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

The risks of chiropractic spinal manipulations (CSMs) feature regularly on my blog, not least because most chiropractors are in denial of this important issue and insist that chiropractic spinal manipulations are safe!!!. I therefore thought it might be a good idea to try and summarize the arguments they often put forward in promoting their dangerously fallacious and quasi-religious belief that CSMs are safe:

  1. There is not evidence to suggest that CSMs do harm. Such a statement is based on wishful thinking and ignorance motivated by the need of making a living. The evidence shows a different picture.
  2. There are hundreds of clinical trials that demonstrate the safety of CSMs. This argument is utterly unconvincing for at least two reasons: firstly clinical trials are far too small for identifying rare (but serious) complications; secondly, we know that clinical trials of CSM very often fail to report adverse events.
  3. Case reports of adverse effects are mere anecdotes and thus not reliable evidence. As there is no post-marketing surveillance system of adverse events after CSMs, case reports are, in fact, the most important and informative source of information we currently have on this subject.
  4. Case reports of harm by CSMs are invariably incomplete and of poor quality. Case reports are usually published by doctors who often have to rely on incomplete information. It would be up to chiropractors to publish case reports with the full details; yet chiropractors hardly ever do this.
  5. Case reports cannot establish cause and effect. True, but they do provide important signals which then should be investigated further. It would be up to chiropractors to do this; sadly, this is not what is happening.
  6. Adverse effects such as arterial dissections or strokes occur spontaneaously. True, but many have an identifiable cause, and it is our duty to find it.
  7. The forces applied during CSM are small and cannot cause an injury. This might be true under ideal conditions, but in clinical practice the conditions are often not ideal.
  8. If an arterial dissection occurs nevertheless, it is because there was a pre-existing injury. This argument is largely based on wishful thinking. Even if it were true, it would be foolish to aggravate a pre-existing injury by CSMs.
  9. Injuries happen only if the contra-indications of CSMs are ignored. This obviously begs the question: what are the contra-indications and how well established are they? The answer is that they are largely based on guess-work and not on systematic research. Thus chiropractors are able to claim that, once an adverse effects has occurred, the incident was due to a disregard of contra-indication and not due to the inherent risks of CSM.
  10. Only poorly trained chiropractors cause harm. This is evidently untrue, yet the argument provides yet another welcome escape route for those defending CSMs: if something went wrong, it must have been due to the practitioner and not the intervention!
  11. Chiropractors are an easy target. In my fairly extensive experience in this field, the opposite is true. Chiropractors tend to have multiple excuses and escape routes. As a consequence, they are difficult to pin down.
  12. Other causes, e.g. car accidents, are much more common causes of vascular injuries. Even if this were true, it does certainly not mean that CSM can be ruled out as the cause of serious harm.
  13. Patients who experience harm had pre-existing issues. Again, this notion is mostly based on wishful thinking and not based on sound evidence. Yet, it clearly is another popular escape route for chiropractors. And again, it is irresponsible to administer CSM if there is the possibility that pre-existing issues are present.
  14. The alleged harms of CSMs are merely an obsession for people who don’t really understand chiropractic. That is an old trick of someone trying to defend the indefensible. Chiropractors like to pompously claim that opponents are ignorant and only chiropractors understand the subject area. They use arrogance in an attempt to intimidate or scilence experts who disagree with them.
  15. Chiropractors do so much more than just CSN. True. They have ‘borrowed’ many modalities from physiotherapy and, by pointing that out, they aim at distracting from the dangers of CSMs. Yet, it is also true that practically every patient who consults a chiropractor will receive a CSM.
  16. Doctors are just jealous of the success of chiropractors. This fallacy is used when chiropractors run out of proper arguments. Rather than addressing the problem, they try to distract from it by claiming the opponent has ulterior motives.
  17. Medical treatments cause much more harm than CSM. Chiropractors are keen to mislead us into believing that NSAIDs, for instance, are much more dangerous than CSMs. The notion is largely based on one lousy article and thus not convincing. Even if it were true, it would obviously be no reason to ignore the risks of CSNs.

I am sure my list is far from complete. If you can think of further (pseudo-) arguments, please use the comments section below to let us know.

60 Responses to Chiropractic spinal manipulations are safe!!! … Or aren’t they?

  • Thank you so much for providing these 17 detailed points, on the many “fact evading technique’s”, that chiropractors continue to use to validate their continued barbaric use of rapid upper neck manipulations.

    Here’s hoping that 2024 will shed more light on this nonsense. Sites like this are invaluable.

    Carry on Dr. Edzard Ernst… carry on!

  • Envious, not jealous; the former is of a situation or item, while the latter is of personal interactions.
    I am envious of his new car. I am jealous of my friend’s hot girlfriend.

  • Item 11. Since you are not licensed or registered as a chiropractor, you are not in a position to say “In my fairly extensive experience in this field.” What you should say, FROM MY UNDERSTANDING “of my extensive experience in this field. “
    From my understanding, you are registered as a medical doctor and not as a Doctor of Chiropactic.

