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

I was alerted to an outstanding article by an unusual author, a law firm, on the subject of chiropractic. Allow me to quote a few passages from it (without changing a word or adding a comment):

When Katie May passed away suddenly from a stroke at just 34 years old, it was initially ruled an accident. After further investigation, a coroner determined the stroke that claimed the model and single mother’s life was caused by injuries sustained during neck manipulation by a chiropractor. And Ms. May is not the first to be affected by this seemingly harmless procedure…

What health issues can be caused by chiropractic manipulation?

Chiropractors typically use their hands to apply pressure to joints, aiming to help alleviate pain and improve body function. This is referred to as a chiropractic adjustment.

Adjustments are commonly performed for neck and/or back pain. Although the Mayo Clinic says the risk of a serious complication is relatively small, these complications can include:

  • A herniated disk, or worsening of an existing herniated disk
  • Compression of nerves in the lower spinal column
  • Stroke, which can result in paralysis or death

The last item on this list is particularly concerning.

Patients who receive neck manipulation are at risk for a stroke caused by vertebral artery dissection. Located in the neck, the vertebral arteries supply blood to the brain and can be torn by stretching and sudden force applied during a neck adjustment.

Studies have shown that vertebral artery dissection occurs in approximately 1 in 100,000 people and can be caused by something as simple as cracking your neck.

How could a chiropractor be responsible for a patient’s injury?

Although the risk of being seriously injured by a chiropractor is low, tragic accidents can and do happen. If you or a loved one believe you have been the victim of medical malpractice, please contact an experienced personal injury attorney.

Explaining how an injury or medical error occurred will help your attorney determine the potential liability of a chiropractor and any other involved parties. A chiropractor’s liability could fall into a legal category such as:

  • Failure to Diagnose a Medical Condition – The chiropractor breaches a duty of care to their patients by failing to diagnose an underlying medical condition. This could occur when a patient reveals or exhibits symptoms of a severe issue, such as a stroke, and is not referred for appropriate medical attention.
  • Lack of Informed Consent – A patient is treated without being properly informed of the potential risks or side effects, and experiences an injury from that treatment.
  • Negligent Manipulation – The patient’s body is adjusted by the chiropractor in such a way that it causes a new injury or worsens an existing injury. This could also include manipulation of a patient who is pregnant and goes into premature labor.
  • Chiropractic Induced Injury – A patient suffers injury, permanent irreversible damage such as paralysis or wrongful death as the direct result of a chiropractic manipulation.

To find out whether or not you may have a case, please discuss your concerns with a qualified personal injury attorney.

What should I do if I think I have been injured by chiropractic manipulation?

A personal injury attorney can help recover compensation for victims of medical malpractice, including those who have experienced a chiropractic injury. Surviving loved ones can also pursue their case after a family member’s wrongful death.

An attorney will help you collect documents, photos and other items pertaining to your case – but staying organized early in the process will be helpful. Try to preserve important documents, such as:

  • Photographs before and after treatment
  • Medical records and medical bills
  • Receipts, appointment confirmations and other paperwork from your chiropractor

There is a time limit to file a medical malpractice lawsuit, referred to as a statute of limitations…

66 Responses to An outstanding article on the subject of harms of chiropractic

  • Really?
    is this an “outstanding article” or is it just another advertisement by ambulance chasers?

    I am the first to admit Chiropractic can do harm just like any other medical intervention.

    It should be practiced with care and utmost ethics but I prefer reading published studies not attorney website adds.

  • The lawyers left out some pertinent information, if I recall the case, she had a bilateral VAD, the ED did not rule out VAD but rather sent her home, her family said she fell during a photo shoot, the autopsy stated bruising on the side of her body dated around the time of the photo shoot, the coroner didn’t determine when the VADs actually occurred, etc.

    Rebleeding of VAD can be as high as 71.4% in untreated patients with mortality occurring in 46.7% in rebleeds. Around 80% of rebleeds occur within one week of initial occurrence. (Neurosurgery, Volume 36, Issue 5, May 1995, Pages 905–913.)

    Strange how anytime this case comes up people tend to leave out those details.

    • strange how chiros never accept blame

      • If the facts warrant blame they can be blamed.

      • @EE
        “strange how chiros never accept blame”.
        My kids when they were little used to use absolutes like “never” and “always” to exaggerate/make their point.
        Argument continues, not going well if the other person is reasonable.
        Time to do a Donald Trump and double down.
        “but chiros are the world champions at refusing to accept responsibility.”

        Please read the red banner at the top of your page.

        • then tell me about a few cases where chiros accepted responsibility, please.

          • Lets start with some recent cases.
            Are you aware of the recent battles that have been going on within the World Federation of Chiropractic (WFC) and what triggered it?

            How about this united statement from 170+ chiro PhD’s which has been cited before so you are aware of it:
            https://chiromt.biomedcentral.com/articles/10.1186/s12998-020-00312-x
            Good enough for you or is it tainted since it’s from chiropractors?

            How about this paper you blogged about recently with your usual spin in ignorance of it’s significance and I called you out:
            https://chiromt.biomedcentral.com/articles/10.1186/s12998-020-00342-5

            How about our old friend Sam Homola.
            Ring a bell?

