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Chiropractor Anthony Pellagrino touts a dubious study of chiropractic for stroke

“Dr.” Anthony Pellagrino is a chiropractor who fancies himself a scientist. Unfortunately, his touting a dubious study of chiropractic for stroke shows that he doesn’t know a crappy study when he sees it.

When it comes to chiropractic, my viewpoint is along the lines of a frequent saying for which I’m known: Chiropractors are poorly trained physical therapists with delusions of grandeur. What do I mean? First, although chiropractors are trained in spinal manipulation, their training is generally based on a long discredited notion based on the existence of subluxations. Unlike physical therapists, they are not trained in the full range of physical modalities and exercises to help with spine problems, and, worse, what they are trained in is not science-based. Second, all too many chiropractors go beyond spinal manipulation and claim to be able to treat all manner of conditions and disease unrelated to the spine, such as allergies, autism, asthma, and many more. As a result, I can’t really recommend chiropractic for anything. When patients ask me about it, I’ll say that it might be OK for uncomplicated back pain, but not for anything else, and for heaven’s sake don’t ever allow a chiropractor to manipulate your cervical spine. No, I really mean it. Even when there’s a small risk of stroke, it’s too high a risk when there’s no demonstrable benefit to neck manipulation, contrary to what chiropractors like Anthony Pellagrino claim.

Speaking of stroke, I came across this Tweet the other day from him:

Of course, I’ll get to the study soon enough. First, however, meet Anthony Pellagrino, a chiropractor, whose Twitter page amused me, as his Twitter bio describes him as “Chiropractor. Advocate. Scientist.” Um, no. If you’re a chiropractor, you’re not a scientist, because you’re practicing a specialty rooted in prescientific vitalism. In any case, “Dr.” Pellagrino runs a website called ChiroEdge, which claims to provide, “fresh, relevant, research-backed content for your practice.” (Well, not my practice. I’m not a chiropractor, fortunately.) But practice, if you can call it that:

“Research-based.” You keep using that term. I do not think it means what you think it means. And make no mistake “Dr.” Pellagrino is all in on the pseudoscience of chiropractic. He’s not one of the “reasonable” chiropractors who rejects the vitalistic, superstitious elements of chiropractic and focuses on physical manipulation to relieve spine and musculoskeletal complaints. Just check out his practice website, Absolute Chiropractic in Monmouth, NJ:

Neurologically-based chiropractic corrective care focuses on the proper function of the central nervous system in order to not only address the root cause of health concerns, but to allow you to live your best life possible. The role of the central nervous system, comprised of the brain and spinal cord, is to control and coordinate the function of every system in the body. Because messages to and from the brain travel through the spinal cord and spinal nerves, misalignments in the bones of the spine can interfere with this communication: resulting not only in pain and irritation, but also dysfunction of cells, organs, and tissues of the body.

This phenomenon is known in scientific literature as “subluxation,” and has been shown to decrease our body’s ability to adapt to the various physical, chemical, and emotional stresses in our lives. Through the use of gentle, specific chiropractic adjustments, we remove these misalignments, restoring proper communication between the body and the brain, allowing the body to function at its absolute potential.

This is, of course, nothing more than a more sciencey-sounding restatement of the vitalistic root of chiropractic in which the “vital force” flows from the nervous system and spinal cord, a flow whose disruption by subluxations causes disease and can be restored by chiropractic manipulation. Perusing “Dr.” Pellagrino’s Facebook page, I see all sorts of bizarre claims, for example, the claim that chiropractic can treat neurodevelopmental disorders:

And this unsupported claim that chiropractic can help dysmenorrhea:

And this horrifying post suggesting chiropractic for ADHD:

And, of course:

Which brings us back to the study. First of all, note that “Dr.” Pellagrino doesn’t actually link to the study itself, even though it’s in the open access journal Scientific Reports. The study claims that even a single chiropractic treatment can improve symptoms after a stroke, which is a pretty bold (and totally unsupported) claim. The study is entitled The effects of a single session of chiropractic care on strength, cortical drive, and spinal excitability in stroke patients, and it comes from the New Zealand College of Chiropractic; Auckland University of Technology; Aalborg University, Denmark; Riphah International University, Pakistan; National University of Science and Technology, Pakistan; University of North Texas Health Science center; and Koç University, Turkey. (Truly an international collaboration of quacks!) Heidi Haavik is the corresponding author.

