chiropractic
To accuse anyone of an abuse of science is a hefty charge, I know. In the case of proponents of so-called alternative medicine (SCAM) doing science, it is, however, often justified. Let me explain this by using the example of chiropractors (I could have chosen homeopathy, faith heaalers, acupuncturists or almost any other type of SCAM professional, but in recent times it was the chiros who provided the clearest examples of abuse).
Science can be seen as a set of tools that is used to estabish the truth. In therapeutics, science is employed foremost to answer three questions:
- Is the therapy plausible?
- Is the therapy effective?
- Is the therapy safe?
The way to answer them is to falsify the underlying hypotheses, i.e. to demonstrate that:
- The therapy is not plausible.
- The therapy is not effective.
- The therapy is not safe.
Only if rigorous attempts at falsifying these hypotheses have falied can we conclude that:
- The therapy is plausible.
- The therapy is effective.
- The therapy is safe.
I know, this is rather elementary stuff. It is taught during the first lessons of any decent science course. Yet, proponents of SCAM are either not being properly taught or they are immune to even the most basic facts about science. On this blog, we regularly have the opportunity to observe exactly that when we read and are bewildered by the comments made by SCAM proponents. This is often clearest in the case of chiropractors.
- They cherry-pick the evidence to persuade us that their hallmark intervention, spinal manipulation, is plausible.
- They cherry-pick the evidence to persuade us that their hallmark intervention, spinal manipulation, is effective.
- They cherry-pick the evidence to persuade us that their hallmark intervention, spinal manipulation, is safe.
If they conduct research, they set up their investigations in such a way that they confirm their beliefs:
- Spinal manipulations are plausible.
- Spinal manipulations are effective.
- Spinal manipulations are safe.
In other words, they do not try to falsify hypotheses, but they do their very best to confirm them. And this, I am afraid, is nothing other than an abuse of science.
QED
And how can the average consumer (who may not always be in a position to realize whether a study is reliable or not) tell when such abuse of science is occurring? How can he or she decide who to trust and who not?
A simplest but sadly not fool-proof advice might consist in 2 main points:
- Never rely on a single study.
- Check whether there is a discrepancy in the results and views of SCAM proponents and independent experts; e.g.:
- Chiropractors claim one thing, while independent scientists disagree or are unconvinced.
- Homeopath claim one thing, while independent scientists disagree or are unconvinced.
- Acupuncturists claim one thing, while independent scientists disagree or are unconvinced.
- Energy healers claim one thing, while independent scientists disagree or are unconvinced.
- Naturopaths claim one thing, while independent scientists disagree or are unconvinced.
- Etc., etc.
In all of those cases, your alarm bells should ring and it might be wise to be cautious and avoid the treatment in question.
For many years, Dale Thompson has been one of our most loyal commentators, often defending the indefensible, or willfully misleading us, or deliberately distracting us from the topic at hand. He has made his comments under several names or pseudomyms, sometimes with and sometines without using the doctor-title, sometimes disclosing that he is a chiropractor and someimes not disclosing either this information or his most obvious conflicts of interest.
Recently, several readers became more interested in Dale and his activities. I therefore thought it would be relevant to find out how he is being presented on the Internet. Here are the mentions I found that include some relevant information about Dale:
- Dr. Dale Thompson. Over 20 years of delivering a conservative approach to muscle and joint issues. Trained in approaches that don’t require the typical adjustment but it is available when needed. Use a whole body approach and consider other factors that may be contributing to problems such as diet, ergonomics, lifestyles, etc.
- Dr. Dale Thompson is a Stratford, Iowa based male chiropractor with 22 years of experience in General Chiropractor. He completed his graduation from Logan College Of Chiropractic in 2002. He accepts the Medicare-approved amount. Patients will not be billed for any more than the Medicare deductible and coinsurance. Active license number of Dr. Dale Thompson as General Chiropractor is 06631 in Iowa. Dr. Dale Thompson is qualified as a Doctor of Chiropractic (D.C.), licensed by the State and who practices chiropractic medicine -that discipline within the healing arts which deals with the nervous system and its relationship to the spinal column and its interrelationship with other body systems.
- Dr. Thompson graduated from the Logan College of Chiropractic in 2002. He works in Stratford, IA and specializes in Chiropractor.
- DALE THOMPSON, D.C. practices at 813 SHAKESPEARE AVE, STRATFORD, IA 50249. Chiropractors diagnose and treat common spinal misalignments that can occur from lifestyle or injuries causing pain, discomfort and degenerative conditions. DALE THOMPSON, D.C. may be able to treat; back pain, sciatica, neck pain, shoulder pain, headaches, sports injuries, and auto accident injuries.
- Dr. Dale Thompson – Why I Like Being An Evidence-Based Chiropractor. Today we’re going to talk about being an evidence-based chiropractor. What does it mean to be practicing evidence-based chiropractic and we’re going to be talking about with Dr. Dale Thompson from Iowa. USA.
As we see, these texts are not always entirely clear about the fact that Dale has no medical degree. Dale recently posted: “Here in the USA it would be a board violation to ‘conceal’ that one is a doctor of chiropractic.” And in August 2021, he made this comment: “There are several professions that use the title doctor which aren’t earned from a medical college: dentists, optometrists, physical therapists. Within chiropractic, when we advertise, at least in the USA, we are required to identify that we are a doctor of chiropractic. Of course the word doctor originally was used by a religious sect but the medical profession decided they wanted it … “Several authors have recently lamented the continued chiropractic inclination to use outdated and anatomically incorrect language to describe the nature of the manipulable lesion (“subluxation”) and the method of treatment (“adjustment”).2,3,11 J Chiropr Educ. 2020 Oct; 34(2): 172–176.”
