Did chiropractic manipulation of her neck cause Katie May's stroke?

This story illustrates how difficult it is to determine whether or not chiropractic is involved in strokes following both injury and neck manipulation. I'm glad you pointed out the nuances of this case and that we can't be certain which was responsible. It reminds us to question our own reactions, just as much as we question the quacks.

I've seen 2 carotid artery dissections in young women after fairly mild injuries- one was from a flexion/hyperextension injury at an amusement park. The other was from a severe coughing fit.

I'm sorry for the friends and family of Katie May.

@Todd: What I was surprised to learn in my reading for this post is that the incidence of spontaneous carotid artery dissections in young people is higher than I would have guessed.

Orac,
Following this blog for a few years, I've seen the occasions when you have examined the details of a number of unfortunate deaths of young people and been castigated by those that see you as an threat to their belief in alternative medicine. I humbly suggest that in future, any such attacks on you can be met by directed them to this post so they can see how much you are led by the evidence when others might have just leapt to an easy conclusion that chiropractic did it.

This post is a true example of what it means to be a skeptic. Sorry if I sound sycophantic but I truly admire what you wrote.

"For instance, one study of patients under 45 found that those who had this kind of stroke were more than five times more likely to have visited a chiropractor during the preceding week than control patients."

1) This is a very specific sub-case, " those whose "Most recent cervical chiropractic visit," was within one week. 2) the numbers directly don't indicate anything staggering, just that one very small percentage of risk was bigger than another...

Doesn't this just obfuscate more than clarify or indict?

Whether going to the chiropractor caused her stroke or not, we may not know. However, going to the chiropractor certainly did not (and could not) prevent that stroke. We also don't know if the problem would have been caught if she had gone to the ER for her pain instead, but there was certainly a much better chance of it happening there than in the chiros office. Especially after the first adjustment didn't help, she needed the services of a real doctor.

Whether or not it was the chiropractic, hopefully the publicity will caution people, especially with neck injuries.

While at medicare.gov yesterday, I saw this:

Medicare Part B (Medical Insurance) covers manipulation of the spine if medically necessary to correct a subluxation when provided by a chiropractor or other ...
https://www.medicare.gov/coverage/chiropractic-services.html

And this (for clarification )
subluxation (when one or more of the bones of your spine move out of position) when provided by a chiropractor or other qualified provider.

I actually am curious just what is meant by “out of position”?

@#6 MarryMeMindy-

It might have been caught in the ER, but these presentations are real zebras. Unless someone did a CT angio of the neck, it's unlikely to be caught. It's an easy miss, and unfortunately one that can have a catastrophic outcome.

Yeah, I pointed that out in my post. Given how rare these are, it's hard to fault anyone for not doing a CT angio, although a carotid duplex might also have picked up the intimal tear, particularly if a clot had already formed.

And this is where it is best to have ER docs doing it, because the one thing ER docs do better than others is to look for the worst. When Arnold goes to the ER with a headache, they are going to make sure it's not a tumor.

How long does pain from a "pinched nerve" typically last? WebMD says that if the pain persists or is severe, see your doctor. But what counts as persistent?

" Of course, there are some spinal conditions for which manipulation is an effective treatment" Huh? I don't think so.

Um, yes, I do think so. Physical therapists frequently do spinal manipulation. They just do it in an evidence-based fashion—unlike the vast majority of chiropractors.

@ Marry Me, Mindy: How long does pain from a “pinched nerve” typically last? WebMD says that if the pain persists or is severe, see your doctor. But what counts as persistent? IANAD, but I've had "trigger point" pain that has lasted for 2-3 weeks before I had it treated...(yes, I'm stubborn). Persistent pain is generally considered to be more than 2-3 days at the same level that nothing is relieving or is worsening.

Orac said "Um, yes, I do think so. Physical therapists frequently do spinal manipulation. They just do it in an evidence-based fashion—unlike the vast majority of chiropractors."

Yeah, you don't know what you're talking about. Chiros are better educated and more skilled in manipulation than PTs. 80% of chiropractors are evidence-based these days. May want to learn more about what you're actually talking about.

Marry me, Mindy, she did go to the ER and they released her so.
.

@Stanimal032: yeah, if you go to Science-Based Medicine, you'll see lots of posts about how "evidence-based" most chiropractors are. And Reasonable Hank has quite a good series about many Australian chiros and their "evidence-based" practices, too. The only evidence most of them believe in is what fills their wallets.

By the way...you don't happen to be Stan Mrak, do you?

she did go to the ER and they released her so.

Yes, she apparently initially went to the ER. I am talking about her lack of followup care. Not even going to the chiro the first time, but more the second.

If it was still hurting that bad after the chiro adjustment, that's when it's time to get back to the ER and say, "That didn't work."

If you cringe when you hear the pop during the violent twist given to the neck, you’re not alone.

I'd guess that the *popping* is the same mechanism as cracking knuckles -- That is, it is pulling a vacuume and producing cavitation in the synovial fluid of the joint.

In the 1970s, most experts thought it had to do with the collapse of air bubbles in the synovial fluid that lubricates joints. But new evidence suggests the sound is actually caused by precisely the opposite: the formation of a gas-filled cavity when the bones in joints stretch apart.

http://www.wired.com/2015/04/watch-gross-mri-knuckle-cracking/

^^That's probably not the best link, but it does sport a knarly, knuckle video demonstrating that the 'crack' happens upon collapse of the bubble.

Interestingly, I do find that after the induced popping of the whole spine by somebody holding a pole above and *lightly walking* down it does seem to relieve various feelings of limbs tingly, 'falling asleep'. -- For me, this pinched nervedness used to occure after a set amount of time on the interstate; This would yeild a consistant distance traveled every day before my throttle hand went dead and I'd have to raise and swing it around some.

speaking of *lightly*,

Lohse and his colleagues recorded a flash of light that occurs when the bubble collapses.

The flashing phenomenon is thought to be similar to sonoluminescence, in which bubbles that are in a liquid driven by a strong sound field emit light. The researchers have dubbed the shrimp activity shrimpoluminescence.

http://news.nationalgeographic.com/news/2001/10/1003_SnappingShrimp.html

^^ Whatever is going on inside the small bubbles must be pretty violent because the light given off is into the ultraviolet -- I wonder if someone's joint fluid were replaced with all tritium-based waters... never mind.

addendum:

I must wonder if some relief is derived of the in situ popping serving as a microscopic, local lithotrypter.

Medicare Part B (Medical Insurance) covers manipulation of the spine if medically necessary to correct a subluxation when provided by a chiropractor or other …

So if a chiropractor provides a subluxation, creating the medical necessity to correct it, Medical insurance will cover the cost of repairing the chiropractor's incompetence?

Perhaps I am reading this too literally.

Currently in the state where I practice (evidenced based chiropractic), we have two specific legal cases currently in the system in regards to spinal manipulation of the cervical spine. In both cases, a stroke occurred two days afterward. In both cases, the courts have not been able to demonstrate that the adjustment was or was not the factor that caused it to occur. AND in both cases, the adjustment was performed by non-chiropractors. An MD and a PT (which do not even have the legal right in the state to do so) to be exact. I enjoyed the article since I am very open to others opinions of my profession. But you spent the entire article with the sole purpose of wanting to lead people to believe that the adjustment caused the stroke. The whole thing is saying it was the factor and then you throw in the last line "well we can never know for sure". This is a well written article and nice opinionated discussion.

Because there is a evidence that chiropractic neck manipulation could cause stroke, wouldn't it make sense to do some sort of imaging of the vertebral and the carotid arteries prior to any manipulation? It could protect both the patient and the chiropractor. Shouldn't this be mandated?

If she had the symptoms of a carotid artery occlusion we can''t say for sure exactly what caused the stroke without a cerebral angio or autopsy. Both the carotid and the vertebrals connect through the circle of Willis and it has large person to person variablilty. So a a plaque can migrate to another area and a moderate restriction of one artery, say the carotid, can be asymptomatic until another, say the vertebral, becomes compromised.

"wouldn’t it make sense to do some sort of imaging of the vertebral and the carotid arteries prior to any manipulation? It could protect both the patient and the chiropractor. Shouldn’t this be mandated?"

Adding expensive imaging studies to supposedly make an unnecessary and (in a low but alarming percentage of cases) hazardous maneuver safer doesn't sound like a proper solution to me. (also, who would allow a chiro to touch their neck if they acknowledged potential for harm in that overt a fashion?)

I agree that there's no good way for outside observers (or even probably for an M.E.) to tell if the catastrophic outcome in this particular case was due to the initial neck trauma, or to creation of or worsening of existing injury to the carotid artery by chiropractic manipulation.

I question the justification for doing any forceful "adjustment" maneuver in the event of acute spinal injury, whether to the neck or back. It sounds like an invitation for trouble. We don't know exactly what chiropractic intervention was done in this instance, but I cringe at the thought of a neck "popping" adjustment being performed on someone with a recent history of cervical trauma.

In the 1970s, most experts thought it had to do with the collapse of air bubbles in the synovial fluid that lubricates joints. But new evidence suggests the sound is actually caused by precisely the opposite

Gilbert, you are under-estimating the laziness of Wired journamalists, and their willingness to make stuff up. The original PLoS article does not say "most experts"... the authors cite cavitation as the original, default explanation for knuckle-cracking, but then note a couple of dissidents coming up with their own bubble-collapse theory in 1971. Hence lack of consensus; unanswered questions; yadda yadda, as a rationale for the authors spending MRI time on a IgNobel-prize-worthy project.

Some mook at Wired turns that into "scientists have never really understood the physics behind..." and "most experts thought it had to do with [straw-man wrong theory]" because spreading ignorance is central to his job description.

Granted, herr doktor bimler #27. Stil, it is more plausible than what my 3'rd grade teacher chastised us with back in the day -- "Stop that right now! Don't you know that you're breaking calcium bindings in your knuckles and will give yourself crippling arthritis by keeping that up? ... Are you chewing gum?"

I can almost guarantee that "individual" is indeed the troll from Science-Based Medicine.

I have been going to my chiro for 30 years. If not for him I believe I would be in bad shape after being hit with a guy on a surf board right on my neck. Did my chiro adjust my neck then? Absolutly not! He took exrays and we did some therapy to help the pain and it was a while before he did manipulations. Now years late he does not manipulate my neck ....he said in the condition of my neck it could cause a stroke. He uses an activator but knows how to use it and it gets my neck back where it belongs. Sometimes when my hip or sacrum slip, nothing takes the pain away but my chiro adjustments. There are good chiros and bad chiros, good doctors and bad doctors, good cops and bad cops! It's up to you to do your homework and find an honest one who knows what they are doing and where YOU come first not their pocket book!

And with all of that said....Chiropractic physicians have seen over 30% of the entire population with over 100million cervical adjustments performed every yr and continue to have the lowest malpractice Insurance premiums of any health care practitioner out there. Critical thinking (no, common sense) tells an upright bipedal that this would NOT be the case if Chiropractic had even an inkling of a possibility of causing a stroke. No evidence to prove this without being legitimately rebutted by evidence to the contrary......Ridiculous!!

@Jacki Hawes - as long as your chiropractor sticks to doing things he can actually do that is all to the good. I would suggest being cautious if he starts discussing cures for things other than back and spine conditions.

It wouldn’t be too hard for me to ask a “friend” to compare the IP address...

Boggles the mind that the most of the posers haven't figured this out yet.

We must wait for the medical professionals to make their determination We cannot speculate without their medical diagnosis Let's be compassionate to her grieving family and get educated to prevent this from happening again and causing such a tragedy

Good article. No blame on chiropractic, no blame on the medical doctors who didn't catch the potential problem before she went for the chiropractic adjustment. I will point out that chiropractic is used by millions of people worldwide with little malpractice compared to conventional medicine. You may check yourself that more than 60,000 deaths in the US are due iatrogenic cause. Iatrogenic means "induced by medical treatment". But most of us will not take on medical doctors or conventional medicine and suggest that they are quacks because they are helping many others. As far as I know, chiros are far better trained in human anatomy than medical docs. That's why many medical docs go for an specialty in one organ or system. Osteopaths are medical docs who manipulate the spine and neck, but their training hours is far less than chiros. For the most part, health providers regardless of the field of practice do their best to help people, but sometimes fatalities occur. Good article, though. My prayers go to the family for this irreparable loss.

What concerns me is that there are lots of people who believe that seeing a chiropractor is the same as seeking medical attention. I hope she did go to the ER and not straight to a chiropractor believing that they are medical doctors as people are led to believe by their self imposed title of Dr.

Another recent tragic case, this one involving stroke secondary to vertebral artery damage:

http://kdvr.com/2014/11/06/30-year-olds-death-linked-to-routine-adjustm…

The chiro excuses and justifications in that article sound familiar.

Huh. Appeal to popularity seems to be the crowd favorite this time around.

RON@38

...believing that they are medical doctors as people are led to believe by their self imposed title of Dr.

It always bothered me that 'doctor' is not a protected title in the US. Not that that would make much of a difference. 'Physician' is protected and that doesn't stop chiros without the requisite qualifications from calling themselves chiropractic physicians.

Not that that would make much of a difference it would solve the problem.

Although they exist I see far fewer unqualified chiropractic/naturopathic physicians than DC/ND's.

"‘Physician’ is protected and that doesn’t stop chiros without the requisite qualifications from calling themselves chiropractic physicians."

One of my favorites is "chiropractic neurologist".

I would take this article more seriously if the author wouldn't use the phony word "embiggen." It was invented for a Simpsons episode. The real word is "enlarge."

Chiropractic physicians have seen over 30% of the entire population with over 100million cervical adjustments performed every yr and continue to have the lowest malpractice Insurance premiums of any health care practitioner out there.

Not true in Canada, at least. A chiropractor pays about the same malpractice premium as an office-based family doctor. Citation pending later tonight.

