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

I have reported about the risks of chiropractic manipulation many times before. This is not because, as some seem to believe, I have an axe to grind but because the subject is important. This week, another case of stroke after chiropractic manipulation was in the news. Some will surely say that it is alarmist to mention such reports which lack lots of crucial details. Yet, as long as chiropractors do not establish a proper monitoring system where serious adverse effects of spinal manipulation are noted, I think it is important to record even incomplete cases in this fashion.

Barbara Shand is a working mom who lives in Alberta, Canada. She went to see a chiropractor because she had neck pain. “Near the very end of the appointment, the chiropractor asked: ‘Do you want your neck adjusted?’ I said: ‘Sure.’” “As soon as she did it, everything went black,” Shand recalls.

The patient was then rushed to a hospital by ambulance. “When I did open my eyes, I couldn’t focus. It was all blurry, I had massive vertigo, I didn’t know what was up or down,” Shand told the journalist. The diagnosis, Shand explains, was a right vertebral artery dissection, followed by a stroke. Mrs. Sands continues to struggle with coordination and balance.

The Alberta College and Association of Chiropractors acknowledges “there have been reported cases of stroke associated with visits to various healthcare practitioners, including those that provide cervical spine manipulation.” But they claim it is rare. They did not comment on the informed consent which, according to Shand’s description, was more than incomplete.

The fact that the ACAC admits that such events have happened before is laudable and a step in the right direction (some chiropractic organizations don’t even go that far). Yet, their caveat that such cases are rare is problematic. Without a monitoring system, nobody can tell how frequent they are! What we do see is merely the tip of a much bigger iceberg. There have been hundreds of cases like Mrs. Shand. The truth of the matter is this: Chiropractic neck manipulations are not supported by sound evidence of effectiveness for any condition. This means that even rare risks (if they are truly rare) would tilt the risk/benefit balance into the negative.

The conclusion is, I think, to avoid neck manipulations at all costs. Or, as one neurologist once put it:

don’t let the buggars touch your neck!

21 Responses to “As soon as the chiropractor manipulated my neck, everything went black”

  • CHIROPRACTIC IS NOT WITHOUT DANGERS — The Oakland Tribune 4-17-93

    I’m a 36-year-old woman. One week ago I had a stiff neck and went to a chiropractor. Immediately after he aligned my neck, the right side of my lips and cheek went numb and I felt dizzy. I told the chiropractor of the problem but he sent me home. Within 90 minutes I began falling and vomiting. I returned to the chiropractor and he said this has happened before and I’d be fine. I was hospitalized and it was found that the cervical manipulation had ruptured an artery in my neck and caused a stroke. Now I am taking blood thinners and in several months my neurologist will determine if I need surgery to repair the artery. How often does this happen? Should my chiropractor have recognized the symptoms?

    • Fortunately, we have higher level evidence and don’t have to rely on a 28 year old newspaper story.

      • Fortunately, we have higher level evidence and don’t have to rely on a 28 year old newspaper story.

        “Fortunately, we have higher levels of evidence?”

        “We,” DC? “Levels of evidence?” Evidence of what, DC?

        This 28 year old article provides the same “level of evidence” about “chiropractic” and chiropractors that you provide each and every time you post here … 28 years later.

        There’s nothing new when it comes to a chiropractic meatball. Can you provide any evidence that argues otherwise? You haven’t, so far.

        ~TEO.

  • Almost anything is better than a 28 year old newspaper story. Start with Church, et al. Cureus. 2016 Feb; 8(2): e498.

  • DC wrote on Monday 24 May 2021 at 20:15 “Still high level evidence than a poorly written newspaper story from 28 years ago.”

    @ DC

    Evidently you require a refresher from the link I gave you – i.e. https://edzardernst.com/2020/08/chiropractic-not-all-that-its-cracked-up-to-be/#comment-125747

    Here is what Dr Hall, the author, also says in it:

    QUOTE
    “I certainly agree that there is no definitive evidence for causation, but I think there is evidence to support a strong enough *probability* of causation to constitute a good reason to avoid neck manipulation.

