Confessions of a Quackbuster

This blog deals with healthcare consumer protection, and is therefore about quackery, healthfraud, chiropractic, and other forms of so-Called "Alternative" Medicine (sCAM).

Friday, December 22, 2006

Dangers of chiropractic therapy

Manipulation of the cervical spine: risks and benefits

Table of Contents:

1. Introduction: Read before proceeding!

2. Three films worth seeing

3. References and articles

4. Risks Related to Manipulation of the Cervical Spine: Consequences for Evidence Based Practice

..... and as a bonus....;-)

5. The FSU School of Pseudoscience Scandal


Part 1. Introduction:

This blog entry is not a normal article, but a collection of sources and research on the subject. To benefit from it, make extensive use of the hyperlinks and read those sources. Above all, let the benefit of the doubt fall on the side of patient safety, not on the protection of a profession.

My views on this subject (The Obligatory Disclaimer....;-):

- The message of this blog entry should be taken seriously by all involved professions, not by chiropractors alone.

- It is only directed mainly at chiropractors because they are the ones who stand for the greatest number of injuries and deaths, and they are the ones in denial. If they weren't so adamant in their denial, then a great deal of the focus of criticism would be removed from them.

- I don't believe that high neck manipulation has a very high risk of causing serious injury, but when it happens, it can be catastrophic.

- I don't believe that high neck manipulation should be banned entirely. It should be reserved for extremely rare situations, and performed under extremely well-controlled conditions. Those situations are so rare as to be out of the range of ordinary DCs, PTs, DOs, or MDs.

- I believe that all involved professions should adopt the same policy of limited use. That policy shouldn't apply to chiropractors alone.

- I don't believe that any supposed benefits outweigh the risks.

- I don't believe there is normally any excuse for using it, especially since other effective methods with less risk are easily available.

- I hope that this blog entry will facilitate an adoption of a limited-use policy, both for the protection of the public, and for an improvement in the standards for diagnostic and treatment methods for problems that somehow involve the cervical spine.


Part 2. Three films worth seeing:

The first film will come as a real shock to anyone who thinks chiropractic is completely safe. The chiropractic industry does all it can to hush this down, but dead patients do tell tales.

Do you want to see a chiropractic leader squirm while he attempts to distort and downplay the evidence against potentially lethal chiropractic neck manipulations? His face just reeks of delusional (dare I say deceptive?) denial as he desperately attempts to avoid admitting the truth.

Man does he squirm!! It's really rather amusing.....;-), but actually it's rather pitiful that he isn't smart enough to admit that chiropractic's diller is hanging out for all to see, when he is publicly presented with the evidence that its zipper is open. He doesn't even have smarts enough to admit it, and then later deny or reinterpret his "admission".

Well, Hagan McQuaid, International Vice-President of the Chiropractic Association of Ireland does just that in this excellent exposé.

There are extensive interviews with key players, including injured patients, surviving family members, doctors, researchers, etc. It is well worth taking the time to see it in its entirety.

RTE News - Prime Time May 5, 2005

  • Dangers of alternative medicine 35 min.

    Presented by Donagh Diamond

    You can watch the entire show, or watch individual reports using the menu below.

  • Dangers of alternative medicine 35 min.

  • Donagh Diamond explores the fascination with alternative medicines and the dangers of chiropractic therapy.

    (If the film doesn't start promptly, just try again. Sometimes it doesn't connect on the first try.)

    You need RealPlayer for it to play.

    Free Download: 14 Day free trial. If you cancel, the basic player is yours to keep!


    The second film:

  • Is A Headache Worth Dying For? 2 min.


    The third video:

  • Adjusting the Joints: Video - PBS

    (Go to the "Adjusting the Joints" section. Then turn on your speakers and watch the video.)

    It was hosted by Alan Alda and features filmed interviews with believers and skeptics alike.


    Part 3. References and articles

  • Spinal manipulation: Its safety is uncertain

    "One gets the impression that the risks of spinal manipulation are being played down, particularly by chiropractors. Perhaps the best indication that this is true are estimates of incidence rates based on assumptions, which are unproven at best and unrealistic at worse. One such assumption, for instance, is that 10% of actual complications will be reported. Our recent survey, however, demonstrated an under-reporting rate of 100%. This extreme level of underreporting obviously renders estimates nonsensical."

