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

The tragic case of John Lawler who died after being treated by a chiropractor has been discussed on this blog before. Naturally, it generated much discussion which, however, left many questions unanswered. Today, I am able to answer some of them.

  • Mr Lawler died because of a tear and dislocation of the C4/C5 intervertebral disc caused by considerable external force.
  • The pathologist’s report also shows that the deceased’s ligaments holding the vertebrae of the upper spine in place were ossified.
  • This is a common abnormality in elderly patients and limits the range of movement of the neck.
  • There was no adequately informed consent by Mr Lawler.
  • Mr Lawler seemed to have been under the impression that the chiropractor, who used the ‘Dr’ title, was a medical doctor.
  • There is no reason to assume that the treatment of Mr Lawler’s neck would be effective for his pain located in his leg.
  • The chiropractor used an ‘activator’ which applies only little and well-controlled force. However, she also employed a ‘drop table’ which applies a larger and not well-controlled force.

I have the permission to publish the submissions made to the coroner by the barrister representing the family of Mr Lawler. The barrister’s evidence shows that:

a. The treating chiropractor owed a duty of care to the Deceased, her patient;
b. That duty was breached in that:
i. After the Deceased reported loss of sensation and paralysis in his arms, the only safe and appropriate response was to:
1. Leave him in situ;
2. Await the arrival of the paramedic;
3. Provide an accurate history to the ambulance controller and attending paramedic;
ii. The treating chiropractor, in fact:
1. Manhandled the Deceased from the treatment bed into a sitting position on a chair;
2. Tipped his head backwards and gave “mouth to mouth” breaths;
3. Provided an inaccurate and misleading history to the paramedic and ambulance controller, causing the paramedic to treat the incident as “medical” not “traumatic” and to transport the Deceased downstairs to the ambulance without stabilising his neck.
c. The risk of death was a reasonably foreseeable consequence of the breach;
d. In the absence of the breach:
iii. The paramedic would have stabilised the neck, in situ, and transported the Deceased on a scoop stretcher;
iv. The deceased would have survived.
e. Having regard to the risk of death involved, the misconduct was grossly negligent so as to be condemned as the serious crime of manslaughter. The decision to intervene as she did, went beyond a very serious mistake or very serious error of judgment having regard to the fact that:
i. She held herself out as a provider of (quasi) medical treatment;
ii. She styled herself as “doctor”, (when she was not entitled to do so);
iii. She intervened without any understanding of the injury she had caused nor any training in how to intervene safely.
___________________________________________________________________________
To put it in blunt layman’s terms, the chiropractor broke Mr Lawler’s neck and, by then moving his head the way she did (she put him into the sitting position and bent his head backwards), may well have caused his death.
Here are five lessons we might learn from this tragic case:
  1. Chiropractors are not medical doctors and should make this perfectly clear to all of their patients.
  2. Elderly patients can have several contra-indications to spinal manipulations. They should therefore think twice before consulting a chiropractor.
  3. A limited range of spinal movement usually is the sign for a chiropractor to intervene. However, this may lead to dramatically bad consequences, if the patient’s para-vertebral ligaments are ossified which happens in about 10% of all elderly individuals.
  4. Chiropractors are by no means exempt from obtaining informed consent. (In the case of Mr Lawler, this would have had to include the information that the neck manipulation carries serious risks and has not shown to work for any type of pain in the leg and might have saved his life, as he then might have refused to accept the treatment.)
  5. Chiropractors are not trained to deal with medical emergencies and must leave that to those healthcare professionals who are fully trained.

66 Responses to Death by chiropractic neck manipulation? More details on the Lawler case

  • I think a sixth lesson is that if you refer a someone to another team for further care, you should not lie about the treatment they have had so far.

  • Also:
    1. There is no credible evidence that chiropractic manipulation of the neck is effective for any condition.
    2. There is compelling evidence that it is potentially harmful, even lethal.
    3. The chiropractic trade has no systematic adverse event reporting system.
    4. Practitioners overestimate their expertise and do not fully understand the appropriate limits on their scope of practice.
    5. Practitioners misperceive themselves as highly trained medical specialists (rather than glorified physiotherapists with only one therapeutic intervention in their bag) and hence misrepresent themselves as such to patients.

    The BCA needs to stop the use of neck manipulation, institute an adverse event reporting system, and introduce an urgent programme of remedial education on scope of practice. If it will not do this it should be shut down.

  • Your additional excerpts present an additional confounder….IF in fact the chiroquacker wasn’t lying about the treatment administered (since it’s a profession OF and ABOUT lying that she was telling the truth to investigators is dubious) but my interest is in the actual “adjustment”. IF in fact she didn’t crank the poor guys neck with the bombastic “rotary break” manipulation chiroquackery is famous for, but in fact used an Activator and/or Drop table, I think it should give us all pause as to the extensive dangers of this artifice. These 2 entrepreneurial-theatrics masquerading-as-healthcare (Activators and Drops) are ALWAYS touted as the safe-alternate adjustment for the elderly and children….albeit pointless theatrics BUT plausible placebo-generators….AND ASSUMED SAFE. This story brings that “safe-haven” into doubt.

    • She used an activator and drop table only. Mrs Lawler was there throughout and witnessed the treatment and its ramifications.

      The chiropractic experts were unable to answer the fundamental paradox that a) forces must be strong enough to move vertebrae and so produce therapeutically beneficial effects, yet b) they are so weak that they cannot do harm.

      Two chiropractors gave evidence: Richard Brown and Martin Young.

  • I note that the expert witness in this case is a chiropractor, Mr Richard Brown (who like Miss Scholten, the chiropractor involved, also styles himself ‘Dr’).

    The North Yorkshire Police has sought Brown’s opinion as to chiropractic treatment – but IMHO they should have sought the opinion of a practitioner professing the profession that the patient Mr John Lawler, thought they professed. That is, a ‘doctor practising medicine’ with a special interest in and experience of spinal pathology.

