I was criticised for not referencing this article in a recent post on adverse effects of spinal manipulation. In fact the commentator wrote: Shame on you Prof. Ernst. You get an “E” for effort and I hope you can do better next time. The paper was published in a third-class journal, but I will nevertheless quote the ‘key messages’ from this paper, because they are in many ways remarkable.
- Adverse events from manual therapy are few, mild, and transient. Common AEs include local tenderness, tiredness, and headache. Other moderate and severe adverse events (AEs) are rare, while serious AEs are very rare.
- Serious AEs can include spinal cord injuries with severe neurological consequences and cervical artery dissection (CAD), but the rarity of such events makes the provision of epidemiological evidence challenging.
- Sports-related practice is often time sensitive; thus, the manual therapist needs to be aware of common and rare AEs specifically associated with spinal manipulative therapy (SMT) to fully evaluate the risk-benefit ratio.
The author of this paper is Aleksander Chaibi, PT, DC, PhD who holds several positions in the Norwegian Chiropractors’ Association, and currently holds a position as an expert advisor in the field of biomedical brain research for the Brain Foundation of the Netherlands. I feel that he might benefit from reading some more critical texts on the subject. In fact, I recommend my own 2020 book. Here are a few passages dealing with the safety of SMT:
Relatively minor AEs after SMT are extremely common. Our own systematic review of 2002 found that they occur in approximately half of all patients receiving SMT. A more recent study of 771 Finish patients having chiropractic SMT showed an even higher rate; AEs were reported in 81% of women and 66% of men, and a total of 178 AEs were rated as moderate to severe. Two further studies reported that such AEs occur in 61% and 30% of patients. Local or radiating pain, headache, and tiredness are the most frequent adverse effects…
A 2017 systematic review identified the characteristics of AEs occurring after cervical spinal manipulation or cervical mobilization. A total of 227 cases were found; 66% of them had been treated by chiropractors. Manipulation was reported in 95% of the cases, and neck pain was the most frequent indication for the treatment. Cervical arterial dissection (CAD) was reported in 57%, and 46% had immediate onset symptoms. The authors of this review concluded that there seems to be under-reporting of cases. Further research should focus on a more uniform and complete registration of AEs using standardized terminology…
In 2005, I published a systematic review of ophthalmic AEs after SMT. At the time, there were 14 published case reports. Clinical symptoms and signs included:
- central retinal artery occlusion,
- nystagmus,
- Wallenberg syndrome,
- ptosis,
- loss of vision,
- ophthalmoplegia,
- diplopia,
- Horner’s syndrome…
Vascular accidents are the most frequent serious AEs after chiropractic SMT, but they are certainly not the only complications that have been reported. Other AEs include:
- atlantoaxial dislocation,
- cauda equina syndrome,
- cervical radiculopathy,
- diaphragmatic paralysis,
- disrupted fracture healing,
- dural sleeve injury,
- haematoma,
- haematothorax,
- haemorrhagic cysts,
- muscle abscess,
- muscle abscess,
- myelopathy,
- neurologic compromise,
- oesophageal rupture
- pneumothorax,
- pseudoaneurysm,
- soft tissue trauma,
- spinal cord injury,
- vertebral disc herniation,
- vertebral fracture…
In 2010, I reviewed all the reports of deaths after chiropractic treatments published in the medical literature. My article covered 26 fatalities but it is important to stress that many more might have remained unpublished. The cause usually was a vascular accident involving the dissection of a vertebral artery (see above). The review also makes the following important points:
- … numerous deaths have been associated with chiropractic. Usually high-velocity, short-lever thrusts of the upper spine with rotation are implicated. They are believed to cause vertebral arterial dissection in predisposed individuals which, in turn, can lead to a chain of events including stroke and death. Many chiropractors claim that, because arterial dissection can also occur spontaneously, causality between the chiropractic intervention and arterial dissection is not proven. However, when carefully evaluating the known facts, one does arrive at the conclusion that causality is at least likely. Even if it were merely a remote possibility, the precautionary principle in healthcare would mean that neck manipulations should be considered unsafe until proven otherwise. Moreover, there is no good evidence for assuming that neck manipulation is an effective therapy for any medical condition. Thus, the risk-benefit balance for chiropractic neck manipulation fails to be positive.
- Reliable estimates of the frequency of vascular accidents are prevented by the fact that underreporting is known to be substantial. In a survey of UK neurologists, for instance, under-reporting of serious complications was 100%. Those cases which are published often turn out to be incomplete. Of 40 case reports of serious adverse effects associated with spinal manipulation, nine failed to provide any information about the clinical outcome. Incomplete reporting of outcomes might therefore further increase the true number of fatalities.
- This review is focussed on deaths after chiropractic, yet neck manipulations are, of course, used by other healthcare professionals as well. The reason for this focus is simple: chiropractors are more frequently associated with serious manipulation-related adverse effects than osteopaths, physiotherapists, doctors or other professionals. Of the 40 cases of serious adverse effects mentioned above, 28 can be traced back to a chiropractor and none to a osteopath. A review of complications after spinal manipulations by any type of healthcare professional included three deaths related to osteopaths, nine to medical practitioners, none to a physiotherapist, one to a naturopath and 17 to chiropractors. This article also summarised a total of 265 vascular accidents of which 142 were linked to chiropractors. Another review of complications after neck manipulations published by 1997 included 177 vascular accidents, 32 of which were fatal. The vast majority of these cases were associated with chiropractic and none with physiotherapy. The most obvious explanation for the dominance of chiropractic is that chiropractors routinely employ high-velocity, short-lever thrusts on the upper spine with a rotational element, while the other healthcare professionals use them much more sparingly.