The introduction cracks me up. After a recitation of the burden of stroke and the lengthy and intensive nature of known effective rehabilitative treatments for stroke patients, Haavik and colleagues speculate wildly:

One possible intervention that may improve post-stroke motor recovery, but has to date not been adequately tested, is chiropractic care. Chiropractic care involves an holistic approach to health with a particular focus on the relationship between the spine and nervous system11. Traditionally, the main focus of chiropractic care has been the location, analysis and correction of vertebral subluxations. Vertebral subluxations are recognized as a biomechanical lesion of the spine by the World Health Organization (ICD-10-CM code M99.1). They have been defined as a self- perpetuating, central segmental motor control problem that involves a joint, such as a vertebral motion segment, that is not moving appropriately, resulting in ongoing maladaptive neural plastic changes that interfere with the central nervous system’s ability to self-regulate, self-organize, adapt, repair and heal. Chiropractors identify vertebral subluxations using a combination of pathophysiologic indicators of spinal dysfunction and then correct them using a variety of manual techniques, the most common being specific high-velocity, low amplitude adjustments that are delivered by hand to the subluxated spinal segment

The World Health Organization embracing quackery? Again? In any event, this is nonsense. The motor difficulties associated with stroke are not due to problems in the spine but because relevant parts of the brain have been killed or seriously injured by the stroke. Hence, there is no reason to suspect that subluxations have anything to do with it or that spinal manipulation would be particularly helpful in post-stroke therapy. None of that stops Haavik from paddling bravely up the river of chiropractic pseudoscience by conducting a randomized clinical trial of chiropractic care for stroke patients. Subjects were recruited from the Department of Physiotherapy and Rehabilitation at Railway General Hospital. Study volunteers were required to be at least 12 weeks out from a stroke and to have ongoing plantar (foot) flexor muscle weakness, but have the ability to contract their plantar flexor muscles on command. These are pretty broad inclusion criteria; most notably they do not appear to control for overall severity of stroke. As for the exclusion criteria, subjects were ineligible to participate if they exhibited no evidence of spinal dysfunction (presence of vertebral subluxation indicators identified by a chiropractor). (This one cracked me up. No subluxation? How does the chiropractor know?) Potential subjects were also excluded if they had absolute contraindications to spinal adjustments (including spinal fracture, atlanto-axial instability, spinal infection, spinal tumor, or cauda equina syndrome), or had experienced a previous significant adverse reaction to chiropractic care (defined as an untoward occurrence that results in death or is life threatening, requires hospital admission, or results in significant or permanent disability).

Here’s the flow chart:

A single session of routine chiropractic care was the experimental intervention, described thusly:

The chiropractic adjustments performed in this study were either high-velocity, low-amplitude thrusts to the spine or pelvic joints or instrument assisted adjustments15. These are standard adjustment techniques used by chiropractors.

More interesting was this, the control intervention:

The control intervention involved the chiropractor performing a similar examination to the chiropractic care intervention followed by the participant being moved into adjustment setup positions similar to the chiropractic care intervention. The chiropractor did not contact on a segment deemed to be subluxated during the control set-up and no adjustive thrusts were applied during any control intervention. This control intervention was primarily intended to act as a physiological control for possible changes occurring due to the cutaneous, muscular or vestibular input that would occur with the type of passive and active movements involved in preparing a participant/patient for a chiropractic adjustment.

Basically, I hope you can see the problem. Participants could well be aware of what group they were in if they had even a passing familiarity with chiropractic. This might not have been a big deal, but this was a crossover study; so participants saw both interventions. Also, there was no questionnaire to assess whether patients guessed which group was which, and, of course, the chiropractors couldn’t be blinded with respect to group. Yes, the statistician was blinded to experimental group, and the patients were not told which group they were in, but this is in essence a poorly blinded experiment. Worse, it enrolled only 12 subjects.

So what were the outcomes? Obviously, there was a reported benefit, but look at the confidence intervals! They’re huge:

Following the chiropractic care intervention there was a significant increase in strength (F (1,11) = 14.49, p = 0.002; avg 64.2 ± 77.7%) and V-wave/Mmax ratio (F(1,11) = 9.67, p = 0.009; avg 54.0 ± 65.2%) compared to the control intervention. There was a significant strength decrease of 26.4 ± 15.5% (p = 0.001) after the control intervention.

