MD, PhD, FMedSci, FRSB, FRCP, FRCPEd.

I know, I have reported about the risks of chiropractic manipulations many times before. But I will continue to do so, because the subject is important and mentioning it might save lives.

The purpose of this study from the US was to determine the frequency of patients seen at a single institution who were diagnosed with a cervical vessel dissection related to chiropractic neck manipulation.  The researchers identified cases through a retrospective chart review of patients seen between April 2008 and March 2012 who had a diagnosis of cervical artery dissection following a recent chiropractic manipulation. Relevant imaging studies were reviewed by a board-certified neuroradiologist to confirm the findings of a cervical artery dissection and stroke. The investigators also conducted telephone interviews to ascertain the presence of residual symptoms in the affected patients.

Of the 141 patients with cervical artery dissection, 12 had documented chiropractic neck manipulation prior to the onset of the symptoms that led to medical presentation. The 12 patients had a total of 16 cervical artery dissections. All 12 patients developed symptoms of acute stroke. All strokes were confirmed with magnetic resonance imaging or computerized tomography. The researchers obtained follow-up information on 9 patients, 8 of whom had residual symptoms and one of whom died as a result of his injury.

The authors concluded that, in this case series, 12 patients with newly diagnosed cervical artery dissection(s) had recent chiropractic neck manipulation. Patients who are considering chiropractic cervical manipulation should be informed of the potential risk and be advised to seek immediate medical attention should they develop symptoms.

Cerebellar and spinal cord injuries related to cervical chiropractic manipulation were first reported in 1947. By 1974, there were 12 reported cases. Non-invasive imaging has since greatly improved the diagnosis of cervical artery dissection and of stroke, and cervical artery dissection is now recognized as pathogenic of strokes occurring in association with chiropractic manipulation.

The authors also point out that another institution had previously described 13 stroke cases after chiropractic manipulation. The patients at both institutions were relatively young and incurred substantial residual morbidity. A single patient at each institution died. If these findings are representative of other institutions across the United States, the incidence of stroke secondary to chiropractic manipulation may be higher than supposed. To assess this problem further, a randomized prospective cohort study could establish the relative risk of chiropractic manipulation of the cervical spine resulting in a cervical artery dissection. But such a study may be methodologically prohibitive. More feasible would be a case-control study in which patients who had experienced cervical artery dissection were matched with subjects who had not incurred such injuries. Comparing the groups’ odds of having received chiropractic manipulation demonstrated that spinal manipulative therapy is an independent risk factor for vertebral artery dissection and is highly suggestive of a causal association.

I very much agree with the authors when they sate that until the actual level of risk from chiropractic manipulation is known, patients with neck pain may be better served by equally effective passive physical therapy exercises.

In other words: there is very little reason to recommend chiropractic care for neck pain (or any other condition).

54 Responses to Until the precise risks from chiropractic manipulation are known, patients are better served by other treatments

  • Excellent insights! Not that Chiropractors submit to science, even the self-proclaimed evidenced based scoundrels sound like the pope suggesting evolution need not be summarily dismissed by “good Catholics”…however we can also appeal to Professor Bogduk and his paper: “Spinal manipulation for neck pain does not work”, IF we need put a finer point on the criminal enterprise.

    • Firstly a case series is hardly good science. Secondly it is well establish that there is an extremely small risk of a catastrophic event from cervical manip. Thirdly it is important that the patient is aware of these risks so that an informed choice can be made. Fourthly cervical manips have been shown to provide some use and is reasonable as a treatment option in some situations.

      As for Mr Kenny’s comment. He appears to be blowing smoke out of an orifice to which smoke should not come. I have complete both a Doctor of Physiotherapy and Master of Chiropractic and have found both provide good training in the use of evidence based practice and its application

  • So if chiropractors believe that all medical complaints are caused by spinal subluxations and require a good back cracking to fix them, I wonder how chiropractors treat stroke?

