neck-pain
This study aimed to evaluate the comparative effectiveness of “fire cupping therapy” (FC) versus electroacupuncture for reducing pain and improving cervical spine range of motion in patients with neck pain due to cervical spondylosis. FC is essentially nothing else than the TCM version of cupping.
Eighty-two participants with neck pain caused by cervical spondylosis were randomly allocated in 1:1 ratio to either the fire cupping (FC) or the electroacupuncture (EA) group. Both groups received treatment at the EX-B2, A-shi, and GB21 acupuncture points. The two-week study assessed pain levels using the Visual Analog Scale (VAS) at 2 points in time post-intervention and evaluated adverse effects weekly.
After 2 weeks of intervention, VAS scores significantly decreased in both the FC group (from 6 (6–7) to 3 (2–3)) and the EA group (from 6 (6–7) to 2 (1–3)) (p<0.001). However, inter-group pain relief was not statistically significant (p = 0.5794, Cohen’s d = 21 0.12; 95% CI [-0.31–0.6]). Both groups showed statistically significant ROM improvement (p<0.001), though the EA group demonstrated better improvement in flexion, extension, and left/right lateral flexion (p<0.05). No adverse effects of FC were reported.
The authors concluded that FC appears to be an effective and safe therapy for neck pain due to cervical spondylosis, showing similar pain relief efficacy with no statistically significant difference compared to electroacupuncture despite a lower treatment dosage. However, due to methodological limitations, these findings should be interpreted with caution and warrant further validation in rigorously designed studies.
I do agree with the authors’ call for caution – but with little else of what they state. Here are some of my concerns:
- A trial comparing two supposedly active treatments is an ‘equivalence study’; and such investigations require much larger sample sizes that 80.
- Equivalence studies only make sense, if one of the two treatments has been shown beyond doubt to be effective; this is not the case for electroacupuncture nor for FC.
- As it stands, the study does not control for placebo effects; thus the findings are in accordance with both treatments being pure placebos.
- A study with 80 patients tells us as good as nothing about the safety of the iterventions; to draw conclusions about safety is thus unwarranted
My conclusion (yet again) is this:
If you design a nonsense study, you are asking for a nonsense result.
The United States spends more money on the care of back and neck pain than any other health condition. Despite this, the cost-effectiveness for many recommended treatments is unclear. Our primary objective for this project was to estimate the cost-effectiveness of spinal manipulative therapy (SMT), supervised exercise therapy (ET), and home exercise and advice (HEA) for spinal pain in the U.S.
The researchers analyzed cost and clinical outcome data from eight randomized trials conducted in the U.S. using an individual participant data meta-analysis approach. They calculated cost-effectiveness from the societal and healthcare perspective of various comparisons between SMT, ET, and HEA. Incremental cost-effectiveness ratios (ICERs) were calculated using quality-adjusted life years as the main outcome.
The 8 trials included a total of 1803 participants and 1488 (83%) provided complete data. Incremental cost-effectiveness ratios and probabilities of cost-effectiveness varied substantially between studies; thus, the reseaarchers did not conduct meta-analysis and report findings from individual trials.
Cost-effectiveness findings were favorable for SMT compared to HEA for acute neck pain (ICERs below $50k/QALY) and when added to HEA for chronic back-related leg pain and chronic neck pain in older adults (better outcomes and lower costs). However, SMT was not likely cost-effective compared to HEA for chronic back pain in adults or when added to HEA for older adults (higher costs and worse outcomes).
Findings for SMT were favorable when compared to ET in adults with chronic back pain and when added to ET for chronic neck pain in adults (better outcomes and lower costs) and chronic back pain in adolescents (ICERs below $50k/QALY). However, SMT is not likely cost-effective when compared to ET for chronic neck pain in adults (ICERs below $70k/QALY for exercise) and findings were inconsistent across outcomes in older adults with chronic back pain.
Finally, ET may be cost-effective compared to HEA for adults with chronic neck pain (ICERs largely between $100-$200k/QALY), but not for chronic back pain or when added to HEA for older adults with chronic neck or back pain (higher costs and worse outcomes).
The authors concluded that overall based on willingness to pay thresholds of $50-$200k/QALY, there was moderate to high probability that spinal manipulation is cost-effective relative to HEA for neck pain and back-related leg pain, but not for chronic back pain. There was also moderate to high probability spinal manipulation was cost-effective relative to exercise therapy for chronic back pain but findings were mixed for neck pain and more favorable in older adults. Cost-effectiveness findings for exercise therapy were mostly not favorable relative to less intensive home exercise programs as costs were higher, and outcomes were often worse.