    – snip –

    Flaws in the study’s Discussion section
    Here’s where it really becomes problematic. They report that they found a small association between chiropractic care and cervical artery dissection, but then they discount their own finding and try to rationalize it away. They say the evidence is low quality; I agree. They say they found no evidence of causation; I agree. But then they try to say there is no convincing evidence of even the *association* that they themselves found.

    They found no evidence for causation. On the other hand, they found no evidence *against * it.

    They say they are concerned that a false belief in a causal connection ‘may have significant adverse effects such as numerous episodes of litigation’. On the other hand, a lack of belief might prevent justified litigation where patients were harmed or killed.

    They say neck pain and headache are confounders. They say patients with headache and neck pain more frequently visit chiropractors, and patients with cervical artery dissection more frequently have neck pain and headache, so the appearance of more cervical artery dissections after visits to chiropractors is spurious. They say the Cassidy study showed that visits to a primary care provider or a chiropractor were likely to be due to pain from an existing dissection. It did not. There is absolutely no evidence to support that speculation.

    In fact, there are numerous ‘smoking gun’ cases where patients consulted a chiropractor not for neck pain or headache, but for pain in parts of the body below the neck, such as shoulder pain or tailbone pain, and developed stroke symptoms on the chiropractor’s table at the time of neck manipulation. Sandra Nette had no pain at all; she felt fine and let the chiropractor manipulate her neck only because she falsely believed that regular maintenance adjustments were an effective means of keeping her healthy.

    They fail to even mention the smoking gun cases or the evidence that the incidence of stroke rises with the proximity to the time of manipulation.

    They make a big deal of Hill’s criteria for assigning causation to association. With a rare condition like VBA dissection, and with the characteristics of this condition, it would be very difficult to fulfil all of Hill’s criteria. We may never see that kind of proof, so we must rely on lesser quality evidence.

    They cite cadaver studies to claim that SMT doesn’t place significant strain on the vertebral artery. And yet we know that very small strains can cause strokes in susceptible live patients. ‘Shampoo strokes’ have been reported after hyperextension of the neck at beauty parlors.

    Other considerations
    The indications for neck manipulation are questionable. Upper cervical (NUCCA) chiropractors do neck manipulations on every patient, no matter what the complaint. Some chiropractors do neck manipulations for somatovisceral conditions rather than just for musculoskeletal conditions. Whatever the indications, chiropractors certainly have no business doing neck manipulations on a patient with an existing dissection, and they have not shown that they can reliably diagnose a stroke in progress. There are no tests to reliably identify patients at risk of dissection.

    Underreporting is a problem. If a dissection is temporarily sealed by a clot that breaks loose several hours or days later, the connection with manipulation may be missed. Patients may never return to the chiropractor. I heard of at least one case where a patient developed stroke symptoms immediately following manipulation, was hospitalized for a disastrous stroke, and never let the chiropractor know what had happened.

    Edzard Ernst weighs in
    Edzard Ernst reported on a case of a man who had a stroke following chiropractic manipulation for chronic neck pain. *Chronic*, not a new symptom suggesting a stroke in progress. He also reported on a case of phrenic nerve injury from neck manipulation.

    Ernst commented:
     There is no effective monitoring scheme to adequately record serious side-effects of chiropractic care.
     Therefore the incidence figures of such catastrophic events are currently still anyone’s guess.
     Publications by chiropractic interest groups seemingly denying this point are all fatally flawed.
     It is not far-fetched to fear that under-reporting of serious complications is huge.
     The reliable evidence fails to demonstrate that neck manipulations generate more good than harm.
     Until sound evidence is available, the precautionary principle leads most critical thinkers to conclude that neck manipulations have no place in routine health care.

    The American Heart Association and American Stroke Association agree. They were concerned enough about the apparent association to have issued a joint scientific statement warning about it and recommending that patients be informed of the possible risk prior to manipulation.

