While some chiropractors now do admit that upper neck manipulations can cause severe problems, many of them simply continue to ignore this fact. It is therefore important, I think, to keep alerting both consumers and chiropractors to the risks of spinal manipulations. In this context, a new article seems relevant.

Danish doctors reported a critical case of bilateral vertebral artery dissection (VAD) causing embolic occlusion of the basilar artery (BA) in a patient whose symptoms started after chiropractic Spinal manipulative therapy (cSMT). The patient, a 37-year-old woman, presented with acute onset of neurological symptoms immediately following cSMT in a chiropractic facility. Acute magnetic resonance imaging (MRI) showed ischemic lesions in the right cerebellar hemisphere and occlusion of the cranial part of the BA. Angiography demonstrated bilateral VADs. Symptoms remitted after endovascular therapy, which included dilatation of the left vertebral artery (VA) and extraction of thrombus from the BA. After 6 months, the patient still had minor sensory and cognitive deficits.

The authors concluded that, in severe cases, VAD may be complicated by BA thrombosis, and this case highlights the importance of a fast diagnostic approach and advanced intravascular procedure to obtain good long-term neurological outcome. Furthermore, this case underlines the need to suspect VAD in patients presenting with neurological symptoms following cSMT.

I can already hear the excuses of the chiropractic fraternity:

  • this is just a case report,
  • the risk is very rare,
  • some investigations even deny any risk at all,
  • the risk of many conventional treatments is far greater.
However, these excuses are lame for a number of reasons:
  • as there are no functioning monitoring systems, nobody can tell with certainty how big the risk truly is,
  • the precautionary principle in health care compels us to take even the slightest of suspicions of harm seriously,
  • the risk/benefit principle compels us to ask whether the demonstrable benefits of neck manipulations outweigh its suspected risks.


43 Responses to Vertebral artery dissection after chiropractic manipulation: yet another case

  • This is a sobering reminder that the benefit of a treatment or the risk of a treatment is irrelevant: it is the risk-benefit ratio that is of fundamental importance in medicine, and in most, if not all, other fields of applied science.

    Whenever the benefit is indistinguishable from placebo, the risk-benefit ratio [the risk:benefit ratio] becomes infinity when just one person is harmed — regardless of how many people were NOT harmed by the treatment. Only when the benefit has been firmly established to be greater than that of placebo [i.e., a benefit value greater than zero efficacy beyond placebo] does the number of people NOT harmed by the treatment become relevant to risk-benefit ratio analysis and discussions.

    Promotors and vendors of alternatives to medicine [aka sCAM and Integrative Medicine] will go to *any* lengths to sweep this vital (essential to life) issue under the carpet.

  • Prof. Ernst wrote: “…there are no functioning monitoring systems, nobody can tell with certainty how big the risk truly is”

    Does anyone else find it disturbing that reasons identified for under-reporting by UK chiropractors to an unreliable monitoring system include ‘fear of retribution’, ‘being too busy’, and ‘insufficient clarity on what to report’?

    More recently, the main barriers to implementing a chiropractic paediatric monitoring system were revealed as being ‘time pressure’ (96%) and, oddly, ‘patient concerns’ (81%):

    The above suggests that, despite regulation, most chiropractors are prepared to put profit before patient safety.

    Further, as things currently stand, it would appear that in a court case a defendant practitioner/chiropractor can rely on his *colleagues* to testify in his defence regarding the safety of treatment…

    Also see:

  • I hope you haven’t just read the abstract. There is nothing here of why the patient presented to the chiropractor. Edzard, if the patient presented with neck pain, are you able to tell me the chances that this person was already undergoing a stroke? You presume the neck manipulation caused the stroke yet fail to mention that the chiropractor may have not performed a thorough history and examination which may have revealed a potential VAD.
    As a chiropractor of 10 years I perform neck manipulations daily and have helped thousands of patients with chronic conditions. In my clinical experience as long as a thorough case history and examination are performed, knowing when NOT to adjust the neck is the important issue. Every intervention has a risk, but I’m afraid for some reason you fail to put this into its proper context. Reviews have shown that dissection following cervical manipulation is approximately 1:8.06 million office visits, 1:5.85 million cervical manipulations, 1:1430 chiropractic practice years and 1:48 chiropractic practice careers.

    I recommend you read this case study: Recognition of Spontaneous Vertebral Artery Dissection Preempting Spinal Manipulative Therapy: A Patient Presenting With Neck Pain and Headache for Chiropractic Care

    • I am not assuming anything, I am reporting the interpretation of the events as seen by the physicians who cared for the patient and should therefore be best positioned to make the correct judgements.

    • @Simbo

      There is nothing here of why the patient presented to the chiropractor.

      You are demonstrably wrong! Either you have not read the case report yourself or rather, you have not understood it.


      A 37-year-old woman with a 1-month history of neck pain presented with acute onset of dizziness, diplopia, dysarthria, right hemiparesis, and right-sided central facial palsy in immediate continuation of cSMT in a chiropractic facility. The neck pain was initially ascribed to recent physical exercise on a step trainer with dumbbells. The patient had received cSMT once a week for her neck pain, and had just completed her third treatment when the symptoms developed while sitting in the chiropractor’s waiting room after treatment.