Next, I looked on Medline to find out wether Dale has ever published any research on his subject. I failed to find a single article in his name. This is remarkable because, all too often, he presents himself as THE expert in research.
Subsequently, I looked at some of the claims made by Dale. Here are a few of them:
- I can go to a conference and know if the speaker is generally telling the truth or is trying to sell a lie.
- I can read a research paper and know if it’s good or bad and how it may apply to what I do.
- I can take the best evidence and apply it and yet also have the freedom to find novel ways to approach a problem.
- I can take a seemly complex problem and find a simple solution as well as understand the complexity of an apparently simple problem.
- I know my clinical strengths and limitations as well as the strengths and limitations of other healthcare professionals.
- I do not have to jump on board the latest health fad but I can, and may, scrutinize it using logic, reasoning and supporting evidence.
- I can respect my colleagues desire to practice different than me but I still demand they do so in an evidence-based chiropractor and ethical manner.
- My patients come first, my profession second and I am last.
So, what should we conclude about Dale Thompson?
I don’t know about you, but I get the impression that Dale lacks the ability to be critical of his own abilities and of the value of chiropractic. He likes to post comments that are aimed at misleading us. He might not be a ‘straight chiropractor‘ in the usual sense of the term, but in my view he also is still far from straight. Personally, I have not taken much notice of his deeply biased, often pompous and smug comments for some time. I suggest you consider doing the same.
But Dale is just one chiro!
He hardly has any wider significance.
So, why even bother and write a whole blog post about him?
I certainly agree that such a man does not deserve the attention we have been giving him. But Dale stand for so many of his colleagues. In fact, he is a prime example of a chiro victim of the ‘Dunning Kruger Effect‘. These people have a thin veneer of respectability which allows them to pretend to be veritable ‘know alls’. They remain entirely oblivious to the fact that they have been brain-washed at chiro school and have become a life-time members of a cult unable to see how deluded they truly are. As such they are dangerous, and I feel that the public needs to be aware of the danger.
And here you have the true reason why I am writing these lines.
Jay Kennedy is an experienced chiropractor of some standing.
In “2018, ‘The American Chiropractor’ wrote this about Jay Kennedy:
Jay Kennedy, DC, is a 1987 graduate of Palmer Chiropractic College and maintains afull time practice in western Pennsylvania. He is the principal developer of the Kennedy Decompression Technique. Dr. Kennedy teaches his non-machine specific technique to practitioners who want to learn clinical expertise required to apply this increasingly mainstream therapy. Kennedy Decompression Technique Seminars are approved for CE through various Chiropractic Colleges.
‘The Dynamic Chiropractor’ published plenty of articles authored by Jay Kennedy.
I am telling you this because Jay Kennedy recently posted a comment which is far too important to be burried in the many other comments on this blog. I think it deserves full recognition and loud applause. I have therefore decided to take the unusual step and re-post it here as an entirely seperate post.
Here we go:
I was a DC for 30+ years and a notable one for the last 20 years. I taught 200+ seminars, wrote innumerable articles and taught at many chiropractic colleges. I had (3) private practices and was a technique “guru”: “Kennedy decompression technique” or KDT. We “certified” nearly 5000 DCs to be “decompression experts”!
Kdt still sells farcical traction-tables I developed and designed (labeled as “decompression systems”) as well as useless lasers, ultrasonic vibrators and other scam modalities to confound the DCs and milk the public. (I have been out of it for several years now).
I am not proud of the fact I made a lot of money both in practice and as a lying cultist-entrepreneur.
I have read your blog for several years and many of your books, especially related to Chiropractic. You are not mistaken and I do NOT believe you are biased, the fact that you define the practice as SCAM and a cult is absolutely the case. As has been said before it is “the world’s largest non-scientific healthcare delivery system”. I was fortunate many years ago to meet Stuart McGill PhD. It changed my practice considerably. I opened a gym and focused dramatically on exercise. I also had other income steams from selling bullshit equipment. The regrettable feature is chiropractors sell “treatments”…. Some of which superficially alter pain signals temporarily like many OTHER less expensive and less mendacious things. This “traps” many patients into an erroneous paradigm….one a DC is ready, willing and able to exploit. “Chiropractic treatments” NEVER get to the root of a problem, alter any disease-process or substantially improve a patient. Regrettably selling exercise simply WILL NOT garner the income that selling (and coercing) subluxation-elimination treatments will (and virtually NO DC has the experience or expertise a PT PhD has in that arena).
Interestingly when you do seminars as a chiropractor, most states make you sign a waiver stating that you will not disparage Chiropractic or discuss information that minimize the value of Chiropractic. Can you imagine medical seminars or a scientific seminar having such a waiver? Chiropractic is and has always been a moneymaking scheme. That doesn’t exclude the fact there are many chiropractors who buy into it as a supreme truth….just like Muslims who murder with the thought of getting directly to Heaven to start porking some virgins.
I have discovered most DCs are on the low IQ scale, have poor critical thinking skills and rarely question their golden-goose (or perhaps more sympathetically; never venture outside the bounds of the profession and its rhetoric and hyperbole. They have been effectively able to compartmentalize Chiropractic from rightful and accurate criticism). Most of the successful ones are of course entrepreneurs with ravenous appetites for money, prestige and approval (and have little or no interest in the “truth”…..oops I described myself I guess).