    Bottom line: A double standard

    Edzard Ernst has said:
    ‘Imagine a conventional therapy about which the current Cochrane review says that it has no proven effect for the condition in question. Imagine further that this therapy causes mild to moderate adverse effects in about 50% of all patients in addition to very dramatic complications which are probably rare but, as no monitoring system exists, of unknown frequency…’

    Now I ask you to imagine that there is a pharmaceutical drug that fits this description. Imagine that there are the same numbers of studies showing an association of that drug with a deadly side effect like stroke or death. The FDA would pull it off the market; they wouldn’t wait for definite evidence of causation that fulfilled all of Hill’s criteria. And I think the people who are making excuses for neck manipulation would want them to take that drug off the market. I don’t think they would want to take such a drug. I wouldn’t risk taking a drug like that, and I wouldn’t risk neck manipulation.”

    Ref: https://sciencebasedmedicine.org/chiropractic-and-stroke-no-evidence-for-causation-but-still-reason-for-concern/

    @ DC

    Are you able to tell us if Dr Hall, the author of that piece, is for, against, or undecided, regarding neck manipulation? Does she think patients should have it, or should avoid it?

    • Dr Hall is free to have her opinion…whatever it may be. But it doesn’t change her statement…

      ”They say they found no evidence of causation; I agree.”

      • If your intention was to support the original blog you need to do better than a 28 year old newspaper story. You are failing.

        Oh, I disagree, DC. My claim is that you are an average meatball chiropractor. Not a complicated assertion. Your posts to this “original blog” provide more than ample evidence to support this claim. That you don’t see this, never mind appreciate it, is just a matter of being still another chiropractic fish swimming in chiropractic waters.

        You can argue that this is just my opinion and you’d be right … but an expert one, it is. It’s not like there have been studies. Yet, you object to my characterization that you are a chiropractic meatball even as you do your level best to rationalize a “chiropractic” with each and every post. Case closed.

        DC for the defense, your Honor.”

        BTW, posting that 28 year old Oakland Tribune article is quite perfect when it comes to gaining more insight into chiropractors and “chiropractic” … in this case, related to any discussion of chiropractors and stroke. Not that you’d notice, but it’s a story that perfectly illustrates the empty chiropractic enthusiasm of a chiropractor “adjusting,” an absolutely stunning level of denial that they had possibly caused a stroke, their inability to recognize an evolving stroke when they see one, and (god bless her) the chiropractic patient who innocently asks, “Should my chiropractor have recognized the symptoms?”

        Does this article provide evidence that chiropractic neck cracking can cause a stroke? I never would claim that it does. I’ll only offer what I just said about what the article does provide and note that 28 years later, a chiropractor who would actually respond with a protestation that, “We have higher levels of evidence” (proving chiropractors hardly ever cause strokes) is evidence of my assertion that you are, indeed, a chiropractic meatball.

        Resistance only causes pain, DC.

        ~TEO.

      • DC: Dr Hall is free to have her opinion…whatever it may be. But it doesn’t change her statement… ”They say they found no evidence of causation; I agree.”

        You know, when you’re up to your ears in chiropractic doobleck, you _really_ shouldn’t open your mouth.

        That said, I realize you can’t help yourself when your chiropractic identity is at stake … anymore than I couldn’t help from pointing to the open fly in the chiropractic profession’s pants ever since I wandered onto the internet in 1993 and noted that cracking the synovial type joints of the spine does not a medicine make anymore than cracking your knuckles does.

        But hey … as a chiropractor selling the Chiropractic Dream, you’re “free to have [YOUR] opinion” … just like Dr Hall. You’d hope, however, that after more than 100 years of chiropractic dalmatians, chiropractors would have more than their self-serving opinion and say-so to show for themselves … at least enough to justify an entire and separate profession dedicated to spinal “knucke-cracking,” that is.

        Let me ask, 28 years later, what your name is and where you practice? I’m assuming your DC moniker references “Doctor of Chiropractic” and not your initials. You ARE a chiropractor, aren’t you? What would be the problem with identifying yourself? Perhaps you have a WEB page participants here can visit.

