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

On this blog, I have been regularly discussing the risks of so-called alternative medicine (SCAM). In particular, I have often been writing about the risks of chiropractic spinal manipulations.

Why?

Some claim because I have an ax to grind – and, in a way, they are correct: I do feel strongly that consumers should be warned about the risks of all types of SCAM, and when it comes to direct risks, chiropractic happens to feature prominently.

But it’s all based on case reports which are never conclusive and usually not even well done.

This often-voiced chiropractic defense is, of course, is only partly true. But even if it were entirely correct, it would beg the question: WHY?

Why do we have to refer to case reports when discussing the risks of chiropractic? The answer is simple: Because there is no proper system of monitoring its risks.

And why not?

Chiropractors claim it is because the risks are non-existent or very rare or only minor or negligible compared to the risks of other therapies. This, I fear, is false. But how can I substantiate my fear? Perhaps by listing a few posts I have previously published on the direct risks of chiropractic spinal manipulation. Here is a list (probably not entirely complete):

  1. Chiropractic manipulations are a risk factor for vertebral artery dissections
  2. Vertebral artery dissection after chiropractic manipulation: yet another case
  3. The risks of (chiropractic) spinal manipulative therapy in children under 10 years
  4. A risk-benefit assessment of (chiropractic) neck manipulation
  5. The risk of (chiropractic) spinal manipulations: a new article
  6. New data on the risk of stroke due to chiropractic spinal manipulation
  7. The risks of manual therapies like chiropractic seem to out-weigh the benefits
  8. One chiropractic treatment followed by two strokes
  9. An outstanding article on the subject of harms of chiropractic
  10. Death by chiropractic neck manipulation? More details on the Lawler case
  11. Severe adverse effects of chiropractic in children Another serious complication after chiropractic manipulation; best to avoid neck manipulations altogether, I think
  12. Ophthalmic Adverse Effects after Chiropractic Neck Manipulation
  13. Is chiropractic treatment safe?
  14. Cervical artery dissection and stroke related to chiropractic manipulation
  15. We have an ethical, legal and moral duty to discourage chiropractic neck manipulations
  16. Cerebral Haemorrhage Following Chiropractic ‘Activator’ Treatment
  17. Vertebral artery dissection after chiropractic manipulation: yet another case
  18. Horner Syndrome after chiropractic spinal manipulation
  19. Phrenic nerve injury: a rare but serious complication of chiropractic neck manipulation
  20. Chiropractic neck manipulation can cause stroke
  21. Chiropractic and other manipulative therapies can also harm children
  22. Complications after chiropractic manipulations: probably rare but certainly serious
  23. Disc herniation after chiropractic
  24. Evidence for a causal link between chiropractic treatment and adverse effects
  25. More on the risks of spinal manipulation
  26. The risk of neck manipulation
  27. “As soon as the chiropractor manipulated my neck, everything went black”
  28. Spinal epidural haematoma after neck manipulation
  29. New review confirms: neck manipulations are dangerous
  30. Top model died ‘as a result of visiting a chiropractor’
  31. Another wheelchair filled with the help of a chiropractor
  32. Spinal manipulation: a treatment to die for?

Of course, one can argue about the conclusiveness of this or that case report, but I feel that the collective evidence discussed in these posts makes my point abundantly clear:

chiropractic spinal manipulation is not safe.

66 Responses to Chiropractic spinal manipulation is not safe!

  • Like a Covid-19 vaccine but safer, the risk is real but rare.

  • So it’s not safe because you say so??? I can live with that as long as you don’t claim this is evidance based…

  • EE: Chiropractors claim it is because the risks are non-existent …

    If a chiropractor states there is no “risk” to spinal manipulation they would be wrong.

  • “Unsafe” is relative. What matters is risk vs benefit.
    Suppose doctors practicing mainstream medicine were doing something that had similar risks to the neck manipulation that is done by chiropractors, BUT it also had verified benefits.
    And suppose the doctors were obtaining informed consent before doing it; getting the patient to sign something describing the risks. This is apparently something chiropractors don’t do before a neck manipulation.