Another review summarised published cases of injuries associated with cervical manipulation in China. A total of 156 cases were found. They included the following problems:
- syncope (45 cases),
- mild spinal cord injury or compression (34 cases),
- nerve root injury (24 cases),
- ineffective treatment/symptom increased (11 cases),
- cervical spine fracture (11 cases),
- dislocation or semi-luxation (6 cases),
- soft tissue injury (3 cases),
- serious accident (22 cases) including paralysis, deaths and cerebrovascular accidents.
Manipulation including rotation was involved in 42% of all cases. In total, 5 patients died…
To sum up … chiropractic SMT can cause a wide range of very serious complications which occasionally can even be fatal. As there is no AE reporting system of such events, we nobody can be sure how frequently they occur.
[references from my text can be found in the book]66 Responses to “Adverse events from manual therapy are few, mild, and transient” … best not to listen to chiros, I think
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sorry just a question… other than you saying so, do you have any EVIDENCE that Chiropractic SMT (interesting that you exclude physio manipulating but don’t let this trouble you) is:
Not rare?
Not mild in most cases?
Not transient in most cases?
Does not “… include spinal cord injuries with severe neurological consequences and cervical artery dissection (CAD), but the rarity of such events makes the provision of epidemiological evidence challenging.”
I can understand the urge to criticize but this time the author was 100% correct…
Possibly, you asking these question is already fairly good evidence!
If not it might help to read the chapter [https://www.amazon.co.uk/Chiropractic-Not-All-That-Cracked/dp/3030531171] and the articles referenced it it.
so you have no evidence… that is ok, Everyone is entitled to a personal biased opinion
sorry to hear that you are a bit slow on the uptake; there is plenty of evidence and the original references are in the book.
Sorry but the science is not with you… there are no evidence that Chiropractic SMT AE are:
1. Not rare
2. Not mild in most cases
3. Not transient in most cases
And please reference real studies not your own book please.
I am sorry to trouble you with the burden of proof… this is something us EBP people tend to like…
I did not expect a chiro to have an eye for the evidence.
as you insist, let me provide just one piece of evidence:
“Data from prospective studies suggest that minor, transient adverse events occur in approximately half of all patients receiving spinal manipulation.”
https://pubmed.ncbi.nlm.nih.gov/12015249/
[is 50% rare for a chiro?]
Great so the author was correct… the AE are MINOR and TRANSIENT and the serious AE that you present are so rare that you can not even quote their frequency (that does not mean they do not exist or we should not consider them).
By the way these are the same numbers as presented by Thiel and colleagues in the study you like to dismiss.
ABSOLUTELY!
but only if you have a doctorate in spin. this is what the athor wrote:
Adverse events from manual therapy are few, mild, and transient. Common AEs include local tenderness, tiredness, and headache. Other moderate and severe adverse events (AEs) are rare, while serious AEs are very rare.
Serious AEs can include spinal cord injuries with severe neurological consequences and cervical artery dissection (CAD), but the rarity of such events makes the provision of epidemiological evidence challenging.
Sports-related practice is often time sensitive; thus, the manual therapist needs to be aware of common and rare AEs specifically associated with spinal manipulative therapy (SMT) to fully evaluate the risk-benefit ratio.
AND THIS IS WHAT I CONCLUDED:
To sum up … chiropractic SMT can cause a wide range of very serious complications which occasionally can even be fatal. As there is no AE reporting system of such events, we nobody can be sure how frequently they occur.
“the serious AE that you present are so rare that you can not even quote their frequency”
That would be the charitable interpretation.
The other interpretation is that Prof Ernst cannot quote their frequency for the same reason that you can’t: because the chiropractic profession has no reporting system for reliably detecting and recording its AEs; and not only doesn’t have one but doesn’t believe that it should. So what does that say about your [mis]priorities?
@has
This topic has been discussed here many times:
https://edzardernst.com/2020/09/beliefs-perceptions-and-practices-of-chiropractors-and-patients-about-adverse-events-after-spinal-manipulation/#comment-126166
https://edzardernst.com/2020/09/beliefs-perceptions-and-practices-of-chiropractors-and-patients-about-adverse-events-after-spinal-manipulation/#comment-126192
Edzard Ernst – “To sum up … chiropractic SMT can cause a wide range of very serious complications which occasionally can even be fatal. As there is no AE reporting system of such events, we nobody can be sure how frequently they occur.”
Re-read this systematic review and meta-analysis by neurosurgeons:
https://www.cureus.com/articles/4155-systematic-review-and-meta-analysis-of-chiropractic-care-and-cervical-artery-dissection-no-evidence-for-causation
The neurosurgeons discuss the poor quality of the MEDICAL case studies and this:
“In spite of the very weak data supporting an association between chiropractic neck manipulation and CAD, and even more modest data supporting a causal association, such a relationship is assumed by many clinicians. In fact, this idea seems to enjoy the status of medical dogma. Excellent peer reviewed publications frequently contain statements asserting a causal relationship between cervical manipulation and CAD [4,25,26]. We suggest that physicians should exercise caution in ascribing causation to associations in the absence of adequate and reliable data. Medical history offers many examples of relationships that were initially falsely assumed to be causal [27], and the relationship between CAD and chiropractic neck manipulation may need to be added to this list.”
