MD, PhD, FMedSci, FSB, FRCP, FRCPEd

case report

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Not being a native English speaker, I was not entirely sure what precisely slapping means. A dictionary informed me that it stands for “hitting somebody/something with the flat part of your hand”. And ‘slapping therapy’? What on earth is that? It occurred to me that there might be several types of slapping therapy.

HITTING SOMEONE WHO DISAGREES

Yes, it might be therapeutic to do that! Imagine you discuss with someone and realize that you do not have very good arguments to defend an irrational position. Eventually, you are cornered and angry. All you can think of is to slap your opponent.

No, not very constructive, but all too human, I suppose.

This sort of thing has happened to me several times during discussions at conferences: my opponents went so mad that I saw them clinching their fists or raising their hands. Fortunately, I can run quite fast and (so far) always managed to avoid the impending physical violence.

INSULTING SOMEONE WHO DISAGREES

That sort of thing happens regularly. I have written posts about the phenomenon here, here, here and here, for instance. If you read the comments sections of this blog, you regrettably find plenty of examples.

If I am honest, I must admit that, on some occasions, I have in desperation joined into such mud-battles. I am not proud of it but sometimes it just happens. We are all just human, and it certainly feels therapeutic to be rude to someone who is a continuous and deplorable nuisance by hurling insults at opponents.

Having made this confession, I must stress (again) that, on this blog, we ought to avoid this sort of slapping therapy. In the long run, it is unhelpful and only escalates the aggression.

KINKY SLAPPING

When I googled ‘slapping’ I was referred to all sorts of sleazy websites which were essentially displaying maso-sadistic pornography that involved one person slapping another for sexual pleasure. Personally, I do not get a kick out of this type of slapping therapy and find it sad that some people obviously do.

PAIDA

Paida is the form of slapping therapy that recently made headlines and which therefore prompted this post. Paida in Chinese means to slap your body. Sure enough, the TCM people have made it into an alternative treatment which is usually called SLAPPING THERAPY (what will they think of next? you may well ask!). Already the sexual version of slapping therapy was not really funny, but this certainly is where the satire stops!

Hongchi Xiao, a Chinese-born investment banker, popularised this treatment some time ago. It involves slapping the body surface with a view of stimulating the flow of ‘chi’. Slapping therapists – no, they are not called ‘slappers’!!! – believe that this ritual restores health and eliminates toxins. In fact, they claim that the bruises which patients tend to develop after their treatment are the visible signs of toxins coming to the surface.

The treatment is not based on evidence — I know of not even a single clinical trial showing that it works — and it is certainly not agreeable. But at least it’s safe! No, you’d be wrong to think so: if slapping therapy, or any other bizarre and useless intervention is being employed as a replacement for treating a serious condition, it inevitably becomes life-threatening.

Recently, it was reported that a woman from East Sussex died after receiving slapping therapy; other fatalities have been documented previously. The latest victim had been suffering from diabetes and was led to believe that Paida was an effective treatment for her condition. Consequently, she discontinued her medication, a decision which eventually killed her.

Deaths after apparently harmless alternative treatments are being reported with depressing regularity. However, much more often, the resulting harm is not quite so dramatic, simply because the conditions treated are fortunately not life-threatening. In such cases, the ineffectiveness of the treatment does not lead to disaster, but it nevertheless causes unnecessary expense and prolongation of suffering.

We live in a time where we are constantly being told, for instance by ‘experts’ like Prince Charles, that we ought to be respectful towards ancient traditions of healthcare. So, let’s be clear: I am all for respect towards other cultures, but in medicine there should be limits. I do not see any benefit in either respecting or implementing ancient, obsolete notions of life energies, meridians, toxins and other disproven assumptions of alternative practitioners. They originate from a pre-scientific era and have been disproven. They do not belong in modern treatment manuals; at best, they belong in the history books of medicine.