    Mr Lawler already had surgical instrumentation/rods to stabilise his lower spine. Any 80-year-old almost certainly has spondylolysis in the cervical spine. I cannot imagine any registered medical practitioner attempting to manipulate a neck in these circumstances.

    Did the witness Mr Brown really say he would have carried out such treatment, or it was reasonable to do so? Is that really what the other ‘experts’ who advised the police said? It is important to be quite sure about this, as all patients need to know just what standards the chiropractic profession is working to.

    Did the police obtain any advice from a registered medical practitioner who has experience dealing with comparable patients? (A pathologist advises on pathology, not treatment.)

    Mr Lawler almost certainly did not appreciate that chiropractic is a ‘healthcare system different to that of medicine’ – as D. D. Palmer, the system’s originator clearly stated. I doubt the police or coroner appreciate this either.

    Mr Lawler surely should have been advised of that fact, and of the fact that the consensus of medical opinion is that the ‘subluxations’ which chiropractors claim to ‘adjust’ do not exist.

    And why does Miss Scholten style herself as ‘Dr’- unless it be to ‘pass off’ and claim a professional status to which she is not entitled? Why do chiropractors not style themselves as ‘Ch’ for ‘Chiropractor’. That is what they are. Are they not proud of their profession?

    Mr Brown is a graduate of the Anglo-European College of Chiropractic (‘DC’ – diploma in chiropractic). He has a master’s degree in law (Cardiff LL.M.) I cannot identify any doctorate he has obtained, and I do hope he has not misled the court by passing himself off as a doctor if he does not have that professional status. I reiterate, chiropractic is a different system from that of medicine.

    Patient autonomy requires that all patients have to give informed consent to all treatments – even blood taking.
    Assault otherwise.
    Consent may be verbal, by signification (putting out an arm for phlebotomy), or by a legal guardian. Exceptions in emergencies.
    It is good practice to record the fact consent has been given – the ‘signed consent form’ is really a ‘Record that consent has been obtained’.
    And consent should be fully informed – that is the patient must know and understand all factors any reasonable person would or should consider before consenting. Risks, benefits, status/experience of practitioner, whether research is involved etc. (See the case of Ali).

    In 2018, Dr Bawa-Gaba was convicted of gross negligence manslaughter (and struck off the medical register) because, the criminal court determined, she had failed to secure appropriate experienced assistance when dealing with a child who subsequently died. Presumably, that is the standard which will be applied by this coroner’s court, and should have been applied by the police – irrespective of Mr Brown’s opinion and admission as to the standards reasonably to be expected of chiropractors (of which Mr Lawler was unaware, due to the failure of Miss Scholten to properly advise him).

    For the CPS to decide that a practitioner who breaks the arthritic neck of an elderly man by a violent manoeuvre has not perpetrated an act of gross criminal negligence is bizarre. A court should make that determination. And note the evidence of the paramedic who attended that she failed to stabilise the patient’s neck because Miss Scholten did not give an accurate account of events.

    Just why do chiropractors manipulate necks? The risks are high. In this case, the results of massage and conscientious care surely would have sufficed – or if not, referral to a neurosurgeon was indicated.

    • Interestingly, in its September 2018 Council Meeting papers, the GCC addressed the Williams review into gross negligence manslaughter in healthcare https://www.gov.uk/government/publications/williams-review-into-gross-negligence-manslaughter-in-healthcare and the key issues and recommendations identified by the Williams review that were relevant to the GCC and the initial analysis of GCC’s response to the recommendations:

      “Whilst the recommendations made in relation to gross negligence manslaughter, the review identifies the concerns regarding experts are wider. The GCC should review what it requires from experts in terms of experience and training.”

      For more, see item 7, p.15 here: https://www.gcc-uk.org/assets/council/September_2018_Council_papers_WEBSITE.pdf

    • The case was never referred by the police to the CPS. The police made the decision not to charge Ms Scholten. The case was reviewed under the Victims Right to Review process by another independent police officer, who again decided not to charge.

      There has been a lot more information coming out from the inquest, and the written evidence to be tested. The police investigation concentrated on the initial chiropractic manoeuvre, rather than the follow up. The fact that the police decided not to charge does not / should not preclude the coroner making a finding of unlawful killing.

      • @ David on Saturday 16 November 2019 at 22:21

        If the police in Britain are as competent as the police in Australia, then nothing they decide surprises me any more. In my view, the average copper in Oz is SLIC (stupid, lazy, incompetent and corrupt) and the fundamental principle of democracy (the three pillars) is also corrupted.

        Mr Lawler was killed by this pretend doctor and she must face the legal consequences for the average person to have confidence in the dispassionate operation of the law.

  • Consent may be … by a legal guardian.

    I should clarify here that a legal guardian may give consent on behalf of a minor. In the case of an adult who is not able to give consent themselves, nobody else can give consent on their behalf unless there is a pre-existing Power of Attorney in place. In that situation if there is time the case can be referred to the Court of Protection. Otherwise you have to make the best decision you can, in consultation with relatives and patient advocates, and document everything carefully.

    Exceptions in emergencies

    No exceptions. Emergency treatment without consent is still assault. You just have to hope that this is mitigated by circumstances and that nobody will press charges.

    In 2018, Dr Bawa-Gaba was convicted of gross negligence manslaughter (and struck off the medical register)

    She was struck off in January 2018, but reinstated in August the same year following an appeal. This is a very insteresting case to look at as it highlights a series of systemic failures (including understaffing) in the hospital where she was working which all contributed to the death of the child. She had just returned from maternity leave to find herself in the midst of chaos with no support from senior staff. The reaction of most doctors has been “There, but for the grace of God, go I”.