    How much in the way of benefits would it have to have, to outweigh the risks?
    There would be various aspects to that decision:
    – How much extra will it cost in terms of malpractice insurance?
    – What would result in the best outcomes for the patients?
    – How much risk will patients accept, if honestly informed beforehand?

    • getting the patient to sign something describing the risks. This is apparently something chiropractors don’t do before a neck manipulation.

      Apparently?

    • Simply put, there’s little reason to accept risk when there’s questionable benefit.

    • Suppose doctors practicing mainstream medicine were doing something that had similar risks to the neck manipulation that is done by chiropractors, BUT it also had verified benefits. …
      How much in the way of benefits would it have to have, to outweigh the risks?

      A comment by one doctor about this:

      Given three studies that now show an increase in the stroke rates in the young after neck manipulation, I would not let a chiropractor come close to my neck.

      In real medicine, it takes less data than this to bring a drug under scrutiny to decide if the benefits are worth the potential risks of a therapy. In my own world of infectious diseases, there have been millions of doses of the antibiotic telithromycin given and only a handful of liver failure and death associated with the antibiotic. I would not prescribe this antibiotic unless I had no other options given the potential risks, albeit very small, and this is for a therapy that actually works.

  • I wonder what neurologists who treat stroke patients generally think these days about the risks of neck manipulation by chiropractors.

    • one famously said: don’t let these buggars touch your neck.

    • It depends on how well read up they are on the topic. Most that I have discussed this with only go by what others have told them which is based upon what others have told them…Very few have actually dug into the research. It is what some refer to as “risk of medical dogma”.

      Interestingly enough, typically when I start going thru the research with them, most just walk away…as though the research challenges their views and they don’t want to deal with it. Kind of ironic.

      • “when I start going thru the research with them, most just walk away…as though the research challenges their views and they don’t want to deal with it”
        or maybe they are put off by your blinkered approach?

        • “or maybe they are put off by your blinkered approach?”

          They certainly don’t like to be questioned. I usually start of with:

          How did you determine when the VAD actually occurred since neurological symptoms may not manifest for a week or longer?

    • I wonder what they think about epidural injections?

      A review of data from the FDA Adverse Event Reporting System found cases of death, spinal cord infarction, paraplegia, quadriplegia, cortical blindness, stroke, seizures, nerve injury, and brain swelling in patients who had received epidural steroid injections. These events occurred within minutes to 2 days after injection. According to the FDA, many of the patients did not recover from these injuries.

      https://jamanetwork.com/journals/jama/article-abstract/1874492

      After 50 years of use:

      safety and effectiveness of epidural administration of corticosteroids have not been established

      FDA April 23, 2014

      Overall, the available literature supports the view that serious complications following injections of corticosteroid suspensions into the cervical and lumbar epidural space are uncommon, but if they occur they can be devastating.

      Conclusions
      The true incidence of such complications remains unclear.

      https://link.springer.com/article/10.1007/s40268-015-0119-3

      How about benefit? MCID not met?

      The literature indicates that ESI induces larger improvements in pain and disability on the short term compared to epidural placebo, though evidence is of low to moderate quality and MCID is not met.

      https://link.springer.com/article/10.1007/s00586-021-06854-9

      And yet

      The statistics show that epidural injections, including percutaneous adhesiolysis procedures, are the most commonly performed procedures in managing spinal pain among interventional techniques, varying from 58.6% in 2000 to 45.2% in 2014 of all interventional techniques.

      https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5168679/#s1title

  • From the American Heart Assoc. in 2014:

    Although current biomechanical evidence is insufficient to establish the claim that CMT (cervical manipulative therapy) causes CD (cervical artery dissection), clinical reports suggest that mechanical forces play a role in a considerable number of CDs and most population controlled studies have found an association between CMT and VAD (vertebral artery dissection) stroke in young patients. Although the incidence of CMT-associated CD in patients who have previously received CMT is not well established, and probably low, practitioners should strongly consider the possibility of CD as a presenting symptom, and patients should be informed of the statistical association between CD and CMT prior to undergoing manipulation of the cervical spine.