    At what stage of a patient losing consciousness on the treatment table would a chiropractor say ‘thats probably enough neck manipulation and maybe an ambulance is a good idea’?

  • How many of these cases presented to the chiropractors because they were experiencing a VAD?

    • DC wrote: “How many of these cases presented to the chiropractors because they were experiencing a VAD?”

      @ DC

      The study says “12 [patients] had documented chiropractic neck manipulation prior to the onset of the symptoms that led to medical presentation. The 12 patients had a total of 16 cervical artery dissections. All 12 patients developed symptoms of acute stroke.”

      As we know that there are no reliable methods available to screen for patients who might be predisposed to a dissection, and, in your scenario, it is evident that the chiropractors failed to recognise a VAD in progress, why aren’t chiropractors discarding neck manipulation?

  • “To assess this problem further, a randomized prospective cohort study could establish the relative risk of chiropractic manipulation of the cervical spine resulting in a cervical artery dissection. But such a study may be methodologically prohibitive.”
    So the only way would be a retrospective study comparing patients who presented to a chiro compared to a primary care physician with the same presenting condition, mining big data from a country with nationalized care and records covering both professions (Canada) is the only feasible way to rule out association v causation for something so rare. Since chiro’s manipulate and doctors don’t there should should be a difference between the groups. Well;
    “Risk of Carotid Stroke after Chiropractic Care: A Population-Based Case-Crossover Study.
    Cassidy JD, Boyle E2, Côté P, Hogg-Johnson S, Bondy SJ, Haldeman S.”
    https://www.ncbi.nlm.nih.gov/pubmed/27884458
    So even then if causation is not established then using the precautionary principle then patients must be informed of the possible risk through informed consent.
    Well:
    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2051308/
    Its been a common law requirement here for 18 years and I have used it as standard on every patient since 1995.
    So an interesting question. Has the risk associated with physiotherapy neck manipulation ever been investigated?
    Not that I know of but if there are any please post. So the physio’s have an adverse event reporting system like we tried to push for here for chiropractic and all health professions but was killed off by the doctors??
    Patient presents to the emergency department with stroke and the ER doctor asks “So have you recently seen a chiro OR a physio?” That would be a first.

    “patients with neck pain may be better served by equally effective passive physical therapy exercises.”
    According to the regulars here I’m a chiro so that means I just manipulate mythical subluxations and don’t prescribe exercises, rehab, soft tissue work, lifestyle advice, pain education, self management, foster resilience etc.

    • Cassidy has be criticised many times

      • Not only are his methods and interpretation questionable. Cassidy has a horse in this race. A customer of his suffered stroke after he wrung his neck so his integrity in this matter May be compromised.

      • Article by Neurosurgeons on this topic is very illuminating. They also discuss Cassidy’s papers. What would be the response if chiro’s had published this article with this title:
        “Systematic Review and Meta-analysis of Chiropractic Care and Cervical Artery Dissection: No Evidence for Causation”
        https://www.cureus.com/articles/4155-systematic-review-and-meta-analysis-of-chiropractic-care-and-cervical-artery-dissection-no-evidence-for-causation
        You would accuse us of burying our head in the sand. This article was criticized by FSM. In their blog they referred to the authors as “they” not once did they acknowledge that “they” were neurosurgeons and this line is telling:
        “In spite of the very weak data supporting an association between chiropractic neck manipulation and CAD, and even more modest data supporting a causal association, such a relationship is assumed by many clinicians. In fact, this idea seems to enjoy the status of medical dogma. Excellent peer reviewed publications frequently contain statements asserting a causal relationship between cervical manipulation and CAD [4,25,26]. We suggest that physicians should exercise caution in ascribing causation to associations in the absence of adequate and reliable data. Medical history offers many examples of relationships that were initially falsely assumed to be causal [27], and the relationship between CAD and chiropractic neck manipulation may need to be added to this list.”
        Imagine the backlash if a that had been written by a chiropractor.