            How about all the academics and researchers at my FOUR Australian University chiropractic faculties who consigned subluxation dogma to the history books and resulted in the vitalists attempting to set up a private college in South Australia because they are now outcasts?
            We discussed this in detail recently as well.
            Good enough for you?

            Or is it “never” going to be good enough for the cynics on this blog/echo chamber?

          • @Crackpot_Chiro,
            Chiro schools belong at places where Harry Potter went, not universities.

    • DC wrote: “the coroner didn’t determine when the VADs actually occurred, etc.”

      @ DC

      “TMZ obtained May’s death certificate, which says that she suffered a blunt force injury during a “neck manipulation by [a] chiropractor.” That injury tore an artery in her neck and cut off blood flow to her brain, which led to the stroke that killed her.”

      Refs:
      https://respectfulinsolence.com/2016/10/20/mystery-solved-chiropractic-manipulation-of-the-neck-did-cause-katie-mays-death-from-stroke/
      and
      https://www.tmz.com/2016/10/19/model-katie-may-chiropractor-cause-of-death/

      • this is the only thing in quotes in the article:

        “neck manipulation by [a] chiropractor.”

        How did the coroner determine the VAD was caused by the chiropractic manipulation?

        From what I have read, he did not. He assumed.

        • in this case, read more and stop bullshitting

          • What tests can be run on a corpse that determines the timing of a VAD?

            I have asked this question to several MDs. No one can (or will) give me answer. Can you?

          • yes, I can: the test of common sense.
            the poor man virtually lost control over his body while on the treatment bench and the chiro then gave him the rest.

          • EE…”the poor man virtually lost control over his body while on the treatment bench and the chiro then gave him the rest.”

            You are confused. The case under discussion is Katie May. Please try to keep up.

          • indeed, I was referring to Mr Lawler.

          • So the question remains unanswered…

            What tests can be run on a corpse that determines the timing of a VAD?

          • it’s a daft question that only you ask; so, you can answer it or not; it’s irrelevant.

          • It is a very critical point if one is wanting to try and establish causation of the VAD….or is the timing of the VAD not relevant as long as a chiropractor is in the somewhere in the picture?

          • It is a very critical point if one is wanting to try to white-wash chiropractic of any responsibility!

          • Instead of posting more and more nonsense, why don’t you anser the questions I asked you recently:

            FOUR QUESTIONS TO DC + CRITICAL CHIRO:

            1) what does the law say about informed consent for Australian chiros?
            2) what info exactly do you have to provide?
            3) who monitors it?
            4) what published evidence do we have about compliance?

          • I am not in Australia. Ask them.

          • “Instead of posting more and more nonsense…”

            Determining when a VAD actually occurred is nonsense? Wow. I suppose it is just easier to blame the chiropractor than determine the facts in the case.

        • @DC
          Coroners never assume, they come to conclucions based on the evidence before them and indicate the strength/likelyhood of their conclusion as well. In my reply to you below I demonstrate why the coroner is without much doubt correct.

    • @DC

      Let us say Ms. May had bilateral VAD’s caused by the photoshoot fall. She had symptoms from the neck and sought the services of a chiropractor who applied manipulations to her neck, repeatedly if memory serves me right.
      This raises the question of what effect chiropractic neck manipultion can have in someone who presents with symptoms that are due to recent cervical artery injury.

      Allow me to ask you once again a simple question that relates to your suggestion that Ms. May died from VAD injuries sustained in the photoshoot fall and not the manipulations.
      How do you think chiropractic manipulations modulate the risk of a serious complication, e.g. stroke or death, to bilateral (or unilateral) preexisting VAD?
      I will make answering very simple for you.
      You just neeed to choose which one you think is closest to the truth. I am not asking you to look this up in books or journals, just use your own professional insight and knowledge of anatomy, pathology and traumatology in relation to the mechanics of neck manipulation. I am sure all these subjects are taught in chiro school, right?

      Please choose one:
      a. The risk of serious outcome or death from preexisting bilateral VAD is less because of a protective or beneficial effect of neck manipulation
      b. The risk of serious outcome or death from preexisting bilateral VAD is unchanged by chiropractic neck manipulation because careful neck manipulation does not affect the condition
      c. The risk of serious outcome or death from preexisting bilateral VAD is increased because careful neck manipulation can strain the already injured vertebral arteries and causee tear of a loose but intact internal lining, increase a preexisting tear and thereby cause increased clot formation or even loosen a forming clot, which can obstruct blood wessels in the brain and cause fatal stroke.

      • I think the odds were against her surviving since the ED didn’t diagnose the bilateral VAD (assuming it was preexisting to the manipulation). If they had most likely she would not have gone to the chiropractor and she would be alive today.

        “Rebleeding of VAD can be as high as 71.4% in untreated patients with mortality occurring in 46.7% in rebleeds. Around 80% of rebleeds occur within one week of initial occurrence.” (Neurosurgery, Volume 36, Issue 5, May 1995, Pages 905–913.)

        She presented with contraindications to cSMT. So yes, doing cSMT in such cases increases the probablity of a serious AE. That’s why it is a contraindication. Why this chiro preceeded IDK. I know chiros who know him and they say he is one to do a good exam and history.