Critical_Chiro wrote: “Re-read this systematic review and meta-analysis by neurosurgeons:
https://www.cureus.com/articles/4155-systematic-review-and-meta-analysis-of-chiropractic-care-and-cervical-artery-dissection-no-evidence-for-causation ”
Then read this:
https://edzardernst.com/2020/08/chiropractic-not-all-that-its-cracked-up-to-be/#comment-125747
@BW
Then read this:
https://edzardernst.com/2020/08/chiropractic-not-all-that-its-cracked-up-to-be/#comment-125804
Now read this at the top of this page in the red banner:
“Please remember: if you make a claim in a comment, support it with evidence.”
Blogs are not evidence.
“Blogs are not evidence.”
That’s more than a bit simplistic. blogs can contain evidence; for instance, they can refer to published studies, or report original new evidence that is at least as trustworthy as some of the 3rd class SCAM journals peer-reviewed within the cult.
Critical_Chiro wrote on Saturday 09 January 2021 at 23:55 “Then read this:
https://edzardernst.com/2020/08/chiropractic-not-all-that-its-cracked-up-to-be/#comment-125804 ”
That link records Critical_Chiro writing: “Harriet Hall’s blog not once refers to the authors as neurosurgeons. All the way through it is ‘they’.”
@ Critical_Chiro
One merely has to click on the link to the paper provided by Dr Hall and then click on the authors’ names below its title to read their credentials.
For the sake of extra transparency, click here:
https://sciencebasedmedicine.org/chiropractic-and-stroke-no-evidence-for-causation-but-still-reason-for-concern/
In the first paragraph, the words ‘A systematic review found a small association between stroke and chiropractic care’ provide an embedded link to the paper:
https://www.cureus.com/articles/4155-systematic-review-and-meta-analysis-of-chiropractic-care-and-cervical-artery-dissection-no-evidence-for-causation
Critical_Chiro wrote on Saturday 09 January 2021 at 23:55 “Then read this:
https://edzardernst.com/2020/08/chiropractic-not-all-that-its-cracked-up-to-be/#comment-125804 ”
That link records Critical_Chiro writing: “She [Harriet Hall, MD] even references Edzard’s blog on phrenic nerve injury from chiropractic neck manipulation. That blog cites a paper where the patient clearly described to the doctor what treatment was performed by the chiro. It was a bog standard levator scapulae stretch used by just about every profession (chiro/physio,osteo/massage/etc) then called it a “chiropractic neck manipulation”. Very poor science.”
@ Critical_Chiro
Here’s a closer look at the content of that blog piece by Professor Ernst and why it’s relevant:
https://edzardernst.com/2015/02/phrenic-nerve-injury-a-rare-but-serious-complication-of-chiropractic-neck-manipulation/#comment-64573
Also see:
“All but one of these cases clearly state that the culprit in each case was a practitioner of the ‘chiropractic’ kind. Does that not say something about the methods used and adverse results caused by practitioners identifying themselves with the term?”
https://edzardernst.com/2015/02/phrenic-nerve-injury-a-rare-but-serious-complication-of-chiropractic-neck-manipulation/#comment-64597
______________________________________________________________________
“Chiropractic is the correct term for the collection of deceptions DD Palmer invented.”
Björn Geir Leifsson, MD
@BW wrote:
“Here’s a closer look at the content of that blog piece by Professor Ernst and why it’s relevant:
https://edzardernst.com/2015/02/phrenic-nerve-injury-a-rare-but-serious-complication-of-chiropractic-neck-manipulation/#comment-64573”
Reply to Bjorn Geir here:
https://edzardernst.com/2015/02/phrenic-nerve-injury-a-rare-but-serious-complication-of-chiropractic-neck-manipulation/#comment-64591
Harriet Hall’s blog is poor science trying to put spin on the systematic review and sidesteps the fact that the reviews authors are neurosurgeons and the POOR SCIENCE they discuss are medical case studies not chiropractic.
Imagine the outcry if chiropractors wrote this:
“In spite of the very weak data supporting an association between chiropractic neck manipulation and CAD, and even more modest data supporting a causal association, such a relationship is assumed by many clinicians. In fact, this idea seems to enjoy the status of medical DOGMA. Excellent peer reviewed publications frequently contain statements asserting a causal relationship between cervical manipulation and CAD [4,25,26]. We suggest that physicians should exercise caution in ascribing causation to associations in the absence of adequate and reliable data. Medical history offers many examples of relationships that were initially falsely assumed to be causal [27], and the relationship between CAD and chiropractic neck manipulation may need to be added to this list.”
The phrenic nerve blog is another classic example of what the neurosurgeons are discussing. The patient described to the doctor what the chiropractor did which was a bog standard levator scapulae stretch used by just about every profession. The doctor has the correct information yet makes an assumption, called it a chiropractic neck manipulation and wrote a poor case study. This poor quality paper is then published. This poor paper is then quoted by Radiopedia ascribing chiropractic neck manipulation to phrenic nerve injury (Edzard does the same) and it has now entered the realm of medical folk lore and dogma.
See the pattern Blue?
Then you wrote:
“One merely has to click on the link to the paper provided by Dr Hall and then click on the authors’ names below its title to read their credentials.”