    So that’s fairly recent.

  • From the American Heart Assoc. in 2014:

    Although current biomechanical evidence is insufficient to establish the claim that CMT (cervical manipulative therapy) causes CD (cervical artery dissection), clinical reports suggest that mechanical forces play a role in a considerable number of CDs and most population controlled studies have found an association between CMT and VAD stroke in young patients. Although the incidence of CMT-associated CD in patients who have previously received CMT is not well established, and probably low, practitioners should strongly consider the possibility of CD as a presenting symptom, and patients should be informed of the statistical association between CD and CMT prior to undergoing manipulation of the cervical spine.

    So that’s fairly recent.

  • I still do not understand why folks who want to treat spinal conditions do not train to be spinal surgeons, physiotherapists, or even, osteopaths.

    Why take up with Palmer’s concepts?
    What’s the attraction?

    • Does being a chiropractor necessarily entail believing in subluxations?
      I heard of someone recently who was trained both as a physical therapist and then years later, as a chiropractor. Maybe the money is better for chiros.

      • “Does being a chiropractor necessarily entail believing in subluxations?”

        Subluxations are real[1] therefore no belief is required.

        Chiropractic vertebral subluxations are metaphysical therefore no evidence is required.

        1. real: actually existing as a thing or occurring in fact; not imagined or supposed.

  • There should be legally mandated standardized informed consent before chiropractors do neck manipulations, written by independent experts and not by the chiropractors themselves. When the chiropractors obtain consent for a neck manipulation, their wording is very likely slanted by their belief that it doesn’t actually cause or aggravate cervical artery dissections.

    • So, basically with mandating, you want the courts (USA) to overturn Natanson v Kline, 186 Kan 393, 350 P 2d 1093 (1960), opinion on denial of motion for rehearing 187 Kan 186 354 P 2d 670 (1960) [Natanson]. Good luck with that as it would affect every healthcare provider in the USA.

  • Edzard, are you familiar with Aaron Kubal? He’s a chiropractor (DC) from the USA who posts on social media platforms (TiKToK, Twitter and Instagram). I think you’d really appreciate him and what he says.

  • It is acceptable chiropractic pracitce in the UK for a chiropractor to use the ‘drop table’ technique to adjust the cervical spine in an elderly man with ankylosing spondylitis and who had already had a surgical spinal fusion.

    I say ‘acceptable’ because when the patient died as a result, the coroner accepted the ‘expert’ evidence of a chiropractor witness that such a technique was acceptable – as did the General Chiropractic Council.

    Caveat emptor.

  • Yes, joints do sometimes subluxate (partially dislocate). I had subluxating shoulders at one point.
    To put my question more precisely – do chiropractors usually go around diagnosing the chiropractic version of subluxations in their patients? Or do a lot of them ignore that part of what they’re taught?
    “Palmer’s concepts” would include other things besides subluxations, same question for those things. Do a lot of chiropractors ignore the BS part of what they’re taught, or no?

    • Surveys have been done which cover chiropractors beliefs or approaches in practice. Roughly around 20-25% hold onto the old Palmer “philosophy”. The use of the word “subluxation” appears to be fading from use. I suspect because it carries too much baggage.

      Personally I have only used the word subluxation (chiropractic context) once in a discussion with a patient and that was only because she was curious after seeing the word on a Google search.

  • “do chiropractors usually go around diagnosing the chiropractic version of subluxations in their patients?”
    yes

    • I wonder how many people see chiropractors for problems not related to their muscles or joints, and yet the chiropractor recommends their manipulative therapy. That’s where it gets seriously wacky.
      I saw a chiropractor once, inadvertently 🙂 and not for muscle/joint symptoms. They seemed a little surprised that I would go to a chiropractor for it.
      Most people who see chiropractors are looking for help with some musculoskeletal problem, no?
      This chiropractor did come out with BS, but at least they didn’t recommend a long course of adjustments.