        (See. https://www.researchgate.net/figure/Absolute-contraindications-to-performing-cervical-spine-manipulation-CSM_tbl1_234016874)

        “From a clinical perspective, a thorough examination to rule out all contraindications and red flags may have the potential to prevent nearly half of all AEs related to CSM. Additionally, 19.4% of CSMs reviewed were performed for inappropriate conditions, meaning that patients were placed at risk for AE although they were not likely to benefit from the technique.” J Man Manip Ther. 2012 May; 20(2): 66–74.

        BTW…if i recall the chiro did two cSMT…one on Friday and a second on Monday. The neuro signs manifested Monday evening. (I havent reviewed the details for several years)

        We also know the neuro signs of a stroke can be latent for days. Thus the stroke could have occurred before the first cSMT.

        From the MDs i have talked to they say the best they can do is narrow the window of the timing of a stroke to 6 hours.

        So in this case we cannot say the cSMT caused the VADs or stroke. Is it possible? Yes.

        Thus my original question remains unanswered…what tests can been done postmortem to determine the timing of a VAD? Did the coroner do those tests? I suspect not….rather he assumed probably based on medical dogma (although apparently the wording in his report is vague)

        I will address your scenarios in another post.

        • @DC

          I think the odds were against her surviving since the ED didn’t diagnose the bilateral VAD (assuming it was preexisting to the manipulation). If they had most likely she would not have gone to the chiropractor and she would be alive today

          So you are saying she might be alive had she not visited the chiropractor. I agree and I will explain why below.
          In the reference you cite, acute soft tissue injury is listed as an absolute contraindication to cervical spinal manipulation (Table 1).

          So we agree that the chiropractor performed an absolutely contraindicated procedure and may very well have contributed or even caused her death.

          You ask if the coroner could have done tests to determine the age of the lesions and if he did them. A rough guestimation can be done from the maturity of the clotting not much more. I do not have the pathology report but it is not necessary in order to show that such a test, even if it existed, cannot rule out anything.
          We know that Ms. May saw a chiropractor for a “pinched nerve” shortly after her fall and then again three days later. On the evening of the second chiro-visit she reported neurological symptoms to her family by phone and went to the hospital where she succumbed to a massive stroke from a left VAD. This is according to sources cited on her wikipedia page.
          Whether the fall or the first manipulation caused a VAD can obviously not be determined as both happened within a short period, several days before the fatal event, i.e. the stroke. Even if a test could pinpoint the time of injury it would only be able to indicate which is more likely, that it happened near the fall and the first manipulation or at the second manipulation. It could harldy determine which of the first events was the causative trauma and thus not rule out that the chiropractor caused the VAD by manipulation. What is certain is that severe symptoms of stroke started later in the day after the second manipulation, at least three days after the first traumatic event and the first manipulation. The second manipulation is thus an overwhelmingly likely causal factor in the development of stroke, either by mobilisation of a previous clot or by causing a de novo VAD with immediate clot forming and subsequent stroke when the clot detached.
          My reconstruction, from available information, is that the chiropractor either caused an aggravation of a milder previous vascular injury (that she very well might have survived) or he caused the vascular injury either at the first or second manipulation session or both. The stroke happened shortly after the second manipulation, several days after the fall. In both cases the manipulations can definitely be determined to be responsible for the outcome.
          The lesson from this discussion should be that, in light of very limited if any evidence for benefit from cervical spine manipulation post trauma and even in general, and in light of the terrible albeit rare consequences, cervical spinal manipulation should never be performed.

          Acc. to Wikipedia, the fall happened on or before Jan. 29th when she first saw the chiro and the second visit and the subsequent stroke happened on Feb. 1st

          • Or she may have had the stroke and died without seeing the chiropractor or in spite of seeing him.

            This is why i have an issue when people say the chiropractor *caused* it.

            Using words like possibility or probablity…i can accept that.

            And i have been telling researchers for years…the issue is not so much the risk as it appears to be rare the issue is the benefit. Research the possible benefits….thats what is lacking.

            FWIW…a paper is suppose to be coming out re the stroke and cSMT which apparently will not be favorable. We shall see.

          • “rough guestimation can be done from the maturity of the clotting not much more.”

            guesstimate: an estimate usually made without adequate information

            Assume: to take as granted or true

            “Los Angeles Assistant Chief Coroner Ed Winter tells PEOPLE that a chiropractor shifted May’s neck, tearing her left vertebral artery.”

            https://people.com/bodies/playboy-model-katie-may-died-after-chiropractor-ruptured-an-artery-in-her-neck-coroner-says/

      • Based upon such limited information in your scenarios i would say all three are possible.

        • @DC

          Based upon such limited information in your scenarios i would say all three are possible.

          You are certainly doing your best to convince us that you have serious problems with deductive reasoning.

          • Perhaps. But the unknown is what is the ideal condition for a VAD to heal and can SMT help move the cervical spine/VA towards those conditions?

            Hemodynamics, autonomic regulation, spinal configuration, muscle spasms, VA tension, etc.

            Would i recommend it? Nope.

            Is there a possible benefit? Maybe…in some cases.

          • @DC
            Oh, my! You obviously have no idea what you are talking about. I thought chiropractors were taught at least some anatomy and pathology?