Chiropractic physicians have seen over 30% of the entire population

Population of where? That sounds high for the U.S., but I don't have the tools to easily reduce the 2012 NHIS "COM_EVER" data (and IHIS doesn't include these in the SDA, unlike 12-month utilization).

with over 100million cervical adjustments performed every yr

With 7.6% utilization, for the U.S. population that would mean that more than 1 in 4 chiropractic visits entail cervical adjustment. Is there a math section in the NCBE exams?

I'm so disappointed in you Orac, you missed a perfectly cromulent opportunity.

^ Oh, wait: more than four cervical adjustments per chiropractic visit.

All of these people who show up to defend the obviously quacky chiropractic cracking make me extremely tempted to gin up some kind of alt med nonsense, since it obviously won't matter how many times it gets disproved. Oil may fall, stocks might crash, but apparently stupidity is a non-stop money maker.

It always bothered me that ‘doctor’ is not a protected title in the US.

It is. Varies by state.

My question is whether her follow up visits to a chiropractor led to important signs being missed.

The sympathetic innervation of the pupil runs down to the T1 sympathetic ganglion, and then back up along the internal carotid artery which is envelops with a plexus.

If you have disturbance of the ICA it can potentially cause ipsilateral miosis (pupil constriction) though it is more classically seen with ICA aneurysm than stroke.

If she had developed a pupillary defect, one wonders had she gone back to the ER instead of a chiropractor if this could have been caught.

http://image.slidesharecdn.com/pupil-141114005351-conversion-gate01/95/…

Perhaps I have missed something, but in a young woman like this I would wonder about a hemorrhagic stroke from a ruptured aneurism. Less likely, but still possible (especially if this poor woman had been using OCPs, or even been pregnant, and moreso if a smoker) could be a DVT and a paradoxical embolus - patent foramen ovale not that uncommon. I assume the information we have is not informed by postmortem results (and really, at the end of it all, is it really our business?)

A completely informed nuanced and intelligent examination of this tragedy you will find no place else. I became aware of this vertebral artery tear chiropractic caused stroke scenario when working on a neurologic floor in about 2010. I have had a curiosity for rare trauma injuries since I learned about Commotio Cordis: to think a baseball could kill a healthy child if the ball hits the chest in a 30 millisecond window before the peak of a T-wave is just a mind blowing anomaly of rare coincidence. Yet it is completely true and scientifically proven. (S. M. Yabek M.D. Stuart Berger M.D.) One look at the anatomy of the vertebral artery as it snakes its way through the C1-C2 vertebrae and it is clear a HVLA manipulation of the cervical neck is exactly -40% of a hanging- To put it in terms that a Chiro-quacker might understand: it is what it is. "It is what it is" rates as my least favorite phrase because I notice it seems to be the favored phrase of the least intelligent. My observation is completely anecdotal but doesn't that perfectly explain the science behind "subluxation" and the general Quackery of Chiropractic "Doctors": Anecdotal. Read anything written by these Chiro=quacks and you will see defensiveness, flawed thinking, and bad science. But why would you expect anything less from a pseudoscience based on a guy who was a magnetic healer and spiritualist.

Ask yourself this question. Why does a chiropractor make you sign an indemnity waiver?
This sounds more like a dissected artery causing a stroke than a blocked carotid. In my work i see strokes aplenty frequently after chiropractic manipulations. Yet you cannot prove anything as who is to say it wouldnt have happened anyway? Thats what they argue. Seems like tgere are an awful lot of "coincidences" though. Time for more scrutiny. Neck manipulations should carry a regulated warning. Most chiros that ive met just gloss over the issue when asked, dont explain anything and when asked about risks just get snotty and refuse to "treat" you if they cant crunch your neck.

I am a chiropractor of seven years in private practice. I will have to admit that I agree totally with this article. I might point out however, that not all of us are quacks and properly limit ourselves to low risk musculoskeletal therapy. And some of us even use common sense. One of the biggest problems in this case was that the chiropractor manipulated her at all after a recent neck trauma. I think one of the real issues with neck manipulation associated stroke is under reporting due to the time lag between events. Also, I think in some of these cases they are similar to Mays case in there is an existing problem and the manipulation makes it worse. I have had two potential cases where the client was showing neurological deficits associated with vertebrobasilar insufficiency following neck trauma and a careful screening along with cranial nerve testing meant they were promptly referred for medical care and likely saved their lives.
Just saying that at least some of us are diligent, well trained and responsible ...

"Chiropractic physicians have seen over 30% of the entire population"

Pretty sure that isn't the case here: where are we talking about? Citation needed and all that?

And the bit about malpractice etc insurance premiums: mebbe, just mebbe, those who use chiros and the like are less likely to sue as they are True Believers who cannot/will not see that a chiro could ever do anything wrong?

And as for chiros studying more anatomy than a real medic: has the bod who suggested that ever looked at a medical school curriculum? Or seen how long medical training is before the "specialising in one organ"? Especially as many of the basic principles of chiro have no basis in generally recognised anatomy or physiology...

i have been to chiros all my adult life, always had my neck done. 3 yrs ago, had my neck manipulated. Next day, woke up deaf in my left ear. Had a basilar artery stroke otherwise known as a labyrinthine infarct. Luckily, only a Teeny Tiny artery involved

Please can we stop the direction just toward chiropractors. HVLA manipulation in Australia is performed by physiotherapists, osteopaths, naturopaths and even general practioneers that have done "workshops" in the area. The techniques are very similar and have the same inherent risks.
Unfortunately any practitioner with a sensible approach, if a trauma is in the acute inflammatory stage should not have performed such a technique based simple on the time frame. The hospital should not have release her without an MRI to rule out dissection or other injuries ( fractures, lig tears, disc injuries etc...). Unfortunately drs aren't trained in musculoskeletal injuries enoughto be able to clearly discern the difference between musculoskeletal injuries and others and rely on scans. Therefore hopefully they did do an MRI on the initial presentation, but I doubt it. And with the severity of pain she shouldn't have been discharged, thus never making to her chiropractor. The blame game will go on but unfortunately it doesn't change the fact that she is gone, is a terrible tragic event.

With the previous statement on the anatomical study, within Australia gross Anatomy is becoming an elective in medical degrees. Which personally is appalling. The physio, osteo and Chiro degrees in Australia would do a lot more gross structure anatomy and neurology than gps. To get that level of training they have to go on to specialize in sports med or orthopaedics. It's understandable when you look at the amount of info needed to train doctors on disease and treatments, there is a lot the need to keep abreast of, and musculoskeletal issues don't tend to generally life threatening.

Any way back to the original point. Please stop just singling out the chiropractic industry, I know many chiros that do not practice HVLA because of the risks. And I know many physiotherapists, osteopaths, naturopaths and a few gps that still perform the technique. I understand that chiropractic may have made a reputation on this but please understand esp in Australia there are many professions that perform this technique. Perhaps as a society we should look at the technique and not the industry. As a false sense of safety could come out of " it's dangerous if a Chiro performs the technique but it's ok because my physiotherapist just cracks my neck"

I suffered a carotid artery dissection 11 days after visiting a chiropractor for a neck manipulation in April of this year... RIP Katie.

You are LITERALLY more ignorant than there are words when it comes to your knowledge of chiropractic medicine. "Completely unqualified as PCPs"? They are essentially DOs without a prescribing license. Didn't DOs go through this very same fight? I agree, there ARE quack chiropractors, but there are terrible MDs & DOs that over-prescribe pain medications and botch surgeries. Don't put all chiropractors in one box, I know you wouldn't do that to ALL *other* doctors.
P.S. - a "hanging" results from a fracture to the odontoid or posterior process of the Axis (2nd vertebra), you can't fracture this by moving (adjusting) the head left/right, only by hyperextending the neck, but thanks for playing.

I can't believe this article that based it's facts on someone who puts an spinous process on C1 (the atlas). Did anyone else catch this on the figure that was stolen from one of Mark Crislip’s posts? But what do I know about anatomy... I am just some chiropractor. BTW, not all chiropractor schools teach innate intelligence. Most schools use evidence based medicine.

I am not here to play the blame game. Just do better research next time or don't write at all!

Thanks

So many fallacies, so little time...

No, chiropractors are NOT essentially DOs without a prescribing license. They do not go through the pharmacy classes and residencies required of MDs in the USA. If I had a back ache, I might see a chiro (not likely) or a physical therapist (more likely). But for other health issues, I'm going to go to someone trained and educated to take care of them.

As for the Australian chiro defenders: If your chiro is a member of Chiropractic Australia, then I'll believe they practice evidence-based care. If not, then I doubt it.

Oops...meant to say " do not go through the pharmacy classes and residencies required of MDs and DOs in the USA." I recognize that a DO in other countries is not the same as a DO in the USA.

That is incorrect about the pharmacy classes MI Dawn. My chiro education consisted of pharmacology classes taught by a person with a phd in pharmacology... same person who also teaches medical schools. Just facts...

So, Kevin, which hospital did you do a three year residency?

DOs actually do residency programs.

My point, Chris, was to merely state that pharmacology classes are included in some chiro schools education. No where did I state that I, or other chiros, did a residency.

But.. I did intern at a VA hospital!

Andrew

I might point out however, that not all of us are quacks

Bofa's Law of Professions: If your defense of a profession/group consists of "not all of them are bad" then that is a sign of a serious problem.

And chiropractors are the poster child for it.

I have to ask, Andrew, why do you put up with it? You admit you have a bunch of complete quacks who are making your profession look bad. How can you accept that? What are you doing to get rid of them? Do you go to chiro internet boards and call them out and tell them to go away?

Your profession has a serious problem. Your admission that "not all of them are quacks" shows that. Do something about it.

TBruce: "A chiropractor (in Canada) pays about the same malpractice premium as an office-based family doctor."

I wonder if people are aware that in most states in the U.S., chiros are not required to carry malpractice insurance.
That fact might affect lawsuit incidence and overall malpractice insurance costs.

@Kevin: I'm glad you had a pharmacology class in your program. From the chiros I have spoken with, that's pretty rare. You still can't compare the training you received to the training the MD/DO students received unless you were in the same class and know that the same information was taught.

I can vouch that my pharmacology class, as a CNM, was not the same as what any MD/DO program. We had to learn about far fewer medications and drug interactions, as well as biochemical interactions.

I wonder if people are aware that in most states in the U.S., chiros are not required to carry malpractice insurance.

This is very, very bad, of course. It lets the chiros shirk their professional responsibility to their patients, because one of the most important parts of being a professional is accountability. If you screw up, there needs to be recourse. However, by not having malpractice insurance, it is left to cash, and it's easy to have nothing available, so there is nothing to sue and lawyers won't take it. Whoops, patient, I may have screwed up, but there's nothing you can do about it.

This actually happened to my brother in law. He got his next adjusted, immediately was nauseous couldn't walk straight, dizzy (this is when the artery got torn). Next day he felt better, brushed it off - his doc said it was an allergic reaction (ok we all know that isn't possible). He worked out, got the same symptoms, now he couldn't walk straight and his eye and mouth drooped. This is the stroke part due to the blood clot moving. He went to the hospital and they determined he was having a stroke. They were able to treat him and he recovered but it was a close call.

How do we know that she had manual manipulation? She very well could have had instrument manipulation that creates absolutely zero rotation and extension in the cervical spine. AGAIN, media jumping to conclusions.

I can’t believe this article that based it’s facts on someone who puts an spinous process on C1 (the atlas). Did anyone else catch this on the figure that was stolen from one of Mark Crislip’s posts?

Here's another version of the same diagram -- perhaps the original -- at Painter's "Comprehensive Review of Chiropractic Research":
http://www.chiro.org/LINKS/FULL/GRAPHICS/ROSNER/Rosner_2010_Figure_11.j…

Another version:
http://www.chiro.org/LINKS/CVA/Figure_I.jpg

There is a significant fault in this article.

You show a video of a rotary cervical adjustment and imply that this was the exact adjustment given by the chiropractor. How do you know that? Have you seen the chart notes?

Many chiropractors adjust the cervical spine in very different ways. Atlas Orthogonal, Grostic, NUCCA, even Gonstead (which is more of "aggressive popping") do not rotate the head during the delivery of the adjustment

@Marry me, Mindy.

How do I put up with it? With great difficulty, Mindy. My profession does have a serious problem. I do call out the anti vaccine chiros, those that treat outside the scope of their practice. I've donated money to evidence based research and am a member of Chiropractic Australia.

A large percentage of my referrals are from local medical doctors who trust my judgement, that I practice safely and refer when necessary. I largely use soft tissue work and mobilization of joints. I do manipulate when appropriate and safe and obtain informed consent whenever I do it.

I have often laid awake at night pondering why I joined a profession that is constantly at war with itself. But I do think the profession has a lot to offer and that in order to save itself it needs to pull registration away from the quacks who refuse to change, who, like Christian fundamentalists still clinic to the tenets of a magnetic healer from over a century ago.
The medical profession needs to extend an olive branch to those of us willing to work with you, for the good of the patient, not the practitioner.

There are good chiros and bad chiros, good doctors and bad doctors, good cops and bad cops! It’s up to you to do your homework and find an honest one who knows what they are doing

If a doctor does not know what he or she is doing, we tend to expect (rightly or wrongly) the professional body to do something about it... rather than shrug it off, and advise the patients' families that they should have done their homework.

As for bad cops, it would be nice if we could shop around and avoid them. Word would get out not to consult Officer X who keeps shooting people.

