Stay away from chiropractic neck manipulation

From time to time I answer questions from reporters about alternative medicine.  In general, the coverage given my comments has been accurate and fair.  One such accurate a fair representation of my words appeared recently in Readers Digest:

“Over the years, a number of my patients have had strokes after chiropractic neck manipulation. It can cause something called vertebral artery dissection, where the main artery leading to the back of the brain actually splits. Now I tell patients, if you want to see a chiropractor, fine, but never let him touch your neck.”

Shortly after this was published, I began to receive phone calls and letters from chiropractors around the country.  They were not happy.  Here’s a typical example:

Dear [Dr Pal],

Really! You really felt the need to outright lie in a national publication.  “Over the years, a number of my patients have had strokes after chiropractic neck manipulation.”  A number of your patient’s[sic], you lie.  I am willing to bet you have never had a case of stroke caused by chiropractic among your patients.  This issue of stroke and chiropractic has been studied and studied.  It’s been proven that the odds of a stroke after a chiropractic adjustment are infinitesimally small yet you lied.

I was going to quote the studies conducted by the Canadian government and NIH and give you statistics from my malpractice carrier, the largest insurer of chiropractors in the United States to prove you wrong, but you already know you lied.  I don’t have to prove it to you.

Watch next month’s issue of Reader’s Digest to the the publication having to correct its outrageous error in printing your lie.

I don’t know what your motivation was and I really don’t care.  I just wanted you to know that “we” as a profession know you lied and the majority of the public who have benefitted[sic] from safe chiropractic care know your profession has a history of failure and safety that will always surpass my profession by a high margin.

Very truly yours,

Dennis B. Mutell, D.C.

Unfortunately, most of the mail has been about this quality, with statements such as “you lie” and “I would give you safety statistics but I don’t want to.”

I am sure there are better defenders of chiropractic neck manipulation out there, but so far I haven’t heard from them.  The letter basically consists of multiple accusations of lying.  Of course, he has no way to know if I’m lying or not, and if he knows anything about confidentiality, he knows that it would be unwise for me to give him specific numbers of patients.  I can tell you that the number isn’t large, but is certainly greater than one.  I certainly cannot show him charts to prove anything.

And of course, correlation does not prove causation. It may be that these patients, who had vertebral artery dissections shortly after chiropractic neck manipulation represent coincidences.  Plausibility and the medical literature suggest causation however.

He apparently also has an ax to grind with real doctors about our “history of failure and safety.”  That’s an old saw from altmed folks that I’ve addressed many, many times, and I’ll leave it to the archives for now.

The evidence in the literature is quite clear: vertebral artery dissection (VAD), a type of stroke,  is associated with chiropractic neck manipulation.  It is not a common outcome, perhaps 1.5/100,000 manipulations, but it happens.  What’s left is a somewhat subjective decision regarding the risks vs. benefits of the procedure.

VAD is an uncommon type of stroke that affects the back of the brain.  Rather than go into the details, I think we can all agree that strokes are a bad outcome, and that if a procedure carries that risk, it better have a lot of benefit.  For example, coronary artery bypass surgery carries a definite risk of stroke, but the benefits are strong: bypass helps people with heart disease live better and longer, and in many cases saves lives.  The risk of stroke is often less than the risk of not having surgery.

The best literature has failed to show a significant benefit of chiropractic neck manipulation vs. more conservative therapy for the treatment of neck pain.

What we have here is an intervention that carries a small but real risk of a catastrophic complication, whose benefits are unclear at best.  While I don’t recommend chiropractic treatment to my patients, for those who use it I give them this information.  I succinctly tell them that they should not let a chiropractor manipulate their neck.  It’s just not worth it.  I do the same for “mainstream” medical therapies whose risk benefit ratios are not favorable.  It’s just good medicine.