      There is no reason to assume that the authors left anything of importance untold in this case history. The patient had a one month[sic] history of neck pain initially ascribed to recent physical exercise. She had two weekly cSMT sessions for this before the signs of stroke suddenly(!) presented immediately(!) after the third cSMT session. It takes a good helping of delusional denial to interpret this as her having had the stroke before going to the chiropractor. More likely, the previous manipulations had torn her VA’s and the third one dislodged the thrombus that built on the tear. (You can look up these difficult medical terms on WP if you do not understand them)

      Instead of trying to make things up to convince us that your ministrations are safe, why don’t you tell us how you audit your own practice and how you follow up on your cases so you can register the ones who do not return because they are in hospital with a stroke. Or in simple English: How do you know that none of your patients have had a stroke after neck manipulation? Do you call all the patients who do not return for more “adjustments”??

      • VADs have been know to be assoc with exercise. It is possible the reason she originally sought chiropractic care was due to the symptoms of a VAD.

        Example, albeit a more extreme presentation:

        • .Shorter chiropractic: “It wasn’t me. I didn’t do it. I wasn’t even there.”

          There are multiple causes of VADs. I think we can all agree that. The question that matter is: for any given activity, what are its benefits vs its risks of harm? So what are the benefits of chiropractic neck twists, other than they make for great (and billable) drama?

          Because if those benefits do not greatly outweigh the risks then you should not be doing that. (And even if they do, you should not be doing it without informed patient consent and very good insurance.)

      • @DC
        Yes, it is possible, and may even have been the case.
        It is true that many cervical artery dissections are diagnosed after intensive activity, Very many are also not preceded by any noteable activity. In the latter of your case reports it says that 75% of those diagnosed with VAD’s make good recovery and mortality is 5%. That is a f-ng high death rate, especially as we are talking about many of these patients are in the beginning of their adult life. A deadly serious condition indeed, if one in twenty dies. Many others also suffer serious debilitating permanent neurological injury from the resulting stroke.
        Also, there is no mention that recent chiropractic attention was ruled out in these cases, that should be routine if we want to know more about the risks of such practice. Symptoms can take days to developand it may not be something the patients connect to the later development. Or they are unable to report anything about the recent past.

        The young mother in this case sought the services of a chiropractor for neck pain, related to a fall, if I remember right. Let’s postulate that she actually had a vertebral artery injury, which gave her the symptoms. The chiro wrung her neck instead of referring her to hospital for suspected VAD. I guess that’s what chiropractors do when presented with a case of neck pain, right? What do you think her chances of survival had been if she had NOT had chiropractic neck adjustment? Would it have been 95%, like in those who seek medical care?
        The chances of survival from cervical artery injury is X % (unknown) in those who seek chiropractic care for neck pain caused by a pre-existing cervical artery lesion?
        Here is a very important question for you, DC:
        What do you think the true value of X may be?
        Higher than 95%
        Equal to 95%
        Lower than 95%
        Or very much lower than 95% ?

        Please justify your estimation.

        • In the case of the fall, acute soft tissue injuries are often listed as a contraindication to spinal manipulation.


          Many published serious AE could have been avoided if the practioneers had not done spinal manipulation because of the presence of red flags or contraindications.

          “This review showed that, if all contraindications and red flags were ruled out, there was potential for a clinician to prevent 44.8% of AEs associated with CSM.”


          So it appears what is going on is we have practioneers doing cSMT when there is evidence that it should not be done. That is practioneer error not procedure error (although the later can occur too).

          Thus there are two main issues here.

          1. Educating practioneers on contraindications to cSMT (this was covered in depth in my education, not sure about other professions. I know PTs and MDs have weekend classes to learn SMT)

          2. Proper technique. Chiropractors have the most training in SMT compared to any other health profession.

          It is also interesting to note that chiropractors do around 90% of spinal manipulation amongst the four health professions but only have 70% of the published serious AE. Of course there are several reasons that could explain this but it appears non chiropractors could be more of a risk of a serious AE.

          Yet i have yet to see any official PT, DO or MD organization call for a ban on cSMT.

          • Why do you not answer the questions, DC??

          • There are several reasons I didn’t answer your question. Such as:

            1. I was addressing this comment of yours…”More likely, the previous manipulations had torn her VA’s…”
            2. I happen to be very busy at this time.
            3. To properly answer your question (which is a good question) would be the equivalent of writing a paper if one takes into account the many variables that need to be considered.

          • I think you must be misunderstanding me, DC. This was only one very simple multiple choice question. Maybe I wrote it up too complicated for you. I am sorry but I was in a bit of a hurry then, and even more when I quipped at you for not answering.
            I will repeat the quiestion here, more clearly so you can better understand it. You only have to choose a, b, c, or d. Just like in high school.

            Here is the background, redacted for better clarity:
            The young mother in this case sought the services of a chiropractor for neck pain, related to a fall. Let’s postulate that she actually had a vertebral artery injury, which gave her the symptoms. The chiro “adjusted” her neck twice in a few days instead of referring her to hospital for suspected VAD.
            We have already established that the chances for survival with medical care are around 95% (your own reference)

            And the question:
            What do you think her chances of survival had been if she had NOT had chiropractic neck adjustment but been referred directly for medical care when she first presented with neck pain, gven that she already then had a pre-existing cervical artery lesion?

            Just choose one and explain yor choice.

            a. More than 95%
            b. Equal to 95%
            c. Less than 95%
            d. Very much less than 95%

          • Bjorn,

            And the question:
            What do you think her chances of survival had been if she had NOT had chiropractic neck adjustment but been referred directly for medical care when she first presented with neck pain, gven that she already then had a pre-existing cervical artery lesion?

            I don’t think that was the question you posed originally. You asked what did DC think her chances of survival would have been had she sought chiropractic care for symptoms caused by a pre-existing vertebral artery lesion. We have already established that her chance of survival if referred directly for medical care would have been 95% (though in practice it is never that simple, of course).