The authors admit that their analyses have several limitations: Randomized clinical trials are often designed to detect important differences in disease-specific clinical outcomes that are most likely to be impacted by the treatments assessed (e.g., pain severity, disability). Important measures for assessing cost-effectiveness include general health outcomes like changes in QALYs, healthcare use, and missed work. These measures were collected alongside disease-specific measures, but the trials were not powered to detect important differences in cost-effectiveness outcomes. Participants self-reported their use of healthcare and medications along with number of missed workdays. We did not have access to administrative data for healthcare use or costs. While access to administrative data would have reduced potential measurement error for these variables, it is not without limitations due to the high variability in coverage and re-imbursement policies for healthcare procedures across insurance products in the U.S. Costs for reduced productivity due to spinal pain included missed work in and outside of the home, but costs due to reduced productivity while still at work (i.e., presenteeism) were not included. This is an important limitation as costs due to reduced productivity while at work consistently account for a large proportion of total costs in spinal pain burden of illness studies. Finally, all studies were conducted in the U.S. with resources valued using U.S. prices and findings are not likely generalizable to populations or healthcare systems in other countries.
The authors stress that additional studies are needed to assess the cost-effectiveness of these approaches relative to medical care, the most common treatment approach in the US , as well as other guideline recommended treatments such as massage, acupuncture, mindfulness-based stress reduction, tai chi, yoga, and cognitive behavioral therapy
In view of these limitations and the fact that just 8 trials could be included, the relatively firm comclusions are surprising, in my view. To me, much of the data look unconvincing, somewhat random, inconsistent and implausible. could it be that the authors were trying to generate and emphacize positive results? After all, most of them are affiliated to the “Integrative Health and Wellbeing Research Program Earl E. Bakken Center for Spirituality & Healing, University of Minnesota”!
This systematic review was aimed at evaluating if musculoskeletal manipulations (MMs), including osteopathic manipulation and chiropractic care, are effective to improve quality of life, pain intensity and function in older adults with musculoskeletal disorders.
Randomised controlled trials, controlled non-randomised trials and open label trials evaluating the efficacy and safety of MM such as osteopathic manipulation, chiropractic manipulation, myofascial release, craniosacral therapy, as monotherapy or adjunctive therapies in older people (age ≥65 years) with musculoskeletal disorders. The main outcomes included pain intensity, functionality and quality of life. Additionally, other related outcomes were considered, such as medical use duration, mood, mobility, motion, strength and endurance. Finally, we considered any adverse events.
Selection and data extraction were performed independently by two authors. The effect estimates for each study were performed using Review Manager V.5.14. Continuous outcomes were analysed using the mean difference (95% CI). The methodological quality of the included studies was assessed using the Cochrane Risk of Bias tool 2 (RoB 2). No meta-analysis was performed.
Five parallel randomised controlled trials were included, with a total sample size of 676 participants (41.6% women with a mean age of 77.3 years): 34 with chronic pain, 265 with neck pain and 377 with low back pain. MMs were not effective in patients with chronic pain, neither in pain intensity nor in functionality.
For neck pain, considering the main outcomes, only in one of the two studies was there a statistically significant improvement in neck pain intensity only at week 12 for spinal manipulative treatment (SMT)+home exercise (HE) compared with HE alone (ES=-0.90 (95% CI -1.46 to -0.34); p=0.002).
For low back pain, SMT+HE showed a statistically significant reduction in pain at 12 weeks compared with HE (ES=-0.79 (95% CI -1.39 to -0.19) p=0.010.
For neck pain and low back pain, no statistically significant improvement in functional status and quality of life was observed with MM compared with any control group.
RoB 2 showed a high risk of bias in three studies and some concerns in the others. At the domain level, the lowest risk was observed in the randomisation process (80% with some concerns). All five studies reported adverse events, none of which were serious.
The authors concluded that this systematic review highlights the need for further investigation into complementary therapies, particularly osteopathy, for chronic pain management and prevention in elderly individuals. The results of the current work emphasise that there is a need to further investigate this topic and move the focus more on the promotion of healthy and management behaviours (eg, more physical activity, self-efficacy and adaptive coping, less healthcare utilisation, medication use) and less on the pain symptoms. The fundamental need for complementary medicine, and in particular MM such as chiropractic care and osteopathic manipulative treatment, is the development of clinical trials and RCTs to assess efficacy on quality of life, pain, functionality and general health of the elderly patient. These will help us to determine where MM can be significant.