    For the CPS to decide that a practitioner who breaks the arthritic neck of an elderly man by a violent manoeuvre has not perpetrated an act of gross criminal negligence is bizarre

    The CPS has to base its decision on whether they think that they can secure a conviction, not on whether a criminal act has occurred. The also have to consider whether the case would be in the public interest, though I have no idea how they reach that decision.

    • Still a bizarre decision.
      CPS were content to go for Bawa-Gaba – and succeded in their intentions.
      Why was this case not put to jury?
      (It might yet be.)

  • How many known recorded cases are there of death by manipulating the neck so far ??

  • Links to Dr. Ernst’s articles about Mr. Lawler’s death have been posted on “#The Chiropractic Daily” the blog of one Yolanda Loafer, D.C. Surprisingly, Ms. Loafer frequently links to articles critical of chiropractic – including Dr. Ernst’s.

    On her website, Ms. Loafer claims to have graduated from “medical school.” This is, of course, disingenuous since chiro schools bear no resemblance to actual medical schools.

  • A source for this?

    “if the patient’s para-vertebral ligaments are ossified which happens in about 10% of all elderly individuals.”

    Several sources place OPLL around 1% in elderly male Caucasians.

    Example….https://europepmc.org/abstract/med/28966802

    • Prof Mangham, expert histopathologist, gave evidence that “anterior longitudinal ligament ossification is present in about 10% of the elderly and osteophytes are common in degenerative joint disease”.

      • Thanks, but I am looking for an actual journal reference.

      • obviously the issue here is OPLL and not DISH or osteophytes so your quote is irrelevant

        • Obviously?

          His report continues……”This combination of findings suggest the described entity of diffuse idiopathic skeletal hyperostosis (DISH, or Forestier’s disease or senile ankylosing spondylosis), a condition of ligamentous calcification, (particularly the anterior longitudinal ligament as seen here) with associated disk space preservation and hyperostosis (bone overgrowth).”

          • Ah, if he meant DISH, that’s a different condition with its own prevalence in elderly males.

          • Yes obviously

            If you suggest that in this case Mr. Lawler had DISH and the fracture involved only the ossified ALL than you have to explain the neurological involvement as such cases traumatic as they may be are not considered unstable nor is there any central canal involvement.

            If you refer to a possible fracture of an ossified ligament causing spinal shock you normally refer to OPLL (that is why the K line measurement is only relevant for OPLL and not extra-canal space occupying lesions).

            Two different clinical entities with different prevalence, outcome and causation

  • Sorry for not joining the heated discussion here but I will say two things…

    1. This is a terrible tragedy for the patient and his family but also for the Chiropractor involved. I know in this blog you feel we all grow tails and horns but I am sure the chiropractor involved is devastated like every other clinician losing a patient under such circumstances.

    2. You are quoting here the family barrister claims only! I would suggest bringing the other side claims or even better… wait for the coroner report and discuss FACTS rather than claims.

    • Quote: “This is a terrible tragedy for the patient and his family but also for the Chiropractor involved.”

      @ Mr. Almog:
      Are you serious?!
      An innocent, trusting patient is dead and a fake doctor is shedding self-pity crocodile tears because she mistreated and even killed him and now has to face the consequences.
      I feel for Mr. Lawler´s family and have no empathy for “Dr.” Scholten at all.

  • Yes obviously

    If you suggest that in this case Mr.Lawler had DISH and the fracture involved only the ossified ALL than you have to explain the neurological involvement as such cases traumatic as they may be are not considered unstable nor is there any central canal involvement.

    If you refer to a possible fracture of an ossified ligament causing spinal shock you normally refer to OPLL (that is why the K line measurement is only relevant for OPLL and not extra-canal space occupying lesions).

    These are two distinct clinical entities with different prevalence and causality

    • The expert histopathologist who examined the deceased and the bone samples stated that in his opinion Mr Lawler had DISH, according to the quotes from his report above.

      The forensic neuropathology consultant, Dr McKenzie, stated that: “The pattern of pathology in the cervical cord is of a contusion ie a traumatic abnormality at the level of C4/C5, with secondary ischaemic change in the form of anterior spinal artery territory infarction, extending in a rostral direction to approximately the level of C3.”
      There was narrowing of the anteroposterior diameter of the spinal canal to approximately 5.5mm.

      iPhones and large reports on PDF don’t play well for me I’m afraid but if I can help with anything else from the case?

  • this was just tweeted:
    “The coroner Jonathan Heath returned a narrative conclusion that Mr Lawler suffered a fractured neck and spinal cord injury while undergoing (chiropractic) treatment.”

      • Here is the full statement from Mr Lawler’s family this morning (permission has been given to use it):

        QUOTE

        “We were devastated to lose John in such tragic and unforeseen circumstances two years ago. A much-loved husband, father and grandfather, he continues to be greatly missed by all of us. Having to re-live the circumstances of his death has been particularly difficult for us but we are grateful to have a clearer picture of the events that led to John’s death. We would like to take this opportunity to thank the coroner’s team, our legal representatives and our wider family and friends for their guidance, empathy and sensitivity throughout this process.

        There were several events that went very wrong with John’s chiropractic treatment, before, during, and after the actual manipulation that broke his neck.

        Firstly, John thought he was being treated by a medically qualified doctor, when he was not. Furthermore, he had not given informed consent to this treatment.

        The chiropractor diagnosed so-called ‘vertebral subluxation complex’ which she aimed to treat by manipulating his neck. We heard this week from medical experts that John had ossified ligaments in his spine, where previously flexible ligaments had turned to bone and become rigid. This condition is not uncommon, and is present in about 10% of those over 50. It would have showed on an X-ray or other imaging technique. The chiropractor did not ask for any images before commencing treatment and was seemingly unaware of the risks of doing a manual manipulation on an elderly patient.

