spinal manipulation
This multicentre pragmatic randomized controlled trial evaluated the effectiveness and cost-effectiveness of physiotherapy, chiropractic care, and the combination of physiotherapy and chiropractic care compared with information and advice for the treatment of patients with nonspecific chronic low-back pain (CLBP) in Sweden.
Eighty-eight participants with nonspecific CLBP were randomly assigned to receive physiotherapy, chiropractic care, combination treatment, or information and advice. The Oswestry Disability Index (ODI), health-related quality of life (HRQoL), quality-adjusted life-years (QALYs), working status, and costs were the main outcome measures.
The study revealed no statistically significant differences in any of the outcome measures when physiotherapy, chiropractic care, and combination treatment with information and advice were compared (p > 0.05). The ODI changes between baseline and the 6-month follow-up ranged from 6.13 to 12.56 across the treatment groups, indicating reduced disability in all groups. Compared with the other treatment options, the combination treatment resulted in the greatest QALY gain (0.418) and lowest cost (SEK 3,081).
The authors concluded that, compared with alternative standalone treatment options, the combination treatment strategy resulted in greater QALY gain and lower costs from a heath care perspective. Although the study did not detect statistically significant differences in outcomes or costs among the treatment options, the combination treatment showed promising potential for cost-effectiveness. Given the small sample size and low statistical power of the study, further clinical trials with fewer treatment arms and a focus on the combination group are warranted to confirm these findings. The insights gained from this study are important for informing the design and conduct of future clinical studies investigating the effectiveness, costs and cost-effectiveness of treatments for CLBP.
I have said it countless times before – but I will say it again: we are all not very effective in curing CLBP. In terms of effectiveness, it therefore hardly matters what treatment we opt for. In this situation, our preference should be guided not by the (in)effectiveness of the therapy but by its
- safety,
- cost,
- availability.
If you apply these criteria, one thing seems very clear:
CHIROPRACTIC CANNOT BE THE TREATMENT OF CHOICE FOR CLBP.
No, the article I am referring to is NOT entitled ‘ANIMAL CHIROPRACTIC (AC) IS NONSENSE’ – quite to the contrary, it is entitled ‘Animal Chiropractic. A Basic Description and Its Importance in Veterinary Practice’. Yet, I feel that the former title would be more suitable.
Judge for yourself. Here is the abstract:
Properly applied AC can be safe and effective. Only licensed health care professionals who have completed extensive postgraduate training should offer AC. As we initially described, AC’s goal is to improve afferent and efferent homeostasis, stability of joints through better sensitivity, and efferent motoric response to improve joint stability. By providing AC, veterinarians can help their patients achieve the highest level of function, independence, and quality of life possible. In this article, we have described AC as a valuable modality that, by improving afferent input and positive modulation of the ventral horn cells and their efferent motor neurons, can positively affect patient strength, stability, and mobility. Therefore, improved conditioning, performance, and postoperative recoveries can enhance patient outcomes by including AC in veterinary practice.
“Any evidence?”, I hear you ask.
Yes, there is an entire paragraph entitled ‘Efficacy and safety’; here it is in full:
There have been several articles published showing the efficacy of AC. Most articles published discussing effectiveness and safety have been from human research, reporting a very low incidence of injuries when provided by licensed and trained professionals. Other national agencies have published information showing the statistical significance of SMT in humans over other treatment therapies.
Surely, this cannot be all!
But it is!
So, let me help out and provide a full summary of the evidence:
THERE IS NO RELIABLE EVIDENCE THAT ANIMAL CHIROPRACTIC DOES MORE GOOD THAN HARM.
And that’s why I think the article should best be entitled:
ANIMAL CHIROPRACTIC IS NONSENSE.
PS
And on reflection, I even think that ‘nonsense’ might be too polite a term for describing it correctly
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!
Common Harms of CSM
- Musculoskeletal discomfort: Temporary soreness, stiffness, or pain in the muscles or joints after treatment.
- Headaches: Some individuals may experience headaches following spinal manipulation.
- Fatigue: Feeling tired or experiencing fatigue after treatment.
These harms occur after CSM in about 50% of all patients. They impact on their quality of life and usually last 1-3 days.
Serious Harms of CSM
- Vertebral artery dissection (VAD) and stroke: A tear in the vertebral artery can lead to stroke; the harm can be permanent.
- Death: A stroke can be fatal.
- Atlantoaxial dislocation
- Spinal cord injury: Damage to the spinal cord, potentially resulting in numbness, weakness, or paralysis.