The majority however struggle to get by and are constantly seeking SOMETHING that might actually work. Thus 70%+ use and advertise “decompression”, Activators (and other ridiculous “adjusting guns”), drop-tables, energy-techniques, orthotics and whatever other nonsense some company advertises in Chiropractic Economics with a testimonial of how much money can be made. It always fascinated me that if “subluxation-reduction or elimination” was the solution for disease and pain WHY did the profession embrace all of these other nonsensical modalities? If your guess is: “chiropractic doesn’t really work”…give yourself a beer.
When you graduate as a DC you CAN ONLY be in private SCAM practice….no other opportunities exist. Is it really any wonder that lying is the only avenue available to support a practice and an income stream? Nope.
______________________
I wish to express my thanks to Jay for his courage and honesty in writing these lines.
The comment sections of this blog have provided plenty of reason to suspect that chiropractic is a cult, a health cult to be precise. A health cult is defined as a system for the cure of disease based on dogma set forth by its promulgator. The promulgator, in this case, is DD Palmer. As discussed previously, he ‘invented’ chiropractic and promoted many extraordinary claims and ideas, e.g.:
- I was the first to adjust the cause of disease
- Chiropractors adjust causes instead of treating effects
- 95% of all diseases are caused by subluxations of the spine
- Vaccination and inoculation are pathological; chiropractic is physiological
- It was my ingenious brain which discovered [chiropractic’s] first principle; I was its source; I gave it birth; to me all chiropractors trace their chiropractic lineage
- Among the wonderful achievements of this century, the discovery and development of chiropractic is preeminent; it is destined to replace all methods which treat effects
- Dis-ease is a condition of not ease, lack of ease
- His magnetic cure for cancer involved freeing the stomach and spleen of poisons
- Chiropractic is a science of healing without drugs
- Wants to turn chiropractic into a religion (as this would avoid chiropractors being sued for practising medicine without a license)
Since DD Palmer, the chiro-cult has changed. In fact, it has split into two camps. The ‘straights’ have become a Palmer worship cult, while the rest delude themselves of being based on evidence. That the former are cultists is impossible to deny. The latter reject such allegations but, in my mind, they too belong to a cult.
Let me explain.
The criteria for a cult can be defines as follows:
- Charismatic Leader: the ‘mixers’ might no longer worship Palmer, yet they are far from free of his ‘philosophy’; after all, they went to chiro-school where they were educated in the Palmer tradition.
- Isolation: chiropractors seek surprisingly little co-operation with other healthcare professionals and thus tend to be isolated.
- Control: chiropractors are under tight control of their professional bodies, peers, journals, etc. which all make sure that heretic ideas are kept at bay.
- Deception: chiropractors are masters of deception in persuading the public and their patients of the value of spinal manipulations, regardless of the actual evidence.
- Us vs. Them Mentality: chiropractors tend to create an “us vs. them” mentality, demonizing real doctors and promoting group cohesion.
- Exploitation: chiropractors have a long history of exploiting their patients; maintenance care is just one of many examples.
- Fear Tactics: chiropractors are scare mongers, for instance, when they diagnose subluxations even in perfectly healthy people and claim that this invented diagnosis needs urgent adjustments.
What, you don’t agree with these arguments?
In this case let me quote a different set criteria that might help to decide whether chiropractic might be a cult. Here they are:
- Absolute authoritarianism without accountability
- Zero tolerance for criticism or questions
- Lack of meaningful financial disclosure regarding budget
- Unreasonable fears about the outside world that often involve evil conspiracies and persecutions
- A belief that former followers are always wrong for leaving and there is never a legitimate reason for anyone else to leave
- Abuse of members
- Records, books, articles, or programs documenting the abuses of the leader or group
- Followers feeling they are never able to be “good enough”
- A belief that the leader is right at all times
- A belief that the leader is the exclusive means of knowing “truth” or giving validation
Bearing in mind that not all of the 10 criteria need to be fulfilled, I ask you: is chiropractic a cult?
This review was aimed at quantifying the proportion attributable to contextual effects of physical therapy interventions for musculoskeletal pain. Randomized placebo-controlled trials evaluating the effect of physical therapy interventions on musculoskeletal pain.
Risk of bias was evaluated using the Cochrane risk-of-bias tool for randomized trials (ROB 2.0). The proportion of physical therapy interventions effect that is explained by contextual effects was calculated, and a quantitative summary of the data from the studies was conducted using the random-effects inverse-variance model (Hartung-Knapp-Sidik-Jonkman method).
Sixty-eight studies were included in the systematic review (total number of participants: n=5,238), and 54 placebo-controlled trials informed our meta-analysis (participants: n=3,793). Physical therapy interventions included:
- soft tissue techniques,
- mobilization,
- manipulation,
- taping,
- exercise therapy,
- dry needling.
Placebo interventions included manual, non-manual interventions, or both.
The results show the following:
- The type of treatment with the largest proportion not attributable to the specific effects (PCE) for pain intensity assessed immediately after the intervention was mobilization, which represented 87% of the overall treatment effect (PCE = 0.87, 95% CI: 0.54, 1.19).
- For soft tissue techniques, the PCE was 81% of the overall treatment effect (PCE = 0.81, 95% CI: 0.64, 0.97).