        Are you embarrassed? 🙂

        ~TEO.

        • No embarrassment. I am just protecting my family. We had threats of violence in the past from on-line wackos.

          • big deal!
            I had death threats and still do not hide behind a pseudonym

          • Did they threatened to physically harm your disabled daughter?

            Besides, what different does it make who I am? Lets just deal with the evidence or lack there of.

          • Incidentally, how does the date of that Oakland Tribune article change the nightmarish chiropractic tale it tells? The date is quite irrelevant. The fact of the matter is, it could have been this very morning in a chiropractic office somewhere in the USA. A patient goes to a chiropractor with a stiff neck and the chiropractor cracks their neck … “to make it unstiff,” the chiropractor might think to themselves as they give them “thuh” Adjustment.

            But this never happens 🙂

            So, what’s different, really. Well, nothing. Compare this to what’s posted here: “As soon as the chiropractor manipulated my neck, everything went black.” That’s last week, DC.

            So, let’s read and review what happened _without_ the date:

            I had a stiff neck and went to a chiropractor. Immediately after he aligned my neck, the right side of my lips and cheek went numb and I felt dizzy. I told the chiropractor of the problem but he sent me home. Within 90 minutes I began falling and vomiting. I returned to the chiropractor and he said this has happened before and I’d be fine. I was hospitalized and it was found that the cervical manipulation had ruptured an artery in my neck and caused a stroke.

            You can, as you clumsily tried to do, argue that this is just anecdotal. At least that’s my best translation of you might mean by “We have a higher level of evidence” … to which I asked “Who’s we” and “Evidence of what?” You’re so crippled by your “chiropractic,” you couldn’t even answer this.

            DC for the defense, your Honor!” 🙂

            I don’t know where you are in your chiropractic trajectory and I long ago stopped helping chiropractors find their way out of their chiropractic entanglements … which I admit are quite significant and challenging. So, it’s likely I’ll leave you alone with your “chiropractic” unless I hear a clear cry for help … which I’m fairly confident you won’t offer given your resistance to insight into your own chiropractic situation … which sounds grave given your compensatory need to rationalize what you think, say, and do as a chiropractor.

            DC for the defense, your Honor!” 🙂

            I realize this is all too challenging for a chiropractic meatball. I’m sorry for that. And I appreciate you wanting to maintain anonymity for this reason. I still would encourage you to come clean with yourself and your chiropractic predicament. The first step is always a simple acknowledgement.

            DC: No embarrassment. I am just protecting my family. We had threats of violence in the past from on-line wackos.

            Well, this is certainly complete baloney. The only “family” you’re protecting now are your own “family jewels” by covering a chiropractic crotch.

            It’s true that whistleblowers and truth tellers can get threats and perhaps, in the criminal world on TV, I’ve seen bad guys threaten someone’s _family_ as a way of getting someone to do what they want them to do. But in the world of chiropractic, you are certainly not a whistleblower and I would argue, by misrepresenting the nature of the chiropractic beast, not really a truth teller, either. Quite the contrary, in fact.

            DC for the defense, your Honor!” 🙂

            Edzard: big deal! I had death threats and still do not hide behind a pseudonym

            DC: Did they threatened to physically harm your disabled daughter?

            Besides, what different does it make who I am? Lets just deal with the evidence or lack there of.

            YIKES! You don’t even see how much you’re contorting yourself to keep your chiropractic boat afloat. Really, you go WAY too far.

            Now, you’re actually asking with a straight face, “What difference does it make who [you are]?” Well, in my case, because I DO represent what’s considered controversial positions WRT “chiropractic” and AltMed, I feel I owe this level of honesty and straightforwardness to those at whom my criticism is directed. This makes me and my arguments more credible. I’m not up to something. I’m not hiding.

            Given your apparently completely banal relationship to “chiropractic,” the very idea that you’re hiding-out and being anonymous to protect your disabled child is preposterous.

            By the way, you might have at _least_ said something about cultism and “chiropractic” which is very real and one of the main reasons those who are not of “The Chiropractic Body” are often reviled and on rare occasions threatened.