 

 

 

The risks of consulting a chiropractor have regularly been the subject of this blog (see for instance here, here and here). My critics believe that I am alarmist and have a bee in my bonnet. I think they are mistaken and believe it is important to warn the public of the serious complications that are being reported with depressing regularity, particularly in connection with neck manipulations.

It has been reported that the American model Katie May died earlier this year “as the result of visiting a chiropractor for an adjustment, which ultimately left her with a fatal tear to an artery in her neck” This is the conclusion drawn by the L.A. County Coroner.

katie-may-ist-mit-34-jahre-gestorben

According to Wikipedia, Katie tweeted on January 29, 2016, that she had “pinched a nerve in [her] neck on a photoshoot” and “got adjusted” at a chiropractor. She tweeted on January 31, 2016 that she was “going back to the chiropractor tomorrow.” On the evening of February 1, 2016, May “had begun feeling numbness in a hand and dizzy” and “called her parents to tell them she thought she was going to pass out.” At her family’s urging, May went to Cedars Sinai Hospital; she was found to be suffering a “massive stroke.” According to her father, she “was not conscious when we got to finally see her the next day. We never got to talk to her again.” Life support was withdrawn on February 4, 2016.

Katie’s death certificate states that she died when a blunt force injury tore her left vertebral artery, and cut off blood flow to her brain. It also says the injury was sustained during a “neck manipulation by chiropractor.” Her death is listed as accidental.

Katie’s family is said to be aware of the coroner’s findings. They would not comment on whether they or her estate would pursue legal action.

The coroner’s verdict ends the uncertainty about Katie’s tragic death which was well and wisely expressed elsewhere:

“…The bottom line is that we don’t know for sure. We can’t know for sure. If you leave out the chiropractic manipulations of her neck, her clinical history—at least as far as I can ascertain it from existing news reports—is classic for a dissection due to neck trauma. She was, after all, a young person who suffered a seemingly relatively minor neck injury that, unbeknownst to her, could have caused a carotid artery dissection, leading to a stroke four or five days later… Thus, it seems to be jumping to conclusions for May’s friend Christina Passanisi to say that May “really didn’t need to have her neck adjusted, and it killed her.” … Her two chiropractic manipulations might well have either worsened an existing intimal tear or caused a new one that led to her demise. Or they might have had nothing to do with her stroke, her fate having been sealed days before when she fell during that photoshoot. There is just no way of knowing for sure. It is certainly not wrong to suspect that chiropractic neck manipulation might have contributed to Katie May’s demise, but it is incorrect to state with any degree of certainty that her manipulation did kill her.”

My conclusions are as before and I think they need to be put as bluntly as possible: avoid chiropractors – the possible risks outweigh the documented benefits – and if you simply cannot resist consulting one: DON’T LET HIM/HER TOUCH YOUR NECK!

Prince Charles’s car has been involved in a collision with a deer in the area around Balmoral, THE GUARDIAN reported. Charles remained uninjured but shaken by the incident. The condition of the deer is unknown but might be much worse. The Prince’s Audi was damaged in the collision at the Queen’s Aberdeenshire estate and sent away for repairs. A spokesman for Clarence House declined to comment on the crash.

This is the story roughly as it was reported a few days ago. It is hardly earth-shattering, one might even say that it is barely news-worthy. Therefore, I thought I might sex it up a little by adding some more fascinating bits to it – pure fantasy, of course, but news-stories have been known to get embellished now and then, haven’t they?

Here we go:

As the papers rightly state, Charles was ‘shaken’, and such an acute loss of Royal well-being cannot, of course, be tolerated. This is why his aids decided to make an urgent telephone call to his team of homeopaths in order to obtain professional and responsible advice as to how to deal with this precarious situation. This homeopathic team discussed the case for about an hour and subsequently issued the following consensual and holistic advice:

  • Scrape some hair or other tissue of the deer from the damaged car.
  • Put it in an alcohol/water mixture.
  • Take one drop of the ‘mother tincture’ and put it in 99 drops of water.
  • Shake vigorously by banging the container on a leather-bound bible.
  • Take one drop of the resultant mixture and put it in 99 drops of water.
  • Shake vigorously by banging the container on a leather-bound bible.
  • Repeat this procedure a total of 30 times.
  • This generates the desired C30 remedy.
  • Administer 10 drops of it to the Prince by mouth.
  • Repeat the dose every two hours until symptoms subside.