        It has become clear that the chiropractor did the manipulation incorrectly, and broke these rigid ligaments during a so-called ‘drop table’ manipulation, causing discs in the cervical spine to rupture and the spinal cord to become crushed. Although these manipulations are done frequently by chiropractors, we have heard that the force applied to his neck by the chiropractor would have had to have been “significant”.

        Immediately John reported loss of sensation and paralysis in his arms. At this stage the only safe and appropriate response was to leave him on the treatment bed and await the arrival of the paramedics, and provide an accurate history to the ambulance controller and paramedics. The chiropractor, in fact, manhandled John from the treatment bed into a chair; then tipped his head backwards and gave “mouth to mouth” breaths. She provided an inaccurate and misleading history to the paramedic and ambulance controller, causing the paramedic to treat the incident as “medical” not “traumatic” and to transport John downstairs to the ambulance without stabilising his neck. If the paramedics had been given the full and accurate story, they would have stabilised his neck in situ and transported him on a scoop stretcher – and he would have subsequently survived.

        The General Chiropractic Council decided not to suspend the chiropractor from practicing in September 2017. They heard evidence from the chiropractor that she had “not touched the neck during the appointment” and from an expert chiropractor that it would be “physically impossible” for the treatment provided to cause the injury which followed. We have heard this week that this is incorrect. The family was not allowed to attend or give evidence at that hearing, and we are waiting – now 2 years further on – for the GCC to complete their investigations.

        We hope that the publicity surrounding this event will highlight the dangers of chiropractic, especially in the elderly and those with already compromised spines. We would again urge the regulator to take immediate measures to ensure that the profession is properly controlled: that chiropractors are prevented from styling themselves as medical professionals; that patients are fully informed and consent to the risks involved; that imaging is done before certain procedures and on high risk clients; and that the limits of the benefits chiropractic can provide are fully explored.”

  • From the GCC: Statement following the Inquest into the death of Mr John Lawler

    The General Chiropractic Council (GCC) was notified in August 2017 of the death of Mr John Lawler. An Inquest into his death was undertaken by the Coroner on 11-18 November 2019. Today the Coroner published his findings.

    These are sad circumstances. It has been difficult hearing the testimony of those affected and our sympathy goes to the whole family. The GCC followed the proceedings carefully each day. Following the completion of the Inquest we are now in a position to resume the investigation opened in 2017 following the death of Mr Lawler.

    We must consider the Coroner’s findings carefully as we take our next steps. The case will be prepared for consideration by the GCC Investigating Committee for it to decide whether a hearing into the chiropractor’s fitness to practise be held. We will progress this matter as swiftly as possible.

    We look forward to receiving the Coroner’s report on steps that might prevent deaths in the future.

    • From the Lawler family’s statement: “The General Chiropractic Council decided not to suspend the chiropractor from practicing in September 2017. They heard evidence from the chiropractor that she had “not touched the neck during the appointment” and from an expert chiropractor that it would be “physically impossible” for the treatment provided to cause the injury which followed. We have heard this week that this is incorrect.”

      IMO, the General Chiropractic Council needs investigated.

  • What proportion of the world do you think self-manipulates their necks and why would they do so?

    • not beyond the physiological range of motion!

      • No one has answered my question which is certainly relevant to this discussion including your response Prof. Ernst.
        We see people in public, in private even in their cars self manipulating their necks. Either by rotating their heads quickly or even using their hands under their jaw and back of head. Considering, the evidence that is continually presented or refuted, why would people do this to themselves?

        • I DID ANSWER IT: they do it within the range of motion [therefore it has little relevance to what chiros tend to do to their patients]

          • I asked why do people self manipulate not what degree of force or movement is being applied. No one will answer this.

          • if that question is so important to you, do some research and find out. it seems interesting only to you, so you are the ideal person to carry out the research. [be warned, you might not get a Nobel for it]

        • Robin. That is an intriguing question. I am not aware of any research on that specific topic, thus, it would be interesting to see the research to back up Ernst’s claim (I think he made it up, but I am open to see the evidence).

          I also see that Ernst failed to address the why in your question, but rather told you to go find it out for yourself. That is a strange response considering how much time he has supposedly looked into spinal manipulation and his repeated posting that it’s probably just a placebo.

          I also see that thus far no other so called skeptic has chimed in. Interesting is the silence.

          I eagerly await to see Ernst evidence.

          “they (the layperson) do it (self manipulation) within the range of motion (of the spine).”

        • @ Robin

          there is a vast difference between the force a person can administer to their own neck seated in a car or similar and using their own hands or by twisting their own neck rapidly in one direction or another as against the forces that are possible when that same person has external forces applied by another person using traction devices such as slings, drop-tables, or other mechanical aids.

          These mechanical forces are much magnified when the patient is old and frail and often much lighter and usually in a lying position and when the force is applied either against resistance or in a jerking fashion against inertia and the person applying the force is in a standing or superior position.
          In addition the chiro is usually younger, stronger, fitter and has much greater leverage – and the application of a sudden jerking movement uses the body’s inertia to make the movement far more powerful than any individual could manage on their own body.

          Once again I recommend (or not) the viewing of the quite horrifying You-Tube videos to see the extraordinary forces that some Chiros apply to the necks of some of their unwitting clients in the apparent belief that they are in some way benefitting them. Personally I wouldn’t let these people handle my luggage.
          These videos have a following just because of how horrifying they are.

          https://www.youtube.com/watch?v=69R-UH5yFuw

          https://www.youtube.com/watch?v=LDh1QQHL0_g

          https://www.wired.co.uk/article/youtube-chiropractors – the scale of youtube chiros

          https://www.youtube.com/watch?v=i4BhXOP6c84

          People obviously do minor “adjustments” to themselves in the belief that that they can slip something back into place that is out of place – and this is apparently the same belief that many chiros have as well with their aberrant subluxation complexes. However those of us based in reality are aware that it is far more complicated than that and that it is not possible to fix all ills merely by tugging on someone’s neck.