          • As stated in my point 3, too many unknown variables (assumptions) to provide an informed answer.

          • Oh rats!

            Many thanks Julian.
            My mind was elsewhere when I wrote this. An upcoming exam, age and a dash of ADD.
            Of course I was asking DC what he thought were her chances WITH chiropractic care instead of medical care. Where would we be if we didn’t have your erudite and attentive brain to keep us on track, Julian? I wish I could come visit and have a chat at your pub.

            Now, DC!
            From your prevaricative response, I can tell you didn’t even read my redacted and then corrected question. At least you didn’t even attempt to understand it.
            Try to read the question again, with the above correction, and just tell us what you think. You don’t even need to look up from the computer, just THINK! No variables needed, just common sense.
            Of course this is in reality not so simple, as Julian correctly reminds us, but I am not asking you to start on some futile excercise in playing scientist or sooth-sayer, just a little bit of your professional insight. Takes half a minute, really! You are a real chiropractor so you should have an informed opinion on this matter, right?

  • That case report just described what the chiro did as cSMT and is a very poor reference on this topic. It went into no further detail as its main focus was on what the doctor did. We had a conversation here with the doctors last year following an article in The Medical Journal of Australia where there was agreement that an adverse event reporting system for all professions (chiro, osteo, physio, GP etc) was needed. What the doctors also ageed upon was accurate and detailed reporting unlike the above case report. It is discussed here I recently talked to one of the doctors whether it has progressed? He replied that there was “snivelling” within the hospitals over who would pay for it and it went no further!

  • @C-C
    What do you mean poor reference on this topic? Its a case report for goodness sake. Should they have asked the chiro for a demonstration of how he “adjusted” the victim?.
    The patient went to a chiropractor for neck symptoms, got chiropractic care and stroked at the third session. The victim was positively diagnosed with VAD and was saved by genuine medical care. What more informmation do you want? It is crystal clear to me and anyone with a modicum of sense, what happened
    VAD/stroke is a rare complication of neck manipulation. There are scores of case reports to substantiate this risk. No one has been able to confirm any benefit from (chiropractic) neck manipulations. Stroke is always a serious event and can lead to injury worse than death, e.g. Wallenberg syndrome. Ergo… Neck manipulations, whether performed by chiropractor or not, should be strongly discouraged and its perils publicised.
    Do you not agree and if so, why?

    • Dr Geir, you clearly do not understand what Critical Chiro was asking. There are many ways of treating a patient. From soft tissue massage, mobilisation, medications, ultrasound, exercises, pilates,TENS, manipulations and adjustments, just to name a few. Even within this list, areas of the spine that are treated are important. E.G upper cervical, thoracic area. Within this, the practitioner’s experience and expertise comes into affect, as with any procedure in health care. CC was asking for a more precise description of the method of treatment the practitioner used, and area treated. This is a reasonable request and it is a shame that you have chosen to be so offensive and aggressive about this.

      • Offensive, aggressive… ? Nah. Harsh and outspoken… Maybe.

        Perhaps you do not realise GG, what is at stake here? People are being exposed to a fairly uncommon but extremely severe risk and the chiropractic core is blatantly blind to their own responsibility. Instead of getting their act together and doing the right thing, they prattle on about the evidence not being good enough… etc.

        The reason I use harsh words is very simple. Spending most of your life dealing with disease, injuries, desperation and misery, you get involved, very much involved!
        So when you come across a whole “discipline” of charlatans, “educated” in pure, demonstrable nonsense who are allowed to play[sic] with peoples problems and pretend they are fixing non-existent problems (subluxations) defrauding[sic] customers for financial gain and putting people at terrible risk on top of it… then of course one’s language hardens.

    • @Björn Geir
      Good questions.
      Chiropractic is not a single technique and most chiropractors utilise a multimodal approach. What is the ideal approach, combination and dosage is the subject of much recent research.
      Risk/Benefit and cost benefit are also important. Some recent research:
      Treatment preferences amongst physical therapists and chiropractors for the management of neck pain: results of an international survey
      Evidence-based guidelines for the chiropractic treatment of adults with neck pain.
      Manipulation and mobilisation for neck pain contrasted against an inactive control or another active treatment.
      Short term treatment versus long term management of neck and back disability in older adults utilizing spinal manipulative therapy and supervised exercise: a parallel-group randomized clinical trial evaluating relative effectiveness and harms
      Spinal manipulative therapy and exercise for seniors with chronic neck pain.
      Spinal Manipulation, Medication, or Home Exercise With Advice for Acute and Subacute Neck Pain: A Randomized Trial
      Is one better than another?: A randomized clinical trial of manual therapy for patients with chronic neck pain.
      Spinal manipulations for tension-type headaches: a systematic review of randomized controlled trials.
      Cervical spinal manipulations for the treatment of mythical subluxations, definitely No!
      Cervical spinal manipulations for musculoskeletal conditions where a thorough history and examination has ruled out any red flags and a detailed informed consent covering risk and benefit has been done, Yes!

      • @ GG

        Cervical spinal manipulations for musculoskeletal conditions where a thorough history and examination has ruled out any red flags and a detailed informed consent covering risk and benefit has been done, Yes!

        What red flags are there to rule out?? The distressing risk of VAD-stroke appears to possibly be highest in those under forty i.e. in their best health. Most case histories I have seen do not describe preexisting symptoms that could be defined as clinical “red flags” .
        Do you not think that if there had been any known preexisting symptoms other than neck pain in the presently discussed case report, that the authors would have omitted to describe them? No, of course not.

