Guest guest Posted July 8, 2011 Report Share Posted July 8, 2011 Docs: I especially like their "Conclusion." Lyndon McGill, D.C. Salem, Oregon www.SalemSpineClinic.com www.EvolvingDaily.com Deaths after Chiropractic: A Review of Published Cases E. Ernst Posted: 08/30/2010; Int J Clin Pract. 2010;64(10):1162-1165. © 2010 Blackwell Publishing Abstract and Introduction Abstract Objective: The aim of this study was to summarise all cases in which chiropractic spinal manipulation was followed by death. Design: This study is a systematic review of case reports. Methods: Literature searches in four electronic databases with no restrictions of time or language. Main outcome measure: Death. Results: Twenty six fatalities were published in the medical literature and many more might have remained unpublished. The alleged pathology usually was a vascular accident involving the dissection of a vertebral artery. Conclusion: Numerous deaths have occurred after chiropractic manipulations. The risks of this treatment by far outweigh its benefit. Introduction Vascular accidents after upper spinal manipulation are a well-recognised problem (e.g.[1,2]). Dissection of a vertebral artery, caused by extension and rotation of the neck beyond the physiological range of motion, is thought to be the underlying mechanism.[2] Several deaths have been reported as a consequence. Some proponents of chiropractic seem to believe that the critical evaluation of this evidence amounts to a 'scare story' (Chairman of the UK General Chiropractic Council)[3] or to 'puffing up (the evidence) out of all proportion' (President of the British Chiropractic Association).[4] A responsible approach to serious therapeutic risks, however, requires an open discussion of the facts. In this review, I aimed to provide the basis for such a discussion by summarising all fatalities which occurred after chiropractic spinal manipulation and were published in the medical literature. Methods Electronic searches were conducted in the following electronic databases: Medline, Embase, AMED, Cochrane Library (September 2009). No restrictions of time or language were applied. Search terms were chiropractic, spinal manipulation, vascular accidents, stroke, death and fatality. In addition, our own departmental files and the bibliographies of the articles thus located were searched. Several experts were also contacted for further data. Case reports were included if they provided information on human patients who had died after receiving one or more treatments from a chiropractor. Data were extracted from the included articles according to predefined criteria (Table 1). Table 1. Published case reports of deaths after chiropractic treatments References Year of publication Victim Type of vascular accident Time between treatment and death Anon[5] 1934 Woman, age unknown Tear in left lateral sinus 2 weeks Pratt- and Berger[6] 1947 32-year-old man Thrombosis of basilar, left anterior-inferior cerebellar and right posterior-inferior arteries 24 h Pratt- and Berger[6] 1947 35-year-old woman Thrombosis of posterior-inferior cerebellar artery 10 h Anon[7] 1955 Woman, age unknown Intra-spinal bleeding and compression of spinal cord 18 h Ford and [8] 1956 37-year-old man Thrombosis of basilar, left-posterior cerebellar and left-posterior cerebral arteries 6 h Ford and [8] 1956 No information provided Thrombosis of basilar artery No information provided and Estridge[9] 1962 33-year-old woman Infarct of cerebellar and brainstem 3 days Lorenz and Vogelsang[10] 1972 39-year-old woman Thrombosis of basilar artery 58 days Schmitt[11] 1976 35-years-old woman Infarct of brainstem 1 h Krueger and Okazaki[12] 1980 25-year-old man Infarct of brainstem and cerebellum 48 h Sherman et al.[13] 1981 60-year-old woman Dissection of vertebral artery 4 days Ali Cherif et al.[14] 1983 51-year-old man Infarct of medulla oblongata 11 days Nielsen[15] 1984 34-year-old man Dissection of vertebral artery aneurysen 3 h Zak and Carmody[16] 1984 53-year-old man Left vertebral, posterior-inferior and superior cerebellar artery occlusion; cerebellar infarction 27 days Modde[17] 1985 26-year-old woman Dissection of vertebral artery 1 day Jentzen et al.[18] 1987 51-year-old man Infarct of cerebellum and brainstem No information provided Sherman et al.