So basically, this was, as is the case for most studies of this type, a very unimpressive bit of data. The study was small. The blinding was questionable. The outcomes demonstrated wide variability. I also can’t help but wonder why investigators in several countries spread all over the world were only able to recruit 12 subjects, failing to meet their accrual goal of 15 subjects.

So what we have is yet another example of dubious science in the form of a small clinical trial conducted by practitioners of pseudomedicine that doesn’t really result in any evidence supporting the efficacy of that pseudomedicine. Yet a “chiropractor” named Anthony Pellagrino, who describes himself as a scientist, seizes on these incredibly preliminary and questionable results as strong evidence for the efficacy of chiropractic in stroke, same as it ever was. It matters not to him that chiropractic causes, not treats, stroke. Meanwhile, what the heck is Scientific Reports doing publishing such nonsense?

By Orac

Orac is the nom de blog of a humble surgeon/scientist who has an ego just big enough to delude himself that someone, somewhere might actually give a rodent's posterior about his copious verbal meanderings, but just barely small enough to admit to himself that few probably will. That surgeon is otherwise known as David Gorski.

That this particular surgeon has chosen his nom de blog based on a rather cranky and arrogant computer shaped like a clear box of blinking lights that he originally encountered when he became a fan of a 35 year old British SF television show whose special effects were renowned for their BBC/Doctor Who-style low budget look, but whose stories nonetheless resulted in some of the best, most innovative science fiction ever televised, should tell you nearly all that you need to know about Orac. (That, and the length of the preceding sentence.)

DISCLAIMER:: The various written meanderings here are the opinions of Orac and Orac alone, written on his own time. They should never be construed as representing the opinions of any other person or entity, especially Orac's cancer center, department of surgery, medical school, or university. Also note that Orac is nonpartisan; he is more than willing to criticize the statements of anyone, regardless of of political leanings, if that anyone advocates pseudoscience or quackery. Finally, medical commentary is not to be construed in any way as medical advice.

To contact Orac: orack[email protected]

69 replies on “Chiropractor Anthony Pellagrino touts a dubious study of chiropractic for stroke”

I’ve long thought chiroquacks were one of the worst sort of quacks, most quacks do harm by omission, and by that I mean they give you sugar pills or diluted water that do absolutely nothing, but if its a self limiting condition its usually fine, the harm comes when its something that needs actual medicine to treat and using snake oil delays treatment. Chiros on the other had do actual harm, a couple of my patients have sustained joint damage due to chiros and we all know of cases where they are caused brain stem strokes leading, in some cases, to death. On top of that they are at the forefront of anti-vax peddling.

Sadly they have gained acceptance to such a degree, often by using the old bait and switch of mixing actual physio into their quackery, all too many don’t even see chrio’s as ‘alternative’ medicine (sic)

Anecdote only but my wife was cured of her tendency to attend altmed practitioners by a chiropractor who she attended regarding low back pain. She described the treatments he was using and I was reassured (falsely as it turned out) that the treatments sounded mostly like what a physiotherapist would do. Then one day she came back literally shaking. The chiropractor had decided to manipulate her cervical spine (even though she had only low back pain) and she experienced a sudden momentary sensation that she interpreted as momentary quadriplegia. I doubt that could actually happen unless there is atlanto-axial instability and she has had no problems since, but at least she now won’t go near a chiropractor or any other altmed practitioner.

This might be the only known instance of a chiropractor actually curing anything?

Ouch, sounds like a scary experience. I’m glad she’s okay.

Wow. That is terrifying 🙁

My car insurance company sent me to a chiropractor for neck and back pain after a car accident. He might have been one of the “reasonable chiropractors” because he wasn’t into other forms of woo I could see. He just manipulated my spine and that was that. It seemed to work; I got better. Of course I know now my body probably just healed.

I later saw a similar chiropractor in California who manipulated my spine for migraines and again it seemed to help.

But when I moved to North Carolina and heard my new chiro talking about manipulating newborn spines, I got worried. His technique on my neck scared the bejeeus out of me. Even without an experience like your wife’s I was unnerved enough to stop going and I’ve never been to one since.

I really wonder just how hot the fire I was playing with got, then I’m glad I don’t know.

“… significant adverse reaction to chiropractic care (defined as an untoward occurrence that results in death …”
I would think that having had an experience causing death would result in exclusion from most therapeutic studies.