        As far as I am concerned, there’s no use trying to “intellectualise” the problem. If chiropractors want to start being taken seriously, they have to take their responsibility and declare that any form of cervical manipulation that can remotely be causative in VAD is to be banned.
        Then we can start talking about the finer points.

        • @Björn Geir
          Interestingly, I regularly have conversations like this with my referring doctors and we discuss the risk/benefit and cost/benefit of chiropractic for the treatment of chronic musculoskeletal conditions and the statistics. They look ay me in bafflement and ask why are we even having this conversation with risks that low!
          That case study like so many I have read fails to investigate what procedures the chiropractor actually used as GibleyGibley has stated. They just make assumptions. Its like saying a patient has had failed back surgery, what surgical procedure was used?
          I have never subscribed to subluxation or any of that BS as I have stated many times on this site!
          You state:
          “whole “discipline” of charlatans, “educated” in pure, demonstrable nonsense who are allowed to play[sic] with peoples problems and pretend they are fixing non-existent problems (subluxations) defrauding[sic] customers for financial gain and putting people at terrible risk on top of it… then of course one’s language hardens.”
          We have discussed this as well in the past, the BS merchants make up 15-18% of the profession. which is 15-18% too many in my humble opinion. If you are going to attack the profession then you need to be a tad more surgical! Vigorously attacking the fringe minority is fine but you also need to support the reformers within the profession otherwise its just carpet bombing!

          • “… the BS merchants make up 15-18% of the profession. which is 15-18% too many in my humble opinion. If you are going to attack the profession then you need to be a tad more surgical! Vigorously attacking the fringe minority is fine but you also need to support the reformers within the profession otherwise its just carpet bombing!” In my view, this argument only makes sense, if the rest can be shown to be of significant value. Do you have any good evidence for this notion?

  • What an interesting blog your’s is professor Ernst in that you are magnanimous in publishing comments that are against your and your followers’ beliefs, ie anything that doesn’t conform to your beliefs is absolute rubbish; those that support their beliefs eg chirooractic, homeopathy, shiatsu ………..and so on are variously quacks or buffoons and worse. I am amazed at the quantity of comments that arise from one or two contributors standing up for their complementary therapies whatever that may be. How sad that medicine (or should I say that which is proven, empirical evidence based, well you get the picture) cannot be allowed to be supported by effective complementary therapies. There really is room for it all, and complementary medicine users are many fold – they vote with their feet and use that which supports their health, and that is what we are all striving for, isn’t it? Do I reside on an alternative planet ?( yes I know the critics are queueing to answer that one, even naming the planet Woo), In my world I see an abundance of complementary therapies that are extremely efficient alongside an abundance of users, Homeopathy and Chirooractic are alive and kicking judging by the quantity of users and looking at the waiting lists of those practitioners I know. Whilst I may be an idiot in the critics’ eyes, that’s ok with me because I am accountable for me thankfully and will make my decisions on good health practice. There really are chiropractors (admittedly on My planet) that have enabled people to walk again – yes I know more fodder for the critics. I have even got an opinion on the placebo/conditioning debate – one has to say my experience far surpassed any advocates of the need for evidence of efficacy: I witnessed my baby granddaughter screaming with teeth pain for an hour and a half and no amount of willing, loving, nurturing on my part had any effect, and then I remembered her homeopathic remedy and it worked. One has to assume on My Planet it was the remedy that worked and not the conditioning (which apparently didn’t) Similarly Homeopaths sometimes get the prescribed remedy wrong having thought it was the correct one – conditioning and willing to no avail. I am fascinated by homeopathy as the correct remedy can be life changing, I also have tried many ‘alternative’ therapies that have been outstandingly effective: Cranial Osteopathy, Shiatsu, energy healing, Reiki, Acupuncture, kinesiology, nutrition. And all I can finally say is thank you to Planet Woo for allowing me to make my own decisions with regard to my health, and thank you Professor Ernst for this platform ……if, indeed, you do, as I finish with ‘and that’s me’ as we say in my charity supervision sessions, as I shan’t be replying to any accusations of being a quack, or worse, however, I shall never give up on the wish for a true integrative approach to good health- thank you Professor Ernst.

    • @A
      ” Whilst I may be an idiot in the critics’ eyes”.. not in mine. You represent a very common point of view. The problem is that your argument is based on fallacies.
      “Homeopathy and Chirooractic are alive and kicking judging by the quantity of users”. This is the argument from popularity fallacy. As someone else put it: 40 trillion flies can’t be wrong: eat shit! To judge from the quantity of users, astrology is also alive and kicking. Does that mean it should be supported and used by astronomers? You may argue that it does no harm, then you read of a US President using an astrologer to determine his actions; perhaps you might rethink?
      “There really are chiropractors … that have enabled people to walk again”. “I witnessed my baby granddaughter screaming with teeth pain … and then I remembered her homeopathic remedy and it worked.” “I also have tried many ‘alternative’ therapies that have been outstandingly effective”. These are all examples of the fallacy known in posh Latin as ‘post hoc ergo propter hoc’: it happened after something else, therefore the something else must have caused the effect. To extend from the previous example: “I ate shit when I had a headache and the headache went away: therefore eating shit cures headaches.”
      Your baby granddaughter story particularly shows up the dangers of this kind of subjective, post-hoc reasoning: “it was the remedy that worked and not the conditioning (which apparently didn’t)”. As a grandfather myself I know how when my own brand of conditioning fails, passing the baby to another adult often resolves the problem, without any oral medicine, homeopathic or otherwise. If you can stand back just a bit from your story; try to imagine how you might design an experiment to prove that the homeopathic medicine had the effect in this case, and not the change in handling of the child that must have accompanied administering the medicinewater.
      A lot of people on this blog talk of pseudomedicines working by the placebo effect. A recent post by David Colquhoun shows how simple regression to the mean (symptoms usually get better anyway) is a better explanation than the placebo effect for the apparent success of medicines that have no basis in fact or reason.