References

Reuter, U., Hämling, M., Kavuk, I., Einhäupl, K., Schielke, E., & , . (2006). Vertebral artery dissections after chiropractic neck manipulation in Germany over three years Journal of Neurology, 253 (6), 724-730 DOI: 10.1007/s00415-006-0099-x

Norris JW, Beletsky V, & Nadareishvili ZG (2000). Sudden neck movement and cervical artery dissection. The Canadian Stroke Consortium. CMAJ : Canadian Medical Association journal = journal de l’Association medicale canadienne, 163 (1), 38-40 PMID: 10920729

Rothwell DM, Bondy SJ, & Williams JI (2001). Chiropractic manipulation and stroke: a population-based case-control study. Stroke; a journal of cerebral circulation, 32 (5), 1054-60 PMID: 11340209

Ernst, E. (2003). Chiropractic spinal manipulation for neck pain: a systematic review The Journal of Pain, 4 (8), 417-421 DOI: 10.1067/S1526-5900(03)00735-1

40 Comments

  1. Nothing makes you more nervous about chiropracters and necks than having a coworker have a stroke mere minutes after walking out of her chiropracter’s office after having neck manipulation…It took her (a late 40s age gal) a year to recuperate.

  2. Rebekah Dekker

     /  September 30, 2011

    When I saw your contribution in Reader’s Digest, first I thought, “Excellent!” Then I thought, “Oh dear, poor PAL will be getting the hate mail now!” Thank you for writing it anyway – I’m sure you knew what to expect.

  3. John Simms

     /  September 30, 2011

    What about cervical manipulation performed by MDs/DOs/PTs? Is it as risky?

    • Unknown. MD’s don’t normally do that sort of thing, and DOs who do are increasingly rare. PTs normally don’t do it these days.

  4. Susan Sharpe

     /  September 30, 2011

    Chiropractors have zero ability to know the condition of a patient’s arteries. Ever read the warnings in front of roller coasters that talk about strokes? That’s due to the jarring of the neck. I do not wish the pain of a VAD on anyone. I am very clear with whoever will listen about the dangers of having someone grab your head with both hands and jerk in one direction…

  5. tim01

     /  September 30, 2011

    Not sure where the 1.5 out of 100,000 was pulled from maybe you could site the source…? A good source to site on this is the Cassidy Study out of Canada which is the largest to date http://www.chiropracticcanada.ca/ecms.ashx/Doc/EntireStrokeStudy.pdf. Malpractice insurance is another good assesment for risk of injury to any treatment modality.

    • maybe you could site the source

      Perhaps you didn’t see the “References” section at the bottom of the post.

  6. I had a VAD about 5 months ago, albiet it was not from a chiropractor. Instead, it was from a fall down the stairs which resulted in my going to a massage therapist and requesting a vigorous neck massage.

    I was healthy and in my late 30’s, perfect cholesterol and blood pressure levels. Stroke was never in our radar, and was not in the ERs radar either due to my perfect health (mirgaines, they kept insisting). Needless to say, I was not diagnosed for 3 days, experienced a major stroke resulting in brain swelling and ICU monitoring. Walked out of the hospital with a walker– lucky I could even walk given the damage to my cerebellum.

    Based on the most recent MRA, my artery has not healed and is, in fact, static– the clot is still there, there is minimal flow, and I have to be very very careful. Which is difficult given that I have a 22 month old who is extremely physical, active, and requires to be picked up (dangerous in my condition).

    I agree with you here– stay away from chiropractors and neck manipulations. The artery in your neck is sensitive and can dissect. If I were a chiropractor, I would just stay away from neck manipulations altogether.

    • APKurt

       /  October 1, 2011

      I certainly feel for patients who suffer a stroke for any reason and I take every precaution in my office to screen for risk factors. I also understand that there are some patients who have suffered a stroke following chiropractic manipulation. The fact remains that any medical intervention carries with it some risk, however small. However, the preponderance of the evidence suggests that manipulation is safer and more effective than other treatment options.

      http://advancedphysicalhealth.blogspot.com/2011/10/choose-treatment.html

      • Then you are clearly misreading the studies.

        • “Then you are clearly misreading the studies” you say? That’s your response? What happened to your need for references? Did you even look at my blog post or read my references? I provided numerous (19) peer-reviewed, indexed references to support my position and I even discussed your references in detail.

          How about this. I challenge you to provide a single quality reference that shows that the standard medical management you provide for your neck pain patients is superior to manipulation. I further challenge you to provide a single quality reference that estimates the risk of death from CMT (estimated at about 0.27 -10 per million) as being higher than the estimated risk of death from NSAIDs (estimated at about 400-2800 per million)?

          Until then I will consider you as suffering from delusion (n): a false belief held with absolute conviction despite superior evidence.

      • David W. Reichard

         /  November 23, 2011

        Unfortunately our daughter was killed by a chiropractor. She suffered Vascular dissection during a manipulation of her neck. She had no prior health issues which would, or could have been contributing factors.