The Prince’s loyal aids followed these instructions punctiliously, and after 24 hours the Prince’s anxiety had all but disappeared. Upon hearing the good news, the homeopaths were delighted and instructed to discontinue the ‘rather potent’ remedy. Now they plan to publish the case in Peter Fisher’s journal ‘Homeopathy’.

The Prince showed himself even more delighted and told a reporter that he “had always known how incredibly powerful homeopathy is.” He added that he has already written to Health Secretary Hunt about homeopathy on the NHS, “it is high time that the NHS employs more homeopathy”, Charles said, “it would save us all a lot of money and might even solve the NHS’s current financial problems with one single stroke.”

The Faculty of Homeopathy is preparing a statement about this event, and the homeopathic pharmacy Ainsworth allegedly is considering marketing a new range of remedies called ROADKILL. The Society of Homeopaths feels somewhat left out but stated that “homeopathy is very powerful and should really be in the hands of professional homeopaths.” A group of homeopathic vets declared that they could have saved the deer, if they had had access to the animal and added “homeopathy works in animals, and therefore it cannot be a placebo.”

Everyone at Balmoral and beyond seems reasonably happy (perhaps not the deer). However, this does not include the local car mechanics charged with the repair of the Audi. They were reported to lack empathy and knowledge about ‘integrative, holistic body work’. Their opposition to following orders went as far as refusing to repair the car according to homeopathic principles: sprinkling ‘Deer C30’, as the new remedy is now called, on the car’s bonnet.

For far too many proponents of alternative medicine, belief in alternative methods seems disappointingly half-hearted. Not so for this enthusiast who invented an alternative form of resuscitation – but sadly failed.

This article explains:

A Russian woman spent more than 4 months trying to bring her dead husband back to life. How?  With the help of holy water and prayer!

The retired therapist said she didn’t report the death of her 87-year-old husband because she believed she could revive him by sprinkling holy water on his body and reading prayers. The woman’s bizarre secret was revealed when she accidentally flooded the apartment below, and a neighbour forced his way into her home to turn off the water. He found the almost completely mummified husband laying on the living-room couch. Forensic pathologists determined that the man had been dead for 4 – 6 months, but found no traces of violence on his body and concluded he had died of natural causes.

Neighbours said that they did sense a strange smell coming out of the apartment, but didn’t think anything of it. The deceased had suffered a serious injury to his leg in 2015 and had been bed-ridden since then. Therefore his disappearance from public view went unnoticed. To make sure nobody interfered with her resuscitations, the woman told everyone that he was fine, but too tired for receiving guests. Even the couple’s children were asked not to visit.

The 76-year-old woman who had worked as a doctor for most of her life, became interested in the occult and obsessed with the work of Leonid Konovalov, a Russian psychic who stars in a television show where he tries to communicate with the dead. “When we started talking to the woman, it turned out that she was fascinated by alternative medicine and believed that, by sprinkling holy water on her husband, she would be able to bring him back, to revive him,” Chief investigator commented.

Is there a lesson in this story?

Perhaps this one: conviction in one’s methods might be good, but evidence is better.

AROMATHERAPY is one of the most popular alternative therapies. The experience is usually pleasant enough, but what are the risks? None!!! At least this is what the therapists would claim. But is this true? Perhaps not. According to a recent press-release, the risks might be considerable.

Officials with the Tennessee Poison Control Center (TPC) are warning that they are seeing an increasing number of toxic exposures, mostly involving children, to essential oils used in aromatherapy. The TPC says the number of essential oil exposures doubled between 2011 and 2015, and 80 percent of those cases involved children. The primary route of poisoning is by ingestion, but also occurs with excessive or inappropriate application to the skin. Children are at risk because their skin easily absorbs oils and because they may try to ingest essential oils from the container.

