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

Spinal manipulative therapy (SMT), especially hyperextension and rotation. have often been associated with cervical artery dissection (CAD), a tear in the internal carotid or the vertebral artery resulting in an intramural haematoma and/or an aneurysmal dilatation. But is the association causal? This question is often the subject of fierce discussions between chiropractors and the real doctors.

The lack of established causality relates to the chicken and egg discussion, i.e., whether the CAD symptoms lead the patient to seek cervical SMT or whether the cervical SMT provokes CAD along with the non-CAD presenting headache and/or neck complaint.

The aim of a new review was to provide an updated step-by-step risk-benefit assessment strategy regarding manual therapy and to provide tools for clinicians to exclude cervical artery dissection.

In light of the evidence provided, the reality, according to the review-authors, is:

  • a) that there is no firm scientific basis for direct causality between cervical SMT and CAD;
  • b) that the internal carotid artery (ICA) moves freely within the cervical pathway, while 74% of cervical SMTs are conducted in the lower cervical spine where the vertebral artery (VA) also moves freely;
  • c) that active daily life consists of multiple cervical movements including rotations that do not trigger CAD, as is true for a range of physical activities;
  • d) that a cervical manipulation and/or grade C cervical mobilization goes beyond the physiological limit but remains within the anatomical range, which theoretically means that the artery should not exceed failure strain.

These factors underscore the fact that no serious adverse event (AE) was reported in a large prospective national survey conducted in the UK that assessed all AEs in 28,807 chiropractic treatment consultations, which included 50,276 cervical spine manipulations.

The figure outlines a risk-benefit assessment strategy that should provide additional knowledge and improve the vigilance of all clinicians to enable them to exclude CAD, refer patients with suspected CAD to appropriate care, and consequently prevent CAD from progressing.

It has been argued that most patients present with at least two physical symptoms. The clinical characteristics and recommendations in the figure follow this assumption. This figure is intended to function as a knowledge base that should be implemented in preliminary screening and be part of good clinical practice. This knowledge base will likely contribute to sharpening the attention of the clinicians and alert them as to whether the presenting complaint, combined with a collection of warning signs listed in the figure, deviates from what he or she considers to be a usual musculoskeletal presentation.

Even though this is a seemingly thoughtful analysis, I think it omits at least two important points:

  1. The large prospective UK survey which included 50,276 cervical spine manipulations might be less convincing that it seems. It recorded about one order of magnitude less minor adverse effects of spinal manipulation than a multitude of previously published prospective surveys. The self-selected, relatively small group of participating chiropractors (32% of the total sample) were both experienced (67% been in practice for 5 or more years) and may not always have adhered to the protocol of the survey. Thus they may have employed their experience to intuitively select low-risk patients rather than including all consecutive cases, as the protocol prescribed. This hypothesis would firstly account for the unusually low rate of minor adverse effects, and secondly, it would explain why no serious complications occurred at all. Given that about 700 such complications are on record, the low incidence of serious adverse events could well be a gross underestimate.
  2. The effect of chiropractic spinal manipulative therapy is probably due to a placebo response. This means that it should probably not be done in the first place.

49 Responses to A risk-benefit assessment of (chiropractic) neck manipulation

  • EE…The effect of chiropractic spinal manipulative therapy is probably due to a placebo response.

    Or possibly not…

    Taken independently, the findings of the studies suggest that manual therapy on the cervical spine is more effective than traditional physical therapy interventions or sham intervention in reducing pain intensity and frequency of headaches in this population.

    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4800981/#!po=17.5000

  • “Cervical manipulation for acute/subacute neck pain was more effective than varied combinations of analgesics, muscle relaxants and non-steroidal anti-inflammatory drugs for improving pain and function at up to long-term follow-up.”

    The Chocrane review 2015… just in case we are intrested in “real science” and not political agenda

    • Authors conclusion…”Multiple cervical manipulation sessions may provide better pain relief and functional improvement than certain medications at immediate/intermediate/long-term follow-up.”

      So if cervical manipulation “is probably due to a placebo response”, what does that say about these “certain medications”?

  • In what way is a cervical manipulation carried out by a chiropractor different from a cervical manipulation carried out by a physiotherapist, osteopath or orthopaedic physician?

    • I’m not an expert on the various forms but my understanding is that chiropractors tend to use short lever approach, osteopaths use long lever, physical therapists use more of an oscillator approach.

      I am unware of any evidence of any increased benefit or reduced risk between the various approaches.

      • roughly correct – except that
        1) there is a Cochrane review suggesting that there is not difference between the techniques in terms of effectiveness;
        2) the vast majority of complications occurred after short lever high velocity thrusts.

        • As i wrote…i am not aware of any increased benefit or risk between approaches.

          Well, since chiropractors perform around 90% of spinal manipulations and since they tend to use a short lever approach, it only makes sense that most AE are associated with that approach.

          • @ DC

            Increased risk from chiropractors, apparently. See Fig. 2 here:
            https://academic.oup.com/ptj/article/79/1/50/2857770

          • No, that figure doesn’t show increased risk from chiropractors. One would also need to look at utilization within each profession. For example, in the USA, physical therapists cannot do spinal manipulation in all 50 states (I think in half of the states) therefore one would expect to see a lower percentage of reported AE.

            What that figure 2 indicates that if chiropractors are doing approximately 90% of cervical spine manipulation but around 70% of AE are attributed to chiropractors, they appear to have a reduced ratio of risk of AE, whereas MDs have the higher ratio of cSMT:AE, assuming reporting is equal across all professions.

  • DC wrote: “…figure 2 indicates that if chiropractors are doing approximately 90% of cervical spine manipulation but around 70% of AE are attributed to chiropractors, they appear to have a reduced ratio of risk of AE, whereas MDs have the higher ratio of cSMT:AE, assuming reporting is equal across all professions”

    That paper seems to have been superseded by a 2002 systematic review entitled ‘Manipulation of the cervical spine: a systematic review of case reports of serious adverse events, 1995–2001’:
    https://www.mja.com.au/journal/2002/176/8/manipulation-cervical-spine-systematic-review-case-reports-serious-adverse

    This is its data synthesis:

    “Thirty-one case reports (42 individual cases) were found. The patients were equally distributed between the sexes (21 male, 20 female, one unknown) and mostly middle-aged (range, 3 months to 87 years). Most were treated by chiropractors. Arterial dissection causing stroke was reported in at least 18 cases.”

    Returning to my original comment in which I said there *apparently* was an increased risk from chiropractors, given that there are no reliable screening methods available to determine who might be predisposed to injury, and that the evidence of benefit is pitiful (with cheaper, safer, and more convenient options available – e.g. exercise), these days all cervical spine manipulations should be deemed unnecessary regardless of who does them.