  • Regarding the risk of immediate stroke from cervical spine manipulation, mechanisms of causation have been in the literature for years, and these strokes are avoidable if physicians would rule out cervical artery dissection before performing cervical spine manipulation. And, when in doubt, don’t perform the cervical spine manipulation. I published a study in Cureus on this topic in March 2024:

    https://www.cureus.com/articles/239108-plausible-mechanisms-of-causation-of-immediate-stroke-by-cervical-spine-manipulation-a-narrative-review#!/

    • I did know your paper.
      In my view, it set out to find evidence for your hypothesis, rather than properly testing it.
      Pre-existing thrombi are, in my view, just one of several possibilities.

      • Understood.

        1. But how could we test it? RCTs are infeasible due to the rarity and life-threatening nature of CAD and stroke. Large-scale epidemiological studies are technically possible, but difficult due to the rarity of CAD and stroke. It seems the best available method is to examine the phenomena of immediate post-manipulative stroke and see if the hypothesis explains that phenomena. I believe that it does. It explains every case of immediate post-manipulative stroke I have reviewed as an expert witness, and it explains all the case reports in the literature that have been completely documented.

        2. What are the other possibilities? I didn’t find any other plausible mechanisms of causation in the literature that could explain the phenomena of immediate post-manipulative stroke. There is no convincing evidence CSM can cause dissection in healthy cervical arteries (2016 Church), even if it did stroke would not be immediate (1999 Hufnagel). There is no convincing evidence that CSM may cause immediate stroke by way of vasospasm, hemostasis, subclinical endothelial injury, or turbulent flow (2019 Moser, 2014 Achalandabaso).

        What are the several possibilities that you believe are plausible?

        • there is plenty of evidence for dissection
          “even if it did stroke would not be immediate” – and it often is not immediate.

          • 1. “Please remember: if you make a claim in a comment, support it with evidence.”

            Where is the evidence that CSM can cause dissection in an otherwise healthy cervical artery?

            How do you refute the 2016 Church study? How do you refute Biller’s 2014 comments that biomechanical evidence is insufficient to establish the claim that CSM causes CAD?

            2. My study concerns mechanisms of causation of immediate stroke by CSM only.

            I have found no plausible mechanisms of causation for a non-immediate stroke by CSM.

          • 2. My study concerns mechanisms of causation of immediate stroke by CSM only.

            I have found no plausible mechanisms of causation for a non-immediate stroke by CSM.

            Neither have I — very likely for the same reason 🤣

          • The association of cervical spine manipulation and non-immediate stroke can be accounted for without postulating that CSM caused a dissection. The patient sought DC treatment due to pain and headache from an existing dissection, the DC failed to diagnose and refer the dissection for emergency medical treatment, the dissection later dislodged a thrombus and caused thromboembolic stroke. The DC did not cause the dissection, but they are still liable for the failure to diagnose and refer. Same with MDs who miss the diagnosis of dissection. (Cassidy 2008, Cassidy 2017)

          • There are two main situations in which people visit a chiropractor for treatment:

            1. the worried well who’ve been convinced that they need treatment to ‘avoid becoming unwell’;

            2. those who have become unwell with a yet-to-be-diagnosed medical condition.

            The first group do not need (do not require) chiropractic spinal manipulation. The second group should not receive chiropractic spinal manipulation because the chiropractor cannot possibly know that their client does not have any of the plethora of conditions that are contraindications to chiropractic spinal manipulation.
             

            Steven Brown wrote:

            The association of cervical spine manipulation and non-immediate stroke can be accounted for without postulating that CSM caused a dissection.

            followed by

            The patient sought DC treatment due to pain and headache from an existing dissection

            then states, without providing evidence, that

            The DC did not cause the dissection

            Thereby illustrating one of the pillars of so-called alternative medicine:
            Always blame the victim.

          • It is hardly disputable that in the case of a preexisting cervical artery dissection, any externally applied force including massage and manipulation may initiate a thromboembolic stroke by rupturing the dissection and dislodging a blood clot from the intimal lesion. We can only postulate that manipulation may initiate a dissection in an intact vessel, namely if there is a predisposing condition e.g. vascular Ehler’s Dahnlos. Many case histories of post-manipulation dissection and stroke invole repeated manipulations.
            A vascular dissection can heal without causing an embolic stroke, this is a confirmed fact. We will nwver know the incidence of such events as they only come to medical attention if they cause specific symptoms leading to diagnostic imaging.

            In the case of someone walking into a manipulators office with pain above his shoulders from a preexisting vascular dissection and is later transported to hospital in a stretcher with stroke, the manipulator may not have caused the dissection – but he or she will definitely have contributed to the development of the stroke that may not have been the result of a dissection had the manipulator sensibly refrained from applying any force by pressure or movement and instead instructed the patient to avoid aggravating factors and even seek proper medical attention. Most head or neck pain resolves without intervention and massage or manipulation has not been shown to be necessary.

