What alternative health

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Adverse events associated with spinal manipulation. Regarding neck manipulation, the risk/benefit ratio for the procedure appears to be in question due to the availability of safer options.

NOTE: In the UK, there appears to be no publicised national system for reporting adverse events related to chiropractic treatment. Furthermore, the UK General Chiropractic Council's current promotional literature appears to make no mention of serious risks.


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Safe for children?

Sandra Nette v. Stiles et al

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“Spinal manipulative therapy performed by chiropractors is increasingly common in the United Kingdom. Spinal epidural haematoma is a rare complication of such physical therapy but when identified represents a neurological emergency. We describe the case of a 64 year-old man who presented with a dense hemiplegia due to a spinal epidural haematoma following cervical spine manipulation performed for acute neck pain. The clinical features and surgical management of the case are discussed and we stress the importance of recognition of chiropractic manipulation as a potential cause of neurological sequelae and discuss the potential pitfalls of such therapy as it becomes more widespread.”  J R Army Med Corps (December 2010)

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“Cervical artery dissection (CAD) represents an increasingly recognized cause of stroke and the most common cause of ischemic stroke in young adults…known risks factors for CAD are major head/neck trauma like chiropractic maneuver…” Open Neurol J. (June 2010)

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“VADs are associated with a variety of minor traumatic mechanisms including painting a ceiling, yoga, chiropractic manipulation of the spine, and driving. These events cause injury to the vessel wall either by shearing forces secondary to rotational injuries or direct trauma to the vessel wall on bony prominences, especially the transverse processes of the cervical vertebrae.” J Card Surg. (14th November 2010)

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Only 45% of chiropractic respondents in this study indicated they always discussed risk with patients in need of cervical manipulation. When asked whether they believed discussing the possibility of a serious adverse reaction to cervical manipulation could increase patient anxiety to the extent there was a strong possibility the patient would refuse treatment, 46% said they believed this could happen. Jennifer Langworthy and Lianne Forrest, Chiropractic & Osteopathy (October 2010)

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“It is concluded that adverse effects after spinal manipulation are not specific to chiropractic but occur with most types of spinal manipulation. Incidence figures can, however, not be derived from the data available to date.” Byung-Cheul Shin, Myeong Soo Lee, Tae-Yong Park, and Edzard Ernst, Focus on Alternative and Complementary Therapies (Volume 15, Issue 3, pages 198–201, September 2010)

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“… the National Quality Forum lists 28 ‘never events’ healthcare mistakes that should never happen and need to be reported. Death or serious disability from spinal manipulation is listed as no. 16. But chiropractors do not have to report this because they have a loophole. The National Quality Forum demands it of clinics and hospitals but no reporting is mandated for individual doctor’s offices where 99% of spinal manipulation is done. Chiropractors generally do not practise in hospitals or clinics. Therefore, there is no accurate reporting for injuries that occur as a result of spinal manipulation. Yet we have hundreds of victims who have suffered needless injuries due to a stroke as a direct result of a chiropractic manipulation, and they are horrible, permanent injuries and they happen to mostly young healthy people under the age of 45 years.” Focus on Alternative and Complementary Therapies (March 2010)

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“Clinical evidence strongly supports the notion that the dissection occurred during the maneuver since an MRI scan prior to the manipulation showed a protruded intervertebral disk and intact cervical vessels.” Clinical Neuroradiology (20th October 2010) [FULL TEXT - pdf]

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“…based on the totality of the best evidence available to date, there can be little doubt that the formal criteria for causality are, in fact, fulfilled, and that upper spinal manipulation is the cause of vascular accidents. Moreover, the Cassidy study is seriously, some would say fatally, flawed. Finally, there are several case-control studies that contradict its findings; so the totality of the evidence from case-control studies does suggest that upper spinal manipulation is risky.  Even if one conceded that there is still reasonable doubt about this question, responsible and ethical healthcare professionals have to subscribe to the precautionary principle. Neck manipulation is not of proven therapeutic value for any condition. Therefore, we have to err on the safe side. Put bluntly, this means that, until the matter is settled, we should not routinely use or recommend upper spinal manipulation. At the very minimum, we should only do so after fully informed consent.”  Edzard Ernst, Pulse (27th July 2010) [Free registration] 

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“Weak to moderately strong evidence exists to support causation between Cervical Manipulative Therapy (CMT) and Vertebral Arterial Dissection and associated stroke. Ultimately, the acceptable level of risk associated with a therapeutic intervention like CMT must be balanced against evidence of therapeutic efficacy. Further research, employing prospective cohort study designs, is indicated to uncover both the benefits and the harms associated with CMT.” The Neurologist (January 2008) [PDF]

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Victims of Chiropractic Abuse, Inc. (VOCA) has initiated a class-action lawsuit charging the Connecticut Chiropractic Council, the Connecticut Chiropractic Association, and their members with knowing that neck manipulations are associated with strokes and can cause stroke but refusing to inform patients of the risks in order to maximize profits. The suit also accuses the chiropractors of employing a strategy of misrepresentations or omissions designed to mislead patients by violating state laws that require they clearly identify themselves as chiropractors in advertising and marketing materials when using the title of "Doctor". VOCA is seeking financial damages; an injunction forbidding the use of the deceptive tactics; and other equitable relief, including but not limited to an order requiring chiropractors who have engaged in these deceptive tactics to pay appropriate fines. The suit was filed immediately after the Connecticut State Board of Chiropractic Examiners refused to grant VOCA's request to order chiropractors to warn patients that neck manipulation entails a risk of stroke. 