It would be interesting to evaluate the consistency of “high-velocity, low-amplitude thrusts.”
How does a chiropractor determine if a thrust has achieved the intended result?

How does a chiropractor determine if a thrust has achieved the intended result?

The check clears
The mark returns

“Vertebral subluxations are recognized as a biomechanical lesion of the spine by the World Health Organization (ICD-10-CM code M99.1)”

It’s not tbe first time I’ve read that. What’s the truth behind this “recognition” by the WHO.

There are too many people with a vested interest who have an input into the recommendations. The WHO recommendations cannot be assumed to be good science-based advice. The IPAC, which is part of the WHO, listed glyphosate as a cancer hazard and this resulted in the recent court decision to award someone $300 million because of NHL said to have been caused by glyphosate to which he was exposed, even though every other scientific organisation has come to the conclusion that there is no link between glyphosate and NHL.

It’s not tbe first time I’ve read that. What’s the truth behind this “recognition” by the WHO.

It’s an ICD-10 billing code.

The journal name, Scientific Reports, was already enough to raise my eyebrows. Too reminiscent of titles like Medical Hypotheses and Physics Essays, known hotbeds of pseudoscience. So I consulted my research assistant Mr. Google, and was dismayed by the results. Et tu, Nature Publishing Group?

Tell me how to get back to the timeline where we had jetpacks, flying cars, and scientific publishers who understood that they had a duty to avoid the appearance of backing pseudoscience like chiropractic. I can understand why laymen are fooled by some of this stuff when the people who are knowledgeable enough and in a position to do something about it give their implicit blessing by failing to act.

You do realize, don’t you, that Scientific Reports is owned and run by Nature Publishing Company. Basically, it’s Nature’s answer to PLoS One.

Increasingly it is Nature’s answer to OMICS.

Meanwhile, what the heck is Scientific Reports doing publishing such nonsense?

Raking in money. Not even spell-checking.

“Meanwhile, what the heck is Scientific Reports doing publishing such nonsense?”

Well may you ask, given that this august (cough) outlet also recently published a paper claiming that glyphosate has significant epigenetic effects, yay, even unto the F2 & F3 generations.
In rats. Relatively small numbers of rats. Exposure via intraperitoneal injection And some strange things in the results (Tables 1 & 2; I don’t follow the others), where the number of animals are quite variable.
https://www.nature.com/articles/s41598-019-42860-0#Sec18

As Smut’s said, they’re looking more like Omics by the day.

So the control group supposedly had a 26% decrease in strength, meaning that setting patients up for chiropractic adjustments but not actually doing them has a significant deleterious effect.

I’d love to know the mechanism behind that. Negative feedback from the disappointment-autonomic system relay network?

And were their measurements post-treatment showing decrease in or elimination of subluxations? If you can see ’em on x-rays, surely you can tell if they’re diminished or gone after therapy.

” failing to meet their accrual goal of 15 subjects”
nearly putting them in Andy Wakefield territory

Well, you know, strokes were rare until kids started getting all those vaccines, just sayin’

And this unsupported claim that chiropractic can help dysmenorrhea:

Evidently it can’t help with the ability to spell difficult words like “dysmennorhea”.

Sorry Smut Clyde but the double r in dysmenorrhea is the correct English spelling of the word. The “orrhea” suffix is one of the things that makes “haemorrhage” such a hard word to spell even though it is quite common. On the up side it isn’t as bad as sphygmomanometer which every one I know just calls “the blood pressure machine”.😊

Smut Clyde sorry to misread you. “Dr” Pellagrino doesn’t foster much confidence in a profession if he can butcher a word that spell check will automatically highlight, but considering he can cure brain damage by manipulating someone’s spine……

They aren’t trained to diagnose a stroke so why would anything think a chiropractor could treat a stroke? They truly have dangerous delusions of grandeur.

Also, the insolence here is most excellent.

Orac writes,

I can’t really recommend chiropractic for anything.

MJD says,

I can recommend it for hockey players having a pinched nerve. After 6-weeks of chiropractic therapy, I was back on the ice and in the penalty box.

Q. How is chiropractic therapy like a cross-check in hockey.

A. When both are done properly, no one gets hurt.

I can recommend it for hockey players having a pinched nerve.