            No, even if you wish it was so, a medical student can tell you there is no way that any kind of force applied to an injured cervical artery can be beneficial. That need not be proven, not any more than the utility of a parachute when ejected from an aeroplane. On the contrary the ideal condition for an intimal (you know what the intima is, right? ) injury to heal is to avoid any strain onthe vessel. What happens in traumaticarterial injury, from any cause, is that a pulling, compressing and/or shearing force on the artery causes a tear in the inner lining of it. The vertebral artery lies in a bend through holes in the bony side projections of the cervical vertebrae, that can cause it to get streched/sheared by a rotatory movement of the vertebrae. No one can predict who may be at risk from even modest manipulation. Congenital predisposition may play a role. Furthermore, many injuries heal without consequences so the incidence is definitely under-reported. I have seen both in my professional capacity. Also, even if the intima, the inner lining of the vessel is intact, a haematoma (a collection of blood) between the layers of the arterial wall, without a tear in the lining may result from forces applied to the artery. I recently saw a case where pressure by fingers caused a haematoma in the upper part of the carotid artery that caused total obstrucyion. This caused subtle neurological signs the chiro missed. Fortunately the swelling receded and the injury healed in a few weeks without consequences. The chiropractor repeated manipulation despite clear, albeit subtle neurological warning signs. Blockage of one artery is not a problem if the other three going to the brain and their interconnections (the circle of Villis) are intact. But this is not always the case, sometimes due to developmental defects. However, if there is a tear on the inside of the vessel, a blood clot will form. If this clot becomes dislodged, e.g. by a repeat manipulation, the clot will travel into the brain and cause a stroke. Clots from the vertebral artery, which is the one more prone to injury by manipulation of the neck, are more likely to travel to areas of the brainstem that control vitalmfunctions and e.g. awareness. That is why such events may result in death or even worse, a permanent state of total paralysis, with intact consciousness, also called “locked-in state” or “Wallenberg syndrome”. You wouldn’t like that to happen to one of your customers, do you?
            That happened to Mr. Cassidy, who famously went on a science-excursion to relieve himself from blame He did research but fell into the trap of massaging numbers to fit his desire for self-absolution.
            This web page shows a typical chiropractor using this erroneous evidence to absolve himself while demonstrating with graphic pictures showing the exact extreme range of movement manipulation that puts undue strain on the vertebral arteries: https://www.comolakechiropractic.com/no-risk-of-stroke-after-chiropractic-care-a-population-based-case-crossover-study/

            I could go on at length to describe the finer points of what and why manipulation can cause a stroke.
            Of course this is fortunately a rare occurrence. But neck manipulations are extremely common so the incidence of terrible consequences is enough to regularly produce stories in the press like Ms. May’s or Mr. Lawler’s.
            I could go on. But hopefully this is enough for you to understand that we need not be in any doubt that there exists a clear and present mechanism of trauma from neck manipulation and it should be crystal clear that manipulation is NOT something that can have a beneficial effect on a cervical vessel that is even slightly injured or compromisediin some way.
            I am not going to search for it now, but my aging memory tells me we discussed a study some while ago that concluded it was not possible to clinically rule out vascular injury in someone with symptoms from the neck. I am sure “Blue” can find the link if he is reading this?
            When the rare but irrefutable hazard from neck manipulation that I have described here is put in context with the lack of reliable evidence of benefit from neck manipulation, for whatever indication, it should be obvious why chiropractors need to stop wringing necks and discourage such practices.

          • “that can cause it to get streched/sheared by a rotatory movement of the vertebrae.”

            Ignoring your condescending remarks, you never said it had to be a rotatory adjustment. There are adjustments that have no rotatory componenet.

            Also, look into the effect Luschka’s joints can have on the VA. You do know we have manipulations that address that joint.

            And yes VAD can and do heal without intervention. And some ADLs put more force into the VA than manipulation without apparent damage, in some cases. (I haven’t looked into it but probably more force from the weight of the head into the VA by bending over than cSMT…100N or so from cSMT)

            Research has shown that the greatest strain on the VA occurs not during manipulation but during normal ROM.

            Maybe you should look into the effect an altered sagittal curve can have on VA hemodynamics. Does this change the odds of a stroke? Unknown.

            I am aware of only one study of any effect SMT may have on a VAD…it showed no negative effect.

            As far as stopping all cSMT…first get all the PTs, DOs and MDs organizations to call for a ban. After all, they are the research and science informed ones.

            Which begs the question…Why haven’t they?

          • Maybe start by changing guidelines…they must be uninformed…

            https://onlinelibrary.wiley.com/doi/10.1002/ejp.1679#.X6_trBK1_zV.twitter

          • “that can cause it to get streched/sheared by a rotatory movement of the vertebrae.”

            You left out that this applies in particular to the vertebral artery.

            Ignoring your condescending remarks,

            What remarks? Perhaps you mean the assertion you don’t know what you are talking about. That is a statement you earned.

            you never said it had to be a rotatory adjustment.

            Should I have?

            There are adjustments that have no rotatory componenet.

            The rotatory manipulations specifically affect the vertebral artery, as can easily be understood by the anatomy. These also seem most common, to judge by the wealth of frightful demonstrations found on social video media.. Non- or minimally rotatory manipulations can stretch the carotid artery as well. Also the handling fingers may directly damage the carotid by compressing it against the vertebral bodies anterolaterally. I have seen such a case.

            Also, look into the effect Luschka’s joints can have on the VA. You do know we have manipulations that address that joint.

            And your point by this stub remark is?