About 15 years ago, I started having intermittent pain, numbness, and tingling in both shoulders, arms, and hands. I went to a doctor, who sent me to physical therapy, which did not help. Another doctor just gave me pain meds. Desperate, I went to see a chiropractor recommended by a massage therapist. He insisted on taking an x-ray, something neither of the doctors had done. On seeing that there was very little space between C5 and C6, he declined to treat me, and he sent me to a sports medicine specialist, who did an MRI. Turns out the disk between those two vertebrae was in pieces, and pieces were extruded into the foramen on both sides, impinging on the neurovascular bundle. I ended up having C5 & C6 surgically fused by a neurosurgeon. That chiropractor did two things: he didn't make me worse, and he got me to an appropriate specialist. I still don't think much of chiropractic in general, but I'm grateful to that guy for not inflicting the various injuries that could have been caused by spinal manipulation and for starting my recovery process.

In my believe, it did kill her.

Odd that we haven't yet seen a typical chiro justification for neck cracking - that it supposedly alleviates hypertension.

The only source for this claim that I've ever seen was a single small pilot study involving a specialized technique. But it's flogged as supposedly conclusive evidence supporting generalized neck cracking, just as other small studies (usually in chiro journals) are cited to support adjustments for infant colic and various other non-musculoskeletal indications.

Still unsatisfied and want my question answered.

How do you know that the adjustment seen in the video that you posted was the same adjustment given by the chiropractor in this case? Have you heard specifics about this case/seen detailed chart notes of this patient interaction? There are many different ways that chiropractors adjust the cervical spine.

Until you can answer this question with certainty, the entirety of your article is presumption. Not so scientific.

How do you know that the adjustment seen in the video that you posted was the same adjustment given by the chiropractor in this case?

Did he say it was?

Can someone please tell me how the hell do chiro's always find scoliosis in their patients back ?and how can they align it?marketing genius ?

I meant to say 11 hours, not days, and April of last year, not this year.. Oops. My brain is fucked...

@Miss Anthropy: very happy to hear that you found a good chiro who didn't step out of his scope of practice, and sent you for the correct treatment. Unfortunately, it sounds you got thrown into the "whiny woman" trap rather than the first doctors taking your complaints seriously after the PT didn't help. (I was fortunate - when I had similar problems, after the PT didn't help, my MD did further investigation into my shoulder problems and treated it appropriately).

Glad you are much better!

"There are many different ways that chiropractors adjust the cervical spine."

No doubt all are evidence-based...

"Orac
February 8, 2016

Um, yes, I do think so. Physical therapists frequently do spinal manipulation. They just do it in an evidence-based fashion—unlike the vast majority of chiropractors."

Orac
February 8, 2016
80% of chiros are evidence based? Citation required.

I require your citation that the vast majority of chiropractors don't practice evidence-based manipulation of the cervical spine first.

@Stanimal032: Guess what? This is Orac's blog. You can't require him to cite. You can ask him where his statistics are from, and I'm sure he'll give you links, if they aren't already in his post, because he always gives citations, unlike certain poseurs we know.

@Orac

Here is a study that goes along with the 80% number I gave earlier.

http://www.biomedcentral.com/content/pdf/1472-6882-14-51.pdf

Results:

Of 740 deliverable questionnaires, 503 were returned for a response rate of 68%. Less than 20% of
chiropractors (18.8%) were aligned with a predefined unorthodox perspective of the conditions they treat.
Prediction models suggest that unorthodox perceptions of health practice related to treatment choices, x-ray use
and vaccinations were strongly associated with unorthodox group membership (X2 =13.4, p = 0.0002).

Conclusion:

Chiropractors holding unorthodox views may be identified based on response to specific beliefs that
appear to align with unorthodox health practices. Despite continued concerns by mainstream medicine, only a
minority of the profession has retained a perspective in contrast to current scientific paradigms. Understanding the
profession’s factions is important to the anticipation of care delivery when considering interprofessional referral.

@MI Dawn,

If he's going to throw out a statistic that most chiropractors aren't evidence-based, he should have a citation. I have provided the citation for my statistic.

@Stanimal032: Nothing like stacking the deck in that article! The *only* group pulled out as "unorthodox" were those that claimed that subluxions lead to other health problems. And they had to answer all of 3 questions!! Their random sampling was only 12% of chiros in each *English-speaking* Canadian province, and they had a 68% return rate (which was unclear whether those who returned the form saying they didn't want to participate were included or not).

I'll leave it to those better at reading articles than I am as to how good of a test this was. After reading it, I'm not impressed, and I am not sure my Stats teacher would be either.

Ml Dawn,

That is the largest group of "unorthodox" practitioners in chiropractic so obviously they will be singled out.

68% return rate is a pretty good return rate, actually.

It's obvious your mind is made up and you will pick apart any evidence shown to the contrary.

Here's another article.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2271108/

"Risk of Vertebrobasilar Stroke and Chiropractic Care"

Results

There were 818 VBA strokes hospitalized in a population of more than 100 million person-years. In those aged <45 years, cases were about three times more likely to see a chiropractor or a PCP before their stroke than controls. Results were similar in the case control and case crossover analyses. There was no increased association between chiropractic visits and VBA stroke in those older than 45 years. Positive associations were found between PCP visits and VBA stroke in all age groups. Practitioner visits billed for headache and neck complaints were highly associated with subsequent VBA stroke.

Conclusion

VBA stroke is a very rare event in the population. The increased risks of VBA stroke associated with chiropractic and PCP visits is likely due to patients with headache and neck pain from VBA dissection seeking care before their stroke. We found no evidence of excess risk of VBA stroke associated chiropractic care compared to primary care.

The important thing in that article is

"Three times more likely to see a chiropractor OR PCP before their stroke..."

"No evidence of excess risk of VBA stroke associated with chiropractic care compared to primary care."

My big issues it is seems like this "Science Blog" is not actually looking at the science when it doesn't fit their narrative. Even when they acknowledge that the evidence isn't there, they still say "but you shouldn't do it anways because we don't think it's safe."

Science is unbiased. Science doesn't confirm what we want to believe or what we think exists, it simply confirms what is true.

You can roll out case study after case study about chiropractic and VBA dissection, but the research shows that there's no direct cause/effect relationship.

You can make a case study make a case for any intervention you want, but you can't establish causation from a case study.

I'm not dismissing the fact that the chiro should've been more cautious (ESPECIALLY after the initial response to the adjustment), and he didn't help the situation, but the reality is that people like this are often having the dissection before they ever walk into their PCP/Chiro office.

It could happen washing your hair at the salon, it could also happen turning to back out of your driveway.

Now a common argument is "But there's no proof that manipulation is good for anything", which is incorrect.

To that, I provide a study from the JMPT re: CMT and Cervicogenic Headache:

http://www.ncbi.nlm.nih.gov/pubmed/11562654

CONCLUSIONS:

SMT appears to have a better effect than massage for cervicogenic headache. It also appears that SMT has an effect comparable to commonly used first-line prophylactic prescription medications for tension-type headache and migraine headache. This conclusion rests upon a few trials of adequate methodological quality. Before any firm conclusions can be drawn, further testing should be done in rigorously designed, executed, and analyzed trials with follow-up periods of sufficient length.

More on the efficacy of manipulation compared to mobes/exercise:

http://www.ncbi.nlm.nih.gov/pubmed/26852024

CONCLUSIONS:

Six to eight sessions of upper cervical and upper thoracic manipulation were shown to be more effective than mobilization and exercise in patients with CH, and the effects were maintained at 3 months.

My last issue before I bow out is that SMT is SMT whether it is done by a PT/Chiro/MD/DO

To single out chiropractic and say that they don't provide evidence-based SMT is a lie and nothing more. Chiros have more training in SMT than any of the other groups listed and the techniques are the same with the same intent of restoring proper joint mobility.

Saying the SMT has any different effect because it is done by a PT/DO/MD instead of a chiro is pure BS and nothing more.

Also, the statement that chiros don't have to have malpractice insurance is also incorrect. All chiros are required to have malpractice insurance like any other provider.

@#21 - herr doktor

Actually, it means that Medicare will pay for chiropractic services as long as they are performed by a chiropractor and for the purpose of “subluxations”. They are actually giving credence to the nubulous subluxations.

Stanimal's contention/link alleging that the great majority of chiros are not into 'unorthodox" health beliefs is contradicted by abundant evidence of their predilection for woo. For instance, most chiro colleges still preach that disease is caused by "subluxations" (which cannot be identified by non-chiros and do not exist apart from the accepted medical definition). Recent studies have shown that nearly all chiros think spinal misalignment causes many or most diseases, and 75% were on record believing that "subluxations" were a significant factor in 50% or more of visceral diseases (like asthma and colic).

https://www.sciencebasedmedicine.org/the-end-of-chiropractic/

Sam Homola has noted chiropractic's affinity with other sorts of woo:

"In view of increasing opposition to subluxation theory, some chiropractic colleges have read the handwriting on the wall and moved into the camp of alternative medicine. The National University of Health Sciences (NUHS), for example, often referred to as the foremost American chiropractic college, offers Doctor of Chiropractic, Doctor of Naturopathic Medicine, Master of Science in Acupuncture, and Master of Science in Oriental Medicine degrees. NUHS recently announced a new cooperative arrangement with the Graduate Program in Complementary and Alternative Medicine at Georgetown University Medical Center in Washington D.C. Faculty at the two schools will work together to help students seeking advanced degrees in health care by advising students of the benefits of each other’s programs and providing preferential seating and advanced standing in each other’s programs when appropriate."

"The web site of the Association of Chiropractic Colleges, in its “What Is Chiropractic?” section, states: “Because of the emphasis on holistic health care, chiropractic is associated with the field of complementary and alternative medicine.” (Accessed December, 13, 2011) Most health-care professionals consider “alternative medicine” to be a haven for unproven and implausible treatment methods."

https://www.sciencebasedmedicine.org/subluxation-theory-a-belief-system…

There are a number of chiros who reject woo and try to improve their profession. They continue to fight an uphill battle.

In other news, I was astounded today to read (in an article about prison time handed out to a chiro for massive overbilling of insurance companies and the state), that he had earlier been sanctioned by the chiro board for, among other things, "misleading advertising". This appeared in the same paper that regularly features chiro ads about treating diabetes and offering the services of a "chiropractic neurologist".
God knows what you have to do in chiro-world to be guilty of "misleading advertising".

"Also, the statement that chiros don’t have to have malpractice insurance is also incorrect. All chiros are required to have malpractice insurance like any other provider."

Stanimal should complain to the Federation of Chiropractic Licensing Boards for providing this information.

http://www.fclb.org/AboutCINBAD/Malpractice.aspx

I require your citation that the vast majority of chiropractors don’t practice evidence-based manipulation of the cervical spine first.

Evasion noted, along with the observation, "Be careful what you wish for. You just might get it."

You can roll out case study after case study about chiropractic and VBA dissection, but the research shows that there's no direct cause/effect relationship.

Some research shows that, mostly research done by chiropractors themselves.. Other research strongly suggests a link. I find that research more convincing.

Also, "Stanimal" is getting on my nerves by posting so much. It has nothing to do with his disagreeing; we get that here all the time. However, when more than a quarter of the posts in a 102-post comment thread are by one person, I start to get a little irritated.

The medical profession needs to extend an olive branch to those of us willing to work with you, for the good of the patient, not the practitioner.

And this isn't going to happen until the chiropractor profession cleans it's shit up. As long as it's "not all chiros are bad" the medical profession is going to on the whole stay away.

It's a profession with a serious problem. Come back when your problems are solved.

@DB: well, if Stanimal032 is in Canada, as the article they posted seems to reflect, then they are correct that *Canadian* chiros must carry malpractice insurance, according to what your link shows.

Orac
February 10, 2016
I require your citation that the vast majority of chiropractors don’t practice evidence-based manipulation of the cervical spine first.

Evasion noted, along with the observation, “Be careful what you wish for. You just might get it.”
------------------
I provided my citation. Now, I ask for yours.

I also didn't know that DCs in other states didn't need malpractice. My state requires it. The fact that all states don't is absurd so I retract my statement on that.

That BMJ article? Bwahahahaha. 80% of chiropractors practice evidence-based care because a survey of chiropractors by chiropractors found that 80% say they practice evidence-based care? Hilarious.

I'm sorry that I"m posting a high volume, but you seem to have made up your minds regardless of the evidence that I bring forth.

Sciencebasedmedicine is a blog. A biased blog. One with an obvious agenda against all things chiro. You might as well source "Quackwatch" while you're at it.

And of course chiro reasearch is done by chiros. Who is going to do it? MDs? Who does medical research? Mostly MDs and PhDs. Who does physical therapy research? Mostly PTs. That point is ridiculous.

You also evaded my point that SMT is SMT regardless of who provides it, especially when no one gets more training in SMT than chiros. So your zeroing in on chiro instead of SMT done by physios/MDs/osteopaths shows your clear bias.

I again ask for your citation that most chiros are subluxation-based.

Sciencebasedmedicine doesn't count because it's a blog and not a legitimate source.

Here's a survey of chiropractic students that found that a majority of them think that chiropractic should be evidence-based. However, it also found that the majority also thought that chiropractic should emphasize the correction of subluxations (a non-evidence-based practice).

Ontario seems to not have that 80%+ figure Stanimal quotes, as this study found about 50% of Ontario chiropractors were subluxation-based.

@Stanimal032: I'm sure Sam Homola would be very amused that SBM is biased against chiropractors, since he is one, and he posts on chiropractic medicine. And along with Quackwatch, you could mention Chirowatch...

Then there's also the group Chiropractic Australia, which is a group of chiros in Australia trying very hard to promote only science-based care. I suppose you could say they are biased, too.

@MI Dawn

Not at all, I also push for evidence based care. As do a number of my peers.

Trust me, the subluxation-based chiros are not doctors. They are purely technicians who choose to shirk their clinical duties in the pursuit of the unscientific subluxation. We are working from within to get rid of them and the profession is not what it used to be. There are also chiros pushing for a Primary Spine Care Practitioner program which would pair with medical schools for further education on pharmaceuticals and more evidence-based care options to provide better care for patients and to meet the increased need for skilled MSK practitioners.