        Grieving in Atlanta

  7. Aaron

     /  September 30, 2011

    As a doctor i like non-bias science based evidence!
    Please read the article and know the facts.

    http://www.chiropracticcanada.ca/ecms.ashx/Doc/EntireStrokeStudy.pdf

    Key Points

    ● Vertebrobasilar artery stroke is a rare event in
    the population.
    ● There is an association between vertebrobasilar
    artery stroke and chiropractic visits in those under
    45 years of age.
    ● There is also an association between vertebrobasilar artery stroke and use of primary care physician visits in all age groups.
    ● We found no evidence of excess risk of VBA
    stroke associated chiropractic care.
    ● The increased risks of vertebrobasilar artery
    stroke associated with chiropractic and physician
    visits is likely explained by patients with vertebrobasilar dissection-related neck pain and headache
    consulting both chiropractors and primary care
    physicians before their VBA stroke.

    • Notice it is from a chiropractic specific site. Please ask/poll everyone who has ever had a VAD and ask if they are willing to take the risk of going to a chiropractor or having any sort of neck manipulation, including neck massages.

      Or, if you would be so gracious as to practice what you preach, it would be very interesting if you would be so willing to get a neck manipulation every week for, let’s say 5-10 years, and then tell me it doesn’t happen to you.

    • PS– Aaron, what kind of doctor are you? A chiropractic doctor? My father, and ENT, my brother in law, a radiologist, my sister, an internist, my best friend, an internist, my fiancee, a MD/PHD in training, and all my medical (MD) friends, as well as my neurologists and primary care physicians, tell me never to get my neck manipulated or touched ever again. It would be interesting to see whether you, as a “doctor” are biased in any way whatsoever. I had a major stroke due to a VAD. 10 days in the hospital in the ICU, throwing up and unable to walk, is enough for me to not only personally stay away from any neck manipulations, but to beg others to stay away as well.

    • Your cited study implies that patients may be suffering symptoms of VAD before the visit to the chiro, that is, they are seeking relief from the symptoms of VAD from a chiro. Since chiropractors have no expertise in this area, they have simply sought out the wrong specialist and delayed proper care. Additionally, they put themselves at risk of worsening their condition by undergoing manipulation.

  8. Mia Stephen

     /  October 1, 2011

    I suffered a stroke during neck manipulation with a chiropractor was 36!!!!

    She dissected my carotid artery!

    This is more common than people are believed to realise!!!! They are not reported cases as chiropractors always settle out of court and put a gagging clause on us!!!!!!

    Well I for one wouldn’t be gagged!!

    Chiropractors cause STROKES and that’s a fact!!!!

  9. Aaron

     /  October 1, 2011

    I dont want to give my opinion. That is bad medicine. I just wanted to give the most recent non-bias and largest study to date on this topic.

    -non-bias- and most recent and largest to date-
    in fact people use information from the research article all the time and leave out certain information to write their own bias anti-chiropractic article. In fact i pulled this article from a post on this article.

    From the *Centre of Research Expertise for Improved Disability
    Outcomes (CREIDO) and the Division of Heath Care Outcomes and
    Research, University Health Network, Toronto, ON, Canada; †Department of Public Health Sciences, Faculty of Medicine, University
    of Toronto, Toronto, ON, Canada; ‡Department of Health Policy,
    Management and Evaluation, Faculty of Medicine, University of
    Toronto, Toronto, ON, Canada; §Institute for Work & Health,
    Toronto, ON, Canada; ¶University Health Network Stroke Program, Toronto Western Hospital, Toronto, ON, Canada; and Division of Neurology, Department of Medicine, Faculty of Medicine,
    University of Toronto, Toronto, ON, Canada.
    Acknowledgment date: August 6, 2007. Acceptance date: December 5,
    2007.
    Supported by Ontario Ministry of Health and Long-term Care. P.C. is
    supported by the Canadian Institute of Health Research through a New
    Investigator Award. S.H.-J. is supported by the Institute for Work &
    Health and the Workplace Safety and Insurance Board of Ontario.

