecticut Center for Patient Safety. According to Janet Levy, a chiropractic stroke survivor and founder of Victims of Chiropractic Abuse, Inc. who gave testimony at the hearings, the Chiropractic Board of Examiners was missing two of three public members required by law. Jean Rexford also commented “…they relied on one study [Cassidy et al]. It’s time to really take a close look at how all these boards are being run. We have way too many foxes watching the henhouse”.

    However, according to Jann Bellamy (JD) the 4-1 vote result could be a Pyrrhic victory for chiropractors:

    QUOTE
    “What does this ruling mean? The Board’s declaration that there is no risk of cervical artery dissection and stroke following manipulation is a finding of fact and not binding on the courts. As is their ruling that informed consent does not require a warning. Under Connecticut law, whether a warning of risk is required is determined by the “reasonable patient” standard, that is, what would a reasonable patient consider important in making his decision whether to undergo a particular procedure. One of the very purposes of the reasonable patient standard is to prevent practitioners from setting low standards and then claiming they’ve abided by their profession’s standard of care. Imagine the chiropractor sued for failure to warn who erroneously thinks he’s been inoculated against malpractice claims by following the Board’s ruling. Surprise! As a matter of fact, the hearing transcript and videotape are now in the hands of plaintiffs’ personal injury attorneys, who will mine it for useful information. A couple of years ago the American Justice Society (formerly known as the Association of Trial Lawyers of American) started a chiropractic interest group (that is, interest in suing chiropractors for personal injury). The section collects and distributes such information for AJS members. The chiropractors may have won this battle, but they could be losing the war.”
    Ref: http://www.sciencebasedmedicine.org/not-to-worry-chiropractic-board-says-stroke-not-a-risk-of-cervical-manipulation/

    The following are also very revealing about chiropractors in Connecticut:

    1. The founder of Victims of Chiropractic Abuse, Inc. – a survivor of chiropractic stroke – testifies before the Connecticut State Board of Chiropractic Examiners on the need for Informed Consent prior to neck manipulation. At 1 min 50 secs in she highlights the fact that chiropractors in the audience heckled her during the hearing:
    http://www.youtube.com/watch?v=vk6XFuB90u0

    2. The head of the Connecticut Chiropractic Council, a trade group, refuses to answer an easy question, “What is neck manipulation?” during testimony before the Connecticut State Board of Chiropractic Examiners on 19th January 2010. [3:32 mins video segment]
    http://www.youtube.com/watch?v=LdVMjnaY6L4

    3. Three members of the Connecticut Board of Chiropractic Examiners were caught breaking the law and the state Department of Public Health ordered compliance. Their response? Lobby the legislature for a bill to change the law:
    http://c-hit.org/2011/03/09/state_finds_three_members_of_chiropractic_board_violated_law/

    Also interesting are the following three facts that chiropractors cannot evade:

    First, there are no chiropractic adverse event reporting systems in the US (where the vast majority of chiropractors practice). Despite the US National Quality Forum listing 28 ‘never events’ healthcare mistakes that should never happen and need to be reported – with death or serious disability from spinal manipulation is listed at no. 16 – chiropractors do not have to report this because they have a loophole. That is, the National Quality Forum demands it of clinics and hospitals but no reporting is mandated for individual doctor’s offices where 99% of spinal manipulation is done.
    Ref: http://www.ebm-first.com/chiropractic/risks/1842-letter-from-britt-harwe-president-chiropractic-stroke-awareness-group-csag.html

    Second, bearing the above in mind, according to the US National Practitioner Data Bank, between September 1, 1990 and January 29, 2012, a total of 5,796 chiropractic medical malpractice reports were filed. Common reasons for the lawsuits were strokes and other injuries.
    Ref: http://www.hg.org/article.asp?id=29867
    [NB. Chiropractic malpractice carriers refuse to provide data on the number of claims filed, settlement amounts, etc.]

    Third, reports of deaths after chiropractic treatment are about three times the number of deaths from trovafloxacin, an excellent antibiotic abandoned in the U.S. as too dangerous.
    Ref: http://www.sciencebasedmedicine.org/compare-and-contrast/

    The reality is, that with no reliable reporting systems in place, and only a handful of unimpressive studies to wave about, it’s becoming increasingly obvious to people who care about science that any claims made by chiropractors that spinal manipulation is safe are very definitely not to be believed.

  • In reply to Blue Wode:
    The Connecticut hearings had chiropractors here shaking out heads in disgust. The piecemeal legislation in the USA varying across all the individual states is wrong and needs fixing, though the inherent American phobia of centralized government will be an impediment! Just look at Wall Street! The doctors have done it and so should the chiro’s!