[20] 1987 37-year-old man Infarct of brainstem 3 days Mas et al.[19] 1989 35-year-old woman Dissecting aneurysm of vertebral artery 16 h Raskind and North[21] 1990 47-year-old woman Cerebellar haemorrheae No information provided Sullivan[22] 1992 41-year-old woman Haemorrhage in ventricular system 8 h Haynes[23] 1994 36-year-old woman Dissecting aneurysm of vertebral artery, thrombo-embolism No information provided s et al.[24] 1995 29-year-old woman Infarct of right hemisphere 3 days Klougart et al.[25] 1996 34-year-old man Unclear Few hours Haldeman et al.[26] 2002 Previously unpublished legal cases No information provided No information provided Haldeman et al.[26] 2002 Previously unpublished legal cases No information provided No information provided Dziewas et al.[27] 2003 No information provided No information provided No information provided Results Twenty-six fatalities were published since 1934 in 23 articles (Table 1).[5–27] Table 1. Published case reports of deaths after chiropractic treatments References Year of publication Victim Type of vascular accident Time between treatment and death Anon[5] 1934 Woman, age unknown Tear in left lateral sinus 2 weeks Pratt- and Berger[6] 1947 32-year-old man Thrombosis of basilar, left anterior-inferior cerebellar and right posterior-inferior arteries 24 h Pratt- and Berger[6] 1947 35-year-old woman Thrombosis of posterior-inferior cerebellar artery 10 h Anon[7] 1955 Woman, age unknown Intra-spinal bleeding and compression of spinal cord 18 h Ford and [8] 1956 37-year-old man Thrombosis of basilar, left-posterior cerebellar and left-posterior cerebral arteries 6 h Ford and [8] 1956 No information provided Thrombosis of basilar artery No information provided and Estridge[9] 1962 33-year-old woman Infarct of cerebellar and brainstem 3 days Lorenz and Vogelsang[10] 1972 39-year-old woman Thrombosis of basilar artery 58 days Schmitt[11] 1976 35-years-old woman Infarct of brainstem 1 h Krueger and Okazaki[12] 1980 25-year-old man Infarct of brainstem and cerebellum 48 h Sherman et al.[13] 1981 60-year-old woman Dissection of vertebral artery 4 days Ali Cherif et al.[14] 1983 51-year-old man Infarct of medulla oblongata 11 days Nielsen[15] 1984 34-year-old man Dissection of vertebral artery aneurysen 3 h Zak and Carmody[16] 1984 53-year-old man Left vertebral, posterior-inferior and superior cerebellar artery occlusion; cerebellar infarction 27 days Modde[17] 1985 26-year-old woman Dissection of vertebral artery 1 day Jentzen et al.[18] 1987 51-year-old man Infarct of cerebellum and brainstem No information provided Sherman et al.[20] 1987 37-year-old man Infarct of brainstem 3 days Mas et al.[19] 1989 35-year-old woman Dissecting aneurysm of vertebral artery 16 h Raskind and North[21] 1990 47-year-old woman Cerebellar haemorrheae No information provided Sullivan[22] 1992 41-year-old woman Haemorrhage in ventricular system 8 h Haynes[23] 1994 36-year-old woman Dissecting aneurysm of vertebral artery, thrombo-embolism No information provided s et al.[24] 1995 29-year-old woman Infarct of right hemisphere 3 days Klougart et al.[25] 1996 34-year-old man Unclear Few hours Haldeman et al.[26] 2002 Previously unpublished legal cases No information provided No information provided Haldeman et al.[26] 2002 Previously unpublished legal cases No information provided No information provided Dziewas et al.[27] 2003 No information provided No information provided No information provided Most of the victims were relatively young; 14 were below the age of 40. There was a slight majority of female patients. The type of complication associated with death frequently related to a vascular accident leading to thrombosis and cerebral infarction. The time between treatment and death ranged from 1 h to 58 days; in 10 cases, it was 1 day or less. Unfortunately, the published information was often incomplete. Many other fatalities seem to have remained unpublished. For instance, the testimony of the chiropractor Preston Long for a court in Connecticut recently listed the family names of nine victims: Mathiason, Solsbury, Mc Cornick, Venegas, Bedenbaugh, , Fawcett, Parisien, Standt. Long also states that 'many others [are] unknown hidden behind legal agreements of silence'.