Traditionally, strokes were considered a condition primarily affecting older adults. But in recent years, doctors have noticed a disturbing trend: the rise of stroke cases among younger adults, a demographic that was once considered low-risk. New data reveals an increase in the number of young adults facing an unexpected battle with strokes. Experts point to poor lifestyle choices as the main risk factor. Smoking, unhealthy diets, lack of exercise, and increased stress have played a role because they lead to problems like high cholesterol, high blood pressure and obesity.
But one risk factor most people don’t consider has to do with chiropractic adjustments. US doctors say forceful and rapid neck rotations during these procedures can potentially cause damage to the vertebral arteries supplying blood to the brain stem. “We see five, if it’s a bad year, up to eight or 10 a year per hospital, and some of them can be quite devastating because the brain stem and the cerebellum are in an enclosed compartment and that only so much room,” said Dr. Melissa McDonald, with McKay Dee Hospital.
Stroke symptoms in young adults are similar to those seen in older adults: weakness or numbness in the face, arm, or leg; sudden change in speech, difficulty walking or keeping your balance; and sudden severe headaches and change in vision. Any of these symptoms require immediate medical attention, but doctors say younger adults tend to wait longer than older adults to go to the ER.
Dr. McDonald says younger adults face an increased risk of complications from brain swelling following a stroke due to the relatively larger size of their brains within the skull compared to older individuals.
Readers of this blog can hardly be surprised by this news. I have often enough reported on the fact that chiropractic adjustments can cause a stroke, e.g.:
- Another case of stroke due to chiropractic
- One chiropractic treatment followed by two strokes
- Cervical artery dissection and stroke related to chiropractic manipulation
- An unusual case report of a stroke caused by chiropractic neck manipulation
- New data on the risk of stroke due to chiropractic spinal manipulation
- Chiropractic neck manipulation can cause stroke
And what is the solution?
I’m glad you asked; it is simple! In the words of one neurologists:
DON’T LET THE BUGGARS TOUCH YOUR NECK!
51 Responses to Chiropractic adjustments are causing more and more strokes in younger adults
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The king of “Chiropractic Neurology” – Ted Carrick – told a class I attended to reset the brain (that is what they do you know), you hit the neck (adjustment) hard. I objected and Carrick immediately shut me down. When I protested, he just said, “I know what you are trying to do.” I think not. I knew the risks. Hit the neck hard is bad advice.
https://americanloons.blogspot.com/2015/08/1448-ted-carrick.html
Thank you! Must read on Carrick: https://www.skeptic.com/reading_room/origin-of-chiropractic/
THANKS
you might also have a look at this:
https://edzardernst.com/2020/02/david-daniel-palmer-the-life-of-a-genius-or-the-career-of-a-charlatan/
“Must read on Carrick: https://www.skeptic.com/reading_room/origin-of-chiropractic/”
Very interesting article, Michael. But I must be missing something… it doesn’t mention Carrick at all, and only mentions functional neurology once, in passing.
Perhaps you intended to link to a different article?
Thanks for sharing, Michael.
From the Carrick article: “… detecting an enlarged blind spot in one eye, which is supposed to reflect a malfunction in the brain that can be treated by manipulating the neck on the same side.”
Strangely, in not even one of all the videos I have watched on Youtube where chiropractors proudly show off their risky behavior have I seen anyone manipulate only one side. Every time they crack the spine both ways. So every “misalignment” must be symmetric and “adjusted” symmetrically?
Is there a known increase in chiropractic adjustments?
I am not sure
Chiropractors simply need to “adjust” their way of thinking and the methods of “treatment” they endorse.
They could easily start cleaning up their act by ceasing to engage in the allowance of any more rapid upper neck manipulations. Full stop.
Looking forward to the day when common sense will prevail.
There needs to be an immediate halt to the use of any rapid upper neck manipulation, regardless of the practitioner.
When my wife was injured by a Chiropractor and suffered a catastrophic brain stem stroke, we were informed that there was yet another young lady on the same ward as Sandy. She, just like my young wife, had just visited a Chiropractor. Hmm….what are the odds you say?
Seems evident that there are more tragic events than are being reported.
Will the Chiropractors ever admit fault or cease to perform this dangerous manipulation? Sadly I think not , as any order or direction must come from within their “Industry”.
Level 5 evidence, personal opinion from a television show. True data details that the risk is real but rare. I’m still waiting for my first incident after 39 years as a practicing chiropractor.
perhaps you need to read it again; here is an ecerpt:
“Readers of this blog can hardly be surprised by this news. I have often enough reported on the fact that chiropractic adjustments can cause a stroke, e.g.:
Another case of stroke due to chiropractic
One chiropractic treatment followed by two strokes
Cervical artery dissection and stroke related to chiropractic manipulation
An unusual case report of a stroke caused by chiropractic neck manipulation
New data on the risk of stroke due to chiropractic spinal manipulation
Chiropractic neck manipulation can cause stroke.”
[with 6 links to previous posts]
“Dr” Michael Epstein, Looking forward to it? Do you also play Russian roulette?
I love how this notice appears at the top of the website:
“Please remember: if you make a claim in a comment, support it with evidence.”
Yet the “evidence” for Prof Ernst’s claim there are more strokes is an anecdote from a TV report.
The claim of an increased incidence needs to be found in an epidemiological study of high quality.
Further he cites no current evidence showing a risk of stroke after cervical SMT.
I thought the burden of proof is on the person who makes the claim.
are we talking about the same post?
perhaps you need to read it again; here is an ecerpt:
“Readers of this blog can hardly be surprised by this news. I have often enough reported on the fact that chiropractic adjustments can cause a stroke, e.g.:
Another case of stroke due to chiropractic
One chiropractic treatment followed by two strokes
Cervical artery dissection and stroke related to chiropractic manipulation
An unusual case report of a stroke caused by chiropractic neck manipulation
New data on the risk of stroke due to chiropractic spinal manipulation
Chiropractic neck manipulation can cause stroke.”
[with 6 links to previous posts]
in any case, my post on my blog is not a comment!
It is intellectually lazy to cite one’s own blog as support m. You can’t cite the actual evidence.
“the fact that chiropractic adjustments can cause a stroke”
To call something a fact when at best it is debatable is disingenuous. It would be more correct to have said in your judgement chiropractic adjustments can cause a stroke.
Of course, your judgment is inconsistent with the most UpToDate systematic review and meta-analysis, that I am aware of.
Church, Ephraim W, Sieg, Emily P, Zalatimo, Omar, Hussain, Namath S, Glantz, Michael & Harbaugh, Robert E. 2016. Systematic Review and Meta-analysis of Chiropractic Care and Cervical Artery Dissection: No Evidence for Causation.. Cureus 8: e498. doi: 10.7759/cureus.498. http://eutils.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&id=27014532&retmode=ref&cmd=prlinks
Please cite a more current one that you rely upon, if it exists.
The most recent and largest epidemiological study, that I am aware of, does not find that cervical SMT is a risk factor for strokes.
Whedon JM, Petersen CL, Schoellkopf WJ, Haldeman S, MacKenzie TA, Lurie JD. The association between cervical artery dissection and spinal manipulation among US adults. Eur Spine J. 2023 Oct;32(10):3497-3504. doi: 10.1007/s00586-023-07844-9. Epub 2023 Jul 8. PMID: 37422607; PMCID: PMC10591258.
Please cite a more current one that you rely upon, if it exists.
Finally, I understand that your post is not a comment, which I assume by your comment (above) means it must meet a lower standard for scholarship than any comment it provokes. Makes complete sense to me 🤪
to be called ‘intellectually lazy’ by a chiro is more than a little ironic!
btw: each of the blog posts that I listed [and many more on my blog] do contain the original data that you are too intellectually lazy to recognize.
Ironic or not having read all your linked blogs and I stand by my statement.
Most of your “evidence” are anecdotes. As I noted in my LTE regarding one of your papers citing low level evidence when higher quality evidence is available is not a good way to prove your point and clearly you cherry pick to prove your point.