            A preexisting cervical artery (vertebral or carotid) dissection may be without any symptoms at all. A vascular dissection seldom causes more specific symptoms than unspecific pain in the head and neck area. Carotid dissection involving the bulb may cause very subtle signs e.g. different sized pupils (Horner’s syndrome). Pain in the head and neck area, including so-called cervicogenic headache, should be considered an absolute contraindication against any kind of manipulation involving the cervical spine. It is impossible for the practitioner to exclude dissection clinically. This means that a massage or manipulation practitoner or even a neurologist cannot rule out preexisting dissection by examination in the office. Definite diagnosis is only possible with medical imaging.

          • Bjorn. Should people with neck pain not play golf until a VAD is ruled out?

  • @ Steven Brown DC FYI, see here for a closer look at the Church study:

    https://edzardernst.com/2020/08/chiropractic-not-all-that-its-cracked-up-to-be/#comment-125747

    IMO, if properly informed about the current debate surrounding it, I think most chiropractic customers would refuse to undergo neck manipulation.

  • Pete Attkins: I am not blaming the victim. I am blaming the DC who failed to diagnose and refer the existing dissection and caused the stroke. I am not letting the DC off the hook. I am one of the most unpopular people in Chiropractic precisely because I do not let the DC off the hook.

    My experience reviewing all the chiropractic and medical records of cases of post-manipulative stroke, and not just reading research on a topic that is difficult to research and filled with bias on both sides, is that dissections hurt like a bitch or have a recent history of hurting like a bitch and can be suspected and diagnosed with a thorough history and examination and advanced imaging (2019 Chaibi) (2023 Rushton) (2020 Harper).

    My experience is that examination of all the chiropractic and medical records of asymptomatic cases finds that symptoms were present and ignored, or that a thorough history and examination was not performed. In other words, in every case of immediate post-manipulative stroke I have reviewed the DC failed to diagnose and refer the dissection when they should have, and I blame the DC for that, not the victim.

    I agree that less manipulation and more arterial imaging should be done in cases of head and neck pain. Less than half of my patients receive CSM, and I order CTA scans on a regular basis. Ordered one this week after the patient had seen multiple MDs and the ER who all refused to do so. However, there is no evidence to stop performing cervical spine manipulation altogether.

    As with any medical procedure that has potentially deadly side effects, only competent practitioners should be performing it. The Chiropractic educational system needs improvement, many people in Chiropractic agree with me. See my 2016 article:

    https://dynamicchiropractic.com/article/57714-chiropractic-needs-a-lesson-in-education

    All Chiropractors should complete a residency program like the one at the University of Bridgeport, however, that is not happening. Having all Chiropractors complete rotations in a stroke unit should be mandatory, also. Residency training is a must for the Chiropractic profession.

    “Probably of most critical importance in making positive change in our current (Chiropractic) educational programs is the establishment of mandatory post-graduate internships and residencies with hospital and interdisciplinary training. Exposure to a large volume and variety of patients is critical to our students training if the profession is to take a place at the center of our mainstream health care system. Interns and residents must be routinely exposed to patients with conditions that represent the full spectrum of potential diagnoses that are considered by Chiropractors. This first hand, on-the-job experience by new Chiropractors, not just via didactics or textbook exposure, is paramount to the best clinical experience available. Certainly hospital rounds would be a great advantage in this respect. Rigorous post-graduate residencies, such as is the case currently for (Chiropractic) radiology, need to be developed to train our brightest new doctors to be leaders.”

    -Wyatt L, Perle S, Murphy D, Hyde T. The necessary future of chiropractic education: a North American perspective. Chiropractic & Osteopathy, July 2005.

    “It is essential that the Chiropractic profession establish hospital-based residencies. There is a tremendous void in how Chiropractic graduates develop any meaningful hands-on clinical experience with real patients in real life situations. It is widely recognized in medical and podiatric education that abundant exposure to clinical environments is essential to developing top-quality professions. The Council on Chiropractic Education requirement of 250 adjustments forces interns to use manipulation on patients whether they need it or not, and the radiographic requirement forces interns to take radiographs on patients whether they need them or not. Rather than focus on interns meeting certain numerical requirements, interns should be encouraged to develop clinical decision making and patient management skills. Further, the emphasis on achieving a certain number of procedures as opposed to the acquisition of skill and knowledge impedes the development of professional moral reasoning by training interns to use patients as a means to meet their own goals, rather than focusing on the needs of the patients themselves. The Chiropractic internship should, as with medicine and podiatry, occur after graduation.”

    -Murphy D, Schneider M, Seaman D, Perle S, Nelson C. How can chiropractic become a respected mainstream profession? The example of podiatry. Chiropractic & Osteopathy 2008;16:10.

    Blue Wode: I am properly informed about the current debate surrounding cervical spine manipulation. I know more about it than just about anyone, and I do not refuse to undergo neck manipulation. However, I only have it done by a competent practitioner, Chiropractic or otherwise.

