Yes, this post is yet again about the harm chiropractors do.
No, I am not obsessed with the subject – I merely consider it to be important.
This is a case presentation of a 44-year-old male who was transferred from another emergency department for left homonymous inferior quadrantanopia noted on an optometrist visit. He reported sudden onset left homonymous hemianopia after receiving a high-velocity cervical spine adjustment at a chiropractor appointment for chronic neck pain a few days prior.
The CT angiogram of the head and neck revealed bilateral vertebral artery dissection at the left V2 and right V3 segments. MRI brain confirmed an acute infarct in the right medial occipital lobe. His right PCA stroke was likely embolic from the injured right V3 but possibly from the left V2 as well. As the patient reported progression from a homonymous hemianopia to a quadrantanopia, he likely had a migrating embolus.
The authors discussed that arterial dissection accounts for about 2% of all ischemic strokes, but maybe between 8–25% in patients less than 45 years old. Vertebral artery dissection (VAD) can result from trauma from sports, motor vehicle accidents, and chiropractor neck manipulations to violent coughing/sneezing.
It is estimated that 1 in 20,000 spinal manipulation results in vertebral artery aneurysm/dissection. Patients who have multiple chronic conditions are reporting higher use of so-called alternative medicine (SCAM), including chiropractic manipulation. Education about the association between VAD and chiropractor maneuvers can be beneficial to the public as these are preventable acute ischemic strokes. In addition, VAD symptoms can be subtle and patients presenting to chiropractors may have distracting pain masking their deficits. Evaluating for appropriateness of cervical manipulation in high‐risk patients and detecting early clinical signs of VAD by chiropractors can be beneficial in preventing acute ischemic strokes in young patients.
Here we have a rare instance where the physicians who treated the chiro-victim were sufficiently motivated to present their findings and document them in the medical literature. Their report was published in 2021 as an abstract in conference proceedings. In other words, the report is not easy to find. Even though two years have passed, the full article does not seem to have emerged, and chances are that it will never be published.
The points I am trying to make are as follows:
- Complications after chiropractic manipulation do happen and are probably much more frequent than chiros want us to believe.
- They are only rarely reported in the medical literature because the busy clinicians who end up treating the victims do not consider this a priority and because many cases are settled in or out of court.
- Normally, it would be the ethical/moral duty of the chiros who have inflicted the damage to do the reporting.
- Yet, they seem too busy ripping off more patients by doing neck manipulations that do more harm than good.
- And then they complain that the evidence is insufficient!!!
39 Responses to Another case of stroke due to chiropractic
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The most prevalent complication of ‘chiropractic’ cervical manipulation is that it is of no proven benefit; patients do not give properly informed consent with this understanding; and many chiropractors “seem too busy ripping off more patients by doing neck manipulations that do more harm than good.”
Sadly, many of us remember the case of John Lawler (a patient with ankylosing spondylosis, surgically fused lumbar spine, RIP after chiropractic manipulation).
I have personal knowledge of an orthopaedic surgeon who manipulated a cervical spine (under GA), caused partial paralysis and only then did an XR which identified a tumour in a vertebral body.
(Successfully treated by orthopaedic and neuro surgeons).
However, just because some other professionals are incompetent, that is no excuse for the general approach adopted by chiropractors.
IMHO, no one should have their neck manipulated – except to reduce a traumatically induced dislocation.
Which I have done – and bone leavers are needed with some force at open operation to achieve resolution.
Caveat emptor – but the chiropractic community denies the awareness the emptors need.
All emptors should be aware of the Professor’s wise words and this blog.
“Caveat emptor – but the chiropractic community denies the awareness the emptors need.
All emptors should be aware of the Professor’s wise words and this blog.”
And should buy and read “Real Secrets of Alternative Medicine” and “Chiropractic; Not all that it’s Cracked Up To Be”!
“It is estimated that 1 in 20,000 spinal manipulation results in vertebral artery aneurysm/dissection.”
Estimated by whom and based on what data?
The earliest I have found for such a number was by Vickers in BMJ. However, his statement was regarding AE in general but also wrote it could be up to 1 in 1 million. However he provided no references or data.
It was Schievink a few years later in the NEJM who applied the 20,000 to cSMT causing a stroke. Again no data to back this up, he only referenced Vickers.
One would think if authors want to reference an actual study they would use Rothwell’s paper.
it’s from the published abstract; abstracts do not normally have references.
It depends on the conference, some allow references in the abstract, some don’t. Regardless, they shouldn’t have used the 1:20,000.
your attempts to distract from the main points of the post is all too transparent.
Oh, I could go thru points. But it’s all circular.
“Estimated by whom and based on what data?”