Still your reply cited no evidence that refutes the studies I cited. And it is ironic that a researcher like yourself is so lazy as to not provide any current evidence to refute what I cite: a systematic review by neurologists and largest epidemiology study to date.
As it is said: In God We Trust; Others Must Provide Data
https://quoteinvestigator.com/2017/12/29/god-data/?amp=1
“Most of your “evidence” are anecdotes”
yes, of course! because you chiros have so far been unable to have a proper post-marketing surveillance system.
I might have a look at the study you cited when I awake from my notorious laziness.
but at first glance, I am not impressed and – as you must know – the best evidence is not one study but a systematic and critical evaluation of the totality of the evidence, e.g.:
https://pubmed.ncbi.nlm.nih.gov/17606755/
[not recent, I know]
Chiropractor Stephen Perle wrote: “…your judgment is inconsistent with the most UpToDate systematic review and meta-analysis, that I am aware of. Church, Ephraim W, Sieg, Emily P, Zalatimo, Omar, Hussain, Namath S, Glantz, Michael & Harbaugh, Robert E. 2016. Systematic Review and Meta-analysis of Chiropractic Care and Cervical Artery Dissection: No Evidence for Causation.. Cureus 8: e498. doi: 10.7759/cureus.498.” http://eutils.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&id=27014532&retmode=ref&cmd=prlinks
For those interested, that paper is critiqued here:
Ref: https://sciencebasedmedicine.org/chiropractic-and-stroke-no-evidence-for-causation-but-still-reason-for-concern/
“There is no definitive evidence for causation, but there is evidence to support a strong enough *probability* of causation to constitute a good reason to avoid neck manipulation.
Flaws in the study’s Discussion section
Here’s where it really becomes problematic. They report that they found a small association between chiropractic care and cervical artery dissection, but then they discount their own finding and try to rationalize it away. They say the evidence is low quality; I agree. They say they found no evidence of causation; I agree. But then they try to say there is no convincing evidence of even the *association* that they themselves found.
They found no evidence for causation. On the other hand, they found no evidence *against * it.
They say they are concerned that a false belief in a causal connection ‘may have significant adverse effects such as numerous episodes of litigation’. On the other hand, a lack of belief might prevent justified litigation where patients were harmed or killed.
They say neck pain and headache are confounders. They say patients with headache and neck pain more frequently visit chiropractors, and patients with cervical artery dissection more frequently have neck pain and headache, so the appearance of more cervical artery dissections after visits to chiropractors is spurious. They say the Cassidy study showed that visits to a primary care provider or a chiropractor were likely to be due to pain from an existing dissection. It did not. There is absolutely no evidence to support that speculation.
In fact, there are numerous ‘smoking gun’ cases where patients consulted a chiropractor not for neck pain or headache, but for pain in parts of the body below the neck, such as shoulder pain or tailbone pain, and developed stroke symptoms on the chiropractor’s table at the time of neck manipulation. Sandra Nette had no pain at all; she felt fine and let the chiropractor manipulate her neck only because she falsely believed that regular maintenance adjustments were an effective means of keeping her healthy.
They fail to even mention the smoking gun cases or the evidence that the incidence of stroke rises with the proximity to the time of manipulation.
They make a big deal of Hill’s criteria for assigning causation to association. With a rare condition like VBA dissection, and with the characteristics of this condition, it would be very difficult to fulfil all of Hill’s criteria. We may never see that kind of proof, so we must rely on lesser quality evidence.
They cite cadaver studies to claim that SMT doesn’t place significant strain on the vertebral artery. And yet we know that very small strains can cause strokes in susceptible live patients. ‘Shampoo strokes’ have been reported after hyperextension of the neck at beauty parlors.
Other considerations
The indications for neck manipulation are questionable. Upper cervical (NUCCA) chiropractors do neck manipulations on every patient, no matter what the complaint. Some chiropractors do neck manipulations for somatovisceral conditions rather than just for musculoskeletal conditions. Whatever the indications, chiropractors certainly have no business doing neck manipulations on a patient with an existing dissection, and they have not shown that they can reliably diagnose a stroke in progress. There are no tests to reliably identify patients at risk of dissection.
Underreporting is a problem. If a dissection is temporarily sealed by a clot that breaks loose several hours or days later, the connection with manipulation may be missed. Patients may never return to the chiropractor. I heard of at least one case where a patient developed stroke symptoms immediately following manipulation, was hospitalized for a disastrous stroke, and never let the chiropractor know what had happened.
Edzard Ernst weighs in
Edzard Ernst reported on a case of a man who had a stroke following chiropractic manipulation for chronic neck pain. *Chronic*, not a new symptom suggesting a stroke in progress. He also reported on a case of phrenic nerve injury from neck manipulation.
Ernst commented:
There is no effective monitoring scheme to adequately record serious side-effects of chiropractic care.
Therefore the incidence figures of such catastrophic events are currently still anyone’s guess.
Publications by chiropractic interest groups seemingly denying this point are all fatally flawed.
It is not far-fetched to fear that under-reporting of serious complications is huge.
The reliable evidence fails to demonstrate that neck manipulations generate more good than harm.
Until sound evidence is available, the precautionary principle leads most critical thinkers to conclude that neck manipulations have no place in routine health care.
The American Heart Association and American Stroke Association agree. They were concerned enough about the apparent association to have issued a joint scientific statement warning about it and recommending that patients be informed of the possible risk prior to manipulation.
Bottom line: A double standard
Edzard Ernst has said:
‘Imagine a conventional therapy about which the current Cochrane review says that it has no proven effect for the condition in question. Imagine further that this therapy causes mild to moderate adverse effects in about 50% of all patients in addition to very dramatic complications which are probably rare but, as no monitoring system exists, of unknown frequency…’
Now I ask you to imagine that there is a pharmaceutical drug that fits this description. Imagine that there are the same numbers of studies showing an association of that drug with a deadly side effect like stroke or death. The FDA would pull it off the market; they wouldn’t wait for definite evidence of causation that fulfilled all of Hill’s criteria. And I think the people who are making excuses for neck manipulation would want them to take that drug off the market. I don’t think they would want to take such a drug.
I wouldn’t risk taking a drug like that, and I wouldn’t risk neck manipulation.”
Chiropractor Stephen Perle wrote: “The most recent and largest epidemiological study, that I am aware of, does not find that cervical SMT is a risk factor for strokes.” Whedon JM, Petersen CL, Schoellkopf WJ, Haldeman S, MacKenzie TA, Lurie JD. The association between cervical artery dissection and spinal manipulation among US adults. Eur Spine J. 2023 Oct;32(10):3497-3504. doi: 10.1007/s00586-023-07844-9. Epub 2023 Jul 8. PMID: 37422607; PMCID: PMC10591258.
Prof. Ernst critiqued that study here:
https://edzardernst.com/2023/07/associations-between-cervical-artery-dissection-and-spinal-manipulation/
“What seems fairly clear from this and a previous similar analysis by the same authors is, I think, this: retrospective studies of this type can unfortunately not provide us with much reliable information about the risks of spinal manipulation. The reasons for this are manyfold, e.g.: less than exact classifications in patients’ records, or the fact that multiple types of spinal manipulations exist of which only some might be dangerous.”
@ Stephen Perle, IMO you seem to lack the cautious attitude demanded of an academic researcher.
interesting!
WOWSA!
I do believe school is in session…lol
My advise; One had best be well informed and on their “A” game before entering these waters!
Dr. Edzard Ernst and Bill Wode … it is a pleasure to read your responses on this important subject. You both truly are amazing and provide a wealth of knowledge.
Many thanks!
Criticism of peer-reviewed literature by blog. Thank you for further examples of intellectual laziness or maybe it’s really intellectual cowardice.. Amazing how such poor scholarship did not stimulate letters to the editor, the normal route of scientific criticism. But specious criticism in blogs protects the writer from the demands and scientific rigor of peer-review
As to AHA/ASA that paper is not a systematic review, and very outdated. But I can see how cherry picking poorly done old news to support your thesis would be your preferred methodology.
