It has been reported that a young woman’s visit to a chiropractor left her unable to walk due to a torn artery.
Mariah Bond, 29, went to visit a chiropractor in the hope to get some relief from her neck pain. During the appointment, the chiropractor quickly twisted her neck from side to side. “It cracked both ways and I’d seen chiropractor videos so I thought it was normal but when I stood up I got super dizzy,” Mariah recalled. Next, Mariah started profusely vomiting and her hand began to tingle. Then she was rushed to a hospital.
It took a few hours before the doctors could find the diagnosis. “I was still throwing up constantly, it was non-stop. I couldn’t open my eyes because if I did I’d start throwing up because I was so dizzy,” Mariah said. “I was transferred via ambulance to another hospital where they did a CT scan and confirmed that I was having a stroke.”
It turned out that Mariah’s chiropractor dissected an artery in her neck which then limited the blood supply to the brain. Mariah was kept in the hospital for five days while her condition was monitored. During that time, she was left unable to walk. But slowly she did become able to rely on a zimmer frame to get around. “I couldn’t walk properly or correctly use my hands to eat, it was like I was a child. It was very weird. My brain was there but I couldn’t do it,” she stated. “My first stroke was a cerebral stroke and they were saying that I probably had a mini-stroke as I was having weird feelings in my legs. They were very confused because that wasn’t common with the stroke I had, so they said that I probably had two.”
Within a fortnight, Mariah was able to walk again but had to have physiotherapy for two months before she could return to work. After her last CT scan, she received the good news that the dissected vessel had completely healed. She said: “I was very strong-willed at the time because everyone was telling me how well I was handling this. I think my husband was more scared than I was, poor thing.”
Mariah has vowed never to visit a chiropractor again and is doing her best to raise awareness of the damage they can cause. “I was shocked because I’m so young and you don’t really hear about young people having strokes, especially from the chiropractor. I’m pretty paranoid with my neck now. I know I probably shouldn’t be but sometimes if I have a weird feeling in my head, it would probably be called PTSD, I automatically start thinking am I having a stroke? I start freaking out. I’d tell people not to go to a chiropractor. I’ve already told a million people not to do it. Just don’t go or at least don’t let them do your neck.”
I would be surprised if this case ever got written up as a proper case report and published in a medical journal. We did a survey years ago where we found over 35 cases of severe complications after chiropractic in the UK within a period of 12 months. The most amazing result was that none of these cases had been published. In other words, under-reporting was precisely 100%.
Mariah’s case might be a true rarety, or it might be a fairly common event. It might be a most devastating occurrence, or there could be far worse events.
We simply do not know because under-reporting is huge.
Meanwhile, chiropractors – the professionals who should long have made sure that under-reporting becomes minimal or non-existent – claim that there is no evidence that strokes happen at all or regularly or often. They can do this because the medical literature seems to confirm their opinion. The only reporting system that seems to exist, the “chiropractic patient incident reporting and learning system” (CPiRLS), is for several reasons woefully inadequate and also plagued by under-reporting.
So, what advice can I possibly give to consumers in such a situation? I feel that the only thing one can recommend is to
stay well clear of chiropractors
until they finally present us with sufficient and convincing data.
You left out this part of the story.
“Mariah Bond, 29, went to visit a chiropractor in the hopes of fixing her neck, after a medical massage failed to do the trick.”
“Like many other medical practices, chiropractic adjustment does come with its risks but injuries causes are incredibly rare – especially when the procedures are performed by someone who is trained and licensed in the field.”
“injuries causes are incredibly rare – especially when the procedures are performed by someone who is trained and licensed in the field”
that’s just speculation, as well you know.
Speculation? It is based upon the current evidence.
When looking at these cases one needs, at minimum, a detailed history including potential risk factors. This news article falls very short.
The stroke…probably due to cSMT based on timing.
carry on trying to white-wash your dirty linen; it only exposes you as the quack you are.
White wash? I just stated the stroke was probably due to cSMT.
First: there is no special technique to avoid carotic artery damage. Head twist is head twist. Not even a trained specialist is able to avoid it. He just accepts the possibility of an injury. It may also cause damage to the uncovertebral joints of the lower cervical spine.
Second: do they check the cervical arteries for sclerosis or vulnerable plaques prior to head twist. No, they dont. It may also cause spontaneous rupture leading to stroke.
Fazit: no neck pain should ever be treated by headtwist!
Someone who is properly trained also knows to look for contraindications (or should).
“This review showed that, if all contraindications and red flags were ruled out, there was potential for a clinician to prevent 44.8% of AEs associated with CSM.”
You say you would need to know a detailed history and risk factors. What would you be looking for and why?
Bjorn, I have a question for you.
If I recall you are in risk management at a hospital. That indicates you have connections.
I have contacts with chiropractic researchers that have an interest in this general topic, some are in you region.
How about your people get with my people and they work together on these concerns?
Or shall we just keep pointing out issues on this little blog?
why do you call it a ‘little blog’?
it has >2500 posts; do you know one that is bigger?
How about you answer the question.
Don’t you realise that your half-assed, dodging reply only makes you look like a fool?
Bjorn, so your answer is ‘no, I won’t be part of the solution’? Got it.
What a horribly cynical reply!
Rare is relative when the complication is catastrophic and the benefit is negligible.
Dear Dr. Edzard Ernst;
Thank you for addressing the seriousness of the underreporting of Chiropractic injuries and directly related Vertebral Strokes, following rapid neck twisting.
Years ago, I recall reading an article where several dozen Neurologists (Many across Canada) tried to bring awareness to this very issue, but it essentially fell on deaf ears despite their cries of alarm. They were becoming more and more aware of a direct connection between Chiropractor visits and stroke related injuries. The Chiropractors as I understand it, did a good job counter launching an all-out attack on the Doctors and somehow managed to silence their findings from being made public.
Interestingly, when my wife was injured by a local Chiropractor ( September 13th, 2007 ) she initially spent six months in the U of A Hospital before being transferred to the Glenrose Rehabilitaion Hospital. There, within the halls of the U of A University Hospital, just three doors down from Sandys room, was yet another young person that came in with a Stroke as well! The nurses told me she too was the victim of a Chiropractor adding that they see this ALL THE TIME! WHAT WERE THE ODDS??
Too wrapped up in our own nightmare we never did find out this unfortunate gal’s outcome.