            And yes VAD can and do heal without intervention.

            Yes luckily. Probably most do. At least if a chiropractor or some other manipulator doesn’t come along and tear it up.

            And some ADLs put more force into the VA than manipulation without apparent damage, in some cases. (I haven’t looked into it but probably more force from the weight of the head into the VA by bending over than cSMT…100N or so from cSMT)

            Purely speculative, and inconsequential in this context. Everyone knows that CAI’s occur without manipulation. It is the unnecessary iatrogenic ones we want to prevent.

            Research has shown that the greatest strain on the VA occurs not during manipulation but during normal ROM.

            Yes, I remember reading such exercises in wishful thinking, produced by chiropractors trying to defend their source of income. It is sad to see this kind of misuse of logic and reason.

            Maybe you should look into the effect an altered sagittal curve can have on VA hemodynamics. Does this change the odds of a stroke? Unknown.

            Do you have a point where you want to take this stub, or are you just obfuscating?

            I am aware of only one study of any effect SMT may have on a VAD…it showed no negative effect.

            Another pointless stub, unless you intend to follow it up with a reference to discuss.

            As far as stopping all cSMT…first get all the PTs, DOs and MDs organizations to call for a ban. After all, they are the research and science informed ones.
            Why should the chiropractors wait? Don’t they care about their clients well-being?

            Which begs the question…Why haven’t they?

            You tell us 😀

  • If you want to discuss Katie May case please bring the coroner’s full report and let’s discuss that, if it’s the Chiro fault I will be the first to say so. Until than try to choose your “references” more wisely.

    • @G. Almog

      DC already related pertinent information from the coroner’s report. Ms. May was found to have sustained bilateral VAD’s that were deemed the cause of stroke and death. It could of coursee not be determined whether these artierial injuries had been sustained when she fell or by the chiropractor’s repeated manipulations.

      DC suggested that these injuries were sustained when she had a fall during a photoshoot. It was added that she had bruises that I presume DC thinks indicate her fall might have been substantial? Of course this may be right.
      I asked DC a question just now (see above) in the hope of clarifying whether the chiropractors repeated manipulation may have affected the risk from preexisting cervical artery injury. It would be very interesting to also see your answer to this question.

  • @EE
    Here we go again you demand evidence while providing little if any for your own assumptions (poor case studies do not count. The pleural of anecdote does not equal evidence whether it’s from chiro’s or you).
    We have been over this many times over many years, I cite research/provide links yet you still find it challenging to take it onboard. It is human nature to feel obligated once making a public statement to defend it no matter how much evidence is sent your way. So not surprising.

    “1) what does the law say about informed consent for Australian chiros?”
    It is all freely available on the national regulators website (as you know and as I have referenced in the past):
    https://www.chiropracticboard.gov.au/Codes-guidelines/Code-of-conduct.aspx
    https://www.chiropracticboard.gov.au/Search.aspx?q=Informed+consent
    Some research by chiropractors on this topic (cited many times in the past):
    Risk Management for Chiropractors and Osteopaths. Informed consent
    A Common Law Requirement (2004):
    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2051308/
    Quick advanced PubMed with filters set to “Chiropractic” AND “Informed consent”.
    https://www.ncbi.nlm.nih.gov/pmc/?term=(Chiropractic)+AND+Informed+consent
    Not rocket science
    Latest paper that you wrote an ill informed blog on and the comments were not going as you expected (So I expected you to double down like Donald Trump with a new blog within days. Your getting predictable).
    https://chiromt.biomedcentral.com/articles/10.1186/s12998-020-00342-5
    This paper questions the legal implications of vertebral subluxations with high powered legal input and is a broadside by evidence based chiropractors against vitalistic chiropractors. You respond a snide fantasy informed consent dialogue when you should be supporting the authors:
    https://edzardernst.com/2020/11/informed-consent-why-chiropractors-dont-like-it/

    “2) what info exactly do you have to provide?”
    “4) what published evidence do we have about compliance?”
    We have discussed this as well. It is a common law requirement for every profession and is checked upon re-registration by AHPRA every year and by the professional indemnity insurers every year. No informed consent, no registration and no professional indemnity insurance.
    Checked AHPRA’s panel decisions and went back 5 YEARS and found ONE decision relating to informed consent:
    https://www.ahpra.gov.au/Publications/Panel-decisions.aspx

    “3) who monitors it?”
    Another of your tired old arguments that we have discussed many times over the years.
    In the UK there is the “‘Chiropractic Reporting and Learning System’ (CRLS)” but this is set up by the association representing chiropractors and not the registration board that advocates for patients. Right idea and step in the right direction, wrong organization.
    Here years ago there was a trial of an adverse event reporting system in a Melbourne emergency department systematically collected relevant AE information on all professions which was sent to the relevant board for investigation.
    It was supported by doctors and chiropractors while physio’s were not involved. A doctor involved told me it was killed off by ER doctors who “snivelled” about the extra paperwork.
    There is no AE reporting system for physio’s, chiro’s, osteo’s, GP’s in private practice etc.
    Over the years you have harped on and on about this topic as if it is a failing purely of the chiropractic profession when we have supported initiatives for its implementation.
    You have also kept up with the research even commenting on an chiropractic researcher on AE’s Charlotte Leboeuf-Yde (who you highly regard) yet ignored until you could take issue with two sentences written in a blog then you wrote this hatchet blog:
    https://edzardernst.com/2017/04/we-have-an-ethical-legal-and-moral-duty-to-discourage-chiropractic-neck-manipulations/
    So you are asking for evidence yet willfully ignore an author who “I have always thought highly of Charlotte’s work”.