  10. Aaron

     /  October 1, 2011

    I am not stating there are bad chiropractors out there, just as you probably know of some bad M.D.’s. I am actually quite disappointed in the results and with the technique especially to the neck that some chiropractors perform. However, The facts are out there on the safety of the chiropractic manipulation. Another fact is that for the average chiropractor the malpractice insurance is 1000 to 2000 dollars a year. This is seeing anywhere from 50 patients to 200 patients a day for most doctors, some see upward to 1000 a week!!! Now compare chiropractic malpractice insurance costs to the average M.D.’s insurance cost and one can see how safe chiropractic really is. Atleast anywhere from 20,000 to 50,000 on a average, and that is with seeing a significant less amount of patients. This is stone cold hard rational facts. Insurance companies run the numbers and will not lose money on chiropractors or M.D.’s. This large discrepancy demonstrates chiropractic safety. And about 75% of the lawsuits against chiropractors are sexual harassment due to the hands on nature of the treatment and the chiropractors inability to properly explain the treatment.

  11. Aaron

     /  October 1, 2011

    “Study Design
    We undertook population-based case-control and casecrossover studies. Both designs use the same cases. In the casecontrol design, we sampled independent control subjects from
    the same source population as the cases. In the case-crossover
    design, cases served as their own controls, by sampling control
    periods before the study exposures.
    Conditional logistic regression was used to estimate the association between VBA stroke after chiropractor and PCP visits.
    Separate models were built using different a priori specified
    hazard periods, stratified by age (45 years and 45 years)
    and by visits with or without head and neck pain related diagnostic codes. For the chiropractic analysis, the index date was
    included in the hazard period, since chiropractic treatment
    might cause immediate stroke and patients would not normally
    consult a chiropractor after having a stroke. However, the index day was excluded from the PCP analysis, since patients
    might consult these physicians after experiencing a stroke. We
    tested different hazard periods, including 1 day, 3 days, 1 week,
    2 weeks, and 1 month before the index date. Exposure occurred
    if any chiropractic or PCP visits were recorded during the designated hazard periods.
    We also measured the effect of cumulative numbers of chiropractic and PCP visits in the month before the index date by
    computing the odds ratio for each incremental visit. These estimates were similarly stratified by age and by diagnostic codes
    related to headache and/or neck pain. Finally, we conducted
    analyses to determine if our results were sensitive to chiropractic and PCP visits related to neck complaints and headaches.
    We report our results as odds ratios (OR) and 95% confidence
    intervals. Confidence intervals were estimated by accelerated
    bias corrected bootstraps with 2000 replications using the variance-covariance method.
    33
    All statistical analyses were performed using STATA/SE version 9.2.
    34”

  12. Shane

     /  October 1, 2011

    In response to: “When Alternative Medicine Goes Wrong,” (Reader’s Digest, October 2011 Issue)
    Dear Editor,
    The comments by Peter Lipson, M.D. in your recent article “When Alternative Medicine Goes Wrong” (Reader’s Digest, October 2011) related to chiropractic care were inaccurate and misleading to say the least.
    In 2008, an article published by Cassidy et al in the journal SPINE detailed the largest, most inclusive and in-depth study on the occurrence of vertebral artery dissection in history. The study included a review of nearly 110 million person-years for the occurrence of vertebral artery dissection in the province of Ontario, Canada. The researchers, using comprehensive provincial health records data, found no greater likelihood of a patient experiencing a vertebral artery dissection after seeing a chiropractor than after seeing their primary care physician.
    Dr. Lipson’s view is an out-of-date anecdotal perspective that is contradicted by the findings of the Cassidy study. Current thinking with respect to vertebral artery dissection is that rather than being “caused” by the primary care physician or the chiropractor or any other provider, it is more likely that the patient is in the process of dissection when they presented for care. A dissection in process produces neck pain and headache – the reason they initially sought healthcare.
    The “take-away” message is not for patients to avoid cervical spine adjustment by a chiropractor, rather that all providers should be more alert to the possibility that neck pain and headache in rare cases may be the result of a vertebral artery dissection in process.
    Gerard W. Clum, D.C.
    Spokesperson, Foundation for Chiropractic Progress

  13. Shane, Shane, Shane, Shane…

    If you think that article “disproves” the link between chiropractic neck manipulation and stroke, you are sadly mistaken. Our very own Mark Crislip said why not long after the paper was released:

    http://www.sciencebasedmedicine.org/index.php/chiropractic-and-stroke-evaluation-of-one-paper/

    In other words, you’re way late.