  • Well. You have made me renege on my statement that I wouldn’t reply , Frank Odds, but you have been respectful and truly you caught my attention when you mentioned you were a grandparent; isn’t it the most rewarding role? Anyway, your comment about the change of carer caught my eye and made me reflect on the said scenario. For a moment I thought you may be psychic and a member of Planet Woo, because indeed I did pass baby to my husband and she quietened. I like to be honest and open, so it was important to look at the facts: I did hold her for the 1 and half hours of screaming and toward the end of this time I rang my husband to come and help as I was also looking after a two year old who was coughing upstairs. One can rely on men to take their time, so maybe fifteen minutes before he arrived, I administered the remedy. Babies and toddlers love the little sugar pills (yes I know that is a whole other debate) so it was a very easy exercise – I placed her on the settee and hey presto remedy taken ( I even managed to make her bottle as well) So a little while later husband arrived, picked her up and she was very happy. Now we have a dilemma, because you may be correct that the change of carer (not handler) was key. I am trying to play devil’s advocate and really I am not so intransigent that my mind cannot be changed. But here lies the difficulty – whilst I have no idea what posh Latin means, I am assuming it alludes to those that relate their positive experiences of complementary therapies which iin the critics’ opinions are anecdotal. You ask me to stand back from my story – it’s not easy ( you may find it so?) because all I have as a human being is myself and connected experiences. In my case, boringly I know for you to hear, it has included almost a long lifetime of using a variety of complementary therapies. I am not an academic or scientist, but I am considered, thoughtful and discerning. Now using these qualities for the ‘baby’ situation, my conclusion is that the homeopathic remedy worked; because of the very many years of witnessing efficacy, one has to take that into consideration, Do you see that I have no choice but to believe it is that albeit I concede it could have been the change of carer, as my husband certainly is the most wonderfully caring person. However, on balance I lean towards the remedy, as about an hour later she was placed in her cot wide awake but happy.

    You mention flies and the s … Word ( I am an oldfashioned older woman) and truthfully don’t understand the analogy, but as I said I am not an academic so what am I missing? Flies and humans are very different species, however. I think I get your ‘regression to the mean’ statement but surely if that worked there would be no requirement at all for medicine of any kind let alone complementary, as at some point we would organically recover from whatever it is we are suffering from; If only …….wouldn’t that be wonderful?

    you mention astrology – again that was quite an insight by you, as I do have an interest in it. However I have no interest in astronomy; surely they are completely different disciplines: never the twain shall meet? You ask me if I would rethink my views in the context of astrology determining a U.S. President’s decisions in office. Not very politically correct I know but my view is that a lot of global leaders are mere puppets: so would one assume that the real leaders behind the ‘leader’ were also into astrology, and if not why was it not eradicated? But that’s a whole different debate, and before I am accused of being a conspiracist, I shall finish by wishing you happy grandparenting, in the full acknowledgement we are not going to alter each other’s views.

    • To A
      Thank you very much for your honest and well thought through response. Whether or not you fully realize it, you have joined the world of critical thinking. Let me respond to your points (and, since it offends you, I shall avoid any kind of potentially coarse words).
      In your first paragraph, about the struggle with your screaming granddaughter, you come very close to understanding that, just because one event follows another, it does not mean the two are related. Suppose you had given your granddaughter some milk or some sugar instead of the homeopathic so-called medicine, and she stopped crying and settled down, would you conclude that milk or sugar was a cure for toothache? No, you’d argue that milk and sugar are kinds of food and there is no reason to imagine they can have that sort of effect. That is the same sort of thnking that makes people like me find it impossible to believe homeopathic products have any medical effect at all. We know how they’re made (you can find the information all over the web) and even homeopaths themselves admit there’s nothing in them but water or sugar. Your granddaughter probably stopped crying after one-and-a-half hours because she had no more crying left in her. Babies do stop crying without any external help — you know that — and that’s what scientists and statisticians call ‘regression to the mean’.
      A better answer to my question: how would you design an experiment to prove it was really the homeopathic remedy that stopped the crying would be this. First of all, you need to recognize that your individual, personal, subjective experience proves nothing. The trick would be to supply a large number of grandmothers (we’re talking at least hundreds here) with identical bottles, distributed at random. Half of the bottles contain the proper homeopathic remedy, the other half contain just the base sugar pill, but none of the grandmothers know what their bottle contains. Then the grandmothers are asked, each time their grandchild has a prolonged crying session, to treat them with the ‘remedy’ and to note down whether it worked. After several months, by collecting the grandmothers’ records, the person who randomized the genuine and sham homeopathic remedies can break the code and we can figure out if the ‘real’ homeopathic product stopped the crying more often than the sham on a scale sufficient to provide what a statistician would regard as proof that the difference wasn’t the sort of chance difference you get when you, say, toss a coin 100 times.
      I assure you this kind of experiment has been done clinically very many times for all kinds of homeopathic medicines. and — when the experiment has been done on a sufficiently large scale and with proper controls in place to exclude any kind of cheating — they turn out, as expected, to do nothing at all.
      Since you didn’t understand my point about astrology, let me first say that, historically, astronomy evolved from astrology and has long since rejected astrology as complete nonsense. But what I was driving at is the simple point that, just because large numbers of people believe things doesn’t make them true. It’s Christmas Eve. The number of children who believe Santa Claus is a real person must add up to many millions in the Western Hemisphere. Does that make the belief true? Millions of people are certain that psychic phenomena are genuine, but when precautions are taken to exclude cheating (conscious or unconscious) there is no psychic phenomenon that has been shown to be part of reality. Consider the millions of people who believe the number 13 is unlucky (they never define in what way!) to the extent that many hotels avoid having a 13th floor and airlines avoid having a row 13. The argument to popularity is a fallacy: just because lots of folk think something is true just doesn’t make it true.
      Have a great holiday!