          As long as Chiros remain simplistic souls wedded to anti-scientific beliefs and insist that they can cure anything and everything by “cracking” joints and persist in trying to persuade the public along their mystical belief system then it remains an uphill battle.
          Of course it is profitable for people not smart enough to become real doctors or vets to pretend at being ones and style themselves as ones instead – often with deleterious consequences as mentioned above. It’s bad enough when they stay inside the MSK system but they so often stray into other areas where they have zero credibility whatever.

          • “As long as Chiros remain simplistic souls wedded to anti-scientific beliefs and insist that they can cure anything and everything by “cracking” joints…”

            Actually, very few chiropractors hold that extreme view. Even looking at a broader belief, it typically reaches around 20%.

            “The fact that 93.4% endorse the differential diagnosis at new patient examinations is a clean break with the old proposition that chiropractors should eschew all diagnosis in favor of analyzing the spine for subluxations only.” Seminars in Integrative Medicine · September 2004

            “The data in this investigation suggest that only 18.8% of chiropractors in Canada today define themselves in accordance with Langworthy’s original premise. This figure is consistent with McDonald’s data in the United States from 2003 [22], whereby a survey of 647 chiropractors suggested that 19.3% of practitioners could be identified in this way relative to their scope of practice. McGregor-Triano [3] found 17.2% of 64 chiropractors from around the world, responding to a survey at a chiropractic conference, could be identified as belonging to the subgroup of practitioners for whom subluxation was considered an obstruction to human health. Finally Palmer [36], evaluating attitudes among chiropractors in South Africa, found that 17.9% of 56 practitioners in the great Durban area responding to his survey, considered themselves to be “straight” practitioners, as defined by removing subluxation to facilitate healing (p. 71).” BMC Complement Altern Med. 2014; 14: 51.

  • Hello Doctor Ernst, it is important to clarify it was a THORACIC manipulation (NOT cervical) that was a causative factor in Mr Lawler’s injuries. I noticed other commenters have made the same assumption. Research suggests even mild forces can create spinal fractures in ossified ligaments. Very tragic in any case.

    More reading on fractures associated with ossified longitudinal ligaments can be found here:
    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5347267/
    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3230657/

    • I think you are wrong; it was the cervical spine, as far as I know.

      • @ Jimmy

        From the Lawler family statement issued post-inquest:

        QUOTE
        “The chiropractor diagnosed so-called ‘vertebral subluxation complex’ which she aimed to treat by manipulating his neck. We heard this week from medical experts that John had ossified ligaments in his spine, where previously flexible ligaments had turned to bone and become rigid. This condition is not uncommon, and is present in about 10% of those over 50. It would have showed on an X-ray or other imaging technique. The chiropractor did not ask for any images before commencing treatment and was seemingly unaware of the risks of doing a manual manipulation on an elderly patient.

        It has become clear that the chiropractor did the manipulation incorrectly, and broke these rigid ligaments during a so-called ‘drop table’ manipulation, causing discs in the cervical spine to rupture and the spinal cord to become crushed. Although these manipulations are done frequently by chiropractors, we have heard that the force applied to his neck by the chiropractor would have had to have been “significant”.”

        Ref: https://edzardernst.com/2019/11/we-hope-that-the-publicity-surrounding-this-event-will-highlight-the-dangers-of-chiropractic-a-statement-of-the-family-of-the-man-who-died-after-treatment-of-a-vertebral-subluxation-complex/

        It’s also reported that when Mr Lawler lost sensation in his arms, the chiropractor “started to apply an activator, a small handheld clicking device that stimulates the spine, to his neck”
        Ref: https://www.telegraph.co.uk/news/2019/11/11/bank-manager-died-left-broken-neck-following-session-chiropractor/

        • The ‘Drop Technique’ was used with the patient lying face down on a table (face in a cut out, forehead supported).
          The ‘drop’ section of the table was lifted, and then dropped.
          The centre of effort was stated to be at T2/3 – but manifestly, the spine can be considered as a bridge with the lower thoacic spine and pelvis the fulcrum at one end, and the head the fulcrum at the other.

          The ‘adjustment’ may have been centred on T2/3, but as the downward force was applied, aided by the ‘drop’ of a section of the table – so equal and opposite upward forces must have been applied to thoracic and cervical spine. (Unless Newton got it wrong.)

          The cervical spine went into extension, the vertebra was fractured, the cord compromised and death ensued. Res ipsa loquitur.

  • DC wrote on 09 November 2020 at 18:11: “Actually, very few chiropractors hold that extreme view.”

    @ DC

    Unless you have better data, it seems to be a majority of chiropractors who continue to be mired in pseudoscience. For example…

    DC quoted on 09 November 2020 at 18:11: “The data in this investigation suggest that only 18.8% of chiropractors in Canada today define themselves in accordance with Langworthy’s original premise.”

    Significantly, that 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.”

    DC quoted on 09 November 2020 at 18:11: “This figure is consistent with McDonald’s data in the United States from 2003 [22], whereby a survey of 647 chiropractors suggested that 19.3% of practitioners could be identified in this way relative to their scope of practice.”

    But then there’s this from McDonald’s data:

    In response to the question, “Should chiropractic retain the term vertebral subluxation complex?,” the respondents (n⫽638) overwhelmingly voted to do so: 88.1% yes (95% confidence interval 85.5-90.7), 11.9% no (95% CI 9.3-14.5)

    To the question, “Should the adjustment be limited to musculoskeletal conditions?,” 89.8% of the respondents (n = 646) answered no (95% CI 87.4-92.2) and 10.2% yes (95% CI 7.8-12.6).

    Ref: https://chiro.org/research/ABSTRACTS/How_Chiropractors_Think_and_Practice.shtml

    • This is what he wrote and that which i was responding to…

      “insist that they can cure anything and everything by “cracking” joints…”

      What percentage of chiropractors hold that view? Very few.