    • No, that data does not show there is an *increased* risk of serious AE from chiropractors, even as “apparently”. If fact it indicates the opposite if one considers percentage of application of cSMT in clinical settings (assuming all other variables are equal).

      • DC wrote: “No, that data does not show there is an *increased* risk of serious AE from chiropractors”

        @ DC

        Even so, the Precautionary Principle must be applied – i.e. (as I said above) given that there are no reliable screening methods available to determine who might be predisposed to injury, and that the evidence of benefit is pitiful (with cheaper, safer, and more convenient options available – e.g. exercise), these days all cervical spine manipulations should be deemed unnecessary regardless of who does them.

        • Well, thats a different topic than there is an apparent increased risk of serious AE with chiropractors doing cSMT.

          This is one of the more recent reviews that include the topic of cSMT and any perceived benefit.

          https://onlinelibrary.wiley.com/doi/abs/10.1002/ejp.1374?fbclid=IwAR0In7IjUclxmTKEDMgbdYNmDEywtQKMUibrI58o4NbrKYaMOyErSyISh2I

          Also, there is an older paper where the authors concluded that almost half of serious AE from cervical spinal manipulation were deemed preventable due to pre existing conditions. Another 25% due to continued care without improvement. Around 20% for conditions not appropriate for cSMT. Only 10% were classified as unpreventable.

          Hence…the main issue is the provider, not the procedure.

          So again, looking at the reports, based upon the ratio, chiropractors appear to be providing safer care than say MDs and DOs when doing cSMT (again with some assumptions).

          Regarding screening…another topic for another time.

          • DC wrote: “…the main issue is the provider, not the procedure…chiropractors appear to be providing safer care than say MDs and DOs when doing cSMT (again with some assumptions). Regarding screening…another topic for another time.”

            Screening is a crucial matter. Until reliable methods of determining those at risk from neck manipulation are available, and until those who administer neck manipulations have reliable adverse event monitoring systems in place, the Precautionary Principle must be applied. As already pointed out, there is no need to use neck manipulation when safer, cheaper, and more convenient options are available.

          • I didnt say “screening tools” arent crucial. The topic however is complex and several background issues would have to be agreed upon. Based upon your comments it appears we are not there yet.

  • DC wrote: “I didn’t say ‘screening tools’ aren’t crucial. The topic however is complex and several background issues would have to be agreed upon. Based upon your comments it appears we are not there yet.”

    @ DC

    Meanwhile, millions of people are having their necks manipulated despite there being safer, cheaper, and more convenient options available. And many of those millions are having their necks manipulated to correct mythical chiropractic ‘subluxations’.

    Where’s the sense in that? Why does it continue?

    • BW….Meanwhile, millions of people are having their necks manipulated despite there being safer, cheaper, and more convenient options available.

      What are the “more convenient options available” which you referring to and for what conditions? NSAIDs, mobilizations, muscle relaxers, opioids, etc? They all have risk:benefit:cost profiles; short, medium, long term effects; acute, subacute, recurrent, chronic states; indirect and direct costs; valid outcome measures; research of pragmatic vs reductionistic methodology; internal and external validity of the research; casual vs correlation of AE; treating direct vs indirect trauma; unimodal vs multimodal, etc…. it’s not as cut and dry and you suggest.

      BW…And many of those millions are having their necks manipulated to correct mythical chiropractic ‘subluxations’.

      DC, MD, DO, PT all adjust the same lesion…we just have different names for it.

      • DC wrote: “…it’s not as cut and dry and you suggest”

        @ DC

        With regard to neck manipulation, I repeat, the Precautionary Principle MUST apply. At least NSAIDs, muscle relaxers, opioids, etc., have pretty reliable post-marketing surveillance (which chiropractic does not) and, taken at recommended doses for a short time, they are generally very low-risk for appropriately selected patients. In addition to that, they are invariably accompanied by Patient Information Leaflets explaining risks, benefits, and contradictions whereas we know that a sizeable number of chiropractors do not give their patients such information prior to treatment. And let’s not forget that patients often continue to take such medications while undergoing neck manipulation, and possibly even for exacerbations of pain caused by neck manipulation.

        DC wrote: “DC, MD, DO, PT all adjust the same lesion…we just have different names for it.”

        How disingenuous of you. You know perfectly well that many chiropractors use manipulation for unjustified reasons:

        QUOTE
        “…for some manual therapists, treatment is still based on a belief system that incorporates vitalism, energy healing, and other metaphysical concepts. Cooperation of practitioners in researching the effects of manual therapy would require uniformity based upon the guidelines of science, following rules for selection of an evidence-based therapy that produces predictable and replicable results. Such an approach would not allow contamination by dogma or by an agenda that is designed more to support a belief system than to find the truth. The chiropractic profession, which began with a founding father in 1895, is identified primarily by its use of manipulation. But chiropractic is based upon a vertebral subluxation theory that is generally categorized as supporting a belief system. The words ‘manipulation’ and ‘subluxation’ in a chiropractic context have meanings that are different from the meanings in evidence-based literature. An orthopedic subluxation, a partial dislocation or displacement of a joint, can sometimes benefit from manipulation or mobilization when there are joint-related symptoms. A chiropractic subluxation, however, is often an undetectable or asymptomatic ‘spinal lesion’ that is alleged to be a cause of disease. Such a subluxation, which has never been proven to exist, is ‘adjusted’ by chiropractors, who manipulate the spine to restore and maintain health. The reasons for use of manipulation/ mobilization by an evidence-based manual therapist are not the same as the reason for use of adjustment/manipulation by most chiropractors. Only evidence-based chiropractors, who have renounced subluxation dogma, can be part of a team that would research the effects of manipulation without bias.”