Sadly Blue you and others just quote the blog as evidence or even worse read the abstract only without reading the full paper.
““Chiropractic is the correct term for the collection of deceptions DD Palmer invented.”
Björn Geir Leifsson, MD”
Thank you for making the point Blue that this echo chamber/blog/regular commenters use similar arguments as the vitalistic chiropractors “If it not subluxation then it’s not chiropractic”. The irony seems to escape you.
Both the vitalistic chiropractors and the critics are stuck in the past and resistant to change.
Again the irony seems to evade you.
Not unexpected though as it is human nature.
You have spent too much time making public statements on one extreme and are now locked in to defending them.
Well, you’ve spent too little time yourself editing this comment, dear, CC. You seem to be confusing comments and replies and are not making any sense..
Your not the first critic dear BG to split hairs over grammar.
Could a serious AE occur due to cSMT? Perhaps, if the person was predisposed to such an event or cSMT was not properly performed. That is why we have contraindications to cSMT and training.
“It is now thought that vertebral artery dissection is a multifactorial disease process where certain intrinsic factors are present in the setting of an exacerbating extrinsic factor such as a low speed car accident, direct trauma, heavy lifting, or a rotational sports injury.” The American Journal of Emergency Medicine, 16 November 2020
“Of the 134 cases, 60 (44.8%) were categorized as preventable, 14 (10.4%) were unpreventable and 60 (44.8%) were categorized as ‘unknown’. CSM was performed appropriately in 80.6% of cases.” J Man Manip Ther. 2012 May; 20(2): 66–74.
Hence, if someone doesn’t know what they are doing they could cause a serious AE. That is probably practitioner error, not procedural error.
DC wrote: “Could a serious AE occur due to cSMT? Perhaps, if the person was predisposed to such an event or cSMT was not properly performed. That is why we have contraindications to cSMT and training.”
@ DC
The bottom line is that the evidence of benefit for cSMT is pitiful and there are no reliable screening methods available to determine who might be predisposed to injury. Ergo, the Precautionary Principle applies (i.e. cervical spine manipulations should be viewed as too risky regardless of who does them).
Nonspecific neck pain, compared to what?
Exercise, Yoga, steriod injections? They all have been associated with VAD and really aren’t that effective.
NSAIDs? Not very good with known serious AE
Opioids? Yah, how did that pan out?
Nerve ablation? Darn sprouting and possible serious AE
Botox? Doesn’t seem to help and some possible serious AE
So, what do you purpose as the best approach to non specific neck pain, that with the best risk:benefit profile?
DC wrote: “So, what do you purpose as the best approach to non specific neck pain, that with the best risk:benefit profile?”
Coping tactics, including psychotherapy if required.
you mean stuff like this?
“Authors’ conclusions: With the exception of one trial, this review has not shown effectiveness for educational interventions, including advice to activate, advice on stress-coping skills, workplace ergonomics and self-care strategies.” https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD005106.pub4/full
DC wrote: “you mean stuff like this?”
What I mean is that patients should be fully informed about all treatments available (including coping strategies). Of course, being fully informed about treatments would need to include a thorough explanation of the chiropractic ‘bait and switch’:
https://sciencebasedmedicine.org/the-bait-and-switch-of-unscientific-medicine/
It’s also important to remember that healthcare doesn’t have the answers for everything, so some patients, unfortunately, after exhausting all interventions, will likely not find any relief for their pain.
“Active coping was not associated with recovery of neck pain or disability.”
Coping and recovery in whiplash-associated disorders: early use of passive coping strategies is associated with slower recovery of neck pain and pain-related disability
Linda J Carroll et al. Clin J Pain. 2014 Jan
I don’t think there is currently an optimal treatment for neck pain.
this, however, does not mean that SMT is ok.
accepting this wrong conclusion would only hinder our research to find one.
Current evidence suggests a two week/forth visit to determine if manual therapy is an appropriate intervention (below). If I recall NSAIDs and opioids have around a four day recommended usage with no certainty of alleviating the condition. Of course other interventions are not reversible (ablation, Botox, steroids injections, etc) which may or not help.
Pain collected shortly after completion of 6 weeks of study intervention predicted future pain the best. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4545558/
Being low-back pain free at the fourth visit was a strong predictor for being low-back pain free both at 3 months and 12 months. http://www.jmptonline.org/article/S0161-4754(04)00158-7/fulltext
Improvement at the fourth visit is a predictor of long-term outcome. https://www.ncbi.nlm.nih.gov/pubmed/?term=16182020
The results suggest there is a significant association between a within/between-session change after the second physiotherapy visit and discharge outcomes for pain and ODI in this sample of patients who received a manual therapy intervention. https://www.ncbi.nlm.nih.gov/pubmed/?term=22445052
Of the 115 patients in the most favorable prognostic group, 84% (95% confidence interval, 77-91) reported to be “definitely improved” by the 4th visit… https://www.ncbi.nlm.nih.gov/pubmed/12214186
Those who experienced a ≥33% pain reduction by 2 weeks had 6.98 (95% CI = 1.29, 37.53) times higher odds of 50% improvement on the GRoC and 4.74 (95% CI = 1.31, 17.17) times higher odds of 50% improvement on the ODI (at 6 months). Subjects who reported a ≥50% pain reduction at 2 weeks had 5.98 (95% CI = 1.56, 22.88) times higher odds of a 50% improvement in the GRoC and 3.99 (95% CI = 1.23, 12.88) times higher odds of a 50% improvement in the ODI (at 6 months). https://www.tandfonline.com/doi/full/10.1080/09593985.2017.1345025
DC wrote: “Current evidence suggests a two week/forth visit to determine if manual therapy is an appropriate intervention”
Even so, there’s still this to resolve with regard to chiropractic manual therapy:
“The chiropractic profession has a long history of internal conflict. Today, the division is between the ‘evidence-friendly’ faction that focuses on musculoskeletal problems based on a contemporary and evidence-based paradigm, and the ‘traditional’ group that subscribes to concepts such as ‘subluxation’ and the spine as the centre of good health. This difference is becoming increasingly obvious and problematic from both within and outside of the profession in light of the general acceptance of evidence-based practice as the basis for health care.”
