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

spinal manipulation

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The purpose of this systematic review was to assess the effectiveness and safety of conservative interventions compared with other interventions, placebo/sham interventions, or no intervention on disability, pain, function, quality of life, and psychological impact in adults with cervical radiculopathy (CR), a painful condition caused by the compression or irritation of the nerves that supply the shoulders, arms and hands.

A multidisciplinary team autors searched MEDLINE, CENTRAL, CINAHL, Embase, and PsycINFO from inception to June 15, 2022 to identify studies that were:

  1. randomized trials,
  2. had at least one conservative treatment arm,
  3. diagnosed participants with CR through confirmatory clinical examination and/or diagnostic tests.

Studies were appraised using the Cochrane Risk of Bias 2 tool and the quality of the evidence was rated using the Grades of Recommendations, Assessment, Development, and Evaluation approach.

Of the 2561 records identified, 59 trials met the inclusion criteria (n = 4108 participants). Due to clinical and statistical heterogeneity, the findings were synthesized narratively.

There is very-low certainty evidence supporting the use of:

  • acupuncture,
  • prednisolone,
  • cervical manipulation,
  • low-level laser therapy

for pain and disability in the immediate to short-term, and

  • thoracic manipulation,
  • low-level laser therapy

for improvements in cervical range of motion in the immediate term.

There is low to very-low certainty evidence for multimodal interventions, providing inconclusive evidence for pain, disability, and range of motion.

There is inconclusive evidence for pain reduction after conservative management compared with surgery, rated as very-low certainty.

The authors concluded that there is a lack of high-quality evidence, limiting our ability to make any meaningful conclusions. As the number of people with CR is expected to increase, there is an urgent need for future research to help address these gaps.

I agree!

Yet, to patients suffering from CR, this is hardly constructive advice. What should they do vis a vis such disappointing evidence?

They might speak to a orthopedic surgeon; but often there is no indication for an operation. What then?

Patients are bound to try some of the conservative options – but which one?

  • Acupuncture?
  • Prednisolone?
  • Cervical manipulation,?
  • Low-level laser therapy?

My advice is this: be patient – the vast majority of cases resolves spontaneously regardless of therapy – and, if you are desperate, try any of them except cervical manipulation which is burdened with the risk of serious complications and often makes things worse.

I was alerted to the updated and strengthened guidance to ensure safer practice by chiropractors who treat children under the age of 12 years that has recently been published by the Chiropractic Board of Australia after considering the recommendations made by the Safer Care Victoria independent review. The Board also considered community needs and expectations, and specifically the strong support for consumer choice voiced in the public consultation of the independent review.

The Board examined how common themes in the independent review’s recommendations align with its existing regulatory guidance, and used these insights to inform a risk-based approach to updating its Statement on paediatric care. This includes updated advice reinforcing the need to ensure that parents or guardians fully understand their rights and the evidence before treatment is provided to children. ‘Public safety is our priority, and especially so when we consider the care of children’, Board Chair Dr Wayne Minter said.

According to the statement, the Board expects chiropractors to various things, including the following [the numbers in the following passage were added by me and refer to my brief comments below]:

  • inform the patient and their parent/guardian about the quality of the acceptable evidence and explain the basis for the proposed treatment [1]
  • provide the patient and their parent/guardian with information about the risks and benefits of the proposed treatment and the risks of receiving no treatment [2]
  • appropriately document consent, including considering the need for written consent for high-risk procedures [3]
  • refer patients when they have conditions or symptoms outside a chiropractor’s area of competence, for example ‘red flags’ such as the presence of possible serious pathology that requires urgent medical referral to the care of other registered health practitioners [4]

______________________________

  1. I know what is meant by the ‘quality of the evidence’ but am not sure what to make of the ‘quality of the acceptable evidence]. Acceptable by whom? In any case, who checks whether this information is being provided?
  2. Imagine the scenatio following this guidance: Chiro informs that there is a serious risk and no proven benefit – which parent would then procede with the treatment? In any case, the informed consent is incomplete because it also requires information as to which conventional treatment is effective for the condition at had [information that chiros are not competent to provide].
  3. Who checks whether this is done properly?
  4. Arguably, all pediatric conditions or symptoms are outside a chiropractor’s area of competence!

In view of these points, I fear that the updated guidance is a transparent attempt of window dressing, yet unfit for purpose. Most certainly, it does not ensure safer practice by chiropractors who treat children under the age of 12 years.

A case report of a U-type sacral fracture, or spinopelvic dissociation, resulting from chiropractic manipulation has recently been published. It presents the case of a 74-year-old male patient who sustained a U-type sacral fracture after drop-table chiropractic manipulation.