        Ref: http://jmmtonline.com/documents/HomolaV14N2E.pdf

        For readers who might not be aware, the following terms either relate to, are synonyms for, or have been used or cited in connection with describing a (mythical) chiropractic subluxation or aspects of the (mythical) chiropractic Vertebral Subluxation Complex (VSC):

        Aberrant motion
        (Ab)normal articular sensory input
        Abnormal dysfunction
        Abnormal fixation
        Abnormal instantaneous axis of rotation
        Abnormal mechanics
        Abnormal motion or position
        Abnormal muscle function
        Abnormal nervous system function
        Abnormal spinal function
        Altered intervertebral mechanics
        Altered joint structure and function
        Altered nociceptive and proprioceptive input
        Altered regional mechanics
        Arthropathic
        Abnormal function
        (Ab)normal joint mechanics
        Abnormal joint motion
        Abnormal motion or position
        Abnormal muscle function
        Abnormalities of range of motion or coupling
        Abnormal nervous system function
        (Ab)normal regional sympathetic tone
        Abnormal restrictive barrier in or around joints
        Abnormal spinal function
        (Ab)normal structural relationship
        Acute joint locking
        Acute locking
        Adverse mechanical tension of the nervous system
        Altered alignment
        Altered joint motion
        Altered nervous system movement
        Altered physiological function
        Apophyseal subluxation
        Arthron (extremity joint subluxation — see also “vertebron”)
        Articular derangement
        Articular dyskinesia
        Articular juxtaposition
        Biomechanical distortion
        Biomechanical impropriety
        Biomechanical insult
        Biomechanical stress
        Blockage
        Blocking
        Bony displacement
        Bony maladjustment
        Bony lesion
        Cervical joint dysfunction
        Changes of the dynamic segment
        “Changes of thoracic segments”
        Chiropractic lesion
        Compensatory structural subluxations
        Comprehensive lesion
        ” … compromise proper function”
        Deconditioned syndromes
        Deviation of the bodies
        Errors of static or motor mechanics
        Facet joint syndrome
        Facet synovial impingement
        Facilitated spinal system
        Facilitated subluxation*
        Functional pathology
        Functional subluxation*
        Chiropractic subluxation
        Chiropractic subluxation complex
        Comprehensive lesion
        ” … compromise proper function.”
        Delayed instability
        Deformation behaviour
        Degenerative dynamic segment
        Derangement
        Derangement of the opposing joint surfaces
        Discoradicular conflict
        Disorder of the disc
        Disrelationship of the facets
        Displacement
        Disturbance in the mechanico-dynamics
        “(vertebrae) … don’t move enough, or they move too much.”
        Dynamic forceps
        Dynamic segment
        Dysarthric lesion
        Dysarthrosis
        Dysfunctional joint
        Dysponesis
        Dystopia
        Dysfunctional segments
        Engagement of the spinal segment in a pathologic reflex chain
        Erratic movement of spinal articulations
        Excursion (Conley) = (“Wandering from the usual path.” — Taber’s)
        Facet imbrication
        Facet joint dysfunction
        Facet syndrome
        Facilitated segment
        Facilitative lesion
        Fanning of interspinous space
        Fixation
        Fixed vertebra
        Focal tenderness
        ” … force other joints to move too much.”
        Functional block
        “(subluxations) … force other joints to move too much.”
        Functional compromise
        Functional deficit
        Functional defects
        Functional derangement
        Functional and structural changes in the three joint complex
        Functional disturbance
        Functional impairments of motion
        Functional spinal lesion
        Functional subluxation*
        Gravitational (im)balance of joints (with) reduced chronic, asymmetrical forces
        Harmful dysfunction of the neuromusculoskeletal system
        Hyperaemic subluxation
        Hyperanteflexion sprain
        Hypermobility
        Hypopmobility
        Hypokinetic aberration*
        Impairment
        (Im)properly direct(ed) coordinated, (in)harmonious motor programming
        Inability of the segment to articulate about its new axis
        Incomplete luxation
        Incomprehensible pattern of symptoms and clinical findings when compared to with examination of mechanical lesions in the extremities
        Instability of the posterior ligament complex
        Interdiscal block
        Internal joint derangement
        Internal vertebral syndrome
        Intersegmental instability
        Intersegmental subluxation
        Intervertebral blocking
        Intervertebral disrelationship
        Intervertebral dysfunction of the mobile segment
        Intervertebral joint subluxation
        Intervertebral obturations
        Intervertebral subluxation
        Joint bind
        Joint disturbances
        Joint dysfunction
        Joint immobilization
        Joint “instability”
        Joint movement restriction
        “Just short of a dislocation”
        Kinesiopathology
        Kinetic intersegmental subluxation
        Kinetic subluxation
        Lesion
        Less than a locked dislocation
        Ligatights
        Localised/referred pain
        Locked
        Locking
        Locked subluxation
        Locks up and restricts motion
        Lose their normal motion or position
        Loss of elasticity
        Loss of joint movement
        Loss of juxtaposition
        Loss of segmental mobility
        Low back dysfunction
        Malalignment
        Maladjustment (of a vertebra)
        Malposed vertebra
        Mechanical interferences
        Mechanical malfunctioning
        Mechanically infringe
        Manipulatable joint lesion
        Manipulatable lesion (adjustable subluxation!)
        Mechanical derangement
        Mechanical disorder
        Mechanical dysfunction
        Mechanical instability
        Mechanical irritation of the sympathetic ganglionic chain
        Mechanical musculoskeletal dysfunction
        Mechanico-neural interaction
        Metameric dysfunction
        Mild pubic diastasis
        Minor derangement
        Misalignment
        Misalignment of the fibrocartilaginous joint
        Motor unit derangement complex
        Motion restriction
        Movement restriction
        Multisegmental spinal distortion
        Musculoskeletal dysfunction
        Myopathology
        Nervous system impairment by the spine
        Neuro-articular dysfunction*
        Neuro-articular subluxation*
        Neuro-articular syndrome*
        Neurobiomechanical
        Neuro-dysarthric
        Neuro-dysarthrodynic
        Neurological dysfunction
        Neurodystrophy
        Neurofunctional subluxation*
        Neuro-mechanical lesion*
        Neuromuscular unit
        Neuromuscular dysfacilitation
        Neuromuscular dysfunction
        Neuropathology
        Neuropathophysiology
        Neurospinal condition
        Neurospinal distortions
        Neurostasis (Wilson)
        Occult subluxation
        Offset
        Orthokinetics
        Ortho-spondylo-dysarthrics
        Osteological lesion
        Osteopathic lesion
        Osteopathic spinal lesion
        Osteopathic spinal joint lesion
        Pain and debility without recognisable pathology
        Painful intervertebral dysfunction (“PID”)
        Painful minor intervertebral dysfunction (“PMID”)
        Palpable changes
        Paravertebral subluxation
        Partial dislocation
        Partial or incomplete separation
        Partial fixation
        Partial luxation
        Pathogenic interaction of spine and nervous system
        Pathophysiological mechanics
        Pathologically altered bradytrophic tissue
        Pathologically altered dynamic segment
        Pathomechanics
        Pathophysiology
        Perverted function
        Physiologic displacement
        Physiologic lock the motion segment
        Positional dyskineria
        Posterior facet dysfunction
        Posterior joint dysfunction (“PJD” — see “three-joint complex”!)
        Posterior joint syndrome
        Post-traumatic dysautonomic
        Prespondylosis
        Primary dysfunction
        Primary fibromyalgic syndrome
        Pseudosubluxation
        Putative segmental instantaneous axis of rotation
        Reflex dysfunction
        Reduced mobility
        Regional dysfunction
        “Relative as absolute lack of space within the intervertebral foramen”
        Residual displacement
        Restricted motion
        Restriction
        Restriction of unisegmental mobility
        Reversible with adjustment/manipulation
        Sagittal translation (Conley)
        Sectional subluxation
        Segmental dysfunction
        Segmental instability
        Segmental movement restriction
        Segmental vertebral hypomobility
        Semiluxation
        Simple joint and muscle dysfunction without tissue damage
        Shear strain distribution
        Slight luxation
        Slightly luxated
        Slightly misaligned vertebra
        Soft tissue ankylosis
        Somatic dysfunction
        Spinal dysfunction
        Spinal fixation
        Spinal hypomobilities
        Spinal irritation
        Spinal joint blocking
        Spinal joint complex
        Spinal joint dysfunction
        Spinal joint malfunction
        Spinal kinesiology
        Spinal lesion
        Spinal mechanical dysfunction
        Spinal pathophysiology
        Spinal segmental facilitation
        Spinal segmental instability
        Spinal subluxation
        Spine restriction
        Spino-neural conflict
        Spinostasis (Wilson)
        Spondylodysarthric lesions
        Sprain
        Stable cervical injury of the spine (see also “instability” above)
        Static intersegmental subluxation
        Static subluxation
        Strain
        Strain distribution
        Structural abnormalities
        Structural derangement
        Structural disrelationship
        Structural intersegmental distortion
        Structural lesions
        “Stuck”
        Subtle instability
        Sub-luxation
        Subluxation
        Subluxation complex
        Subluxation complex myopathy
        Subluxation syndrome
        Subluxes
        Three joint complex
        Tilting of the vertebral body
        Tightened, deep, joint related structures
        Total fixation
        Translation
        Unresolved mechanical tension or torsion
        Unstable lumbar spine
        Unstable subluxation
        Vertebragenous syndromes
        Vertebral derangement
        Vertebral displacement
        Vertebral dysfunction
        Vertebral dyskinesia
        Vertebral factor
        Vertebral genesis
        Vertebral induction
        Vertebral lesion*
        Vertebral pathology
        Vertebral subluxation
        Vertebral subluxation complex
        Vertebral subluxation syndrome
        Vertebrally diseased
        Vertebroligamentous sprain strain
        Vertebron (see also “arthron”)
        Wedged disc
        Zygopophyseal pathophysiology