    • @A
      Oh, I am being long-winded, but you are being so reasonable about this discussion. I forgot to pick up your comment “…surely if [regression to the mean] worked there would be no requirement at all for medicine of any kind let alone complementary, as at some point we would organically recover from whatever it is we are suffering from.” Spot on! I bet you know people who flatly refuse to go near a doctor (they may go to alternative practitioners but that’s not the point). Like all of us they know that, very often, if you just suffer a bit and wait, the disease cures itself.
      Unfortunately, while this is true for a large number of conditions, it is not true for all of them, which is why people have struggled for thousands of years to understand the workings of the body in health and disease and to find ways of preventing or curing the latter. In the 21st century we have an amazingly deep knowledge of huge numbers of diseases. We know which ones normally heal themselves and which ones need medical intervention. That’s why I and many others on this blog keep popping up with our comments. If you become convinced that one or more of the many kinds of snake oil being peddled as ‘alternative medicine’ are reliable, you’re actually depending entirely on exactly the foolishness you’re getting at above: the body’s self-curing properties have limits. That’s why medicine backed by science has managed so successfully, particularly over the past 100 years or so, to prolong our life spans. Relying on non-scientific ‘beliefs’ as medicine leaves you at risk of death.

      • Thank you Frank Odds for both your posts – on a busy Christmas Eve too. This has become quite a respectful little exchange, admittedly I have had to come away from the wrapping to just balance things a little (of course from my perspective) so I hope it is received as it is meant : in the context of two people with diametrically held beliefs. You assume that I have just joined the world of critical thinking ( I digress here but to make the point, I trained in counselling those at end of life in their own homes – a privilege but the big No No was never to assume, and we do it all the time, don’t we? But in this situation it is disempowering further the already disempowered) ️The point is that you don’t know me but you assume it is this blog item that platformed me to the world of critical thinking because I said I would reflect on the screaming baby scenario. The reality is I have been critically thinking from childhood as a necessity and have continued to do so all my life. It’s what stands me in good stead in choosing my path in life, in the way I raised my family and the medical routes I choose; although I am randomly addressing your points over two posts, you assume also I would choose alternative medicine (snake oil? )over conventional when nothing could be further from the truth; I did say in my first blog that I continue to wish for an integrative approach. And there is good reason for that: I have a close family relative who is reliant on conventional medicine to survive and another who had life saving treatment by the NHS in a frightening emergency, not to mention other family and friends who bear witness to the value of mainstream medicine. Now I do get that that Prof Ernst et al, Good Thinking Society etc are attempting to save those who think differently from themselves. And However much success is achieved ie. removal of homeopathy from the NHS etc and so on and on, complementary therapies are not going away, One only has to look at the various websites supporting homeopathy, the BMJ homeopathy and doctors debate, to see it is popular. You say it has been proved that the pillules contain nothing but sugar, etc, well I am no expert, but have definitely seen reports that conclude the opposite. So when I take a remedy I am aware that I am not taking sugar and milk and water only, so leading on from that to address one of your points, I see no correlation to administering a food substance and expecting it to have a medicinal effect, not in this case anyway. The mere thought of gathering many grandmothers together to prove a point is anathema – the very tedium – oh no, For every study that denies homeopathy, there is one that supports. It really is the most tedious debate because, although I am not an expert, homeopathy cannot be tested the way drugs are are. We have come into this life with choices, if some people choose to support their health with other than drugs, so be it. I for one never impose my beliefs on others unless it is asked for. However, I am engaging in this debate for balance – the majority of bloggers seize every opportunity to denigrate those who believe in an alternative, be it chiropractic, acupuncture etc. and sometimes in unkind ways. Now I know you are thinking at this point that I am ignoring your comments ie ‘you have to recognise your individual, personal, subjective experience proves nothing’. But there lies the validity – it is the very experience of millions of people that tells them homeopathy works. And yet the deniers tell us our experience is wrong. Oh dear – what does the human race collectively say when it is told its experience amounts to an absolute of nothing? How would you feel if your experiences were invalidated in that way? A rhetorical question, because it won’t happen; we are our experiences, we make choices from our experiences. I know this must sound like nonsense to you because you are looking at this from a different perspective. But those decisions we make for ourselves are going to be different : you and your your fellow sceptics are looking at every way to change the minds of complementary medicine believers. I can’t speak for others but even the scaremongering (you mention risk of death) doesn’t change my mind because I make the right choice, be it conventional or complementary or a mix of both. I do get your point that a large number of people believing something doesn’t make it true : I think you mean because the empirical evidence is missing, ie in astrology, psychic ability, etc,. But that doesn’t mean it doesn’t exist in an individual!s truth, and in full circle it comes back to the point of experiential evidence. And that is never going away whilst hearts beat in humans. I know you are probably frustrated with my answers – I know they will not be to your expected scientific standard, but it’s ok isn’t it because Christmas Joy looms, so we can agree to disagree. Oh by the way there are many alternative scientists out there – yes there really is room for all – you may be interested in a book by Dr Joe Dispenza called You are the Placebo – making your mind matter. Sincere wishes to you and your’s for a bright Christmas.