Because of the seriousness of Sandy’s Stroke, there was a substantial amount of media attention. To this day, over fifteen years later, we continue to receive emails and letters from all over the world from Chiropractor visits gone horribly wrong. The last one was from a young Canadian female who was going into the medical field of all things. She is now confined to a wheelchair, her life turned upside down. The father reached out to me personally and I am encouraging them along with Sandy, as much as I can. This young gal is very strong and in great health, so she stands a good chance of attaining some quality of life moving forward.
David. We need better research.
I have a proposal on the desk, it would be a huge study. I have chiropractic researchers interested. The road block…MDs/trauma centers allowing us access.
FWIW I had a gal in yesterday. VAD was high on the differential diagnosis. After history and focused exam I sent her to ER. Fortunately the CT was negative.
I try to educate my peers on these subjects. Yes, some are in denial, some want to learn.
Can you explain what this access involves – access to records? or to prospective patients? something else?
Zebra: access to patients and medical records, particularly imaging.
Hitchens’s razor: “What can be asserted without evidence, can also be dismissed without evidence.”
This has been an issue for decades. The “better research” should happen BEFORE the manoeuvre is continued, not blithely continue to harm people.
Many chiros like to argue that they didn’t “cause” the dissection – that it was already present and was the cause of the initial neck pain.
Even accepting that argument, how could it ever be safe to apply high velocity force to a neck? Ever?
What system do you use in your history and exam pre-manipulation to exclude VAS and how sensitive and specific has it been to be?
Ah, the lady who refused to do simple math and answer questions on this topic.
DC, your “research” is biting the wrong end. First show that neck manipulation has any beneficial effect at all. Noone has shown that yet. Zero benefit.
So, even if it were true, as you claim, that the risk of an adverse effect is very low, the risk ratio with a division by zero is even uncalculatably high.
SOK: “First show that neck manipulation has any beneficial effect at all. Noone has shown that yet. Zero benefit.”
“Consistent with previous reviews (Gross et al 2007, Hurwitz et al 2008), our results support the use of physical therapies that involve combinations of manual therapy and exercise. Our results add to the evidence supporting manual therapy by demonstrating short-term analgesic benefit from neck manipulation, thoracic manipulation, and neck mobilisation applied as single modality interventions.”
“Two majors points could be highlighted, the first one is that combining different forms of MT with exercise is better than MT or exercise alone,…”
DC, you can’t be serious. None of your references supports the specific use of neck manipulation for any ailment at all, or if there may be any theoretical benefit of such intervention. Have you really read them? Although a priori a waste of time, I browsed them now.
The second reference sums it up nicely:
“Two majors [sic!] points could be highlighted, the first one is that combining different forms of MT with exercise is better than MT or exercise alone, and the second one is that mobilization need not be applied at the symptomatic level(s) for improvements of NP patients. These both points may have clinical implications for reducing the risk involved with some MT techniques applied to the cervical spine.” (Hidalgo &al, 2017)
That is, first, A+B is better than A or B alone, which is a wellknown, unsurprising effect (almost all of the studies involved used that kind of rather useless protocol);
second, neck manipulation doesn’t really have to be directed specifically to the neck, a strong sign of placebo effect;
and third, they do admit the “risk involved with some MT techniques applied to the cervical spine.” Well done!
Here is your statement:
First show that neck manipulation has any beneficial effect at all. Noone has shown that yet. Zero benefit.
Those studies indicate benefit. Thus your “zero benefit” is rejected.
How do you ascertain the studies ‘indicate’ benefit? And do you understand rhe difference between ‘indicate’ and ‘support’?
Bjorn: How do you ascertain the studies ‘indicate’ benefit? And do you understand rhe difference between ‘indicate’ and ‘support’?
I am responding to his/her statement:
“First show that neck manipulation has ANY beneficial effect at all.” (emphasis added)
Is it your position that none of the studies show “any beneficial effect”?
DC, groundless rejection. The “benefit” was weakly supported in sloppy studies, and no mechanism has been suggested for that “benefit”, if any.
I repeat the following results from your references, results that dismiss the “benefit”. I hope you will understand it the second time:
First, A+B is better than A or B alone, which is a wellknown, unsurprising effect (almost all of the studies involved used that kind of rather useless protocol);
second, neck manipulation doesn’t really have to be directed specifically to the neck, a strong sign of placebo effect;
and third, they do admit the “risk involved with some MT techniques applied to the cervical spine.”
Even if we, for the sake of argument, believe in that small “benefit”, it is so small that the risk/benefit ratio becomes astronomical, considering the catastrophic side effects that can be expected in unfortunate cases.
@ Språkdoktorn Olle Kjellin,
Above was at least the fifth time that the chiro‑troll has spammed Edzard’s blog with “…combining different forms of MT with exercise is better than MT or exercise alone…”.
Four of the previous instances were:
BREAKING NEWS: Widespread strikes of SCAM practitioners immobilize the wellness industry
DC on Friday 27 January 2023 at 18:09
Spinal Manipulation vs Prescription Drug Therapy for Chronic Low Back Pain. More pseudoscience from the chiro cult
DC on Saturday 23 April 2022 at 12:09
Cervical spondyloptosis following spinal manipulation
DC on Tuesday 07 June 2022 at 19:31
Catastrophic injuries after chiropractic treatment
DC on Monday 04 July 2022 at 22:22
good name for him/her/it: ‘chiro-troll’
PRECISELY WHAT HE/SHE/IT IS!
Which message did I post that you found insulting?
Troll: “the act of leaving an insulting message on the internet in order to annoy someone:” Cambridge
TROLL = “someone who leaves an intentionally annoying or offensive message on the internet, in order to upset someone or to get attention or cause trouble”
Noone has shown that yet. Zero benefit
The “benefit” was weakly supported in sloppy studies
Two incompatible statements.
Manipulation or mobilisation versus inactive treatment:
For subacute/chronic neck pain, a single manipulation produced temporary pain relief.
Manipulation or mobilisation versus another active treatment:
Cervical manipulation for acute/subacute neck pain was more effective than varied combinations of analgesics, muscle relaxants and non-steroidal anti-inflammatory drugs for improving pain and function at up to long-term follow-up.
For chronic cervicogenic headache, cervical manipulation provided greater benefit than light massage in improving pain and function at short-term and intermediate-term follow-up.