@Mephistopheles O'Brien

Did you read the article?

"First, check out this video of a chiropractor doing neck adjustments:...If you cringe when you hear the pop during the violent twist given to the neck, you’re not alone. So do I. So how could such a motion cause a stroke? To understand that, you need to know a bit more about the anatomy of the neck."

Not all cervical adjustments are performed this way. There is no EVIDENCE in this article that this was the fashion in which the adjustment was delivered.

This is BS. Just read the facts below in the most extensive research done on this subject matter. Your just as likely to get a stroke at the chiropractors as in your medical doctors office. You know why? Because you usually come in with a stroke already active.
JD Cassidy's studies and Dr Tuchin are world renown on this subject so I advise reading the experts veiwpoints rather than some guy on his ass writing what he wants. Thes studies are in New England Journal of Medicine and Journal of Spine, etc. Big time Journals for well done studies. Not BS studies.

http://www.ncbi.nlm.nih.gov/pubmed/18204390

"Cassidy concluded VBA stroke is a very rare event in the population. The increased risks of VBA stroke associated with chiropractic and PCP visits is likely because of patients with headache and neck pain from VBA dissection seeking care before their stroke. The study found no evidence of excess risk of VBA stroke associated with chiropractic care compared with primary care"

@Derry Merbles - Did you read the article? He gives an example of a chiropractor doing neck adjustments but does not say that was done in that way in this case. You've chosen to think he implied that, but I don't see him stating it.

All the "defenders" of chiropractic commenting here are so eager to say that our host is wrong that they don't seem to have read as far as the end of the article. Orac, having looked at the evidence, concludes that we don't know what killed Katie May, and that that it probably wasn't chiropractic manipulation. The defenders of chiropractic are singing a resounding chorus of "Orac is wrong."

OK, chiro chorus, have it your way: our host is mistaken, and a chiropractic adjustment killed Katie May.

P.S. It may not always be true that if a headline asks a question, the answer is "no," but that's a good starting point.

Stanimal: "Sciencebasedmedicine doesn’t count because it’s a blog and not a legitimate source."

Wooists often denigrate SBM and similar sources on this basis, pretending that they are just opinion and ignoring the hard data they present (published research, professional practice guidelines etc.). Wholesale dismissal of other informed and reliable sources on the basis that they are "biased" or part of the government/pharma/Illuminati conspiracy is part of the game too.

MI Dawn: "@DB: well, if Stanimal032 is in Canada, as the article they posted seems to reflect, then they are correct that *Canadian* chiros must carry malpractice insurance, according to what your link shows."

I never made any reference to the situation in Canada.
My original post on the subject of chiro insurance was:

"I wonder if people are aware that in most states in the U.S., chiros are not required to carry malpractice insurance."

Which is true, and may have a bearing on overall chiro insurance rates (claimed to be low, as if that rules out catastrophic injury from neck cracking).

And of course chiro reasearch is done by chiros. Who is going to do it? MDs? Who does medical research? Mostly MDs and PhDs. Who does physical therapy research? Mostly PTs. That point is ridiculous.

You missed the point completely. Chiros do not have any training to conduct clinical studies and certainly not any training developing objective, unbiased questionnaires and administering them for external validity. The study you cited is evident of that.

The increased risks of VBA stroke associated with chiropractic and PCP visits is likely because of patients with headache and neck pain from VBA dissection seeking care before their stroke.

This is an interesting theory, which requires people to know in advance that their headache / neck pain is due to VBA dissection, so that they can selectively seek out a chiropractor to have it treated...
No, wait, it's a bizarre specimen of special pleading.

@Mephistopheles O'Brien

Oh then "Check out this video of a chiropractor doing neck adjustments" must have just been for entertainment value!
Take a break, watch the video, then read on. Assume nothing.

@Vicki
He does not state that "...it probably wasn’t chiropractic manipulation"
In fact, he states "don’t mistake my concluding that we can’t be sure that the chiropractic neck manipulation didn’t cause May’s stroke with my concluding that it didn’t cause her stroke."
But thank you for your participation!

@Science Mom we actually take classes on research and have to present a research paper that could be a clinical trial, lit review, etc as a requirement before graduation.

@herr doktor you missed the whole point of that. Symptoms of a VBA are often only neck pain, or headaches. Therefore they seek out care for the neck pain or headache, not for a VBA.

A chiropractor cracked my neck seven years ago. I was left with a dissection of my carotid artery with an aneurysm. One of my partners in my office had a stroke on the table after chiropractic manipulation of my neck.
Because of this chiropractic manipulation, I was left with debilitating migraines. I have headaches every day of my life. I have been on more medicines than I can count, both for the chronic aspect of the migraines as well as the acute aspect.
Before someone wants to try chiropractic manipulation, spend a month with me. You'll change your mind pretty quickly.

@Science Mom we actually take classes on research and have to present a research paper that could be a clinical trial, lit review, etc as a requirement before graduation.

And how is this in any way adequate education and experience to conduct a rigorous study? You chiros love to compare yourselves to MDs and PhDs but you overlook the many more years of education and experience they have particularly cross-disciplinary collaborations. Chiros are an incestuous bunch only working and being educated by other chiros.

@DB: sorry, I think we're talking at cross-purposes, here! :)

I appreciated your link however I meant to comment that since the article Stan originally posted looked at Canadian chiros, maybe he was Canadian also (which he apparently isn't per later comments) and therefore was correct in his thinking about malpractice in his experience. I round your link informative and interesting. That's what I get for posting on my break!

Our Biochemistry teacher was a PhD who taught at Wash U med school. Our pediatrics professor was an MD and pediatrician. Our OB-GYN professor was a practicing OB who also taught at Wash U med. Pharmacology and Pharmacokinetics was also taught by an MD.

Chiropractic classes were taught by chiropractors. The rest of our classes were taught by PhDs and MDs. Including our research program.

Might want to do some research on the actual classes that you're making incorrect assumptions about.

I had four years of a Bachelor's degree where I also worked in the research lab of our Kinesiology and Exercise Science program. The Doctorate program was then another 3.5 years of over 2000 hours of classroom time and hundreds of hours of clinical time. All taught by a mixture of MDs/PhDs/DOs and DCs.

You don't know what you're talking about when it comes to chiropractic education.

Oh then “Check out this video of a chiropractor doing neck adjustments” must have just been for entertainment value!
Take a break, watch the video, then read on. Assume nothing.

OK. The video was an introduction to the discussion of how it is plausible that certain neck manipulations could cause a stroke. He also states that it is less likely that neck manipulation could cause the type of stroke suffered in this case. He never once states that the type of manipulation from the video was performed on this patient. He did point to tweets that said that her neck was manipulated, but does not state that it was done like the video. He also concludes it is impossible to state that any such manipulations caused her death.

Perhaps you should try reading it without preconceptions.

@Science Mom since you're into research, you may want to do some before you make a comment that is blatantly false and based on your own assumptions and not facts.

Again, of course Chiros are taught by Chiros. Who teaches in Med Schools? PhDs and MDs. Just like PTs and PhDs teach in PT school and MDs and PAs teach in PA school. And Nurses, MDs and PhDs teach in Nursing school.

@Stanimal032 - did they teach you about subluxations and universal intelligence? If so, why?

Thanks.

You're welcome to look at our professors at the link below:

http://www.logan.edu/home/faculty-search

You can find their credentials under the "Basic Science" and "Clinical Science" tab.

@Mephistopheles O'Brien

We learned about subluxation and universal intelligence in our first class called "Chiropractic Philosophy" as a construct that DD and BJ Palmer came up with. We learned it as a more historical factoid and not as a diagnosis or finding since the definition of the "subluxation" can't even be agreed upon by most chiropractors.

So yes, we learned about it, no it was not something that we looked for or based clinical treatment on. Our diagnostic classes stressed more orthopedic/neurological/physical examination to determine the cause of the problem and to rule out any contraindications to manipulation or treatment such as malignancy/VBA dissection/cord compromise.

Personally, I have never once said the word subluxation to a patient, nor made any claims that chiropractic is a viable option for anything other than NMSK conditions. I use evidence-based evaluations such as the SFMA (Gray Cook, DPT). I don't x-ray anyone unless there is an indication for it. I have referred pts out for suspected VADs and I have caught a few aortic aneurysms and even a popliteal aneurysm that was about to rupture.

I have a good working relationship with many MDs and I have a few as patients who also refer many patients to me.

I know there are some nut jobs in chiropractic. But we are working on getting them out. We don't like them either lol.

Those patients I sent out for suspected VADs were BEFORE I adjusted them as well.

The study found no evidence of excess risk of VBA stroke associated with chiropractic care compared with primary care

"The case control and case crossover analyses gave similar results. (Tables 3-7) Age modified the effect of chiropractic visits on the risk of VBA stroke. For those under 45 years of age, there was an increased association between chiropractic visits and VBA stroke regardless of the hazard period. For those 45 years of age and older, there was no association. Each chiropractic visit in the month before the index date was associated with an increased risk of VBA stroke in those under 45 years of age (OR 1.37; 95% CI 1.04–1.91 from the case crossover analysis) (Table 7). We were not able to estimate bootstrap confidence intervals in some cases because of sparse data.

"Similarly, we found that visiting a PCP in the month before the index date was associated with an increased risk of VBA stroke regardless of the hazard period, or the age of the subject. Each PCP visit in the month before the stroke was associated with an increased risk of VBA stroke both in those under 45 years of age (OR 1.34; 95% CI 0.94–1.87 from the case crossover analysis) and 45 years and older (OR 1.52; 95% CI 1.36–1.67 from the case crossover analysis) (Table 7)."

It's charming remarkably condescending to have a newcomer to someone else's blog thank me for my participation, Derry, but I'll forgive you, as it would be equally inappropriate for me to tell you whether/what you should be posting here.

Stan, nice try palming the card while admitting that Ph.D.s do medical research and they don't chiro research.

Wow. That's what you picked up from that? They do, but they do it alongside chiros.

I think I'm done here. You guys will pick apart anything and overlook my whole point. It's obvious your bias won't be changed.

Again, Dr. Barrett of Quackwatch was found to be biased and unworthy of credibility n a court of law in the case of NCHAF v King.

That is your "source" for chiro info.

Nice.

NCHAF v King*

More on the efficacy of manipulation compared to mobes/exercise:

ht[]p://www.ncbi.nlm.nih.gov/pubmed/26852024

In another tribute to the technical magnificence of DOIs, this one comes up 404 on the BMC site. The PDF is here (sometimes; the tracking seems to be flaky as well), if anyone wants to read more than the abstract.

@Science Mom since you’re into research, you may want to do some before you make a comment that is blatantly false and based on your own assumptions and not facts.

Again, of course Chiros are taught by Chiros. Who teaches in Med Schools? PhDs and MDs. Just like PTs and PhDs teach in PT school and MDs and PAs teach in PA school. And Nurses, MDs and PhDs teach in Nursing school.

PhDs and MDs with the requisite education and expertise in the subject they are teaching teach med students. Chiros don't have that specialised training which doesn't prepare chiros to be PCPs. Stick to the scope of practice, do it in an evidence-based manner and you'll find a lot less hostility toward the profession and maybe even some collaboration.

You’re welcome to look at our professors at the link below:

http://www.logan.edu/home/faculty-search

You can find their credentials under the “Basic Science” and “Clinical Science” tab.

Yah and nearly every single one is a chiro, that includes Chiropractic Health Center and Chiropractic Science. Pretty much what I said.

My 20 old daughter died as a direct result of a chiropractic neck manipulation. Some of you have indicated it may never be known how Miss May died. Hello, there are forensic neuron pathologists who can take that artery right back to the initial injury. These scientists will know exactly what killed her at autopsy. The unconscionable manipulation of chiropractic should be stopped. It is barbaric, unwarranted and down right dangerous. If there was any talk of a pinched nerve, you can bet it was a chiropractor she saw, as her brother says, and not an MD. If that clot was there when she attended at that chiropractor's office, then why the hell was she manipulated? Never, ever let a chiropractor touch you above the shoulders.

Dangerous Bacon @99

Stanimal’s contention/link alleging that the great majority of chiros are not into ‘unorthodox” health beliefs is contradicted by abundant evidence of their predilection for woo.

Maybe it is just me, but I often see chiropractors offering a cornucopia of woo, almost always including acupuncture for starters. Although to be fair the Canmore Quack Shack is run by an MD. Of course it has a chiropractor on staff. I suspect that many of the chiros surveyed don't consider acupuncture to be "unorthodox" and this may extend to other things they do as well.

Again, Dr. Barrett of Quackwatch was found to be biased and unworthy of credibility n a court of law in the case of [NCAHF] v King.

BTW, locus classicus: Pattimmy Bolen. The failure to correctly name the case (I'm not referring to the typo) strongly suggests to me that this was regurgitated from a downstream source.

Oh, and the case was about homeopathy, making it a red herring. Moreover, the "found to be ... [in] a court of law" bit refers to the opinion of a single L.A. County* judge (the "Superior Court" is the lowest rung on the California ladder).

Was it a poorly thought out and argued case? "Signs point to yes." The published part** of the appellate decision doesn't exactly have "promising theory" written all over it, but maybe it was a strategic Hail Mary.

By contrast, trying to invoke it as a distraction does have "tactical failure" emblazoned.

* They charge $1 "per search"; as I don't know whether there's a further per-document (if any) fee, I didn't bother. It's BC245271, if anybody wants to go fishing for the whole docket.
** I can't find the unpublished part using courtinfo.ca.gov; the further supreme court escapade for depublishing between nonparties is a complete mystery.

"the case was about homeopathy, making it a red herring."

Wooists seemingly operate from a single playbook when it comes to Quackwatch. They are able to cite (with varying degrees of accuracy) some court decision where the judge/verdict went against Dr. Barrett. What they never do in my experience is point to a single article on the site (whether written by him or anyone else) and explain why it is inaccurate.

