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

@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?

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.

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.

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!

@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.

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?

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

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

It is. Varies by state.

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?)

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.

“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…

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”

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.

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.

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…

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!

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.

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.

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.

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

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.

In my believe, it did kill her.

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.

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 ?

@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!

“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.

@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.

@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.

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.”

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.

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’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-that-continues-to-define-the-practice-of-chiropractic/

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”.

@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 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.

@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.

@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.

@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.

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.

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.

@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!

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.

@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!

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.

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

Thanks.

@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.

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

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.

NCHAF v King*

@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.

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.

“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).

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

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.”

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.

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.

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.

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.

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

“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.

@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

@ 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.

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.

@HDB,

Nothing vulgur at all until it turns into petting.

@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.

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

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

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.

MOB

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

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)

@Dangerous Bacon

Only if @anon ymous goes too…

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.”

^ 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.

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.

@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.

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.

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-analysis-of-chiropractic-care-and-cervical-artery-dissection-no-evidence-for-causation

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!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

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

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-evidence-based-wrong

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

“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”.

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?!”

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).

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!”)

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!

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.

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

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.

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.

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?

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.”

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!

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.