This, it seems to me, is merely a polite way of stating that neither chiropractic nor osteopathy are supported by sound evidence, and that therapeutic claims by chiropractors and osteopaths are usually hugely exaggerated. Therefore, the prudent thing to do, if you are suffering from back or neck pain, is to use treatments that are less expensive and less likely to cause severe, sometimes life-threatening adverse effects.
This paper aimed to systematically review the current literature comparing hands-off approaches with hands-on approaches from a biopsychosocial perspective of pain processing in people suffering from chronic primary neck pain (CPNP).
An electronic search was conducted on PubMed, Web of Science, Scopus, and Cochrane Library. Initial searches were carried out in November 2022, with electronic database searches repeated on November 25, 2024. Eligibility criteria which were randomized controlled trials comparing hands-off approaches alone or in combination with hands-on approaches and hands-on approaches alone in people with CPNP were checked by two independent authors. The risk of bias was assessed using the revised Cochrane Risk of Bias Tool (RoB). The strength of conclusion was determined using the evidence-based guideline development approach.
Fifteen studies with a total of 1029 participants were included in this review. The RoB was rated as low RoB for two studies, some concerns for two studies and high RoB for 11 studies. Pain processing was assessed by pain intensity (100 % of the studies), pain sensitivity (53 % of the studies), pain-related participation in social roles (46 % of the studies), pain-related emotions (26 % of the studies), and pain-related beliefs (6 % of the studies).
Limited quality of evidence was found for the hands-off approaches alone being more effective on pain intensity than hands-on approaches alone in the long term. Limited- to moderate-quality of evidence was found for hands-off approaches combined with hands-on approaches, being more effective than hands-on approaches alone in improving pain intensity, pain sensitivity, pain-related participation in social roles, pain-related emotions, and pain-related beliefs in the short-, mid- or long-term.
The authors concluded that the current findings suggest that hands-off approaches alone are superior to hands-on approaches in the long term, at least for pain intensity. Hands-off approaches in combination with hands-on approaches were also more effective than hands-on approaches for pain processing. However, substantial heterogeneity warrants a cautious interpretation of these results. More high-quality, randomized, controlled trials with homogenous data collection and larger sample sizes are needed.
We probably all know what “hands-on” therapies are; they comprise, for instance, manipulation, mobilisation or massage. But what precisely are “hands-off” approaches for treating neck pain? “Hands-off” approaches for treating neck pain generally refer to methods that don’t involve direct manual manipulation of the spine or aggressive interventions. There are many different options; here are some examples:
- rest,
- exercise,
- heat or cold therapies,
- medications,
- life-style modifications’
- ergonomics,
- stress management,
- mind-body therapies.
This review suggests that an ill-defined bunch of “hands -off” treatments are preferable to those that involve manual manipulations. The review is not focussed on safety issues which would even more clearly favour the former over the latter.
As we are not told which “hands-off” approaches are better than others, we cannot draw many meaningful conclusions from this finding – except, of course, for the one I have mentioned more often than I care to remember:
Don’t ever let a chiropractor (or osteopath) touch your neck!
Carissa Klundt, a 41 year old mom-of-three from Las Vegas, decided to start treatmentsto fix her sore back. She had attended three appointments with her chiropractor before a substitute practitioner stepped in to perform her spinal adjustments on the fourth. Carissa was immediately concerned when she felt a sharp pain in her neck after the chiropractor performed one particular cracking procedure. She experienced pain after the appointment but initially brushed it off as a ‘strained muscle’. When she began ‘blacking out’, her husband insisted she went to a hospital.
There, doctors confirmed that Carissa had suffered a tear in the inner lining of the vertebral artery – a condition known as a vertebral artery dissection (VAD). Doctors warn chiropractic neck manipulation heightens the risk of otherwise rare VADs. It is estimated that one in 20,000 spinal manipulations results in the condition.
Carissa was rushed to the intensive care unit at a specialist hospital as medics feared the VAD could trigger a stroke. After she was discharged, Carissa had a long road to recovery, facing constant pain, and mobility issues. She didn’t suffer a stroke, but was diagnosed with aphasia, due to reduced blood flow to the brain from the torn artery. The condition impairs a person’s ability to express and understand language, whether spoken, written, or signed.