The drop table chiropractic technique is claimed by chiropractors to involve lesser brute force for spinal manipulation than traditional chiropractic care. It involves low-velocity movement and less spinal manoeuvring on the specific area of injury. It is said to be particularly beneficial for adjusting the pelvis or sacroiliac joints. Furthermore, this is, according to chiros, one of the only methods that can adjust spondylolisthesis. In fact, the evidence that it is effective for anything other that boosting the chiros’ income is more than thin, while there is at least one tragic report that it can be lethal.

The recent case of a spinopelvic dissociation demonstrates that chiropractic manipulative therapy involving the commonly used drop-table can cause severe injury. The patient’s course was complicated by a delay in diagnosis and a prolonged hospital stay. Orthopaedic surgeons should have a high degree of suspicion for spinopelvic dissociation in the setting of bilateral sacral fractures. One year after injury, with conservative management, the patient returned to baseline function with mild residual neuropathy.

Spinopelvic dissociation is a rare injury associated with 2% to 3% of transverse sacral fractures and 3% of sacral fractures associated with pelvic ring injuries. When spinopelvic dissociation is expediently identified and treated appropriately, patient outcomes can be maximized, highlighting the importance of early diagnosis and treatment. Because of its rarity and complexity, there remains a paucity of high-level evidence-based guidance on treating this complex issue.  Most cases are caused by a fall from heights, followed by road accidents. Many patients show neurologic impairment at initial presentation, which often improves after surgery, the treatment of choice.

 

According to chiropractic belief, vertebral subluxation (VS) is a clinical entity defined as a misalignment of the spine affecting biomechanical and neurological function. The identification and correction of VS is the primary focus of the chiropractic profession. The purpose of this study was to estimate VS prevalence using a sample of individuals presenting for chiropractic care and explore the preventative public health implications of VS through the promotion of overall health and function.

A brief review of the literature was conducted to support an operational definition for VS that incorporated neurologic and kinesiologic exam components. A retrospective, quantitative analysis of a multi-clinic dataset was then performed using this operational definition.

The operational definition used in this study included:

  • (1) inflammation of the C2 (second cervical vertebra) DRG,
  • (2) leg length inequality,
  • (3) tautness of the erector spinae muscles,
  • (4) upper extremity muscle weakness,
  • (5) Fakuda Step test,
  • radiographic analysis based on the (6) frontal atlas cranium line and (7) horizontal atlas cranium line.

Descriptive statistics on patient demographic data included age, gender, and past health history characteristics. In addition to calculating estimates of the overall prevalence of VS, age- and gender-stratified estimates in the different clinics were calculated to allow for potential variations.

A total of 1,851 patient records from seven chiropractic clinics in four states were obtained. The mean age of patients was 43.48 (SD = 16.8, range = 18-91 years). There were more females (n = 927, 64.6%) than males who presented for chiropractic care. Patients reported various reasons for seeking chiropractic care, including, spinal or extremity pain, numbness, or tingling; headaches; ear, nose, and throat-related issues; or visceral issues. Mental health concerns, neurocognitive issues, and concerns about general health were also noted as reasons for care. The overall prevalence of VS was 78.55% (95% CI = 76.68-80.42). Female and male prevalence of VS was 77.17% and 80.15%, respectively; notably, all per-clinic, age, or gender-stratified prevalences were ≥50%.

The authors concluded that the results of this study suggest a high rate of prevalence of VS in a sample of individuals who sought chiropractic care. Concerns about general health and wellness were represented in the sample and suggest chiropractic may serve a primary prevention function in the absence of disease or injury. Further investigation into the epidemiology of VS and its role in health promotion and prevention is recommended.

This is one of the most hilarious pieces of ‘research’ that I have recently encountered. The strategy is siarmingly simple:

  • invent a ficticious pathology (VS) that will earn you plently of money;
  • develop criteria that allow you to diagnose this pathology in the maximum amount of consumers;
  • show gullible consumers that they are afflicted by this pathology;
  • use scare mongering tactics to convince consumers that the pathology needs treating;
  • offer a treatment that, after a series of expensive sessions, will address the pathology;
  • cash in regularly while this goes on;
  • when the consumer has paid enough, declare that your fabulous treatment has done the trick and the consumer is again healthy.

The strategy is well known amongst practitioners of so-called alternative medicine (SCAM), e.g.:

  • Traditional acupuncturists diagnose a ficticious imbalance of yin and yang only to normalise it with numerous acupuncture sessions.
  • Naturopaths diagnose ficticious intoxications and treat it with various detox measures.
  • Iridologists diagnose ficticious abnormalities of the iris that allegedly indicate organ disstress and treat it with whatever SCAM they can offer.