  14. If you read the Cassady article carefully, ie more than the abstract, which no one ever seems to do, it does demonstrate an increase in stroke in young people 24 hours after visiting a chiropracter.

    I will quote myself

    “Young people should not have any stroke. In the young, vertebral artery dissection is a common cause of a rare event. It is also the worry from chiropractic neck manipulation. If you could find an effect of chiropractic, it would be in the young. And they do. The people who have an increase in stroke are those under age 45. And it is a big association: odds ratios from 3 to 12.
    The association is most noticeable in the first 24 hours after seeing a chiropractor. Usually if you rip an artery it is symptomatic right away. Again, we do not know if these people had dissection or not. We only know they had stroke of some sort, within a day after seeing a chiropractor. One would predict that if there were an association between chiropractic and stroke you would most easily find it in the young and the effect would be most noticeable in the first day or so after the chiropractic visit.
    And this article confirms this association.
    Note the word association. Association is not causation. You would need a prospective study comparing stoke rates from chiropractic patients vs non chiropractic patients to find causality.
    But if you are less than 45 and visit a chiropractor, there is a strong association between that visit and a stroke in the next 24 hours.”

    from
    http://www.sciencebasedmedicine.org/index.php/chiropractic-and-stroke-evaluation-of-one-paper/

    • I read the article as well. You claim to be evidence based, yet you are clearly biased by your preconceived notions regarding chiropractic.

      You state that in this study, VBA stroke is associated with a chiropractic visit in the preceding 24 hours as having a “big association: odds ratios from 3 to 12”. Yet you fail to mention that the association between VBA stroke and a medical doctor visit in the preceding 3 days is equally large with odds ratios from 9 to 11.

      Therefore, you could equally conclude that if you are less than 45 and visit a medical doctor, there is a strong association between that visit and a stroke in the next 3 days. I don’t recall reading that statement anywhere in your post or on your website.

      But, you might ask, how could a medical doctor cause a stroke? Are you unaware the most commonly prescribed treatments for neck pain and headaches from medical doctors are NSAIDs? If you were as familiar with the evidence as you claim to be, you would know that there is a very strong association between NSAID use and stroke. When compared to placebo, NSAID use is associated with a 42% relative increase in the incidence of serious vascular events. Further, NSAIDs are associated with a two-fold proportional increase in myocardial infarction (rate ratio 1.86, 1.33 to 2.59; P = 0.0003).

      Because I know you are interested in “evidence-based medicine” and you’re not in the least biased, I look forward to your upcoming article titled “Medical doctors cause as many strokes as chiropractors and far more heart attacks.”

      Ref:
      Kearney, P.M., et al., Do selective cyclo-oxygenase-2 inhibitors and traditional non-steroidal anti-inflammatory drugs increase the risk of atherothrombosis? Meta-analysis of randomised trials. BMJ, 2006. 332(7553): p. 1302-1308.

  15. So your argument is, since MD’s cause strokes, it is ok for chiropracters to do the same?

    Or is the conclusion doc should give fewer nsaids and chiropracters should not manipulate necks?

    I would tend towards the second.

    • That is certainly a more rational thing for you to say. Thank you. However, my argument is that you have gone out of your way to perpetuate an irrational fear of chiropractic while remaining completely silent about similar (and often greater) risks in your own profession. If you are going to claim to be “evidence-based” you can’t ignore evidence that doesn’t agree with your preconceptions. This is known as “confirmation bias”.

      I can agree that both professions need to consider risks when prescribing any treatment. For instance, a longer course of NSAIDs is likely to carry greater risk than short-term NSAID use. And, an acute neck complaint is perhaps more likely to carry risk of VAD. Further, the research supporting chiropractic manipulation for chronic neck pain is more convincing than for acute pain. Therefore, a rational approach based on the evidence would be for chiropractors to perform fewer manipulations on acute neck pain patients and for MDs to refer for more of their chronic neck pain patients for chiropractic manipulations. This would be “evidence-based”.

      Because I am an evidence-based practitioner, I will be applying more mobilization procedures and fewer manipulations in my acute neck pain patients. I expect that you, as an evidence-based practitioner, will be referring more of your chronic neck pain patients for chiropractic manipulation. The evidence suggests that this will decrease their risk and improve their outcomes.