Ref: ‘Chiropractic, one big unhappy family: better together or apart?’
https://chiromt.biomedcentral.com/articles/10.1186/s12998-018-0221-z
Red herring.
@ DC
The unvarnished truth:
“Chiropractic is perhaps the most common and egregious example of the bait and switch in medicine. The deception begins with the name itself – ‘chiropractic’ fails the basic test of transparency because it is not unambiguously defined…Therefore someone may go to see a chiropractor and think they will be seeing a medical professional who will treat their musculoskeletal symptoms, but in reality they will see the practitioner of a cult philosophy of energy healing.”
Ref https://sciencebasedmedicine.org/the-bait-and-switch-of-unscientific-medicine/
The topic was AE. I let it slide into evidence of benefit as the two are often considered together. You can either stick to the topic or move along.
DC wrote: “The topic was AE.”
Then here’s a timely reminder from Prof. Ernst’s post:
“the precautionary principle in healthcare would mean that neck manipulations should be considered unsafe until proven otherwise. Moreover, there is no good evidence for assuming that neck manipulation is an effective therapy for any medical condition. Thus, the risk-benefit balance for chiropractic neck manipulation fails to be positive”
NB. There are no reliable chiropractic adverse events reporting systems in the United States where the vast majority of chiropractors practice:
https://www.ebm-first.com/chiropractic/risks/1842-letter-from-britt-harwe-president-chiropractic-stroke-awareness-group-csag.html
A more comprehensive look at the problem here: https://edzardernst.com/2020/08/chiropractic-not-all-that-its-cracked-up-to-be/#comment-125800
Yep, and then you switched the topic…see your posts from Friday 15 January 2021 at 09:44 and Friday 15 January 2021 at 13:41. Red Herring.
If you don’t want to stick on topic, sobeit. But that doesn’t mean I have to address any topic you decide to bring up.
DC wrote: “Yep, and then you switched the topic…see your posts from Friday 15 January 2021 at 09:44 and Friday 15 January 2021 at 13:41. Red Herring. If you don’t want to stick on topic, sobeit. But that doesn’t mean I have to address any topic you decide to bring up.”
@ DC
What I wrote in those posts was very relevant to the topic in hand – i.e. when discussing the risk/benefit of chiropractic spinal manipulation it’s imperative to understand that many chiropractors mislead their customers with plausible-sounding interventions that, in reality, amount to little more than blatant quackery. In essence, here’s the problem:
QUOTE
“… chiropractic is based upon a vertebral subluxation theory that is generally categorized as supporting a belief system. The words ‘manipulation’ and ‘subluxation’ in a chiropractic context have meanings that are different from the meanings in evidence-based literature. An orthopedic subluxation, a partial dislocation or displacement of a joint, can sometimes benefit from manipulation or mobilization when there are joint-related symptoms. A chiropractic subluxation, however, is often an undetectable or asymptomatic ‘spinal lesion’ that is alleged to be a cause of disease. Such a subluxation, which has never been proven to exist, is ‘adjusted’ by chiropractors, who manipulate the spine to restore and maintain health. The reasons for use of manipulation/mobilization by an evidence-based manual therapist are not the same as the reason for use of adjustment/manipulation by most chiropractors. Only evidence-based chiropractors, who have renounced subluxation dogma, can be part of a team that would research the effects of manipulation without bias.”
Ref: http://jmmtonline.com/documents/HomolaV14N2E.pdf
I have yet to see a chiropractor regulator issue widespread information about the above to the general public.
Another red herring. The blog was about AE and SMT. A brief mention was made of benefit.
As he wrote…
“A 2017 systematic review identified the characteristics of AEs occurring after cervical spinal manipulation or cervical mobilization. A total of 227 cases were found; 66% of them had been treated by chiropractors. Manipulation was reported in 95% of the cases, and NECK PAIN was the most frequent indication for the treatment.” (Emphasis added).
DC wrote on Friday 15 January 2021 at 13:58 : “The topic was AE. I let it slide into evidence of benefit as the two are often considered together. You can either stick to the topic or move along.”
@ DC
You seem to be trying to defend the indefensible – i.e. don’t adverse events associated with spinal manipulation have to be viewed in the context of benefit?
Again, here’s the problem:
“The reasons for use of manipulation/mobilization by an evidence-based manual therapist are not the same as the reason for use of adjustment/manipulation *by most chiropractors*.”