“Tea tree oil is commonly cited, and most of those cases are accidental ingestions by children.” said Justin Loden, PharmD, certified specialist in Poison Information (CSPI) at TPC. Most essential oils have a pleasant smell but bitter taste, so children easily choke on them and aspirate the oil to their lungs, Loden said.

Several essential oils such as camphor, clove, lavender, eucalyptus, thyme, tea tree, and wintergreen oils are highly toxic. All of the oils produce oral and throat irritation, nausea, and vomiting when ingested. Most essential oils either produce central nervous system (CNS) stimulation, which results in agitation, hallucinations, delirium, and seizures or CNS depression, which results in lethargy and coma. Other toxic effects include painless chemical burns, hypotension, acute respiratory distress syndrome, acute liver failure, severe metabolic acidosis, and cerebral edema depending on which essential oil is in question.

Tennessee Poison Center Tips for using essential oils

  • Safely using and storing essential oils is extremely important
  • Use essential oil products ONLY for their intended purpose.
  • Use only the amount stated on the label/guide.
  • Do not swallow an essential oil unless the label says to do so.
  • Do not use a product on the skin unless the label says to do so.
  • Do not leave the product out (i.e. as a pesticide) unless the label says to do so.
  • If you have bottles of essential oils at home, keep them locked up, out of sight and reach of children and pet at all times. Children act fast, so do poisons.

Many will think that this is alarmist – but I don’t. In fact, in 2012, I published a systematic review aimed at critically evaluating the evidence regarding the adverse effects associated with aromatherapy. No, it was not funded by ‘BIG PHARMA’ but by THE ROYAL COLLEGE OF PHYSICIANS, LONDON.

Five electronic databases were searched to identify all relevant case reports and case series. Forty two primary reports met our inclusion criteria. In total, 71 patients experienced adverse effects of aromatherapy. Adverse effects ranged from mild to severe and included one fatality. The most common adverse effect was dermatitis. Lavender, peppermint, tea tree oil and ylang-ylang were the most common essential oils responsible for adverse effects.

At the time, we concluded that aromatherapy has the potential to cause adverse effects some of which are serious. Their frequency remains unknown. Lack of sufficiently convincing evidence regarding the effectiveness of aromatherapy combined with its potential to cause adverse effects questions the usefulness of this modality in any condition.

I might add – before the therapists start making comments – that, yes, aromatherapy is still dimensions safer than many conventional treatments. But remember: the value of a therapy is not determined by its safety but by the risk/benefit balance! And what are the proven benefits of aromatherapy, I ask you.

I just came across this article which I find remarkable in several ways. Here is the abstract:

OBJECTIVE:
The purpose of this report is to describe 2 patients with coronary artery disease presenting with musculoskeletal symptoms to a chiropractic clinic.
CLINICAL FEATURES:
A 48-year-old male new patient had thoracic spine pain aggravated by physical exertion. A 61-year-old man under routine care for low back pain experienced a secondary complaint of acute chest pain during a reevaluation.
INTERVENTION AND OUTCOME:
In both cases, the patients were strongly encouraged to consult their medical physician and were subsequently diagnosed with coronary artery disease. Following their diagnoses, each patient underwent surgical angioplasty procedures with stenting.
CONCLUSION:
Patients may present for chiropractic care with what appears to be musculoskeletal chest pain when the pain may be generating from coronary artery disease necessitating medical and possibly emergency care.

