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

Today is the start of chiropractic awareness week 2022. On this occasion the BCA states most categorically: First and foremost, chiropractic is a statutorily regulated healthcare profession, supported by evidence, which offers a safe form of treatment for patients with a range of conditions.  Here I am tempted to cite my friend Simon Singh:

THEY HAPPILY PROMOTE BOGUS TREATMENTS

I am, of course, particularly impressed by the BCA’s assurance of safety. In my view, the safety issue needs to be addressed more urgently than any other in the realm of chiropractic. So, to make a meaningful contribution to the current chiropractic awareness week, I conducted a few Medline searches to identify all publications of 2022 on chiropractic/spinal manipulation risks.

This is what I found:

paper No 1

Objective: Patients can be at risk of carotid artery dissection and ischemic stroke after cervical chiropractic manipulation. However, such risks are rarely reported and raising awareness can increase the safety of chiropractic manipulations.

Case report: We present two middle-aged patients with carotid artery dissection leading to ischemic stroke after receiving chiropractic manipulation in Foshan, Guangdong Province, China. Both patients had new-onset pain in their necks after receiving chiropractic manipulations. Excess physical force during chiropractic manipulation may present a risk to patients. Patient was administered with recombinant tissue plasminogen activator after radiological diagnoses. They were prescribed 100 mg and clopidogrel 75 mg daily for 3 months as dual antiplatelet therapy. There were no complications over the follow-up period.

Conclusion: These cases suggest that dissection of the carotid artery can occur as the result of chiropractic manipulations. Patients should be diagnosed and treated early to achieve positive outcomes. The safety of chiropractic manipulations should be increased by raising awareness about the potential risks.

paper No 2

Spontaneous intracranial hypotension (SIH) still remains an underdiagnosed etiology of new-onset headache. Important risk factors include chiropractic manipulation (CM). We present a case of a 36-year-old Filipino woman who presented with severe bifrontal and postural headache associated with dizziness, vomiting, and doubling of vision. A cranial computed tomography scan was done which showed an acute subdural hematoma (SDH) at the interhemispheric area. Pain medications were given which afforded minimal relief. On history, the headaches occurred 2 weeks after cervical CM. Cranial and cervical magnetic resonance imaging revealed findings supportive of intracranial hypotension and neck trauma, respectively. The patient improved with conservative management. We found 12 articles on SIH and CM after a systematic review of literature. Eleven patients (90.9%) initially presented with orthostatic headache. Eight patients (66.7%) were initially treated conservatively but only 5 (62.5%) had complete recovery. Recovery was achieved within 14 days from start of supportive therapy. Among the 3 patients who failed conservative treatment, 2 underwent non-directed epidural blood patch and one required neurosurgical intervention. This report highlights that a thorough history is warranted in patients with new onset headache. A history of CM must be actively sought. The limited evidence from the case reports showed that patients with SIH and SDH but with normal neurologic examination and minor spinal pathology can be managed conservatively for less than 2 weeks. This review showed that conservative treatment in a closely monitored environment may be an appropriate first line treatment.

paper No 3

Introduction: Cranio-cervical artery dissection (CeAD) is a common cause of cerebrovascular events in young subjects with no clear treatment strategy established. We evaluated the incidence of major adverse cardiovascular events (MACE) in CeAD patients treated with and without stent placement.

Methods: COMParative effectiveness of treatment options in cervical Artery diSSection (COMPASS) is a single high-volume center observational, retrospective longitudinal registry that enrolled consecutive CeAD patients over a 2-year period. Patients were ≥ 18 years of age with confirmed extra- or intracranial CeAD on imaging. Enrolled participants were followed for 1 year evaluating MACE as the primary endpoint.

Results: One-hundred ten patients were enrolled (age 53 ± 15.9, 56% Caucasian, and 50% male, BMI 28.9 ± 9.2). Grade I, II, III, and IV blunt vascular injury was noted in 16%, 33%, 19%, and 32%, respectively. Predisposing factors were noted in the majority (78%), including sneezing, carrying heavy load, chiropractic manipulation. Stent was placed in 10 (10%) subjects (extracranial carotid n = 9; intracranial carotid n = 1; extracranial vertebral n = 1) at the physician’s discretion along with medical management. Reasons for stent placement were early development of high-grade stenosis or expanding pseudoaneurysm. Stented patients experienced no procedural or in-hospital complications and no MACE between discharge and 1 year follow up. CeAD patients treated with medical management only had 14% MACE at 1 year.