        42 Terms for a Sacroiliac Subluxation:

        Abnormal pelvis biomechanics
        Altered sacroiliac mechanics
        Changed motor pattern (in muscles)
        Change in relation
        Displacement
        Disturbed normal relationship
        Distorting the normal mechanics
        Downslips (see also “upslips”)
        Dysarthria
        Dysarthric syndrome
        ” … effect on body mechanics”
        Instability of the pelvic joints
        ” … irritation of the nerves is possible … ”
        Joint binding
        Joint dysfunction
        Joint lesion
        Joint motion restriction
        Joint slip
        Joint syndrome
        Limitation of motion
        Malposition
        Malrotation
        Mechanical dysfunction
        Misplaced
        Misplacement
        Motions are restricted
        Partial luxation
        Primary dysfunction
        Restrictions
        Rotatory slips
        Shear dysfunction
        Shear mechanism
        Slight luxation
        Slip
        Slipping sacroiliac joints
        ” … stick at the limit of normal motion …”
        Strain
        Strain and laxity
        Tilts (anterior, posterior)
        Upslips (see also “downslips”)
        Vertical slipping of the innominate on the sacrum

        59 Synonyms or Metaphors for the ‘Spinal Adjustment’:

        Arthral alignment
        Atlas therapy
        Biokinetic remediation
        Bone setting
        Chiropractic manipulation
        Chiropractic manipulative therapy
        Corrective spinal care
        Disengage
        Diversified-type force application to release the segment at its articulation
        Facet adjusting
        Fix
        Flexion distraction manipulation
        Functional restoration
        Gentle adjusting
        Gently relieve the locked subluxation
        High velocity facet adjusting
        Human readjustments
        Joint manipulation
        Low force/amplitude manipulation
        Manipulation
        Manipulative surgery
        Manipulative therapy
        Manipulatory
        Manual adjustment
        Manual cavitation
        Manual medicine
        Manual reflex neurotherapy
        Manual therapy
        Manual treatment
        Mechanical treatment of the nerve centres.
        Mobilisation
        Neuro-mechanical spinal chiropractic management
        Neuromechanical correction*
        Neurotherapeutic
        Neurotherapy
        Orthokinetics
        Orthopedic orthokinetics
        Osteopathic manipulative therapy
        Osteopathic osteological adjustment
        Physiatry
        Physical medicine
        Readjustment
        Reconstructive measure
        Reduced
        Reduction
        Reduction of dislocation
        Release of intraarticular pressure
        Replacement
        Repositioning
        Restoration of mobility
        Slipped into place
        Specific mobilization
        Spinal adjustment
        Spinal manipulative therapy
        Spinal manual therapy
        Spondylotherapy
        “Springing the spine”
        Vertebral adjustment*
        Vertebral medicine

        * Unreferenced

        Ref: Rome P. L., Usage of chiropractic terminology in the literature — 296 ways to say ‘subluxation’. Chiropractic Technique 1996;8:1-12.

        In view of the above, you have to wonder how a chiropractic customer could possibly distinguish between an evidence-based chiropractor and a quack one.

        Any ideas, DC?

        • @BW: Oh man! ⭐️⭐️⭐️⭐️⭐️!

        • BW…With regard to neck manipulation, I repeat, the Precautionary Principle MUST apply.

          PP (definition): One should take reasonable measures to prevent or mitigate threats that are plausible and serious. https://www.tandfonline.com/doi/pdf/10.1080/03605310490500509

          DC…First one has to establish plausibility of serious harm of neck manipulation when appropriately applied to the appropriate subjects by a qualified person.

          BW…At least NSAIDs, muscle relaxers, opioids, etc., have pretty reliable post-marketing surveillance (which chiropractic does not)

          DC…So? If those are what one is suggesting as a “more convenient option” to spinal manipulation then one takes the evidence one has available.

          BW…taken at recommended doses for a short time, they are generally very low-risk for appropriately selected patients.

          DC…and doesn’t the research indicate the same can be said for cSMT?

          BW…they are invariably accompanied by Patient Information Leaflets explaining risks, benefits, and contradictions

          DC…yes, by law

          BW…whereas we know that a sizeable number of chiropractors do not give their patients such information prior to treatment.

          DC…I would say it is foolish not provide such info to a patient that is based upon current best evidence.