    Stop the cynical cherry picked blogs and start supporting the researchers and reformers otherwise you are just someone standing on the sidelines blindly throwing grenades. You do not care who you hit or the damage you do to the chiropractors leading the reform you demand yet consistently fail to support.

  • So it goes on and on….
    But I still have no answer to the question: “What do practitioners of ‘chiropractic’ think they are up to?”

    Thery know the evidence for ‘subluxations’ is paltry, they know the evidence that ‘adjustments’ provide little lasting effects, if any, (which is why ‘maintenance’ is so-often called for), they know there can be serious complications, even fatalities after chiropractic intervention, and surely they know there is no evidence for ‘innate intellegence’ which can be released by ‘adjustment’ – a concept which was, and is, the prime premise of ‘chiropractic’.
    (If it is not, then they ain’t doin’ chiropractic – but thar is gold in them thar ills.)

    Just why don’t folks who feel drawn to dealing with pathology of the musculoskeletal system become doctors (MD), physical therapists or even osteopaths?

    Why enter such an anachronistic and controversial profession and then try to re form it?
    Why not select a rational form of healthcare practice in the first place?

    • I think i have addressed this at least on a personal level. But i will state this based upon conversations with many chiropractors…

      You want to see a mass exodus of chiropractors from the profession? It’s simple…fast track to transfer to a DPT or DO.

      This for two main reasons…

      1. Seperation from the whacky doodles in the chiro profession.

      2. Better reimbursement/opportunities.

  • @ Ernst,

    I am just wondering what was your criteria for choosing, which passages from the article to include in your blog and which passages to exclude, considering the whole article is about chiropractic malpractice?

  • Many moons ago I stopped in at a chiro’s practice (was looking for someone to do xrays for an unrelated project) and we got to talking shop. Anyway she mentioned that she would not do “spinal manipulations” because the risk of injury was too great; she personally knew of over a dozen cases that had resulted in paralysis.

    If a chiropractor (young enough to have recently studied all the latest techniques) was paranoid about “spinal manipulations” — what should the rest of us be??

  • Björn Geir wrote on Friday 13 November 2020 at 23:26: “we discussed a study some while ago that concluded it was not possible to clinically rule out vascular injury in someone with symptoms from the neck. I am sure ‘Blue’ can find the link if he is reading this?”

    I think it might have been the study that is critiqued here: https://sciencebasedmedicine.org/chiropractic-and-stroke-no-evidence-for-causation-but-still-reason-for-concern/

    Also see:

    Hutting N, Verhagen AP, Vijverman V, Keesenberg MD, Dixon G, Scholten-Peeters GG. Diagnostic accuracy of premanipulative vertebrobasilar insufficiency tests: a systematic review. Man Ther. 2013;18(3):177-82.
    “Based on this systematic review of only 4 studies it was not possible to draw firm conclusions about the diagnostic accuracy of premanipulative tests. However, data on diagnostic accuracy indicate that the premanipulative tests do not seem valid in the premanipulative screening procedure. A surplus value for premanipulative tests seems unlikely.”

    Link: https://www.leidenfysiotherapie.nl/artikelen_projecten_online/VBI-Fysiotherapie-Manuele-Therapie.pdf

    Childs JD, Flynn TW, Fritz JM, et al. Screening for vertebrobasilar insufficiency in patients with neck pain: Manual therapy decision-making in the presence of uncertainty. J Orthop Sports Phys. 2005;35:300–306.
    “Despite the existence of guidelines advocating specific screening procedures, research does not support the ability to accurately identify patients at risk.”

    Link: https://www.jospt.org/doi/pdf/10.2519/jospt.2005.35.5.300

  • Björn Geir wrote on Friday 13 November 2020 at 23:26: “we discussed a study some while ago that concluded it was not possible to clinically rule out vascular injury in someone with symptoms from the neck. I am sure ‘Blue’ can find the link if he is reading this?”

    I think it might have been the study that is critiqued here: https://sciencebasedmedicine.org/chiropractic-and-stroke-no-evidence-for-causation-but-still-reason-for-concern/

    Also see:

    Hutting N, Verhagen AP, Vijverman V, Keesenberg MD, Dixon G, Scholten-Peeters GG. Diagnostic accuracy of premanipulative vertebrobasilar insufficiency tests: a systematic review. Man Ther. 2013;18(3):177-82.
    “Based on this systematic review of only 4 studies it was not possible to draw firm conclusions about the diagnostic accuracy of premanipulative tests. However, data on diagnostic accuracy indicate that the premanipulative tests do not seem valid in the premanipulative screening procedure. A surplus value for premanipulative tests seems unlikely.”

    Link: https://www.leidenfysiotherapie.nl/artikelen_projecten_online/VBI-Fysiotherapie-Manuele-Therapie.pdf

    Childs JD, Flynn TW, Fritz JM, et al. Screening for vertebrobasilar insufficiency in patients with neck pain: Manual therapy decision-making in the presence of uncertainty. J Orthop Sports Phys. 2005;35:300–306.
    “Despite the existence of guidelines advocating specific screening procedures, research does not support the ability to accurately identify patients at risk.”

