MD, PhD, FMedSci, FRSB, FRCP, FRCPEd

This is a fascinating new review of upper neck manipulation. It raises many concerns that we, on this blog, have been struggling with for years. I take the liberty of quoting a few passages which I feel are important and encourage everyone to study the report in full:

The Minister of Health, Seniors and Active Living gave direction to the Health Professions Advisory Council (“the Council”) to undertake a review related to high neck manipulation.

Specifically, the Minister directed the Council to undertake:

1) A review of the status of the reserved act in other Canadian jurisdictions,

2) A literature review related to the benefits to patients and risks to patient safety associated with the procedure, and

3) A jurisprudence review or a review into the legal issues that have arisen in Canada with respect to the performance of the procedure that touch upon the risk of harm to a patient.

In addition, the Minister requested the Council to seek written input on the issue from:

  • Manitoba Chiropractic Stroke Survivors
  • Manitoba Chiropractic Association
  • College of Physiotherapists of Manitoba
  • Manitoba Naturopathic Association
  • College of Physicians and Surgeons of Manitoba
  • other relevant interested parties as determined by the Council

… The review indicated that further research is required to:

  • strengthen evidence for the efficacy of cervical spinal manipulations (CSM) as a treatment for neck pain and headache, “as well as for other indications where evidence currently does not exist (i.e., upper back and should/arm pain, high blood pressure, etc.)”
  • establish safety and efficacy of CSM in infants and children
  • assess the risk versus benefit in consideration of using HVLA cervical spine manipulation, which also involve cost-benefit analyses that compare CSM to other standard treatments.

… the performance of “high neck manipulation” or cervical spine manipulation does present a risk of harm to patients. This risk of harm must be understood by both the patient and the practitioner.

Both the jurisprudence review and the research literature review point to the need for the following actions to mitigate the risk of harm associated with the performance of cervical spine manipulation:

  • Action One: Ensure that the patient provides written informed consent prior to initiating treatment which includes a discussion about the risk associated with cervical spine manipulation.
  • Action Two: Provide patients with information to assist in the early recognition of a serious adverse event.

3 Responses to THE MANITOBA REVIEW OF UPPER NECK MANIPULATION

  • All I can say is that upper neck manipulation has made me disabled. However, let me clarify my experience with having had it done over the years. More than 20 years ago, I began having terrible tension headaches. Taking pills wasn’t the answer to having a normal day and I began seeking out chiropractic care. In those early days, my neck was manually adjusted or “cracked.” The experience was very quick and not painful at all, but the sound of the bones “cracking” wasn’t the most pleasant. Over a period of one month with going to these adjustments two or three times a week, then tapering off and eventually going in as needed, which was perhaps once a year or 18 months, most of my headaches went away. Getting a new mattress also helped and the having a diagnosis of sleep apnea led me to hsving a CPAP machine further helped my situation. But the initial chiropractic adjustments definitely helped.

    One of the two chiropractors in the office moved away and I began seeing the one who stayed. He used a little tool called an “activator “ where he would give certain spinal discs a little thump with the spring loaded device. It was not painful at all and seemed to work just fine. This chiropractor did not do manual adjustments, at least on me. I went to him off and on for several years and always came back feeling much better.

    About five years ago, I was suffering from sciatica and sought out a new chiropractor who accepted my insurance. He also helped my tremendously along the way, but he used manual adjustments on me and they seemed to work. Manual neck cracking was part of the treatment when I was complaining of headaches, though their frequency wasn’t bad as in the past.

    After going to him for several months, I had read about the dangers of such manual neck adjustments and I brought that up as a concern. His repsonse was that any risks were so low, that his medical malpractice insurance premiums reflected that and that I shouldn’t worry. His claim was that any potential risks were well under 1 percent. I never left his office feeling poorly either.