      • DC wrote: “What percentage of chiropractors hold that view? Very few.”

        @ DC

        That is not indicated by my citations above. Do you have any better data?

        • The key words are “anything” and “everything”.

          Not some, not most…but anything and everything.

          What percentage of chiropractors hold that view?

          • @ DC

            Once again:

            “Should chiropractic retain the term vertebral subluxation complex?”, the respondents (n⫽638) overwhelmingly voted to do so: 88.1% yes’

            “Should the adjustment be limited to musculoskeletal conditions?”, 89.8% of the respondents (n = 646) answered no

            IMO, that is wholly reconcilable with what John Travis wrote:

            QUOTE
            “As long as Chiros remain simplistic souls wedded to anti-scientific beliefs and insist that they can cure anything and everything by “cracking” joints and persist in trying to persuade the public along their mystical belief system then it remains an uphill battle.”

            …and not with what you originally wrote:

            “very few chiropractors hold that extreme view”

            So, I ask once more, do you have any better data than those I cited here:
            https://edzardernst.com/2019/11/death-by-chiropractic-neck-manipulation-more-details-on-the-lawler-case/#comment-128019

          • @ DC

            ChiroWeb.com [Internet]. Gallup poll: Americans have low opinion of chiropractors’ honesty and ethics; 2006 Mar 25 [cited 12 Mar 9].

            Department of Health and Human Services, Office of Inspector General. Hundreds of Millions in Medicare Payments for Chiropractic Services Did Not Comply With Medicare Requirements. oig.hss.gov. 2016. PainSci #53330 ❐

            Chiros are still taught about subluxations in chiro school:

            Funk MF, Frisina-Deyo AJ, Mirtz TA, Perle SM. The prevalence of the term subluxation in chiropractic degree program curricula throughout the world. Chiropr Man Therap. 2018;26:24. PubMed #29988608 ❐ PainSci #53049 ❐

            “Despite the controversies and paucity of evidence the term subluxation is still found often within the chiropractic curricula of most North American chiropractic programs.”

            Biggs L, Hay D, Mierau D.
            Canadian chiropractors’ attitudes towards chiropractic philosophy and scope of practice: implications for the implementation of clinical practice guidelines.
            J Can Chiropr Assoc. 1997;41(3):145–154. PainSci #57174 ❐
            Less than 19 percent of Canadian chiropractors “reject traditional chiropractic philosophy as espoused by D.D. and B.J. Palmer and emphasize the scientific validation of chiropractic concepts and methods.”

            Keating JC. The Specter of Dogma. J Can Chiropr Assoc. 2001;45(2). PainSci #56491 ❐
            We are at risk of accepting dogma and pseudoscience and ambiguous platitudes in order to come together.

            “Chiropractic is the profession most obsessed with the generally shabby idea that anatomical alignment is a key factor in chronic pain problems of all kinds (not just spinal pain). “Adjusting” the spine refers to many different manual therapies that wiggle, pop and otherwise manipulate spinal joints, with the general goal of “straightening” patients or restoring normal motion. The correct umbrella term for these treatments is “spinal manipulative therapy” or SMT.”
            There is no evidence that “straightening” the spine or “aligning” anything makes any significant difference to pain or function.

            https://pubmed.ncbi.nlm.nih.gov/19954544/

            In two recent studies cited in the Mirtz et al. article, 98% of chiropractors believed that “most” or “many” diseases were caused by spinal misalignments and over 75% of chiropractors believed that subluxation was a significant contributing factor to 50% or more of visceral disorders (such as asthma and colic), an implausible idea that is not supported by any evidence whatsoever.

            https://www.painscience.com/biblio/chiropractic-identity-role-and-future–survey.html
            Chiropractic identity, role and future: survey
            This survey of more than 7000 chiropractic students showed that traditional chiropractic subluxation theory is alive and well. 61% agreed that the “emphasis of chiropractic intervention is to eliminate vertebral subluxations/vertebral subluxation complexes …

            https://chiromt.biomedcentral.com/articles/10.1186/s12998-018-0221-z
            Chiropractic, one big unhappy family: better together or apart?
            Charlotte Leboeuf-Yde, Stanley I. Innes, Kenneth J. Young, Gregory Neil Kawchuk & Jan Hartvigsen

            In this article the authors argue that there are two extremes in Chiropractic – the EBM group vs the Subluxationists with the vast majority in the centre consisting of an apathetic bunch who want to pay lip service to both sides and are essentially happy to continue adjusting spines as long as it keeps paying the bills and don’t want to rock the boat.
            “We believe that this ‘silent majority’ makes it possible for groups of chiropractors to practice outside the logical framework of today’s scientific concepts.”
            “Increasingly, this position reminds us of the saying ‘The standard you walk past is the standard you accept’, since acquiescence makes it possible for groups of chiropractors to practice outside the logical framework of today’s scientific concepts and sometimes even outside the law. Virtually every chiropractor knows of other chiropractors who x-ray every patient, or sign patients up to long contracts, or dubious ‘family plans’, or pre-payment plans, or use high-pressure sales tactics, or advertise unsubstantiated claims, yet very few report these breaches [55]. This ‘silent majority’ may in fact be responsible for the inertia and acceptance of traditionalist paradigms (seen from the evidence-friendly side) and the gradual destruction of traditional values (seen by the traditional chiropractors).”
            They also loudly bemoan the various anti-scientific controversies that have been raised by the activities and associations of chiropractors around the world at various times in the recent past.
            This ‘silent majority’ may in fact be responsible for the inertia and acceptance of traditionalist paradigms (seen from the evidence-friendly side) and the gradual destruction of traditional values (seen by the traditional chiropractors).
            “…..vitalism and other idealistic concepts based on theories and beliefs rather than scientifically accepted logic and evidence……
            They are, however, not compatible with the ‘official’ evidence-friendly chiropractic profession, and to accept and protect such an approach, is a serious issue, potentially one of public safety.
            For us it appears obvious that stakeholders, public, and the chiropractors would be better off, if the two factions and the middle group clearly stated where they belong. In addition, if patient interests are given true primacy, the arguments for unity, in our opinion, seem less significant than those for divorce.