"You guys will pick apart anything and overlook my whole point."

Awwww (pats Stanimal on his pointy little head).

I have no letters after my name, but after reading your article, this seemed plausible: The fall/neck injury caused an intimal tear in the carotid artery. The resulting clot could have resolved itself completely unassisted. The chiropractic treatment possibly loosened the clot that caused the fatal blockage.
Just speculation, but worth a second thought if i ever get a neck injury.
Thanx for the article ;)

@Mephistopheles O'Brien

If he did not want the reader to assume that this was the type of adjustment performed, he would not have posted the video. The theory to follow about vertebral artery dissection was purely based off of damage done during "rapid rotation" which is demonstrated in the video.
He then states "While it is true that cervical manipulation very likely can cause vertebral artery strokes, it is not at all clear whether such manipulation can cause carotid artery strokes. From a simple anatomic standpoint, there is less plausibility, as well, but not zero."

"But not zero" is what bridges the gap between vertebral artery stroke and carotid artery stroke. Therefore the implication that a rotary cervical manipulation was performed stands.

Your literal stance that he "never once states that the type of manipulation from the video was performed on this patient" is a frustratingly infantile argument. The video is preceded by "First, check out this video of a chiropractor doing neck adjustments."

The video is 100% unnecessary if it was not intended to help the reader visualize what happened in the adjusting room.

I still need EVIDENCE that rapid rotation was performed on this particular occasion. Without that, absolutely none of this information is valid.

@Vicki
I just thought your incredibly aggressive and sarcastic argument should be made fun of after being proved inaccurate. You may need to gain some humility

Interesting article and perspective, although highly biased and very good use of insinuation and appeal to emotion.
I teach technique instruction at a chiropractic college and we cover this topic in great depth...and with the patient safety as our main focus.

Most of my comments will utilize the information contained in Donald Murphy's article titled "Current understanding of the relationship between cervical manipulation and stroke: what does it mean for the chiropractic profession?"
Although it is slightly dated (2010) it is still one of the best reviews of this particular topic and suggests a slightly different view than what you present.

I am unsure of the basis for your obvious hatred of the chiropractic profession and understand that my discourse may fall on deaf ears if you have already made up your mind and do not want to be confused with facts...at least the ones you conveniently want to overlook.

To cut to the chase and discuss some of your "points"...
"With HVLA it is possible to "tear the intima"...while the artery may become stretched...the amount of force required to actually tear the artery cannot be reached with the standard HVLA procedures commonly employed by chiropractors (or PT's or MD's, or chinese "bone setters" or many of the osteopathic techniques) With the obvious problem of performing these studies on humans we are left with animal models, and these studies strongly suggest that there is a significant amount of "extra stretch" that allows the vertebral artery to slide thru the anatomic structures. If we did not have this extra wiggle room everybody would be at risk by simply turning their head...which is simply NOT the case. That being said I agree that the stretching of the artery could potentially dislodge an embolus that has already been formed. The unfortunate aspect of this is that there is no test that would help a practitioner to know that it was present before they treat the patient.

The bottom line is that osseous manipulative techniques have been employed for thousands of years, and the number of people who have experienced a "stroke" as a result is not even close to the amount to the number of patients killed in one year by medical procedures. I will compare body counts any day you want...by the way my malpractice rates are significantly less than what a general medical practitioner pays and not even close to what an OB/GYN will have to pay. Granted this is not to say that chiropractors cannot harm patients...everything we do has some risk associated with it. We drive cars everyday, yet most people do not realize that it is one of the most dangerous activities they do on a daily basis. Good time to point out that accidental deaths due to motor vehicle accidents has just been eclipsed by prescription medication overdose/adverse reactions as the leading cause of accidental death. (Didn't see that fact listed in your article.)
You are correct in saying that there is a "correlation" of cervical manipulation to vertebral artery strokes NOT causation. The previously mentioned article strongly suggests what we have suspected for many years in that a patient suffering from a stroke is more likely to present to a chiropractor for treatment. One of the most frequent symptoms experienced by a stroke victim is HA...and whether you believe it or not, HVLA procedures as well as many of the myofascial techniques employed by chiropractors, PT's, osteopaths, and massage therapists are very effective at alleviating those symptoms. Our focus at the current time is to make sure that my students can recognize a stroke in progress and make the proper referral to the ER…where unfortunately it may also be missed (somewhere around 30% of the time)
What you did not tell your readers was that the "association" of stoke and visits to the chiropractor are actually a little less than stroke and a visit to the medical doctor. Does that mean that the medical doctors are doing something to cause stroke?...there is after all an association.
I am also curious as to how PT's are able to perform these procedures in an evidence based fashion, yet chiropractors are apparently unable to do the same thing. If you are referring to the use of HVLA procedures in the treatment of non-musculoskeletal complaints, I agree that there are not many well designed studies to support the use of spinal manipulation. This is mostly due to the fact that pharmaceutical companies get the lion’s share of research money and chiropractic has had to scratch to get a tiny fraction of that money just to "prove" what we know via decades of clinical practice. I assume you have heard of the Wilke vs the AMA case...a systemic and coordinated effort by the AMA to "contain and eliminate" the chiropractic profession...best way to spread misinformation, play on inherent patients fears, reaffirm your place as the only true "experts", and eliminate your competition.
We know that "real" doctors wouldn't use therapies that are not scientifically proven right...how about the fact that the serotonin/depression theory has pretty much been disproved and that medical literature is filled with studies that seem to concur with each other in that about 70% of the effects of antidepressant medication effectiveness is due to the placebo effect. Yet many medical doctors can use a medication “off label” for conditions like fibromyalgia or in children ( a population which was not included in the original studies)…sounds scientific to me.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4172306/

As to your comments regarding chiropractors not providing "informed consent" I agree that it could likely be improved, however I do not know of any studies that can show the extent. The chiropractic profession is still in it’s infancy (or perhaps adolescence) The fact that it’s founder was interested in magnetic therapy sound pretty whacky until you look at where medicine was at that time. There were many intelligent skeptics that were criticizing the germ theory and our understanding of the world had some significant knowledge gaps. I will offer the term ” heroic medicine” and let you decide if medicine has it’s shaer of skeletons in the closet. I would offer that medical doctors are equally deficient with their delivery of informed consent...how many medical doctors actually go thru the hassle of handing out those vaccine information sheets and going over the potential risks of those vaccines that they give (Another topic for a different day perhaps)

I do not think you are capable of writing an unbiased essay regarding chiropractic when I see you say things like "while the stroke chiropractic is admittedly uncommon" ( I would say rare, but I am a chiropractor and obviously am ignorant) you follow up with more of the same innuendo and misleading prose by giving case studies of dubious merit to infer that this is a common occurrence. You also use words like "a landmark lawsuit" and the emotional appeal of a 6 year old boy who suffered a stroke to cement the association even though none may exist. I could give you hundreds of "case studies" of similar instances of harm by medical doctors, but these would be dismissed as rare or worse yet simply the cost of doing business.
EVERY procedure performed by a clinician (don't want to call myself a doctor) has the potential for harm...our job is to eliminate the known problems and discuss the risk reward balance with the patient. They can decide what procedures are worth the risk, instead of the fascist/paternalistic mandates of "Real Doctors'. Last time I checked the evidence informed methodology lists the clinical experience of the doctor, the best available evidence, as well as patient preferences.

You mention that the link/association between HVLA procedures and carotid artery dissections is "much thinner"(...I would say negligible or non-existent), but then continue to cloud the issue by using your "good conscience" to blame the chiropractor via inference.
A little long, and I am fairly sure this is an exercise in futility, but hope that you will not delete my comment as it will differ from your obviously biased frame of mind.
FYI there is an increasing body of evidence to suggest that HVLA procedures seem to be effective not due to the local joint effects, but more by the changes which occur in the brain and its attempt to coordinate sensory motor integration...ie. it can have effects on non-musculoskeletal complaints

While we have a few "evidence based"chiropractors around, I'd like to ask -

Our host tells the story of DD Palmer "who claimed to have restored the hearing to a deaf janitor by “adjusting” a bump on his spine". Is this story plausible? That is, is it likely to have happened the way DD Palmer claims? Is it plausible that he cured a deaf janitor by spinal manipulation?

The previously mentioned article strongly suggests what we have suspected for many years in that a patient suffering from a stroke is more likely to present to a chiropractor for treatment.

"In addition, most of the chiropractic cases had also seen a PCP before their stroke."

You mention that the link/association between HVLA procedures and carotid artery dissections is “much thinner”(…I would say negligible or non-existent), but then continue to cloud the issue by using your “good conscience” to blame the chiropractor via [sic] inference.

Yes, dastardly inference.

"In studying the association between cSMT and CAD, it is important to understand the events preceding the application of cSMT and the onset of CAD. Unfortunately, the results from this study demonstrate a general deficiency in reporting events preceding cSMT or CAD other than that the patient presented to the emergency clinic following cSMT."

Please do not use inference should you care to address this item.

Mr./Ms. Differrence(sic) of opinion suggests chiro neck cracking cannot cause arterial damage: " these studies strongly suggest that there is a significant amount of “extra stretch” that allows the vertebral artery to slide thru the anatomic structures. If we did not have this extra wiggle room everybody would be at risk by simply turning their head…which is simply NOT the case."

Maybe he should impart this wisdom to all those chiropractic apologists who, when presented with evidence of arterial tears after neck cracking, argue that simple activities of daily living like turning one's head (even in a young healthy person) can cause such damage and ensuing strokes.

But what do I know - I must have a consuming hatred of chiropractic for no good reason. The woo, harming of patients and smarmy self-justifications have nothing to do with it.

Replying to Johnny, #148. From "Inside Chiropractic" by Samuel Homola, D.C. DD (Old Dad Chiron) Palmer describes his seminal event in his 1910Textbook, The Chiropractor's Adjuster. Harvey Lillard, a janitor, in the Ryan Block, where I had my office, had been so deaf for 17 years that he could not hear the racket of a wagon on the street or the ticking of a watch. I made inquiry as to the cause of his deafness and was informed that when he was exerting himself in a cramped, stooping position, he felt something give way in his back and immediately became deaf. An examination showed a vertebra racked from its normal position. I reasoned that if that vertebra was replaced, the man's hearing should be restored. With this object in view, a half-hour's talk persuaded Mr. Lillard to allow me to replace it. I racked it into position by using the spinout process as a lever and soon the man could hear as before. There was nothing "accidental" about this, as it was accomplished with an object in view, and the result expected was obtained. There was nothing "crude" about this adjustment; it was specific, so much so that no chiropractor has equalled it...." He then goes onto to tell about how he racked into position a vertebra on another man who had heart trouble and he recovered. Yup, old dad chiro spent a half hour talking to a deaf man and yup old dad chiro restored hearing in ears not connected to the spine and fixed the heart of another man with no nerves connected to the spine. Chiroquactors practising quackery then, and 140 years later still practising quackery. That manipulation to poor old Lillard must have been so violent as to knock the wax out of his ears. The same violence that killed my child. The cause of her death as determined by the jury into the inquest of her death, was "Traumatic injury of the left vertebral artery". The trauma was the chiropractic manipulation. According to my dictionary traumatic means done by violence from an outside source. Extraneous, from the outside, not inherent. It is probably safe to say that all these strokes and deaths caused by chiropractors could be categorized in the same way

Orac, I want to thank you for this post. I should have put it together sooner, but you prompted me to put some baffling and seemingly unconnected symptoms together and get me and my neurologist thinking of a VBA insufficiency, cause not yet determined.
So, indirectly, you have pushed forward the chance to solve a problem that has been going on for years.

Re:152
That is a fine telling of the story, but perhaps I wasn't clear.

Yes, DDPalmer said he cured deafness. My question for the 'evidence based' chiropractors is 'do you think this is how it went down?'. More specifically, "is it possible for chiropractic to cure any form of deafness?". My next question would be to ask for details - what types of deafness, and how is it cured.

They seem to have left, but, hey, I'm late to this string. They might be back in a day or three.

How doea chiro work? Why does PT work? Why does DO manipulations work? Let me explain..
There is a ton of aweful logic going on here. Chiropractic has been very effective for over a hundred years at giving the population relief of joint pain. This has been well established by evidence based research for decades, yet reinforced and supported by the population at large in experience based word of mouth. Meaning, its efficacy is undoubted. But why does it work? Why does PT work? Why does mobilization of the spinal segments....help people? Those are the questions you all seem to need an answer to.
Simply put, when joints begin to NOT move well, bad things happen. Stiffness leads to pain. Stiffness leads to arthritic degeneration. Loss of joint motion can occur from 3 main causes: Trauma, assymetries (when observing anterior to posterior), or poor posture (visible from the side).
I have seen the health impact of joints that degrade around spinal cords, nerve roots, and vascular structures. Morbidity and mortality from these degenerative events are catastrophic and avoidable. The health consequences in NOT addressing dysfunc tional joints is very dire.
We currently have the gift of adjustments and mobilizations, from doctors of Chiropractic, PT, and OD. Chiropractors focus mainly on this, and are therefor the most experienced at doing it comfortably and in a safe, effective manner. Yet, I have had some PTs do a decent job and its not rocket science.
KNOW THIS: MOVEMENT OF JOINTS IS HEALTHY. LACK OF MOVEMENT IS NOT.
Many health care practitioners come to my office for help. PTs, MDs, Dentists, etc.. they get it. Never before has chiropractic been so embraced! I think communication is the barrier to most of your understanding. For example...
Whether the term subluxation is used, or joint dysfunction, it is the same. Being that the spine houses the nervous system makes these particular joint structures even more important.
Can you effect the visceral information flowing in and out of the the spinal column with joint dysfunction??? YES. Does it cause all disease? NO. But every, EVERY health care practitioner on this stream that has dissected a cadaver, gone to his/her neurology classes instructed by PHDs should understand the potential neurological interference that can occer with swelling or mechanical pressure on spinal nerves.
The amount of reported changes in visceral function in my office convinced me a decade ago about this relationship. Understanding that the brain needs full communication through these conduits in order to facilitate proper health is a very simple concept. Immune reacton, blood flow shunting, hormonal secretions etc... all orchestrated through these nerves passing through these structures.
I have read people on this thread dismissing the founders of chiropractic using terminology such as "life force" or "innate". In understanding what we know now to be absolute, those words are extremely synonymous. One has to consider that those words were from 1895-1920s. During the formation of ideas as to why these outcomes were occurng.
The medical profession was in its infancy not much earlier, using terms that sound quakerish and some that absolutely were. We all know of the evolution of health care in the medical profession and we know of the atrocities that have occurred. Yet we are here and thankful that it has evolved.
What IS concrete and substantial, is that spinal joint manipulations are extremely effective at recreating joint health, no matter WHO is doing them. And getting it done helps prevent many unnecessary drug regimines and surgury that create truly scary morbidity and mortality statistics.
You have to take a step back and see risks in a rational perspective.
Im a chiropractor and would allow any one of you to try to adjust my neck at any time, thankfully.