    Link: https://www.jospt.org/doi/pdf/10.2519/jospt.2005.35.5.300

    • Blue delivers :).
      Thanks!

      • I ran some numbers. In the US a sVAD will come thru a chiro practice about once every 9 years.

        Most place the risk of a serious AE at 1 out of 1 to 5 million.

        So we are to screen 5 million visits to find one sVAD? Does modern medicine do that for any condition?

        • @DC
          If I understand your statement right, someone has estimated that one person with a preexisting VAD is seeing a chiropractic establishment and being manipulated every nine years, right?
          There are somewhere between 40.000 and 70.000 chiropractors in the US depending on the source, the latter figure from the chiropractors association. Let’s be very restrictive and postulate there are about 30.000 practices. Many of them employ more than one chiropractor so this should be a reasonable minimum figure, right? The bureau of labour statistics seems to put this number at a little more than 32.000, but I didn’t dig deep there.
          This means, if every practice manipulates one person with a preexisting arterial lesion every 9 years, that no less than 3.333 patients seek the wrong health care provider and are put at undue risk of catastrophic stroke every year in the US. That is absolutely frightening!!

          The answer is not that you should be screening for CAI’s, that is neither within the scope or ability of a chiropractor and cannot be reliably done in such a setting. Instead you should stop performing useless theatrical acts of pretending to “adjust” non-existent problems in the neck (and elsewhere).

    • @BW
      “I think it might have been the study that is critiqued here: https://sciencebasedmedicine.org/chiropractic-and-stroke-no-evidence-for-causation-but-still-reason-for-concern/
      SBM not once referred to the authors of the Cureus (2016) paper as neurosurgeons only as “they” and it comes across as chiropractors burying their heads in the sand. The SBM critique also discusses the poor science yet not once acknowledges that the poor science (case studies) are coming form doctors and NOT chiropractors. Unless you read the original article the SMB blog is an exercise in smoke and mirrors to support their medical “dogma” (to quote the neurosurgeons in the systematic review and meta-analysis).

      “Blue delivers :).” I think not.

      Your other two papers cited are way out of date Blue. Search for Roger Kerry’s recent paper. Or if you want to go back to when chiropractors discussed this topic you will need to go to the 1980/90’s. Nice to see the physio’s finally catching up to the chiro’s. Especially when so many of them are jumping on the HVLA bandwagon with Maitland Grade 5 mobilizations (HVLA’s). A recent paper from the Netherlands puts 30% of physio’s using HVLA on the cervical spine. There are 4 times as many physio’s as chiro’s. Food for thought.

      A thorough history is more important to screen for serious pathology or trauma. Then again I would advise you to look up several recent paper on red flag screening questions and you will be surprised that no one can even agree on standardized questions for those as well. BTW it’s research by chiro’s and physio’s collaborating.

      “Blue delivers :).” I think not.

      • Critical_Chiro wrote: “Unless you read the original article the SMB [sic] blog is an exercise in smoke and mirrors”

        @ Critical_Chiro

        There is a highlighted live link to the original article on the third line of the introduction, so you can’t accuse Science Based Medicine of not being transparent. See https://sciencebasedmedicine.org/chiropractic-and-stroke-no-evidence-for-causation-but-still-reason-for-concern/

        Critical_Chiro wrote: “Search for Roger Kerry’s recent paper”

        I don’t know why you haven’t provided a link to it (as per Prof. Ernst’s request at the the top of the page: ‘Please remember: if you make a claim in a comment, support it with evidence’), but I’m assuming that this is it…
        https://www.researchgate.net/publication/264157982_Cervical_spine_pre-treatment_screening_for_arterial_dysfunction_out_with_the_old_in_with_the_new

        Conclusion:
        “Existing data and theory regarding serious adverse events related to physiotherapy intervention is not sufficiently complete or relevant to guide future practice. A new evidence-based paradigm of risk assessment, referred to as cervical arterial dysfunction, has been proposed. Latest international guidance has adopted this approach as a framework for understanding the nature of pain presentations and clinical features, with respect to awareness and management of those individuals who may be at risk. While clinicians should be cognisant that movement of the head and neck does indeed influence vascular tissue mechanics and blood flow to the brain, the real-world risk of how this relates to the onset of a serious adverse event is contextualised by which sub-group the patient belongs to. Assessing and sub-classifying patients into appropriate predisposition or pathology groups will assist clinical decision making.”