      Evidence:

      A literature review of quality clinical trials (scoring above 11.5 on the Amsterdam-Maastricht Scale) found that “There is moderate- to high-quality evidence that subjects with chronic neck pain not due to whiplash and without arm pain and headaches show clinically important improvements from a course of spinal manipulation or mobilization at 6, 12, and up to 104 weeks posttreatment.” Vernon, H., K. Humphreys, and C. Hagino, Chronic Mechanical Neck Pain in Adults Treated by Manual Therapy: A Systematic Review of Change Scores in Randomized Clinical Trials. Journal of manipulative and physiological therapeutics, 2007. 30(3): p. 215-227

      In a study evaluating the long-term benefits of medication (NSAIDs), acupuncture, and spinal manipulation researchers concluded that: “In patients with chronic spinal pain syndromes, spinal manipulation, if not contraindicated, may be the only treatment modality of the assessed regimens that provides broad and significant long-term benefit.” Muller, R. and L.G.F. Giles, Long-Term Follow-up of a Randomized Clinical Trial Assessing the Efficacy of Medication, Acupuncture, and Spinal Manipulation for Chronic Mechanical Spinal Pain Syndromes. Journal of manipulative and physiological therapeutics, 2005. 28(1): p. 3-11.

      A clinical trial comparing manipulation with acupuncture and medication found that: “In patients with chronic spinal pain, manipulation, if not contraindicated, results in greater short-term improvement than acupuncture or medication.” The highest proportion of early (asymptomatic status) recovery was found for manipulation (27.3%), followed by acupuncture (9.4%) and medication (5%). Giles, L.G.F. and R. Muller, Chronic Spinal Pain: A Randomized Clinical Trial Comparing Medication, Acupuncture, and Spinal Manipulation. Spine, 2003. 28(14): p. 1490-1502.

      A literature (Cochrane) review from 2004 found that mobilization and/or manipulation when used with exercise are beneficial for persistent mechanical neck disorders. Gross, A.R., et al., A Cochrane Review of Manipulation and Mobilization for Mechanical Neck Disorders. Spine, 2004. 29(14): p. 1541-1548

      A review published in the British Medical Journal concluded that, “Manual therapy (spinal mobilisation) is more effective and less costly for treating neck pain than physiotherapy or care by a general practitioner.”Korthals-de Bos, I.B.C., et al., / Cost effectiveness of physiotherapy, manual therapy, and general practitioner care for neck pain: economic evaluation alongside a randomised controlled trial / Commentary: Bootstrapping simplifies appreciation of statistical inferences. BMJ, 2003. 326(7395): p. 911-914.

  16. The issue at hand is not the complications with NSAIDS or the treatment of neck pain, but whether or not chiropractic is associated with stroke. I also do not mention the dangers of cars, of spiders and bathtubs.

    the Cassidy reference, touted as demonstrating safety, suggests otherwise in the less than 45 year group, a finding confirmed by others:

    “Results for those aged <45 years showed VBA cases to be 5 times more likely than controls to have visited a chiropractor within 1 week of the VBA (95% CI from bootstrapping, 1.32 to 43.87). Additionally, in the younger age group, cases were 5 times as likely to have had ≥3 visits with a cervical diagnosis in the month before the case’s VBA date (95% CI from bootstrapping, 1.34 to 18.57). No significant associations were found for those aged ≥45 years."

    http://stroke.ahajournals.org/content/32/5/1054.abstract

    Biologic plausibility and the preponderance of the information to date suggests the association between neck manipulation and stroke is causal and come reasonably close to fulfilling Hills criteria
    http://www.drabruzzi.com/hills_criteria_of_causation.htm

    The risk is small, but there, estimated at

    "The frequency of adverse events varied between 33% and 60.9%, and the frequency of serious adverse events varied between 5 strokes/100,000 manipulations to 1.46 serious adverse events/10,000,000 manipulations and 2.68 deaths/10,000,000 manipulations."
    http://www.ncbi.nlm.nih.gov/pubmed/19444054

    Drugs get black box warnings or are pulled from the market with this kind of safety profile, depending on what is being treated.

    Given that there is a strong reason to worry about stroke with neck manipulation, then treatment depends on the risk benefit. The risk of catastrophe is low, but greater than the risk of having neck pain. The risk of the therapy has to be less than the risk the disease. I would never give chlorampenicol for meningitis as there are safer alternatives without the 1 in 40,000 aplastic anemia. If it were the only drug available, then it would be an easy decision, since the meningitis is almost 100% fatal.