          BW…And let’s not forget that patients often continue to take such medications while undergoing neck manipulation, and possibly even for exacerbations of pain caused by neck manipulation.

          DC…Most minor AE from spinal manipulation, such as increase pain, resolve within a few days. Same is true for many PT procedures, dental procedures, etc.

          BW…QUOTE
          “…for some manual therapists, etc

          DC…I have no issue with the Homola quote if one is looking as philosophy based vs evidence based approach to care.

          BW…For readers who might not be aware, etc

          DC…so? Call it what you want. Again, is the physical lesion any different from what a DO, PT or a MD manipulates? Heck, even BJ Palmer wrote, “don’t forget that the MDs sprain is the chiropractor’s subluxation.”

          BW…In view of the above, you have to wonder how a chiropractic customer could possibly distinguish between an evidence-based chiropractor and a quack one.

          Any ideas, DC?

          DC…yep, but I need to get on the road. So briefly, I would suggest they ask the chiropractor three questions…

          1. What does a spinal adjustment actually do?
          2. How do use x rays in your practice?
          3. What are your views on vaccinations?

          • DC wrote (re the Precautionary Principle): “First one has to establish plausibility of serious harm of neck manipulation when appropriately applied to the appropriate subjects by a qualified person.”

            @ DC

            The plausibility is there. Even some chiropractors agree, e.g. Samuel Homola and Preston Long (as well as many scientists).

            DC wrote in response to my comments on NSAIDs, muscle relaxers, opioids, etc., having pretty reliable post-marketing surveillance (which chiropractic does not): “So? If those are what one is suggesting as a ‘more convenient option’ to spinal manipulation then one takes the evidence one has available.”

            The point is, chiropractors have NO reliable adverse event monitoring systems and no robust evidence for neck manipulation, so other options, which have more favourable risk/benefit profiles, should be used.

            DC wrote regarding my comment that NSAIDs taken at recommended doses for a short time, are generally very low-risk for appropriately selected patients: “…and doesn’t the research indicate the same can be said for cSMT?

            No. It cannot be justified for the reasons given above and because many chiropractors still use it for pseudoscientific purposes.

            DC wrote in response to my comments that drugs are invariably accompanied by Patient Information Leaflets explaining risks, benefits, and contradictions: “…yes, by law”

            But aren’t chiropractors required by their regulatory bodies to obtain *fully informed* consent from their customers?

            DC wrote in response to my comment that we know that a sizeable number of chiropractors do not give their patients such information prior to treatment: “…I would say it is foolish not provide such info to a patient that is based upon current best evidence.”

            But with chiropractors, the failure to inform accurately is widespread and happening repeatedly. It’s utterly indefensible.

            DC wrote in response to my comment about patients often continuing to take medications while undergoing neck manipulation, and possibly even for exacerbations of pain caused by neck manipulation: “…Most minor AE from spinal manipulation, such as increase pain, resolve within a few days. Same is true for many PT procedures, dental procedures, etc.”

            Nevertheless, patients still take them during their treatment plans. And let’s remember that the vast majority of PTs do not administer interventions based on pseudoscience, and that dental procedures almost invariably have excellent benefits and aren’t life-threatening.

            DC wrote in response to my list of terms for the chiropractic subluxation and Vertebral Subluxation Complex: “…so? Call it what you want. Again, is the physical lesion any different from what a DO, PT or a MD manipulates? Heck, even BJ Palmer wrote, ‘don’t forget that the MDs sprain is the chiropractor’s subluxation’.

            You cannot be serious.

            BJ Palmer was ruthless businessman. A brief browse through this link https://www.chirobase.org/05RB/psc_catalog_1922.pdf is all you need in order to understand that he was a charlatan and a chancer. However, I think it’s important to know a little more about his wholly unsavoury background and character:

            In 1910, he testified that, at the age of 11, that he had been “kicked from home, forced to make a living” (State of Wisconsin vs. S.R. Jansheki, December 1910).
            He spent years as a vagrant, living largely by hustling on the streets, and slept in dry-goods boxes, hotel kitchens, pool halls, etc. He was permanently expelled from school in the 7th grade, did jail time for petty thievery, and was well-acquainted with the red-light district of town. (Magner, G. Chiropractic: The Victim’s Perspective).
            In the preface to one of BJ’s books, a dean of Palmer College wrote, “The first 20 years of this boy’s life were spent in being educated to hate people and everything they did or were connected with”. (Hender H. Preface. In Palmer BJ. The Bigness of the Fellow Within. Davenport. IA: Palmer School of Chiropractic, 1949)
            Indeed, R.C. Schafer DC, a former director of public affairs for the American Chiropractic Association, reported that as a self-proclaimed ‘keeper of the flame’ BJ was suffocating and ruthless to anyone who dared oppose him, and he remembered him as a bigot and an outlandishly vulgar person. Apparently it was common knowledge that BJ openly supported Hitler in the 1930s (Schafer RC. The imbroglio of the professional greyhound. Dynamic Chiropractic 9(17)10, 1991.) and, like his father, BJ was afflicted by megalomania.
            His book titles revealed an enormous ego and he made many sweeping pronouncements about the nature of health, disease and the human body. His ignorance and ego also combined to discover a ‘duct of Palmer connecting the spleen with the stomach’(https://tinyurl.com/y4kmfkgg ) .
            During his pre-chiropractic years he worked with a mesmerist and in a circus – both of which may have honed his showmanship and salesmanship. From the beginning, BJ did everything possible to distance chiropractic from medicine and osteopathy. His views came to dominate the profession and he greatly expanded chiropractic’s metaphysical basis, which constituted a major part of chiropractic education. He described chiropractic as a ‘health serve-us’ (Palmer BJ. Selling Yourself. Davenport, IA: Palmer College Press, 1921)
            BJ also claimed “I do nothing. It is Innate that does the work’ (Bach, M The Chiropractic Sotr. Austell, GA: Si-Nel Publishing & Sales Co., 1968)
            On page 424 of his book ‘Answers’ (1952), BJ refers to Innate as the ‘other fellow’, or the ‘fellow within’, and the real originator of chiropractic.
            And in his book, ‘The Bigness of the Fellow Within’ (1949), he states that “Innate…has been building and running millions of bodies for millions of years” and he exhorted all chiropractors to harness this divine power. He also states: “One spark of Innate is greater than all the education, books, and libraries of man”.
            `
            BTW, it’s worth noting that, in 1901, six years after inventing chiropractic, BJ’s father, DD Palmer, wanted to discard it:
            https://www.facebook.com/204610332906631/photos/a.349152545119075/2047167945317518/?type=3&theater

            DC wrote in response to my question about how a chiropractic customer could possibly distinguish between an evidence-based chiropractor and a quack one: “I would suggest they ask the chiropractor three questions… 1.) What does a spinal adjustment actually do? 2.) How do use x rays in your practice? 3.) What are your views on vaccinations?”