- Herniated discs: Manipulation can exacerbate existing disc issues or cause a new disc herniation.
- Fractures: Osteoporotic patients or those with bone conditions are at risk of vertebral fractures.
- Cauda equina syndrome: Compression of nerves in the lower spine, potentially causing bowel or bladder dysfunction.
- Nerve damage: Injury to spinal nerves, leading to numbness, tingling, or weakness.
- Eye Injuries: these include central retinal artery occlusion, nystagmus, Wallenberg syndrome, ptosis, loss of vision, ophthalmoplegia, dipiopia and Horner’s syndrome.
The frequency of these harms is not known.
Other Risks
- Neglect: This happens whenever a chiropractor treats a condition that can more effectively be treated with another therapy.
- Misleading advice: This occurs whenever a chiropractor gives advice outside his area of competence, for instance, a recommendation against immunisations.
- False diagnoses: Chiropractors often diagnose a ‘vertebral subluxation’, a condition that exists only in their fantasy.
- Worsening of existing conditions: Manipulation may exacerbate underlying spinal problems or conditions like spinal instability.
- Waste of money: This occurs each time a patient pays for ineffective CSM.
The frequency of these risks is not well-documented but can be estimated to be very high.
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I have often pointed out that the value of a therapy is not solely determined by its potential for harm. It depends crucially on the risk/benefit profile. The benefits of CSM are few and mostly uncertain. Thus the question arises:
DO THE BENEFITS OF CSM OUTWEIGH ITS RISKS?
I let you, the reader, answer this question.
PS
References for the above statements can be found in my book.
This systematic review aimed to map and summarize the existing literature on the use of osteopathic manipulative techniques (OMT) in the management of acute otitis media (AOM) in pediatric patients, with an emphasis on reported outcomes and identifying gaps in the current evidence.
A comprehensive literature search was conducted across multiple databases following the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) guidelines. Studies were charted and summarized based on key characteristics, including study design, population, types of OMT applied, and reported outcomes on management of AOM and recurrent AOM in pediatric patients using OMT. No formal meta-analysis was performed, and all outcome measures were descriptively synthesized.
Three randomized controlled trial (RCT) studies and one pilot cohort study (N = 205) pertaining to application of OMT in pediatric patients with otitis media were included. Mean age for OMT and control (either sham OMT or standard of care) groups were 19.1 months and 16.8 months; proportions of males were 53.2% and 55.9%, respectively.
In the pilot cohort study done by Degenhardt and Kuchera, 62.5% of the subjects experienced no documented recurrence of AOM symptoms at one year post-OMT intervention follow-up; however, since no control group was available for this study, any statistical comparison of recurrence-free rate was unfeasible.
In the RCT study by Mills et al., the OMT group showed statistically significant effects on reducing frequency of mean monthly AOM episodes, resulting in fewer surgical procedures, delaying surgical interventions, increasing resolution of middle ear effusion and better tympanogram readings based on mean sum of types A and C tympanograms, and higher parental satisfaction with overall experience and perceived effectiveness of the OMT on their children on a scale of 0 to 5 when compared to the control group. While statistical interpretation showed some significance in various aspects, OMT’s clinical significance remained questionable, especially considering natural course of healing in AOM. In the other RCT study by Steele et al., at the second-week visit during the 3-week OMT intervention period, the OMT group showed a significantly higher likelihood of middle ear effusion resolution based on tympanogram findings and acoustic reflectometer measurements, respectively. However, at one month follow-up visit, there was no statistical significance, alluding to the limited effects of OMT. Finally, in the last RCT study by Whal et al., the OMT group failed to show any significant effects on prevention of recurrence of AOM.
The authors concluded that the current literature on the use of OMT for acute and recurrent otitis media in pediatric patients suggests, with low certainty, that OMT may provide modest benefits in reducing recurrence rates and improving middle ear function. However, the existing evidence is limited in scope and quality. Further research with larger sample sizes and rigorous randomized controlled trial designs is needed to better understand the potential role of OMT in the management of AOM in pediatric patients.
I disagree!
The 3 RCTs were small and flimsy. They do not even show “low certainty, that OMT may provide modest benefits in reducing recurrence rates and improving middle ear function”. On the contrary, they demonstrate that there is no reliable evidence! Our own systematic review concluded that the effectiveness of OMT for pediatric populations remains unproven which applies to any condition.
We should also ask why on earth OMT should be an effective intervention for AOM? Is there a plausible mechanism of action? The answer is NO!
This leaves us with little more than wishful thinking. Call me ould-fashioned, but I really don’t think that this is a sound basis for responsibly treating kids that are suffering.