Sure some chiros can help with a pinched nerve (depending on where it is) but why would anyone recommend visiting a chiro and running the gauntlet of potential quackery/poor training over visiting a physiotherapist instead? You know of physios right? The people who are required to undergo a properly rigorous science-based education and training process as opposed to chiros who can just attend a Palmer school and “learn” about fairy tales and “medical advice” that was passed down to a power-hungry lunatic by a ghost.

I honestly don’t know why anyone wouldn’t go to a PT instead. Even if a chiro stays in their lane, there’s nothing they can do that a PT couldn’t do better.

I’ve had to see PTs for two injuries and recovery from three surgeries; the measure of their success is that I went for a short time and didn’t have to go back. I’ve had relatives go to chiros for years.

@Roadstergal

Couldn’t agree more.. I see my physio on a long-term basis but that’s because the condition is long term and incurable. Still he’s always keen that when my body is playing ball that the frequency of my visits should be reduced, despite it directly affecting his own bottom line he doesn’t want to treat me unless I actually need it.

What is the correct sort of Respectful Insolence to apply when confronted with an especially disturbing chiropractic anecdote?–that is, “my child was in a car accident and had neck problems that mutiple MD specialists could not help, but the chiro fixed her in two visits” (by manipulating her neck!). Anything I gently suggested was met with, “I don’t care–he helped her and the doctors didn’t.” She now gets all her healthcare from the chiro and has delved into essential oils for her migraines, among other woo. This woman’s husband works with mine so I can’t entirely avoid her, although I let the other half have it when he bought a $70 tiny bottle of essential oil from her (she’s a rep for Big Essential Oil now, of course).

What’s her intellectual background, education and religion? If you want to shove reason down her throat, you need to know how she is intellectually structured.

I don’t want to “shove” anything “down her throat”. I just want her to have an understanding of what chiropractic really is–and isn’t. She’s an average person with a good job and a nice home in the suburbs. I don’t know if she has college but she is a believer of the sort who doesn’t go to church but believes in a “higher power”–at least when it suits her.

I’m well aware that once people latch onto an idea, it’s very difficult to change it, so that’s why I posed the question; I was just looking for some angle I may have missed.

I’d advise you to avoid tackling beliefs head on, and advise you to look into so-called street epistemology.

https://streetepistemology.com/resources/

Basically, the idea is to create gentle and safe conversations where you build knowledge on epistemological issues. Then, you let the person you’re talking to deal with the cognitive dissonance between his beliefs and his new epistemological knowledge.

The first belief to destroy is not belief in chiropractic care. It is the belief that her experiential validation with her kid is reason enough to deal with the risks of this kind of care not working. You have to find relevant examples to make her understand that the evidence she provides is not sufficient to deal with the risk of being wrong. You therefore have to find good counter-analogies: situations where she could employ the same reasoning, but where, for whatever weird reason of her, she doesn’t hold the belief that she should have logically come to with her reasoning. Once she’s at that point, you start investigating with her what the weird reason holding her back from her conclusion really is. Et ceterae.

It’s supposed to be a recursive and gentle mindfuck. No “snotty” lecturing. Dialogue, questions, finding common grounds, the socratic method…

When I was a kid, my maths teacher once said to a comrade who was making a fallacious mathematical argument: “You’re confusing your desires with reality”. That kind of stuck with me, and I’ve forever been wary of confusing my desires with reality. Served me well.

The trick is to get her interested in epistemology. Unfortunately, there are no popsci books on the topic that I’ve been able to find on the net. Maybe someone reading this comment is aware of one, who knows…

Mimi, here’s an example of “street epistemology” with an antivaxxer.

It doesn’t do wonders, but at least the “victim” will go back home with a clearer outlook of her own arguments, and may eventually change in the medium to long run.

I also can’t help but wonder why investigators in several countries spread all over the world were only able to recruit 12 subjects, failing to meet their accrual goal of 15 subjects.

They were only recruiting at the one hospital in Pakistan, however. The quack-in-chief (Imran Niazi) is evidently based at the New Zealand College of Chiropractic, which paid for the study and arranged for a team of NZ quacklets to travel to Pakistan and collect the data. It may be that Riphah International University (Islamabad) was the only place where they could find an ethics review board sufficiently compliant and entrenched in fraudulence to give them approval.

“Following consultation, the study was registered retrospectively and was approved on 17th June 2016 by the Australian New Zealand Clinical Trials Registry” WTF?
https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=370497

You may also enjoy the parallel study by the same people at the same site (with the same IRB for ethics approval), using chiro to treat Alzheimer’s Syndrome.
Results not yet published.