“‘Shampoo strokes’ have been reported after hyperextension of the neck at beauty parlors.”
And yet, I have never seen you or Ernst get on a soapbox to warn against the dangers of having a shampoo at a parlor.
Double standard indeed.
I also note how it was said that all chiropractors should abolish high velocity cervical manipulation to “clean up” their practice. I wonder why they don’t say the same for physical therapists (or DOs) who do this as well. Why just chiropractors? Bias or just coincidence/oversight 🤷
Why just chiropractors?
Of course, this would need to be a plea to all.
However, osteos and physios tend to use high velocity cervical manipulation rarely, whereas chiros employ it with nearly 100% of their patients.
I know data won’t change anyone’s mind in this silo but the evidence does not support the conclusion that anywhere near 100% of chiropractic office visits include SMT
Kosloff, T. M., Elton, D., Tao, J. & Bannister, W. M.. 2015. Chiropractic care and the risk of vertebrobasilar stroke: results of a case-control study in U.S. commercial and Medicare Advantage populations. Chiropr Man Therap 23: 19. doi: 10.1186/s12998-015-0063-x. https://www.ncbi.nlm.nih.gov/pubmed/26085925
thanks, I had not thought of this word; it’s a perfect word to describe chiropractic
silo
[ˈsʌɪləʊ]
NOUN
a tall tower or pit on a farm used to store grain.
SIMILAR:
storeroom
storehouse
warehouse
repository
depository
an underground chamber in which a guided missile is kept ready for firing.
a system, process, department, etc. that operates in isolation from others:
“it’s vital that team members step out of their silos and start working together” · “we have made significant strides in breaking down that silo mentality”
“They say the Cassidy study showed that visits to a primary care provider or a chiropractor were likely to be due to pain from an existing dissection. It did not. There is absolutely no evidence to support that speculation.
In fact, there are numerous ‘smoking gun’ cases where patients consulted a chiropractor not for neck pain or headache, but for pain in parts of the body below the neck, such as shoulder pain or tailbone pain, and developed stroke symptoms on the chiropractor’s table at the time of neck manipulation.”
These are important cases to consider.
It is also worth considering cases when patients presented to a chiropractor with symptoms of a dissection, were referred without any treatment, and later confirmed to have a dissection – clearly not caused by manipulation.
Futch, D., Schneider, M. J., Grayev, A., Jan Hartvigsen DC, P., Michael Schneider DC, P., & Murphy, D. R. (2015). Vertebral artery dissection in evolution found during chiropractic examination. BMJ Case Reports, 2015(nov12 1), bcr2015212568–bcr2015212568. https://doi.org/10.1136/bcr-2015-212568
There has also been a VAD case that clearly shows the dissection present on MRI before receiving cervical manipulation.
Arning, C., & Hanke-Arning, K. (2022). Vertebral artery dissection after—And also before—Chirotherapy. Journal of Neurology, 1–2. https://doi.org/10.1007/s00415-022-10964-9
These cases and the long list of potential risk factors and precipitating movements cast doubt on manipulation as the cause.
Prof. Ernst wrote: “…to be called ‘intellectually lazy’ by a chiro is more than a little ironic!”
Indeed, I wonder how chiropractor Stephen Perle’s CV looks when compared to this:
Professor Ernst is/was founder/Editor-in-Chief of three medical journals (‘Focus on Alternative and Complementary Therapies’, ‘European Journal of Physical medicine and Rehabilitation’ and ‘Perfusion’). He has been a columnist for many publications (BMJ, GP, MMW, PJ, The Guardian, The Independent, The Spectator, Publikum, Skeptic Magazine, etc.). His work has been awarded 17 scientific awards (most recent: John Maddox Prize 2015 and Ockham Award 2017) and two Visiting Professorships (Canada and USA). He served on the ‘Medicines Commission’ of the British ‘Medicines and Healthcare Products Regulatory Agency’ (1994 – 2005).
According to Ioannidis et al Updated science-wide author databases of standardized citation indicators, he is currently ranked
• No 107 amongst ~160 000 most-cited scientists of all disciplines worldwide,
• No 70 amongst all scientists working in any medical field,
• No 1 amongst all researchers in the category of ‘Complementary & Alternative Medicine’,
He has published >1000 papers in the peer-reviewed medical literature (current H-Index=143), >50 books, translated into over a dozen languages, >100 book chapters. He has given > 700 invited lectures worldwide and supervised >50 MD and Ph.D. theses. He has also served as an expert witness in numerous legal disputes. In 2022, he was elected as a member of the Academia Europaea.
More:
https://tinyurl.com/39rnvxm3
It is surprising that someone so accomplished would not submit their criticism of peer-reviewed literature to the journals involved as letters to the editor. Thank you for giving the evidence that it wasn’t an issue of inability or ignorance of the process thus supporting the criticism that it’s laziness or cowardice.
But as an anonymous presence online Blue Wode shows its cowardice constantly. Or have you wiped the blue stain off your face finally? I can’t tell as you blocked me on Twitter so many years ago, I didn’t even know you still existed. Well maybe you don’t and a new generation of Pecks is behind that handle.
who has published more ‘letters to the editor’ – you are me?
who is retired since ~10 years, you or me?
who is speaking out of he arse, you or me?
I freely admit you have published more. But living on your past glory doesn’t validate your blog as a way to criticize peer-reviewed literature. As I said to your blue-faced friend the fact you have demonstrated your knowledge of the process is only a greater indictment of your current laziness or cowardice.
Got valid criticism of Church et al or Whedon et al write letters to the editor.
And yet while you try to defend your laziness or cowardice with expletives you’ve not provided any citations to peer-reviewed literature that refute or critique these studies.
Maybe your excuse is retirement – then retire and stop using your blog to pretend you still are a scientist.
thanks – to be called a lazy coward by a chiro prof must be a high compliment indeed!
Nevertheless you have presented zero evidence that refutes either the systematic review or epidemiology.
So my point is not refuted that SMT isn’t a risk for stroke. Thank you for confirming what the best evidence is and that your “facts” are anachronistic and wrong.
According to Bill Murray, “It’s hard to win an argument with a smart person. It’s damn near impossible to win an argument with a stupid person”
Chiropractic SMT isn’t a risk for curing anything.
Professor Stephen Perle plays pigeon chess: He knocks the pieces over, craps on the board, and flies back to its flock to claim victory.
It’s easy to claim victory when the other side does cite any better evidence only an outdated book.
It seems “Prof.” Perle has very large blind spots in both eyes. Fortunately for him, they are not likely amenable by cervical manipulation to either side, so no immediate risk of manipulation-induced stroke at this time.
“in recent years, doctors have noticed a disturbing trend: the rise of stroke cases among younger adults, a demographic that was once considered low-risk.”
How recent? How big of an increase? It isn’t news that CeAD is more common in a younger demographic. (https://pubmed.ncbi.nlm.nih.gov/17130413/)
“New data reveals an increase in the number of young adults facing an unexpected battle with strokes.”
What new data? The news article doesn’t include any link to a study.
“We see five, if it’s a bad year, up to eight or 10 a year per hospital, and some of them can be quite devastating…”
Five to ten what? Strokes in young people? Strokes presumed to have been caused by manipulation?
It is very easy to win the argument with me. Cite better research. Since you haven’t my point stands. There is no credible scientific evidence that cervical SMT is a risk for stroke.
It’s really no fun winning an argument with someone who comes armed with no evidence. Prove I’m stupid by citing more current evidence. I know you can’t because you are as Jethro Tull sings: living in the past.
Hitchens’ razor:
“What can be asserted without evidence can also be dismissed without evidence.”
Christopher Hitchens “God Is Not Great: How Religion Poisons Everything” 2007
And yet I provided high quality svkxsm d
“There is no credible scientific evidence that cervical SMT is a risk for stroke.”