    • Well Steven Brown…hurt like a bitch?
      As a victim of Chiropractic rapid upper neck manipulation ( September 2024 will mark year 17 of my wife’s ongoing “recovery” ) I feel that I must chime in on your above comment…”My experience reviewing all the chiropractic and medical records of cases of post-manipulative stroke, and not just reading research on a topic that is difficult to research and filled with bias on both sides, is that dissections hurt like a bitch or have a recent history of hurting like a bitch…”

      My sweet wife NEVER experienced ANY such pain prior to seeing her Chiropractor. In fact, the only reason she frequented him was on his advice and encouragement that he could provide this necessary maintenance routine and ultimately keep her in excellent health.

      What a mistake!

      Anyway, I feel like a broken record, but if there is a risk of serious harm or in rare cases even possible death, and little to no long-term real benefit in doing these rapid upper neck manipulations, why the persistent need to push for this nonsense to continue? I just don’t get it.

      • Mr. Nette, I thought of you and your wife as I typed those words. I am familiar with your wife’s case, of course. All I can tell you is that in every instance where I have been able to review all the chiropractic and medical records in these cases of immediate post-manipulative stroke, the DC should have known better. In every case I have reviewed, there was characteristic neck pain and/or headache prior to manipulation. There were also other factors that made the manipulation contraindicated. I have not reviewed the chiropractic and medical records in your wife’s case, so I cannot comment on her case specifically. I appreciate your comment and wish the best for you and your wife.

    • Steven. As I have stated several times on this forum, improved education would dramatically reduce these associated serious events. I would also like to see kinematic/diagnostic US in chiropractic offices. Although US does not have the best S/S for VAD compared to CT or MRA.

      • I apologize, DC. I responded too quickly without thoroughly reading your comment.

        I do not agree that US should be done in a chiropractic office in cases of suspected CAD. Ultrasound could dislodge a thrombus. And if CAD is truly suspected, the patient doesn’t belong in a chiropractic office, they belong in an ER as soon as possible. Keeping them in the chiropractic office longer than necessary would be beneath the standard of care when dealing with a potential CAD or stroke.

        All things considered, CTA is the best choice, in my opinion. (2008 Vertinsky) The combination of image quality and speed is what is needed is such cases.

        However, the choice of imaging is not up the DC. The standard of care for the DC is simply to get the patient to the ER as quickly as possible. (2019 Chaibi) It is up to the ER physician to choose the most appropriate imaging for the situation. DCs spend a lot of time debating what imaging is best when that is not even their job in an emergency situation.

        And I don’t frequent this forum, so I have not seen your comments on this topic before. Whoever you are.

        • We need to differentiate between “suspected” and probability.

          I can suspect a VAD for anyone with neck pain, dizziness and/or an occipital headache.

          Are you suggesting anyone with those symptoms presenting to a manual therapist automatically have a CTA?

  • Dr. Ernst, you’ve posted your list of 17 arguments twice now. I assume you are trying to generate a response. Here it is:

    1. There is not evidence to suggest that CSMs do harm. Such a statement is based on wishful thinking and ignorance motivated by the need of making a living. The evidence shows a different picture.

    Misinformed DCs living in a state of denial may claim this, but not all DCs.

    2. There are hundreds of clinical trials that demonstrate the safety of CSMs. This argument is utterly unconvincing for at least two reasons: firstly, clinical trials are far too small for identifying rare (but serious) complications; secondly, we know that clinical trials of CSM very often fail to report adverse events.

    Agreed on your first point, especially regarding strokes.1 To your second point, if that is happening, it needs to stop happening.

    3. Case reports of adverse effects are mere anecdotes and thus not reliable evidence. As there is no post-marketing surveillance system of adverse events after CSMs, case reports are, in fact, the most important and informative source of information we currently have on this subject.

    Agreed. The Chiropractic profession must start publishing case reports of adverse events.

    4. Case reports of harm by CSMs are invariably incomplete and of poor quality. Case reports are usually published by doctors who often have to rely on incomplete information. It would be up to chiropractors to publish case reports with the full details; yet chiropractors hardly ever do this.

    Agreed. The Chiropractic profession needs to publish honest case reports. See my critique of the 2014 Mattox case report.2 3 See my 2024 case report in Cureus.3 I failed to order an x-ray when I should have. Fortunately, there were not severe consequences. However, I published the case report to help educate DC students in the importance of a thorough evaluation.

    5. Case reports cannot establish cause and effect. True, but they do provide important signals which then should be investigated further. It would be up to chiropractors to do this; sadly, this is not what is happening.

    Agreed. The Chiropractic profession must improve in this area.

    6. Adverse effects such as arterial dissections or strokes occur spontaneously. True, but many have an identifiable cause, and it is our duty to find it.