[28] A website names further North American fatalities: Epping (California), G. Fowden (Utah), Grainger (Alberta), Hoffman (land), Renate Dora Labonte (Ontario), (California), Pereyra (Connecticut), A. Roth (Ontario) and Lee Strohecker (Pennsylvania).[29] Discussion This systematic review demonstrates that numerous deaths have been associated with chiropractic. Usually high-velocity, short-lever thrusts of the upper spine with rotation are implicated. They are believed to cause vertebral arterial dissection in predisposed individuals which, in turn, can lead to a chain of events including stroke and death.[1,2,26,30] Many chiropractors claim that, because arterial dissection can also occur spontaneously, causality between the chiropractic intervention and arterial dissection is not proven. However, when carefully evaluating the known facts, one does arrive at the conclusion that causality is at least likely (e.g.[30,31]). Even if it were merely a remote possibility, the precautionary principle in healthcare would mean that neck manipulations should be considered unsafe until proven otherwise. Moreover, there is no good evidence for assuming that neck manipulation is an effective therapy for any medical condition.[32] Thus, the risk-benefit balance for chiropractic neck manipulation fails to be positive. Reliable estimates of the frequency of vascular accidents are prevented by the fact that under-reporting is known to be substantial. In a survey of UK neurologists, for instance, under-reporting of serious complications was 100%.[33] Those cases which are published often turn out to be incomplete. Of 40 case reports of serious adverse effects associated with spinal manipulation, nine failed to provide any information about the clinical outcome.[34] Incomplete reporting of outcomes might therefore further increase the true number of fatalities. Obviously, the present article is not aimed at providing incidence figures; this would require a different methodology entirely. To date, no reliable incidence data are available. This review is focussed on deaths after chiropractic, yet neck manipulations are, of course, used by other healthcare professionals as well. The reason for this focus is simple: chiropractors are more frequently associated with serious manipulation-related adverse effects than osteopaths, physiotherapists, doctors or other professionals. Of the 40 cases of serious adverse effects mentioned above, 28 can be traced back to a chiropractor and none to an osteopath.[34] A review of complications after spinal manipulations by any type of healthcare professional included three deaths related to osteopaths, nine to medical practitioners, none to a physiotherapist, one to a naturopath and 17 to chiropractors.[35] This article also summarised a total of 265 vascular accidents of which 142 were linked to chiropractors. Another review of complications after neck manipulations published by 1997 included 177 vascular accidents, 32 of which were fatal. The vast majority of these cases were associated with chiropractic and none with physiotherapy.[36] The most obvious explanation for the dominance of chiropractic is that chiropractors routinely employ high-velocity, short-lever thrusts on the upper spine with a rotational element, while the other healthcare professionals use them much more sparingly.[37,38] In conclusion, numerous deaths have been associated with chiropractic neck manipulations. There are reasons to suspect that under-reporting is substantial and reliable incidence figures do not exist. The risks of chiropractic neck manipulations by far outweigh their benefits. Healthcare professionals should advise the public accordingly. Sidebar What's Known Chiropractic upper spinal manipulation has repeatedly been associated with arterial dissection followed by stroke and, in some cases, death. What's New The article is the first systematic review of all fatalities reported in the medical literature. Twenty-six deaths are on record and many more seem to have remained unpublished. References Ernst E. Adverse effects of spinal manipulation: a systematic review. J R Soc Med 2007; 100: 330–8. Leon- A, Cuetter A, Ferrer G. Cervical spine manipulation: an alternative medical procedure with potentially fatal complications. South Med J 2007; 100: 201–3. Dixon P. Letter to the Editor. Adverse effects of spinal manipulation. J