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

I have reported previously about the tragic death of John Lawler. Now after the inquest into the events leading to it has concluded, I have the permission to publish the statement of Mr Lawler’s family:

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.

___________________________________________________________________

Before someone comments pointing out that this is merely a single case which does not amount to evidence, let me remind you of the review of cervical manipulation prepared for the Manitoba Health Professions Advisory Council. Here is the abstract:

Neck manipulation or adjustment is a manual treatment where a vertebral joint in the cervical spine—comprised of the 7 vertebrae C1 to C7—is moved by using high-velocity, low-amplitude (HVLA) thrusts that cannot be resisted by the patient. These HVLA thrusts are applied over an individual, restricted joint beyond its physiological limit of motion but within its anatomical limit. The goal of neck manipulation, referred to throughout this report as cervical spine manipulation (CSM), is to restore optimal motion, function, and/or reduce pain. CSM is occasionally utilized by physiotherapists, massage therapists, naturopaths, osteopaths, and physicians, and is the hallmark treatment of chiropractors; however the use of CSM is controversial. This paper aims to thoroughly synthesize evidence from the academic literature regarding the potential risks and benefits of cervical spine manipulation utilizing a rapid literature review method.

METHODS Individual peer-reviewed articles published between January 1990 and November 2016 concerning the safety and efficacy of cervical spine manipulation were identified through MEDLINE (PubMed), EMBASE, and the Cochrane Library.

KEY FINDINGS

  • A total of 159 references were identified and cited in this review: 86 case reports/ case series, 37 reviews of the literature, 9 randomized controlled trials, 6 surveys/qualitative studies, 5 case-control studies, 2 retrospective studies, 2 prospective studies and 12 others.
  • Serious adverse events following CSM seem to be rare, whereas minor adverse events occur frequently.
  • Minor adverse events can include transient neurological symptoms, increased neck pain or stiffness, headache, tiredness and fatigue, dizziness or imbalance, extremity weakness, ringing in the ears, depression or anxiety, nausea or vomiting, blurred or impaired vision, and confusion or disorientation.
  • Serious adverse events following CSM can include the following: cerebrovascular injury such as cervical artery dissection, ischemic stroke, or transient ischemic attacks; neurological injury such as damage to nerves or spinal cord (including the dura mater); and musculoskeletal injury including injury to cervical vertebral discs (including herniation, protrusion, or prolapse), vertebrae fracture or subluxation (dislocation), spinal edema, or issues with the paravertebral muscles.
  • Rates of incidence of all serious adverse events following CSM range from 1 in 10,000 to 1 in several million cervical spine manipulations, however the literature generally agrees that serious adverse events are likely underreported.
  • The best available estimate of incidence of vertebral artery dissection of occlusion attributable to CSM is approximately 1.3 cases for every 100,000 persons <45 years of age receiving CSM within 1 week of manipulative therapy. The current best incidence estimate for vertebral dissection-caused stroke associated with CSM is 0.97 residents per 100,000.
  • While CSM is used by manual therapists for a large variety of indications including neck, upper back, and shoulder/arm pain, as well as headaches, the evidence seems to support CSM as a treatment of headache and neck pain only. However, whether CSM provides more benefit than spinal mobilization is still contentious.
  • A number of factors may make certain types of patients at higher risk for experiencing an adverse cerebrovascular event after CSM, including vertebral artery abnormalities or insufficiency, atherosclerotic or other vascular disease, hypertension, connective tissue disorders, receiving multiple manipulations in the last 4 weeks, receiving a first CSM treatment, visiting a primary care physician, and younger age. Patients whom have experience prior cervical trauma or neck pain may be at particularly higher risk of experiencing an adverse cerebrovascular event after CSM.

CONCLUSION The current debate around CSM is notably polarized. Many authors stated that the risk of CSM does not outweigh the benefit, while others maintained that CSM is safe—especially in comparison to conventional treatments—and effective for treating certain conditions, particularly neck pain and headache. Because the current state of the literature may not yet be robust enough to inform definitive prohibitory or permissive policies around the application of CSM, an interim approach that balances both perspectives may involve the implementation of a harm-reduction strategy to mitigate potential harms of CSM until the evidence is more concrete. As noted by authors in the literature, approaches might include ensuring manual therapists are providing informed consent before treatment; that patients are provided with resources to aid in early recognition of a serious adverse event; and that regulatory bodies ensure the establishment of consistent definitions of adverse events for effective reporting and surveillance, institute rigorous protocol for identifying high-risk patients, and create detailed guidelines for appropriate application and contraindications of CSM. Most authors indicated that manipulation of the upper cervical spine should be reserved for carefully selected musculoskeletal conditions and that CSM should not be utilized in circumstances where there has not yet been sufficient evidence to establish benefit.