Adamant her visit to the chiropractor nearly cost her her life, Carissa is warning others to be wary of alternative medicine. Detailing what originally led her to visit a chiropractor, she said: ‘I went to my chiropractor because I’d been having a lot of strain in my chest and my back and a friend had recommended one.
After visiting a chiropractor to help relieve some of her symptoms, Carissa felt a sharp pang of pain in her neck during her fourth session. Carissa said: ‘As soon as it happened, I knew something was wrong. You do hear a crack anyway when you get an adjustment but I knew something had gone wrong. There was a pain in my neck. I got home and felt like I was going to throw up. I had no idea a VAD could even happen. Because I work in health, fitness and wellness, I was active after [the appointment]. I was teaching classes, I went to a salon – I did everything wrong. A few weeks after seeing the chiropractor, I was seeing things and blacking out and my husband said ‘we’re taking you to the ER’.’
After undergoing a CAT scan, doctors told Carissa that she had suffered a VAD and transferred her to an ICU at a specialist hospital. Carissa said: ‘I knew straight away that it was from the chiropractor – that’s where the pain all started from. ‘They said I could’ve had a stroke. If I hadn’t gone to hospital, I would’ve had a stroke. I could’ve so easily died. It traumatized my whole family. For the first month I was pretty much in bed. I was exhausted, sleeping for 17 hours a day. I needed help walking. I was in constant pain.’
Carissa says her life was put on pause after suffering the artery tear and is now spreading awareness of the signs and symptoms of the life-threatening condition. Touching on her health status years on, she concludes: ‘I still have lingering symptoms now – it’s a whole lifestyle change. I’ll never ski again, I’ll never go on a rollercoaster, I’m not teaching classes anymore. There’s still a residual fear of it happening again. I’m doing well now but it’s been a long recovery process. My life was really put on pause. I absolutely regret going to the chiropractor. It’s not about blaming anyone, it’s just about spreading more awareness. I want people to understand what the symptoms are and that this is a life-threatening condition. I never thought anything like this could happen to me. I was healthy, active and deeply in tune with my body.’
_____________________
Yes, I know!
Yet another case with insufficient details to draw firm conclusions. My chiro friends will not be happy. This is not evidence!, they will say. And right they are! So, let’s look at some more reliable evidence. Here are 3 recent and relevant abstracts:
- 1st abstract: Vertebral artery dissection (VAD) has been observed in association with chirotherapy of the neck. However, most publications describe only single case reports or a small number of cases. We analyzed data from neurological departments at university hospitals in Germany over a three year period of time of subjects with vertebral artery dissections associated with chiropractic neck manipulation. We conducted a country-wide survey at neurological departments of all medical schools to identify patients with VAD after chirotherapy followed by a standardized questionnaire for each patient. 36 patients (mean age 40 + 11 years) with VAD were identified in 13 neurological departments. Clinical symptoms consistent with VAD started in 55% of patients within 12 hours after neck manipulation. Diagnosis of VAD was established in most cases using digital subtraction angiography (DSA), magnetic resonance angiography (MRA) or duplex sonography. 90% of patients admitted to hospital showed focal neurological deficits and among these 11 % had a reduced level of consciousness. 50% of subjects were discharged after 20 +/- 14 hospital days with focal neurological deficits, 1 patient died and 1 was in a persistent vegetative state. Risk factors associated with artery dissections (e. g. fibromuscular dysplasia) were present in only 25% of subjects. In summary, we describe the clinical pattern of 36 patients with vertebral artery dissections and prior chiropractic neck manipulation.
- 2nd abstract: Background: Vertebral artery dissections (VAD) are a rare but important cause of ischemic stroke, especially in younger patients. Many etiologies have been identified, including MVAs, cervical fractures, falls, physical exercise, and cervical chiropractic manipulation. The goal of this study was to investigate the subgroup of patients who suffered a chiropractor-associated injury and determine how their prognosis compared to other-cause VAD. Methods:We conducted a retrospective chart review of 310 patients with vertebral artery dissections who presented at our institution between January 2004 and December 2018. Variables included demographic data, event characteristics, treatment, radiographic outcomes, and clinical outcomes measured using the modified Rankin Scale.Findings: Overall, 34 out of our 310 patients suffered a chiropractor-associated injury. These patients tended to be younger (p = 0.01), female (p = 0.003), and have fewer comorbidities (p = 0.005) compared to patients with other-cause VADs. The characteristics of the injuries were similar, but chiropractor-associated injuries appeared to be milder at discharge and at follow-up. A higher proportion of the chiropractor-associated group had injuries in the 0–2 mRS range at discharge and at 3 months (p = 0.05, p = 0.04) and no patients suffered severe long-term neurologic consequences or death (0% vs. 9.8%, p = 0.05). However, when a multivariate binomial regression was performed, these effects dissipated and the only independent predictor of a worse injury at discharge was the presence of a cervical spine fracture (p < 0.001). Interpretation: Chiropractor-associated injuries are similar to VADs of other causes, and apparent differences in the severity of the injury are likely due to demographic differences between the two populations.