Ref: http://jmmtonline.com/documents/HomolaV14N2E.pdf
Where’s the benefit in an intervention that’s based on pure quackery? IOW, isn’t it unethical for ‘most chiropractors’ to administer neck manipulations based on their belief in traditional subluxation-based chiropractic? IMO, chiropractors cannot have a place at the science-based table until they clean up their house, and even then the evidence of benefit for neck manipulation would likely remain vanishingly slim or become non-existent.
“don’t adverse events associated with spinal manipulation have to be viewed in the context of benefit?”
Clarity on true risk needs to be established based upon the evidence that is currently available.
Granted if there is no clinical benefit then the answer is simple. This does not appear to be the case.
Since the primary topic of this blog was AE, that is my focus.
DC wrote: “Clarity on true risk needs to be established based upon the evidence that is currently available.”
@ DC
‘Clarity’ on true risk? But we don’t know the true risk. With no reliable AE reporting systems in place and hundreds of case reports of serious injuries on record, the current evidence is likely to be misleading – ergo, the Precautionary Principle applies.
The precautionary rule isn’t as cut and dry as you make it appear…
Examples:
“Although most experts agree that the precautionary principle does not call for specific measures (such as a ban or reversal of the burden of proof), opinions are divided on the method for determining when to apply precautionary measures.” https://www.europarl.europa.eu/thinktank/en/document.html?reference=EPRS_IDA(2015)573876
“The precautionary principle is a useful strategy for decision-making when physicians and patients lack evidence relating to the potential outcomes associated with various choices. According to a version of the principle defended here, one should take reasonable measures to avoid threats that are serious and plausible. The reasonableness of a response to a threat depends on several factors, including benefit vs. harm, realism, proportionality, and consistency.” J Med Philos. 2004 Jun.
“The precautionary principle does play a role in health care, but it should never rule medical decision making as an absolute principle.” Toxicol Appl Pharmacol. 2005.
“This paper recommends against the use of the precautionary principle as a decision rule in medical decision making, based on an impossibility theorem presented in Peterson (2005).” Journal of Medical Ethics 2007;33:5-10.
DC wrote: “The precautionary rule isn’t as cut and dry as you make it appear…”
@ DC
This is the Precautionary Principle’s general message:
“The precautionary principle demands that we ‘err on the safe side’. This means taking anecdotes seriously in relation to safety issues while taking them with a pinch of salt when evaluating efficacy or effectiveness.”
Ref: https://www.pulsetoday.co.uk/news/uncategorised/anecdotal-evidence/
In view of the above, you need to address the following for readers who may be unaware of the chiropractic ‘bait and switch’*:
“The reasons for use of manipulation/mobilization by an evidence-based manual therapist are not the same as the reason for use of adjustment/manipulation by MOST chiropractors.”
Ref: http://jmmtonline.com/documents/HomolaV14N2E.pdf
*See https://sciencebasedmedicine.org/the-bait-and-switch-of-unscientific-medicine/
“In view of the above, you need to address the following for readers who may be unaware of the chiropractic ‘bait and switch’*:”
Do you have evidence that this “bait and switch” increases the odds of having a serious AE?
Clarity based upon the evidence we have avaliable.
The greatest true risk appears to be when cSMT is done in the presence of contraindications to cSMT. This is shown in many of the case reports.
“Conclusions: This review showed that, if all contraindications and red flags were ruled out, there was
potential for a clinician to prevent (at least) 44.8% of AEs associated with CSM. Journal of Manual and Manipulative Therapy 2012 VOL. 20 NO. 2
And based upon published case reports and utilization percentage who appears to put these patients at greatest risk? PTs and MDs.
But when you have 35% of PT schools that dont even teach cSMT, leaving therapists to take questionable weekend classes, it may be part of the reason. J Man Manip Ther. 2017 May; 25(2): 74–82.
Of course there is the topic of VA strain, pre-existing condition, proper technique, etc.
So yes, clarity.
DC wrote: ““Conclusions: This review showed that, if all contraindications and red flags were ruled out, there was potential for a clinician to prevent (at least) 44.8% of AEs associated with CSM. Journal of Manual and Manipulative Therapy 2012 VOL. 20 NO. 2”
@ DC
So it’s fingers crossed for 55.2%?
“So it’s fingers crossed for 55.2%?”
No. Many of the case reports didn’t report enough information to know if a contraindication was present or not. i.e. poorly written case report.
Recent study in the Netherlands puts physio’s performing HVLA (Maitland Grade 5) neck manipulations at around 30% of the profession. Physio’s are also told not to perform Grade 5 manipulations without proper training. Since there are 4 times as many physio’s as chiro’s this would indicate that many physio’s are jumping on the HVLA bandwagon without adequate training.
They discuss it in Physiopedia here:
https://www.physio-pedia.com/Maitland%27s_Mobilisations
“**A 5th grade is possible but further training will be required to perform safely**”
Even then any physio adverse events are unlikely to get reported. Just read this article:
https://www.abc.net.au/news/2019-08-05/concerns-over-the-rise-of-resistant-superbugs/11377930
“Mr Fox had developed a clot on his brain following a neck manipulation by a physiotherapist, officially known as a carotid artery dissection.”
One line then ignored. Imagine the outcry from Blue Wode and Co if it had been a chiro.
You would have been splashing it all over social media/internet/blogs etc.
Pointed this out to Edzard and Blue Wode on Twitter at the time of this articles publication and guess what the response was? Crickets. Says it all.
DC wrote: “Many of the case reports didn’t report enough information to know if a contraindication was present or not. i.e. poorly written case report.”