          • Actually you didn’t counter the argument Blue. In your post cited above:
            “It showed an association between stroke and chiropractic.”
            Not Causation Blue. Similar association to patients presenting to their GP/PCP for the same condition in Cassidy’s paper and GP’s do not adjust/manipulate necks and the data sets were large (109,020,875 person-years of observation over 9 years). So even an extremely rare adverse event ( 1:400,000 to 1:1.04million would be likely to show up.
            “But the quality of the studies was judged to be poor and at risk for bias.”
            That is poor quality Medical studies reporting chiropractic adverse events with a high risk of Medical bias.
            “This relationship may be explained by the high risk of bias and confounding in the available studies”
            That’s medical bias and confounding Blue.
            “These authors evidently think litigation is worse than a stroke.”
            These authors are Neurosurgeons not chiropractors Blue.
            Science Based Medicine kept on calling the authors “they” throughout their blog. Not once did SBM acknowledge that “they” were neurosurgeons.

  • “In this overview, the included reviews did not provide sufficient data for synthesis, and therefore it is currently not possible to provide an overall estimate for the risk of SAEs associated with SMT. Of the few reviews providing estimates for the incidence of SAEs, no reliable single estimate was provided, and it was not possible to identify any agreement regarding the safety of SMT across the included reviews. Interestingly, we found indications that reviews with higher methodological quality generally used language suggesting SMT to be safer (or less harmful). However, when analysing this across the reviews whose objective was to investigate safety, this could not be replicated. In the few reviews assessing the likelihood of a causal relationship between SMT and SAEs, this relationship was not in all cases certain. However, it should be noted that these assessments were based on case reports and case series, which cannot determine causality.”

    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5366149/#MOESM4

  • The terrible truth in this matter is that pain in the neck might be a sign of ongoing dissection, therefore wringing the neck of anyone with pain may worsen such a situation. Cervical artery dissection cannot be diagnosed or ruled out by symptoms alone, or any diagnostic procedure possible in a chiropractor’s office. Many dissections probably heal without causing stroke.
    Ergo – chiropractors should never ever touch the neck of someone with neck pain and absolutely not twist or manipulate it in any way!

    Even if it were so that Katie May or any of the thousands of young people who are known to have suffered post-chiropractic stroke (and certainly many more who could not report their chiro visit because they were locked-in or dead), all came to the chiropractor with ongoing dissection, many of them might have survived if the fools… sorry, chiropractors had not twisted their neck.

    Wake up chiropractor-sheeple !!
    Show that you are a responsible and sensible herd who cares more for their customers than the money… or?

  • Let’s say it’s been asked a 1000 times…but never answered…but once again:
    IF a person desires to be a DOCTOR why become a Chiroquacker?? Why not be a real DOCTOR (MD) and then save the world with your DD & BJ theatrics (as MDs have no treatment restrictions, they can do spinal manipulations and all the other theatrics if they choose without reservations).
    AND: a DC is a 6 year, $200,000 non-transferable, disrespected, non-internship, non-evolving degree pretending to have real University equivalence, but NEVER has and NEVER will.
    AND where is the listing of names of MDs and PhDs (especially in kinesiology and biomechanics etc) who have pursed a DC degree POST their real degree?? There are none:
    BECAUSE: Chiropractic…is…..fraud.

  • DC seems to be repeatedly asking: “How many of these cases presented to the chiropractors because they were experiencing a VAD?”

    @ DC

    I don’t know, but if there were any, the precautionary principle should have been applied – i.e. they should not have had their necks manipulated.
    https://en.wikipedia.org/wiki/Precautionary_principle

    Also see https://edzardernst.com/2017/04/we-have-an-ethical-legal-and-moral-duty-to-discourage-chiropractic-neck-manipulations/

    • So, its unknown from that paper if cSMT actually caused the VADs.