    There is no convincing evidence that CSM can cause arterial dissections in healthy cervical arteries, so it is not an adverse effect according to the research.4 5 6 7 As for strokes, strokes occurring immediately after CSM are not likely to be spontaneous. See my 2024 Cureus study for plausible mechanisms of causation of how these strokes occur.1 The identifiable cause has been in the literature for at least 35 years.8

    7. The forces applied during CSM are small and cannot cause an injury. This might be true under ideal conditions, but in clinical practice the conditions are often not ideal.

    Even small forces can cause an injury in the presence of other conditions, like dissection. Competent chiropractors know when and when not to apply treatments, just as in any other profession. If DC makes an error, they are liable for the injuries.

    8. If an arterial dissection occurs nevertheless, it is because there was a pre-existing injury. This argument is largely based on wishful thinking. Even if it were true, it would be foolish to aggravate a pre-existing injury by CSMs.

    Regarding strokes, the only plausible mechanism whereby this can happen does involve a pre-existing injury, a pre-existing arterial dissection.1 The physician is under a duty to rule out cervical artery dissection before performing CSM.9 10 11 12 If they breach this duty, and stroke occurs, they are liable.

    9. Injuries happen only if the contra-indications of CSMs are ignored. This obviously begs the question: what are the contra-indications and how well established are they? The answer is that they are largely based on guess-work and not on systematic research. Thus, chiropractors are able to claim that, once an adverse effect has occurred, the incident was due to a disregard of contra-indication and not due to the inherent risks of CSM.

    The contraindications are known and are based on the best available research.1 9 If they are disregarded, the DC is liable for the injuries.

    10. Only poorly trained chiropractors cause harm. This is evidently untrue, yet the argument provides yet another welcome escape route for those defending CSMs: if something went wrong, it must have been due to the practitioner and not the intervention!

    Sometimes well-trained chiropractors make mistakes and cause harm, as in any other health care profession. Poorly trained chiropractors are more likely to cause harm, as in any other health care profession.13 If a chiropractor causes harm, they are liable for that harm.

    11. Chiropractors are an easy target. In my fairly extensive experience in this field, the opposite is true. Chiropractors tend to have multiple excuses and escape routes. As a consequence, they are difficult to pin down.

    An easy target for criticism? Bring it on. Competent DCs have nothing to fear from honest criticism. I’m not running from your criticisms.

    My experience is that most DCs do not run from your criticisms, they simply ignore you. Many of things you say, especially about manipulation, dissection and stroke, are not supported by the research. However, I think you have some valid criticisms of our profession and are worth responding to.

    12. Other causes, e.g. car accidents, are much more common causes of vascular injuries. Even if this were true, it does certainly not mean that CSM can be ruled out as the cause of serious harm.

    Agreed.

    13. Patients who experience harm had pre-existing issues. Again, this notion is mostly based on wishful thinking and not based on sound evidence. Yet, it clearly is another popular escape route for chiropractors. And again, it is irresponsible to administer CSM if there is the possibility that pre-existing issues are present.

    Agreed. If the DC fails to diagnose the pre-existing issues and harms the patient, the DC is liable.

    14. The alleged harms of CSMs are merely an obsession for people who don’t really understand chiropractic. That is an old trick of someone trying to defend the indefensible. Chiropractors like to pompously claim that opponents are ignorant and only chiropractors understand the subject area. They use arrogance in an attempt to intimidate or silence experts who disagree with them.

    I don’t. The DCs I hang around with don’t. I advise you to meet a wider variety of DCs.

    15. Chiropractors do so much more than just CSM. True. They have ‘borrowed’ many modalities from physiotherapy and, by pointing that out, they aim at distracting from the dangers of CSMs. Yet, it is also true that practically every patient who consults a chiropractor will receive a CSM.

    No. Some days less than half of my patients will get CSM. All Chiropractic practices are different. This does show that you have some degree of ignorance about chiropractic practice. But I think you are capable of learning.

    16. Doctors are just jealous of the success of chiropractors. This fallacy is used when chiropractors run out of proper arguments. Rather than addressing the problem, they try to distract from it by claiming the opponent has ulterior motives.

    I don’t think MDs are jealous of chiropractors. You certainly don’t seem to be.

    17. Medical treatments cause much more harm than CSM. Chiropractors are keen to mislead us into believing that NSAIDs, for instance, are much more dangerous than CSMs. The notion is largely based on one lousy article and thus not convincing. Even if it were true, it would obviously be no reason to ignore the risks of CSMs.

    Agreed. All treatments, medical and chiropractic, have the potential for harm. Competent medical and chiropractic practitioners will minimize risks.

    References

    1. Brown SP. Plausible Mechanisms of Causation of Immediate Stroke by Cervical Spine Manipulation: A Narrative Review. Cureus. 2024 Mar;16(3):e56565.

    2. Mattox R, Smith LW, Kettner NW. Recognition of spontaneous vertebral artery dissection preempting spinal manipulative therapy: a patient presenting with neck pain and headache for chiropractic care. J Chiropr Med. 2014 Jun;13(2):90–5.