- 3rd abstract: Purpose: The purpose of this study was to determine the frequency of patients seen at a single institution who were diagnosed with a cervical vessel dissection related to chiropractic neck manipulation. Methods: We identified cases through a retrospective chart review of patients seen between April 2008 and March 2012 who had a diagnosis of cervical artery dissection following a recent chiropractic manipulation. Relevant imaging studies were reviewed by a board-certified neuroradiologist to confirm the findings of a cervical artery dissection and stroke. We conducted telephone interviews to ascertain the presence of residual symptoms in the affected patients. Results: Of the 141 patients with cervical artery dissection, 12 had documented chiropractic neck manipulation prior to the onset of the symptoms that led to medical presentation. The 12 patients had a total of 16 cervical artery dissections. All 12 patients developed symptoms of acute stroke. All strokes were confirmed with magnetic resonance imaging or computerized tomography. We obtained follow-up information on 9 patients, 8 of whom had residual symptoms and one of whom died as a result of his injury. Conclusion: In this case series, 12 patients with newly diagnosed cervical artery dissection(s) had recent chiropractic neck manipulation. Patients who are considering chiropractic cervical manipulation should be informed of the potential risk and be advised to seek immediate medical attention should they develop symptoms.
I hope my chiro friends are happy now.
This meta-analysis evaluated and compared the safety and efficacy of spinal manipulation, mobilization, and massage for the management of cervicogenic headache (CGH). Comprehensive searches were conducted in Cochrane, Embase, PubMed, and ClinicalTrials.gov to identify studies investigating the effects of manipulation, mobilization, and massage on pain, disability, and physical function in patients with CGH. Key outcomes included pain severity (visual analog scale, VAS), Neck Disability Index (NDI), Flexion-Rotation Test (FRT), and Headache Disability Inventory (HDI) at various follow-up timepoints.
Fourteen studies totaling 1,297 CGH patients were included. Standard pairwise meta-analysis revealed that sustained natural apophyseal glides (SNAG*) mobilization produced significantly greater improvements compared to non-SNAG interventions in VAS (MD = 1.73, 95%CI: 1.05, 2.40), NDI (MD = 8.55, 95%CI: 2.73, 14.37), FRT (MD = -7.22, 95%CI: -9.38, -5.07), and HDI (MD = 9.29, 95%CI: 3.64, 14.95), with benefits maintained over time. Network meta-analysis showed that for VAS improvement, the surface under the cumulative ranking curve (SUCRA) probabilities were: cervical spine manipulation (CSM, 98.9%), mobilization (67.3%), exercise (21.0%), and massage (12.8%). For NDI, the SUCRA scores were: CSM (82.2%), mobilization (57.2%), exercise (6.7%), and massage (53.9%). CSM exhibited significantly greater VAS reductions compared to exercise, massage, and mobilization, while mobilization was superior to exercise and massage for VAS. For NDI, CSM was significantly better than exercise, but no other between-group differences were observed.
The authors concluded that, in patients with CGH, SNAG mobilization can significantly improve pain and function, with benefits maintained in the long-term. Additionally, CSM may be the most effective short-term intervention for reducing pain and disability compared to mobilization, massage, and exercise, although clinician expertise appears to be an important factor.
The authors note that both components of this study exhibited substantial heterogeneity, with variability in the frequency, duration, and nature of spinal interventions across studies. This lack of standardization complicates the translation of findings to clinical practice. Additionally, while the network meta-analysis allowed for comparative evaluation of several manual therapy modalities, the large differences between sham/control groups precluded the inclusion of SNAG, thereby limiting the comprehensiveness of the analysis.
They also admit that The small sample sizes and potential selection biases in the primary studies significantly limit the ability to generalize their findings to the broader CGH patient population. While the studies provide important insights into the effectiveness of manual therapy interventions, their conclusions should be interpreted cautiously. Larger, more diverse studies with more robust sampling strategies would help improve the external validity and reliability of the findings, allowing for more confident recommendations that can be applied to the wider CGH population in clinical settings.