… is the mantra of all chiros.
They repeat it so often that, eventually, they believe it themselves.
BUT
Sadly, it’s not true.
So says the former scientist who cites no research to support his dogma.
Hitchens’ razor:
“What can be asserted without evidence can also be dismissed without evidence.”
Christopher Hitchens “God Is Not Great: How Religion Poisons Everything” 2007
As you are so impressively slow on the uptake, I present you with chapter 13 of my recent book (https://www.amazon.co.uk/Chiropractic-Not-All-That-Cracked/dp/3030531171) on the subject; ENJOY!:
13. DIRECT RISKS OF SPINAL MANIPULATION
Chiropractic is widely recognized as one of the safest drug-free, non-invasive therapies available (American Chiropractic Association 2019)
Most chiropractors steadfastly deny that SMT can cause serious harm (Box 1). Here is just one of virtually thousands of examples:
… any concerns about [chiropractic] adjustment are unfounded and merely a convenient access point used by a handful of chiropractic detractors or those ignorant of the truth.
As evidence for such assertions, chiropractors often rely on a large prospective survey from the UK. It included 50,276 cervical spine manipulations and noted no serious adverse events (AEs). However, the investigation also recorded one order of magnitude less minor adverse effects of SMT than previously published prospective surveys (see below). This casts serious doubts on its validity. Several explanations of this discrepancy exist:
• The sample was self-selected.
• It consisted of a relatively small group of participating chiropractors (32% of the total sample)
• The participating chiropractors were more experienced than the average chiropractor (67% been in practice for 5 or more years).
• They may not always have fully adhered to the protocol of the survey.
The participating chiropractors might, for instance, have employed their experience to select low-risk patients rather than including all consecutive cases, as the protocol demanded. This hypothesis would account for the unusually low rate of minor adverse effects and could explain why no serious complications occurred at all. In any case, given that about 700 serious AEs are on record, their total absence in this survey is surprising.
A 2016 analysis aimed at describing the extent of AE-reporting in published studies of SMT. A total of 368 articles were included in the review. Adverse events were mentioned in only 38% of these articles. The authors concluded that although there has been an increase in reporting adverse events since the introduction of the 2010 CONSORT guidelines, the current level should be seen as inadequate and unacceptable.
My team evaluated all 60 RCTs of chiropractic SMT published between 2000 and 2011 and found that half of them did not mention AEs at all. Sixteen RCTs reported that no AEs had occurred (which is hardly credible, since reliable data show that about 50% of patients experience AEs after consulting a chiropractor, see below). Our conclusion was that adverse effects are poorly reported in recent RCTs of chiropractic manipulations.
To conduct a clinical trial without mentioning AEs is a violation of medical ethics. The effects of such non-reporting are obvious: anyone looking at the published evidence (for instance via systematic reviews) will get a wrong impression of the safety of SMT. Consequently, chiropractors feel free to claim that very few AEs have been reported, and that therefore SMT is demonstrably safe. Unfortunately, this is precisely what is happening; take, for instance, this statement by the American Chiropractic Association (ACA):
Chiropractic is widely recognized as one of the safest drug-free, non-invasive therapies available for the treatment of neuromusculoskeletal complaints. Although chiropractic has an excellent safety record, no health treatment is completely free of potential adverse effects …Doctors of chiropractic are well trained professionals who provide patients with safe, effective care for a variety of common conditions…
In the following section, we shall discuss whether such views are truly justified. We will first evaluate the evidence regarding minor AEs and subsequently assess the evidence regarding serious complications of SMT.
Minor problems
Relatively minor AEs after SMT are extremely common. Our own systematic review of 2002 found that they occur in approximately half of all patients receiving SMT. A more recent study of 771 Finish patients having chiropractic SMT showed an even higher rate; AEs were reported in 81% of women and 66% of men, and a total of 178 AEs were rated as moderate to severe. Two further studies reported that such AEs occur in 61% and 30% of patients. , Local or radiating pain, headache, and tiredness are the most frequent adverse effects.
Chiropractors often counter that such AEs are normal events which are necessary steps on the path towards healing. However, in view of the lack of evidence that SMT is an effective treatment for most, if not all conditions (chapters 9 -12), this is hardly a rational argument. Imagine a drug that has no or very little proven benefit, but causes mild to moderate AEs in about half of all patients. Surely, such a drug would long have been banned from the market. Or imagine a drug that has been tested in multiple clinical trials of which most fail to even mention AEs.
Whichever way we turn or twist the arguments, one thing is undeniably clear: the popular claim by chiropractors and their supporters that SMT is one of the safest treatments around (like the one by the ACA cited above) is based on denial, ignorance and wishful thinking. Even more deeply delusional, is the denial that serious complications have been associated with SMT, the issue discussed in the following section.
Cerebral accidents
If SMT is applied to the neck – which it regularly is, even if the patient is complaining of lower back pain – there is a risk of injury to the fragile structures in this regions. The following case is as good as any of the hundreds of similar reports to illustrate the danger.
In 2015, US doctors published the case of a young woman who developed headache, vomiting, diplopia, dizziness, and ataxia following a neck manipulation by her chiropractor. A CT scan revealed an infarct in the inferior half of the left cerebellar hemisphere and a compression of the fourth ventricle causing moderately severe, acute obstructive hydrocephalus. Magnetic resonance angiography showed severe narrowing and low flow in the intracranial segment of the left distal vertebral artery. The patient was treated surgically and made an excellent recovery. The authors of the case-report concluded that this report illustrates the potential hazards associated with neck trauma, including chiropractic manipulation. The vertebral arteries are at risk for aneurysm formation and/or dissection, which can cause acute stroke.
Most chiropractors are in denial about this danger and usually quote the Cassidy study which concluded that vertebral artery accident (VBA) stroke is a very rare event in the population. The increased risks of VBA stroke associated with chiropractic and primary care physician visits is likely due to patients with headache and neck pain from VBA dissection seeking care before their stroke. We found no evidence of excess risk of VBA stroke associated chiropractic care compared to primary care. Yet, the Cassidy study was but one of several case-control studies investigating this subject. And the totality of all such studies does quite clearly suggest that neck manipulation can cause a stroke. More importantly, a re-analysis of the Cassidy study found a classification error in the paper. Therefore, the researchers re-analysed the data, and the re-calculated results indicated a significant risk of SMT. For patients less than 45 years of age, the OR was as high as 6.91. The authors concluded: If our estimates of case misclassification are applicable outside the VA population, ORs for the association between SMT exposure and CAD are likely to be higher than those reported using the Rothwell/Cassidy strategy, particularly among younger populations.
Perhaps even more critical is that fact that cases of severe complications after SMTcontinue to be reported with depressing regularity suggesting that SMT does cause serious damage. Here are but a few recent examples:
• Danish doctors reported a case of a patient with bilateral vertebral artery dissection (VAD) causing embolic occlusion of the basilar artery (BA). The symptoms started after chiropractic SMT of the neck. The patient presented with acute onset of neurological symptoms immediately following SMT in a chiropractic facility. Acute magnetic resonance imaging (MRI) showed ischemic lesions in the right cerebellar hemisphere and occlusion of the cranial part of the BA. Angiography demonstrated bilateral VADs. Symptoms remitted after endovascular therapy, which included dilatation of the left vertebral artery (VA) and extraction of thrombus from the BA. After 6 months, the patient still had minor sensory and cognitive deficits. The authors concluded that this case underlines the need to suspect VAD in patients presenting with neurological symptoms following SMT.
• Korean neurosurgeons reported the case of a man with signs of cerebellar dysfunction, vertigo and imbalance. Two weeks before, he had been treated by a chiropractor for neck pain. At the time of admission, brain computed tomography, magnetic resonance imaging, and angiography revealed an acute infarction in the left PICA territory and occlusion of the extracranial vertebral artery as a result of a dissection of his vertebral artery (VA). Angiography revealed complete occlusion of the left PICA and arterial dissection was shown in the extracranial portion of the VA. The patient was treated with antiplatelet therapy and discharged three weeks later without any sequelae. The authors concluded that the possibility of VA dissection should be considered at least once in patients presenting with cerebellar dysfunctions with a recent history of chiropractic cervical manipulation.
