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):
- Chiropractic manipulations are a risk factor for vertebral artery dissections
- Vertebral artery dissection after chiropractic manipulation: yet another case
- The risks of (chiropractic) spinal manipulative therapy in children under 10 years
- A risk-benefit assessment of (chiropractic) neck manipulation
- The risk of (chiropractic) spinal manipulations: a new article
- New data on the risk of stroke due to chiropractic spinal manipulation
- The risks of manual therapies like chiropractic seem to out-weigh the benefits
- One chiropractic treatment followed by two strokes
- An outstanding article on the subject of harms of chiropractic
- Death by chiropractic neck manipulation? More details on the Lawler case
- Severe adverse effects of chiropractic in children Another serious complication after chiropractic manipulation; best to avoid neck manipulations altogether, I think
- Ophthalmic Adverse Effects after Chiropractic Neck Manipulation
- Is chiropractic treatment safe?
- Cervical artery dissection and stroke related to chiropractic manipulation
- We have an ethical, legal and moral duty to discourage chiropractic neck manipulations
- Cerebral Haemorrhage Following Chiropractic ‘Activator’ Treatment
- Vertebral artery dissection after chiropractic manipulation: yet another case
- Horner Syndrome after chiropractic spinal manipulation
- Phrenic nerve injury: a rare but serious complication of chiropractic neck manipulation
- Chiropractic neck manipulation can cause stroke
- Chiropractic and other manipulative therapies can also harm children
- Complications after chiropractic manipulations: probably rare but certainly serious
- Disc herniation after chiropractic
- Evidence for a causal link between chiropractic treatment and adverse effects
- More on the risks of spinal manipulation
- The risk of neck manipulation
- “As soon as the chiropractor manipulated my neck, everything went black”
- Spinal epidural haematoma after neck manipulation
- New review confirms: neck manipulations are dangerous
- Top model died ‘as a result of visiting a chiropractor’
- Another wheelchair filled with the help of a chiropractor
- 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!
Leave a Reply to Edzard Cancel reply
This site uses Akismet to reduce spam. Learn how your comment data is processed.
Like a Covid-19 vaccine but safer, the risk is real but rare.
What a comparison!
Vaccines have positive effects and their benefits thus outweigh the risks.
The same cannot be said about spinal manipulations.
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…
“So it’s not safe because you say so??”
said a chiro after having been shown several dozens of peer-reviewed papers.
PERFECT EXAMPLE OF DENIAL!
thanks, Almog
The papers do not conclude SMT to be unsafe. This is your own interpretation
if you say so.
Almog: Ernst above blog on this is so broad and vague it’s difficult to even enter a discussion on the topic. I wonder if that was intentional?
A Trumpish question. There should be a word for such questions. Trumpquiry maybe.
there is already a good term:
https://edzardernst.com/2021/11/proctophasia-a-nasty-affliction-of-many-proponents-of-so-called-alternative-medicine/
Yes I’ve heard about proctophasia … but I was wondering about insinuating questions specifically. Trumpie did that a lot, it adds deniability. Should be a word for them.
“A Trumpish question. There should be a word for such questions. Trumpquiry maybe.”
Or maybe he wanted to leave himself a lot of wiggle room in case he started to get cornered.
Well, if it wasn’t intentional, maybe it was poor writing or a failure to understand the topics or…
trumpery
[ˈtrʌmp(ə)ri]
NOUN
attractive articles of little value or use.
“None of your woollen drapery, nor linen drapery, nor any of your frippery or trumpery. I hate ostentation”
synonyms:
trinkets · baubles · cheap finery · knick-knacks · ornaments · bibelots · gewgaws · gimcracks
ADJECTIVE
showy but worthless.
“trumpery jewellery”
synonyms:
showy · gaudy · garish · vulgar · tasteless · worthless · valueless · cheap · tawdry · shoddy · meretricious · Brummagem
Also trumpish. Not a good resemblance.
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.
Super, can you clarify the risks then?
You could either make up your own list or simply refer to Edzard’s.
I fear it will be the former.
Risk is a very broad term. Regardless, this paper covers some of the topic. Table 6 has a partial list of some potential serious “risks” (causal vs probable vs possible?)
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5366149/pdf/13643_2017_Article_458.pdf
My focus here is regarding VAD.
“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?
https://pubmed.ncbi.nlm.nih.gov/17693332/
Most practitioners obtain consent for treatment associated with the possibility of a serious adverse event (around 80-90%) (from Ernst’s above reference)
and what about the much more frequent and therefore more relevant non-serious AEs?
“and what about the much more frequent and therefore more relevant non-serious AEs?”
consent regarding minor risks, per the paper:
USA: 97%
UK: 98%
Crickets.
This paper is just a survey of chiropractors. A survey of their patients, asking what risks they had been informed of before treatment, would be more to the point.
Asking the patients might give a different perspective, since the chiropractors have an incentive to give the socially appropriate answers.
And another question would be how many patients were fairly informed of the risks in advance. How many patients who’ve had a stroke after a chiropractor manipulates their neck, were fairly informed ahead of time that this might happen? Young patients, since older patients often have strokes regardless of chiropractic treatment.
yes
It is from the paper that Ernst linked to. If you have better evidence, based upon whatever meets your criteria, please share it.
Simply put, there’s little reason to accept risk when there’s questionable benefit.
A comment by one doctor about this:
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:
So that’s fairly recent.
From the American Heart Assoc. in 2014:
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.
words can fade from use while the concept remains
“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 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 …”
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.
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.
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 …