    Given the alternatives and risks, my assessment of the literature I could not ethically recommend neck manipulation for my patients. Or chlorampenicol for meningitis. Or gemafloxicin for pneumonia. Or vertebralplasty for spine compression. Etc etc.

  17. “I also do not mention the dangers of cars, of spiders and bathtubs.” That’s cute. I was under the impression that we were discussing the relative risks and benefits of the two most common treatments for neck pain.

    You claim that chiropractic is unsafe and less efficacious than alternative treatments. I have provided solid evidence that, at least for chronic neck pain, manipulation is superior in terms of efficacy and safety when compared to NSAIDs. Despite your claims to be “evidence-based” you have chosen to ignore the evidence. If you have an equal amount of evidence to prove otherwise, I’d love to hear it. So far you haven’t provided any. I can only assume you don’t have such evidence or you would not have resorted to bringing up spiders and bathtubs. This is what people do who are experiencing cognitive dissonance, they bring up fanciful ideas to distract from the discussion at hand.

    You say, “Drugs get black box warnings or are pulled from the market with this kind of safety profile.” Is that so? I call bullsh…. Let’s use the numbers you just provided of 2.68 deaths per 10 million. Just for fun, I’ll even spot you a factor of 10 and assume that the risk of death from chiropractic manipulation is 10 times higher than the number you gave. So let’s go with 2.68 deaths per 1,000,000 which is a higher estimate than any of the numerous references I provided. I challenge you to provide a single peer-reviewed reference that shows the risk of death from ANY drug you prescribe for ANY condition that carries a lower risk of death than 2.68 per 1,000,000.

    Let’s keep this discussion to actual evidence. If you’re just going to make stuff up then we can’t have an intelligent conversation.

  18. Aaron

     /  October 3, 2011

    The study “http://stroke.ahajournals.org/content/32/5/1054.abstract” biggest flaw is that it left out a control group of patients seeking care from practitioners other than chiropractors. This is huge considering the facts that VBAs are more and more considered the result of cumulative events over an extended period of time rather than recent traumas or recent visits to the chiropractor, and a patient who is either seeking care from either a chiropractor or another practitioner for neck pain has obvious and rational greater risks of having a VBA. This is clearly shown in a more recent and larger study http://www.chiropracticcanada.ca/ecms.ashx/Doc/EntireStrokeStudy.pdf. I can certainly agree that strokes in young patients are unfortunate but the numbers for the people in this age group are the same whether visiting a PCP or a chiropractor for there health care!!!! Please lets not even try to associate the other risks of visiting a PCP and the drugs they prescribe!!!!

  19. Trovafloxicin was pulled from the market for 140 cases of severe hepatitis after 2,500,000 prescription with 5 deaths.

    Ketek got a black box warning for 14 cases of hepatitis per 10,000,000 prescriptions or 167 cases of hepatitis (all hepatitis, not severe and liver failure) per million patient years, most of whom did not die.

    Compared to an estimated 5 strokes per 100,000 manipulations.

    • I’m sorry but I think somehow your peer-reviewed references were not included in your post. Unless you provide peer-reviewed evidence, I will have to assume you just made those numbers up.

      5 strokes per 100,000? We both quoted the same reference and arrived at agreed-upon estimate of 2.68 deaths per million.

      Let’s keep our discussion to the evidence please.

      Plus you have still not addressed my point that you failed to mention that the association between VBA stroke and a medical doctor visit in the preceding 3 days is equally large with odds ratios from 9 to 11.

      My peer-reviewed references supporting my position that current scientific evidence estimated death from manipulation is less than 2.68 per million:

      Haldeman, S., et al., Arterial Dissections Following Cervical Manipulation: The Chiropractic Experience. Canadian Medical Association Journal 2001. 165(7): p. 905-906.

      Rothwell, D.M., et al., Chiropractic Manipulation and Stroke : A Population-Based Case-Control Study. Stroke, 2001. 32(5): p. 1054-1060.

      Your references, please?