Im a chiropractor and would allow any one of you to try to adjust my neck at any time, thankfully.

If you're willing to let random people from the internet "adjust" your neck, "chiropractor" is not what I would call you.

224,000 people die each year from mistakes made either by the hospital or by a doctor. The number they believe is closer to 400,00 die each year from medical mistakes. Wow why don't you write about that.

Nope!!!!!!!!!!!!!!!!!!!!! I don't know who the bigger idiots on this site are. The bloggers or the ones sucking their dicks. What a bunch of losers sucking on the tit of corporate America why they steal everything we have. Even our health. Wake the fuck up and fight the real cause for all the problems in the world. Greed!!!!!!!!!!!!

I guess we can assume the person with the stuck explanation point key must be a chiropractor.

Evidently there is a stiff joint on anon ymous' keyboard that can only be freed up by keyboard cracking (a technique performed by al chiropractors, plus a few select physical therapists).

Sharyl Attkisson got off on the wrong track thinking her computer had been hacked, when it was a simple life force derangement affecting her "delete" key.

"Wake the f[*] up and fight the real cause for all the problems in the world. Greed!!!!!!!!!!!!"

I always thought the real cause of problems in the world today is the exclamation mark. I propose a Unicode amendment.

I tried a manipulation to fix a keyboard subluxation but only broke the punctuation

@Anon ymous,

We can't wake the f*ck up. We live in the Matrix and have to take the blue pill every day.

Al

oups...I see two black helicopter out the windows....Did I say too mu½¬[¬¤¢¤~[CARRIER LOST]

@ johnmccreery:
"224,000 people die each year from mistakes made either by the hospital or by a doctor. The number they believe is closer to 400,00 die each year from medical mistakes. Wow why don’t you write about that." [sic]
It's Orac's blog. I checked with the Medical Blog Police and they deny putting a gun to your head to force you read it.* If you don't like his choice of topics I am sure you can find a blog belonging to some So-Called Alternative Medicine quack which will be more to your liking, or you can start your own blog and write whatever you wish.

*The Punctuation Bureau of Investigation reports that they have opened an active file on you.

"Im a chiropractor and would allow any one of you to try to adjust my neck at any time, thankfully."
You slut!

You slut!

Hey man, as long as the interest is mutual, whatever.

It's not my neck.

Nor that of either of my nephews, thank you very much.

What possible vulgar connotations could there be to the innocent term "necking"?

@HDB,

Nothing vulgur at all until it turns into petting.

@anon ymous

Troll. But effective in making every chiropractic advocate look ignorant.

Now i realize the best argument I could have made on this site would look like this:
"y wood u go to a chiropractor?????? the docters in usa has never klled any body!!!!! chiros kill milions of peeple evry day!!!!!"

Also, why does this site pretend to check comments if something so vulgar can make it through? Is it possibly because that one comment paints a narrative better than you can?

By the way, still waiting for my response from the editor for EVIDENCE that a rotary cervical manipulation was used in this particular case. Your whole article depends on that. Present facts. That's what science really is.

@Meg The point is that cervical manipulations are very benign. And i could coach just about anyone in attempting to adjust my neck. Id rather have a poor adjustment than no adjustement. I know its difficult to wrap your head around (no pun intended), yet it illustrates my trust in movement trumps immobility when it comes to a rational risk assessment.

@Derry Merbles: Orac doesn't "check" comments. First comments automatically go into moderation to eliminate spam. Once your name/email is approved, comments go through with no stopping unless you hit issues like too many links or (very few) blacklisted words.

Orac moderates with a very light hand. Even known trolls are allowed to post, provided they abide by the rules, although a few have gone into automatic moderation when they don't follow the minimal requirements. In all the years I've been reading Orac, I can only think of a few (less than 5) people who have been permanently banned from commenting.

Sean: You are FAR more trusting than I am. No way would I let anyone do a cervical manipulation. There are very few people I trust to simply do gentle stretching, much less manipulations.

I don't even have a cervix, so feel no need to have it manipulated.

I don’t even have a cervix, so feel no need to have it manipulated.

Is anybody else reminded of that movie Patch Adams?

@ M O'B: I'd say you don't know what you are missing...but then, I don't have a prostate. :)

Any chiropractor who goes anywhere near my cervix will be prosecuted to the full extent of the law for sexual misconduct! And don't think about touching my neck.

MI Dawn,

I’d say you don’t know what you are missing

By definition not only do I not know there's no way I could (at least, none that come to me in the moment). I agree with you.

What possible vulgar connotations could there be to the innocent term “necking”?

Not nearly as many as I can come up with for "cervical manipulations," nudge nudge wink wink.

MOB

When gold seeds are placed in your prostate, your feet are in the stirrups.

@MI Dawn

Thank you for that break down. The knowledge that sucking and fucking dicks and tits is permitted on this site will definitely be useful for later arguments

By what rational argument should a procedure reported to be associated with 901 cases of cervical artery dissection and 707 incidents of stroke over a 10 year period be considered 'benign'? (PMID: 23527121)

Oh woe! Could we be about to lose our Merbles?

@Dangerous Bacon

Only if @anon ymous goes too...

Sean,

I think your profession would garner a little more respect if your colleagues would begin to recognize their limitations. As it stands right now, the vast majority do not.

EG:

https://www.youtube.com/results?search_query=chiropractor+allergy

When an entire profession spouts blatant nonsense, and doesn't even appear to realize how far from reality it is, then you should expect a dismissive attitude from those who are in fact knowledgeable about the functioning of the body in health and illness.

Sean--

Are you really claiming that the current position/state of every living human being's neck is so bad that any adjustment whatsoever, by the least-competent person, is better than no adjustment?

If you have just had your neck adjusted by someone you know and trust, would you still consider it a good idea to let a random stranger manipulate your neck?

That only makes sense if any benefits of adjustments wear off so fast that they are a waste of time and money.

A person doesn't have to be dubious of chiropractic to be dubious of the claim "Chiropractic is so wonderful that even when it is done ignorantly or incompetently, to a previously healthy and well-adjusted person, it will always make things better."

If you have just had your neck adjusted by someone you know and trust, would you still consider it a good idea to let a random stranger manipulate your neck?

I will confess (again?) that I had such bad neck problems as an undergraduate that at the end, I was eager to find anyone who would mercilessly pound the general area with the nose of a tiki doll that happened to be around.

It went away on its own.

^ Oh, but I forgot the best part: At one point, Phil Agre did a double-take at my seemingly trying to pull my head off before a meeting, and after I explained my flexibility and intent, he advised, "just don't ever let a chiropractor touch your neck." A quarter-century ago.

http://www.cureus.com/articles/4155-systematic-review-and-meta-analysis…

Narad

At one point, Phil Agre did a double-take at my seemingly trying to pull my head off before a meeting

I have been in may many meetings where I wanted to pull my head off, but I refrained from acting on the impulse.

"The bottom line is that you should never let a chiropractor, or anyone else for that matter, perform high velocity neck manipulation on yourself or your children. The evidence is clear that this type of adjustment is not more effective than safer options for neck pain, and the evidence is nonexistent when it comes to indications, like sinusitis, that have no plausible connection to the spine."

https://www.sciencebasedmedicine.org/chiropractic-manipulation-of-the-n…

@Dangerous Bacon

I'm always baffled by the double standard of "research" submitted to prove a point. You cited an opinionated article as if it delivers a definitive statement.

Case studies supporting chiropractic are dismissed as the lowest form of research available. However, this entire article (which has solidified the approval and persuasion of many) is WORSE than a case study because there is not one piece of factual onsite information available to the public describing what actually happened in that adjusting room.

Case studies are not dismissed out of hand here, by me or others. It is well recognized that when one is claiming a benefit for a procedure or drug, mere case studies are no more than suggestive at best and need to be confirmed by well-conducted large clinical trials.

It's a different matter when we're faced with serious complications and death from unwarranted medical or pseudomedical interventions.

I hope you're not suggesting that it's necessary to recruit a large group of six-year-old children and subject a portion of them to high-velocity neck cracking to see if there's a difference in stroke and death rate between the neck cracked and non-neck cracked groups.*

Meantime when a young child without risk factors has a stroke after chiropractic manipulation, we're apparently supposed to believe that he suffered the stroke because he turned his head to look at a bird or something.

*if ethics was suspended so that thousands of kids were recruited for such a study and a small number in the chiro group suffered devastating complications compared to much fewer or none in the non-chiro group, statistical manipulations could be performed to show "no significant difference" between the two groups. Which is essentially what happened in one comparative study of adults of which I'm aware.

Lets gain some context, shall we?

The National Center for Health Statistics reports children 0 to 18 years of age seeking medical treatment for an ADE between 1995 and 2005 is 585,922. In fact, the most modest number I have been able to find for ADE was between 2008 and 2012. Reported by ISMP (using FDA figures) was 45,610 adverse drug events reported in children less than 18 years of age. Of these, 64% (29,298) indicated a serious injury.You may claim that you are constantly researching to improve, but this study clearly explains that ADEs grew substantially over time--from 6,320 in 2008 to 11,401 in 2012.

A review of cases published in Pediatrics in January 2007 showed 14 cases of direct harm from spinal manipulation.

That study does not even state that the manipulations were performed solely by chiropractors.

Your use of incendiary language, "pseudomedical" "neck cracking" is manipulative at best. Pun intended.

Also, yes strokes occur in children. From the American Stroke Association:
"Delayed or misdiagnosis of stroke in children is still
common. Nevertheless, the incidence of stroke in
children has been stable over the last 10 years and
childhood mortality from stroke fell by 58% between
1979 and 1998. However, the decline appears to be
the result of decreasing fatalities after stroke, not a
decrease in stroke incidence.
• Between 20% and 40% of children die after a
stroke.
• About 3,000 children and young adults had a
stroke in the United States in 2004.
• Boys are at higher risk for stroke than girls.
• African American children are at higher risk for
stroke than Caucasian and Asian children."

You have never seen any "proof." You have heard theory that appeals to you.
Basically, you're emotional. It guides you.

"Lets gain some context, shall we?"

Wonder if the chiro said this to the parents of the six-year-old who had the stroke after forceful neck cracking.

I'm sure a reference to incidence of drug side effects would've been very comforting to them.

The trolls are thriving...chiropractic always seems to polarize people. To the point...a more recent meta-analysis of the issue (done by real doctors associated with Johns Hopkins...)

http://www.cureus.com/print/articles/4155-systematic-review-and-meta-an…

Those of you who advise people to "Never let a chiropractor adjust your neck"...if you actually look at good non-biased research you will find a plethora of well designed studies that prove efficacy as well as safety. (I cannot EVER recall seeing a VBI listed as an adverse reaction in a well supervised study.)

Medicine is in need of some housecleaning as well...around 70% of commonly practiced procedures/prescriptions are NOT based on any reliable scientific based "evidence"...again taken directly from respected medical journals and "real" doctors. You can trust whoever you want, but it is YOUR decision and ultimately your body, I do not think it is a coincidence that the typical chiropractic patient has a higher level of education when compared to traditional medical care.

The philosophy is pretty simple...

1. The body is a self correcting, self correcting organism. This could be called Vitalism...or "innate Intelligence" which is how the founder described the theory. Why would a medication cause a desired effect? the answer is that the body can already produce a similar chemical/hormone and a has matching receptors already in place.
2. The nervous system is the "master control system" and is responsible for recognizing stresses and appropriately changing physiology/chemistry to appropriately respond to those stresses.
3. abnormal position and/or movement of the spinal joints or the extremities can cause the nervous system to become "uncoordinated" in its response to stresses. Either poor input from the sensory organs or altered motor/efferrent response. (If you don't believe this, then you will never understand why anyone would go to a chiropractor...which is fine...just stop the ignorant bashing and name calling and submit yourself to the benevolent and omniscient Gods of medicine)
4. Chiropractors are the ONLY professionals that are trained to identify and correct these alterations in spinal function. Correction (adjusting) of these "Subluxations" (or if you prefer..."Somatic Dysfunction") allows the ENTIRE nervous system to function more efficiently. YES...this means that even non-musculoskeletal complaints may resolve with treatment. I never promised a cure to any of my patients, and never took credit when they did respond. I treated many patients with cancer...never once told the patient that I would cure them, but we were able to minimize a lot of the discomfort that they were experiencing and were able to raise their quality of life significantly.

There are NO "perfectly safe" interventions performed by any profession...you just need to put the risk/rewards in the proper perspective.

Troll away!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

around 70% of commonly practiced procedures/prescriptions are NOT based on any reliable scientific based “evidence”…

Citation needed.