            Also disturbing from a scientific standpoint is Chiropractic’s adherence to a religious and spiritual belief in the “innate” which of course comes from it’s “saintly” creator DD Palmer – as here:

            “Yet, a profession-wide survey, “How Chiropractors Think and Practice (2003) “, published by the Institute for Social Research at Ohio Northern University confirmed that most chiropractors (whether “straights” or “mixers”) still hold views of Innate and of the cause and cure of disease (not just back pain) consistent with those of the Palmers. On the one hand, modern promotional brochures make a bid for medical legitimacy by describing Innate and adjustments using more scientific-sounding terms such as “inherent” and “nerve force.” On the other hand, publications targeted to sympathetic audiences quote appreciatively from the Palmers and personify Innate Intelligence as “soul and spirit.” In typical fashion, chiropractor Mike Reid elaborates on the spiritual meanings of Innate in “The Seven Laws of the Power of Attraction,” Chiropractic Journal: A Publication of the World Chiropractic Alliance (2007):

            “We are spiritual beings who are a piece of an entire bigger picture with a purpose in life. . . . As chiropractors, we already know that the universal intelligence lies within us as innate intelligence, causes our heart to beat, digests our food, and allows us to think as free people. . . . Listen to your innate. . . . Sit in a lotus position with your palms opened up. See yourself as one and the same with the universe.”

            And indeed many Chiros’ websites and leaflets still carry religious terminology and talk of God’s healing etc which does little to foster any faith in their adherence to science.

            I think it’s fairly safe to say that chiros will pay lip service to science and EBM when it suits them but in practice will prefer to pay homage to DD Palmer and the great subluxation in the sky rather than actually do any science or actually follow any SBM or EBM because that is far more difficult than carrying on as usual fixing imaginary defects, manipulating babies for colic, taking unnecessary X-Rays and doing preventative adjustments along with all these pre-paid package treatments – after all what can be better than treating people for conditions that are going to subside spontaneously anyhow when you can then take all the credit – or maybe share it with God?

          • @ DC

            BTW on consent see here:

            https://pubmed.ncbi.nlm.nih.gov/33148281/
            J Keith Simpson 1 , Stanley Innes 2
            Informed consent, duty of disclosure and chiropractic: where are we?

            The COVID-19 pandemic has seen the emergence of unsubstantiated claims by vertebral subluxation-based chiropractors that spinal manipulative therapy has a role to play in prevention by enhancing the body’s immune function. We contend that these claims are unprofessional and demonstrate a disturbing lack of insight into the doctrine of informed consent. As such it is timely to review how informed consent has evolved and continues to do so and also to discuss the attendant implications for contemporary health practitioner practice……….
            We argue that a patient cannot provide valid informed consent for the removal of vertebral subluxation. Further, vertebral subluxation care cannot meet code of conduct standards because it lacks an evidence base and is practitioner-centered. The uptake of the expanded duty of disclosure has been slow and incomplete by practitioners and regulators. The expanded duty of disclosure has implications, both educative and punitive for regulators, chiropractic educators and professional associations. We discuss how practitioners and regulators can be informed by other sources such as consumer law………
            Conclusion: Ultimately such matters are informed by the deliberations of the courts. It is our opinion that the duty of a mature profession to critically self-evaluate and respond in the best interests of the patient before these matters arrive in court.

          • “Should the adjustment be limited to musculoskeletal conditions?”, 89.8% of the respondents (n = 646) answered no”

            Are headaches always classified as a MSK condition? How about dizziness? How did chiropractors interpret the question?

            You can’t just toss a percentage out there without knowing the details.

            Regardless, the 89.9% doesnt support the cure anything and everything belief.

          • John Travis…again this is the claim…

            “insist that they can cure anything and everything by “cracking” joints…”

            None of what you shared tells us what percentage believe that.

  • @ DC

    And what of the 88.1% who thought chiropractic should retain the term ‘Vertebral Subluxation Complex’?

    It’s worth taking a look at how chiropractors view the ‘Vertebral Subluxation Complex’. For example, in 2010, the *vitalistic* Alliance of UK Chiropractors (which claims to be the largest of the four UK chiropractic associations), produced this statement:

    QUOTE
    “On 17th August we met with the General Chiropractic Council (GCC) and presented a dossier on the Vertebral Subluxation Complex (VSC)
    https://cdn.vortala.com/static/uploads/3/2011/11/VSC_Position_Statment_AUKC.pdf
    After reviewing this document, and discussions that followed at this meeting, the GCC agreed that they would delete the phrase ‘or health concerns’ in the VSC guidance and provide an explanation why it had done so…”
    Ref. http://www.ebm-first.com/chiropractic/uk-chiropractic-issues/1827-alliance-of-uk-chiropractors-october-2010-newsletter.html

    In essence, it seems that the Alliance of UK Chiropractors pressured the UK chiropractor regulator, the GCC, into changing its former stance about there being no evidence to link the VSC to ‘health concerns’. Further, when the GCC caved in to the Alliance it provided no evidence to support its U-turn. See:
    Ref. https://tinyurl.com/y67h5qyq

    The current GCC guidance advises only that there is no evidence that the VSC causes disease (as opposed to it previously saying ‘disease or health concerns’):
    Ref. https://tinyurl.com/y5bfnlev

    @ DC

    How confusing is that to the public? How can they be properly informed when chiropractic regulators appear to be so easily led?