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"The association between chiropractic neck manipulation and vascular accidents is well established. A recent case control study, however, casts doubt on the notion that the association is caused by nature. A detailed critique of that study reveals several weaknesses. Therefore the balance of probabilities seems to indicate that the association, in fact, is causal."  Professor Edzard Ernst, review and opinion published in Perfusion (February 2010) [pdf]

Professor Ernst defends himself against accusations of bias, particularly relating to his critical assessments of chiropractic, in this January 2011 interview with On The Other Hand podcast host and chiropractor, Brett Kinsler. [Transcript.]

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“We describe the case of a 45-year-old woman who suffered complete paraplegia shortly after a chiropractic maneuver in the thoracic spine. Dorsal CT showed a calcified disc herniation at the T8-T9 level and MRI revealed a diffuse spinal cord ischemia from T6 to the conus medullaris without spinal cord compression at the level of herniation. Despite a normal arteriography, authors suggest a vascular injury as the cause of the deficit.” European Spine Journal (16th June 2010)

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"Twenty six fatalities were published in the medical literature and many more might have remained unpublished. The alleged pathology usually was a vascular accident involving the dissection of a vertebral artery. Conclusion: Numerous deaths have occurred after chiropractic manipulations. The risks of this treatment by far outweigh its benefit. Edzard Ernst, Int. Journal of Clinical Practice, Vol. 64 Issue 8, Pages 1162-1165 (16th June 2010) [pdf]

Deaths after chiropractic spinal manipulations: a reply [Prof. E. Ernst Int J Clin Pract. July 2011]

To the Editor: "This response (1) confirms that many chiropractors find it impossible to accept the key messages regarding spinal manipulation therapy (SMT), namely that this therapy lacks a plausible rationale (2) and its risks outweigh its benefits (3). The risks are, of course, far greater than the relatively few deaths seem to imply. Several hundred cases of severe but non-fatal adverse events are on record (e.g. 4,5). The benefits of SMT have, so far, not been demonstrated; even the many chiropractors who criticised my review (6–12), have not produced convincing evidence for such benefit. Why? The answer is simple: there is none! In the most recent Cochrane review of SMT for chronic low back pain, the main indication for chiropractors, concluded that ‘there is no clinically relevant difference between SMT and other interventions for reducing pain’ (13). For all other conditions, the evidence is even more squarely negative (14). If we focus on the bigger picture, we are confronted with balancing little benefit with considerable risks. The result of such an evaluation can never be positive – no matter how we turn and twist the complex details of this debate.” 

References: (1 ) Haynes MJ. Deaths after chiropractic: a comment. Int J Clin Pract; 65: 817. (2) Homola S. Real orthopaedic subluxations versus imaginary chiropractic subluxations. FACT 2010;15(4): 284–7. (3) Ernst E. Chiropractic: a critical evaluation. J Pain Sympt Man 2008; 35(5): 544–62. (4) Shin BC, Lee MS, Park T-Y, Ernst E. Serious adverse events after spinal manipulation: a systematic review of the Korean literature. FACT 2010; 15(3): 198–201. (5) Terrett AGJ. Current Concepts in Verebrobasilar Complications Following Spinal Manipulation. Iowa, IA: NCMIC Chiropractic Solutions, 2001. (6) Ernst E. Deaths after chiropractic: a review of published cases. Int J Clin Pract 2010; 64: 1162–5. (7) Wenban AB, Bennet M. Critique of review of deaths after chiropractic, 1. Int J Clin Pract 2011; 65: 102. (8) Poelsma C, Owen D. Critique of review of deaths after chiropractic, 2. Int J Clin Pract 2011; 65: 103. (9) Dokos C, Tragiannidis A. Critique of review of deaths after chiropractic, 3. Int J Clin Pract 2011; 65: 103–4. (10) Perle SM, French S, Haas M. Critique of review of deaths after chiropractic, 4. Int J Clin Pract 2011;65: 104–5. (11) Whedon JM, Bove GM, Davis MA. Critique of review of deaths after chiropractic, 5. Int J Clin Pract 2011; 65: 105. (12) Ernst E. Response to critiques of review of deaths after chiropractic. Int J Clin Pract 2011; 65: 106. (13) Rubinstein SM, van Middelkoop M, Assendelft WJ, de Boer MR, van Tulder MW. Spinal manipulative therapy for chronic low-back pain. Cochrane Database Syst Rev 2011; 2: CD008112. (14) Ernst E, Canter PH. A systematic review of systematic reviews of spinal manipulation. J R Soc Med 2006; 99: 192–6.

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“Spinal manipulation therapy (SMT) is often used by people with neck pain or discomfort as an alternative therapy due to its claimed less invasiveness and comparable efficacy. However, excessive manipulations are reported to cause rare but serious complications such as tetraplegia, vertebral artery dissection, epidural hematoma, and phrenic nerve injury.” Spine (March 2010)