R Soc Med 2007; 100: 444. BJ. Letter to the Editor. Adverse effects of spinal manipulation. J R Soc Med 2007; 100: 444. Anon. Medicolegal. Malpractice: death resulting from chiropractic treatment for headache. J Am Med Assoc 1934; 103:1260, 1935; 105:1712–4, 1937; 109:233–4. Pratt- HR, Berger KE. Cerebellar and spinal injuries after chiropractic manipulation. J Am Med Assoc 1947; 133: 600–3. Anon. Medicolegal abstracts. Chiropractors: injury to spinal meninges during adjustments. J Am Med Assoc 1955; 159: 809. Ford FR, D. Thrombosis of the basilar artery with softenings in the cerebellum and brain stem due to manipulation of the neck; a report of two cases with one post-mortem examination, reasons are given to prove that damage to the vertebral arteries is responsible. Bull s Hopkins Hosp 1956; 98: 37–42. RA, Estridge MN. Neurologic complications of head and neck manipulations. JAMA 1962; 182: 528–31. Lorenz R, Vogelsang HG. Thrombosis of the basilar artery following chiropractic manipulation of the cervical spine. [in German] Thrombose der arteria basilaris nach chiropraktischen Manipulationen an der Halbwirbelsäule. Dtsch Med Wochenschr 1972; 97: 36–43. Schmitt HP. Rupturen und Thrombosen der Arteria vertebralis nach gedeckten mechanischen Insulten. Schweiz Arch Neurol Neurochir Psychiatry 1976; 119: 363–79. Krueger BR, Okazaki H. Vertebral-basilar distribution infarction following chiropractic cervical manipulation. Mayo Clin Proc 1980; 55: 322–32. Sherman DG, Hart RG, Easton JD. Abrupt change in head position and cerebral infarction. Stroke 1981; 12: 2–6. Ali Cherif A, Delpuech F, Habib M, Salamon G, Khalil R. Thrombose vertebro-basilaire apres manipulation du rachis cervical. A propos de deux cas. Ann de Med Phys 1983; 25: 459–65. Nielsen AA. Cerebrovascular insults caused by manipulation of the cervical spine. [in Danish]. Ugeskr Laeger 1984; 146: 3267–70. Zak SM, Carmody RF. Cerebellar infarction from chiropractic neck manipulation: case report and review of the literature. Ariz Med 1984; 41: 333–7. Modde PJ. Chiropractic Malpractice. Columbia, land: Hanrow Press. 1985: 269–70, 273–5, 311–8, 322–3, 329–31, 334–7. Jentzen JM, Amatuzio J, GF. Complications of cervical manipulation: a case report of fatal brainstem infarct with review of the mechanisms and predisposing factors. J Forensic Sci 1987; 32: 1089–94. Mas JL, Henin D, Bousser MG, Chain F, Haw JJ. Dissecting aneurysm of the vertebral artery and cervical manipulation: a case report with autopsy. Neurology 1989; 39: 512–5. Sherman MR, Smialek JE, Zane WE. Pathogenesis of vertebral artery occlusion following cervical spine manipulation. Arch Pathol Lab Med 1987; 111: 851–3. Raskind R, North CM. Vertebral artery injuries following chiropractic cervical spine manipulation--case reports. Angiology 1990; 41: 445–52. Sullivan EC. Brain stem stroke syndromes from cervical adjustments. Report on five cases. J Chiropr Res Clin Invest 1992; 8: 12–6. Haynes MJ. Stroke following cervical manipulation in Perth. Chiropr J Aust 1994; 24: 42–6. s M, Bohl J, Thömke F, Kallen K-J, Mahlzahn K, Wandel E. Dissection of the internal carotid artery after chiropractic manipulation of the neck. Neurology 1995; 45: 2284–6. Klougart N, Leboeuf-Yde C, Rasmussen LR. Safety in chiropractic practice. Part I. The occurrence of cerebrovascular accidents after manipulation to the neck in Denmark from 1978–1988. J Manipulative Physiol Ther 1996; 19: 371–7. Haldeman S, Kohlbeck FJ, McGregor M. Unpredictability of cerebrovascular ischemia associated with cervical spine manipulation. Spine 2002; 27: 49–55. Dziewas R, Konrad C, Dräger B et al. Cervical artery dissection – clinical features, risk factors, therapy and outcome in 126 patients. J Neurol 2003; 250: 1179–84. Presentation by Dr Preston Long DC to State of Connecticut. Connecticut State Board of Chiropractic Examiners. Hartford Connecticut. 