    Then, about three years ago, I ended up having a tendon transfer surgery in my left foot/ankle. Keeping the foot elevated for a month was part of the rehabilitation process and that meant spending a lot time in bed. Two days post op, I began having severe breathing difficulties, especially while lying down on my right side. After a few days of that, thinking the surgery had worn me down, I went to the ER fearing a blood clot. It was determined that there wasn’t any blood clot and that I had actelectasis, which is pneumonia caused by too much anesthesia. I was given an antibiotic but my breathing didn’t improve much. After further tests and a confirmation the atelectasis had cleared from my left lung, it was found that the left side of my diaphragm was paralyzed and pushing way up into my left lung, causing the breathing difficulties. I was miserable !

    Seeking out a solution to this problem, I found the only doctor in the world, who performed a specialized surgery for this, After a few months, he asked me to have an EMG and a nerve conduction study done on my phrenic nerves, which are the nerves stemming off of our C3, 4 and 5 discs on our spine and which move our diaphragm, a very large muscle under our rib cage, which assists in our breathing efforts. It wasn’t until two years ago, that I had a phrenic nerve graft performed on the left side of my neck and a diaphragm pacemaker implanted.

    The surgeon’s decductive reasononing based on my chain of events, led him to believe the phrenic nerves (both right and left ) were initially damaged by the manual neck adjustments. Since I did not have the breathing problems until after the ankle surgery, he believes the phrenic nerves were damaged, but still working well enough for me not to notice any breathing issues. He believes the final step which led to the diaphragm paralysis was from the overdose of anesthesia, which put me metabolism into such a low state, that the phrenic nerves stopped conducting and caused the diaphragm to stop moving. Having the nerve graft has helped my breathing, but not to the point I can work or carry on a normal day everyday. So while chiropractic care can help, I would only have a chiropractor use an activator and not have manual adjustments done…especially of you’re older and have osteo arthritis with brittle bones. I’ve had acupuncture for stiff neck spasms which helped tremendously and didnt pose the risks as with manual chiropractic manipulation.

    • @Ronald Cole
      I see nothing in your case history indicating that the chiropractic manipulations added a benefit. You tell how you improved over time and how you added other measures like a better mattress. These factors only get ´an honourable mention´ In your recollections and one suspects there may be more, like excercise and other life style inprovements? The immidiate efects you experienced at times after manipulations can be explained by other well known and more likely factors than the neck-cracking, which has never been reliably shown in studies to have a specific efficacy.
      Why do you conclude chiropractic care helped you? Because the chiropractor said so? There is (only?) one thing chiropractors are very good at and that is convincing their clients that they benefit from their manipulations and that hey need to repeat them indefinitely for continued effect. This happens to co-variate positively with the chiropractor´s cash-flow.

      Chiropractic care works the same way you cook soup on a nail. You put a nail in a pot. You then add some legumes, broth, meat and condiments to.the boiling water and wait until the whole thing has boiled down nicely. When your guest, who during this process has been thouroughly informed of the wonders of using nails in cooking, applauds your culinary prowess, you attribute the good taste and nurishing quality to the nail and deplore the foolery of those who do not know to add nails to nurishment.

      Chiropractic is the nail soup• of health care.

      •The tale of the nail soup / stone soup /soup on a sausage skewer is a common theme of folk tales widely known around the world, which describe a commonly used trick of the trade of charlatans, a method also known as “the bait and switch”

      • And by the way, the same reasoning applies to your impression of the perceived benefits of acupuncture,which you very mistakenly have been led to believe is less hazardous than neck manipulation.
        Here is an example of a very underreported complication of needling. This may even happen when placing needles in the lower neck regions where the top of the chest cavityextends above the collar bone. I have come across several cases of pneumothorax which were never reported anywhere.
        http://nationalpost.com/news/canada/judo-acupuncture-needle

        Recently a man died in Norway from an infection caused by acupuncture needling to the hand.

        Acupuncture has never been reliably shown to have specific efficacy other than the suggestive power of a theatrical placebo intervention.

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