    As for adverse event reporting it is an issue for physio’s, chiro’s and GP’s. An Orthopod here, John Cunningham, made an excellent suggestion that there be a standardized collection and reporting system in hospital emergency departments for all AE’s for all professions, which then gets referred to the relevant registration board for investigation.

    The chiro’s in the UK set up the CPiRLS which was the right idea, wrong organization! It should be the responsibility of the legislators and boards, not a trade organization. That’s like the alcoholic owning the pub!

    As for informed consent, it is a commom law requirement here where what it must contain is clearly spelled out!

  • On Thursday 14 August 2014 at 03:54, SkepdocProf gave a couple of quotes the s/he appears to regard as giving him/her the right to disregard the precautionary principle. Substituting “pain relief” for “cervical artery dissection” and “stroke”, and paraphrasing the quotes and bottomline a bit, SkepdocProf could just as well have said:

    “Treatments involving neck manipulation may be associated with pain relief, though it cannot be said with certainty that neck manipulation causes pain relief”
    “Although a cause-and-effect relationship between these therapies and pain relief has not been established and the chance is probably low…”
    “The association between pain relief and cervical manipulative therapies was not identified in case control studies, which aren’t anyway designed to prove cause and effect.”
    “However, it’s not clear whether other factors could account for the apparent relationship.”
    “The relationship between neck manipulation and pain relief is difficult to evaluate.”

    Bottom-line:
    Oops! Let’s not reveal the weak evidence for neck manipulation but keep telling every provider, patient and human on the planet that neck manipulation causes pain relief!

    What do you think about that, SkepdocProf?

  • Well, Ollie, I’ll tell you what I think of what you wrote: Huh?

    • @ SkepdocProf

      Re: “Well, Ollie, I’ll tell you what I think of what you wrote: Huh?”

      It’s clearly about double standards.

      If it’s any help, my understanding of Olle Kjellin’s post in which he *substitutes* “pain relief” for “cervical artery dissection” and “stroke” (CAD/stroke) is as follows:

      “Treatments involving neck manipulation may be associated with pain relief (CAD/stroke), though it cannot be said with certainty that neck manipulation causes pain relief (CAD/stroke)”
      “Although a cause-and-effect relationship between these therapies and pain relief (CAD/stroke) has not been established and the chance is probably low…”
      “The association between pain relief (CAD/stroke) and cervical manipulative therapies was not identified in case control studies, which aren’t anyway designed to prove cause and effect.”
      “However, it’s not clear whether other factors could account for the apparent relationship.”
      “The relationship between neck manipulation and pain relief (CAD/stroke) is difficult to evaluate.”
      Bottom-line:
      Oops! Let’s not reveal the weak evidence for neck manipulation but keep telling every provider, patient and human on the planet that neck manipulation causes pain relief (CAD/stroke)!

      Essentially, where there’s scant evidence for a therapy, and catastrophic adverse events are on record, an ethical risk/benefit assessment should result in the application of the precautionary principle. Indeed, Olle Kjellin’s post brings to mind section 146 (p.55) of the Statement of Claim of Sandra Nette, a Canadian tetraplegic chiropractic victim:

      Quote:
      “Incredibly, and, acting in bad faith, the College [Alberta College and Association of Chiropractors] attacked the new and surprisingly high number of vascular accidents associated with chiropractic services that were published in the medical literature and reported in the media by demanding a level of evidence it has never demanded of itself. It maintained that the causal link between strokes and chiropractic adjustment remained unproven.”
      Link: http://www.casewatch.org/mal/nette/claim.pdf

      In other words, many chiropractors – and their regulators – seem to find it acceptable to rely on anecdotal or weak evidence where it supports chiropractic treatment, but where similar evidence indicates that serious complications (e.g. stroke) can result from chiropractic treatment, they are quick to dismiss it.

      No prizes for guessing why.

  • Yes, Thinking Chiro, we were shaking “out” heads in disgust here, too. It was the chiropractic profession that set up the hearings. They came from all over. Janet Levy, Murray Katz, Jann Bellamy, Preston Long (well, he didn’t travel far. He was a no-show).

    They were supposed to come here and talk about public safety and informed consent and if doctors need to inform patients they might get a VAD. Instead, they turned it into a circus. It became evident early on that they were more interested in abusing their chance in the spotlight to explain why they just can’t stand chiropractic health care and wanted to demonize chiropractic doctors everywhere. That includes you, too, buddy boy. They have been doing the disgruntled “fear” tactics for years for the purpose of creating a chiropractic-free world. Just like here.