• Dutch neurologists described the case of a woman who presented at their outpatient clinic with a five-week history of severe postural headache, tinnitus and nausea. The symptoms had first occurred soon after chiropractic manipulation of the cervical spine. Cranial MRI showed findings characteristic for intracranial hypotension syndrome. Cervical MRI revealed a large posterior dural tear at the level of C1-2. Following unsuccessful conservative therapy, the patient underwent a lumbar epidural blood patch after which she recovered rapidly. The authors concluded that manipulation of the cervical spine can cause a dural tear and subsequently an intracranial hypotension syndrome. Postural headaches directly after spinal manipulation should therefore be a reason to suspect this complication.
• A US neurosurgeon published the case-report of a woman with a 3-day history of the acute onset of severe left temporal headache. Her current problem started after an activator treatment (chapter 4) to the upper cervical spine. Based on MRI characteristics, a haemorrhage was determined to be primarily subarachnoid and displacing but not involving any brain tissue. After a 4-day hospitalization for evaluation and observation, the patient was discharged, neurologically improved to outpatient follow-up. The author concluded that he was unable to find a single documented case in which a brain hemorrhage in any location was reported from activator treatment. As such, this case appears to represent the first well-documented and reported brain hemorrhage plausibly a consequence of activator treatment. In the absence of any relevant information in the chiropractic or medical literature regarding cerebral hemorrhage as a consequence of activator treatment, this case should be instructive to the clinician who is faced with a diagnostic dilemma and should not forget to inquire about activator treatment as a potential cause of this complication.
• Neurologists from Qatar published a case report of a man who presented with acute-onset neck pain associated with sudden onset right-sided hemiparesis and dysphasia after chiropractic manipulation for chronic neck pain. Magnetic resonance imaging revealed bilateral internal carotid artery dissection and left extracranial vertebral artery dissection with bilateral anterior cerebral artery territory infarctions and large cortical-sparing left middle cerebral artery infarction. The authors concluded that chiropractic cervical manipulation can result in catastrophic vascular lesions
For our own case-series of serious AEs after chiropractic, we obtained data on neurological complications of SMT from members of the Association of British Neurologists. They were asked to report cases referred to them of neurological complications occurring within 24 hours of cervical spine manipulation over a 12-month period. The response rate was 74%. 24 respondents reported a total of 35 cases. These included:
• 7 cases of stroke in brainstem territory (4 with confirmation of VA dissection),
• 2 cases of stroke in carotid territory,
• 1 case of acute subdural haematoma,
• 3 cases of myelopathy,
• 3 cases of cervical radiculopathy.
A 2017 systematic review identified the characteristics of AEs occurring after cervical spinal manipulation or cervical mobilization. A total of 227 cases were found; 66% of them had been treated by chiropractors. Manipulation was reported in 95% of the cases, and neck pain was the most frequent indication for the treatment. Cervical arterial dissection (CAD) was reported in 57%, and 46% had immediate onset symptoms. The authors of this review concluded that there seems to be under-reporting of cases. Further research should focus on a more uniform and complete registration of AEs using standardized terminology.
Even SMT of the thoracic spine is not risk-free: a review analysed reports describing patients who had experienced severe AEs after SMT of their thoracic spine. Ten cases were found. The most frequent AE reported was injury to the spinal cord (7 cases), but pneumothorax/haematothorax (2 cases) and CSF leak secondary to dural sleeve injury (1 case) were also reported. The authors concluded that serious AEs do occur in the thoracic spine, most commonly, trauma to the spinal cord, followed by pneumothorax.
In this context, a statement from the American Heart Association and American Stroke Association seems relevant. Here is its abstract in full:
Purpose—Cervical artery dissections (CDs) are among the most common causes of stroke in young and middle-aged adults. The aim of this scientific statement is to review the current state of evidence on the diagnosis and management of CDs and their statistical association with cervical manipulative therapy (CMT). In some forms of CMT, a high or low amplitude thrust is applied to the cervical spine by a healthcare professional…
Results—Patients with CD may present with unilateral headaches, posterior cervical pain, or cerebral or retinal ischemia (transient ischemic or strokes) attributable mainly to artery–artery embolism, CD cranial nerve palsies, oculosympathetic palsy, or pulsatile tinnitus. Diagnosis of CD depends on a thorough history, physical examination, and targeted ancillary investigations. Although the role of trivial trauma is debatable, mechanical forces can lead to intimal injuries of the vertebral arteries and internal carotid arteries and result in CD. Disability levels vary among CD patients with many having good outcomes, but serious neurological sequelae can occur. No evidence-based guidelines are currently available to endorse best management strategies for CDs. Antiplatelet and anticoagulant treatments are both used for prevention of local thrombus and secondary embolism. Case-control and other articles have suggested an epidemiologic association between CD, particularly vertebral artery dissection, and CMT. It is unclear whether this is due to lack of recognition of preexisting CD in these patients or due to trauma caused by CMT. Ultrasonography, computed tomographic angiography, and magnetic resonance imaging with magnetic resonance angiography are useful in the diagnosis of CD. Follow-up neuroimaging is preferentially done with noninvasive modalities, but we suggest that no single test should be seen as the gold standard.
Conclusions—CD is an important cause of ischemic stroke in young and middle-aged patients. CD is most prevalent in the upper cervical spine and can involve the internal carotid artery or vertebral artery. Although current biomechanical evidence is insufficient to establish the claim that CMT causes CD, clinical reports suggest that mechanical forces play a role in a considerable number of CDs and most population controlled studies have found an association between CMT and VAD stroke in young patients. Although the incidence of CMT-associated CD in patients who have previously received CMT is not well established, and probably low, practitioners should strongly consider the possibility of CD as a presenting symptom, and patients should be informed of the statistical association between CD and CMT prior to undergoing manipulation of the cervical spine.
Collectively the above evidence leaves little doubt that SMT can cause serious complications. Yet, none of the above-cited papers addressed the question as to how frequently they occur. The purpose of this study was to fill this gap. The authors identified cases through a retrospective chart review of patients seen between April 2008 and March 2012 who had a diagnosis of cervical artery dissection following a recent chiropractic manipulation. Relevant imaging studies were reviewed to confirm the findings of a cervical artery dissection and stroke. The authors also conducted telephone interviews with each patient to ascertain the presence of residual symptoms in the affected patients. Of the 141 patients with cervical artery dissection, 12 had documented chiropractic neck manipulation prior to the onset of the symptoms that led to medical presentation. These 12 patients had a total of 16 cervical artery dissections. All 12 patients developed symptoms of acute stroke, confirmed with magnetic resonance imaging or computerized tomography. Follow-up information could be obtained from 9 patients, 8 of whom had residual symptoms and one patient had died. The tables below provide further details.
The authors concluded that in this case series, 12 patients with newly diagnosed cervical artery dissection(s) had recent chiropractic neck manipulation. Patients who are considering chiropractic cervical manipulation should be informed of the potential risk and be advised to seek immediate medical attention should they develop symptoms.
Eye injuries
In 2005, I published a systematic review of ophthalmic AEs after SMT. At the time, there were 14 published case reports. Clinical symptoms and signs included:
• central retinal artery occlusion,
• nystagmus,
• Wallenberg syndrome,
• ptosis,
• loss of vision,
• ophthalmoplegia,
• diplopia,
• Horner’s syndrome.
In most cases, the underlying mechanism was arterial wall dissection. The eventual outcome varied and often included permanent deficits. Causality was frequently deemed likely or certain. I concluded that upper spinal manipulation is associated with ophthalmological adverse effects of unknown frequency. Ophthalmologists should be aware of its risks. Rigorous investigations must be conducted to establish reliable incidence figures.