      • DC wrote: “So, its unknown from that paper if cSMT actually caused the VADs.”

        @ DC

        I’m not sure what your point is. The title of this post is ‘Until the precise risks from chiropractic manipulation are known, patients are better served by other treatments’.

        • He is entitled to his opinion.

          However, the paper he used to support his position doesn’t really support his position. But maybe that’s the best he can do.

          • DC wrote: “He [Professor Ernst] is entitled to his opinion. However, the paper he used to support his position doesn’t really support his position. But maybe that’s the best he can do.”

            Where is your cautious attitude? It is possible that patients are being killed and maimed by chiropractic neck manipulation despite there being cheaper, safer, and more convenient options available. (And, of course, there are no options available to those highly unethical chiropractors – the majority – who manipulate necks for vitalist reasons.)

            I can’t help feeling that you, and very many other chiropractors, are more interested in protecting your livelihoods than your customers.

          • @BlueWode…where is my cautious attitude?

            Not that this is about (its about the evidence)…

            For the first 10 years of practice i didnt perform any cSMT because of my concerns of risk vs benefit (based upon the risk taught to me in college at the time).

            As new evidence came forth and i looked into topics such as risk factors, VA strains, rebleeds, probabilities, etc i began to ease up on my caution.

            As a general policy i do not perform cSMT until other avenues are unsuccessful… i usually allow for 3 or 4 treatments and other approaches. I have and continue to ask other chiropractors to take this approach.

            For those where cSMT appears to be beneficial it costs the patients/insurance more due to this delayed approach.

            Insurance reimbursement is typically higher for non cSMT approaches.

            Whenever i find research that pertains to this topic i share it with my EB peers and encourage discussion (i just shared another one this past week that may indicate a new risk factor).

            I’ve been requesting researchers for years to continue to perform research in this area (particularly in the area of rebleeds and cSMT).

            So, thats my “cautious attitude”.

            Now, let’s stick with the evidence and leave feelings to the less informed.

          • “stick with the evidence”
            EXACTLY!
            what are the risk factors and where is the evidence for them?

          • The known potential associated risk factors for VAD can easily be found with a google search.

            One can start here…

            https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3026338/#!po=34.3023

          • I asked for risk factors of cSMT causing complications

          • That was not what I was referencing in my comment. It was risk factors for VAD.

  • DC wrote: “@BlueWode…where is my cautious attitude? Not that this is about (its about the evidence)…”

    It’s about a cautious attitude that includes the ability to make thorough critical assessments.

    DC wrote: “For those where cSMT appears to be beneficial”

    Your “appears to be beneficial” isn’t good enough when you are administering a potentially life-threatening procedure with a poor evidence base to treat a non-life-threatening condition. It brings to mind section 146 (p.55) of the Statement of Claim of Sandra Nette, a Canadian tetraplegic chiropractic neck manipulation victim:

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

    Link: http://www.casewatch.org/mal/nette/claim.pdf

    In other words, many chiropractors – and their regulators – seem to find it acceptable to rely on anecdotal or weak evidence where it supports chiropractic treatment, but where similar, or more robust evidence suggests that serious complications can result from it, they are usually quick to dismiss it.

    DC wrote: “Insurance reimbursement is typically higher for non cSMT approaches.”

    That might be, but it is important to balance that with the hundreds of thousands of chiropractic customers who don’t need any treatment, but who are financially exploited (many along with their insurance companies) on a regular basis by those chiropractors (the majority) who sell them the (fictional) subluxation maintenance/wellness care business model.

    With regard to “stick with the evidence”, where are the reliable chiropractic adverse event reporting systems? U.S. chiropractors have no patient adverse event reporting systems due to a loophole:
    http://www.ebm-first.com/chiropractic/risks/1842-letter-from-britt-harwe-president-chiropractic-stroke-awareness-group-csag.html

    And the only monitoring system that is in place is worse than useless:
    http://tinyurl.com/6dhcxdc

    • It appears your main issues are with the practices of other chiropractors.