1. The body is a self correcting, self correcting organism. This could be called Vitalism…or “innate Intelligence” which is how the founder described the theory. Why would a medication cause a desired effect? the answer is that the body can already produce a similar chemical/hormone and a has matching receptors already in place.
2. The nervous system is the “master control system” and is responsible for recognizing stresses and appropriately changing physiology/chemistry to appropriately respond to those stresses.

Can you please explain why unmedicated childbirth was so horribly painful for me? And countless other women?

If the body is self-correcting with 'innate wisdom' why does my friend have to visit surgeons repeatedly for Depuytren's contracture?

Why would a medication cause a desired effect? the answer is that the body can already produce a similar chemical/hormone and a has matching receptors already in place.

I wonder what natural chemical/hormone is mimicked by oxiplatin.

Medicine is in need of some housecleaning as well…around 70% of commonly practiced procedures/prescriptions are NOT based on any reliable scientific based “evidence”…again taken directly from respected medical journals and “real” doctors.

Citation please. I believe that this is the zombie canard that will not die. It was taken from a casual survey of 19 GPs in Britain in the 1950s to assess.drug costs. Here is a reference that explains it all.
http://www.bmj.com/rapid-response/2011/10/28/only-20-western-medicine-e…

I firmly believe that anyone attempting to use this bogosity in an argument has already lost.

"1. The body is a self correcting, self correcting organism."

Obviously then, chiropractic adjustments are unnecessary. The body will crack itself.

"This could be called Vitalism""

Or more accurately, bullshit.

"The philosophy is pretty simple…

1. The body is a self correcting, self correcting organism."

Then chiropractors and their "corrections" are entirely unnecessary.*

"This could be called Vitalism"

Or horse droppings. Take your pick.

*"The spine was misbehaving, so I had to correct it."
- Lloyd the bartender, in "The Shining".

Delphine: "Can you please explain why unmedicated childbirth was so horribly painful for me? And countless other women?"

Because he is a clueless man who has never had to push something the size of a bowling ball out of an opening small enough for his little penis. Plus he is a chiropractor who was educated on fantasy not reality.

Good point, Chris, but are we sure "Diffffffferrrrence" is a man?

FWIW, the worst minimizers of childbirth pain that I've encountered are women. When I told my old man (delivered innumerable babies out of necessity without anesthesia) that I was going to do this drug-free he said, "Christ, are you daft?!"

*”The spine was misbehaving, so I had to correct it.”
– Lloyd the bartender, in “The Shining”.

Still the scariest book I've ever read.

Delphine, I don't know. It is just that the spelling impaired person was being annoying.

Yes, some women are the worst. They simply do not understand that there is a great genetic variation in pain perception. I could be one of those annoying women because have delivered without pain medication, but it is not due to a "strong will." It has to do with having actually dull nerves.

This is sometimes not a good thing. I have injured myself and not realized until I notice a bruise and every so often I am actually dripping blood (which happened when I was repairing the white wool drum majors uniform for high school band... I had stabbed myself with a pin). One time I stumbled on uneven pavement, though I had sprained my ankle (again). The next morning my foot was very colorful and swollen, so to the emergency room where we learned I had broken a couple of metatarsal bones.

Though when I do feel pain, I am the worst person to be around. And the cruel thing is that I will still itch. So broken bones don't bother me as much as itchy casts! (the list includes broken ribs, foot, ankle and wrist).

re genetic variation

I've come across a few references that show more sensitivity to pain amongst the red/ ginger haired** - which of course I use to harass someone I know.

Personally, I have experienced the phenomenon Chris describes of not always feeling much despite injury.
My late father was quite able to tolerate much after urological surgery yet - the doctor was amazed.

** except for Chris, which again, illustrates genetic variation. It's not everyone.

I have injured myself and not realized until I notice a bruise and every so often I am actually dripping blood

Yeah, I have this too. "Oh, really, I'm bleeding? Where?"

It does help when one is getting tattoos, though, at least to an extent. There is also a certain amount of "talking oneself into it." ("Well, I paid for this, I got myself into it, I guess it's time to get down to business!")

I have been told by an anesthesiologist at a brain science fair that those of us with red hair drive them crazy. Even though, alas!, my hair is no longer red (the white hairs are taking over).

Please don't make a joke of this topic. Many people have suffered the loss of loved ones at a young age due to arterial dissections. I however, survived my vertebral artery dissection. Yes, it is more common than documented. They can tear and heal asymptomatically with no long term or even noticeable complications. Yes, I saw a chiropractor whom performed neck manipulations I wish I would have know the possibility and I would never have had my neck manipulated. So, as healthcare professionals and yes I am one why don't we work together to solving the mystery. Chiropractors have not been willing to do their part in researching the topic. It will cost money and I can assure you they will lose their ability to state any benefit that could possibly out way a stroke caused by manipulation. Yes! I now know many whom suffered chiropractic stroke. On the bright side, I utilized my experience to shift my career into neurology...nurse practitioner. Believe me, I voice concerns with my patients and always recommend they decline any form of neck manipulation. Please chiros, do the research that needs done. You should be able to afford it since your malpractice is so low, or perhaps business isn't as good as you may lead some to believe. Please stop scaring parents out of vaccines! You are dangerous!

I would just like to respectfully enlighten some of you about Osteopathic Physicians, or D.O.'s on this thread. This is either by ignorance and/or just that most DO's don't incorporate their hands anymore into medical practice. I realize that statistics show that only about 10% of the 100,000 or so practicing Doctors of Osteopathic Medicine ( D.O.'s ) in the U.S. utilize their hands-on skills of Osteopathic Manipulative Treatment, or O.M.T. in clinical practice, so it's conceivable that DC's/Chiropractors are the most recognized practitioners of SMT, or spinal manipulative treatment. However, there are about 700 of us in Osteopathic Medicine that have gone on to specialize in SMT by getting Board-Certified in it. Some of us, myself included, even got double- board certified in both Family Practice as well. There is only one recognized medical board in the U. S for spinal manipulation called the American Osteopathic Board Of Neuromusculoskeletal Medicine ( AOBNMM )-a branch of the American Osteopathic Association ( AOA -based in Chicago ) located in Indiana that oversees this. I have recently been re-certified for another 10 years after passing a rigorous 3 and 1/2 hr. written exam after initially passing an Oral, Practical, and Written 3 day board certification exam process. This was only after having to prove proficiency after submitting case studies to a panel of Osteopathic Manipulative specialists to prove that I had real-time patient practice experience. Also, I graduated from he founding medical school of Osteopathic Medicine in Kirksville, Missouri and had over 600 hours just in medical school and then hundred's more hours in 3rd and 4th year followed by three more years during my residency in Family Medicine wherein Osteopathic SMT was integrated in to many phases of my medical training. Albeit, I was more interested in incorporating this form of the Osteopathic hands-on skillset into my medical practice than my colleagues. I am also an adjunct professor in about 5 medical schools and routinely teach medical students and residents and have been utilized as an expert witness because of my unique training. This is not to brag or be condescending. I wanted to both politely object and correct/enlighten the readers and writers here that there are other extremely well- trained and experienced practitioners of these skills here in the U.S. I have had far more hours and training than many, if not most chiropractors and other D.O.'s and politely object to this being omitted here. I have also been in medical practice of Integrative Family Medicine and Osteopathic Manipulative Medicine for over 24 years and enjoyed great success with my patients. I am very good at and confident in my use of manual techniques including both HVLA ( thrusting ) and non-thrusting maneuvers. One has to know when to use them and when not to. The advantage I have always had is to both step back and look at the 'whole picture' of a person, having the advantage of having had what is, in my opinion, a very 'complete' and comprehensive medical training - 7 years after college and then more board examinations and re-certifications while in practice. The success every day with millions of adjustments, whether it be Chiropractic or Osteopathic ( let me correct some of you- it is my understanding that physical therapists in the US are NOT licensed to do manipulation unless they take a rigorous 2 year extra course of training -this is rare ) proves that this is a relatively safe form of treatment, especially compared to more invasive medical procedures. However, there is no substitute nor comparison for the type of experience that I and many of my Osteopathic medical colleagues in all defferent specialities have been exposed to when it comes to evaluating patients to avoid tragedy. There are also 'good' and 'bad' physicians in every area of medicine, chiropractic, therapists in physiotherapy, massage, physical therapy, acupuncture, etc.. Each case should be construed as a unique one. This unfortunate incident has many aspects. Perhaps if the family requests it, a full investigation, including an autopsy and other aspects may need to ensue.

Thanks for making that point, David.

Most of the readers here are aware that Osteopaths in the U.S. have training roughly equivalent to that of Medical Doctors. My alma mater, Michigan State University, has a College of Osteopathic Medicine created by the state legislature during the more enlightened days of the baby boom when it was clear the state needed more doctors than Orac's alma mater could provide.

But this blog draws readers from around the world, and in all of those countries that I know of, osteopaths have training that is not much better than the average chiropractor.

The key point in this article was that we do NOT know whether manipulation of the neck caused the stroke and probably can't tell for sure.

But it was a bad idea that was highly unlikely to have any medical benefit.

I'm sorry for jumping into the conversation late but was an xray or MRI taken at any point after the injury. I think that chiropractic manipulation should be only be considered after a person is cleared of any underlying or hidden condition.

When a professional football player is injured on the field every step is taken to keep the neck, back and legs in a neutral position until an MRI can be performed,
That said, I think that routine chiropractic manipulation is both risky and irresponsible, and could in fact worsen an injury and patients overall condition.

First, we are all saddened by the loss of a life. My sympathies go out to the family. Unfortunately, this blog will not help others. In fact by misrepresenting the facts, you are dissuading people from seeking safe conservative care in place of more threatening alternatives. This bog is in contrast to the current evidence:

The largest medical study to date (1), encompassing 100 million person years, found that strokes occur at a similar increased rate regardless of whether the patient sees a chiropractor for manipulation or their PCP for consultation. The authors found: “no evidence of excess risk of VBA stroke associated chiropractic care compared to primary care.“ Researchers discovered that patients in the developing stage of a stroke are more likely to visit a chiropractor or PCP for complaints of headache and neck pain. The study suggested that the chiropractic or PCP treatment was not the cause of the stroke, but rather a non-contributory mid-point of an undetected developing crisis.

Another study by Kosloff et al. (2) extracted 3 years of commercial insurance and Medicare advantage plan data for approximately 39 million insured patients- representing approximately 5% of the total US population. The study analyzed a potential correlation between chiropractic visits, PCP visits, and stroke. The study found: “No significant association between VBA stroke and chiropractic visits. We conclude that manipulation is an unlikely cause of VBA stroke.” The study did however find “a significant association between PCP visits and VBA stroke. The positive association between PCP visits and VBA stroke is most likely due to patient decisions to seek care for the symptoms (headache and neck pain) of arterial dissection.” Like the Cassidy study, this study strengthens the premise that chiropractic manipulation may not increase the risk of VBAI stroke; rather, impending VBAI stroke patients may have a higher likelihood to seek care from a variety of providers, including chiropractors.

I hope that you will drop your unfounded bias toward manipulation in consideration for the facts.

1. Cassidy JD et al. Risk of vertebrobasilar stroke and chiropractic care: results of a population based case-control and case-crossover study. Spine 2008 Feb 15;33(4 Suppl):S176-83 http://www.vtchiro.org/Resources/Documents/Chiro%20Stroke%20Cassidy.pdf

2. Kosloff TM, Elto D, Tao J, Bannister WM. Chiropractic care and the risk of vertebrobasilar stroke: results of a case–control study in U.S. commercial and Medicare Advantage populations. Chiropractic & Manual Therapies (2015) 23:19

"What we should not forget is that the Cassidy study was but one of several case-control studies investigating this subject. And the totality of all such studies does not deny an association between neck manipulation and stroke."

"Much more important is the fact that a re-analysis of the Cassidy data found that prior studies grossly misclassified cases of cervical dissection and mistakenly dismissed a causal association with manipulation. The authors of this new paper found a classification error of cases by Cassidy et al and they re-analysed the Cassidy data, which reported no association between spinal manipulation and cervical artery dissection (odds ratio [OR] 5 1.12, 95% CI .77-1.63). These re-calculated results reveal an odds ratio of 2.15 (95% CI.98-4.69). For patients less than 45 years of age, the OR was 6.91 (95% CI 2.59-13.74). The authors of the re-analysis conclude as follows: If our estimates of case misclassification are applicable outside the VA population, ORs for the association between SMT exposure and CAD are likely to be higher than those reported using the Rothwell/Cassidy strategy, particularly among younger populations. Future epidemiologic studies of this association should prioritize the accurate classification of cases and SMT exposure.
I think they are correct; but my conclusion of all this would be more pragmatic and much simpler: UNTIL WE HAVE CONVINCING EVIDENCE TO THE CONTRARY, WE HAVE TO ASSUME THAT CHIROPRACTIC NECK MANIPULATION CAN CAUSE A STROKE."

http://edzardernst.com/2015/01/chiropractic-neck-manipulation-can-cause…

The Kosloff study has its problems too, as even a defender of chiropractic has acknowledged:

"The authors acknowledge certain limitations of their study due to the nature of insurance claims data. These data do not code for what specific treatment was rendered or immediate responses to treatment. Thus it is not known if chiropractic manipulation was performed during any office visit and if there was any immediate adverse response. Further, the accuracy of the VBA stroke diagnoses is unknown. Finally as the authors note there is a loss of “contextual information surrounding clinical encounters between chiropractors and Primary Care Physicians and their patients.” This limits the knowledge of other known risk factors."

http://blogs.biomedcentral.com/on-health/2015/06/19/chiropractic-care-a…

There remains no good justification for forceful neck cracking, which is particularly alarming when inflicted on patients who have suffered acute neck trauma.

first, thanks for your comment #211 ( I don't know your name-sorry ). You're right- if this is read by people all over the world, then they might not know that DO's in other countries as opposed to the US are generally limited to only Osteopathic spinal manipulation and do not have a full plenary medical license as do we in the United States. 'Osteopaths' , as they are generally referred to in other countries, are at the same level as chiropractors.
That said, I am familiar with the cited articles above by Cassidy as well as Shekelle and Cherkin in 1998 and 1999, for ex. in the NEJM as well as the articles on Osteopathic manipulation in the NEJM by Anderson, et al in 1999 and in 2000 with follow-up commentary, and the 'Beauty parlor Syndrome ' reports in The Lancet and I believe JAMA or NEJM. All of this does not preclude that experienced DO's such as myself who are also board-certified in providing this type of clinical skill, perform this almost every day in our offices with great success and to the relief of our patients. My Osteopathic adjustment techniques, albeit, are apparently very different from my chiropractic colleagues, as I am told by my patients, colleagues and my own observations of Chiropractic adjustments. I also have the distinct advantage of a formal medical background/training so that I am keenly aware of a patient's medical history and thus possible elements of complications.
I do believe, from the story as I read it, that no manipulation of any kind should have been attempted after this woman fell and had a neck injury. I believe I would have at least consulted a
neurologist/neurosurgeon after a bonafide workup with radiology ( X-rays, Ct vs. MRI ) to make sure there was no sustained evidence of any bony or neurologic trauma. Any type of forcible trauma like this to the neck deserved a thorough medical investigation by specialists. If the chiro saw the patient after she was cleared by a specialist, then we may have heard about it and that would lend some creedence, but it doesn't sound like that happened. We need more information. The timeline doesn't make sense.