Since the publication of this paper, new evidence has emerged.
• A 2018 case report told the story of a man with left sided weakness after a syncopal episode. He had been treated with regular chiropractic neck manipulations over the past seven years. His last session had been one month prior to presentation. The patient developed a headache, anisocoria, and ptosis of his right upper eyelid. Computed tomography angiography (CTA) showed an internal carotid occlusion with right middle cerebral artery zone of ischemia, and tissue plasminogen activator (tPA) was administered. Subsequently, the patient experienced vision loss in his right eye. MRI and CTA were repeated, revealing a right ICA dissection from below the ophthalmic artery to the posterior communicating artery. A diagnosis of ophthalmic artery occlusion was made, and he was discharged on anticoagulant therapy. Three months after presentation, vision had improved to light perception, and remains stable at one year after the dissection. The authors of this case report concluded that internal carotid artery dissection in this case was permanently devastating to the vision of a previously healthy young patient.
• In 2018, US ophthalmologists published the case of a woman with the acute, painless constant appearance of three spots in her vision immediately after a chiropractor performed cervical spinal manipulation using the high-velocity, low-amplitude technique. She had noted the first spot while driving home immediately following a chiropractor neck adjustment, and became aware that there were two additional spots the following day. Slit lamp examination of the right eye demonstrated multiple unilateral pre-retinal haemorrhages with three present inferiorly along with a haemorrhage over the optic nerve and a shallow, incomplete posterior vitreous detachment. The haemorrhages resolved within two months. The authors concluded that chiropractor neck manipulation has previously been reported leading to complications related to the carotid artery and arterial plaques. This presents the first case of multiple unilateral pre-retinal haemorrhages immediately following chiropractic neck manipulation. This suggests that chiropractor spinal adjustment can not only affect the carotid artery, but also could lead to pre-retinal haemorrhages.
Other serious complications
Vascular accidents are the most frequent serious AEs after chiropractic SMT, but they are certainly not the only complications that have been reported. Other AEs include:
• atlantoaxial dislocation,
• cauda equina syndrome,
• cervical radiculopathy,
• diaphragmatic paralysis,
• disrupted fracture healing,
• dural sleeve injury,
• haematoma,
• haematothorax,
• haemorrhagic cysts,
• muscle abscess,
• muscle abscess,
• myelopathy,
• neurologic compromise,
• oesophageal rupture
• pneumothorax,
• pseudoaneurysm,
• soft tissue trauma,
• spinal cord injury,
• vertebral disc herniation,
• vertebral fracture,
In the following section, we will look at some of the recently reported problems in more detail.
• Neurosurgeons published the case of a man with a two-week history of right sided neck pain and tenderness, accompanied by tingling in the hand. The doctor referred the patient to a chiropractor who performed plain X-rays which allegedly showed “mild spasm”. The chiropractor then manipulated the patient’s neck on two successive days. By the morning of the 3rd visit, the patient reported extreme pain and difficulty walking. Without performing a new examination, the chiropractor manipulated the patient’s neck for a third time whereupon the patient immediately became quadriplegic. Despite undergoing an emergency C5 C6 anterior cervical discectomy/fusion to address a massive disc prolapse found on the magnetic resonance scan, the patient remained quadriplegic.
• Canadian chiropractors reported 6 cases that occurred between 2000 and 2022 where Canadian chiropractors were sued for causing or aggravating lumbar disc herniation after SMT. The following conclusions from Canadian courts seem relevant: 1) Informed consent is an on-going process that cannot be entirely delegated to office personnel. 2) When the patient’s history reveals risk factors for lumbar disc herniation the chiropractor has the duty to rule out disc pathology as an aetiology for the symptoms presented by the patients before beginning anything but conservative palliative treatment. 3) Lumbar disc herniation may be triggered by spinal manipulative therapy on vertebral segments distant from the involved herniated disc such as the thoracic spine. In this context, it seems worth mentioning that disc herniations after chiropractic SMT have been reported regularly and since many years. , , , ,
• American neurologists published a case a man who consulted a chiropractor for his neck pain who treated him with neck SMT. This resulted in a bilateral diaphragmatic paralysis. (Similar cases have previously been reported with some regularity , , , and damage to other nerves has also been documented to be a possible complication of SMT. , ) The authors concluded that physicians must be aware of this complication and should be cautious when recommending spinal manipulation for the treatment of neck pain, especially in the presence of preexisting degenerative disease of the cervical spine.
• Danish neurologists reported the case of a man with drooping of his right upper eyelid and an ipsilateral contracted pupil, combined with pain, weakness, and numbness in his upper right limb. The patient had sought chiropractic treatment for is back and neck pain. Following manipulations of the thoracic and cervical spine, the pain intensity initially lessened. One hour after the SMT, the patient experienced the eye and upper limb symptoms. A neurologic examination revealed moderate right-sided ptosis and miosis, decreased strength of the intrinsic and opponens muscles of the right hand, and reduced cutaneous sensation corresponding to the T1 dermatome, with inability to discriminate pain and light touch. An MRI of the thoracic spine showed a para-median herniation of the T1-T2 intervertebral disc compressing the right T1 spinal nerve root. The patient received no surgery, and follow-up examination 6 months later revealed near-complete recovery, with only mild paraesthesia in the T1 segment of his right arm and a subtle ptosis remaining.
• Atlantoaxial dislocation is a dislocation of the first and second vertebrae which means that the spinal cord is in danger of being compressed which, in turn, would have devastating consequences. A case-report described a man with a history of old cerebellar infarction who presented with acute left hemiplegia after a chiropractic SMT of the neck and back several hours before the symptom onset. Mild hypoesthesia but no speech disturbance, facial palsy, or neck or shoulder pain were observed. Brown-Sequard syndrome (damage to one side of the spinal cord causing paralysis and loss of feeling on one side) subsequently developed with a hypo-aesthetic sensory level below the right C5 dermatome. A magnetic resonance angiography revealed an atlantoaxial dislocation causing upper cervical spinal cord compression. The patient received decompressive surgery, and his muscle power gradually improved, with partial dependency when performing daily living activities two months later. Two months later, his neurological deficits were much improved.
A review summarised cases of cervical spine injury and myelopathy following SMT of the neck. Its authors assessed all patients who had developed neurological symptoms due to cervical spinal cord injury following neck SMT in a spinal unit in a tertiary hospital between the years 2008 and 2018. Patients with vertebral artery dissections were excluded. A total of 4 patients were identified, two men and two women, aged between 32 and 66 years. In three patients, neurological deterioration appeared after chiropractic adjustment and in one patient after ‘tuina’ therapy (a form of massage used in Traditional Chinese Medicine). The patients had experienced symptoms within one day to one week after neck manipulation. The patients had signs of:
• central cord syndrome,
• spastic quadriparesis,
• spastic quadriparesis,
• radiculopathy and myelomalacia.
Three patients were managed with anterior cervical discectomy and fusion, while one patient declined surgical treatment.
Australian researchers published a systematic review aimed at evaluating all reports of serious AEs following lumbo-pelvic SMT. They identified 41 relevant articles reporting a total of 77 cases consisting of cauda equina syndrome (29 cases); lumbar disk herniation (23 cases); fracture (7 cases); haematoma or haemorrhagic cyst (6 cases); and12 cases of neurologic or vascular compromise, soft tissue trauma, muscle abscess formation, disrupted fracture healing, and oesophageal rupture.