For chronic CGH, cervical manipulation may be superior to transcutaneous electrical nerve stimulation (TENS) in improving pain at short-term follow-up.
For acute neck pain, cervical manipulation may be more effective than thoracic manipulation in improving pain and function up to intermediate-term follow-up.
A young woman’s visit to a chiropractor left her unable to walk
Well then, she certainly didn’t receive “zero benefit”. So, how, exactly, did she benefit from her chiropractic treatment? Was it:
• “Cervical manipulation for acute/subacute neck pain was more effective than varied combinations of analgesics, muscle relaxants and non-steroidal anti-inflammatory drugs for improving pain and function at up to long-term follow-up.”
• “For subacute/chronic neck pain, a single manipulation produced temporary pain relief.”
• “For chronic cervicogenic headache, cervical manipulation provided greater benefit than light massage in improving pain and function at short-term and intermediate-term follow-up.”
• “For chronic CGH, cervical manipulation may be superior to transcutaneous electrical nerve stimulation (TENS) in improving pain at short-term follow-up.”
• “For acute neck pain, cervical manipulation may be more effective than thoracic manipulation in improving pain and function up to intermediate-term follow-up.”
I feared that you wouldn’t understand my words. English isn’t my first language either, so I empathize with your problem. Let’s go up to the next level instead:
Why is neck manipulation so sacred for you, despite it’s horrible risks?
It’s not sacred to me. In fact, I don’t commonly perform neck manipulation in the cervical spine.
I use a graded approach based on “invasiveness”.
2. soft tissue manipulation
Usually 1-3 will resolve the complaint.
I use the same approach for the thoracic, lumbar and pelvic regions.
DC, so you don´t “commonly” perform neck manipulations, but you vehemently defend the procedure despite the obvious risks that you seem to deny. Please tell us, what exactly does the neck manipulation do, mechanically and neurologically, when it “benefits” what?
SOK. Having troubles posting on this site. Getting 403 denial.
I don’t think I have ever denied that there are risks with cSMT.
I have questioned causation of a serious AE when there is a lack of sufficient evidence in certain cases. That’s not denial.
I have questioned when, where, how and why a VAD happened. That’s not denial.
– you admit that there are risks with cSMT
– chiros tend to not report the risks at all or fail to report sufficient evidence
– that enables chiros to ‘question causation’
EE: you admit that there are risks with cSMT
Did I ever state otherwise?
if I’m not mistaken, chiro troll, my comment was a bit longer, wasn’t it?
I will add I do have a problem with people who think we should abandon cervical manipulation when the current evidence indicates there can be some benefit and the primary risk appears to be with the individual practitioner, not with the procedure per se.
I think there are some procedures in chiropractic that should be “banned” like the Y strap. Although media reports don’t report this information, I would not be surprised with some of the recent media cases that the Y strap was used.
Just a narrative review so FWIW
“The most recent systematic reviews and meta-analyses examined the effectiveness of SMT by directly comparing it with usual management options (37, 42). Both reviews concluded that SMT is an equally effective approach to reduce pain and disability in the short term when compared to other interventions, including exercise (37, 42). Nevertheless, the strongest evidence was found in support of multimodal approaches, such as the combination of SMT and exercise (37).”
I can get into the A+B design later if one acknowledges that research indicates that cSMT has some benefit. As well as doing the manipulation in a region other than the cervical spine doesn’t necessarily mean cSMT is a placebo.
DC, Please tell us, what exactly does the neck manipulation do, mechanically and neurologically, when it “benefits” what?
That isn’t just evidence, it’s chiropractic evidence 🤣
No idea what Pete point is, but a more recent paper on that topic.
“No idea what Pete point is, but a more recent paper on that topic.”
The chiro‑troll just keeps tossing out links without reading AND understanding the linked articles in relation to the topic of the conversation.
My quote was from link 4: … A Systematic Literature Review.
SPINE 44(15):p E914-E926, 1 August 2019.
Now, here’s chiro‑troll’s “more recent paper on that topic”:
What is this one review that focused on the cervical spine?
72. Schmid A, Brunner F, Wright A, Bachmann LM. Paradigm shift in manual therapy? Evidence for a central nervous system component in the response to passive cervical joint mobilisation. Man Ther. 2008;13:387–96. DOI: https://doi.org/10.1016/j.math.2007.12.007
“We searched randomised trials in three electronic databases from inception to November 2007”
That’s right, it isn’t “more recent”, it’s from 15 years ago.
That’s right, it doesn’t address Språkdoktorn Olle Kjellin’s question about neck manipulation, it’s about passive cervical joint mobilisation.
As usual, the spamming chiro‑troll doesn’t pay attention to important details (as with its fiasco muddling aspirin and paracetamol; neck pain and low back pain), not even when posting comments on an article about the tragedy of:
A young woman’s visit to a chiropractor left her unable to walk.
The other links were likewise vacuous spam, tedious smoke and mirrors.
Thank you Pete for your ever watchful eye and accurate assessment.
Well Pete, if you read the request is was:
“DC, Please tell us, what exactly does the neck manipulation do, mechanically and neurologically,…”
1. It’s naive to ask for an exact explanation. There are pharmaceuticals where they don’t know exactly what’s occurring and others where it’s taken decades to make that discovery. Do we know “exactly” what’s occurring with SMT? Of course not.
2. The request covers many areas from joint mechanoreceptors to cortical response. It would take a lengthy paper to explain “exactly” what’s occurring. I have no interest in doing that here.
3. I offered several papers which cover the neurophysiological topic so he/she could get an overview of the research on said topic. That is why I stated…”start here”.
4. Yes some of the reviews cover other topics. A smart person can tease thru a paper and find the relevant information. Some research can be applied to the cervical spine, others not.
5. I have no idea who this person is or their knowledge on the neurophysiology. So I am not about to spend my time needlessly.
6. I made no claim about the quality of any paper. However the reviews will/should mention that aspect.
7. Have a good day.
David, You’re most welcome.
DC, it’s both unfriendly and aggressive a debate technique to spew a lot of links to articles instead of answering my question. If there indeed IS an answer, you must be able to reveal it. Otherwise it rather seems you have no idea at all what to say.
>”There are pharmaceuticals where they don’t know exactly what’s occurring…”
– Who asked about pharmaceuticals? I must have missed it.