        • You stated: “However, I am engaging in this debate for balance…”

          If your idea of balance was applied to engineering then collapsed bridges would be a frequent occurrence; as would be aircraft frequently falling out of the sky; and frequent failures of your domestic products and services. The questions that you are in dire need of asking yourself are: Why do you have double standards?; Why do you expect the manufacturer of your refrigerator, computer, etc., to honour their 12 month warrantee of 24/7/365 service while at the same time intimating that alternative medicine is a reasonable form of health care?

          Please try to understand that you are, perhaps, “not even wrong”:

          I respectfully ask you, on behalf of those who have reading difficulties, to construct your comments succinctly using separated paragraphs, rather than mono-block walls of text that are extraordinarily difficult to read.

          Wishing you, and all of the readers, a merry festive season and a Happy New Year,

          • Thanks for pointing this out Pete. I had not come across this marvellous phrase before.

            Here’s an extension on the theme I found when I was looking for more:

            Isaac Asimov’s axiom: “Wronger than wrong
            From his book The Relativity of Wrong (Doubleday, 1988):

            When people thought the earth was flat, they were wrong. When people thought the earth was spherical, they were wrong. But if you think that thinking the earth is spherical is just as wrong as thinking the earth is flat, then your view is wronger than both of them put together.

        • @A
          “But that doesn’t mean it doesn’t exist in an individual!s truth, and in full circle it comes back to the point of experiential evidence. And that is never going away whilst hearts beat in humans.” Right enough, A. That’s where we started. But personal experience is NOT evidence. It’s testimony, and that’s not the same thing.
          It’s been proved over and over again that people repeatedly tend to fool themselves. The entire advertising industry is built on that premise. Science is a process (please note, it’s not a belief system at all) that seeks to minimize the extent to which we fool ourselves. Relying on “we are our experiences, we make choices from our experiences” is never good enough. Civilized societies have regulations to prevent unscrupulous manufacturers of all kinds of things cashing in on the way we fool ourselves. If you don’t accept the weakness of your personal experience as ‘evidence’ then you will for sure be suckered in to those who want to sell you something worthless.

          • Thank you, Frank Odds, but yes I do understand that personal experience is not evidence but testimony. However, testimony is good : I would rather be guided by someone’s testimonial than any amount of so called evidence if it is that which is contained within studies, meta-analyses, arguments in various professors’ reports. It is endless and confusing (ie Shang et al v Linde etc – how boring for the health conscious who pursue the correct treatments) but a testimonial tells me a lot in the absence of personal recommendations. However, I am sure the self regulated ASA can’t wait to press the elimination button for testimonials .

            ‘Proved that people repeatedly tend to fool themselves’ you say. Really? On what grounds? Some people may indeed fool themselves, others may be discerning, sane, well any description at all really, because people are individuals. Surely even the foolhardy should be allowed to make their own mistakes? May be only Planet Woo is a democracy, however last time I looked……. but still we have those who know much better than a mere mortal, so,we must be told to follow a certain ‘proven’ path, not very healthy in my book. Yes I agree advertising is a minefield of subliminal and nonsensical information, but the discerning can see through it I think

            Yes I do understand that science is a process, but not a wholly successful one, judging by, in one instance, the antibiotic resistance furore : NICE instructing GP’s to not prescribe, in the first instance, for
            RTI’s. This is major, as you know: where does it leave those undergoing surgery when there is no replacement compound (or untested)? Conventional medicine is far from successful, the NHS is failing, some drugs are not working leaving patients vulnerable,; a call to dismiss GP’s who prescribe homeopathy : really, when we read almost daily that GP’s are under pressure? So no, I do not see ithe science proceed always does a good job in minimising the extent to which we fool ourselves. I am the one who is pilloried for ‘believing’ in CAM, yet I worked out many years ago the problems with antibiotics and steered clear when I could – the writing was on the wall before it blasted into the media. Fool, sucker ?- I don’t think I am, but I am certainly thoughtful and conscientious around healthcare.

            So no I don’t see my personal experience as a weakness, but very much a strength.

            From what I see from this blog and many other similar sites that denigrate CAM, when so called reason by the sceptics has no effect, they resort to ridicule and oftentimes worse, judging by the abuse on Twitter, etc. A civilised society – no evidently not, but I for one will do my best to promote a civilised society, and I do think future generations are not in bad hands when I observe my two teacher children ( no ridiculing, but plenty of respect) and wanting their vocation to make a difference, I have carried out a little snapshot of comments on this blog – and I am saddened – we are the adults but where is the civility and respect?

            Finally, I feel quite buoyant about CAM. – Switzerland, for one, after assessment, has brought homeopathy into their healthcare system; it is seemingly popular in Germany and France, and growing in Asia. Yes, I know, the sceptics disagree. As can be said at this time ‘ it’s been said many times, many ways’ and so it goes…….