Deaths
In 2010, I reviewed all the reports of deaths after chiropractic treatments published in the medical literature. My article covered 26 fatalities but it is important to stress that many more might have remained unpublished. The cause usually was a vascular accident involving the dissection of a vertebral artery (see above). The review also makes the following important points:
• … numerous deaths have been associated with chiropractic. Usually high-velocity, short-lever thrusts of the upper spine with rotation are implicated. They are believed to cause vertebral arterial dissection in predisposed individuals which, in turn, can lead to a chain of events including stroke and death. Many chiropractors claim that, because arterial dissection can also occur spontaneously, causality between the chiropractic intervention and arterial dissection is not proven. However, when carefully evaluating the known facts, one does arrive at the conclusion that causality is at least likely. Even if it were merely a remote possibility, the precautionary principle in healthcare would mean that neck manipulations should be considered unsafe until proven otherwise. Moreover, there is no good evidence for assuming that neck manipulation is an effective therapy for any medical condition. Thus, the risk-benefit balance for chiropractic neck manipulation fails to be positive.
• Reliable estimates of the frequency of vascular accidents are prevented by the fact that underreporting is known to be substantial. In a survey of UK neurologists, for instance, under-reporting of serious complications was 100%. Those cases which are published often turn out to be incomplete. Of 40 case reports of serious adverse effects associated with spinal manipulation, nine failed to provide any information about the clinical outcome. Incomplete reporting of outcomes might therefore further increase the true number of fatalities.
• This review is focussed on deaths after chiropractic, yet neck manipulations are, of course, used by other healthcare professionals as well. The reason for this focus is simple: chiropractors are more frequently associated with serious manipulation-related adverse effects than osteopaths, physiotherapists, doctors or other professionals. Of the 40 cases of serious adverse effects mentioned above, 28 can be traced back to a chiropractor and none to a osteopath. A review of complications after spinal manipulations by any type of healthcare professional included three deaths related to osteopaths, nine to medical practitioners, none to a physiotherapist, one to a naturopath and 17 to chiropractors. This article also summarised a total of 265 vascular accidents of which 142 were linked to chiropractors. Another review of complications after neck manipulations published by 1997 included 177 vascular accidents, 32 of which were fatal. The vast majority of these cases were associated with chiropractic and none with physiotherapy. The most obvious explanation for the dominance of chiropractic is that chiropractors routinely employ high-velocity, short-lever thrusts on the upper spine with a rotational element, while the other healthcare professionals use them much more sparingly.
Another review published in 2012 summarised published cases of injuries associated with cervical manipulation in China. A total of 156 cases were found. They included the following problems:
• syncope (45 cases) ,
• mild spinal cord injury or compression (34 cases),
• nerve root injury (24 cases),
• ineffective treatment/symptom increased (11 cases),
• cervical spine fracture (11 cases),
• dislocation or semi-luxation (6 cases),
• soft tissue injury (3 cases),
• serious accident (22 cases) including paralysis, death and cerebrovascular accident.
Manipulation including rotation was involved in 42% of all cases. In total, 5 patients died.
Not all fatalities after SMT get reported in medical journals. In fact, most seem to end up in court and are not retrievable via the medical literature. Here are just two recent examples:
• John Lawler died in 2018 after being treated by a chiropractor. The cause of death was a tear and dislocation of the C4/C5 intervertebral disc. The pathologist’s report showed that the deceased’s ligaments around vertebrae of the upper spine had been ossified, a common abnormality in elderly patients which limits the range of movement of the neck and therefore can be the reason patients consulting chiropractors. Mr Lawler’s chiropractor had failed to obtain adequately informed consent from her patient and Mr Lawler seemed to have been under the impression that the chiropractor, who used the ‘Dr’ title, was a medical doctor. There is no evidence to assume that the treatment of Mr Lawler’s neck would be effective for his pain located in his leg, the reason for the consultation. The chiropractor used an ‘activator’ a ‘drop table’ which applies a larger and not well-controlled force (chapter 4).
• The American model Katie May died in 2016 as the result of visiting a chiropractor for an adjustment, which ultimately left her with a fatal tear to an artery in her neck. According to Wikipedia , Katie tweeted on January 29, 2016, that she had “pinched a nerve in [her] neck on a photoshoot” and “got adjusted” at a chiropractor. She tweeted on January 31, 2016 that she was “going back to the chiropractor tomorrow.” On the evening of February 1, 2016, May “had begun feeling numbness in a hand and dizzy” and “called her parents to tell them she thought she was going to pass out.” At her family’s urging, May went to Cedars Sinai Hospital; she was found to be suffering a “massive stroke.” According to her father, she “was not conscious when we got to finally see her the next day. We never got to talk to her again.” Life support was withdrawn on February 4, 2016. Katie’s death certificate states that she died when a blunt force injury tore her left vertebral artery and cut off blood flow to her brain. It also says the injury was sustained during a “neck manipulation by chiropractor.” Her death is listed as accidental.
Relative safety
DD Palmer was strictly against drugs; in that tradition today’s chiropractors often insist that drugs are the third leading cause of death, a notion that has been debunked many times. They also like to claim that SMT is much safer that other options to treat pain, such as oral OTC pain killers. In 1995, Dabbs and Lauretti reviewed the risks of cervical SMT and compared them to those of non-steroidal, anti-inflammatory drugs (NSAIDs). They concluded that the best evidence indicates that cervical manipulation for neck pain is safer than the use of NSAIDs, by as much as a factor of several hundred times. This article has since become one of the most-quoted paper by chiropractors, and its conclusion is somewhat of a chiropractic mantra which is being repeated ad nauseam. Even the American Chiropractic Association states that the risks associated with some of the most common treatments for musculoskeletal pain—over-the-counter or prescription nonsteroidal anti-inflammatory drugs (NSAIDS) and prescription painkillers—are significantly greater than those of chiropractic manipulation.
But how reliable are the conclusions of Dabbs and Lauretti? The most obvious criticism of their paper has already been mentioned: it is outdated; today we know much more about the risks and benefits of both approaches. Equally important is the fact that we still have no surveillance system to monitor the AEs of SMT. Consequently, our data on this issue are woefully incomplete and rely mostly on haphazardly published case reports. Most adverse events remain unpublished and under-reporting is therefore huge. We have shown that, in our UK survey, it amounted to exactly 100%. To make matters worse, case reports were excluded from the analysis of Dabbs and Lauretti. In fact, they included only articles providing numerical estimates of risk (even reports that reported no AEs at all), the opinion of exerts, and a 1993 statistic from a malpractice insurer. None of these sources would lead to reliable incidence figures; they are thus no adequate basis for a comparative analysis. In contrast, NSAIDs have long been subject to proper post-marketing surveillance systems generating realistic incidence figures of AEs which Dabbs and Lauretti were able to use. It is, however, important to note that the figures they did employ were not from patients using NSAIDs for neck pain. Instead they were from patients using NSAIDs for arthritis. Equally important is the fact that they refer to long-term use of NSAIDs, while cervical manipulation is rarely applied long-term. Therefore, the comparison of risks of these two approaches seems not valid.
Moreover, when comparing the risks between cervical manipulation and NSAIDs, Dabbs and Lauretti seemed to have used incidence per manipulation, while for NSAIDs the incidence figures were based on events per patient using these drugs. Similarly, it remains unclear whether the NSAID-risk refers only to patients who had used the prescribed dose, or whether over-dosing (a phenomenon that surely is not uncommon with patients suffering from chronic arthritis pain) was included in the incidence figures.
To obtain a fair picture of the risks in a real life situation, one should perhaps also mention that chiropractors often fail to warn patients of the possibility of AEs. With NSAIDs, by contrast, patients have, at the very minimum, the drug information leaflets that do warn them of potential harm in full detail. Finally, one could argue that the effectiveness and costs of the two therapies need careful consideration. The costs for most NSAIDs per day are certainly much lower than those of manipulations. As to the effectiveness of the treatments, it is clear that NSAIDs do effectively alleviate pain , while the evidence is not conclusively positive in the case of cervical SMT.
In other words, the much-cited paper by Dabbs and Lauretti is out-dated, poor quality, fatally flawed, 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. In fact, no sound evidence exists to date in support of such a hypothesis.