25 October 2009. Anon. What's the harm in going to a chiropractor? What's the Harm 2009; http://whatstheharm.net/chiropractic.html (accessed October 2009). Ernst E. Vascular accidents after neck manipulation: cause or coincidence? Int J Clin Pract 2009; in press. Long PH. Stroke and spinal manipulation. J Quality Health Care 2004; 3: 8–10. Ernst E. Chiropractic: a critical evaluation. J Pain Symptom Manage 2008; 35: 544–62. Stevinson C, Honan W, Cooke B, Ernst E. Neurological complications of cervical spine manipulation. J Roy Soc Med 2001; 94: 107–10. Ernst E. Cerebrovascular complications associated with spinal manipulation. Phys Ther Rev 2004; 9: 5–15. Terrett AGJ. Current Concepts in Vertebrobasilar Complications following Spinal Manipulation, 2nd edn. Des Moines: JCMIC Group, 2001. Di Fabio RP. Manipulation of the cervical spine: risks and benefits. Physical Ther 1999; 79: 50–65. Alcantara J, Ohm J, Kunz D. The safety and effectiveness of pediatric chiropractic: a survey of chiropractors and parents in a practice-based research network. Explore (NY) 2009; 5: 290–5. Sweeney A, Doody C Manual therapy for the cervical spine and reported adverse effects: a survey of Irish Manipulative Physiotherapists. Man Ther 2010; 15: 32–6. Int J Clin Pract. 2010;64(10):1162-1165. © 2010 Blackwell Publishing Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 8, 2011 Report Share Posted July 8, 2011 What a bunch of Junk. When are we EVER gonna catch a break??? ph Medlin D.C. From: Lyndon McGill Sent: Friday, July 08, 2011 10:50 AM Subject: Chiropractic deaths Docs:I especially like their "Conclusion."Lyndon McGill, D.C.Salem, Oregonwww.SalemSpineClinic.comwww.EvolvingDaily.com Deaths after Chiropractic: A Review of Published Cases E. Ernst Posted: 08/30/2010; Int J Clin Pract. 2010;64(10):1162-1165. © 2010 Blackwell Publishing Abstract and Introduction Abstract Objective: The aim of this study was to summarise all cases in which chiropractic spinal manipulation was followed by death.Design: This study is a systematic review of case reports.Methods: Literature searches in four electronic databases with no restrictions of time or language.Main outcome measure: Death.Results: Twenty six fatalities were published in the medical literature and many more might have remained unpublished. The alleged pathology usually was a vascular accident involving the dissection of a vertebral artery.Conclusion: Numerous deaths have occurred after chiropractic manipulations. The risks of this treatment by far outweigh its benefit. Introduction Vascular accidents after upper spinal manipulation are a well-recognised problem (e.g.[1,2]). Dissection of a vertebral artery, caused by extension and rotation of the neck beyond the physiological range of motion, is thought to be the underlying mechanism.[2] Several deaths have been reported as a consequence. Some proponents of chiropractic seem to believe that the critical evaluation of this evidence amounts to a 'scare story' (Chairman of the UK General Chiropractic Council)[3] or to 'puffing up (the evidence) out of all proportion' (President of the British Chiropractic Association).[4] A responsible approach to serious therapeutic risks, however, requires an open discussion of the facts. In this review, I aimed to provide the basis for such a discussion by summarising all fatalities which occurred after chiropractic spinal manipulation and were published in the medical literature. Methods Electronic searches were conducted in the following electronic databases: Medline, Embase, AMED, Cochrane Library (September 2009). No restrictions of time or language were applied. Search terms were chiropractic, spinal manipulation, vascular accidents, stroke, death and fatality. In addition, our own departmental files and the bibliographies of the articles thus located were searched. Several experts were also contacted for further data. Case reports were included if they provided information on human patients who had died after receiving one or more treatments from a chiropractor. Data were extracted from the included articles according to predefined criteria (Table 1). Table 1. Published case reports of deaths after chiropractic treatments References Year of publication Victim Type of vascular accident Time between treatment and death Anon[5] 1934 Woman, age unknown Tear in left lateral sinus 2 weeks Pratt- and Berger[6] 1947 32-year-old man Thrombosis of basilar, left anterior-inferior cerebellar and right posterior-inferior arteries 24 h Pratt- and Berger[6] 1947 35-year-old woman Thrombosis of posterior-inferior cerebellar artery 10 h Anon[7] 1955 Woman, age unknown Intra-spinal bleeding and compression of spinal cord 18 h Ford and [8] 1956 37-year-old man Thrombosis of basilar, left-posterior cerebellar and left-posterior cerebral arteries 6 h Ford and [8] 1956 No information provided Thrombosis of basilar artery No information provided and Estridge[9] 1962 33-year-old woman Infarct of cerebellar and brainstem 3 days Lorenz and Vogelsang[10] 1972 39-year-old woman Thrombosis of basilar artery 58 days Schmitt[11] 1976 35-years-old woman Infarct of brainstem 1 h Krueger and Okazaki[12] 1980 25-year-old man Infarct of brainstem and cerebellum 48 h Sherman et al.