  20. Aaron

     /  October 3, 2011

    1 out of 100,000….i doubt a chiropractors malpractice insurance would be as low as it is with those states. Ok, lets see where we got this number. Oh, a “a systematic review.” Oh, where we pulled out articles on “All articles that reported adverse reactions associated with chiropractic were included irrespective of type of design. The outcome measures were the type of adverse events associated or attributed to chiropractic interventions and their frequency.” And how did we get the information we wanted to review and support what we wanted to say in our review? “A total of 376 potential relevant articles were identified, 330 of which were discarded after abstract or complete article analysis. The search identified 46 articles that included data concerning adverse events: 1 randomized controlled trial, 2 case-control studies, 7 prospective studies, 12 surveys, 3 retrospective studies, and 115 case reports.” they discarded 330 relevant articles out of 376 for no stated reason??? And they only searched for all articles that reported adverse reactions associated with chiropractic???? really??? I thought we were having an educated discussion on this topic using scientific based research!!!!! I understand your personal opinion on the matter, but please use valid numbers based on “good” non-bias scientific based research please.

  21. Aaron

     /  October 3, 2011

    Don’t get me wrong. I’ve seen crappy “scientific articles” done by chiropractors too. But we as professionals have the responsibility to research where we pull our data from before we use it to reflect our personal opinion which should be based on non-bias peer reviewed science based research without leaving data out anyway. And we really have the responsibility to the people we serve as doctors not to pull and plug data that supports one way while neglecting to mention the data that supports the opposition. This should not be about being right, it should be about the giving the best care to the patients. “http://www.ncbi.nlm.nih.gov/pubmed/19444054” is about the worst article i have seen yet. And that is saying something!

  22. Veronica.

     /  October 18, 2011

    I just got out of the hospital from having this happen to me, I had went to my chiropractor for neck pain and than the pain got increasingly worse i went to my local er where i was xrayed and than cat scaneed and they found that he had dissected my artery. I than was transfered to the neuro icu and than had to spend six days in the icu hooked up to heperin and taking oral blood thinners, I was given 7 MRIS and 5 Cat scans. Was finally allowed to leave on oral blood thinners, having blood work every few days. MRIs 1,3,6 months to follow up. All because I was told that going to the chiropractor will help. I smell a lawsuit.

  23. alan wellington

     /  February 8, 2012

    My step son recently had a neck adjustment and now is in hospital after a stroke.
    No feeling in the left facial region no feeling in the left leg and a weak left arm.
    He is a career policeman wir=th a doubtful future.

  24. Pippa Thorpe

     /  March 4, 2012

    I had a neck manipulation for the first time last week. It was just what I needed. I had been suffering with a neck injury for four years hoping it would heal itself, and the headaches had become almost constant. After the neck manipulation I felt instantly better, and still feel great. It IS the right solution sometimes. I don’t think anything else would have fixed my problem.

  25. Alex D.

     /  May 22, 2012

    This risks are real, and very dangerous. I had upper cervical manipulations done on me. A few hours after I had tingling in the left face, along with numbness. Although that lasted a few hours, the next few weeks I had terrible muscle spams.
    Everyone should stay away from neck adjustments. Not worth the risks, and the benefits are only temporary. Yes the risks are “low”, but they are dangerous risks. Stretching with massage is all anyone needs it they have neck discomfort.

  26. Jason

     /  July 5, 2012

    I had a serious spinal injury from a football accident, the hospital referred me to an orthopedic surgeon who told me the only option I had was to have a spinal fusion surgery. Luckily I talked to another MD who suggested I see a chiropractor first and see if he could help. I’m now 18 years removed from the injury (migraine headaches having been a part of the complications) and I have ZERO pain, numbness, or muscle spasms.

    I hear what everyone here is saying about having had these horrible experiences, but maybe if you go to any doctor (MD or chiropractor or whatever) for neck or headache pain, you should be screened to see if you have this risk or if this is where your pain is coming from, instead of just claiming that MDs or chiropractors are the cause of all our problems. My father had a stroke after being given blood thinners, a VERY regularly prescribed drug and one that was properly prescribed by his doctor. And, apparently the risk for blood thinners is a lot higher than for neck adjustments. Just saying. Instead of eliminating one treatment because it has a bad side effect 1 in a million times or whatever (which would eliminate nearly every medication and surgery) we should find a way to;

    A. Make it safer
    B. Have MDs and chiropractors work together if they can both behave themselves, grow up, and stop trying to stick their tongues out at each other.

    Luckily for me, I found an MD and chiropractor that worked together and I’m 100% better, was even able to join the military after an accident that left me with weakness and numbness in both arms and legs. See what happens when everyone stops worrying about their own ego and starts worrying about how best to help the patient?

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