This question & the tenor of this chiropractor’s post raise 2 red flags for me:
First is the possibility that he/she is simply ignorant vis-à-vis the safety / efficacy principle.
Or, of greater concern, he/she (based on his/her vested interest as a chiropractor) simply doesn’t give a rap about his/her clientele’s wellbeing.
Or, I think authors should do their homework.
Using the 20,000 would mean cSMT is causing around 40 VADs every week in the USA. Yet no study has even come close to that number. I think Rothwell came to around 1:500,000 but that’s association.
“Results in”?
“It is estimated that 1 in 20,000 spinal manipulation results in vertebral artery aneurysm/dissection.”
Sloppy.
…”First Do No Harm.”
For clarification:
Why does any one decide to train and practice as a chiropractor and not (if they wish to engage in healthcare), as an osteopath, physiotherapist, or registered medical practitioner (doctor)?
‘Chiropractic’ always has been an alternative to ‘conventional medicine’ of the day.
Only alternative patients should be interested.
Good luck with that, emptors.
It’s one my wife and I still struggle with even today. Indeed… why would anyone become a Chiropractor?
When I Google Chiropractic, I remain dumbfounded by the ridiculous health claims made by chiropractors. And they continue to advise in the necessity of going for weekly treatments!
We don’t need “WEEKLY Adjustments”…we need to Adjust our focus and just call it for what it is: Russian Roulette.
There’s a chiropractic place in my area. They have a big poster in the window that advertises “Free spinal checks”. I do wonder what that might consist of, and result in, but I don’t go in – in case they tell me I’m spineless………
these places would check your spine, tell you that you suffer from subluxation [of course], suggest lengthy treatments and maintenance therapy consisting of spinal manipulation, and take a lot of money from you.
Well, the one thing they won’t say is:
Mr. B, thank you for visiting us. We have very good news for you. Your spine is in perfectly adequate health therefore neither treatment nor maintenance care is advisable.
I can only speak for myself on the free thing.
I offer a free consultation. About 10 minutes for a person to tell me their health concern and I tell them my basic approach. No exam. Then we can decide if they should become a patient. Some do, some don’t.
I have two week treatment plans with re-evaluations every 2 weeks. My goal is to release from care within 2-4 weeks. Some chronic pain or complex cases can take longer.
FWIW there are dentists, optometrists and physical therapists that offer free new patient offers. There can be various reasons.
@DC
Do you perform any kind of cervical manipulation? If so, why and how?
Also, how do you rule out underlying pathology that might be disrupted or otherwise aggravated by manipulation?
Bjorn. We both know you are just looking for a “gotacha’ moment”.
DC wrote: “Bjorn. We both know you are just looking for a ‘gotacha’ moment’.”
What a typically evasive chiropractic comment. For DCs, any question or comment that requires justification is regarded thus.
Bjorn asked a simple question & got sarcasm as a reply.
Because Bjorn and I have had many discussions over the years, I know his tactics.
(psst, you should look up the definition of sarcasm before you use the word).
These are well known signs and symptoms to look for (covers full spine).
https://www.physio-pedia.com/Red_Flags_in_Spinal_Conditions
Can there be a silent pathology? Sure, but these are rare even among conditions that are not commonly encountered in practice.
Regarding VAD, I can run the numbers of the probability that:
1. A patient would come into a chiropractic clinic with a VAD
2. That there would be no clinical indications of a VAD
But what’s the point when most here aren’t objective?
… except you, of course.
@DC
Since you do not answer with a simple no, I understand that you do perform cervical manipulations.
I think you should consider answering the rest of my questions, it might be good for you to contemplate what and why you are selling services that you seem to be embarrased to admit and discuss.
I admit stuff like this bothers me…
116.5 million case acute low back and neck pain in USA
Most common use NSAID is low back and headaches
900 OTC and Rx drugs contain NSAIDs
111 million Rx of NSAIDs per year
30 billion doses NSAIDs per year in USA
$4.8 billion cost of NSAIDs per year in USA
46 people die per day from complications of NSAIDs
NSAIDS might account for 41% of the association between OA and CVD.
NSAIDs may actually contribute to developing chronic pain states
NSAIDs may not reach clinical significance for pain reduction in low back pain
NSAID NNT for low back pain is 6
Amazing these are sold OTC. But hey, at least its not CAM.
Are you not a bit like the guy who says it’s ok for him to beat up his wife because his neighbor does even worse things to his partner?
QUOTE
Are cervical manipulations for neck pain truly ‘much safer than the use of NSAIDs’?
…
In conclusion, the much-cited paper by Dabbs and Lauretti is out-dated, poor quality, and heavily biased. It provides no sound basis for an evidence-based judgement on the relative risks of cervical manipulation and NSAIDs. The notion that cervical manipulations are safer than NSAIDs is therefore not based on reliable data. Thus, it is misleading and irresponsible to repeat this claim.