- For dry needling, the PCE was 75% (PCE = 0.75, 95% CI: 0.36, 1.15).
- For manipulation techniques the PCE was 74% (PCE = 0.74, 95% CI: 0.33, 1.14).
- For taping the PCE was 69% of the overall treatment effect (PCE = 0.69, 95% CI: 0.48, 0.89).
- The smallest proportion not attributable to the specific intervention itself for pain intensity was exercise therapy accounting for 46% of the overall treatment effect (PCE = 0.46, 95% CI: 0.41, 0.52).
The authors concluded that the outcomes of physical therapy interventions for musculoskeletal pain were significantly influenced by contextual effects. Boosting contextual effects consciously to enhance therapeutic outcomes represents an ethical opportunity that could benefit patients.
This sounds as though most of the treatments in question rely mainly on placebo effects. But what about conventional therapies? The authors point out that the PCEs of general medicine and surgery in pain-related conditions are also large. In particular, the overall proportion not attributable to the specific effects of general medicine interventions is high (PCE = 65%), with higher values observed in semi-objective and objective outcomes (PCE = 78 and 94%, respectively) than in subjective outcomes (PCE = 50%).
What does that mean for healthcare routine?
As placebo and other context effects are unreliable, usually short-lived, and not normally affecting the cause of the problem (but merely the symptoms), I would say that those treatments with a very high PCE are of limited value, paticularly if they are also expensive or burdened with risks. Of the treatments studied here, I would – based on the current analysis – avoid the following therapies for pain management:
- mobilization,
- soft tissue techniques,
- dry needling,
- manipulation,
- taping.
By and large, these are also the conclusions drawn from various other strands of evidence that we have repeatedly discussed in previous posts.
The objective of this paper was to review the 10 most recent case reports of cervical spine manipulation and cervical artery dissection for convincing evidence of the causation of cervical artery dissection by cervical spine manipulation. The author, Steven P. Brown, a chiropractor (who is quoted as “the authors have declared that no competing interests exist”), lists the following 10 cases:
Case 1: Yeung et al. (2023) [17]
Yeung et al. [17] reported that a “48-year-old female went to a chiropractor for chronic neck pain and developed right-sided weakness, nausea, dizziness, and vomiting immediately after neck manipulation.” Imaging showed occlusion of the V1 segment of the right vertebral artery and cerebellar stroke.
The adverse event immediately following cervical spine manipulation (CSM) was the cerebellar stroke, not the cerebral artery dissection (CAD). Right-sided weakness, nausea, dizziness, and vomiting are symptoms of cerebellar ischemia, not right VAD. The neck pain prior to the CSM is consistent with a CAD being present prior to CSM, not caused by CSM.
Even if CSM had caused the CAD, it is not biologically possible for a thrombus large enough to occlude the vertebral artery to form immediately [6]. Therefore, the CAD was likely pre-existing to CSM. While an existing thrombus may have been aggravated by the CSM, it was not caused by the CSM. In this case, it is plausible that CSM may have suddenly repositioned an already large thrombus in such a way that it blocked the V1 segment of the right vertebral artery, resulting in thrombotic ischemic stroke from vascular occlusion [26]. The practitioner failed to exclude CAD and performed CSM when it was contraindicated [7]. So, while thrombotic stroke may have been causally related to the CSM, the CAD was not.
Cases 2 and 3: Chen et al. (2022) [18]
Chen et al. [18] reported that “a 51-year-old man with a history of mild hypertension noted new-onset right neck pain two days following chiropractic manipulation.” Imaging revealed dissection of the C3 segment of the right ICA and right-sided stroke.
Chen et al. [18] also reported a second case in which “a 55-year-old man with a history of cigarette smoking, no other cerebrovascular risk factors, received chiropractic cervical manipulation 1 day prior to presentation to the emergency department with new onset of left hemiparesis, facial paralysis, right neck pain, and dysarthria lasting for 5 hours.” Imaging revealed dissection of the C3 segment of the right ICA and right-sided cerebral stroke.
In these two case reports, the symptoms that prompted the patients to seek CSM were not documented. In the first case, neck pain started two days after CSM. In the second case, neck pain started 19 hours after CSM.
In these two cases, there was no adverse event immediately following CSM. As there was no neck pain, headache, or ischemic symptoms noted immediately after CSM, it is not likely that CSM caused the ICA dissection or the stroke. Furthermore, the C3 segment of the ICA is intracranial and has not been identified as an area for strain by CSM.
Case 4: Arning et al. (2022) [19]
Arning et al. [19] reported the case of a 47-year-old female with a two-week history of non-traumatic right neck pain who had increased, severe right neck pain immediately after CSM, and paresis of the right deltoid muscle and hypalgesia in the right C3 and right C4 dermatomes. MRI revealed a dissection of the V2 segment of the right vertebral artery.
The adverse event immediately following CSM was a stroke, not a CAD. Paresis and hypalgesia are symptoms of brain ischemia, not right VAD. The right neck pain prior to the CSM is consistent with a right VAD being present prior to CSM, not caused by CSM.
Prior to CSM, cervical spine disc herniation had been ruled out by MRI. Upon review, the pre-CSM MRI also showed dissection of the right V2 segment, which had initially been overlooked by the radiologist. The practitioner performed CSM when it was contraindicated. Therefore, while the CSM may have caused the ischemic stroke by a thromboembolic mechanism, the CSM did not cause the CAD.