        …or is it this one?
        https://www.researchgate.net/publication/246830493_A_'system_based'_approach_to_risk_assessment_of_the_cervical_spine_prior_to_manual_therapy

        Summary:
        “Attempts have recently been made to provide guidelines for the effective screening of patients who may be at risk of neurovascular accident post-manual therapy. However, current evidence questions the validity and utility of such guidelines. It is therefore necessary to re-consider the clinical approach towards assessment of potential cervical arterial dysfunction. Based on the existing evidence base, the authors suggest manual therapists consider the following recommendations;

        1. Expand manual therapy theory to encompass a ‘systems based’
        approach, incorporating the whole cervical vascular system,
        including the carotid arteries.
        2. Expand manual therapy theory and practice to include hae-
        modynamic principals and their relationship to movement
        anatomy and biomechanics.
        3. Develop a high index of suspicion for cervical vascular
        pathology, particularly in cases of acute trauma.
        4. Develop increased awareness that neck pain and headache may
        be precursors to potential posterior circulation ischemia.
        5. Enhance subjective/objective examination by including
        vascular risk factors such as hypertension, and procedures such
        as cranial nerve and simple eye examination.
        6. Consider new advances in the subjective assessment of cervical
        arteries such as questionnaire screening.
        Develop an awareness of the limitations of current objective
        tests such as pre-treatment movement testing and the
        proposed use of hand-held Doppler ultrasound. This should
        enhance the knowledge that reliance on objective testing alone,
        represents incomplete clinical reasoning.
        8. In cases of acute onset headache “unlike any other” couples
        with ambiguous examination findings, retain an index of
        suspicion and use conservative or gentle treatment techniques
        in the early stages of management.
        9. Where frank arterial injury is suspected prior to or following
        a treatment intervention, immediate triage to an appropriate
        emergency centre is recommended, together with a report on
        any treatment methods undertaken.

        The summarised points above are not intended as definitive guidance rather an advancement of theory, practice and clinical reasoning, based on the constantly emerging evidence base.”

        @ Critical_Chiro

        The above are hardly reassuring and raise the question, why bother with dubious attempts at screening when there are other treatment options for neck pain which have a better risk/benefit profile?

        • Indeed.
          There is this wonderful blog entry in SBM which goes to show how chiropractors exemplify that if the only tool you have is a hammer then you see every problem as a nail – and that Chiros are also the world’s best example of Dunning Kruger in action. Is there anything more terrifying than the thought of a baby in distress and the words “the chiropractor is on his way!”

          https://sciencebasedmedicine.org/chiropractic-management-of-a-newborn-with-abnormal-oxygen-levels/

          The sheer idiocy of an incompetent midwife diagnosing a congenital heart defect – and then deciding that the best person to call is a CHIROPRACTOR! That this idiot then believes that he is qualified to attend and make an assessment – and bearing in mind that the baby is allegedly haemodynamically compromised he wastes time making “an in-depth consultation with the parents and the attending midwife” instead of making an urgent assessment of the baby!

          He then makes an adjustment of a cervical “subluxation” in the baby’s neck “treated” with a “gentle sustained-contact type of force with the middle finger”. The argument being that the amount of pressure one would use to check for the ripeness of a tomato.”
          If this amount of force is all that is needed then presumably just picking up the baby for its next feed would be all that is needed to return it to its previously subluxed state!

          Apparently this genius is thus able to exclude a congenital anomaly and all other causes merely by palpation but one is left to wonder how a “subluxation” might cause hypoxia? Never fear this wunderkind has a word salad like no other to dispel your ignorance. He explains it thus: “Sympathetic dominance, due to a reduced parasympathetic function or an increased sympathetic function can affect the autonomic nervous system creating a reduction in dynamic flexibility of the system, as a consequence of poor adaptation to an increase in external and internal demands. This in turn could create an imbalance in the autonomic nervous system which can have negative effects with regard to pathological conditions.”

          I realize that I am at a severe disadvantage here in not having had a Chiropractic education but I fail to understand how an imaginary subluxation in the cervical region could cause an overactive sympathetic nervous system and even if it could how this might result in hypoxia. Obviously Chiros live in some kind of alternate reality where words mean what they want them to mean.

          In addition the quote from this idiot Chiropractor (who should never be allowed near a real live baby ever) is a meaningless jumble of words that in sum total adds up to a total of old cobblers. It is obviously intended to impress journalists or parents but in fact just betrays his arrant bullshit.

          But this is the dangerous world in which we live. Chiros believe they are real doctors. That their imaginary findings have reality because they say so – and that because they press on this point or that that they can make these imaginary findings disappear. And because of logical fallacies, the placebo effect, and per Barry Beyerstein https://quackwatch.org/related/altbelief/
          they so often get away with it.

          I think a large part of it is the kind of anti-hero/ anti-establishment effect. Post-modernism/ Trumpism style type of thing. People are often struck by the idea of a guy in his back room fixing spines by cracking them with some kind of primitive method rather than a doctor doing it – avoiding surgery/ some kind of conspiracy being involved. they like the drama of these You-Tube videos and some of these New Age Chiros sticking it to the Establishment – going against science – proving people wrong.
          It goes with their stance against vaccines and medications and being into herbs and homeopathy – home births and chakras.

          Of course it’s all hypocritical. They rage against Big Pharma – but Big Chiro is worth billions as is Big Homeopathy. Big Alt Med is worth over 100 billion dollars a year! But they like to keep that quiet.
          They were keen to get Big Chiro on Medicaid and Medicare and on every insurance plan going – naturally!
          But in the UK it’s not allowed on the NHS – because it’s not validated and it’s certainly NOT cost-effective!
          In fact no Alt Med is reimbursed on the NHS for this reason.

          If Chiropractic were as effective as its proponents claim it would be child’s play to design an RCT to demonstrate this beyond doubt. The fact this hasn’t been done is evidence that they have no desire to do this for obvious reasons. If there were a significant effect they wouldn’t be arguing about minimal differences in poor quality studies. The emperor has no clothes.

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