– What-aboutism will not help you. It only reveals your lack of knowledge. As for all the approved pharmaceuticals I know as a M.D., there is a great lot of knowledge about their chemical structures, mechanisms of action, indications, doses, overdoses, side effects, contraindications, pharmacodynamics, pharmacokinetics, interactions, effects on driving, pregnancy or breast milk, preclinical data, effects on the environment, mixability with other drugs and substances, etc. etc. etc. etc. Plus a very detailed protocol for reporting any suspected side effects, whether they are old and already wellknown, or new and perhaps surprising or even unlikely. It all has to be reported. Has chiropractic neck manipulation got any at all of this kind of important information and report protocol?
>”Do we know “exactly” what’s occurring with SMT? Of course not.”
– Of course not. That’s what I feared. So, how about “roughly” instead of “exactly”?
>”many areas from joint mechanoreceptors to cortical response. It would take a lengthy paper to explain “exactly” what’s occurring.”
– Where is that lengthy paper? Where in the references you suggested do they even remotely touch upon “exactly”? You must know the place exactly, since you offered it to me instead of saying it yourself. You could have just quoted it, couldn’t you?
>”I have no interest in doing that here.”
– You misspelt “interest” here. It should be “competence”, because you obviously do have interest in debating chiropractic here in Dr. Ernst’s blog. Years and years of comments prove that. So why suddenly “no interest” in revealing the very core of chiropractic?
– I happen to be a he. 🙂
>”Some research can be applied to the cervical spine, others not.”
– So you wilfully included irrelevant references? Why?
>”I have no idea who this person is or their knowledge on the neurophysiology.”
– I am a Swedish, retired diagnostic radiologist with a special interest in the neurosciences. I believe I know quite a lot about the relevant anatomy, physiology, and pathology. Do you? I will likely understand everything you may have to say as a reply to my question (unless it is too outlandish). What does neck manipulation do, mechanically and neurologically?
>”So I am not about to spend my time needlessly.”
– Because you can’t?
SOK> DC, it’s both unfriendly and aggressive a debate technique to spew a lot of links to articles instead of answering my question. If there indeed IS an answer, you must be able to reveal it. Otherwise it rather seems you have no idea at all what to say.
The links provide the research that has been done in the area that you questioned. If, after reading up on the topic, you have further questions, let me know.
Dr. Ollie Kjellin identified himself as a M.D and made his case very eloquently,. He uses his real name and is easily verified by a simple google search.
OTH, you claim to be a chiropractor with decades of experience, yet you hide behind various pseudonyms. You seem to spend time almost daily commenting on this blog, defending chiropractic and gish galloping around. But you don’t have time to answer a few questions. Perhaps you are too afraid to answer questions from someone who has the background and knows what they are talking about?
“The links provide the research that has been done in the area that you questioned.”
No, they don’t. I provided two illustrations above. It seems that the chiro‑troll is clueless, hence this:
“No idea what Pete [sic] point is, but a more recent paper on that topic.”
You’d need to acquire actual knowledge of the subject in order to understand my point.
Talker. There are several reasons I used that approach.
If he is truly interested in the topic he will read those papers and ask questions based upon that information.
In the meantime perhaps, as a radiologist, he can answer a few questions.
I’ve been told that the best means one hospital has to try to time a VAD is to use a comparison of different MRI sequences. T2-F, DWI, ADC with thin slice MR angiography with black blood protocols along with patient reported history. Then a committee of vascular neurologists and neuro-radiologists try to ascertain probable etiology and timeline.
What is the window of that timeline?
Is there a better means to time a VAD?
Have a good day.
You will only answer questions that you are comfortable answering within a narrow range of topics covered in papers selected by you.
You expect others to diligently answer your questions while not answering theirs. Interesting.
Above are examples of some evasive maneuvers you typically employ to avoid answering questions. It tells me that you neither have the knowledge nor the courage to engage in an honest discussion with others who understand the subject matter. No wonder why you are called chiro-troll.
DC, whoever you are,
>”If he is truly interested in the topic he will read those papers and ask questions based upon that information”
– If you are truly educated in the topic, you will be able to give a pertinent, relevant answer to a key question re the very basic justification for the existence of chiropractic treatment at all.
– In scientific and professional debates we don’t try to drown our opponents with a deluge of more or less obscure citations, but give relevant quotes illustrating the point. The quotations in their turn are accompanied by citations. Your behaviour gives the impression that you are neither scientifically educated nor professional.
>”In the meantime perhaps, as a radiologist, he can answer a few questions.”
– This attempt at dodging the question with irrelevant counterquestions is called stealing the topic and is a trick too cheap and blatant to go undetected. Gotcha! 😀
– Why do you call me “he”? Who are you?
SOK: The quotations in their turn are accompanied by citations.
That’s one option. Or I can skip the former and just provide the citations. I’ve been in too many discussions and debates where I honor requests such as yours only to have the other party not respond or rabbit trail. Waste of my time.
SOK: This attempt at dodging the question with irrelevant counterquestions is called stealing the topic and is a trick too cheap and blatant to go undetected.
Nope. It’s giving you time to read up on the former topic and still maintain a dialogue on the general topic.
It appears you won’t do either. So be it.
DC, if these five are the best references you could find for me, it confirms the conclusion that chiropractors don’t really know what they are doing when they manipulate spines. The articles are replete with non-statements hidden behind “thought to be”, “postulated”, “however”, “suggests”, “seems”, “might”, “potentially”, “need for high-quality studies”, etc..
None of them seems to specifically address cervical spine manipulation.
Why on earth did you want me to read up on these papers? And why did you expect me to pay money for them? You could just have written, honestly and friendly, that “So far, the exact mechanism through which spinal manipulation works has not been established” as concluded in (3).
And it should have been added that the phrase “spinal manipulation works” is an overstatement not very well underpinned.
Here are some quotes from these five best references, most certainly cherry-picked to suit my confirmation bias, so please, DC, pick som other sentences that you may regard as better and more objective!
1. From the abstract of Gevers-Montoro &al. Neurophysiological mechanisms of chiropractic spinal manipulation for spine pain. Eur J Pain. 2021. (https://pubmed.ncbi.nlm.nih.gov/33786932/).
Full text needs $$$.