    3. Brown S. Diagnosing Vertebral Artery Dissection: Commentary on the 2014 Mattox Case Report. J Int Acad Neuromusculoskel Med. 2024;21(1):71–9.

    4. Church EW, Sieg EP, Zalatimo O, Hussain NS, Glantz M, Harbaugh RE. Systematic Review and Meta-analysis of Chiropractic Care and Cervical Artery Dissection: No Evidence for Causation. Cureus. 2016 Feb 16;8(2):e498.

    5. Biller J, Sacco RL, Albuquerque FC, Demaerschalk BM, Fayad P, Long PH, et al. Cervical arterial dissections and association with cervical manipulative therapy: a statement for healthcare professionals from the american heart association/american stroke association. Stroke. 2014 Oct;45(10):3155–74.

    6. Cassidy JD, Boyle E, Côté P, He Y, Hogg-Johnson S, Silver FL, et al. Risk of vertebrobasilar stroke and chiropractic care: results of a population-based case-control and case-crossover study. Spine. 2008 Feb 15;33(4 Suppl):S176-183.

    7. Cassidy JD, Boyle E, Côté P, Hogg-Johnson S, Bondy SJ, Haldeman S. Risk of Carotid Stroke after Chiropractic Care: A Population-Based Case-Crossover Study. J Stroke Cerebrovasc Dis Off J Natl Stroke Assoc. 2017 Apr;26(4):842–50.

    8. Mas JL, Henin D, Bousser MG, Chain F, Hauw JJ. Dissecting aneurysm of the vertebral artery and cervical manipulation: a case report with autopsy. Neurology. 1989 Apr;39(4):512–5.

    9. Chaibi A, Russell MB. A risk-benefit assessment strategy to exclude cervical artery dissection in spinal manual-therapy: a comprehensive review. Ann Med. 2019 Mar;51(2):118–27.

    10. Rushton A, Carlesso LC, Flynn T, Hing WA, Rubinstein SM, Vogel S, et al. International Framework for Examination of the Cervical Region for Potential of Vascular Pathologies of the Neck Prior to Musculoskeletal Intervention: International IFOMPT Cervical Framework. J Orthop Sports Phys Ther. 2023 Jan;53(1):7–22.

    11. Harper B, Miner D, Vaughan H. Proposing a new algorithm for premanipulative testing in physical therapy practice. J Phys Ther Sci. 2020 Nov;32(11):775–83.

    12. Brown S. 10 ways for DCs to survive a stroke malpractice claim. Chiropractic Economics. 2014 Feb;

    13. Brown S. Chiropractic Needs a Lesson in Education The future of chiropractic economics: better admissions standards and training. Dynamic Chiropractic. 2016 May;

  • Dr. Edzard, you serve such a valuable role. I am disappointed in your attacking Dr. Brown with a name-calling cognitive distortion. Associating his response with a percentage of his education obviously has nothing to do with artery dissection etiology. Failure to answer his well-referenced specific concerns with a detailed, equally well-cited response, does a disservice to the discussion. Using an ad hominin attack, i.e., ‘cherry-picker,’ rather than addressing the causation issue is a sign of giving up. I have too much respect for you, to think of you as a quitter. There is much more that those of us, ‘in the peanut gallery,’ could gain from the type of educated response you are obviously capable of and more often demonstrate. I am rarely as disappointed as I am by your last response. I appreciate so much of the valuable education you provide and look forward to more facts and less nasty.

    • I think you got more than my name wrong!

      • Dr. Ernst, I apologize for using your first name instead of your last name. I was wrong. I don’t apologize for my compliments or pointing out your failure to respond specifically. I do not profess to be either intelligent or knowledgeable. My role is neither entertainment, nor education. Intelligence, knowledge, entertainment, and education is your role. I am just a disappointed (and a little insulted) audience member.

      • I think my colleague can be forgiven for getting your unusual name wrong.

        You set up this forum presumably to interact with others. However, when presented with an argument that warrants a measured response, you respond with jokes. It seems that this forum is simply an outlet for you to express your views, such as the 17 arguments in this post, which is fine, it’s your forum.

        I find it interesting that the world’s first Professor of Complementary Medicine has no education or clinical experience in any form of complementary medicine. Take care.

        • I set up this blog to inform people about SCAMs

        • I find it interesting that the world’s first Professor of Complementary Medicine has no education or clinical experience in any form of complementary medicine. Take care.

          The old “Not a true Scotsman” fallacy. 😀
          Applying your reasoning Mr. Brown, a magistrate would need to murder a number of people himself before being entitled to judge a fellow murderer.
          I suggest you do a bit of basic reading and research before endevouring to discuss socalled complementary medicine here and risk the audience think you are a fool. I recommend to begin with, Professor Ernst’s book “A scientist in Wonderland”.