I agree with these critical thoughts and wonder why the authors nonetheless formulated their conclusions so definitively. In my view, there are not enough reliable data for arriving at such firm conclusions. Furthermore, it is unclear how thay assessed the safety of the various interventions. Considering the well-documented risks of CSM, I would certainly not name it as the manual therapy of first choice.
*The SNAG technique involves the application of graded mobilization along the treatment plane of the selected cervical facet joint, from the mid-range to the end-range, with the joint position maintained.
Yes, it’s CAW again!
How best should we celebrate?
- I could show you how often we had to discuss the harm chiropractic does to patients.
- I could tell you about the contraproductive advice chiropractors tend to issue to anyone who wants to hear it.
- I could list the fatalities chiropractic manipulations have caused.
- I could write about the unethical transgressions many chiropractors commit.
- I could elaborate on the financial fraud some chiropractors are involved in.
- I could write about the dishonest cherry-picking that chiropractors like to engage in.
But that would not be nice, and they would say that I have an axe to grind, a chip on my shoulder, that I am incompetent, don’t know what I am writing about, in the pocket of BIG PHARMA, etc.
So, I decided to celebrate the CAW by reporting on a chiropractic success story, a type of article that chiropractors like: a case report of a patient cured by chiropractic treatments.
Chronic low back pain (CLBP) has been the leading cause of disability globally for the past few decades, resulting in decreased quality of life physically and emotionally. This case report is, according to its authors, important in the medical literature to add to studies reporting successful conservative treatment of CLBP and chronic neck pain (CNP). Triage, diagnosis, and understanding of economical and conservative therapeutics can, the authors stress, benefit patients; providers as well as institutions and third party payors benefit from improved outcomes.
A 39-year old male presented with severe CLBP who had experienced no long-term success with prior chiropractic spinal manipulative therapy (SMT). After symptoms began to worsen in spite of receiving SMT, the patient sought treatment for his pain, abnormal spine alignment, and poor sagittal alignment at a local spine facility. History and physical examination demonstrated altered spine and postural alignment including significant forward head posture and reduced cervical and lumbar lordosis and coronal plane abnormalities. Treatment consisted of a multi-modal regimen focused on strengthening postural muscles, specific spine manipulation directed toward abnormal full-spine alignment, and specific Mirror Image traction aiming to improve spine integrity by realigning the spine toward a more normal position. The treatment consisted of 36 treatments over three months. All original tests and outcome measures were repeated following care.
Objective and subjective outcome measures, patient-reported outcomes, and radiographic mensuration demonstrated improvement at the conclusion of treatment and maintained at 1-year follow-up re-examination.
The authors concluded that this is case demonstrates that the CBP orthopedic chiropractic treatment approach may represent an effective method to treat abnormal spinal alignment and posture. This study adds to the literature regarding conservative methods of treating spine pain and spinal disorders.
What, you are NOT impressed?
- You even claim that the patient’s symptoms worsend despite long-term SMT?
- You insist that such a case poves nothing and certainly does not justify the conclusion?
- You point out that one of the authors is a compensated researcher for CBP Non-Profit, Inc., while another one is a compensated consultant and researcher for Chiropractic BioPhysics, NonProfit, Inc. and one is the CEO of Chiropractic BioPhysics® (CBP®)?
- And you note that this paper was funded by Chiropractic BioPhysics?
Let me tell you this: you are a spoilt sport! We are, after all, in the realm of chiropractic research where things are different. What is normally called promotion florishes here as research, and the rules of science, ethics or even common sense are suspended.
A popular ‘TikTok creator’ claims that he became bedridden for months after a chiropractic adjustment to his neck left him with a herniated disc, causing him “the worst pain I’ve ever experienced” and the loss of his life savings in medical bills. Tyler Stanton, a Nashville-based ‘content creator’ stated that he’s been recovering from an injury sustained when a chiropractor adjusted his neck.
In a TikTok video Stanton said he’d been working out a lot before his birthday because “I wanted to be in the best shape of my life.” He’d been feeling some tightness in his back, so he went to see a chiropractor. At first, the chiropractor struggled to “get my back to crack,” but finally he was able to do it. Stanton said when they had the same trouble with his neck, “on the second time where he tried to crack my neck, he put a lot of force behind it, and I heard one huge and painful pop,” Stanton explained. “I knew immediately that something was wrong … the whole room was spinning. My equilibrium was just completely f—ked. I was like instantly, like, profusely sweating.”