All the more reason to err on the side of caution then. NB. There are no reliable screening methods to determine who might be predisposed to an adverse event arising from neck manipulation.
“There are no reliable screening methods to determine who might be predisposed to an adverse event arising from neck manipulation.”
Its called identifying contraindications and red flags…that will usually eliminate almost every serious AE.
DC wrote: “Do you have evidence that this ‘bait and switch’ increases the odds of having a serious AE?”
@ DC with reference to this:
QUOTE
“Chiropractors view the spine as an entity. Where they diagnose ‘subluxations’, they will normally manipulate and ‘adjust’ them (11). And ‘subluxations’ will be diagnosed in the upper spine, even if the patient suffers from back pain. Thus many, if not most back pain patients receive upper spinal manipulations. It follows that the risks of this treatment should be included in any adequate risk assessment.”
Ref: Spinal manipulation for the early management of persistent non-specific low back pain — a critique of the recent NICE guidelines, Edzard Ernst, Int J Clin Pract (18th August 2009). Reference (11) is Ernst E. Chiropractic: a critical evaluation. J Pain Sympt Man 2008; 35: 544–62. Page 6 of the paper mentions a report that indicates that only 11% of all cervical manipulations are “appropriate” and gives the reference Coulter I, Hurwitz E, Adams A, et al. The appropriateness of manipulation and mobilization of the cervical spine. Santa Monica, CA: RAND, 1996:18e43.
It would seem that a very high percentage of serious adverse events will be caused by chiropractic interventions that are not based on scientific evidence.
I wrote odds, not incidence.
Also, i dont think you understand bait and switch as it applies to chiropractic.
@ DC
Please explain your understanding of the bait and switch as it applies to chiropractic.
This would be an example
“I spent 3 years going to a Maximized Living chiropractor. I consider it cult-like. He claimed he could fix any ailment, incuding my MS. I initially went to see him for chronic headaches and neck pain. I quit. I never , ever felt the slightest improvement and he made me feel guilty that I was not better even though I followed the “program”. There was constant pressure to buy supplements, cookbooks and more. I felt very uncomfortable and hustled the longer I saw him. Now , when I see him at social events , he pretends he doesn’t know me.”
https://community.qvc.com/t5/Wellness/Anyone-Experienced-quot-Maximized-Living-quot-Chiropractic/td-p/2863877
They often use the new patient bait of $49 for exam, x ray and treatment for low back or neck pain but with the purpose of selling you on expensive treatments or products.
@ DC
Is that the best you can come up with? This exchange with you is becoming like previous exchanges with you – i.e. repetitive. For example, see here:
https://edzardernst.com/2019/04/a-risk-benefit-assessment-of-chiropractic-neck-manipulation/#comment-112602
BTW, it’s been over two years and you still haven’t answered my question here:
https://edzardernst.com/2018/11/chiropractic-the-area-of-bogus-healthcare-where-pseudo-research-keeps-on-coming/#comment-106998
The topic is AE. It’s becoming laborious to try to keep you on topic.
It appears you think doing cSMT on an asymptomatic patient increases the odds of a serious AE compared to a symptomatic person. You may want to rethink that position.
DC wrote: “The topic is AE.”
Indeed it is, so let’s return some of the more salient points in Prof. Ernst’s post above:
QUOTE
“…the risk-benefit balance for chiropractic neck manipulation fails to be positive… This review is focussed on deaths after chiropractic, yet neck manipulations are, of course, used by other healthcare professionals as well. The reason for this focus is simple: chiropractors are more frequently associated with serious manipulation-related adverse effects than osteopaths, physiotherapists, doctors or other professionals… [NB. There are far more physiotherapists than chiropractors] …The vast majority of these cases were associated with chiropractic and none with physiotherapy. The most obvious explanation for the dominance of chiropractic is that chiropractors routinely employ high-velocity, short-lever thrusts on the upper spine with a rotational element, while the other healthcare professionals use them much more sparingly… To sum up… chiropractic SMT can cause a wide range of very serious complications which occasionally can even be fatal. As there is no AE reporting system of such events, we nobody can be sure how frequently they occur.”
I think it’s important here to remind readers that ‘DC’ earns a living as a chiropractor and Prof. Ernst is an expert in alternative medicine from a scientific viewpoint and has been trained in spinal manipulation (bio here https://edzardernst.com/about/ ).
IOW, there’s an obvious reason why ‘DC’ wouldn’t want the above quote to be true.
“chiropractic SMT can cause a wide range of very serious complications which occasionally can even be fatal.”
Ah yes…causation. That will lead us to true risk and the factors behind it.
“there’s an obvious reason why ‘DC’ wouldn’t want the above quote to be true.”
How about we stick to the facts and available evidence and leave the personal assumptions and attacks to lesser people.
@ DC
A chiropractor confesses:
“…if [I] were to tell patients that ‘I can kill you’, then ‘half of them would walk out’…”
Ref: http://www.ebm-first.com/chiropractic/risks/464-amani-oakleys-closing-in-the-lana-dale-lewis-inquest.html
That’s your “evidence” that I don’t want the quote to be true? Don’t waste my time.
Critical_Chiro quoted on Sunday 17 January 2021 at 23:33 : “Mr Fox had developed a clot on his brain following a neck manipulation by a physiotherapist, officially known as a carotid artery dissection” and then wrote: “Imagine the outcry from Blue Wode and Co if it had been a chiro. You would have been splashing it all over social media/internet/blogs etc. Pointed this out to Edzard and Blue Wode on Twitter at the time of this articles publication and guess what the response was? Crickets. Says it all.”