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Just three points which, in my view, sand out most in relation to Mr Lawler’s death:

  1. Mr Lawler had no proven indication (and at least one very important contra-indication)  for neck manipulation.
  2. He did not give infromed consent.
  3. The neck manipulation was not within the limits of the physiological range of motion.

9 Responses to “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’

  • This is why evidence-based chiropractors, not evidence-biased chiropractors recommend imaging to rule out complications before manual spinal manipulation. A reference for you. https://journals.sagepub.com/doi/pdf/10.1177/1559325818781437

    • The paper you reference advocates radiographs in all cases prior to treatment.

      The radiation dose employed for a plain radiograph is very low, about 100 times below the threshold dose for harmful effects. Rather than increasing risk, such exposures would likely stimulate the patient’s own protection systems and result in beneficial health effects.

      This is from the abstract. The authors then go on to argue at quite some length that, far from being harmful, low-dose x-ray exposure has health benefits, such as reducing the risk of cancer.

      Because of the high natural cancer mortality, about 1 in 4, epidemiology with LNT modeling is incapable of showing significantly increased radiogenic cancer mortality at doses below about 100 mGy. Rather, a prevention of cancer may be seen.

      I should point out that 100mGy (milligray) is quite a lot in this context. A typical daily radiotherapy dose is only 20 times as much (i.e. 2Gy) but that is confined to a very small volume, many times smaller than the volume of tissue irradiated in a diagnostic radiograph.

      It is quite clear from the paper that the authors are not trained in radiobiology, and they don’t seem to understand much of what they are saying. It is not even clear that they understand the difference between Grays and Sieverts as units of radiation dose.

      I should add that none of them appear to be affiliated with any kind of academic institution.

      Oh yes, and this is the first of their references:
      Wikipedia. Spinal nerve; 2018. https://commons.wikimedia.org/w/index.php?curid¼1675049. Accessed March 16, 2018

      I don’t know what sort of journal Dose Response is, but it doesn’t resemble any of the scientific journals that I am familiar with. Is it peer-reviewed? Edited?

      I am not even sure what this journal, Dose Response, is all about.

      • i did some background investigation on the editors of Dose Response awhile back. I will just say I can understand why these authors submitted to that journal.

      • There are a lot of papers on the web nowadays which appear to be graduate or even high school research papers. I think it is fun for the student to see their work available to the world but possibly even the authors will admit to being an unreliable source.

    • A proper history and exam will give indications of most contra-indications to SMT. Once suspected, appropriate imaging or further testing is appropriate.

      A review of published AE cases of SMT stated that around 40% of cases, where enough information was provided in the case report, had indications of contra-indications of SMT. Inotherwords, the provider should not have done the SMT at that time point.

      Silent pathologies are uncommon and question the position of x raying everyone “just in case”.

      X rays are not very sensitive or specific for many pathologies. Example…at least 40-50% bone loss has to occur in a vertebrae before being identified on an x ray.

  • From the Lawler family statement: “The chiropractor diagnosed so-called ‘vertebral subluxation complex’ which she aimed to treat by manipulating his neck.”

    Surely this was a bogus diagnosis and therefore not reconcilable with ‘Only recommend care based upon the most appropriate evidence that meets patient preferences’. This is a requirement of the General Chiropractic Council’s Code of Practice, p.9 here: https://www.gcc-uk.org/assets/downloads/The_Code_011019.pdf

    IMO, ‘subluxation stations’ like this https://tinyurl.com/tfcdzfg are quackery, yet Arleen Scholten seemed to have one on her premises https://tinyurl.com/vlee8eg (last photo)

  • You mean you want to scaremonger. Post statistics of injuries by health professionals if you want to be taken seriously.

    • Julian,
      Do statistics matter, does a chiropractor have an emergency room? What would they do for a gunshot victim, meningitis, appendicitis, flu, lesions by knife fight, broken bones, torn ligaments, etc.? I can go on, prescriptions will be allocated for many end of life, near death patients to make them comfortable. Do chiropractors have an end of life procedure to eliminate pain?

  • Julian,
    Surely you know that chiropractic is a different system of healthcare from medicine – as its originator D.D. Palmer stated.
    And you know that the consensus of anatomy, pathology, surgical and medical opinion is that the ‘vertebral subluxation complex’ does not exist.
    And cannot therefore be ‘adjusted’.
    And that in this case Miss Scholten held herself out to be a ‘doctor’ – as did one of the expert witnesses (Mr Richard Brown).
    And that Mr Lawler not unreasonably thought Miss Scholten had a medical qualification.
    And that Miss Scholten did not explain any of the above to Mr and Mrs Lawler.
    And that Mr Lawler therefore did not give informed consent to having his neck manipulated.
    And that posting statistics of other health professionals never events (death) is irrelevant when considering chiropractic, because chiropractic is a different system from medicine. Caveat emptor .
    And that tu quoque is a logical fallacy.

    So what point are you trying to make?

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