    -- Dr. Edzard Ernst, British professor of complementary medicine

    The whole "risk" situation can be likened to an iceberg.

    I am not speaking of the *size* of the self-created iceberg in chiropractic's own back yard fishpond, in relation to the size of other icebergs in Arctic waters, where they are unavoidable.

    While chiropractors would have us believe that the visible portion of the "iceberg" is much smaller than is apparent, more and more scientists, doctors, and patients are becoming aware of the fact that every iceberg has a hidden mass of great size, and - in the case of chiropractic neck manipulations - that mass is apparently much larger than anyone has imagined.

    "Most of the ice in an iceberg is underwater, leaving only the “tip of the iceberg” visible — a fact that is often alluded to in discussions of subjects in which the most important aspects are hidden from view." - (source)

    This is what some chiropractic leaders attempt to do when they deliberately and deceptively deny that the iceberg exists at all. They try to hide, minimize and trivialize any danger. One Danish chiropractic research study on the subject even suggests that cases are overreported, rather than underreported!

    While misreporting occasionally occurs, actual overreporting is a virtual impossibility, since for every case that actually gets discovered, there are many that never get discovered, and are therefore never reported. That's called underreporting, which one (the only?) study (above) found to occur at a rate of 100%. That's massive under-reporting!

    Here is an example of a chiropractor in total denial:

    The stroke connection is a smokescreen to keep the heat off of medicine's dangers and fraud. There is no chiropractic connection to stroke. It is recognized by all major stroke authorities that unlike smoking, weight, various medications, etc., etc., chiropractic is not a cause of stroke. Except of course, in Ontario where krazy pediatrician Murray Katz and angry Polevoy reside. There the populace is dropping dead from chiropractic just by the mere utterance of the word.

    The stroke connection is a fake idea hatched by Katz, probably with the other hate-filled MD's help, to put chiropractic and stroke in the same sentence to scare away patients from chiropractors. Starting in Canada with the help of a neurologist named Norris who admitted under oath at an official inquest that his findings was all BS.

    (emphasis added - PL)

    When chiropractors and their leaders fail to convince us that there are few or no deaths and risks, they try another ruse, and begin comparing the risks associated with unnecessary and avoidable neck manipulations, with the risks associated with brain surgery and other complicated, risky and necessary medical procedures.

  • Chiropractic's Dirty Secret: Neck Manipulation and Strokes

  • "The vertebral artery is shown in the picture to the left. The anatomical problem is illustrated on page 7 of The Chiropractic Report, July 1999. A blood clot formed over the injured area may subsequently be dislodged and block a smaller artery that supplies the brain. Less frequently, the vessel may be blocked by blood that collects in the vessel wall at the site of the dissection." [source]

    "Because of the close anatomical relationship between the vertebral arteries and the cervical spine, chiropractic manipulation or neck rotation may traumatize the vertebral arteries in the neck. The damaged arteries may occlude with thrombus or undergo dissection." source

  • Chiropractic Therapy for Neck Pain May Have High Rate of Adverse Reactions

  • Neck manipulation may cause strokes

  • Spin Doctors I: The Interactive Investigation

  • Spin Doctors II: Manipulating Children

    The following is the best study on the subject to date:
  • Manipulation of the cervical spine: risks and benefits

  • (Richard P Di Fabio, PHYS THER, Vol. 79, No. 1, January 1999, pp. 50-65)

    The graphs are interesting, especially Figure 2, where the type of practitioner was adjusted according to the findings by Terrett.

    DCs were involved in a little more than 60% of all cases of injuries and deaths, and PTs were involved in less than 2% of all cases, with no deaths caused by PTs. Death occurred in 32 cases.

    Before adjusting the numbers according to the findings by Terrett, it looked like DCs were involved in more cases than was actually the case. The revised figures made DCs look a very little bit better, but were still far too high. A casual glance at these numbers could lead to the partially incorrect conclusion, that manipulation, when performed by a chiropractor, is much more dangerous than when performed by other practitioners. No, that would not be entirely correct. They should be seen more as a reflexion of the fact that manipulation is most often performed by DCs.

    Regardless of who performs the manipulation - the more it gets done, the greater the risk. Sooner or later someone is going to get hurt. It needs to be used much more judiciously, by whoever it is that uses it, than most DCs use it today. If a PT or MD were to use spinal manipulation in precisely the same way, extent and frequency that DCs do, they would be exposing their patients to the same risks that chiropractic patients are exposed to every day. The statistics would then reveal more injuries from PTs and MDs.