    • Oh, and just for comparison sake…let’s see what is occuring “across the aisle”.

      Conclusions: Cervical epidural injecions (e.g., CESI, ICESI, and TF‑CESI) which
      are not FDA approved, provide no long‑term benefit, and are being performed for
      minimal to no indications. They contribute to significant morbidity and mortality,
      including; epidural hematomas, infection, inadvertent intramedullary cord injections
      or cord, brain stem, and cerebellar strokes. Furthermore, these injections are
      increasingly required by insurance carriers prior to granting permission for definitive
      surgery, thus significantly delaying in some cases necessary operative intervention,
      while also subjecting patients at the hands of the insurance companies, to the
      additional hazards of these procedures.

      Major risks and complications of cervical epidural steroid
      injections: An updated review
      Nancy E. Epstein1,2
      1
      Professor of Clinical Neurosurgery, School of Medicine, State University of N.Y. at Stony Brook, NewYork, USA, 2
      Chief of Neurosurgical Spine and Education,
      NYU Winthrop Hospital, NYU Winthrop NeuroScience, Mineola, NewYork, USA
      E‑mail: *Nancy E. Epstein ‑ nancy.epsteinmd@gmail.com
      *Corresponding author
      Received: 16 March 18 Accepted: 16 March 18 Published: 23 April 18

      • here comes another fallacy!

        • Is it a fallacy to see whats happening in other professions? Or does it just make folks uncomfortable to do so?

          “This could be related to under-reporting, because there is currently no requirement in the US to report complications from ESI when they do occur.”

          https://link.springer.com/article/10.1007/s40141-013-0038-6

          • @ DC

            Are you saying that chiropractors should wait until medicine puts its house in order before they get round to putting proper adverse event monitoring in place? IOW, that it’s acceptable to put chiropractic customers at risk because medicine isn’t perfect (even although medicine saves many, many, many lives)?

          • @DC
            The topic here is the risk/benefit ratio of chiropractic and progress in chiropractic, not in medicine, of which the example you fallaciously attempt to divert attention with is a good example.

          • BlueWode…I have had conversations with a major chiropractic malpractice carrier, an EHR software company, researchers and a chiropractic college president re the topic of setting up an AE reporting center (embedded within a national data collection center). The main issue is not the setting up an AE reporting system but rather improving communication with MDs when a presumed AE is presented to them.

            Björn…yes, looking at the risk/benefit of various treatments for certain conditions rather than just a single profession seems beyond the scope of this blog. Discussion of those issues is better left to those who make clinical guidelines and deliver front line care.

          • in my view, the ‘main issue’ is secondary. fact is that such a system does not exist – and for that, you have to blame the chiropractic profession who, after 120 years, has not managed to set it up.

          • Yes….chiropractic needs to do better, as do others.

            “By contrast, clinical dentistry does not have any such mandatory reporting requirements for AEs, and if we did, there would be no standardized format for reporting these events.”

            JPatientSaf Volume00, Number00, Month2017

          • @DC
            FYI I am very actively and professionally involved in the process of monitoring and promoting safety and quality within medicine. That is one reason why I am particular about keeping the discussion on the right track here in this forum, i.e. keeping focus on so called alternative medicine.
            This is not a forum equipped to discuss the shortcomings and problems of modern medicine. Misguided attempts at using problem examples from medicine to divert attention from the topic at hand are by default fallacious and only serve to illustrate an inferior understanding of the subject. This applies to your recent input with an out of context reference to a highly specialised, almost marginal problem in medicine, which I believe no one here is qualified to address competently, not even me, even if I believe I know very much more about it than you.

            Your efforts at promoting an AE reporting system for chiropractic are absolutely laudable but may be pipe dreams, I am afraid. Not because it is not necessary but because the members of the profession* for which such a system is most needed are not trustworthy and are not likely to use such a system credibly.