DC on Wednesday 23 January 2019 at 18:53
116.5 million case acute low back and neck pain in USA (1)
NSAID are a common Rx for low back back (2)
900 OTC and Rx drugs contain NSAID (3)
111 million Rx of NSAID per year (1)
30 billion doses NSAID per year is USA (4)
$4.8 billion cost of NSAID per year in USA (1)
71% of those exposed to NSAID for >90 days had visible injury to their small intestine (5)
46 people die per DAY from complications of NSAID (1)
[links omitted]
https://edzardernst.com/2019/01/are-cervical-manipulations-for-neck-pain-truly-much-safer-than-the-use-of-nsaids/
Bjorn, based on memory recall, of my patients with neck complaints this month, around 5% ended up having cSMT. Thus, 95% never had cSMT.
Did I have a MRA, CT or Doppler done on all those? No, just with one of them whom I sent out before rendering care (it was negative for VAD/stroke/pathology)
FWIW as comparison, I think most other chiropractors would have done cSMT on the 95% of which I did not.
FWIW if you look at the data of physical therapists who can do cSMT my percentage closely matches theirs.
How I do cSMT is not easily explained in words. If I can find a decent video that closely represents my approach I will share it later.
Perhaps you didn’t see an early post of mine but I use a graded approach.
Exercise
Soft tissue work
Mobilization
Manipulation
Usually the first three will resolve the complaint.
OK, you can now do your gotcha moment. Ernst can can do his quack comment and Pete his whatever and make me out to be the bad chiropractor.
quack
[I did not want to disappoint you!]
EE
Are you not a bit like the guy who says it’s ok for him to beat up his wife because his neighbor does even worse things to his partner?
Are you a bit like the guy who says it’s OK that he beats his partner because that’s all he knows what to do?
while I tried to put the ‘tu quoque’ fallacy (https://en.wikipedia.org/wiki/Tu_quoque) in words, you just put utter stupidity in a sentence.
BRAVO!
Bjorn, this one is OK. I tend to use a thumb contact and the adjustment is with the wrist.
https://youtu.be/PNk8mfVmc9A
‘DC’ wrote: “How I do cSMT is not easily explained in words.”
Then you are not performing an adequately documented, auditable, procedure.
It’s odd, isn’t it, that a technician who works on your vehicle has to follow thoroughly documented strict procedures — including precise details such as the tightening sequence and torque of wheel nuts and cylinder head bolts — yet a chiropractor is free to use their own version of ‘treatment’ (cSMT) applied to human cervical spines. And when asked for a description of said ‘treatment’, our resident self-proclaimed chiropractor provides a link to a poorly produced YouTube video that is “OK” despite it showing a different technique [“I tend to use a thumb contact and the adjustment is with the wrist”].
Now, what do you think would happen if vehicle technicians, gas engineers, electricians, and nurses had the same level of ‘professionalism’ as this self-proclaimed chiropractor, who hides behind various pseudonyms.
Heck Pete, there are least 12 different possible hand contacts and at least 7 different listings possible.
To explain all those variations here to someone who is probably not familiar with them would not be easy….or at least not worthy of my time.
Share a video….done.
(Psst…your analogy is dumb)
Have a good day.
Dear chiro‑troll,
Heck chiro‑troll, which of those many combinations have led to client injury and/or death, and which have not (thus far, at least)? This isn’t a trivial question, it is a vitally important question considering the context: Another case of stroke due to chiropractic.
If the ‘profession’ was genuinely interested in keeping clients out of wheelchairs and coffins, a good place to start would be to thoroughly document the individual techniques used by chiropractors, then produce both prescribed and proscribed clinical procedural guidelines. Why are there no such guidelines [rhetorical].
As Edzard has said to you previously: oh dear, what a patronising git you seem to be!
Notwithstanding, you have proved my point that you are not performing an adequately documented, auditable, procedure.
Let me make this clear enough for even you to follow: if there were adequately documented, auditable, procedures for chiropractors to follow, then you could simply provide a link to the documentation. You wouldn’t need to concern yourself with the readers of this blog being “not worthy of your time”.
You have often claimed that injuries are most likely caused by the technique of the individual chiropractor involved, and unlikely to be caused by the [chiropractic] procedure per se (or words to that effect).
Without evidence of the precise technique used, which resulted in the injury — and comparing that technique with prescribed and proscribed clinical procedural guidelines — you are just trolling. Playing your pathetic game of pigeon chess.
Having been to many osteopaths and chiropractors over the decades, that video does not even approximate any of the dozens of chiropractic cervical spine manipulations I’ve been subjected to.