Conclusion: In this single high-volume center cohort of CeAD patients, stenting was found to be beneficial, particularly with development of high-grade stenosis or expanding pseudoaneurysm. These results warrant confirmation by a randomized clinical trial.

paper No 4

Background: Manipulation and mobilisation for low back pain are presented in an evidence-based manner with regard to mechanisms of action, indications, efficacy, cost-effectiveness ratio, user criteria and adverse effects. Terms such as non-specific or specific are replaced by the introduction of “entities” related to possible different low back pain forms.

Efficacy: MM is effective for acute and chronic low back pain in terms of pain relief, recovery of function and relapse prevention. It is equally effective but less risky compared to other recommended therapies. MM can be used alone in acute cases and not only in the case of chronic low back pain where it is always and necessarily part of a multimodal therapy programme, especially in combination with activating measures. The users of MM should exclusively be physician specialists trained according to the criteria of the German Medical Association (Bundesärztekammer) with an additional competence in manual medicine or appropriately trained certified therapists. The application of MM follows all rules of Good Clinical Practice.

Adverse effects: Significant adverse effects of MM for low back pain are reported in the international literature with a frequency of 1 per 50,000 to 1 per 3.7 million applications, i.e. MM for low back pain is practically risk-free and safe if performed according to the rules of the European Training Requirements of the UEMS.

paper No 5

Studies have reported that mild adverse events (AEs) are common after manual therapy and that there is a risk of serious injury. We aimed to assess the safety of Chuna manipulation therapy (CMT), a traditional manual Korean therapy, by analysing AEs in patients who underwent this treatment. Patients who received at least one session of CMT between December 2009 and March 2019 at 14 Korean medicine hospitals were included. Electronic patient charts and internal audit data obtained from situation report logs were retrospectively analysed. All data were reviewed by two researchers. The inter-rater agreement was assessed using the Cohen’s kappa coefficient, and reliability analysis among hospitals was assessed using Cronbach’s Alpha coefficient. In total, 2,682,258 CMT procedures were performed in 289,953 patients during the study period. There were 50 AEs, including worsened pain (n = 29), rib fracture (n = 11), falls during treatment (n = 6), chest pain (n = 2), dizziness (n = 1), and unpleasant feeling (n = 1). The incidence of mild to moderate AEs was 1.83 (95% confidence interval [CI] 1.36-2.39) per 100,000 treatment sessions, and that of severe AEs was 0.04 (95% CI 0.00-0.16) per 100,000 treatment sessions. Thus, AEs of any level of severity were very rare after CMT. Moreover, there were no instances of carotid artery dissection or spinal cord injury, which are the most severe AEs associated with manual therapy in other countries.

_______________________________

This is not too bad after all!

Five papers are clearly better than nothing.

What conclusions might be drawn from my mini-review?

I think it might be safe to say:

  1. There is not much but at least some research going on in this area.
  2. The risks of chiropractic/spinal manipulation are real and are being recognized.
  3. BUT NOT BY CHIROPRACTORS! The most remarkable feature of the 5 papers, I think, is that none originates from a chiropractic team.

Thus, allow me to make a suggestion to chiropractors worldwide: Instead of continuing with HAPPILY PROMOTING BOGUS TREATMENTS, what about using the ‘chiropractic awareness week’ to raise awareness of the urgent necessity to research the safety of your treatments?

21 Responses to Chiropractic: “a safe form of treatment”?

  • It is wholly misleading for the British Chiropractic Association to say: “In the UK, chiropractors are regulated by law and required to adhere to strict codes of practice…”
    https://chiropractic-uk.co.uk/chiropractic-awareness-week-2022-rigour-evidence-relevance/

    Because let’s not forget that the death of chiropractic client, John Lawler, recently raised some serious questions about the regulation of chiropractors in the UK: that is, the intentions of the chiropractor who was involved in Mr Lawler’s death seemed to be far, far more important than addressing the fundamental questions of following requirements: https://www.gcc-uk.org/assets/hearings/2021.09.02_-_Scholten_-_Final_Determination__.pdf

    In other words, it would now appear that a UK chiropractor is allowed to do all of the following things without fearing to get reprimanded as long as he or she produces evidence that the deeds were done not with malicious intentions but in a state of confusion and panic:

    • Treat a patient with treatments that are contraindicated.
    • Fail to obtain informed consent.
    • Pose as a real doctor without informing the patient that the practitioner is just a chiropractor who has never been near a medical school.
    • Cause the death of a patient by treatment to the neck.
    • Administer first aid in a way that makes matters worse.
    • Tell lies to the ambulance men who consequently failed to employ a method of transport that would save the patient’s life.
    • Keep inaccurate patient records that conceal what treatments were administered.