  • Sarcasm, name calling, over generalization, red herrings, and statements that do not address if manipulation can cause a dissection versus manipulation dislodging a preexisting thrombus.
    There are typically two arguments, i.e., one concerning the facts and the other based on ego and the desire to be the one who wins.
    It is interesting to step back and analyze this thread to review its evolution.
    Did the discussion bring additional information to the dissection versus embolization question, or did it veer into the ego zone?
    Then there is the question of confirmation bias.
    It is also noteworthy what Dr. Brown did not do. He did not point out the risks associated with medical interventions. Comparing the risks of medication versus manipulation is not the topic and would have been incorrect. He stuck to a very narrow factual concern.

    • I think you may need to read this discussion again Mr. Cerf, you seem to have missed very important information.

      • Mr. Geir, I’m focused on the concern of the possible role of manipulation in causing a vertebral artery dissection versus manipulation dislodging a thrombus resulting from a preexisting dissection. Sadly, “chiropractic” interjected into the conversation serves as a red herring to magnify confirmation bias. There are much more important reasons to consider this question than chiropractors. There are many other cervical maneuvers, e.g., positioning during surgery or intubation by an anesthesiologist that could be potentially impacted by further brainstorming this topic. One of the main keys to brainstorming is avoiding stating no. Great things can happen by adding to the conversation. Imagine saying, no, to the person who made the silly suggestion of creating a photo with a magnet. Allowing this conversation to become personal is also counterproductive. Please point out, specifically what important information I missed. To do otherwise gives condescending appearance more likely to elicit escalating emotions than a mutually beneficial exchange of ideas. You are more likely than not correct that I missed something because I was reading for specific answers that I did not find. Perhaps there is something of different value from which I can learn.

        • Mr Cerf,

          You wrote:

          Sadly, “chiropractic” interjected into the conversation serves as a red herring to magnify confirmation bias.

          The title of this article, on which you have chosen to comment, is:

          Chiropractic spinal manipulations are safe!!! … Or aren’t they?

          QUOTE
          The risks of chiropractic spinal manipulations (CSMs) feature regularly on my blog, not least because most chiropractors are in denial of this important issue and insist that chiropractic spinal manipulations are safe!!!.

          • Mr. Attkins, You are correct! The title concerns chiropractic manipulation. I don’t have citations, but I agree that most chiropractors are unaware of the actual risks of cervical manipulation (provided by chiropractor, physical therapist, osteopath, physician, spouse, or golf buddy). I suspect some of the blame, for the lack of awareness, should go to malpractice carriers and the legal system who settle claims without disclosing the facts surrounding the claims.

            In addition, to what you correctly point out, there is the concept of reality. Chiropractic is not likely disappearing any time soon. In the US, the University of Pittsburg just added a chiropractic college where the chiropractic students will be taking classes with medical physicians and other health profession students. With that reality in mind, it seems logical to dissect the facts to make cervical manipulation (performed by chiropractors and others) as safe as possible.

            Guided by the above-described reality, I remain disappointed that Dr. Ernst engaged in cynicism and name-calling rather than add to the discussion by specifically addressing manipulation embolizing a thrombus versus manipulation as the initial etiology for a vertebral artery dissection. Dr. Ernst has a wealth of knowledge and is obviously of superior intellect.

            Mr. Attkins, you did an excellent job of pointing out my veering away from the original title of the article. Perhaps you can do an equally excellent job of addressing manipulation embolizing a thrombus versus manipulation as the initial etiology for a vertebral artery dissection to help chiropractors become more aware of the real risks.

            Beating me up is easy. I’m not that smart. I’m not that knowledgeable. How about attacking something more important like addressing a very specific aspect of risk to impact the decision making that will naturally follow that understanding.

          • ” I remain disappointed that Dr. Ernst engaged in cynicism and name-calling rather than add to the discussion by specifically addressing manipulation embolizing a thrombus versus manipulation as the initial etiology for a vertebral artery dissection.”
            There are > 500 000 comments on my blog; I only very rarely have the intention to engage with many discussants or get drawn into disputes. If I did, I could not do this blog.
            You may notice that I try to stimulate discussions, for instance, by posting provocative posts and short comments. This is my role as I see it. You don’t have to like it and can go elesewhere.

          • I have not beaten you up!
            [but if you carry on whining, you might change my mind]

          • Accusing me of whining is insulting. You might as well beat me up if that aligns with your mission. Hopefully, you will take the time to find out what aspects of me deserve beating up and do it properly. For the record, you and others have failed to provide any information regarding cervical manipulation as embolizing a preexisting thrombus versus being the primary vertebral artery dissection etiology. I will not speculate that you are not aware of any helpful literature. All I know is that your responses lean more towards insult than education. If you are not aware of pertinent literature, you can state so. Not knowing is not a weakness. My critique is only the lack of any substantive response. Your one liners have unfortunately not encouraged any informative responses. Please feel free to insult me if that aligns with your purpose. Having read your biography, it is an honor to have someone of your stature respond at all–even if just to insult one of your readers asking for additional information.

          • ” you and others have failed to provide any information regarding cervical manipulation as embolizing a preexisting thrombus versus being the primary vertebral artery dissection etiology”
            perhaps that’s because it was not the subject of my post?