“While spinal cord mechanisms of pain inhibition contribute at least partly to the pain-relieving effects of chiropractic treatments, the evidence is weaker regarding peripheral and supraspinal mechanisms, which are important components of acute and chronic pain. This narrative review highlights the most relevant mechanisms of pain relief by SM and provides a perspective for future research on SM and spine pain, including the validation of placebo interventions that control for placebo effects and other non-specific effects that may be induced by SM. SIGNIFICANCE: Spinal manipulation inhibits back and neck pain partly through spinal segmental mechanisms and potentially through peripheral mechanisms regulating inflammatory responses. Other mechanisms remain to be clarified. Controls and placebo interventions need to be improved in order to clarify the contribution of specific and non-specific effects to pain relief by spinal manipulative therapy.”
2. From the abstract of Pickar. Neurophysiological effects of spinal manipulation. Spine J, 2002. (https://pubmed.ncbi.nlm.nih.gov/14589467/).
Full text needs $$$.
“Conclusions: A theoretical framework exists from which hypotheses about the neurophysiological effects of spinal manipulation can be developed. An experimental body of evidence exists indicating that spinal manipulation impacts primary afferent neurons from paraspinal tissues, the motor control system and pain processing. Experimental work in this area is warranted and should be encouraged to help better understand mechanisms underlying the therapeutic scope of spinal manipulation.”
3. From the abstract and snippets of Gyer &al. Spinal manipulation therapy: Is it all about the brain? A current review of the neurophysiological effects of manipulation. J Integr Med, 2019. (https://www.sciencedirect.com/science/article/abs/pii/S2095496419300597).
Full text needs $$$.
“To date, Pickar […] is the only one that provided a theoretical framework for the neurophysiological effects of spinal manipulation. …
“Over the past decades, numerous hypotheses have been offered to explain these mechanisms, but evidence to support these theories is still limited. …
“So far, the exact mechanism through which spinal manipulation works has not been established. …
“However, the clinical relevance of these changes in relation to the mechanisms that underlie the effectiveness of spinal manipulation is still unclear. In addition, there were some major methodological flaws in many of the reviewed studies. Future mechanistic studies should have an appropriate study design and methodology and should plan for a long-term follow-up in order to determine the clinical significance of the neural responses evoked following spinal manipulation.”
4. From the abstract of Wirth &al. Neurophysiological Effects of High Velocity and Low Amplitude Spinal Manipulation in Symptomatic and Asymptomatic Humans. A Systematic Literature Review. Spine, 2019. (https://journals.lww.com/spinejournal/Abstract/2019/08010/Neurophysiological_Effects_of_High_Velocity_and.15.aspx).
Full text needs $$$.
This systematic review points to HVLA-SMT affecting the autonomic nervous system. The effects seem to depend on the spinal level of HVLA-SMT application and might differ between healthy volunteers and pain patients. There is a need for high-quality studies that include patients, well characterized for pain duration and outcome measure baseline values, and address the relation between changes in neurophysiology and pain.
“Level of Evidence: 2
5. From Bialosky &al. Unraveling the Mechanisms of Manual Therapy: Modeling an Approach. J Orthop Sports Phys Ther. 2018. (https://www.jospt.org/doi/pdf/10.2519/jospt.2018.7476)
Full text retrieved.
This paper does not remotely address the mechanism of action, only the authors’ vain efforts to model it. It has a very long, mumbling abstract containing no substance but trying to explain why the modeling was so difficult.
“Despite the popularity of MT, systematic reviews only find small to modest effect sizes, or fail to recommend these interventions …
“Subsequent efforts should focus on a broader understanding of how MT alters processing of nociception to impact the entire pain experience”
SOK: You could just have written, honestly and friendly, that “So far, the exact mechanism through which spinal manipulation works has not been established” as concluded in (3).
DC on Friday 24 February 2023 at 11:51
Do we know “exactly” what’s occurring with SMT? Of course not.
Oh, the irony.
Well, perhaps some here need some basic background information…
“Mechanoreceptors are specialized neurons that transmit mechanical deformation information (e.g. joint rotation due to positional change and motion) into electrical signals.17,18 Stimulation of these receptors results in reflex muscle contraction about the joint as an adaptive control to sudden movements of acceleration or deceleration.9
Each of the above mentioned five mechanoreceptor types responds to different stimuli and transmits specific afferent information that modifies neuromuscular function. All receptors need a stimulus to change their membrane potential causing an action potential to travel to the CNS. For example, it is speculated that longitudinal tension on a ligament results in compression of the connective tissue that stimulates the mechanoreceptors.19 Mechanoreceptors can also be stimulated by muscle-length change, including the rate of change in tension and length. The mechanical deformation of a receptor stretches the membrane and opens the ion channel. This allows positively charged ions (Na+) into the cell, which creates a net depolarizing effect that generates a nerve receptor potential. Mechanoreceptors detect deformation of the receptor itself or of cells adjacent to the receptor.20
Mechanoreceptors demonstrate different adaptive characteristics related to their response to a stimulus. Quick-adapting (QA) mechanoreceptors (Pacinian corpuscle), decrease their discharge rate to extinction within milliseconds of the onset of a continuous stimulus. Slow-adapting (SA) mechanoreceptors (Ruffini ending and the Golgi tendon organ), remain discharging in response to a continuous stimulus. QA mechanoreceptors are very sensitive to changes in stimulation and are therefore considered to mediate the sensation of joint motion QA mechanoreceptors may be more important in some sports characterized with sudden directional changes like pivoting, shifting, tackling etc. SA mechanoreceptors are maximally stimulated at certain joint angles, and thus a continuum of SA receptors is thought to mediate the sensation of joint position.21,22 Stimulation of these receptors results in reflex muscle contraction about the joint.9,23 When there is no capsuloligamentous strain (or load) on the joint (midrange of position), afferent neurons are not active and they do not play a role in proprioception. Rather, many studies argue that joint afferents (especially Ruffini corpuscle) are limit detectors.24
The muscle spindle receptor is a complex, fusiform, SA receptor located within skeletal muscle. Via afferents and efferents to intrafusal muscle fibers, the muscle spindle receptor can detect muscle tension over a large range of extrafusal muscle length. The monosynaptic stretch reflex involves muscle spindle receptor connecting I-a nerve fibers as well as Golgi tendon organs connecting to I-b fibers. During rapid perturbation such as tripping or falling, monosynaptic reflexes are absent and compensation occurs as a result of transmission along group II and III afferent fibers from secondary muscle spindles. These connect through a polysynaptic reflex system to generate an appropriate response. The contribution of vestibular and visual input to these reflexes is minimal. Gravity and pressure on joints and on the plantar skin surface may be critical to these reflexes.25”
Clinical Sports Medicine
Medical Management and Rehabilitation
Book • 2007
Edited by: Walter R. Frontera, Stanley A. Herring, … Timothy P. Young
@DC, again, you can’t be serious! Have you even studied histology? Can you tell which if any of the mechanoreceptors mentioned in your quote is actually positioned in an articulatory capsule?