@ Critical Chiro
How disingenuous of you. I did reply to you on twitter:
https://twitter.com/Blue_Wode/status/1174242265306456069
how polite of you to call a lie ‘disingenuous’!
DC wrote on Sunday 17 January 2021 at 20:55: “The topic is AE. It’s becoming laborious to try to keep you on topic. It appears you think doing cSMT on an asymptomatic patient increases the odds of a serious AE compared to a symptomatic person. You may want to rethink that position.”
@ DC
You confirmed to me in April 2019 that Medicare only paid for manual manipulation of the spine to correct subluxations:
https://edzardernst.com/2019/04/chiropractic-its-the-money-stupid/#comment-111807
And that still seems to be the case:
https://www.medicare.gov/coverage/chiropractic-services#:~:text=Medicare%20Part%20B%20(Medical%20Insurance,necessary%20to%20correct%20a%20Subluxation
Ergo, as we’ve long been told that only chiropractors are able to detect and correct chiropractic ‘subluxations’, it suggests to me that cSMT on asymptomatic patients *would* increase the odds of serious AEs compared to chiropractic symptomatic patients because a subluxation-based chiropractor’s ‘symptomatic’ patient would be considered by medical science to be ‘asymptomatic’ .
IOW, it seems that patients who are ‘symptomatic’ are actually ‘asymptomatic’ when cSMT is used to correct mythical chiropractic subluxations – so it’s all risk and no benefit for them.
No, it may increase the incidence but not the odds.
“It is now thought that vertebral artery dissection is a multifactorial disease process where certain intrinsic factors are present in the setting of an exacerbating extrinsic factor…”
The American Journal of Emergency Medicine. 16 November 2020
DC wrote: “It is now thought that vertebral artery dissection is a multifactorial disease process where certain intrinsic factors are present in the setting of an exacerbating extrinsic factor…” (The American Journal of Emergency Medicine. 16 November 2020)
@ DC
Your quote is lifted from a case report:
‘Delayed vertebral artery dissection after mild trauma in a motor vehicle collision’
Abstract
Vertebral artery dissection can be insidious and is a leading cause of stroke in young patients, second only behind cardioembolic events [1]. We present the case of a 42-year-old patient who presented to the emergency department with diaphoresis and a complaint of neck pain one month after a low speed motor vehicle collision. The patient was transferred to a stroke center where cerebral angiography showed severe vertebral artery stenosis with likelihood of dissection after a noncontrast CT was negative for hemorrhage. She was definitively treated with antiplatelet therapy and discharged to rehab. By reviewing the most recent literature, we better define this illness. Most commonly, patients with arterial dissection present with head or neck pain, stroke, and Horner syndrome. It is now thought that vertebral artery dissection is a multifactorial disease process where certain intrinsic factors are present in the setting of an exacerbating extrinsic factor such as a low speed car accident, direct trauma, heavy lifting, or a rotational sports injury. And while our patient was treated with antiplatelet therapy and intravascular intervention, vertebral artery dissection is rare and further research is required to better guide treatment as there is no definitive data showing superiority of either anticoagulation or antiplatelet pharmaceutics.
Ref. https://pubmed.ncbi.nlm.nih.gov/33298350/
Once again, here is your original quote, but this time in more context: “It is now thought that vertebral artery dissection is a multifactorial disease process where certain intrinsic factors are present in the setting of an exacerbating extrinsic factor such as a low speed car accident, direct trauma, heavy lifting, or a rotational sports injury.”
As cervical spine manipulation is a form of direct trauma, it follows that chiropractors are an exacerbating extrinsic factor.
To sum up: I’m sure that rational readers looking in on the above exchanges would by now have arrived at the conclusion that they’d definitely not visit a chiropractor if they were suffering from neck pain (or anything else for that matter).
“As cervical spine manipulation is a form of direct trauma…”
Evidence that a properly performed cSMT on a patient without contraindications is a form of “direct trauma” particularly to the VA?
@ DC
Manipulation of the cervical spine usually involves a high-velocity rotational thrust that places the blood vessels in the neck under abnormal stress. Further, the rate of the vertebral joint *displacement* during the thrust does not allow the patient to prevent joint movement. Therefore, IMO, such an action is consistent with direct trauma.
FYI, I’m not engaging you with your games any more DC.
So you have no evidence to back your claim but i am accused of playing games. Got it.
“VA strains obtained during SMT are significantly smaller than those obtained during diagnostic and range of motion testing,…” W Herzog et al. J Electromyogr Kinesiol. 2012 Oct
“This study provides new evidence that peak strain in the vertebral artery may not occur at the end range of motion, but rather at some intermediate point during the head and neck motion.” Steven L Piper et al. Clin Biomech (Bristol, Avon). 2014 Dec.
“Chiropractic manipulation of the neck did not cause strains to the ICA in excess of those experienced during normal everyday movements.” JMPT. VOLUME 38, ISSUE 9, P664-671, NOVEMBER 01, 2015
“SMT resulted in strains to the VA that were almost an order of magnitude lower than the strains required to mechanically disrupt it.” Journal of Manipulative and Physiological Therapeutics Volume 25, Issue 8, October 2002, Pages 504-510.