    While the technique itself is potentially problematic, the attitude of most chiropractors towards it makes it doubly so when applied by them.

    Here is a conclusion from the summary of the article above:

    "The literature does not demonstrate that the benefits of MCS outweigh the risks."

  • Spinal manipulative therapy is an independent risk factor for vertebral artery dissection

  • Neurologic complications following chiropractic manipulation: a survey of California neurologists

  • Woman paralyzed by chiropractic neck manipulation

  • Chiropractic patient suffers stroke


  • Neck911USA

    The man behind this site, John W. Kinsinger, MD, has been named "Chiropractic Enemy #1" by Dynamic Chiropractic, the most widely read chiropractic publication.

    (More: An Interview With John W. Kinsinger, MD - July 7, 2005)

    Among opposers of pseudoscience and quackery, a higher honor is hard to come by. Congratulations to Dr. Kinsinger!

  • Families Against Abusive Chiropractic Treatments (FAACT)

  • Diaphragmatic Paralysis Following Cervical Chiropractic Manipulation : Case Report and Review

  • Stroke victims five times more likely to have visited chiropractor

  • Horner's syndrome and dissection of the internal carotid artery after chiropractic manipulation of the neck.

  • Sudden neck movement and cervical artery dissection

  • Cervical manipulation: How risky is it?

  • Spontaneous vs Traumatic Arterial Dissection

  • "Chiropractors distort info negative to their practice"
    -- Sharon J. Mathiason (mother of a deceased victim)

  • Rand Finds Little Justification for Neck Manipulation

    "A 1996 Rand report on The Appropriateness of Manipulation and Mobilization of the Cervical Spine (Coulter 1996) . . . concluded that only 11.1 percent of reported indications for cervical manipulation could be labeled appropriate. A patient who receives regular, frequent, and totally unnecessary neck manipulation is subjected to greater risk." -- Dr. Samuel Homola, DC., Skeptical Inquirer, Jan./Feb. 2001.

  • Complications of Cervical Manipulation

  • Stroke and Spinal Manipulation - by Preston H. Long, PhD, DC

  • Deadly quacks: Neurologists have long protested the practice of 'highest neck manipulation,' which in some cases has resulted in lethal strokes

  • Chiropractic treatment of the neck can be a risk factor for stroke

  • Chiropractic Tied to Rare Strokes

  • Is chiropractic really complete garbage? I was under the impression it was a legit medical thing

  • What is worth knowing about the Chiropractic profession?


    From a former chiropractor:

    "I have been doing a vascular surgery rotation for the past month, which is part of my postgraduate medical education. During my chiropractic training, when the subject of manipulation-induced stroke was brought up, we were reassured that "millions of chiropractic adjustments are made each year and only a few incidents of stroke have been reported following neck manipulation." I recently found that two of the patients on my vascular service that suffered a cerebrovascular accident (stroke) had undergone neck manipulation by a chiropractor, one the day that sympotms had begun and the other four days afterward. If indeed the incidence of stroke is rare, one M.D. would see a case of manipulation-induced CVA about every 10 years. But I believe I have seen two in the past month! I therefore urge my medical colleagues to question their patients regarding recent visits to a chiropractor/neck manipulation when confronted with patients that present with the neurologic symptoms of stroke. I also urge potential chiropractic patients to not allow their necks to be manipulated in any way. The risk-to-benefit ratio is much too high to warrant such a procedure."
    -- Rob Alexander, M.D.


    Nervous chiro customers....

    Yes, even some cartoonists are aware of the dangers of neck manipulation!


    Part 4. Risks Related to Manipulation of the Cervical Spine:
    Consequences for Evidence Based Practice

    Precautionary Guidelines

    1. Cervical manipulation, especially with rotation (the most commonly used method by chiropractors), should be considered a contraindicated technique.

    2. Manipulation of the upper cervical spine - otherwise known as the "cervicocranium" (the occipito-atlanto-axial region) - should be considered absolutely contraindicated. (This is also the area of the neck most commonly manipulated by many chiropractors, most likely as a hangover from BJ Palmer's "Hole-In-One" theory.)