You're welcome, David.

I've read that osteopathic manipulation is more gradual and gentle than chiropractic manipulation, but don't really know.

The bottom line in this case is that there are too many unknowns to draw a clear judgment, but visiting a chiropractor was a bad idea.

In response to David:

"( let me correct some of you- it is my understanding that physical therapists in the US are NOT licensed to do manipulation unless they take a rigorous 2 year extra course of training -this is rare )"

That is incorrect. Physical Therapists have been performing Thrust Joint Manipulation since the 1920s and have been heavily involved in the reasearch into its efficacy since at least the early 1960s. A physical therapist does not require a license to perform manipulation. We are taught SMT in our respective entry-level educational programs. Most therapists however attend continuing education programs (such as the excellent Spinal Manipulation Institute founded by James Dunning. http://www.spinalmanipulation.org/) in order to acquire high level skills in spinal manipulative therapy necessary to safely perform these treatments. And Physical Therapists perform thorough exams prior to performing any SMT on a patient (i.e., evidence based medicine). Certain state practice acts do not allow for a PT to perform Joint Manipulation. PTs in Texas can perform Spinal Manipulation pending a physician signs off on the plan of care.

In response to SMT_PT,

Thank you for the enlightening response #217 and I assume you are indeed Dr James Dunning himself. I did my due diligence and referenced the website link you wrote of and many other reputable sites. First, I applaud you for winning your case in Alabama against the ASBCE and also that your training includes Physiotherapy and Osteopathic training in the UK. It appears very similar to the type of Osteopathic spinal manipulation that I have been privy to learning.
However, it with all due respect that while we all probably agree that there are positive benefits to spinal manipulation in general, there is wide variation amongst our respective training. I reviewed your course outline for a 2 day course after which you offer 'certificates'. I would like to ask you how many hours you teach and what are required to certify one to actually perform such varied and complicated techniques as HVLA?
I had over 800 hours integrated into my medical school curriculum at ATSU- The Kirksville College Of Osteopathic Medicine, much of which is emulated at the British School Of Osteopathy since my school was the founding school of Osteopathic Medicine in the U.S.. During and after medical school ( 4 years med school plus 3 years of residency in one field and 2 years in another -that's a total of 5 years post-graduate) I had to prove my competence as they do now to my peers by passing three national board exams as well as a practical exam in my first specialty of Family Medicine by the American College Of Osteopathic Family Practice to demonstrate proficiency. After this, I went on to become even further board-certified by the American Academy Of Osteopathy's ( AAO ) American Osteopathic Board Of Neuromusculoskleletal Medicine ( located in Indianapolis ) after passing a 1 week-long set of board examinations that included the presentation of 3 peer-reviewed case histories/studies submitted to the board for review prior to taking an Oral, Practical ( real patients/demonstrating hands-on skill proficiency ) , and a 3 1/2 hour written exam following a Residency/Fellowship. Recertification requires a rigorous written examination every 10 years plus Continuing Medical Education. It also qualifies us to be expert witnesses in the subject. This is the ONLY Board in the US that certifies physicians- now open only to D.O.'s in the US. The AAO has started courses to teach MD's as we merge the ACGME in the coming years.

Dr. Dunning advertises that his 'institute' as the 'Worldwide Leader in spinal manipulation education'. I see that a typical 'certificate' take 12-18 months to complete. he also calls them 'Osteopractors', a mash-up of Osteopathic and Chiropractic disciplines, but claiming that it is not the same. Funny, he also must base his principles on that of Osteopathy, from which he received training and whose principles are rooted in American Osteopathic Medicine in Kirksville, Missouri by Andrew Taylor Still, MD begun in 1874 ( the school began in 1892 ).

While you may have some expertise in a field that few MD's and PT's possess, please don't pretend or profess to be the 'worldwide leader' or 'experts' in spinal manipulation when your training far shadows that of a formal medical residency/fellowship in the US in hours, course clinical correlation and years, not 'months' of training. I have been doing this for almost 30 years integrating and teaching these skills into real-world everyday outpatient and inpatient medicine. I am also a professor at several medical schools in this subject.
Like I said, although I applaud you and other PT's and even MD's ( I can't believe some DO's would actually need to take this, but I guess they might need to feel they can sharpen the skills they were already taught -it's their $ ) for taking an interest and I'm sure you are sincere, there is already a bonafide and well-accepted specialty board in spinal manipulation in the US and it's Osteopathic true to it's roots. I still maintain the PT's are not allowed to perform spinal manipulation unless they are certified by a governing and accepted board. As your thread states in the last sentence, a 'physician' ( what kind and what is their certification/background? ) in TX must sign off on their care. Please be more specific and scientific/fact-based before passing yourself off as an expert.

I am certainly not being haughty or disrespectful when I write this, but after you or a self-proclaimed 'expert' in spinal manipulation with years of experience and rigorous proven training spends time in 'my shoes', please make the correct comparison. This is akin to comparing an Orthopaedic Surgeon ( MD or DO- 4 years of med school, plus a 5 year surgery residency and perhaps a 2 year fellowship -includes board Certfication ) to a PA or Physician's Assistant in Orthopaedics ( 3 years of graduate level training ).

Remember- 'Apples to Apples' here in the US.

Man, you are really into yourself. Just calm down. There are more people other than yourself performing Spinal Manipulation worldwide. There are plenty of clinicians in all disciplines that have superior skills. You should know that and maybe have a little humility, before you make assumptions that physical therapists do not have the training or expertise to perform spinal manipulation. I am not James Dunning, but why don't you call him yourself? Pretty sure he could enlighten you and maybe even teach you something.
There are states where PTs have direct access to care, in which they do not require a physician (MD, DO) to refer patients to them. If spinal manipulation benefits a patient/client, and the clinician who is examining them has the skills (not only in the specific techniques, but in differential diagnosis as well (which btw, most PTs possess), does it matter if the treatment is performed by an Osteopath or a Physical Therapist?

First, I apologize for making it seem that, " I am into myself..." that's just not true and I feel your comments about my humility are unnecessary, but you do have a right to express your opinion, as do I. I also qualified my statement in the last paragraph by stating I was not trying to be disrespectful. I never made an 'assumption'- I am citing facts. i also happen to have a excellent professional relationship with my neighbors who have a large PT practice right next door to me referring them a lot of business. I believe in and they appreciate the combination advantage that PT and OMT ( Osteopathic Manipulative Treatment ) offers patients. We both know our limitations.
I was defending a misconception enlightening you and others that there is a clear difference in the amount of skill and training required. You have also not identified yourself as either a professional or a patient here- your honesty is appreciated. If you are a practitioner vs. a patient, this is important. Patients/people are always doing their due diligence by internet or calling/having a consultation and they have a right to know the extent of the person claiming their expertise. That's common sense and client safety and courtesy as they are consumers.
I agree that there are others performing this skill, albeit in different ways and that there are good and bad practitioners all over.
Third, when a patient is receiving spinal manipulation , it does actually matter, on a case by case basis whether it is performed by a PT or other practitioner- at least in New Jersey it is. This is especially true when I refer a patient to a physical therapist, so we're not duplicating services, plus it is by referral only, so it's a professional courtesy to let the referring doctor know as it is part of the medical record/documentation.
You are correct that in certain states PT's don't require a referral as is the case in NJ. However, if they would like another referral from the doctor that they see a patient from despite a referral, they are always coming over to introduce themselves to garner new business.
I am not arguing with you about whether SMT benefits a patient or not, but I do contend that it does matter what type of practitioner does it because it is related to the treatment plan timeline and outcome.
I stand by my background and extensive training and challenge you to compare it to yours or others. That's why physicians and others take these courses and training to justify and prove the best proficiency available. otherwise it can be detrimental, as is why we're all interested on this thread in the first place.

If you must know, yes, I am a Physical Therapist with a clinical Doctorate in Physical Therapy from an American accredited public institution and I have been doing this for several years. I have certifications in manual therapy, diagnosis and treatment and I could care less about word soup. My patients and fellow clinicians know I am capable and safe in providing treatment with good outcomes and our physicians know we treat and diagnose only neuromusculoskeletal disorders and when a patient does not fall under those 3 systems, we refer the patient back to the physician. This is best practice and what the public deserves. If you are still unsure what Physical Therapists do, I challenge you to go to one of Dr. Dunning's courses or any advanced courses taught by Peer reviewed clinicians who are bonafied experts. Dunning's group is a great example and the IAOM-US (They teach physician based clinical examination based on James Cyriax and PT, Dos Winkel's work) is another. Don't fall into Dogma; "You don't know what you don't know."

Ok- thanks for clarifying. It sounds like you have experience and also have gone on to earn a doctorate in your field. That is impressive. I don't know too many PT's who have gone on to do that and you are due recognition. I wish you had written that sooner. I am familiar with Cyriax' work, but he generally was anti- DO and DC. I also had some training with MacKenzie's work and also the physiotherapist, Maitland-good resources. Interestingly enough, I also found Dalton's PT work online on YouTube fascinating, accurate, and very similar to Osteopathic training-confirmed by the fact he trained with Phil Greenman, D.O., at Michigan State College Of Osteopathic Medicine.
If I can, one day, I'd like to see what this course is all about. Until then , I would challenge you back to come to see how the AAO ( American Academy Of Osteopathy) sets up things-they hold a Convocation annually in and around March, but but have stuff going on all year round.
-Respect.

Wow! Yours is the best description of the pathophysiology surrounding a "spontaneous" Carotid dissection i have come across in the 25 years since i suffered a similar fate. As a physician i spent years trying to deduce the cause of my stroke that left me with a right hemiparalysis. At first i speculated that my struggles with a new electric razor, or an accidental elbow during basketball, as possible causes. It was two years until i reached the still speculative conclusion that my pulling a golf cart with my left arm while hustling to clear a fairway was the origin of my fate. The group behind suddenly yelling "fore" and my natural response of quickly turning to the right, and subsequent sudden, but short lived neck pain was the start of my dissection that within the course of 1 week, would lead to my multiple seizures preceding a 5 day coma from which i awoke with dysarthria , right sided paralysis, and a massive stroke which stemmed from my middle cerebral artery and was confirmed by angiography of my carotid that showed the dissection. In those 7 days leading up to the catastrophic event i would have multiple events that i rationalized off as part of migraine even though i had no history of the same. These included a week long headache, some loss of central vision and my right thumb getting periodically numb all leading up to my confusion and subsequent seizures followed by coma. I speculate that my pulling the cart with my left arm had somewhat fixed the L subclavian so that the sudden turn towards the R could supply enough sheering force to cause the intimal tear which would ultimately harbor the clot that broke off and occluded the R middle cerebral artery. There may have been other factors such as a poorly developed anterion communicating artery with in my circle of Willis and the fact that i possessed a faint scar from my childhood chicken pox, directly over the L carotid (which there is some literature supporting intimal damage to the underlying vessel with the varicella virus in childhood) that may have contributed. But ultimately, my struggle to find a source, have lead me towards this conclusion. After 4 mts. of intensive rehab. i learned to walk with an AFO, and learned to write with my L hand and returned to my practice that we started 5 yrs earlier and would ultimately become the largest and most successful family practice in Santa Monica. This was my first exposure to your blog and i am very impressed with your understanding and final conclusions surrounding this dreadful process. You have earned a new reader!

Welcome, Dr. Hak. I hope you enjoy our little part of the internets. By the way, if you like it here you might also like another blog that a "friend" Orac is an editor and contributor: www.sciencebasedmedicine.org

Join his many minions. Join us, join us, join us. ;-)

Look up Kevin Sorbo stroke. His "doctor" cracked his neck despite him telling him not to. His response "I thought you neede it", which is the verbatim retort they all give after a loud crack, some even say "excellent" when no crack is heard. These asshats are frauds and should be thrown into prison for making false medical claims and spewing bullshit medical jargon and disabling people. Cracking your joints does nothing for your health. You can do it yourself or have a friend help and you will not get relief. And these morons in the videos who shout out after getting "adjusted" are just bullshit. You do not feel anything. There's even one melon farmer who says in his video that 98% of newborns have spinal defects and need adjustments.

#226- what is your point/comment? I tried going to the link, but it did not work.

https://www.sciencebasedmedicine.org/chiropractic-manipulation-of-the-n…

http://www.webmd.com/stroke/news/20140807/could-chiropractic-manipulati…