    And aren’t the 89.8% of the respondents in the McDonald study who answered ‘no’ to the question ‘Should the adjustment be limited to musculoskeletal conditions?’ simply keeping the doors open for the vitalists and their quackery despite your apparent exoneration of them when you asked “are headaches always classified as a MSK condition? How about dizziness?”

    • Again..the statement was:

      “insist that they can cure anything and everything by “cracking” joints…”

      Inotherwords they would only do spinal manipulation. No exercise, no supplements, no health advice, etc…nothing could be added per their beliefs…just spinal manipulation to cure all conditions.

      In 25 years in practice, 50 years of going to various chiropractors and online conversations with thousands of chiropractors, i have not come across one. Have you?

      Oh, there may be a few out there in groups like Maximized Living but i suspect not very many.

      • DC wrote on 10 ‎November ‎2020 at ‏‎19:48:29 “Again..the statement was: “insist that they can cure anything and everything by “cracking” joints…” In other words they would only do spinal manipulation. No exercise, no supplements, no health advice, etc…nothing could be added per their beliefs…just spinal manipulation to cure all conditions. In 25 years in practice, 50 years of going to various chiropractors and online conversations with thousands of chiropractors, i have not come across one.”

        @ DC

        Allow me to enlighten you then. See p.42 here: https://cdn.vortala.com/static/uploads/3/2011/11/VSC_Position_Statment_AUKC.pdf

        QUOTE
        “Can chiropractic promote health? Since *MANY* DCs have witnessed first-hand the benefits of chiropractic, they *OFTEN* educate patients about the need for subluxation correction to promote and enhance health and wellness.”

        IMO, that lends further weight to the findings of the McDonald study:

        In response to the question, “Should chiropractic retain the term vertebral subluxation complex?,” the respondents (n=638) overwhelmingly voted to do so: 88.1% yes (95% confidence interval 85.5-90.7), 11.9% no (95% CI 9.3-14.5)

        To the question, “Should the adjustment be limited to musculoskeletal conditions?,” 89.8% of the respondents (n = 646) answered no (95% CI 87.4-92.2) and 10.2% yes (95% CI 7.8-12.6).

        Ref: https://chiro.org/research/ABSTRACTS/How_Chiropractors_Think_and_Practice.shtml

      • @ DC

        https://chiromt.biomedcentral.com/articles/10.1186/s12998-018-0221-z
        Chiropractic, one big unhappy family: better together or apart?
        Charlotte Leboeuf-Yde, Stanley I. Innes, Kenneth J. Young, Gregory Neil Kawchuk & Jan Hartvigsen

        This paper which I quoted earlier is specifically arguing that the chiropractic “profession” (if one can call it that) is so riven with dispute between the ‘straights’ who are so adherent to cracking spines that they won’t hear of anything scientific or even adding CAM to their chiro religion and are wedded to the “innate” and to the idea of lifelong wellness through chiro adjustments versus the small group tending more towards progress and EBM at the other extreme who are more like physical therapists – and as I explained before the vast majority of chiros are in the middle. These latter are apathetic and laissez faire according to the paper as long as the money keeps rolling in I guess and they’ll do whatever it takes and not rock the boat by criticizing anyone or making any waves.

        In other words they’re not bothered about the science, or whether the daft philosophy behind it sounds silly, or whether it makes any sense that you can’t cure deafness by cracking someone’s neck – as long as the suckers keep coming through the door that’s all that matters.
        You can see from the videos how folks are suckers for a bit of bone cracking – and how chiros and osteos love to give them that meaningless bit of drama. “Crack – Crunch!” Your spine is straight! I fixed it for you! And they have no idea that it’s not at all related to any bones slipping into place at all – just flim-flam!

        So yes – there’s plenty of evidence that chiros believe they can get suckers (sorry clients) to fall for the idea that plenty of conditions will respond to a bit of bone cracking – but of course if you do a line in supplements or herbs or acupuncture then I’m sure that’s also a nice bit of extra income to bleed the poor punters with as well. I guess the straights must pay a price for foregoing all those extras but perhaps they make up for it with all the religious like follow-ups they do.

        Anyway if you are going to argue that chiros are giving dietary advice or doling out vitamins or doing acupuncture or whatever – then that’s no longer chiropractic is it? Surely it’s only chiro if you’re actually bone-crunching?
        Surely the whole basis of chiropractic is the religion as expounded by the Palmers? (Looney as that was.)
        Once you stray from that what basis does it have? What is it founded on? At what point does it just deviate off into physical therapy or naturopathy or just some kind of fiddling about non-specifically?

        What kind of training do they get for all this non-chiropractic related stuff that they keep getting into?
        It is a matter of some concern that there is mission creep – especially into the areas of children, babies and pregnant women where it is quite apparent that training and experience are somewhat deficient.

        Anyway if chiropractors do all this research we hear so much about – then all these figures should be available in spades. But as with all things SCAM there is a paucity of good quality research in chiroquackery – most of it is the usual dross showing negative or inconclusive results from poorly thought out or conducted studies that are a waste of time – but that always end with a plea for more research!

  • Boy, the GCC is quick!!!
    I just learnt that their hearing of this case is scheduled for 19 April – 30 April 2021.
    Are we supposed to take this regulator seriously?

  • How can anyone take the GCC seriously, not least when, on International Women’s Day earlier this month, it tweeted:

    “Happy #InternationalWomensDay to all female chiropractors, who make up almost half of our Register, and all to those women who contribute greatly to patient care and improving the profession.”

    Ref https://twitter.com/GenChiroCouncil/status/1368926930897145857

    A recipient of the GCC’s greeting would have included its registered chiropractor, Arlene Scholten, who allegedly killed Mr Lawler, but whom the GCC saw fit to allow to continue to practice.

    The forthcoming hearing particulars can be read here:
    https://www.gcc-uk.org/assets/hearings/2021.02.26_-_GCC_v_Scholten_-_Hearing_Notice__Allegations_(Website)_.pdf

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