It took him a half hour of lying down to “be good enough to walk out the door,” but as soon as he got home, he began “violently throwing up, uncontrollably. I can’t see straight.” Stanton says he went promptly to bed even though it was the middle of the day, and when he woke up the next morning moving to turn his phone alarm off caused him “the worst pain I’ve ever experienced in my entire life.” Stanton described it as “static” all over the “entire right side of my body. It was really scary, I had no idea what was happening, but I knew something was really wrong.”
He went to the hospital, where it was determined that the chiropractor had “herniated my C6,” the disc at the base of the neck. Over the next month, he spent a few weeks “on and off” in the hospital, because the “pain was so bad.” He received epidural injections, and “they didn’t even make a dent into the pain. Like, it literally did nothing.”
At this point, his options were surgery — which he said, “I’ve heard so many horror stories about that” — or physical therapy and learning to live with a herniated disc. He chose the second option, explaining he has a “a pharmacy” at home of pain medication. “I ended up just having to go home and lay down for about two more months. It took, like, three months to get my feeling back in my arm.”
He thought of legal action, as the injury “really hurt me financially … my savings just evaporated … I still deal with pain. I’m still limited on what I can do physically. It just destroyed me mentally, financially, physically — all of it.”
In a later update Stanton said that it’s been hard for him to create content since he herniated his disc. “People asking me why I keep disappearing and why I stopped posting … I didn’t really want to say much about it because one thing I’ve learned over the years being on the internet is that if you have a following, no one cares if you’re sad,” he said. “To be honest with you, I love to come on here and make you guys laugh, but it’s hard to when s—t just ain’t funny.”
_________________
Having treated many patients with herniated discs, I can confirm: it’s not funny!
Having read about many cases of serious complications after chiropractic manipulations, I assume that this one – like so many others – will not enter into the medical literature where sufficient details might be provided to allow a fuller evaluation – doctors are simply too busy to write up the events and findings for publication. The case will also not appear in any system that monitors adverse events, because chiropractors have in their ~120 Years history not been able to establish such a thing. The result will be that this event – as so many like it – will pass virtually undocumented and unnoticed.
And this suits whom exactly?
Yes, it suits the chiros who can continue to falsely claim that, as there are just few records to the contrary,
“our maipulations are entireely safe!”
Yes, this was the (rather sensationalist) headline of a recent article in the Daily Mail that I allegedly wrote. Its unusual genesis might interest some of you.
I was contacted by a journalist who asked for a telephone interview on the subject of chiropractic as well as my recent book. I agreed under the condition that we do this not over the phone but in writing via email. So, he sent me his questions and I supplied the responses; here they are:
· What’s the absolute worst case scenario of seeing a chiropractor?
The worst that can happen is that you die. Certain manipulations that chiropractors regularly do can injure an artery that supplies part of the brain. This would then result in a stroke; and a stroke can of course be fatal. This is what happened, for example, to the American model Katie May. She had pinched a nerve in her neck on a photoshoot and consulted a chiropractor who manipulated her neck. This caused a tear to an artery in her upper spine. The result was a massive stroke of which she died a few days later.
· How did you first become interested in the topic?
I learned hands on spinal manipulation as a junior doctor. Later, as the head of the department of Physical Medicine and Rehabilitation at the University of Vienna, we used such techniques routinely. In 1993, I became chair of Complementary Medicine in Exeter, and my task was to scientifically investigate alternative therapies such as chiropractic. Recently, I decided to summarize all our research in a book.
· What did you learn from your research?
In essence, our investigations found that almost all the claims that chiropractors make are unsubstantiated. Their manipulations are not nearly as effective as they claim. More worryingly, they are also not free of risks. About 50% of patients who see a chiropractor suffer from side effects after spinal manipulation. These are usually not severe and disappear after 2 or 3 days. But, in addition, very serious complications like stroke, death, bone fractures, paralysis can also occur. Chiropractors say that these are rare, and I hope they are right, but the truth is that nobody knows because there is no system of monitoring such events. We once asked British neurologists to report cases of neurological complications occurring within 24 hours of cervical spine manipulation over a 12-month period. This unearthed a total of 35 cases. Particularly striking was the fact that none of these cases had previously been reported anywhere. So, the underreporting was exactly 100%. This tells me that, when chiropractors claim there are just a few such incidents, in truth there might be a few hundred or even thousand.