Case 5: Abidoye et al. (2022) [20]
Abidoye et al. [20] reported, “This is a 40-year-old male with a medical history of migraine headaches and cervicalgia, evaluated for a sudden onset of headache, associated with nausea, vomiting, blurred vision, and dizziness, two months after a chiropractic manipulation. He also reported rigorous exercise and sexual intercourse prior to the headache onset. Vital sign is significant for a 10/10, non-radiating right-sided headache. Neurological examination revealed right ptosis and miosis. Labs were unremarkable. CTA of neck showed tapering of the right ICA with near occlusion at the skull base.” No imaging evidence or diagnosis of stroke was documented. However, with ischemic symptoms of nausea, vomiting, blurred vision, dizziness, right ptosis, and right miosis, it is likely that this patient suffered a stroke.
In this case, there was no adverse event immediately following CSM, and the most recent CSM was two months prior to the onset of symptoms. As there was no neck pain, headache, or ischemic symptoms noted immediately after CSM, it is not likely that CSM caused the ICA dissection or the stroke.
The patient’s medical history of neck pain and headaches are risk factors for CAD. If there was existing right ICA dissection, it is plausible that rigorous exercise and sexual intercourse could have dislodged a loosely adherent ICA thrombus and caused immediate stroke by a thromboembolic mechanism. However, this is not possible to determine as the temporality from exercise and intercourse to ischemic symptoms of stroke was vaguely documented as “prior to.”
Case 6: Yap et al. (2021) [21]
Yap et al. [21] reported a 35-year-old male who presented with a two-day history of expressive dysphasia and a one-day history of right-sided weakness. The patient reported having CSM for pain relief sometime in the prior two weeks. Imaging showed left ICA dissection and left middle cerebral artery stroke. The dissected segment of the left ICA was not documented.
In this case, there was no adverse event immediately following CSM. As there was no neck pain, headache, or ischemic symptoms noted immediately after CSM, it is not likely that CSM caused the ICA dissection or the stroke.
Case 7: Xia et al. (2021) [22]
Xia et al. [22] reported a case of a 44-year-old male with chronic neck pain who reported sudden-onset left homonymous hemianopia after CSM a few days prior. The patient reported progression from a left homonymous hemianopia to a left homonymous inferior quadrantanopia. Imaging revealed bilateral VAD at the left V2 and right V3 segments, and right medial occipital lobe stroke. The authors noted that a right posterior communicating artery stroke was likely embolic from the right V3 and left V2 dissections. They also noted that the patient likely had a migrating embolus as evidenced by the progression from a homonymous hemianopia to a quadrantanopia.
The adverse event immediately following CSM was the stroke, not the CAD. Left homonymous hemianopia is a symptom of brain ischemia, not VAD. The neck pain prior to the CSM is consistent with VAD being present prior to CSM, not caused by CSM.
Even if CSM had caused the CAD, it is not biologically possible for a thrombus to instantly form and dislodge to cause sudden-onset thromboembolic stroke [6]. Therefore, the CAD was likely pre-existing to CSM. While an existing thrombus may have been aggravated by the CSM, it was not caused by the CSM. In this case, it is possible that CSM dislodged a loosely adherent vertebral artery thrombus to cause thromboembolic stroke [26]. The practitioner failed to exclude CAD and performed CSM when it was contraindicated [7]. So, while thromboembolic stroke may have been causally related to the CSM, the CAD was not.
Case 8: Lindsay et al. (2021) [23]
Lindsay et al. [23] reported a case of a 47-year-old male who presented with left neck pain and headache. His medical history was notable for dyslipidemia and a cerebellar stroke six years prior. Imaging revealed dissections of the left vertebral artery extending from the origin of the artery to the V3 segment. The patient also had a dissection of his right renal artery. There was no evidence of a stroke.
Six years prior, the patient had presented with a one-week history of left neck pain and headache, as well as left facial numbness and dizziness. The pain was not relieved with ibuprofen and previously been evaluated and treated by a chiropractor. Imaging done six years prior showed no evidence of CAD but did show a left cerebellar stroke.
There is no plausible biological mechanism by which CSM six years prior could cause a current VAD. Therefore, it is not likely that there was a causal relationship between CSM and CAD in this case.
Ultimately, the patient was diagnosed with vascular Ehlers-Danlos syndrome, a disorder that causes connective tissue weakness and makes a patient susceptible to arterial dissection. This diagnosis is consistent with the left VAD and right renal artery dissection.
Case 9: Monari et al. (2021) [24]
Monari et al. [24] reported a case of a 39-year-old pregnant female with a history of tension headaches presenting with vertigo, vomiting, nystagmus, dizziness, and hindrance in the execution of fine movements of the right arm. The patient reported having CSM by an osteopathic specialist “in the days preceding the beginning of the symptoms.” Imaging showed a dissection of the V2 segment of the right vertebral artery and a right-sided stroke.
In this case, there was no adverse event immediately following CSM. As there was no neck pain, headache, or ischemic symptoms noted immediately after CSM, it is not likely that CSM caused the right vertebral artery dissection or the stroke. Medical history of headache prior to the CSM is consistent with a VAD being present prior to CSM, not caused by CSM. Pregnancy is also a risk factor for CAD.
Case 10: Ramos et al. (2021) [25]
Ramos et al. [25] reported a case of a 48-year-old female with a history of chronic neck pain who experienced sudden neck pain and generalized weakness during CSM. Imaging showed bilateral VAD and occlusion and bilateral acute cerebellar stroke. There was also tetraplegia noted at the C5 sensory level, C5 and C6 vertebral fracture, spinal cord injury, epidural hematoma, and acute disc herniation.