[13] 1981 60-year-old woman Dissection of vertebral artery 4 days Ali Cherif et al.[14] 1983 51-year-old man Infarct of medulla oblongata 11 days Nielsen[15] 1984 34-year-old man Dissection of vertebral artery aneurysen 3 h Zak and Carmody[16] 1984 53-year-old man Left vertebral, posterior-inferior and superior cerebellar artery occlusion; cerebellar infarction 27 days Modde[17] 1985 26-year-old woman Dissection of vertebral artery 1 day Jentzen et al.[18] 1987 51-year-old man Infarct of cerebellum and brainstem No information provided Sherman et al.[20] 1987 37-year-old man Infarct of brainstem 3 days Mas et al.[19] 1989 35-year-old woman Dissecting aneurysm of vertebral artery 16 h Raskind and North[21] 1990 47-year-old woman Cerebellar haemorrheae No information provided Sullivan[22] 1992 41-year-old woman Haemorrhage in ventricular system 8 h Haynes[23] 1994 36-year-old woman Dissecting aneurysm of vertebral artery, thrombo-embolism No information provided s et al.[24] 1995 29-year-old woman Infarct of right hemisphere 3 days Klougart et al.[25] 1996 34-year-old man Unclear Few hours Haldeman et al.[26] 2002 Previously unpublished legal cases No information provided No information provided Haldeman et al.[26] 2002 Previously unpublished legal cases No information provided No information provided Dziewas et al.[27] 2003 No information provided No information provided No information provided Results Twenty-six fatalities were published since 1934 in 23 articles (Table 1).[5–27] Table 1. Published case reports of deaths after chiropractic treatments References Year of publication Victim Type of vascular accident Time between treatment and death Anon[5] 1934 Woman, age unknown Tear in left lateral sinus 2 weeks Pratt- and Berger[6] 1947 32-year-old man Thrombosis of basilar, left anterior-inferior cerebellar and right posterior-inferior arteries 24 h Pratt- and Berger[6] 1947 35-year-old woman Thrombosis of posterior-inferior cerebellar artery 10 h Anon[7] 1955 Woman, age unknown Intra-spinal bleeding and compression of spinal cord 18 h Ford and [8] 1956 37-year-old man Thrombosis of basilar, left-posterior cerebellar and left-posterior cerebral arteries 6 h Ford and [8] 1956 No information provided Thrombosis of basilar artery No information provided and Estridge[9] 1962 33-year-old woman Infarct of cerebellar and brainstem 3 days Lorenz and Vogelsang[10] 1972 39-year-old woman Thrombosis of basilar artery 58 days Schmitt[11] 1976 35-years-old woman Infarct of brainstem 1 h Krueger and Okazaki[12] 1980 25-year-old man Infarct of brainstem and cerebellum 48 h Sherman et al.[13] 1981 60-year-old woman Dissection of vertebral artery 4 days Ali Cherif et al.[14] 1983 51-year-old man Infarct of medulla oblongata 11 days Nielsen[15] 1984 34-year-old man Dissection of vertebral artery aneurysen 3 h Zak and Carmody[16] 1984 53-year-old man Left vertebral, posterior-inferior and superior cerebellar artery occlusion; cerebellar infarction 27 days Modde[17] 1985 26-year-old woman Dissection of vertebral artery 1 day Jentzen et al.[18] 1987 51-year-old man Infarct of cerebellum and brainstem No information provided Sherman et al.[20] 1987 37-year-old man Infarct of brainstem 3 days Mas et al.[19] 1989 35-year-old woman Dissecting aneurysm of vertebral artery 16 h Raskind and North[21] 1990 47-year-old woman Cerebellar haemorrheae No information provided Sullivan[22] 1992 41-year-old woman Haemorrhage in ventricular system 8 h Haynes[23] 1994 36-year-old woman Dissecting aneurysm of vertebral artery, thrombo-embolism No information provided s et al.[24] 1995 29-year-old woman Infarct of right hemisphere 3 days Klougart et al.[25] 1996 34-year-old man Unclear Few hours Haldeman et al.[26] 2002 Previously unpublished legal cases No information provided No information provided Haldeman et al.