            Why aren’t the regulators making this clear? Why do they tolerate their registrants’ blatantly ambiguous and deceptive marketing?

            IMO, it can only be because they know that proper regulation would destroy the chiropractic industry.

          • BW…I’ll try and address these comments later in the week, however, I think many of them we have discussed in the past so I won’t waste my time rehashing them (unless your memory is failing).

          • DC wrote (re the Precautionary Principle): “First one has to establish plausibility of serious harm of neck manipulation when appropriately applied to the appropriate subjects by a qualified person.”
            @ DC
            The plausibility is there. Even some chiropractors agree, e.g. Samuel Homola and Preston Long (as well as many scientists).

            The current research suggest otherwise.

            DC wrote in response to my comments on NSAIDs, muscle relaxers, opioids, etc., having pretty reliable post-marketing surveillance (which chiropractic does not): “So? If those are what one is suggesting as a ‘more convenient option’ to spinal manipulation then one takes the evidence one has available.”
            The point is, chiropractors have NO reliable adverse event monitoring systems and no robust evidence for neck manipulation, so other options, which have more favourable risk/benefit profiles, should be used.

            Dc…A lot of healthcare doesn’t have “robust evidence”. Other professions don’t have AE monitoring systems (ex. Dentistry, Physical Therapists). See below. It does justify chiropractors not having one (and some programs are being developed) but it’s not uncommon.

            DC wrote regarding my comment that NSAIDs taken at recommended doses for a short time, are generally very low-risk for appropriately selected patients: “…and doesn’t the research indicate the same can be said for cSMT?

            No. It cannot be justified for the reasons given above and because many chiropractors still use it for pseudoscientific purposes.

            DC…One has to carefully look at probably causation of AE. The fact that some use it for “pseudoscientific purposes” is not a sound reason to abandon the procedure.

            DC wrote in response to my comments that drugs are invariably accompanied by Patient Information Leaflets explaining risks, benefits, and contradictions: “…yes, by law”

            But aren’t chiropractors required by their regulatory bodies to obtain *fully informed* consent from their customers?

            DC…I am not familiar with the rules on informed consent from around the world.

            DC wrote in response to my comment that we know that a sizeable number of chiropractors do not give their patients such information prior to treatment: “…I would say it is foolish not provide such info to a patient that is based upon current best evidence.”

            But with chiropractors, the failure to inform accurately is widespread and happening repeatedly. It’s utterly indefensible.

            DC…As I stated, it’s foolish not to provide informed consent.

            DC wrote in response to my comment about patients often continuing to take medications while undergoing neck manipulation, and possibly even for exacerbations of pain caused by neck manipulation: “…Most minor AE from spinal manipulation, such as increase pain, resolve within a few days. Same is true for many PT procedures, dental procedures, etc.”

            Nevertheless, patients still take them during their treatment plans. And let’s remember that the vast majority of PTs do not administer interventions based on pseudoscience, and that dental procedures almost invariably have excellent benefits and aren’t life-threatening.

            DC…“By contrast, clinical dentistry does not have any such mandatory reporting requirements for AEs,…

            “Pain and infection were the most common AE types representing 75% of the cases reviewed (55% and 17% respectively). In the remaining reviews, hard tissue damage was assessed in 12%, soft tissue damage/inflammation in 6%, nerve injury in 5%, and other oro-facial harm in 2% of cases.”

            https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5748012/#!po=1.02041

            DC wrote in response to my list of terms for the chiropractic subluxation and Vertebral Subluxation Complex: “…so? Call it what you want. Again, is the physical lesion any different from what a DO, PT or a MD manipulates? Heck, even BJ Palmer wrote, ‘don’t forget that the MDs sprain is the chiropractor’s subluxation’.

            You cannot be serious.

            DC…Note I wrote “physical lesion”.

            DC wrote in response to my question about how a chiropractic customer could possibly distinguish between an evidence-based chiropractor and a quack one: “I would suggest they ask the chiropractor three questions… 1.) What does a spinal adjustment actually do? 2.) How do use x rays in your practice? 3.) What are your views on vaccinations?”

            Why aren’t the regulators making this clear? Why do they tolerate their registrants’ blatantly ambiguous and deceptive marketing?

            IMO, it can only be because they know that proper regulation would destroy the chiropractic industry.

            DC….One can look at board rulings and find examples where chiropractors have been found guilty of false, misleading and deceptive advertising. Just because you aren’t aware of it doesn’t mean it doesn’t happen. Does the general topic and regulatory boards need an upgrading, yes.

            Now, this potpourri approach of yours is getting old. If you want to focus on one or two topics, OK. Otherwise, I am out.

        • Fwiw….this is a current list. However from a public perspective I am working to change it to “how to find an evidence based chiropractor”.

          10 ways to spot a scam chiropractor

          1. They talk about “subluxations” and how they cause disease and getting them removed is equal to health.
          2. They require you to have x rays in order to receive treatment.
          3. They use your x rays and compare them to a “normal” x ray.
          4. They don’t give you a diagnosis
          5. They require you to bring a “co-decision maker” to your report of findings.
          6. They never treat you the first day at their clinic.
          7. They use the same scripts for everyone.
          8. They make you pre-pay for long term plans of care.
          9. They have no separate treatment rooms.
          10. They advise you against vaccinations or advise you to stop taking your medications.

          • DC wrote: “10 ways to spot a scam chiropractor…”

            @ DC

            Why don’t chiropractor regulators advertise such a list? If evidence-based chiropractors represent the majority (as we’re frequently told), why do the chiroquacks hold such sway?

          • I think there are a few reasons they hold sway.

            1. They are very organized, and motivated by emotions… much more then the current evidenced based crowd. However, we are working on the former issue.

            2. They are financially solid and supported. They tend to be the high volume, high income crowd.

            3. Apathy of the middle.

            The Choosing Wisely program is a start for the EB group.

  • DC wrote: “I think there are a few reasons they [the chiroquacks] hold sway.”

    IMO, it’s because chiropractic is, essentially, a cult and the majority of chiropractors cannot be deprogrammed. See here:
    https://edzardernst.com/2016/02/some-chiropractors-seem-to-believe-that-progress-is-a-malignant-disease/#comment-74629

    I blame the chiropractic colleges’ pecuniary interests for perpetuating the nonsense, closely followed by legislators (who aren’t well-versed in science) continuing to condone it.

  • ‪@ DC

    “I don’t think so”, based on those with whom you associate, isn’t good enough. I’m talking about the majority of the chiropractic industry.