There is convincing evidence that CSM caused CAD and stroke in this case. This case is exceptional as the CSM was contraindicated by pre-existing cervical spine pathology. Cervical spine bony ankylosis was noted which existed prior to the CSM. The CSM appears to have been a posterior-anterior manipulation of the cervical spine at the level of C5-C6, which was contraindicated due to the presence of the bony ankylosis [27].
The practitioner failed to exclude cervical spine pathology and performed CSM when it was contraindicated. The spinal pathology in this case could have been diagnosed with a cervical spine X-ray examination.
As the Ramos et al. [25] study provided limited case information, a case report from Macêdo et al. [28] provides additional information on this exceptional case.
“A 47-year-old Afro-Brazilian woman with long-standing back pain sought chiropractic care for symptomatic relief. Until then, she had never consulted a doctor to treat her axial pain and was not aware of having any specific spinal pathology. Since childhood, she had a moderate cognitive deficit, which probably compromised her ability to adequately describe the pain and, thus, led the family to seek medical advice. During her last session of spinal manipulation, she mentioned new-onset paresthesia beginning on the upper limbs and progressing to the lower limbs. Her complaint was disregarded, and the session continued, at the end of which she was unable to stand. Urinary retention ensued a little after. The patient was referred to our service only a week after, completely bedridden. Spine MRI revealed a transdiscal fracture at C5-C6, resulting in critical stenosis and compressive myelopathy. CT angiography revealed traumatic thrombosis of the vertebral arteries emerging on this level. Whole spine-imaging evidenced multiple syndesmophytes giving a characteristic bamboo spine appearance, as well as ankylosis in sacroiliac joints, uncovering the diagnosis of ankylosing spondylitis. She underwent laminectomy from C2 to C6 and arthrodesis from C2 to T2 for spine stabilization but did not recover mobility. Even though a systematic review did not find an increased risk of significant adverse events related to spine manipulation therapy, there have been descriptions of vertebral fracture following a session on patients with ankylosing spondylitis and unsuspected multiple myeloma.”
The author concluded that nine out of the 10 case reports of CSM and CAD did not provide convincing evidence of the causal relationship between CSM and CAD. Only one case report provided convincing evidence of a causal relationship between CAD and CSM. This case was exceptional as the CSM was contraindicated by pre-existing cervical spine pathology. Therefore, we conclude that practitioners of CSM should exclude cervical spine pathology before performing CSM.
I must say that I find it difficult or even impossible to follow most of the arguments of Mr Brown. Do they teach them a different kind of physiology and pathophysiology in chiro-school? Foremost, he seems to think that case-reports can/should establish cause and effect. Do they teach research methodology at all in chiro-school?
Here is what Wiki tells us, for instance:
In medicine, a case report is a detailed report of the symptoms, signs, diagnosis, treatment, and follow-up of an individual patient. Case reports may contain a demographic profile of the patient, but usually describe an unusual or novel occurrence. Some case reports also contain a literature review of other reported cases. Case reports are professional narratives that provide feedback on clinical practice guidelines and offer a framework for early signals of effectiveness, adverse events, and cost.
So, case reports “offer a framework for early signals of adverse events”. To expect that they demonstrate a causal link is ill-informed. Their significance in relation to risks lies mostly in providing a signal, particularly if the signal becomes loud and clear due to numerous repetitions, as is the case in chiropractic manipulations. Once the signal is noted, it needs further investigation to determine its nature. In the absence of conclusive further studies, a signal that has emerged hundreds of times, as in chiropractic, it has to be taken seriously. In fact, the precautionary principle demands that we then assume causality until proven otherwise.
As to the research effort of Mr Brown in assembling 10 case reports, I must say it is frightfully daft for the following reasons:
- Most cases do probably not get connected to a CSM at all.
- Many lead to litigation and are not published.
- In the end, very few get published in the medical literature.
- Being retrospective, they all lack important detail and are thus incomplete.
- None prove causation and only some render it likely.
- A sample size of 10 is laughable.
- Brown’s desire to white-wash chiropractic is plapable.
- So is his naivety.
In a recent comment, our resident chiro, ‘Dr.’ Dale Thompson (alias ‘DC’), in an attempt to provide a rationale for the approach, provided a link to a definition of MAINTENANCE CARE:
Maintenance care is care given to people with chronic illnesses to maintain or slow a decline in their health or function. For example, exercise and physical therapy can minimize abnormal or painful positioning of the joints and may prevent or delay curvature of the spine in a person with muscular dystrophy.
Let’s for the moment ignore that this definition is not necessarily related to CHIROPRACTIC maintenance care and assume it describes the approach adequately. In this case, chiropractic maintenance care would be:
care given to people with chronic illnesses to maintain or slow a decline in their health or function.
That sounds almost reasonable and is very different from what I recently implied it is, namely sly scare mongering of greedy chiros to fleece vulnerable individuals.
So, who is closer to the truth, Dale or Edzard?
How is chiropractic maintenance care employed in ‘real life’?
One way of finding out might be to look at social media and see how chiropractic maintenance care is being promoted or written about. Here are the texts of recent Tweets that I found on 23/6 informing us on this issue:
- Chiropractic care encompasses three main phases: 1. Acute / Intensive Care 2. Healing / Corrective Care 3. Wellness / Maintenance Care
- Maintenance is key! Once you’ve completed your care plan, routine chiropractic visits can help keep you feeling your best. Think of it as preventative maintenance for your body; you deserve it!