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.
It has been reported that members of the U.S. House and Senate are proposing the Chiropractic Medicare Coverage Modernization Act, ensuring reimbursement for all medically necessary services provided by chiropractors. However, the American College of Radiology and American Society of Neuroradiology have now joined over 90 other groups led by the AMA to announce their disapproval. They shared their concerns in a recent letter to the two bills’ sponsors, which ASNR promoted in an update published Tuesday.
“Our organizations are concerned that permitting chiropractors to bill Medicare for the full and likely expanded scope of their license in a given state will lead to an unnecessary redistribution of scarce Medicare resources,” the American Medical Association, all 50 state physician societies, ACR and ASNR recently wrote to lawmakers. Doing so, they added, will likely take funds from medical groups, redistributing them “to nonphysician practitioners for services that they lack sufficient training and expertise to perform. Such expansion would increase overall Medicare costs and jeopardize the health and safety of Medicare patients.”
Supporters of the bill claim the legislation would provide a path for Medicare recipients to better manage pain without resorting to opioids. Currently, the program only covers chiropractic care deemed “medically necessary, subjecting beneficiaries to “burdensome red tape requirements.” The Chiropractic Medicare Coverage Modernization Act seeks to remove these obstacles, bringing coverage rules more in line with rules imposed by private payers.
The radiology societies said they “greatly value the contribution of chiropractors.” However, they’re troubled the legislation would authorize them to use the title “physician” under the Medicare Part B program and be paid the same rate as MDs and DOs. Removing the current “manual manipulation” of the spine limitation in the program opens the door for chiropractors to provide other services “they have not been specifically trained to provide.” Physicians are required to complete upward of 16,000 hours of clinical training, while chiropractic students only must meet a minimum of 4,200 instructional hours.
“Given their relatively limited education and training, chiropractors’ scope of practice is appropriately restricted under Medicare to treatment by means of manual manipulation, i.e., by the use of the hands,” the radiology societies wrote. “This limitation is aligned with chiropractic training and the treatments that chiropractors most often provide involving common musculoskeletal complaints such as back pain.”
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Needless to say what I think about this bill! Chiropractors are not sufficiently trained in medicine, science or ethics to expand their services in the proposed way. One could, of course, train them to practice real medicine. Then most of them would probably give up spinal manipulation and become physicians like MDs.
This is the path that US osteopath have chosen a long time ago.
Would that be desirable?
No, I don’t see a point in having several different types of physicians. It can only confuse patients, lead to uncertainty and to suboptimal healthcare.
A Winnipeg woman is suing her chiropractor, claiming he injured her by tearing an artery during treatment and that she suffered a stroke as a result. The woman had been a patient at Maples Chiropractic in Winnipeg for some time, and she had previously indicated that she did not want the chiropractor treating or adjusting her neck. In May 2023, the patient suffered a right vertebral artery dissection as a result of treatment. “Due to this injury from the treatment, [the plaintiff] suffered a stroke,” says the statement of claim, filed late last month in Court of King’s Bench at Winnipeg.
Maples Chiropractic is claimed to have failed to give the patient immediate care to minimize the effects of her injury. The patient was admitted to hospital at the Health Sciences Centre. The allegations have not been tested in court and statements of defence have not yet been filed. The lawsuit names as defendants the chiropractor, Gilbert Miranda, and his company, Everybody Health Inc., which operates Maples Chiropractic. The lawyer for the plaintiff declined to comment on the case.
The claim states that the patient will need ongoing therapy, psychological treatment and medical attention. It seeks an unspecified amount in damages for the patient’s alleged pain and suffering, loss of income and loss of enjoyment of life. The chiropractor allegedly failed to warn the patient about the risks associated with the chiropractic treatment, “specifically failing to warn her that a stroke could occur from the treatment or from any injury caused by the treatment”. The claim states that the chiropractor was negligent for not obtaining informed consent from the plaintiff about the treatment in general, and specifically for the treatment that allegedly resulted in injury.
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Let me be clear: this case report – like so many similar ones – lacks important details and thus cannot be interpreted properly. Chiropractors will therefore claim – as they did so many times before – that the case does not amount to evidence. They will also pretend that chiropractic manipulations are safe and that there is no sound evidence to prove otherwise. They can make this claim because the chiropractic profession has – since ~120 years! – resisted adopting an adequate monitoring system for registering events like the one above.
And let me be clear again: such claims by chiropractors are based on self-interest and willful ignorance, polite expressions for ‘dishonesty’.
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.”
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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!”