· Is there an especially shocking finding?
What I find particularly unnerving is the way chiropractors regularly disregard medical ethics. Take the issue of informed consent, for example. It means that we all have to fully inform patients about the treatment we plan to give. In the case of chiropractic spinal manipulation, it would need to include that the therapy is of doubtful effectiveness, that other options are more likely to help, and that the treatment carries very frequent minor as well as probably rare major risks. I do understand why chiropractors do often not provide this information – it would chase away most patients and thus impact of their income. At the same time, I feel that chiropractors should not be allowed to violate fundamental principles of medical ethics. This is not in the interest of patients!!!
· Why do you think patients are so keen on chiropractors?
I am not sure that they really are so keen; some are but the vast majority are not. Our own research suggests that, depending on the country, between 7 and 33% of the population see chiropractors. This means that between 93 and 67% have enough sense to avoid chiropractors.
· But what does the evidence actually show about the efficacy of chiropractic?
As it happens our most recent summary has just been published. It concluded that “it is uncertain if chiropractic spinal manipulation is more effective than sham, control, or deep friction massage interventions for patients with headaches” [Is chiropractic spinal manipulation effective for the treatment of cervicogenic, tension-type, or migraine headaches? A systematic review – ScienceDirect]. For other conditions the evidence tends to be even less convincing. The only exception might be chronic low back pain, according to another recent summary [Analgesic effects of non-surgical and non-interventional treatments for low back pain: a systematic review and meta-analysis of placebo-controlled randomised trials | BMJ Evidence-Based Medicine]. But here too, I would argue that other treatments are safer and cheaper.
· Are some chiropractors worse than others?
The profession is divided into 2 groups, the ‘straights’ and the ‘mixers’. The former believe in all the nonsense their founding father, DD Palmer, proclaimed 120 years ago, including that spinal manipulation is the only treatment for virtually all our ailments, and that vaccinations must be avoided at all cost. The mixers have realized that Palmer was a charlatan of the worst kind, focus on musculoskeletal conditions and use treatments borrowed from physiotherapy. Needless to say that the mixers might be bad, but the straights are even worse.
· What can patients do to keep safe?
Avoid chiropractors, go to a library and read my book.
· If you have backpain or joint pain what can you do instead?
There is lots people can do but advice has to be individualized. By far the best is to prevent back pain from happening. Here advice might include more exercise, loosing weight, changing your mattress, avoiding certain things like heavy lifting, etc. If you are acutely suffering, see a physio or a doctor, keep moving and be aware that over 90% of back pain disappears within a few days regardless of what you do.
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I had insisted that I see his edits before this gets published, and a little while later I received the edited version. To my big surprise, the journalist had transformed the interview into an article allegedly authored by me. I told him that I was uncomfortable with this solution, and we agreed that he would make it clear that the article was merely based on an interview with me. I then revised the article in question and the result was the mentioned article published still naming me as its author but with a footnote: “As told in an interview with Ethan Ennals”
Never a dull day when you research so-called alternative medicine!
A long article on chiropractic casts doubt that chiropractic is useful. Here is an abbreviated version of it:
The chemistry and biology graduate from the University of Georgia, 28-year-old Caitlin Jensen, visited a chiropractor to sort out her lower back pain. During the session, the therapist performed an adjustment. It severed four arteries in her neck. She collapsed shortly after, unable to speak or move. The injury had caused her to suffer a series of strokes. Today, she has regained some movement in her head, legs and arms but she is still unable to speak, is partially blind and relies on a wheelchair.
- One 66-year-old grandmother said a visit to a chiropractor to treat her sore shoulder left her covered in bruises, hearing ringing in her ears and with a splitting pain in her jaw. She was later diagnosed by doctors with trigeminal neuralgia – a chronic pain disorder caused by a trapped or irritated nerve in the neck that causes sudden, electric shock-like pain in the face. She believes the condition – which, three years later, still sometimes leaves her unable to open her mouth wide enough to speak to her grandchildren – was triggered by a chiropractic adjustment of her neck.
- A 55-year-old woman was left with chronic neck and shoulder pain after visiting a chiropractor for a sore back. The pain was so bad she once spent 72 hours immobile and unable to sleep despite taking a concoction of painkillers.
- And a 66-year-old man says his back went into spasm as he was leaving his first chiropractor appointment – which left him hospitalised and bedbound for weeks. The intense treatment, he later learned, had pushed one of the discs of his spine out of place, causing him to lose feeling in his right leg for ever.