- Chiropractic maintenance care now encompasses all sorts of patients; no matter their history, symptoms or reasons for seeking a chiropractor
- Chiropractic care goes beyond back pain relief! It’s all about proactive health maintenance, not just reactive illness treatment. Discover the pathway to a healthier, more balanced life
- Understanding the proper documentation and coding of maintenance care in your office will help you sleep better at night knowing you are doing this correctly.
- Staying well with chiropractic has never been easier! Researchers have discovered that people who receive maintenance chiropractic care have better long term outcomes and may even be able to prevent future episodes of back pain. Interested in learning more? Give us a call today.
- Researchers have discovered that people who receive maintenance chiropractic care have better long term outcomes and may even be able to prevent future episodes of back pain. Interested in learning more? Give us a call today!
- Many patients willingly choose to keep getting regular, maintenance Chiropractic care. Just like going to the dentist periodically, spinal hygiene and chiropractic adjustments are part of a healthy lifestyle.
- Consider your body as a biological machine, just like a car needing maintenance. Chiropractic care at The Joint provides essential upkeep, not just alleviating existing pain but also preventing future discomfort.
- We advocate regular maintenance Chiropractic care to keep your spine and posture in as great shape as possible. If you have not been to the clinic for a while, why not call our reception team
- When you finally get that special car you always wanted; you don’t want to trust just anybody for care & maintenance. The same is true with your healthcare.
- Around 22 million Americans turn to chiropractic care each year for pain relief, holistic healing, and preventive maintenance! Experience natural, non-invasive solutions that keep you feeling your best. Discover the benefits today!
- We believe in the beauty of regular maintenance care. Nurture your well-being & witness the transformative difference in your life
- Chiropractic and Maintenance Care “Do I need to keep coming back for treatment to prevent this from happening again?” This method of chiropractic care is known as Maintenance care.
- If you are wanting to improve your overall quality of life. Maintenance care is very important
- Chiropractic “discharge” plans are always something else. “Patient has no pain or complaints and is released from regular chiropractic care. She is recommended to return 4x/mo for maintenance care“. I’m not sure there is a profession that I think less of.
I ought to stress that most of these Tweets were accompanied by pictures of patients receiving spinal manipulations.
Who then is correct, Dale or Edzard?
I let you decide.
We have recently heard much about spinal manipulations for kids. It might therefore be relevant to learn about an international taskforce of clinician-scientists formed by specialty groups of World Physiotherapy – International Federation of Orthopaedic Manipulative Physical Therapists (IFOMPT) & International Organisation of Physiotherapists in Paediatrics (IOPTP) – to develop evidence-based practice position statements directing physiotherapists clinical reasoning for the safe and effective use of spinal manipulation and mobilisation for paediatric populations (<18 years) with varied musculoskeletal or non-musculoskeletal conditions.
A three-stage guideline process using validated methodology was completed: 1. Literature review stage (one scoping review, two reviews exploring psychometric properties); 2. Delphi stage (one 3-Round expert Delphi survey); and 3. Refinement stage (evidence-to-decision summative analysis, position statement development, evidence gap map analyses, and multilayer review processes).
Evidence-based practice position statements were developed to guide the appropriate use of spinal manipulation and mobilisation for paediatric populations. All were predicated on clinicians using biopsychosocial clinical reasoning to determine when the intervention is appropriate.
1. It is not recommended to perform:
• Spinal manipulation and mobilisation on infants.
• Cervical and lumbar spine manipulation on children.
•Spinal manipulation and mobilisation on infants, children, and adolescents for non-musculoskeletal paediatric conditions including asthma, attention deficit hyperactivity disorder, autism spectrum disorder, breastfeeding difficulties, cerebral palsy, infantile colic, nocturnal enuresis, and otitis media.
2. It may be appropriate to treat musculoskeletal conditions including spinal mobility impairments associated with neck-back pain and neck pain with headache utilising:
• Spinal mobilisation and manipulation on adolescents;
• Spinal mobilisation on children; or
• Thoracic manipulation on children for neck-back pain only.
3. No high certainty evidence to recommend these interventions was available.
Reports of mild to severe harms exist; however, risk rates could not be determined.
It was concluded that specific directives to guide physiotherapists’ clinical reasoning on the appropriate use of spinal manipulation or mobilisation were identified. Future research should focus on trials for priority conditions (neck-back pain) in children and adolescents, psychometric properties of key outcome measures, knowledge translation, and harms.
Whether one agrees with these directions or not (and I am not sure I fully do), I have always thought that people who, despite the largely lacking or flimsy evidence for spinal manipulations, insist on having manual therapy should consult a physiotherapist, rather than a chiropractor or osteopath.
Why?
Because, in my experience, physiotherapist:
- display less cult-dependent behaviours,
- do not follow the gospel of charlatans, like Palmer and Still,
- do not believe in the fiction of subluxation,
- are not so money-minded,
- less prone to use un- or disproven methods, like applied kinesiology, homeopathy, cranial osteopathy, etc.,
- unlikely to try to sell you useless dietary supplements,
- tend to judge better their limits of professional competence,
- are far less likely to try to persuade you of BS related to anti-vax, anti-drug, anti-science, anti-EBM, etc.