But surely, there are receptors in articulatory capsules too. How do you verify which one in which joint to “stimulate” and how to manipulate it specifically in order to treat pain?
“Can you tell which if any of the mechanoreceptors mentioned in your quote is actually positioned in an articulatory capsule?”
This has been studied for some time.
Example, from 1994:
My question was: How do you verify which [receptor] in which joint to “stimulate” and how to manipulate it specifically in order to treat pain?
And how do you avoid manipulating the innocent joints of a vertebra?
In case you hadn’t noticed, you’ve been directing your questions to a chiropractic meatball. DC is hopelessly enmired in chiropractic oobleck and disabled with the chiropractic Story of the Chiropractic Nerves. That said, you, and others trying to get substantive answers to direct questions as to what chiropractors think, say, and do, will never get beyond DC’s chiropractic nose which he touches with his every reply.
“What does the neck manipulation do,” Språkdoktorn?
Here’s an answer I offered in one of my responses to viewer mail I received after the PBS documentary A Different Way To Heal? first aired 20 years ago now. Nothing has changed so I’ll copy the question and my answer here below:
I stated that the “popping” of a joint doesn’t signal any change in the “position” of that joint any more than “cracking” a knuckle does. Similarly, “mobilizing” knuckles does NOT a medicine make, despite the testimonials of “knuckle-crackers” who are continually and habitually doing this and claiming relief. In any case, the extension of an argument for “knuckle-mobilization” is that you could imagine an entire profession of chiropractors fully dedicated to providing and billing for the equivalent of “spinal knuckle-cracking.” Vertebral joints are synovial-type joints that “pop” when you “stretch” them just as I demonstrated on the show when I “popped” a single finger joint. There is no evidence that cracking knuckles OR spines makes them “function” any better –at least as “dysfunction” and “function” are variably defined by chiropractors from office to office.
Gas coming out of solution when joint spaces are expanded is (to borrow a phrase of one of the DCs featured on the show), “Just physiology.” Well, so is gas that sometimes evolves in the intestine after eating; but we don’t refer to its casual release as a medicine, even as it might occasionally provide temporary relief. In a society with limited health care resources, we certainly don’t train Doctors of Intestinal Gas (DIGs) and then pretend we’re talking about gastroenterology. This would be making a “medical mountain” out of a physiologic “mole hill,” wouldn’t it.
@John Badanes, “Doctors of Intestinal Gas (DIGs) and then pretend we’re talking about gastroenterology” – Spot on! 😀
Apart from that, it is fascinating to see a person humiliate themselves in absurdum based on religious beliefs. In this case even gaseous beliefs.
Hey John Badanes…fabulous post!
I’ll be sharing this one with Sandy and putting your reply and comments in our forever files!
We’re having Meatballs for dinner.
Språkdoktorn Olle Kjellin : Thank you for your posts! I think you nailed it when you describe the Chiropractors insistence in preforming rapid neck manipulations as some kind of “sacred” act. Perhaps this does indeed define it well. A warped Sacred belief system that personifies what they are as a “profession” and sets them apart from other similar disciplines.
DC: Your last comment, “current evidence indicates there can be some benefit and the primary risk appears to be with the individual practitioner, not with the procedure per se.” …attempts to put the blame on the individual Chiropractor, however my wife Sandra like many other victims, had been seeing her same chiropractor for many years prior to the catastrophic stroke event that would change her life forever. Nothing he did that sad day was any different from any other day.
Again, for the record, I applaud those Chiropractors who have rejected their peers, and have chosen to cease preforming upper cervical manipulations.
Our lives were destroyed from this devasting and foolish cervical neck manipulation practice.
September 13th, 2007, my young healthy vibrant wife was robbed of everything good, and we will never stop sounding the alarm to the inherent and needless dangers of rapid neck manipulations.
David. Something was different that dreadful day. To be blunt, if it wasn’t the chiropractor it was within your wife. Thru research I want to know what was different in these type of cases.
Some have suggested that repeated upper cervical manipulation over time causes micro trauma to the vertebral artery. Then, at some point, the dissection occurs. It’s a sound view IMO. Some consider repeated spinal manipulation in the same area a contraindication. If that was the case with your wife then I still place the blame on the chiropractor if he or she caused the condition.
I appreciate your view to stop all upper cervical manipulation. The only way that will occur is with better evidence and, at least in many countries, an act of the government.
There are grass root activities by some physical therapists and osteopaths to, at minimum, remove cervical manipulation from their clinical guidelines. They also want to stop teaching it to students and in their continuing education classes (some colleges have done so). One would think that an easy task since they do less than 10% of all cervical manipulation. But they encounter resistance within their own profession.
Chiropractors? Current best approach is educating them on the topic which is what I try to do.
“Something was different that dreadful day. To be blunt, if it wasn’t the chiropractor it was within your wife.”
That’s a very daring assumption; do you have any evidence for it?
The assumption is that his premises are true.
“The assumption is that his premises are true.”
No, your assertion is that:
The article on which you also asserted:
Thank you for your response DC.
I am in agreement with you at least on this point. It may very well be, that for some patients, repeated neck manipulations of the high velocity type do indeed increase the odds of a serious injury. An accumulation of small tears within the walls of the Vertebral Arteries perhaps. However, with many Chiropractors insisting on repeated visits and some sessions only mere days apart, things are unlikely to change as for the stroke victim count.
This very fact would once again suggest that there are probably many cases that go unreported. That an impending Stroke happens and is not identified or linked to a past Chiropractic “treatment”.
Our own situation in particular, was well documented throughout my wife Sandy’s ordeal. Her vitals, internal organs, young age, lifestyle and overall health were examined with immense scrutiny. (Hourly, Weekly, Monthly and Yearly) The results were extremely clear as to the “why” this happened as Sandy was a picture of above average health!