[26] 2002 Previously unpublished legal cases No information provided No information provided Dziewas et al.[27] 2003 No information provided No information provided No information provided Most of the victims were relatively young; 14 were below the age of 40. There was a slight majority of female patients. The type of complication associated with death frequently related to a vascular accident leading to thrombosis and cerebral infarction. The time between treatment and death ranged from 1 h to 58 days; in 10 cases, it was 1 day or less. Unfortunately, the published information was often incomplete. Many other fatalities seem to have remained unpublished. For instance, the testimony of the chiropractor Preston Long for a court in Connecticut recently listed the family names of nine victims: Mathiason, Solsbury, Mc Cornick, Venegas, Bedenbaugh, , Fawcett, Parisien, Standt. Long also states that 'many others [are] unknown hidden behind legal agreements of silence'.[28] A website names further North American fatalities: Epping (California), G. Fowden (Utah), Grainger (Alberta), Hoffman (land), Renate Dora Labonte (Ontario), (California), Pereyra (Connecticut), A. Roth (Ontario) and Lee Strohecker (Pennsylvania).[29] Discussion This systematic review demonstrates that numerous deaths have been associated with chiropractic. Usually high-velocity, short-lever thrusts of the upper spine with rotation are implicated. They are believed to cause vertebral arterial dissection in predisposed individuals which, in turn, can lead to a chain of events including stroke and death.[1,2,26,30] Many chiropractors claim that, because arterial dissection can also occur spontaneously, causality between the chiropractic intervention and arterial dissection is not proven. However, when carefully evaluating the known facts, one does arrive at the conclusion that causality is at least likely (e.g.[30,31]). Even if it were merely a remote possibility, the precautionary principle in healthcare would mean that neck manipulations should be considered unsafe until proven otherwise. Moreover, there is no good evidence for assuming that neck manipulation is an effective therapy for any medical condition.[32] Thus, the risk-benefit balance for chiropractic neck manipulation fails to be positive. Reliable estimates of the frequency of vascular accidents are prevented by the fact that under-reporting is known to be substantial. In a survey of UK neurologists, for instance, under-reporting of serious complications was 100%.[33] Those cases which are published often turn out to be incomplete. Of 40 case reports of serious adverse effects associated with spinal manipulation, nine failed to provide any information about the clinical outcome.[34] Incomplete reporting of outcomes might therefore further increase the true number of fatalities. Obviously, the present article is not aimed at providing incidence figures; this would require a different methodology entirely. To date, no reliable incidence data are available. This review is focussed on deaths after chiropractic, yet neck manipulations are, of course, used by other healthcare professionals as well. The reason for this focus is simple: chiropractors are more frequently associated with serious manipulation-related adverse effects than osteopaths, physiotherapists, doctors or other professionals. Of the 40 cases of serious adverse effects mentioned above, 28 can be traced back to a chiropractor and none to an osteopath.[34] A review of complications after spinal manipulations by any type of healthcare professional included three deaths related to osteopaths, nine to medical practitioners, none to a physiotherapist, one to a naturopath and 17 to chiropractors.[35] This article also summarised a total of 265 vascular accidents of which 142 were linked to chiropractors. Another review of complications after neck manipulations published by 1997 included 177 vascular accidents, 32 of which were fatal. The vast majority of these cases were associated with chiropractic and none with physiotherapy.[36] The most obvious explanation for the dominance of chiropractic is that chiropractors routinely employ high-velocity, short-lever thrusts on the upper spine with a rotational element, while the other healthcare professionals use them much more sparingly.