    3. In principle these guidelines and cautions apply to all involved professions, since it is primarily the technique that is the problem, even though chiropractors are by far responsible for the greatest number of injuries, strokes, and deaths.

    This is a logical consequence of their exaggerated and unwarranted self-confidence and erroneous education, combined with their historically and educationally conditioned overrating of the value of spinal manipulation as a whole.

    4. All healthcare professions, including Emergency Room staff, must be alert to the possibility of injuries caused by spinal manipulative therapy (SMT). The patient's medical history should include questions about possible spinal manipulation within the last 30 days, at the very least.

    Symptoms and injuries can include: headache, dizziness, vertigo, nausea, pain, strains, sprains, whiplash type injuries, Horner's syndrome, Wallenberg's syndrome, permanent or transient paralysis, blackouts, fainting, blod clots to the brain, and death.

    Few of these consequences, especially deaths, are ever identified as results of previous SMT, since autopsies are rarely performed in these cases. Since strokes can occur up to a month - and even later - after manipulation of the cervical spine, a suspicion of any connection is rarely awakened.

    5. When dealing with stroke cases, all MDs - be they general practitioners, specialists, pathologists, or coroners - should routinely examine the patient's (or deceased's) medical history (including interviews with relatives) for any cases of SMT within the previous 2-3 months, including number of times, since each repetition increases the risk.

    If this isn't done, the real extent of SMT induced strokes and deaths will not be exposed, and it will be impossible to institute preventive measures in harmony with quality control principles.

    6. Physical Therapists should encourage patients with such injuries to report them to their own doctors. (I can't be the only PT who has encountered patients with fractured spines, spinal stenosis, herniated discs, paralysis, stable fractures made unstable, severe sprains and strains, torn muscles, and unremitting headaches for years, all as a direct result of a specific chiropractic "adjustment". I have seen all of these injuries, but those who have died haven't come to me or their chiro, for obvious reasons.)

    7. Whiplash patients should never receive cervical manipulation, especially in the acute phase. Hairline fractures are easily overseen on x-rays at this point in time. This may create a false sense of security, resulting in treatment which can destabilize otherwise stable fractures. Such fractures become visible after a short time, often within a few weeks *if* the x-ray is taken from precisely the right angle, which isn't necessarily one of the standard angles.

    No more underreporting

    The massive underreporting (nearly 100%) that is currently occurring must stop. Neurologists and Physical Therapists encounter these cases regularly, but may not be recognizing them. Awareness of the problem will help to bring far more cases to light. They should then be reported to centrally established centers in all lands.

    In Canada the Canadian Stroke Consortium is attempting to uncover the real frequency of these injuries and deaths, since they are much more common than are indicated by chiropractic sources, where there is a vested interest to deny, ignore, and even cover-up, the problem.

    No excuse for manipulation of the cervical spine (MCS)

    There is no excuse (with rare exception) for the manipulation of the cervical spine (MCS), especially in light of several facts:

    1. The majority of such manipulations are not indicated, especially when the problem is located elsewhere in the body. MCS in such cases constitutes gross malpractice and reckless endangerment.

    2. The real problems in the neck, head, and upper extremities, for which treatment of the neck is properly indicated, can be treated

    (a) without the use of MCS,

    (b) using other methods,

    (c) with longer lasting results, and

    (d) with much less risk than is involved with MCS.

    I hope that these precautionary guidelines will become widely disseminated, properly adapted, and then formally adopted by all medical professions which deal with the locomotor system.


    Part 5. The FSU School of Pseudoscience Scandal

    The Florida State University flirt with a chiropractic school is covered extensively on this blog. Fortunately it was defeated.

  • Chiropractic school angers FSU professors

    [Times art]

    To poke fun at Florida State University's bid for a chiropractic school, an FSU professor has created a new campus map. Opponents of the proposed school say more than 500 faculty members have signed petitions against it.

    To explore this issue, just use this blog's Chiropractic Index and check out all the posts preceded by "FSU".

    Here are a few of my very late entries in the debate. I doubt very many people read them before the final decision to drop the curtain on the project:

  • Action Alert! Stop FSU School of Chiropractic -

  • Chiropractic: The Exception Does Not Justify the Rule -

  • FSU Chiropractic School is Unneeded -

  • Why the FSU Chiropractic School Shouldn't Happen -

  • No justification for the existence of chiropractic -