      • “I wonder how many people severe chiropractors for problems not related to their muscles or joints”
        because they do very effective PR

        • I wonder how many people see chiropractors for problems not related to their muscles or joints

          I was asking roughly what percentage of visits to chiropractors are for problems not related to their muscles or joints.
          Not *why* someone might see a chiropractor for such problems.

        • Between 3 and 10% of patients who receive care from chiropractors and osteopaths are treated for non-musculoskeletal disorders.
          So not very many. That’s good, because that paper also says

          We found no evidence of an effect of SMT for the management of non-musculoskeletal disorders including infantile colic, childhood asthma, hypertension, primary dysmenorrhea, and migraine.

          • “We found no evidence of an effect of SMT …”
            one can find evidence for almost any stupidity. The question is whether it is conclusive. In the above case, the answer is very clearly no.

          • Laura. Yes, most people go to chiropractors for MSK complaints.

            However, many patients report positive changes in non-MSK conditions while under chiropractic care.

            The possible reasons are multiple. However, some chiropractors attribute those changes to spinal manipulation perhaps in part because of the early claims of DD Palmer and others.

          • many patients report positive changes in non-MSK conditions while under any other quack’s care

          • Laura, FWIW, this update was put out last year by an osteopath regarding their view (or hers) on viscerosomatic reflexes and how OMM may influence those reflexes.

            Sorry, I can’t link to it but it’s free online.

            Bath M, Owens J. Physiology, Viscerosomatic Reflexes. [Updated 2021 May 9]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-.

          • Table 3 in their reference actually has several reasons which could include non-musculoskeletal problems for visiting a chiropractor:
            – extremity problem 10%
            – wellness/maintenance 7.5%
            – headache 5.5%
            – unspecified/miscellaneous 5%
            – visceral/non-musculoskeletal 3%
            So it looks like the actual % of patients who visit a chiropractor for non-musculoskeletal issues is a lot higher than the 3-10% they quoted.

          • Yes they do. But when those reports have a level of consistency between several different professions over a time span of a 100 plus years it shouldn’t be so easily dismissed.

          • “when those reports have a level of consistency between several different professions over a time span of a 100 plus years it shouldn’t be so easily dismissed”
            except, of course, if these reports deal with adverse effects of chiropractic manipulations!

          • “ except, of course, if these reports deal with adverse effects of chiropractic manipulations!”

            Perhaps for some.

            As I am about to present a research proposal that looks at a specific AE within a specific subgroup I shall let your comment apply to others.

            And with that I shall leave this group for awhile.

          • Yes there are some reports that are of such low quality that it’s difficult to accept them as evidence towards causality.

          • Sure. Proper research will tease out pure believe from reality.

      • Again, there are surveys that looked at these topics. Most chiropractors focus on muscle and joint problems. Most patients go to chiropractors for muscle and joint problems. Most of the research is on muscle and joint problems.

        Some here want the majority of the profession to be what it is not so they look like they have something significant to complain about.

        • Some here want the majority of the profession to be what it is not so they look like they have something significant to complain about.

          Speculations about people ‘s motives add nothing useful to the discussion, only detract from it.
          Why does Dr. Ernst even approve that sort of thing? Both the skeptics and the true believers in something or other make a lot of pointless observations on this site about other users.

          • “Why does Dr. Ernst even approve that sort of thing?”
            I find it hard to stop people making fools of themselves.

          • I find it hard to stop people making fools of themselves.

            What would be difficult about not posting ad hominems directed at other users?
            The people saying such things probably think of it more as making a fool of the target, not themselves.
            And such comments just give rise to similar responses.
            In essence it turns into:
            “You bad and silly!”
            “no, YOU bad and silly!”
            repeat …

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