Our question FOR today is also the “why”. Given what we now know: “Why” with all these unfortunate victims, are Chiropractors still using this rapid neck manipulation as a form of treatment?
Truly, if what you say about the acculmulation factor makes sense, and I think it does, why not champion for change?
David I do advocate for change and continuing research.
Basically: if there isn’t a significant change after two weeks of care, regardless of what one is doing, stop, re-evaluate and do something different.
“An Office of Inspector General audit found that about $358.8 million, 82 percent, of the $438.1 million that Medicare paid for chiropractic services was unnecessary. ”
Apparently, chriopractors in US have been fraudulently billing medicare. Do you advocate for change in chiropractic billing practices?
Talker: You nailed this Billing topic so well! Thank you for telling it like it is.
Not to mention our own personal firsthand experience when it comes to Chiropractic records being illegally doctored. In our case the records were WILLFULY altered. The Chiropractor who injured my wife, also admitted to fraudulently not only modifying her visit medical treatment records an, but also admitted to lying under oath and forging her consent signature! And the icing on the cake…once this was revealed the Canadian Chiro Board dropped his insurance coverage and incredibly only gave him a three-month suspension.
Talk about the Fox guarding the Hen House.
I often wonder what the discipline outcome would have been for this Chiropractor, had he been a real Doctor and had to answer to the Alberta Colledge of the Physicians and Surgeons Board?
Björn Geir: What you stated is so powerful!
I’ve never looked at this topic like this before, but you are right on the money… if chiropractic neck manipulations were indeed a drug, it would have been tossed into the list of forbidden ages ago.
Thank you, David. I am sorry to hear about what you and your wife were subjected to. But don’t just listen to what I have to say about the topic of billing, I am just a random anonymous guy on the internet. Here is an article written by then editor-in-chief of a chiro friendly publication, Chiropractic Economics: https://www.chiroeco.com/chiropractic-noncompliance/ and he doesn’t mince words.
Our resident chiro-troll wants us to believe that this is just a minor billing issue that happens all the time and that chrios don’t make much in Medicare reimbursements, therefore there is nothing to see here. However, one must ask oneself, how does mere billing issues moth ball into over a third of a billion dollars in Medicare payments overpayments to chiros? Is it just systemic incompetence among chrios or blatant disregard of the rules and regulations or is its outright fraud during billing or a combination of all? Mind you, according to chrios: https://www.thegoodbody.com/chiropractic-statistics-facts/ they treat only 10% of US population, that percentage would be much lower if you consider Medicare eligible population (65 and older). Fraud and incompetence in Medicare billing is one tiny aspect of chiropractic business and let us not forget the fact that chiropractic itself is a pseudoscientific endeavor started by Palmer and 100+ years later it is still being inflicted on the population at an industrial scale.
Talker. Much of that is due to issues with documentation.
“However, the chiropractors did not document the medical necessity of 559 services (86 percent) as required by Medicare; an additional 56 services (9 percent) were either not documented or insufficiently documented.”
For example, Medicare requires that every page have the chiropractors signature and patient’s ID number. If that is not present Medicare will reject the claim in an audit.
For example: Medicare has certain criteria that needs to be documented with care to show patient improvement. If just one of those criteria is not documented, even though the patient is in fact improving, Medicare will reject the claim as “medically unnecessary.”
Yes it is an issue. To call that fraud?
80% of chiros who treat Medicare patients are sloppy at paperwork and their mistakes cost taxpayers $358 million. According to you, all that can be attributed to “documentation” issues. That is quiet the spin, spin doctor.
On page 4:
Bottomline is, either chiros are defrauding the govt on a massive scale or they are massively incompetent and cannot be trusted to do paperwork or a combination of both. Give the massive levels of incompetence and/or fraud, are patients supposed to trust their necks with chiros?
Besides, you didn’t answer my original question: Do you advocate for change in chiropractic billing practices?
Fraud is an intent to deceive to obtain money. I don’t consider an error on paperwork necessarily fraud. If it’s intentional, sure, call it what it is.
“the crime of getting money by deceiving people” (Cambridge)
Talker: Do you advocate for change in chiropractic billing practices?
I “advocate” for chiropractors to properly document care.
Medicare reimbursement is actually a joke for chiropractors. To adjust a low back I get about $20 from Medicare.
I am sorry you are making so little money from Medicare reimbursements. Meanwhile, your fellow chrios are raking in millions defrauding Medicare.
If you want to ignore the instances of fraud mentioned in the OIG report (and elsewhere) and act like this is just a paperwork issue, so be it.
hehehe … so, you ADJUST the low back, do you 😊
I think you need to describe _precisely_ the “adjustment” for which Medicare pays you “about $20.” And what is the diagnosis that, in your clinical opinion, required “Thuh” Adjustment you’ve described?
Perhaps getting reimbursed $20 for your chiropractic “adjustment” is a joke 🤭
Are you saying that the 80% is the percentage of chiropractic procedures with incomplete paperwork rather than of chiropractic procedures that were unnecessary?
I suppose that would explain the figure being so low.
“Medicare reimbursement is actually a joke for chiropractors. To adjust a low back I get about $20 from Medicare.”
‘DC’: “Fraud is an intent to deceive to obtain money.”
Talker: If you want to ignore the instances of fraud mentioned in the OIG report (and elsewhere) and act like this is just a paperwork issue, so be it.
did I say it was just a paperwork issue? No.
Mojo: Are you saying that the 80% is the percentage of chiropractic procedures with incomplete paperwork rather than of chiropractic procedures that were unnecessary?
No. I’m saying one has to look at the specifics of what they found and separate out what is true fraud and what are errors in documentation.
Let’s see what you wrote:
You certainly implied it.
“ In 2018, the Comprehensive Error Testing Program (CERT) that measures improper payments in the Medicare Fee-For-Service (FFS) program reported a 41 percent error rate on claims for chiropractic services. Most of those errors were due to insufficient documentation or other documentation errors.”
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services.
Article Release Date: May 7, 2019
If “chiropractic” neck manipulation was a drug, it would long since have been withdrawn from the market. It would never have been marketed in the first place, but that is another story.
I wasn’t talking about fraud, I was talking about the percentage of chiropractic procedures that are unnecessary. Given the evidence I would say that 80% is far too low.
Not to defend the chiro therapy practice, I’n neither for or against it.
However, I’m a bit surprised at the focus here of Medicare system fraud attacks placed only on Chiropractic therapy. The same game of double standards on the Ernst forum again.