    Ref. https://edzardernst.com/2021/09/hurray-the-new-professional-standard-by-the-general-chiropractic-council-protects-uk-chiropractors/

    .

    • To which I would add:

      * “Be araigned before the General Chiropractic Council which determined no fault on the part of the chiropractor involved, and which accepted as an ‘expert witness’ a chiropractor, but failed to have any expert advice from specialists in managing ankylosing spondylityis (which the deceased suffered from, and for which he had had surgery), and failed to have any expert advice from spinal surgeons.”

  • EE: I think it might be safe to say: There is not much but at least some research going on in this area. BUT NOT BY CHIROPRACTORS!

    “This work involves a series of projects, with current focus on the implementation of developed data collection instruments. The population has been done within a chiropractic teaching institute. Plans are to reach out to practicing doctors on an international platform. The projects include: 1) Determine the incidence of mild, moderate, and serious adverse events following SMT administered by chiropractic interns using the SafetyNET active surveillance reporting system in teaching clinics and community-based practices. 2) Qualitative evaluation of open-ended questions on SafetyNET’s Survey to Support Quality Improvement.” https://www.carlresearchfellows.org/research-projects

    Our findings suggest that it is feasible to conduct an active-surveillance reporting system at a chiropractic teaching clinic. Important barriers and facilitators were identified and will be used to inform future work regarding patient safety education and research. https://www.sciencedirect.com/science/article/pii/S0161475420301263

    Active Surveillance Reporting to Identify Adverse Events Following Chiropractic Care in Older Adults https://clinicaltrials.gov/ct2/show/NCT04786015

    • my time window was 2022

      • So, your point is that in the first 3 months of 2022 there weren’t any papers on AE by chiropractors. Uh, OK.

        Regardless, an interesting collection of papers:

        Paper one: out of China where chiropractic isn’t regulated thus anyone can call themselves a chiropractor.

        Paper two: “On history, the headaches occurred 2 weeks after cervical CM.” Also neck trauma on a MRI? How much force is required for trauma to show up on a MRI? What else occurred during those two weeks?

        Paper three: No where in the report does it say that spinal manipulation was in the history of any of the dissections.

        Paper four: “MM for low back pain is practically risk-free and safe if performed according to the rules of the European Training Requirements of the UEMS.”

        Paper five: out of Korea. “severe AEs was 0.04 (95% CI 0.00-0.16) per 100,000 treatment sessions. Thus, AEs of any level of severity were very rare after CMT.”

        It would appear a couple of the papers answered your question.

        • “So, your point is that in the first 3 months of 2022 there weren’t any papers on AE by chiropractors”
          YES
          if you check how many papers (>25 000 in 2022) were on AEs of conventional medicine, this is an interesting point, don’t you think?
          AND NO!
          the point is also that ALL the 5 papers were not by chiros.
          NOT INTERESTING?

        • ‘DC’ wrote “Paper one: out of China where chiropractic isn’t regulated thus anyone can call themselves a chiropractor.”

          So, what’s the difference in treatment provided by an unregulated quack playing ‘Doctor’, and a quack playing ‘Doctor’ whose regulator doesn’t specify what the treatment actually is?

          See the first comment above by Blue Wode on Monday 04 April 2022 at 15:20.

  • EE: if you check how many papers (>25 000 in 2022) were on AEs of conventional medicine, this is an interesting point, don’t you think?

    It appears conventional medicine has a greater number of AE. This is not surprising.

    EE: the point is also that ALL the 5 papers were not by chiros.
    NOT INTERESTING?

    It is unfortunate that those who wrote the papers did not include the chiropractor (assuming it was a chiropractor) in the write up of the paper. It would have added more insight.

    Maybe your search was too narrow?