    As for the list in your link (not a definitive checklist), the similarities to chiropractor behaviour cannot be ignored. For example:

    ‘The group displays excessively zealous and unquestioning commitment to its leader and (whether he is alive or dead) regards his belief system, ideology, and practices as the Truth, as law.’

    ME: A chiropractor is a performer of chiropractic, as invented by the charlatan DD Palmer and promulgated by his apparently socio/psychopathic son, BJ. You cannot escape from that fact.

    ‪’Questioning, doubt, and dissent are discouraged or even punished.’

    ME: For a start, one only has to observe how most chiropractors treat skeptics…

    ‘The group is elitist, claiming a special, exalted status for itself, its leader(s) and members (for example, the leader is considered the Messiah, a special being…and/or the leader is on a special mission to save humanity.’

    ME: Just like chiropractors who claim to detect mythical chiropractic subluxations which they further claim only they can correct to free up mythical Innate Intelligence, allegedly in order to optimise health.

    ‪’The group has a polarized us-versus-them mentality, which may cause conflict with the wider society.’

    ME: Where to start? Anti-vax stances, legal chilling…

    ‘The leadership induces feelings of shame and/or guilt in order to influence and/or control members. Often, this is done through peer pressure and subtle forms of persuasion.’

    ME: ‘Subluxation denier’ accusations, ‘Big Pharma’, medipractors….

    ‘The group is preoccupied with bringing in new members.’

    ME: New members are the life blood of chiropractic colleges. No need to say more.

    ‘The group is preoccupied with making money.’

    ME: “Our school,” [B. J.] Palmer explained, “is on a business, not a professional basis. We manufacture chiropractors.”
    Ref: https://www.chirobase.org/05RB/BCC/07.html

    There’s also this:

    What are the principal functions of the spine?

    To support the head
    To support the ribs
    To support the chiropractor.

    — B. J. Palmer, Answers (1952)

    • BW…“I don’t think so”, based on those with whom you associate, isn’t good enough. I’m talking about the majority of the chiropractic industry. (Referring to cult like behavior).

      DC…one would have to look at surveys. Around 20% hold onto the traditional views of chiropractic. They can typically be identified by certain practices and beliefs. Some of them tend to display cult like behavior. I agree with that analysis. I am sure you are familiar with those surveys. If you have credible evidence it’s a higher percentage, please share it.

      As far as the rest of your post…see my comment above.

      • DC wrote: “Around 20% hold onto the traditional views of chiropractic…If you have credible evidence it’s a higher percentage, please share it.”

        @ DC

        The current data on chiropractic practices show clearly that the majority of chiropractors don’t adopt an approach that is based on science.

        For example, a recent study by McGregor et al, which many chiropractors claimed showed that only 18% of chiropractors delivered inappropriate treatment…
        Ref: http://bmccomplementalternmed.biomedcentral.com/articles/10.1186/1472-6882-14-51

        …turned out not to be the good news that chiropractors had hoped for. Significantly, the study stated:

        QUOTE
        “As with any investigation, this study has limitations. First, although the response rate was good at 68%, it remains unclear what practice perspectives and behaviours are associated with non-participants. Also, although the sample was randomly selected and stratified according to the number of licensed practitioners in each province, the sample represented only approximately 12% of practitioners from each province. As always, there is the possibility that despite the randomization scheme, a unique sample was selected, and generalizability is a possible concern.”

        Certainly, the results were somewhat inconsistent with other available data:
        https://edzardernst.com/2013/03/what-is-next-a-royal-college-of-window-salesmen/#comment-54269

        Indeed, McGregor’s 1st, 3rd, 4th, 5th, and 6th subgroup descriptions don’t seem to exclude the unethical chiropractor element. IOW, 5 of the 6 subgroups could easily indulge in chiroquackery – (1) “Wellness”, (3) “general probs”, (4) “organic-visceral”, and (5/6) “subluxations”.

        Also, according to Science Based Medicine author, Jann Bellamy: “The survey was of Canadian chiropractors, most of whom graduated from Canadian Memorial Chiropractic College, which appears to have a more orthodox orientation than, for example, Life or Palmer…the groups not included in the unorthodox category doesn’t mean the others are necessarily free of unorthodox views.”

        As for the recent Chiropractic Observation and Analysis Study (COAST) which claimed to provide “an understanding of current chiropractic practice”, Harriet Hall (MD) at Science Based Medicine, who authored the post in the following link, has pointed out that the study…

        QUOTE
        “…tells us that a substantial number of chiropractors use quack methods, and the ones who do obviously can’t be science-based. It tells us that children are being treated with chiropractic in the absence of any evidence that it is effective…The study leaves many questions unanswered and raises some new ones; and it doesn’t provide any evidence to support the claims that chiropractic is being “reformed”.”

        Ref: http://www.sciencebasedmedicine.org/chiropractic-reform-myth-or-reality/

        • I’ve commented on that study. It’s purpose was to identify traditionalists. So yes, it supports other surveys on the topic.

          You are shifting the topic. It was about cult like behavior.

          • @ DC

            Which study? I mentioned more than one.

            With regard to cult-like behaviour (i.e. the sort displayed by many vitalists/subluxationist chiropractors), I also linked in my comment above to these papers…

            A large survey of (and by) chiropractors which was carried out in 2003 (McDonald W, Durkin K, Iseman S, et al, ‘How Chiropractors Think and Practice’, Seminars in Integrative Medicine, 2004 V.2 No.3 92-98, Institute for Social Research, Ohio University) revealed that 89.8% of chiropractors in the USA (where well over 50% of chiropractors practice) felt that spinal manipulation should not be limited to musculoskeletal conditions – a figure which appears to be supported by this 2004 survey of chiropractors in Portland, Oregon…
            http://www.chirobase.org/02Research/laidler.html
            …which found a 100% incidence of beliefs and practices that were unsubstantiated or clashed with established scientific knowledge. Interestingly, the McDonald et al survey also revealed that 9 in 10 chiropractors believed in (fictitious) subluxations, 4 in 5 thought they were involved in visceral illness, and 2 in 10 thought they explain all of illness (so-called straight chiros).

            A further indication that the majority of chiropractors are using spinal manipulation as a panacea can be found in research which the World Federation of Chiropractic (WFC – an association of chiropractic organisations in 85 countries) gathered during its 2004-2005 consultation on ‘The Identity of the Chiropractic Profession’. It gives valuable insight into the chiropractic profession’s perceptions of itself on an international scale. For example, not only did the consultation result in the participating chiropractors’ unanimous agreement that the most appropriate public identity for the profession within health care was “The spinal health care experts in the health care system” – a definition which clearly allows pseudoscientific chiropractic practices to continue to flourish – it also produced a document entitled “Abstracts of Previous Relevant Research” which cited 2003 McDonald et al study, and specifically mentioned the following in section E, #6:

            Quote:
            “Approximately 9 in 10 [USA chiropractors] confirmed that the profession should retain the term “vertebral subluxation complex” (88.1%) and that the adjustment should not be limited to musculoskeletal conditions (89.8%). Subluxation is rated as a significant contributing factor in 62.1% of visceral ailments.”