To sum up: in this chapter, we have seen that chiropractic SMT can cause a wide range of very serious complications which occasionally can even be fatal. As there is no AE reporting system of such events, we nobody can be sure how frequently they occur. Sadly, this does not conclude our discussions about the risks of chiropractic. In the next chapter, we need to evaluate the arguable even more important topic of indirect risks.
Box 1
Typical statements about safety recently picked up on Twitter
• Chiropractic care is widely recognized as one of the safest drug-free, non-invasive therapies available for the treatment of most back and neck problems. Spinal adjustments are extremely safe when performed by a licensed chiropractor.
• Chiropractic adjustments are safe and effective for ensuring proper spinal health in small children
• Chiropractic treatments, called spinal adjustments are comfortable, safe, and highly effective.
• As new moms know, muscle strains are an all-too-real part of pregnancy. Many women find chiropractic care provides tremendous relief, especially from low back pain that occurs. Spinal adjustments are safe for the pregnant woman and her baby.
• If the twig is bent, so grows the tree! Spinal Adjustments are safe, effective, gentle and help us grow healthy
• The good news is that spinal adjustments are very safe, and often very rewarding for many types of headaches
• Chiropractic spinal adjustments are proven to be a safe, effective, & affordable treatment option
• Spinal adjustments or spinal manipulation are very gentle, safe, and effective movements of the spine.
Boy you sure do like to dig yourself a deeper and deeper hole. Your rebuttal for two peer-reviewed papers is your book of mostly anecdotes. Somewhere, I heard that the plural of anecdote isn’t evidence its anecdotes. .
You book (not peer-reviewed literature) was published in 2020. Unless you are on drugs and hallucinating time travel a 2020 book doesn’t really rebut an epidemiological study published this year.
Whedon JM, Petersen CL, Schoellkopf WJ, Haldeman S, MacKenzie TA, Lurie JD. The association between cervical artery dissection and spinal manipulation among US adults. Eur Spine J. 2023 Oct;32(10):3497-3504. doi: 10.1007/s00586-023-07844-9. Epub 2023 Jul 8. PMID: 37422607; PMCID: PMC10591258.
Further you did not critique of Church’s systematic review anywhere in your book. The word church isn’t in the book at all.
Church, Ephraim W, Sieg, Emily P, Zalatimo, Omar, Hussain, Namath S, Glantz, Michael & Harbaugh, Robert E. 2016. Systematic Review and Meta-analysis of Chiropractic Care and Cervical Artery Dissection: No Evidence for Causation.. Cureus 8: e498. doi: 10.7759/cureus.498. http://eutils.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&id=27014532&retmode=ref&cmd=prlinks
So we are back where we started. You have no evidence to refute the papers I cited. Ergo the best evidence today is that cervical SMT is not a risk for stroke.
Getting desperate aren’t you? I mean it looks like you violated Springer’s copyright in a failed attempt to refute the best current evidence. I am embarrassed for you.
Maybe it’s time for you to accept the evidence and give up your dogma.
CONGRATULATIONS!
you the 1st troll with a professor title we have met here, and you are munch more deluded than I had assumed.
My chapter includes 53 references, most of them are not anecdotes [as I pointed out to you before,
anecdotes are valuable evidence because chiros have resisted any post-marketing surveillance so far].
In any case, I herewith terminate this converstation because you are clearly trolling.
Perle wrote: “Somewhere, I heard that the plural of anecdote isn’t evidence its anecdotes.”
This is utterly wrong. All reports of rare side effects of drugs after they have been accepted for clinical use are anecdotes. This is the only way available to catch rare events.
Compare with drugs: Before approval by the FDA (and corresponding national pharmaceutical authorities in other countries) lots of pre-clinical and clinical tests have been performed, most of them RCTs, with results strongly supporting the intended use as well as a deep understanding of its pharmacodynamics, pharmacokinetics, possible or proven interactions, contraindications, etc. etc.
But then, even after approval, meticulous scrutiny continues as long as anybody uses the drug in question. Even the slightest suspicion of an adverse effect *must* be reported to the authorities by doctors and other health carers, particularly if it is unexpected. And if several reports happen to point to a rare and hitherto unforeseen and potentially risky association, the drug will be stopped immediately and researched even further. Too often in these cases, nothing more about causality can be proved or disproved in this process, but as long as the association is undeniable, the use of the drug will be restricted to certain cases or stopped completely. Among real doctors this is the very important plural of anecdotes = side-effect data, indeed.
(Also see Blue Wode’s comment above.)
In the case of chiropractic spinal manipulation (or any other chiropractic treatment), no or very few valid pre-clinical or clinical tests have been performed, no or virtually no well-performed RCTs, no results strongly supporting the intended use, no deep understanding of possible or proven interactions, contraindications, etc. etc.
And worst of all, no systematic reporting of either rare or common side effects.
I understand that chiropractors don’t want such statistics, but that’s a scary tragedy. If chiropractic were a drug, it would be forbidden.
Chiropractor Stephen Perle on Saturday 11 November 2023 at 20:18 wrote: “Thank you for further examples of intellectual laziness or maybe it’s really intellectual cowardice.”
@ Chiropractor Perle
You imply from your posts above that you have a superior mental capacity to Prof. Ernst, but what sort of intellectual would choose not only to study chiropractic (e.g. instead of physiotherapy or medicine), but also hold a tenure at the University of Bridgeport from Aug 1991 – Aug 2022 in the knowledge that the Rev. Sun Myung Moon of the Moonies cult owned the University of Bridgeport and its College of Chiropractic from 1992?
Ref. https://edzardernst.com/2014/01/visceral-manipulation-you-couldnt-make-it-up/#comment-53935
Chiropractor Stephen Perle on Saturday 11 November 2023 at 20:30 wrote: “…as an anonymous presence online Blue Wode shows its cowardice constantly. Or have you wiped the blue stain off your face finally? I can’t tell as you blocked me on Twitter so many years ago.”
@ Chiropractor Perle
Well that’s rich coming from one who devoted a whole blog post to me without giving me the right to respond. See here:
https://smperle.blogspot.com/2010/12/anonymous-criticism-defending-ernst.html
“If my anonymous critic comes out from behind the curtain I might then publish” was the feeble excuse used to block me from the comments section. (Note that Prof. Ernst doesn’t block me for being anonymous – in fact I can’t recall any source that has.) As for remaining anonymous, we all know what happened to Simon Singh when he dared to criticise the British Chiropractic Association. Fortunately he won the libel suit, but I understand he was still left £20,000 out of pocket.
With regard to Twitter, if you’re still smarting from me blocking you then I think you need to have a good look at yourself. IOW, there’s a great deal of gratuitous nastiness in the way you conduct yourself that doesn’t do you any favours.
Finally, @ Chiropractor Perle, what are your thoughts on this segment which I have lifted from one of my posts above:
QUOTE
“… I ask you to imagine that there is a pharmaceutical drug that fits this description. Imagine that there are the same numbers of studies showing *an association* of that drug with a deadly side effect like stroke or death. The FDA would pull it off the market; they wouldn’t wait for definite evidence of causation that fulfilled all of Hill’s criteria. And I think the people who are making excuses for neck manipulation would want them to take that drug off the market. I don’t think they would want to take such a drug.”
For example:
*Reports* of deaths after chiropractic treatment “about three times the number of deaths from trovafloxacin, an excellent antibiotic abandoned in the U.S. as too dangerous”.
Ref. https://tinyurl.com/5n932kbw
As the husband of a young Chiropractic victim, it’s always encouraging to see this subject being examined and critiqued. Our prayer is that someday common sense will prevail.
Sadly there are still a number of misguided Chiropractors spreading a ton of disinformation and misinformation.
The tragedy is that unfortunately there will continue to be countless more victims resulting from this barbaric neck twisting procedure, until someone puts a stop to the madness once and for all.
“There is no rest stop on the misinformation highway.” ~ Dahlia Lithwick
In the meantime, the clown show taking place on practically every shopping mall/street corner in North America continues.
Upper Neck Manipulation: If it wasn’t so tragic it would be funny.