    “This study aimed to synthesize available literature and characterize outcomes and adverse events for manual therapy interventions in adults with prior cervical spine surgery due to degenerative conditions.” (Jeff King is a chiropractor)

    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8900329/

    “Importantly, no serious adverse events resulted from either of the interventions.”

    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8886833/

    • “It appears conventional medicine has a greater number of AE. This is not surprising.”
      correct!
      real doctors treat really sick patients

      • real doctors treat really sick patients

        This is of course also why SCAM is so ‘successful’: when someone knows or suspects that they have a serious condition, they are far more likely to consult a real doctor instead of a SCAM practitioner – leaving the latter to deal mostly with the worried well, self-limiting minor conditions and other vague complaints that respond relatively well to personal attention and placebo treatments. I find this encouraging, as it suggests that most people know in the back of their mind that SCAM practitioners are not real doctors, and should only be consulted for harmless things.

        I think it would also be interesting to collate a list of ailments which are ‘popular’ with SCAM practitioners, and (categories of) ailments for which they are never consulted. I never heard of a chiro treating even a broken bone or the likes. Then again, they might find it below their dignity to deal with ‘pre-cracked’ bones …

        • RR: “ I never heard of a chiro treating even a broken bone or the likes.”

          Of course not, it’s not within their scope of practice. I doubt you’ve heard of a dentist treating squamous cell carcinoma of the oral cavity or an optometrist treating a retinal detachment.

        • “Straight” chiropractors believe they can treat anything.

          The general public thinks chiropractors are specialists in back problems and are surprised when they learn that there are still chiropractors who believe the original theories, and even that they are still taught in chiropractic schools.

      • “It appears conventional medicine has a greater number of AE. This is not surprising.”
        correct!
        real doctors treat really sick patients

        So the probability of an AE increases based upon how sick a patient is? Is there research that supports that?

        • DC: So the probability of an AE increases based upon how sick a patient is? Is there research that supports that?

          Would you require research to determine if a poke in the eye with a burning stick seems unpleasant? Would you argue as you do here whether or not it was a chiropractor who does the poking or that eye poking isn’t within the scope of a DC’s practice?

          Really, you’re outdoing yourself looking every which way to find any little bit of oxygen to relieve your chiropractic dyspnea and predicament as a DC. This isn’t diversionary as Edzard recently suggested. It’s the usual lame and inept attempt of an average chiropractic meatball to rationalize and defend a Chiropractic.

          You want research for this assertion and description of your dyspneic chiropractic efforts and imperative? Refer to all your posts here and more than 125 years of Chiropractic Dalmatians attempting at every legislative turn to insinuate their chiropractic ooze and chiropractism into medicine and health care.

          ~TEO.

          • So your answer to my question is…oh, you didn’t answer it. Just another little Johnny rant.

          • The ‘question’ is so asinine that it is not even wrong. The ‘question’ does, however, clearly reveal a despicable (but not surprising) level of innumeracy.

          • Pete: The ‘question’ is so asinine that it is not even wrong. The ‘question’ does, however, clearly reveal a despicable (but not surprising) level of innumeracy.

            Interesting response considering the large number of studies on the general topic.

            Of course to even begin to discuss such a topic one would have to delve into subgroups such as preventable vs non preventable, intrinsic vs extrinsic, mild vs moderate vs severe AE, etc.

            Then one can look at procedures, medications, general care, infection related to health care, diagnoses, etc.

            Then of course it will differ by country, region, training, etc.

            But this little blog is about CAM so it appears Ernst comment is off topic and your response Pete indicates your ignorance on the topic.

            Moving on.

          • Comments by a chiropractor: insights into quasi-religious zeal, No 1 & No 6:
            https://edzardernst.com/2022/04/comments-by-a-chiropractor-insights-into-quasi-religious-zeal/

            QED, again!

            It isn’t amusing; it’s pathetic, obnoxious.

          • Nosocomial infections… look into Pete to help reduce your ignorance on the topic.

          • The failure by ‘DC’ to understand the reason why their above comment on Monday 04 April 2022 at 21:42 was not only featured in Comments by a chiropractor: insights into quasi-religious zeal, it was also No 1, is a display of breathtaking idiocy and vacuity; stupid‑squared.

            Here’s another display of stupid‑squared:
            https://edzardernst.com/2022/04/revolutionising-chiropractic-care-for-todays-healthcare-system/#comment-138770

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