            In addition to that, the results of the WFC consultation produced a chart called “Perceptions of How the General Public Perceives the Chiropractic Profession”. It illustrates the percentage of chiropractors who said that the following phrases described the profession “perfectly” (7 on a scale of 1 to 7) or almost perfectly (6):

            Quote:
            “Management of vertebral subluxation an its impact on general health”
            – 65% of chiropractors said that the general public should perceive chiropractic that way
            “Management of vertebral subluxation”
            – 57% of chiropractors said that the public should perceive chiropractic that way

            Those figures are supported by a 2007 survey of UK chiropractors which revealed that traditional chiropractic beliefs (chiropractic philosophy) were deemed important by 76% of respondents, with 63% considering the subluxation to be central to chiropractic intervention:
            http://www.ebm-first.com/chiropractic/uk-chiropractic-issues/1188-the-scope-of-chiropractic-practice-a-survey-of-chiropractors-in-the-uk.html

          • Ok, perhaps i am in the minority. Now what?

          • Interesting comment from the Durkin paper.

            “Within the broad scope camp, especially among the more
            doctrinaire practitioners, there is a need to appreciate the fact
            that, while great numbers of chiropractors believe the sub-
            luxation contributes to visceral ailments, they are not creed-
            alists. As a group, the respondents hold that the subluxation
            contributes to approximately 6 of 10 visceral conditions, not
            9 of 10 as may have been the case in the early 1900s. Other-
            wise, these same broad scope practitioners can celebrate that
            the profession clearly endorses the appropriateness of a
            board spectrum of clinical services.”

  • DC wrote re https://edzardernst.com/2019/04/a-risk-benefit-assessment-of-chiropractic-neck-manipulation/#comment-112628 : “BW…I’ll try and address these comments later in the week, however, I think many of them we have discussed in the past so I won’t waste my time rehashing them (unless your memory is failing).”

    @ DC

    See https://edzardernst.com/2012/12/ad-hominem-attacks-are-signs-of-victories-of-reason-over-unreason/

  • DC wrote: “Now, this potpourri approach of yours is getting old. If you want to focus on one or two topics, OK. Otherwise, I am out.”

    @ DC

    You seem to lack a cautious attitude, preferring to be defensive of your own interests rather than those of your customers. I can only conclude that, in most instances, you need to play irrational games of semantics in order to defend your arguments.

    • semantics is very important, especially in these types of forums.

    • BW. Posting this here because i dont want to search for the original question. Something to do with why arent regulators doing more to stop what some refer to as quack chiros or charlatans.

      Well, I think it has to be a grass root movement in the profession. And one also must understand the internal conflicts chiropractic is dealing with. I think the blog touches on that subject.

      The blog written by the founder and admin of a group of around 8,000 chiropractors who have said…enough is enough…we will call out the BS when we see it.

      Thats all.

      https://www.forwardthinkingchiro.com/blog//2019/4/so-you-say-you-want-a-revolution?fbclid=IwAR3Qg6vfAzYTtt6W5KDdFJbamE8BocOZxpcoQNtoRAR0o-t-mn5geoRTQQQ

      • DC wrote: “…why aren’t regulators doing more to stop what some refer to as quack chiros or charlatans?…Well, I think it has to be a grass root movement in the profession. And one also must understand the internal conflicts chiropractic is dealing with. I think the blog touches on that subject. The blog written by the founder and admin of a group of around 8,000 chiropractors who have said…enough is enough…we will call out the BS when we see it.” [Blog link https://tinyurl.com/y6rldd9o ]

        @ DC

        Thank you for posting that piece.

        Whilst it’s commendable that the ‘forward-thinking chiropractors’ are trying to make a difference, I am pessimistic regarding their success in the long run because they will eventually have to face up to this:
        https://edzardernst.com/2018/08/chiropractors-dammed-if-they-do-and-dammed-if-they-dont-abandon-the-subluxation-myth/

        In essence:

        • Abandoning subluxation is scientifically necessary, as otherwise chiropractors will become the laughing stock of the healthcare community (to a degree, this has already happened; so, there is not much time!).

        • Abandoning subluxation would quickly lead to the end of chiropractic, as it would ‘degrade’ chiropractors to some sort of inferior physiotherapist and thus threaten their right to exist.

        Sadly, it is apparent that chiropractic is already being degraded. One only has to read the following valid criticisms of three major chiropractic researchers (including Jan Hartvigsen, allegedly ‘the world’s leading expert in musculoskeletal pain’) to realise it:

        DAVID CASSIDY, DC

        Analysis and background to some of his research:
        https://edzardernst.com/2017/04/we-have-an-ethical-legal-and-moral-duty-to-discourage-chiropractic-neck-manipulations/#comment-108040

        CHRISTINE GOERTZ, DC

        “This trial follows the infamous ‘A+B versus B’ design. It will almost always generate a positive result – so much so that it is a waste of time to run the study because we know its findings before it has started. And if this is so, the trial is arguably even unethical.”
        Ref: https://tinyurl.com/yc387mgn

        Unfortunately for science, Goertz is Vice Chair-person of the Patient-Centered Outcomes Research Institute (PCORI), an independent non-profit organisation, which has allocated $5.7 million to fund “a study of access to holistic therapies for treating low back pain, including massage, acupuncture, osteopathy,chiropractic…”
        Ref: https://www.massagemag.com/holistic-therapies-alternative-opioids-86376/

        JAN HARTVIGSEN, DC

        Severe criticism of his major research role in the recent Lancet Back Pain series of papers:

        Ref: https://tinyurl.com/y7bd6lna
        Ref: https://tinyurl.com/y8e48oq7
        Ref: https://tinyurl.com/yalash5x

        IMO, chiropractic’s top researchers fall well short of the competence demanded by their positions. They should know by now that spinal manipulation for low back pain is probably a placebo (and no good for any other condition), and that they are offering nothing unique that isn’t already adequately supplied – unambiguously – by other MSK therapists. I can’t see any real progress being made until the words ‘chiropractic’ and ‘chiropractor’ are binned.

        • You are entitled to your opinion.

          A little too late for the profession? Maybe. Time will tell.

          One of the reasons the EB faction is moving away from “subluxation” towards conservative spinal care…hence, the subluxation deniers.

          If one lives by the word one can die by the word.

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