‘Chiropractic economics’ might be when chiropractors manipulate their bank accounts or tax returns, I thought. But, no, it is a publication! And a weird one at that – it even promotes the crazy idea of maintenance care:
The concept of chiropractic maintenance care has evolved significantly. Initially seen as a method for managing chronic pain, it now includes a broader range of patients and focuses on overall wellness. Modern maintenance care aims to keep patients healthy regardless of their symptoms or history, alleviating and preventing pain through regular, prolonged care. This approach is largely preventive, serving as both secondary and tertiary care. Studies show chiropractic maintenance care often includes diverse treatments such as manual therapy, stress management, nutrition advice and more, with flexible intervals typically around three months. This evolution underscores the importance of evidence-based, individualized patient care. This article shares the evolution of chiropractic maintenance care, looks at what a modern maintenance care appointment can include and explores best practices for DC maintenance care in 2024.
An interview study of Danish chiropractic care showed maintenance care sessions included a range of treatment modalities, including manual treatment and ordinary examinations alongside multiple packages of holistic additions, like stress management, diet, weight loss, advice on ergonomics, exercise and more. In other anecdotal accounts, chiropractic maintenance care seemed to follow a more traditional guideline of lower back pain management and adjustment. The study hypothesized that maintenance care could also help patients from a knowledge perspective, stating, “DCs could obviously play an important role here as ‘back pain coaches,’ as the long-term relationship would ensure knowledge of the patient and trust towards the DC.”
Researchers found that three-month intervals were the most common spacing of maintenance care treatments for patients. Most commonly, patients sought or scheduled chiropractic maintenance care over the course of one to three months.
Chiropractic maintenance care has evolved past simply being a method of ongoing chronic pain management. Today’s patients want to achieve overall wellness, and regular trips to their DC can become a part of that if you work to transition patients into a wellness plan after their acute phase of care is over.
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The author of this article seems to have forgotten two little details:
- Chiropractic maintenance care is not supported by sound evidence, particularly in relation to economics (even the above cited paper stated: “We found no studies of cost-effectiveness of Maintenance Care”).
- Chiropractic maintenance only serves one economic purpose: it boosts the chiropractors’ income.
Yes, easy to forget, particularly if your name is ‘Chiropractic Economics’.
And also easy to forget that maintenance care would, of course, require informed consent. How would that look like?
Chiro (C) to patient (P):
If you agree, we will start a program that we call maintenance care.
P: Can you explain?
C: It consists of regular sessions of spinal manipulations.
P: That’s all?
C: No, I will also give you advice on keeping fit and living healthily.
P: Why do I need that?
C: It’s a bit like servicing your car so that it works reliably when you need it.
P: Is it proven to work?
C: Yes, of course, there are tons of evidence to show that a healthy life style is good for you.
P: I know, but I don’t need a chiro for that – what I meant do the manipulations keep my body healthy even if I have no symptoms?
C: The evidence is not really great.
P: And the risks?
C: Well, yes, if I’m honest, spinal manipulations can cause harm.
P: So, to be clear: you ask me to agree to a program that has no proven benefit and might cause harm?
C: I would not put it like that.
P: And how much would it cost?
C: Not much; just a couple of hundred per year.
P: Thanks – but no thanks.
In response to criticism voiced against Australian chiropractors’ decision to re-commence manipulating children, the Australian Chiropractors Association (ACA) president, David Cahill, welcomed the updated statement on paediatric care by the Chiropractic Board of Australia. “The statement serves to reinforce the confidence the Australian public has in chiropractic care provided by registered ACA member chiropractors,” said Cahill.
The Safer Care Victoria Review has shown chiropractic care for children to be extremely safe. Of the 29,599 online submissions received from across Australia (the largest survey of its kind), there were no reports of harm to a child receiving chiropractic healthcare. Of those submissions, 21,824 responses were from parents who had accessed chiropractic healthcare for their children, and there was not a single report of significant harm in these submissions. “In a particularly strong endorsement, 99.6% of those parental submissions affirmed that chiropractic healthcare benefitted their child highlighting the exemplary safety record of chiropractic healthcare,” Cahill said.
ACA member chiropractors are healthcare professionals who effectively treat a wide range of musculoskeletal disorders. Chiropractors are 5-year university degree educated healthcare professionals, equipped with expertise enabling them to tailor the appropriate care for people of all ages including children. Established in 1938, the Australian Chiropractors Association (ACA) is the peak body representing chiropractors. The ACA promotes the importance of maintaining spinal health to improve musculoskeletal health through non-invasive, drug-free spinal health and lifestyle advice to help Australians of all ages lead and maintain healthy lives.
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Mr Cahill and the Australian Chiropractors Association have thus demonstrated that they fail to understand how one needs to establish the benefits and harms of a therapy. That chiropractic spinal manipulations are “extremely safe” cannot be established by an online survey which might or might not have been manipulated by the chiropractors who have an interest in not loosing the lucrative option of treating children. It cannot even establish “the confidence the Australian public has in chiropractic care”.
Mr Cahill and the Australian Chiropractors Association should know that chiropractic spinal manipulation – just like any other intervention – must be evaluated according to accepted principles of risk-benefit analyses. No proven benefit and a possibility of harm mean that the risk-benefit balance fails to be positive. And this means that it is irresponsible to use chiropractic spinal manipulations.
Mr Cahill and the Australian Chiropractors Association, however, seem to not know even the essentials of ethical healthcare. The obvious conclusion, therefore, is to send the lot of them back to school.