            *I had severe reservations against using the term ‘profession’ when referring to chiropractors, until I realised that the term can also be applied to actors, trapeze artists and other professions of the entertainment industry.
            Chiropractors are to all practical purposes entertainers who perform an act of medical mockery while nature or coincident medical attention takes its course. This is of course somewhat unfair to those chiropractors who struggle to crawl form under the burdening rock of chiropractic history and try to adopt the methods of health care e.g. evidence based dietary counseling or evidence based methodology of physiotherapy.

          • BlueWode…chiropractors don’t have an AE reporting system

            Björn…an AE reporting system is not really going to work with chiropractors

            Repeat.

  • Critical_Chiro on Monday 20 August 2018 at 02:25: “These authors are Neurosurgeons not chiropractors Blue. Science Based Medicine kept on calling the authors “they” throughout their blog. Not once did SBM acknowledge that “they” were neurosurgeons.”

    Lifted from the link in the link I provided:

    “But then it gets weird as they then rationalize away the results. And these are neurosurgeons, not chiropractors.”

    Here’s the link again: https://edzardernst.com/2016/10/top-model-died-as-a-result-of-visiting-a-chiropractor/#comment-82799

  • DC on wrote on Monday 20 August 2018 at 22:35 : “BlueWode…chiropractors don’t have an AE reporting system – Björn…an AE reporting system is not really going to work with chiropractors. Repeat.”

    @ DC

    I almost invariably use the word ‘reliable’ when I’m discussing chiropractors and reporting systems.

    In the comments above I wrote:

    “where are the reliable chiropractic adverse event reporting systems? U.S. chiropractors have no patient adverse event reporting systems due to a loophole:
    http://www.ebm-first.com/chiropractic/risks/1842-letter-from-britt-harwe-president-chiropractic-stroke-awareness-group-csag.html
    And the only monitoring system that is in place is worse than useless:
    http://tinyurl.com/6dhcxdc

    I’m sure Björn has read those links and, unfortunately for chiropractic customers, is likely to be correct with his assumption.

    • Correction noted, but it doesn’t change my point.

      Regardless, my purpose of my prior posts re other professions or procedures was simply to point out that these issues are not isolated to chiropractic. Another example?

      “Some argue that the lack of reporting of adverse events in the orthopaedic physical therapy literature suggests that these interventions are safe. But this view is problematic and a lack of reporting does not constitute evidence that harm is not present. However, without standardization in terminology and reporting, this assumption is not supported by evidence. High-quality studies with standardized reporting for both mild to moderate and severe adverse events are needed. Overall orthopaedic physical therapy lacks credible evidence on adverse events, because there is a lack of reporting on the large study populations required to establish rates for rare events and a lack of standardization of terminology and reporting for more common occurrences.” https://www.jospt.org/doi/full/10.2519/jospt.2010.3229

      The point was not to absolve chiropractors from our responsibility.

      Björn point is well taken. The best I/we can do is work with those who value a “reliable” AE reporting system, and that appears to be mainly within the EB crowd.

      • “my purpose of my prior posts re other professions or procedures was simply to point out that these issues are not isolated to chiropractic.” Thank you for a perfect definition of the tu quoque logical fallacy.

        Like Edzard told Iqbal in another thread “ALL THE DEFECTS OF CONVENTIONAL MEDICINE DO NOT RENDER HOMEOPATHY EFFECTIVE!” The parallel for the present case is that “ALL THE DEFECTS OF CONVENTIONAL MEDICINE ADVERSE EVENT REPORTING DO NOT MAKE CHIROPRACTIC SAFE.”

    • Very interesting abstract professor.

      I am unable to access the full paper and the abstract ( in German) contains little information on the results so perhaps someone can prepare a brief resumé of their main findings?
      I am also curious as to the 1995 Bingen recommendations that are mentioned. I could not readily find them, perhaps they are in German as well?

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