Hey, wait – Alzheimers – how on earth can they be assured of informed consent from their ‘volunteers’? (Quite apart from all the other obvious flaws in the proposal!)
Or is it going to be that the patients are ‘volunteered’ by the institution concerned?

“Or is it going to be that the patients are ‘volunteered’ by the institution concerned?”

How prevalent is that kind of practice?

https://www.em-consulte.com/en/article/245671

First line of the abstract:

“The diagnosis of dementia does not mean that a person is by definition incompetent to consent.”

Having been hospitalized for a long time with a person with dementia (allegedly), I find it completely demeaning that he be considered incompetent to consent.

No, it doesn’t. But having had family members living with dementia, I would also say that the ability to consent cannot be guaranteed.

I’m also wondering why the investigators decided not to conduct this ‘trial’ here in NZ.

“But having had family members living with dementia, I would also say that the ability to consent cannot be guaranteed.”

I’d really like to know more about your personal experience that made you reach this conclusion.

I’m also wondering why the investigators decided not to conduct this ‘trial’ here in NZ.

Can you imagine any IRB for a NZ hospital or care facility granting ethics approval?

My partner’s grandfather had Alzheimer’s and vascular dementia. There’s no way he could have given consent for this sort of thing. He couldn’t even understand a request to change his clothes in the later stages.

Competency to consent is a tricky thing, we often have patients we feel are probably not competent to make informed choices, but as no one has done a competency evaluation and filled out the right paperwork to take away their rights they are always assumed to be competent to consent. Though I often feel no one asks the question as its better to have to assume competence than have to through adult guardianship, as once you take away their ability to control their medical autonomy its very hard for them to ever get it back.

“Once you take away their ability to control their medical autonomy its very hard for them to ever get it back.”

I agree. I had to resort to death threats. I’m now in a much better position.

(Note to readers: do not assume that what worked for me will work for you. It’s likely won’t).

I stared at that photo for some time trying to figure out which way ‘round “you” were positioned! The head and the posterior just don’t seem to match.

If medicine is magic, at least it is magic that has proven to work, which can’t be said from homeopathy.

Alas I can’t read French.

To coin a phrase

Any sufficiently advanced medicine is indistinguishable from magic for your average homeopath….

I think we can expect many chiros to use this study to claim that chiropractic is useful in stroke care, just as it became common for chiros to tout adjustments to fix high blood pressure, based on a single small pilot study involving a specialized manipulation technique that apparently is rarely if ever used in typical practice.

What’s next – a study claiming that chiropractic can successfully treat myocardial infarction? The legendary Drs. Wolfson are big on chiropractic for various kinds of heart disease.

“Thank you for the referral to the chiropractor. I feel amazing and my skipped beats were gone after the first adjustment.” I hear stories like this all the time.”

https://www.thedrswolfson.com/can-chiropractic-reverse-heart-disease/

Well there was the young actress who died from a CVA following cervical vertebrae manipulation by a chiropractor, so they can actually induce asystole, also I don’t know if chiropractors are taught about carotid rubs, but I suppose it’s possible that someone playing with a patient’s neck could accidentally perform a rub and effect the patient’s heart rate that way too.

I’ll throw in one more reason why Dr. Peligrosa and his ilk will never touch my neck, and that’s shaver’s syncope. If my neck is sufficiently hyperextended my vertebrobasilar arteries are compressed, causing me to faint and fall literally on my face, I mean soil on my nose and glasses, cut branches abrading my cheek and so on.

On another note, if anyone wonders what I meant by “the dochniak distims the doshes” in reference to MJD, now it can be told: https://en.wikipedia.org/wiki/Gostak, based on the similarity of his name to “gostak” and the meaning I derived from his postings. Funny how no one ever asked, not even him.

Apparently, women having their hair shampooed at salons occasionally have strokes from their necks being overextended over basins. Not common, but it does seem to happen.

my neck is sufficiently hyperextended my vertebrobasilar arteries are compressed, causing me to faint and fall literally on my face, I mean soil on my nose and glasses, cut branches abrading my cheek and so on.

Oh, I have real problems with orthostatic hypotension. I think I’ve gone down on the pavement three times in the past two months. Five-inch scar on my left lower extremity. I just picked up this habit of squatting when there’s no bench at the bus stop to rest my back. I’ll take the scars over the aching.

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