As they say:

No disease can be more surely, effectively, and profitably treated than a condition that the unsuspecting customer did not have in the first place!

 

PS

Sadly, such behavior exists in convertional medicine occasionally too, but SCAM relies almost entirely on it.

I was alerted to this message on ‘reddit’:

I went in to a chiropractor for a sports injury which was completely unrelated to my neck (wrist). While I was there, the chiropractor insisted on also doing a neck adjustment. To make a very long story short, this adjustment caused a vertebral artery dissection. The injury has left me with lifelong symptoms that I won’t get into here.>Because of tort reform law in Texas, and the $250k cap, I had a very difficult time finding any attorney to represent me even though there’s a mountain of evidence in my favor. My time to file a lawsuit has almost run out (statute of limitations).

Out of principle I want to hold this person accountable. How would I go about at least filing my lawsuit so that I get in within the statute of limitations which is very quickly approaching?

My thought is if I do sue this person within the two year timeframe then I can either self represent, have the option of withdrawing my case, or maybe in the meantime find an attorney to represent me for if/when we go to trial.

Any other advice or things that I should be considering? What would you do?

Thank you

____________________

If anyone can help this person, please do so. I have acted as an expert witness in several such cases and would be happy to do so also in this instance.

Chiropractors will, of course, say that this message is not a proper case report and cannot therefore count as evidence against the safety of chiropractic. I agree that it does not in itself amount to compelling evidence. But I would like to remind the chiros that it is up to them to establish a proper surveillance system for such tragic events which seem to occur far more often than they want us to believe (as discussed ad nauseam on this blog).

The concept that the outcomes of spinal manipulation therapy (SMT) – the hallmark intervention of chiropractors which they use on practically every patient – are optimized when the treatment is aimed at a clinically relevant joint is commonly assumed and central to teaching and clinical use of chiropractic. But is the assumption true?

This systematic review investigated whether clinical effects are superior when this is the case compared to SMT applied elsewhere. Eligible study designs were randomized controlled trials that investigated the effect of SMT applied to candidate versus non-candidate sites for spinal pain.

The authors obtained studies from four different databases. Risk of bias was assessed using an adjusted Cochrane risk of bias tool, adding four items for study quality. Between-group differences were extracted for any reported outcome or, when not reported, calculated from the within-group changes. Outcomes were compared for SMT applied at a ‘relevant’ site to SMT applied elsewhere. The authors prioritized methodologically robust studies when interpreting results.

Ten studies were included. They reported 33 between-group differences; five compared treatments within the same spinal region and five at different spinal regions.

None of the nine studies with low or moderate risk of bias reported statistically significant between-group differences for any outcome. The tenth study reported a small effect on pain (1.2/10, 95%CI – 1.9 to – 0.5) but had a high risk of bias. None of the nine articles of low or moderate risk of bias and acceptable quality reported that “clinically-relevant” SMT has a superior outcome on any outcome compared to “not clinically-relevant” SMT. This finding contrasts with ideas held in educational programs and clinical practice that emphasize the importance of joint-specific application of SMT.

The authors concluded that the current evidence does not support that SMT applied at a supposedly “clinically relevant” candidate site is superior to SMT applied at a supposedly “not clinically relevant” site for individuals with spinal pain.

I came across this study when I searched for the published work of Prof Stephen Perle, a chiropractor and professor at the School of Chiropractic, College of Health Sciences, University of Bridgeport, US, who recently started trolling me on this blog. Against my expectation, I find his study interesting and worthwhile.

His data quite clearly show that the effects of SMT are non-specific and mainly due to a placebo response. That in itself is not hugely remarkable and has been suspected to some time, e.g.:

What is remarkable, however, is the fact that Perle and his co-authors offer all sorts of other explanation for their findings without even seriously considering what is stareing in their faces:

SPINAL MANIPULATIONS ARE PLACEBOS

CHIROPRACTIC IS A PLACEBO THERAPY

This might be almost acceptable, if chiropractic would not also be burdened with significant risks (as we have discussed ad nauseam on this blog) – another fact of which chiros like Perle are in denial.

What does all that mean for patients?

The practical implication is fairly straight forward: the risk/benefit balance of chiropractic is negative. And this surely means the only responsible advice to patients is this:

NEVER CONSULT A CHIRO!