Fraud exists through and through the US medical system. MDs are complicit in the fraud also. In fact, since MDs represent a larger work force than acupuncturists, I charge that more fraud is perpetuated from MDs than Chiros…. it’s just a numbers game. Hundreds of millions of dollars of Medicare fraud is due to MDs playing the same game as Chiros.
Why the finger pointing ? …. because you here don’t like the profession.
Nothing to see here.
I know it is impossible for you to understand this but try to wrap your head around the fact that this blog is about SCAM and this specific post is about Chiropractic. Hence the discussion about Chiropractic Medicare fraud.
… might be a bit difficult for RG.
The subject of Chiropractic Medicare fraud is not found in the original post from the professor. It’s another subject up for discussion within the conversation from posters, and I added by pointing out another view of the discussion.
There is only one view they want to discuss here.
Otherwise we could get into stuff like this.
Ok then, while we are at it let’s talk about financial fraud and crimes unrelated to SCAM or medicine in general.
Wait….we don’t have to restrict ourselves to crimes. Why not talk about sports? Or whale watching, mountaineering? We do have a lot to talk about. Who wants to go first?
Considering all the past and current critical reviews and the undeniable proof of numerous injuries being caused by rapid upper neck manipulations, how on earth is this “procedure” still even being allowed to continue? The risk versus harm debate is over.
As an exhaustively documented victim of such an event, my wife Sandys injury and its serious life altering consequences, have unfortunately brought us into the media limelight. As a result, we continue to hear from other folks who across North America and abroad have also been victimized. My wife’s case was publicized and covered on a National and Worldwide level, hence the continued people reaching out to us even today for advice, comfort and encouragement.
We offer condolences of course to every soul who reaches out to us and offer what support we can legally, but it still saddens us greatly. Sometimes the pain is overwhelming, and I choose not to share every new neck manipulation screwup case with Sandy because with each victim, comes a reminder of her own fate.
So where do we go from here? What more can we do to stop this insanity and abuse that continues to go unchecked?
Who has the power to influence common sense and make a difference?
Trying to hold out on to hope, that change will happen soon but with word of each new victim we grow weary.
On behalf of my wife Sandy and myself, I would like to once again thank every person on this blog for sharing their knowledge, wisdom and passion. You do give us faith and the courage to believe all things are possible.
you are too kind!
as far as I am concerned, I will bang on about the subject and hope for the best.
the decisive move, I think, will have to come from a political level.
To start, get PTs and DOs:
To remove cSMT from their clinical guidelines.
To have their respective national organizations proclaim official statements to stop all cSMT.
To have their colleges and continuing education classes stop teaching cSMT.
To make their regulatory boards rule the cSMT is outside their professional boundaries.
To get them to stop all research on any possible benefits from cSMT.
To get insurance companies to stop reimbursement for cSMT.
The chiro‑troll deploys a fallacy of illicit transference: masquerading a term in the distributive as the collective.
If you’re good at pretending and lying, you’re an expert at dissembling. Dissembling is a fancy word for being tricky, slippery, and deceitful. This word isn’t just for people who lie and commit fraud: it specifically has to do with pretending.
No Pete. It has do to with understanding the complexity of the “problem” and the process to achieve David’s goal. I provided the starting points. You provided…nothing.
Solution DC suggested attests to his undeniable genius. PTs and DOs who according to DC: “do less than 10% of all cervical manipulation.” should stop performing cSMT. Chiros who we can safely assume perform far more than 10% of all cSMTs should I guess do nothing? DC doesn’t say what chiros would need to do. His solution makes perfect sense to me and to anyone who reads his post.
Therefore, Pete, you should stop complaining and start coming up with solutions.
Of course, DC fails to link the document and mention that chiros have the highest improper payment rate of 41% among the top 20 service types listed here on page 33: https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/CERT/Downloads/2018MedicareFFSSuplementalImproperPaymentData.pdf
Coming at a distant second place is the category “Lab tests – other (non-Medicare fee schedule)” at 29.8%
To attempt to ban cSMT it would be easiest to do so with those who perform the fewest number of the procedure.
If, or when, what I mentioned is accomplished, it would be as Ernst mentioned, a political battle with chiropractors.
Right now, to attempt a political avenue, one would be taking on at least three professions. Eliminate two of them first.
Assuming we are both talking about banning cSMT for the sake of public health, first targeting the folks who do it the least makes perfect sense. Because that is what make the biggest impact w.r.t public health. Also, it is a win for chiros because competition would be eliminated.
Talker, it’s a form of “divide and conquer”.
Interesting that the only one that has given David an outline of a process to stop the professional use of cSMT is a chiropractor.
But perhaps it’s because I have insight as I know osteopaths and physical therapists who are actively pursuing the means I outlined above.
Interesting that you do not know of any chiros who are actively pursuing the means you outlined above to ban cSMT performed by chiros. Or as I said earlier, you might be a chiro who wants to see the competition eliminated.
As the dissembling chiro‑troll has so clearly revealed via its plethora of comments on this article:
● chiropractic HVLA cSMT is masqueraded as being cSMT — which is a fallacy of illicit transference;
● chiropractic HVLA cSMT is not an adequately documented, auditable, procedure, it is simply whatever the individual chiropractor chooses it to be.
This article, which chiro‑troll is spamming and trolling, is entitled:
A young woman’s visit to a CHIROPRACTOR left her unable to walk
And Sandra Nette was injured by a CHIROPRACTOR performing chiropractic HVLA cSMT in the name of ‘maintenance adjustments‘.
What an excellent job of impersonating an utter moron.
Neither PTs nor DOs injured the victims being discussed.
Neither PTs nor DOs perform chiropractic HVLA cSMT; neither do they perform CHIROPRACTIC maintenance adjustments/treatments with its theatrical neck joint cracking/popping.
In the USA, out of PTs, DOs, and chiropractors, only one category: is classified as pseudoscience; performs bogus diagnoses and bogus treatments; has cosplay ‘doctors’; has utter nincompoops attempting (without success) to whitewash it, failing dismally to defend the indefensible.
David is free to consider my suggestions or not. He is also free to consider your views on my suggestions and about me.
Have a good day.
“The FY 2020 Medicare FFS estimated improper payment rate is 6.27 percent, representing $25.74 billion in improper payments.”