            I am leaving the debate to return to my day job, and wish you well, Frank Odds, you have been very respectful in our exchanges, thank you, and wishing you and your’s a very happy and healthy 2016. A

        • Thank you, Pete Atkins, for struggling through my block text (it was Christmas Eve, and in my haste, let my journalistic hat slip, but it will be firmly placed again in the New Year when I resume writing) to ‘I am engaging in this debate for balance’ and then ask the ‘questions you are in dire need of asking yourself are why do you have double standards………..etc etc ‘ . Ooh, good question, and hope you will bear with me whilst I critically think and give you an answer. The warning is though that my answers will have zero impact on your ‘not even wrong’ accusation; sadly, it will probably exacerbate it, but here goes anyway:

          You mention engineering, and it just happens that I am very familiar with this as my husband is an Oil Safety Engineer, and interestingly, as you mention planes falling from the sky, my father many years ago worked as an aircraft engineer for the largest airline (at that time) and based at the largest airport(at that time). He was responsible ‘signing off’ air craft as safe to fly – quite a responsibility and I observed his ongoing training, his dedication. . I spent my childhood flying more than most children, and to this day I have no fear of flying : who know’s just maybe my childhood experience has stood me in good stead, I have no knowledge of how a bridge is built, but can see the wonder of the engineering involved. So no I see no correlation of engineering to my beliefs in complementary medicine. There is no double standard, because I trust my experiences – without which we are all in for a rocky journey. Now when I had my fall and was in a lot of pain, even though Professor Ernst’s reproof was it was a minor injury and would recover without treatmwnt, in fact I had whiplash and was very comfortable having the atlas bone in my neck manipulated, to be pain free, Good result.

          It’s prescient of you to mention warranties on domestic appliances, etc. it just so happens that I am researching buying a new fridge, and the warranty is not a factor into my research, because realistically I know there is not a lot can go wrong with a refrigerator: what drives it will probably outlive me at my advanced age, albeit the drawers may crack, fall apart, but that won’t be for a while. More Importantly, the specification is key : I would prefer the refrigerator capacity to be much larger than the freezer capacity : in some strange way, it could be a metaphor for choosing my health care. I know I am repeating myself, but I would like the choice of conventional (orthodox, whatever you like to call it) alongside the many effective complementary (alternative, whatever you like to call it) treatments, So may be for me it would be a larger capacity of complementary, but that is me; the point is I would like the choice. How am I doing with ‘not even wrong’ – poorly I guess?

          Well, it will soon be time for the next lot of guests to arrive and will need feeding, so bfore my journalistic hat flies off, I would like to bring this back ‘ to I am engaging in this debate for balance’. A debate usually involves often polarised points of view – isn’t that what this blog is about? Admittedly the volume of bloggers are anti – complementary therapies: this is the context of my ‘balance’. With balance in mind( I know the not even wrong brigade are now irate) could I give a little example of how I hope the future is one that conventional and complementary medicines can be happy bedfellows?

          I have two friends who are Scientists : one has been Head of R and D for maybe? the largest pharmaceutical company in the world; his wife sees an acupuncturist and its efficacy is remarkable; he doesn’t know how it works but he is thankful, and not so closed as to dismiss it, and is willing to chat with acupuncturist to gain some insight. The other friend is a high level statician for a large pharmaceutical company and her husband is a Leading and very effective Chiropractor. She is very supportive and bears witness to remarkable recoveries. How satisfying for all, and no anger in sight as they have their little balanced debates,

          well, the’ Not Even Wrong ‘ bubble is about to burst in protest, so shall leave the debate, and thank you Professor Ernst for the space to give my view. Pete Atkins, judging by the history of this blog, you will have the last word, so I wish you well for the future, and hopefully this had been a slightly easier read for you. Sincere good wishes A

          • The wife of the head of R&D of a pharmaceutical company sees an acupuncturist and its efficacy is remarkable.

            “The other friend is a high level statician [sic] for a large pharmaceutical company and her husband is a Leading and very effective Chiropractor. She is very supportive and bears witness to remarkable recoveries.”

            I hope those pharmaceutical companies use a somewhat higher standard of evidence for their products than your friends use for their healthcare. Thank you for the entertainment — I now have a picture in my mind of a paracetamol tablet, adorned with acupuncture needles, being manipulated by a chiropractor, under the guidance of a reiki practitioner, while a homeopath prepares to dilute and succuss the result. Under what name will the pharmaceutical company market this remedy, Comedy Gold 200C, perhaps?

            Well, ’tis the season to be jolly! I shall add some balance to this discussion:

  • In Reply to EE:
    “In my view, this argument only makes sense, if the rest can be shown to be of significant value. Do you have any good evidence for this notion?”
    I Agree and Yes I have quite a few papers on cost/benefit and risk/benefit. This topic has been gaining more and more attention/journal space over the last few years. Additionallly, the profession needs to be seen cleaning its own house and critically evaluating what we do. This is occuring in the faction I associate with , but is totally lacking in the subluxation faction.
    Off on my christmas holiday, back in a few weeks. To all the critical thinkers on this site Merry Christmas and a Happy New Year. I look forward to some interesting debates next year!

  • Thanks for this post. I have always been skeptical of neck adjustments for this very reason. Sad.

    We’ve just had a big blow up here in Australia about chiropractors overstepping their bounds. Claims they can cure diabetes and cancer abound. The general consensus was that a chiropractor may have value for someone who has back pain and may benefit from some physiotherapy style mobilisation. And in all fairness, I do have a chiro friend here in Sydney who is very balanced and level-headed and knows his scope of practice. Even he takes issue with the mavericks out there overstepping the line and trying to be everything to everyone.

    On a TV program called The Project, they interviewed a rogue chiropractor who said that manipulating babies backs was ok and that it was “supported by case studies” and that “case studies and first hand experience is the best first line evidence.” The presenters tore him apart and fed him to the wolves. Here’s a link below which has a good balanced view on the recent Aussie debate.


    • Marvellous line in that link: “Dr Ken Harvey criticised the industry regulator, AHPRA’s Chiropractic Board, for not cracking down on chiropractors…” (My italics)

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