Traditionally, strokes were considered a condition primarily affecting older adults. But in recent years, doctors have noticed a disturbing trend: the rise of stroke cases among younger adults, a demographic that was once considered low-risk. New data reveals an increase in the number of young adults facing an unexpected battle with strokes. Experts point to poor lifestyle choices as the main risk factor. Smoking, unhealthy diets, lack of exercise, and increased stress have played a role because they lead to problems like high cholesterol, high blood pressure and obesity.

But one risk factor most people don’t consider has to do with chiropractic adjustments. US doctors say forceful and rapid neck rotations during these procedures can potentially cause damage to the vertebral arteries supplying blood to the brain stem. “We see five, if it’s a bad year, up to eight or 10 a year per hospital, and some of them can be quite devastating because the brain stem and the cerebellum are in an enclosed compartment and that only so much room,” said Dr. Melissa McDonald, with McKay Dee Hospital.

Stroke symptoms in young adults are similar to those seen in older adults: weakness or numbness in the face, arm, or leg; sudden change in speech, difficulty walking or keeping your balance; and sudden severe headaches and change in vision. Any of these symptoms require immediate medical attention, but doctors say younger adults tend to wait longer than older adults to go to the ER.

Dr. McDonald says younger adults face an increased risk of complications from brain swelling following a stroke due to the relatively larger size of their brains within the skull compared to older individuals.

Readers of this blog can hardly be surprised by this news. I have often enough reported on the fact that chiropractic adjustments can cause a stroke, e.g.:

And what is the solution?

I’m glad you asked; it is simple! In the words of one neurologists:

DON’T LET THE BUGGARS TOUCH YOUR NECK!

We have repeatedly discussed the fraud committed by many chiropractors. A recent article provided further information on this lamentable issue. Here are a few excerpts:

Fraud in US chiropractic care is on the rise. A shocking 82 percent of the chiropractic services billed to Medicare is unallowable, according to a recent audit by the Office of Inspector General. The audit found a lack of effective controls allowed an estimated $358.8 million in taxpayer funds to be improperly billed to Medicare.

Chiropractors engage in fraudulent billing practices in a variety of ways. Sometimes they target environments like nursing homes or substance abuse rehabilitation centers, looking for new patients who may – or may not – require their services.

In one case, a St. Louis-based chiropractor bribed police officers to get access to personal information about individuals who had been in car accidents. The chiropractor then contacted the accident victims and claimed to be from an insurance company or the state to arrange appointments at his practice.

In another case, a Houston-based chiropractor and his medical group settled with the federal government for $2.6 million and were also banned from billing federal programs for 10 years due to their involvement with a fraudulent billing scheme.

Lastly, in 2021, a chiropractor was found guilty of federal criminal charges, including five counts of healthcare fraud. The chiropractor was accused of defrauding health insurers by submitting $2.2 million in billings for chiropractic services that were never provided, office visits that never occurred, false diagnoses, and falsely prescribed medical devices.

Although other medical specialties also have bad actors, certain specific reasons can be identified as to why fraudulent billing and abuse have been increasing among chiropractors. These practitioners have fewer lower-cost codes to bill for, which means they need more patients to boost their earnings. For example, a service may only be billed at $25 or $50, but if this is billed to every patient on every visit, it quickly adds up. Because employers often have limited resources, it’s easy for minor charges to go unnoticed.

According to a 2018 report, the inspector general has conducted numerous evaluations and audits of chiropractic services since 2005 and has identified hundreds of millions of dollars in overpayments for services that did not meet Medicare requirements. The report also noted that the OIG’s investigations and legal actions involving chiropractors have demonstrated that chiropractic services are susceptible to healthcare fraud.

______________

Personally, I am not surprised by such reports. Sure, not all chiropractors committ financial fraud. But arguably ALL chiropractors are dishonest when they tell their patients that their spinal manipulations are effective and safe for a wide range of conditions. To put it bluntly: chiropractic was founded by a crook on a bunch of lies and unethical behavior, therefore, it is hardly surprising that today the profession has a problem with honesty and fraudulent behavior.

 

 

If you assumed that the best management of a child by chiropractors is not to treat this patient and refer to a proper doctor, think again. This paper was aimed at building upon existing recommendations on best practices for chiropractic management of children by conducting a formal consensus process and best evidence synthesis. Its authors composed a best practice guide based on recommendations from current best available evidence and formal consensus of a panel of experienced practitioners, consumers, and experts for chiropractic management of pediatric patients. They thus syntheized results of a literature search to inform the development of recommendations from a multidisciplinary steering committee, including experts in pediatrics, followed by a formal Delphi panel consensus process.