I FIND THIS REMARKABLE FOR AT LEAST 3 REASONS:

  1. I don’t remember coming across the term ‘medical physician’ before. It is clear what the author meant by it. But it is also quite clear that such phraseology is nonsensical. My Oxford Dictionary defines ‘physician’ as: “A person qualified to practise medicine, especially one who specializes in diagnosis and medical treatment as distinct from surgery.” Therefore, a ‘medical physician’ would be ‘a medical person qualified to practise medicine.’ This begs the question why this term is used in a chiro-journal. The answer is probably quite simple: they want to arrive at a point where we all accept that there are two types of physicians: medical and chiropractic. But, using again my dictionary, this would be not just a little confusing. A chiropractic physician would be ‘a chiropractor qualified to practice medicine.’ And for that you need to go not to chiro-college but to medical school.
  2. The two case reports are remarkable in themselves, I find. They show that “patients may present for chiropractic care with what appears to be musculoskeletal chest pain when the pain may be generating from coronary artery disease necessitating medical and possibly emergency care.” The remarkable thing about this is that such basic knowledge ever merited a mention and publication in a journal. It should be clear to anyone who is in healthcare! I even know shop assistants who have called an ambulance because a customer suffered from what might have been misdiagnosed as a muscular problem in the left arm but was in truth due to coronary hear disease. The fact that chiros and editors of their journals feel that it worthy of publication seems a bit worrying and begs the question: how many other elementary things about the human body (known even to shop assistants) are unknown to the average chiro?
  3. Lastly, I must praise the chiro-profession for the progress they now seem to start making. About 120 years ago, DD Palmer, the founding father of chiropractic, famously treated a man with coronary heart disease by adjusting his spine. The author of the above article did not do that! Yes, progress was painfully slow, but the above article seems to indicate that at least some chiros have come around to agreeing with real physicians that the Palmer-gospel is based on little more than wishful thinking.

This sad story was reported across the world. It is tragic and, at the same time, it makes me VERY angry. A women lost her life after giving birth due to the incompetence of her midwife. On this website, we learn the following gruesome details:

Many question the culpability of Australian midwife Gaye Demanuele in the wake of the investigations into the death of Caroline Lovell during her home birth in 2012. And while Demanuele played a major role in Lovell’s passing, a closer look may show the real culprit: homeopathy. In January 2012, Demanuele, an outspoken home birth advocate, served as senior midwife in Lovell’s home birth. After giving birth, Lovell experienced severe blood loss and begged to call an ambulance. According to the investigating coroner, Demanuele refused several times, never checking her patient’s blood pressure or effectively monitoring her blood loss. Demanuele instead tried a homeopathic “remedy” to relieve Lovell’s anxiety. Only after Lovell fainted in a pool of her own blood and went into cardiac arrest was she taken to a hospital, where she died 12 hours later…

We know that many midwifes are besotted with alternative medicine. Their love-affair with quackery had to lead to serious harm sooner or later. This story is thus tragic and awful – but it is not surprising.

What makes me angry, is the complete lack of critical comment from homeopaths and their professional organisations. Where are the homeopaths who state clearly and categorically that the use of homeopathic remedies in the situation described above (and indeed in midwifery generally) is not based on sound evidence? In fact, it is criminal charlatanry!

Homeopaths are usually not lost for words.

Where is the homeopathic organisation stating that a bleeding patient does not need homeopathy?

How should we interpret this deafening silence?

Does it mean that those homeopaths who quietly tolerate charlatanry are themselves charlatans?

If so, would this not be 100% of them?

Cervical spine manipulation (CSM) is a popular manipulative therapy employed by chiropractors, osteopaths, physiotherapists and other healthcare professionals. It remains controversial because its benefits are in doubt and its safety is questionable. CSM carries the risk of serious neurovascular complications, primarily due to vertebral artery dissection (VAD) and subsequent vertebrobasilar stroke.