Did anyone hear the cracking/popping sound? I didn’t. Many chiropractors, on failing to elicit the sound of cavitation[1] on their first attempt, apply the procedure with more exuberance the second time. Even a third time if the second attempt failed. Furthermore, that theatrical manoeuvre is also performed during each “maintenance treatment”, usually as the grand finale.
This has been documented in academic papers reporting the force vs time graphs from an elaborate network of sensors attached to each ‘patient’.
The chiro‑troll very likely knows all this. Otherwise, it wouldn’t have known to write:
Now, this “about 150N and gaps the Z joint a few mm” combined with the video is the reason for my contrasting this sloppiness in ‘chiropractic adjustment’ techniques, with the strict procedures for tightening vehicle nuts and bolts, using a calibrated torque wrench.
Furthermore, Sue Ieraci wrote this pertinent reply:
“Highly qualified physical therapists do not see the need to ‘take the (neck) joint to lockout’, and, unfortunately, the thrust is also transmitted to the bend in the vertebral artery. No clear benefit, all risk. Just stop manipulating the neck.”
LOL! To echo back to you your rudeness to Gerhard Bahnhof: (psst, you should look up the definition of “analogy” before you use the word).
You don’t appear to be intellectually equipped to engage in any discussion. As you so clearly demonstrated in your reply to Edzard above:
https://edzardernst.com/2023/02/another-case-of-stroke-due-to-chiropractic/#comment-144351
I didn’t use analogy, I used contrast. Good grief!
“Contrast is a rhetorical device through which writers identify differences between two subjects, places, persons, things, or ideas. Simply, it is a type of opposition between two objects, highlighted to emphasize their differences.”
https://literarydevices.net/contrast/
When you started commenting on this blog, circa 2016, I gained the impression that you were deliberately obnoxious, but it became increasingly apparent that a special case of Occam’s razor yields a much better explanation for your behaviour: Hanlon’s razor.
[1] The cracking sound during spinal manipulation: much to do about nothing
https://edzardernst.com/2017/05/the-cracking-sound-during-spinal-manipulation-much-to-do-about-nothing/
As has been said to you several times: you are no good at defending the indefensible.
Pete, I know you have difficulty following a dialogue. Note the “you” in his question
Bjorn asked: Do you perform any kind of cervical manipulation? If so, why and how?
The video demonstrates the how (closely anyway) for the upper cervical spine.
Have a good day.
DC,
Maybe you are new to practicing chiropractic? Maybe you’re feeling a little embarrassed right about now and are wishing you picked another blog site to pitch your case for upper neck manipulations to continue?
I’m really hoping the words and exhaustive researched responses, from the Doctors, Scientists, and those in the know, who are doing their best to inform you of the dangers associated with chiropractic Rapid Upper Neck Manipulations on this site, will somehow strike a serious chord of reason and open you up to true and meaningful exchange. It’s time for common sense to kick in!
BOTH the right and left sides of my sweet young wife’s Vertebral Arteries were torn. Period.
She never made it home from the chiropractor’s office that fateful day. Traded in her car for a wheelchair.
The swallowing issues and speech loss were the worst but thankfully she has regained some use of her limbs and no longer requires the G-Tube, but balance prevents any further advancement regardless.
They have recently replaced her TMJ Joints so she can now open her mouth a little wider.
Over the years, Surgeons have corrected the curvatures of both legs, thus enabling her to do transfers much easier. Even straightened her little twisted feet.
All this in an effort to give Sandy some resemblance of quality of life.
Sandy tells me it was not her choice to give up her career at forty years of age, but she seems to accept my limited cooking and overlook my housecleaning deficiencies. She has not lost her sense of humor although there are days when we just cry and wish we could turn back the hands of time.
As for this topic, perhaps it’s time to put the shovel down and stop digging DC.
David, I am not sure what I am digging.
I have admitted there are risks to upper cervical manipulation
I have admitted there are cases where there is a high probability that cSMT caused a VAD
I have admitted that I rarely perform cSMT
I have admitted that there are other means which can usually achieve similar results
I have admitted that I have research proposal on this topic (which may apply directly to your wife’s case)
I have admitted that I share, discuss and debate this topic with other chiropractors almost daily
I have admitted that I have been studying this topic for over 20 years
Based upon the current evidence, what else do you think I should be doing? Just let people make case claims without proper evidence?
Bjorn, this podcast, in part, covers the topic of VAD and cSMT. Conversation between a surgeon and a chiropractor. Starts around minute 40. Pretty much in line with my approach.
https://www.instagram.com/p/CZAawWzg1W6/?fbclid=IwAR2txRkj9LJxmOcq8MEDX28di_zHNY6ffWYkjYhH_A7_AWlZq7D7Gr2afB0