    They presented no neurologists, trauma experts, researchers, stroke experts, vascular experts, brain experts.
    Instead, they presented, as their “star witness expert” a Canadian guy, Murray Katz, MD, a tired pediatrician who specializes in circumcision of all things. He rambled incoherently citing no reliable data. He was cut off before he was finished by the Assistant Attorney General to move on to the next witness.

    Funny that BW should quote Jann Bellamy after it was all over. She was the “legal expert” who didn’t fail to entertain. She is a Florida attorney who previously did something in real estate before she became a non-expert in anything related to health care. Drinking bottle after bottle of water, she gargled her way through yet another disjointed explanation with an American southern accent why she can’t stand people like you or me. It was her intention to explain to us why the studies showing that spinal manipulation is one of the safest forms of health care is really not safe. Nothing to do with informed consent. The real attorneys asked her if she had any training or previous experience in research or science or interpreting scientific papers. She said no but she started a website devoted to changing the laws of Florida to make sure that anything that’s not drug-based (allopathic) should’t be allowed. Oh, and by coincidence, her husband, an orthopedic surgeon led the crusade to make sure that no chiropractic university opens on the Florida State University campus, his alma mater, despite its approval by the Governor, the state, FSU, the FSU board of trustees, etc. This gray-haired gent had a front-row seat at the hearings. We thought it was her father! The Bellamys contribution was to make sure the circus atmosphere didn’t stop.

    I can give you a lot more. In spite of how Blue Wode spins things with edited clips, he wasn’t even there. He watched from his den 6023 kilometers away. Predictably, the lot of them were all booted out of Connecticut pissed-off as all hell.

    So, don’t let Wode-worship cloud your thinking, Thinking. You seem like a nice guy. But they don’t like you either, will never acknowledge you as an educated, compassionate and caring doctor and would love to see you fail. Trust me.

  • Well, EE, first the person, Dr. Sacco, needs to be transparent about how his “scientific statement” came to be, IMO. Why this? Why now? Who influenced him? What influence did the yearly $400,000 donations to his department have on his decision to co-author this “statement”? These questions, among many others, need to be answered…and will be.

  • @SkepdocProf, did you understand me? Did you ever dismiss patients’ reported adverse experiences associated with neck manipulation? Am I mistaken in perceiving some sneering by you at them?

  • “@SkepdocProf, did you understand me? Did you ever dismiss patients’ reported adverse experiences associated with neck manipulation? Am I mistaken in perceiving some sneering by you at them?” Olle

    Yes, I understood you. I politely answered you. Why are you getting your knickers in a knot? I wrote earlier that MDs often take money/donations/gifts in exchange for loyalty. What’s so difficult to understand about that. Done all the time here. Common.

    But what you wrote has nothing to do with what we were talking about ($400,000 donations from opulent galas to people in influential positions to further a personal agenda) so I just thought you were confused. Who is “sneering” at anyone? To answer your new question, like all caring, compassionate, well-trained and thorough doctors, of course I address all adverse experiences about anything in my office. Where did you come up with the idea that I don’t? You don’t know anything about me.

    Unlike properly prescribed and take medications that kill 100,000 Americans EACH YEAR, and medical errors that kill 400,000 to 1 million Americans EACH YEAR, depending on which research you believe, chiropractic health care in general, and spinal manipulation in particular, is one of the safest forms of health care there is since neither drugs or surgery is utilized. So the good news is that “adverse reactions” might consist of some soreness that goes away very quickly. Muscles might react if they are already stressed. I address it, recheck if necessary, give them instructions for self-care at home. I let them know that they may be a little sore the next day, although most aren’t, but I tell them anyway. No big deal. Then they notice that they are even better in movement and function. Most notice improvement right away.

    Similar to exercising after not exercising for some time. Sore for a day or two, then fine. Only for spinal manipulation it is for a much shorter period. An hour or two. The patient leaves and carries on their normal day.

    Obviously, you comment about this but have never utilized non-drug approaches to health like spinal manipulation or chiropractic care and likely never will. I understand. No problem.

    http://med.miami.edu/news/third-university-of-miami-solving-the-neurological-puzzle-gala-raises-nearl

  • Oh, I see. And a little stroke every now and then doesn’t matter so much. It goes away very quickly.

  • Olle, you have been reading too much fiction.

Leave a Reply to Edzard Cancel reply

Your email address will not be published. Required fields are marked *

Gravityscan Badge

Recent Comments

Note that comments can be edited for up to five minutes after they are first submitted.


Click here for a comprehensive list of recent comments.

Categories