Chinese physicians recently reported a rare case of a ‘locked-in syndrome’ (LIS) due to bi-lateral VAD after CSM treated by arterial embolectomy. A 36-year-old right-handed man was admitted to our hospital with numbness and weakness of limbs after receiving treatment with CSM. Although the patient remained conscious, he could not speak but could communicate with the surrounding by blinking or moving his eyes, and turned to complete quadriplegia, complete facial and bulbar palsy, dyspnoea at 4 hours after admission. He was diagnosed with LIS. Cervical and brain computed tomography angiography revealed bi-lateral VADs. Aorto-cranial digital subtraction angiography showed a vertebro-basilar thrombosis which was blocking the left vertebral artery, and a stenosis of right vertebral artery. The patient underwent emergency arterial embolectomy; subsequently he was treated with antiplatelet therapy and supportive therapy in an intensive care unit and later in a general ward. After 27 days, the patient’s physical function gradually improved. At discharge, he still had a neurological deficit with muscle strength grade 3/5 and hyperreflexia of the limbs.

The authors concluded that CSM might have potential severe side-effect like LIS due to bilaterial VAD, and arterial embolectomy is an important treatment choice. The practitioner must be aware of this complication and should give the patients informed consent to CSM, although not all stroke cases temporally related to CSM have pre-existing craniocervical artery dissection.

Informed consent is an ethical imperative with any treatment. There is good evidence to suggest that few clinicians using CSM obtain informed consent from their patients before starting their treatment. This is undoubtedly a serious violation of medical ethics.

So, why do they not obtain informed consent?

To answer this question, we need to consider what informed consent would mean. It would mean, I think, conveying the following points to the patient in a way that he or she can understand them:

  1. the treatment I am suggesting can, in rare cases, cause very serious problems,
  2. there is little good evidence to suggest that it will ease your condition,
  3. there are other therapies that might be more effective.

Who would give his or her consent after receiving such information?

I suspect it would be very few patients indeed!

AND THAT’S THE REASON, I FEAR, WHY MANY CLINICIANS USING CSM PREFER TO BEHAVE UNETHICALLY AND FORGET ABOUT INFORMED CONSENT.

We all hope that serious complications after chiropractic care are rare. However, this does not mean they are unimportant. Multi-vessel cervical dissection with cortical sparing is an exceptional event in clinical practice. Such a case has just been described as a result of chiropractic upper spinal manipulation.

Neurologists from Qatar published a case report of a 55-year-old man who presented with acute-onset neck pain associated with sudden onset right-sided hemiparesis and dysphasia after chiropractic manipulation for chronic neck pain.

Magnetic resonance imaging revealed bilateral internal carotid artery dissection and left extracranial vertebral artery dissection with bilateral anterior cerebral artery territory infarctions and large cortical-sparing left middle cerebral artery infarction. This suggests the presence of functionally patent and interconnecting leptomeningeal anastomoses between cerebral arteries, which may provide sufficient blood flow to salvage penumbral regions when a supplying artery is occluded.

The authors concluded that chiropractic cervical manipulation can result in catastrophic vascular lesions preventable if these practices are limited to highly specialized personnel under very specific situations.

Chiropractors will claim that they are highly specialised and that such events must be true rarities. Others might even deny a causal relationship altogether. Others again would claim that, relative to conventional treatments, chiropractic manipulations are extremely safe. You only need to search my blog using the search-term ‘chiropractic’ to find that there are considerable doubts about these assumptions:

  • Many chiropractors are not well trained and seem mostly in the business of making a tidy profit.
  • Some seem to have forgotten most of the factual knowledge they may have learnt at chiro-college.
  • There is no effective monitoring scheme to adequately record serious side-effects of chiropractic care.
  • Therefore the incidence figures of such catastrophic events are currently still anyone’s guess.
  • Publications by chiropractic interest groups seemingly denying this point are all fatally flawed.
  • It is not far-fetched to fear that under-reporting of serious complications is huge.
  • The reliable evidence fails to demonstrate that neck manipulations generate more good than harm.
  • Until sound evidence is available, the precautionary principle leads most critical thinkers to conclude that neck manipulations have no place in routine health care.

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.

The last point is perhaps the most important: AS FAR AS I CAN SEE, THERE IS NO INDICATION FOR NECK MANIPULATIONS FOR WHICH THE BENEFIT IS SUFFICIENTLY CERTAIN TO JUSTIFY ANY SUCH RISKS.

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