The consensus process was conducted June to August 2022. All 60 panelists completed the process and reached at least 80% consensus on all recommendations after three Delphi rounds. Recommendations for best practices for chiropractic care for children addressed the following aspects of the clinical encounter:

  • patient communication, including informed consent;
  • appropriate clinical history, including health habits;
  • appropriate physical examination procedures;
  • red flags/contraindications to chiropractic care and/or spinal manipulation;
  • aspects of chiropractic management of pediatric patients, including infants;
  • modifications of spinal manipulation and other manual procedures for pediatric patients;
  • appropriate referral and comanagement;
  • appropriate health promotion and disease prevention practices.

The authors concluded that this set of recommendations represents a general framework for an evidence-informed and reasonable approach to the management of pediatric patients by chiropractors.

Whenever I read the term ‘evidence-informed’ I need to giggle. Why not evidence-based? Evidence-informed might mean that chiros are informed that their treatments are useless or even dangerous for children … but, on reflection and taking their own need for earning a living, they subsequently ignore these facts. And sure enough, the authors of the present paper do mention that a Cochrane review concluded that spinal manipulation is not recommended for children under 12, for a number of conditions, or for general wellness … only to then go on and ignore the very fact.

In doing so, the authors issue a string of self-evident platitudes which occasionally border on the irresponsible. For instance, under the heading of ‘primary prevention’, vaccinations are mentioned as the very last item with the following words:

If parents ask for advice or information about childhood vaccinations, explain that they have the right to make their own health decisions. They should be adequately informed about the benefits and risks to both their child and the broader community associated with these decisions. Consider referral to a health professional whose scope of practice includes vaccinations to address patient questions or concerns.

What that really means in practice, I fear, might be summarized like this: If parents ask for advice or information about childhood vaccinations, explain that they are dangerous, and that even D. D. Palmer recognized as early as 1894 that vaccination is ‘…the monstrous delusion … fastened on us by the medical profession, enforced by the state boards, and supported by the mass of unthinking people …’

Altogether, the ‘Clinical Practice Guideline for Best Practice Management of Pediatric Patients by Chiropractors’ is a thoroughly disreputable document. It was constructed in the way all charlatans tend to construct their consensus documents:

  • convene a few people who are all in favour of a certain motion,
  • discuss the motion,
  • agree with it,
  • write up the process
  • publish your paper in a third class journal,
  • boast that there is a consensus,
  • stress that the motion must thereefore be ethical, correct and valuable.

Do chiropractors know that, using this methodology, the ‘flat earth society’ can easily pass a consensus that the earth is indeed flat?

I am sure they do!

‘The Cult of Chiropractic’ is the title of a video that has just been released. I think it is very good and, if you are interested in the subject at all, I recommend you have a look. You can watch it here:

The Cult of Chiropractic : r/h3h3productions (reddit.com)

The video is not just well-done, it also is fun and informative. I learned a few things from it that I did not yet know. It also brings Simon Singh and myself together after we had not met for several years; and that is always a pleasure!

But back to ‘The Cult of Chiropractic’ and the question whether this assumption is true. Some time ago, I published a post about so-called alternative medicine and cultism. I listed a few questions we should ask ourselves to determine whether chiropractic is a cult. Let me adapt them slightly:

  1. Is chiropractic based on dogma? The answer is yes – think, for instance, of the assumptions that subluxations exist.
  2. Does chiropractic demand acceptance of its dogma or doctrine as truth? For straight chiropractors, the answer is yes.
  3. Is the dogma set forth by a single guru or promulgator? Yes, DD Palmer.
  4. Is chiropractic supposed to cure all ills? For many chiros, the answer is yes.
  5. Is belief used by chiropractors as a substitute for evidence? Yes.
  6. Do chiropractors determine their patients’ lifestyle? Yes.
  7. Do chiros exploit their patients financially? Yes.
  8. Does chiropractors impose rigid rules and regulations? Yes.
  9. Do chiros practice deception? Yes.
  10. Do chiropractors have their own sources of information/propaganda? Yes.
  11. Do chiros cultivate their own lingo? Yes.
  12. Do chiros discourage or inhibit critical thinking? Yes.
  13. Are questions about the values of chiropractic discouraged or forbidden? Yes.
  14. Do the proponents of chiropractic reduce complexities into platitudinous buzz words? Yes
  15. Do chiros assume that health problems are the result of not adhering to the dogma? Yes.
  16. Do chiros instill fear into members who consider leaving? Yes.
  17. Do chiros depict conventional medicine as ineffective or harmful? Yes.
  18. Do chiros ask others to recruit new members to their cult? Yes.

Based on these 18 questions, I conclude that chiropractic is indeed a cult. What about you? Even if you disagree, please have a look at the excellent  video, ‘THE CULT OF CHIROPRACTIC’.

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