            I was once told by the late Bob Dubin, DC, former President of the California Chiropractic Association and Chiropractor of the Century, that he was from Brooklyn and that I should never find myself alone with him in a dark alley. That’s called chiropractic bluster … also real and interesting, psychiropractically, that is.

            ~TEO.

          • And it is because of people like you that I don’t reveal my identity.

          • DC: And it is because of people like you that I don’t reveal my identity.

            Let me suggest that you avoid comments that include the phrase “people like you” without fully explaining what “kind” of people you’re referencing. It really doesn’t sound good.

            People like me, huh …

            In fairness, I’ve been perfectly clear about what _kind_ of chiropractor I’m referencing when I refer to the chiropractic meatball. Admittedly, I have a judgment about this sort of chiropractor and I apologize if I was too hard on you personally. If it helps at all, think of the meatball chiropractor as a garden-variety practitioner … a run-of-the-mill or AVERAGE chiropractor who looks to the chiropractic spine first and foremost to resolve the back and neck pain of their patients. That shouldn’t bother you, should it? Aren’t you a regular chiropractor? If not, what makes you and your practice different from that your colleagues?

            WRT to the topic of this thread … or ANY topic where a chiropractor feels or thinks they’re being criticized for that matter, chiropractors respond very poorly … typically defensively, and too often, incoherently. In short, chiropractors don’t take criticism very well. There’s history related to being quacks and second, third, and fourth class healthcare citizens that accounts for this defensive and compensatory behavior in the face of criticism, but it really doesn’t look good when you see a chiropractor looking for a little oxygen to sustain the Chiropractic Organism.

            That’s what the “DC for the defense” that I see is all about. In case you hadn’t noticed, Edzard’s site tends to be critical of SCAM (so-called alternative medicine). So, it shouldn’t surprise you that “chiropractic” (what chiropractors think, say, and do) along with homeopathy and Traditional Chinese Medicine, for example, is more than frequently discussed here. So, no one is saying you have to join in this criticism, but rushing to the defense of the “chiropractic” is exactly what a garden variety chiropractor does whenever it looks like some of their oobleck is leaking onto the bioscientific carpet of a site like this one.

            This particular thread’s “leak” relates to the relationship of neck cracking and stroke. Chiropractors routinely crack necks. Edzard’s post more than suggests that chiropractors have never taken responsibility for this stroke potential. This is like impossible to argue with. Yet, you do. Your defensive argument exists somewhere between “It could happen to anyone” and “It’s not as bad as Edzard suggests” instead of saying without hesitation, “Exactly, that goes without saying.” Of course, you can always “bivouac and reconnoiter” The Chiropractic Team to a defended position by arguing, “Well, that’s just your opinion” … as you actually did after reading Harriet Hall’s cogent piece. That’s just more “DC for the defense, you Honor,” as far as I can tell.

            Again, I’m not saying you have to jump on the critical of “chiropractic” band-wagon. But you should, in my opinion, own up to and take responsibility for chiropractic’s well deserved black eye instead of rushing to the defense. That involves considerably more than denouncing your chiropractic antler dancing colleagues and tin-foil hat-wearing chiropractic dopes. They are just the identified patient in a sick chiropractic family … their raw chiropractism having morphed into manipulable lesions and spinal dysfunctions, chiropractic roses by another name. In other words, what an ordinary garden variety chiropractor treats. What do you treat, for example, and how do you treat it?

            As to revealing your identity, posting anonymously is certainly your business. It’s not nearly as important as what you say here and it’s not a list requirement. I still think it behooves you to be straight-up with who you are personally and professionally. That begins with, “Hello, my name is […] and I’m a chiropractor.” But, you do what you want, of course.

            ~TEO.

          • John: If you wish to discuss a paper from one of Ernst blogs, i asked a question here that has yet to receive an answer.

            https://edzardernst.com/2021/05/chiropractic-manipulations-are-a-risk-factor-for-vertebral-artery-dissections/#comment-131719

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