          • ” you and others have failed to provide any information regarding cervical manipulation as embolizing a preexisting thrombus versus being the primary vertebral artery dissection etiology”
            perhaps that’s because it was not the subject of my post?

          • LOL!
            We love you Pete!

    • Yes John, one shouldn’t share papers like this one.

      Effectiveness and safety of manual therapy when compared with oral pain medications
      in patients with neck pain: a systematic review and meta-analysis

      https://bmcsportsscimedrehabil.biomedcentral.com/counter/pdf/10.1186/s13102-024-00874-w.pdf

      • I made a comment that Dr. Brown stayed on topic by not stooping to using a red herring argument by pointing out risks associated with procedures other than manipulation, i.e., traditional medical procedures. Dr. Brown had the singular concern of differentiating causing the initial dissection versus dislodging a clot from a preexisting dissection. Providing informed consent is a different topic. A requirement of proper informed consent is to provide options as well as the risks associated with the other options. The cited paper would assist one in providing proper informed consent. You will have to explain your conclusory statement that the cited paper is inappropriate. This blog has the appearance of an intent to prove all chiropractic and every chiropractor in every instance is a scam. That is a difficult foundation upon which to have an open honest conversation, but it does not mean it is impossible. (Or were you being sarcastic?)

        • I was sarcastic. As clinicians we have the obligation to inform our patients on the risks/benefits of the more common approaches to their conditions. This blog isn’t concerned with that. Technically, SMT isn’t alternative as PTs, DOs and some MDs do it at least for some MSK conditions. It’s only alternative when some move it into the treating of non-MSK conditions. But for some here, those are considered trivial facts.

          Regarding VAD vs stroke, I concur, two different, albeit sometimes, related serious AE.

          • It is also interesting to look at malpractice rates when considering the risk of different practitioners. Perhaps that is something patients should also consider when thinking about the safety of the proposed treatment, cervical manipulation or other.

  • Steven Brown, DC, Dipl Med Ac, wrote on Saturday 20 April 2024 at 22:04: “[Edzard Ernst] As the first Professor of Complementary Medicine in the known universe, who has never actually practiced any form of complementary medicine…”

    @ Steven Brown

    Your statement is wholly wrong. It’s obvious you that haven’t done your homework on Prof. Ernst who has received hands-on training in acupuncture, autogenic training, herbalism, homoeopathy, massage therapy and spinal manipulation. See here: https://tinyurl.com/6vcrpy4k

    You are also not doing yourself any favours as a Dipl Med Ac with a web page on acupuncture that declares that “Acupuncture is stimulation of Acupuncture points to control and regulate the flow and balance of energy in the body… ” https://www.brownchiro.com/acupuncture/ Where’s the scientific evidence for that? Hasn’t acupuncture been proven to be a theatrical placebo?

    IMO, your research is not very thorough and I cannot, therefore, take seriously your comment to me that you are “properly informed about the current debate surrounding cervical spine manipulation” and that you “know more about it than just about anyone”.

  • Dr. Ernst, after much deliberation, I have decided the following actions must be taken. I can do no other.

    Regarding your title, “The First Professor of Complementary Medicine in the Known Universe”, while it is an effective marketing strategy, it does not comply with known reality. The only practice of complementary medicine I can find on your Curriculum Vitae is that at one time you were a junior doctor at a homeopathic hospital in Munich. (2015 Baum) The fact that you were at one time gullible enough to believe that useless homeopathic remedies can do anything whatsoever disqualifies you from your title. Therefore, by the powers vested in me by common sense, I revoke your title, “The First Professor of Complementary Medicine in the Known Universe”. Furthermore, as you do not profess any form of complementary medicine, this seems the logical course of action.

    The three largest complementary medicine professions in the US are chiropractic, acupuncture and massage therapy. I have been professing these services for 30 years. Therefore, I bestow upon myself the title, “The First Professor of Complementary Medicine in the Known Universe.”

    Out of respect for your numerous research publications on complementary medicine, I will bestow upon you the more appropriate title, “Critic of Complementary Medicine Who Does Occasionally Have Some Valid Points.”

    I had never frequented your site before the other day. I will no longer be frequenting this site as you have made it clear that the purpose of your blog is for you to state your opinions and to hear the comments of those who agree with you. It’s your blog, so your rules. Namaste.

    • “The First Professor of Complementary Medicine in the Known Universe”
      this is not my title; someone might have called me thus but that has nothing to do with me.
      the rest of your post is in the same vein, I am afraid.

      • Unfortunately for me, I am afraid that I did see the above response from you.

        See graphic posted on this page of your website, ostensibly by yourself, which proclaims you to be, “The First Professor of Complementary Medicine in the Known Universe”.

        https://edzardernst.com/about/

        If it has nothing to do with you, how about you taking the graphic off of your website as it is an insult to those who actually have expertise in Complementary Medicine. However, from what I know of you, insult may be what you had in mind.

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