[37,38] In conclusion, numerous deaths have been associated with chiropractic neck manipulations. There are reasons to suspect that under-reporting is substantial and reliable incidence figures do not exist. The risks of chiropractic neck manipulations by far outweigh their benefits. Healthcare professionals should advise the public accordingly. Sidebar What's Known Chiropractic upper spinal manipulation has repeatedly been associated with arterial dissection followed by stroke and, in some cases, death. What's New The article is the first systematic review of all fatalities reported in the medical literature. Twenty-six deaths are on record and many more seem to have remained unpublished. References Ernst E. Adverse effects of spinal manipulation: a systematic review. J R Soc Med 2007; 100: 330–8. Leon- A, Cuetter A, Ferrer G. Cervical spine manipulation: an alternative medical procedure with potentially fatal complications. South Med J 2007; 100: 201–3. Dixon P. Letter to the Editor. Adverse effects of spinal manipulation. J R Soc Med 2007; 100: 444. BJ. Letter to the Editor. Adverse effects of spinal manipulation. J R Soc Med 2007; 100: 444. Anon. Medicolegal. Malpractice: death resulting from chiropractic treatment for headache. J Am Med Assoc 1934; 103:1260, 1935; 105:1712–4, 1937; 109:233–4. Pratt- HR, Berger KE. Cerebellar and spinal injuries after chiropractic manipulation. J Am Med Assoc 1947; 133: 600–3. Anon. Medicolegal abstracts. Chiropractors: injury to spinal meninges during adjustments. J Am Med Assoc 1955; 159: 809. Ford FR, D. Thrombosis of the basilar artery with softenings in the cerebellum and brain stem due to manipulation of the neck; a report of two cases with one post-mortem examination, reasons are given to prove that damage to the vertebral arteries is responsible. Bull s Hopkins Hosp 1956; 98: 37–42. RA, Estridge MN. Neurologic complications of head and neck manipulations. JAMA 1962; 182: 528–31. Lorenz R, Vogelsang HG. Thrombosis of the basilar artery following chiropractic manipulation of the cervical spine. [in German] Thrombose der arteria basilaris nach chiropraktischen Manipulationen an der Halbwirbelsäule. Dtsch Med Wochenschr 1972; 97: 36–43. Schmitt HP. Rupturen und Thrombosen der Arteria vertebralis nach gedeckten mechanischen Insulten. Schweiz Arch Neurol Neurochir Psychiatry 1976; 119: 363–79. Krueger BR, Okazaki H. Vertebral-basilar distribution infarction following chiropractic cervical manipulation. Mayo Clin Proc 1980; 55: 322–32. Sherman DG, Hart RG, Easton JD. Abrupt change in head position and cerebral infarction. Stroke 1981; 12: 2–6. Ali Cherif A, Delpuech F, Habib M, Salamon G, Khalil R. Thrombose vertebro-basilaire apres manipulation du rachis cervical. A propos de deux cas. Ann de Med Phys 1983; 25: 459–65. Nielsen AA. Cerebrovascular insults caused by manipulation of the cervical spine. [in Danish]. Ugeskr Laeger 1984; 146: 3267–70. Zak SM, Carmody RF. Cerebellar infarction from chiropractic neck manipulation: case report and review of the literature. Ariz Med 1984; 41: 333–7. Modde PJ. Chiropractic Malpractice. Columbia, land: Hanrow Press. 1985: 269–70, 273–5, 311–8, 322–3, 329–31, 334–7. Jentzen JM, Amatuzio J, GF. Complications of cervical manipulation: a case report of fatal brainstem infarct with review of the mechanisms and predisposing factors. J Forensic Sci 1987; 32: 1089–94. Mas JL, Henin D, Bousser MG, Chain F, Haw JJ. Dissecting aneurysm of the vertebral artery and cervical manipulation: a case report with autopsy. Neurology 1989; 39: 512–5. Sherman MR, Smialek JE, Zane WE. Pathogenesis of vertebral artery occlusion following cervical spine manipulation. Arch Pathol Lab Med 1987; 111: 851–3. Raskind R, North CM. Vertebral artery injuries following chiropractic cervical spine manipulation--case reports. Angiology 1990; 41: 445–52. Sullivan EC. Brain stem stroke syndromes from cervical adjustments. Report on five cases. J Chiropr Res Clin Invest 1992; 8: 12–6. Haynes MJ. Stroke following cervical manipulation in Perth. Chiropr J Aust 1994; 24: 42–6. s M, Bohl J, Thömke F, Kallen K-J, Mahlzahn K, Wandel E. Dissection of the internal carotid artery after chiropractic manipulation of the neck. Neurology 1995; 45: 2284–6. Klougart N, Leboeuf-Yde C, Rasmussen LR. Safety in chiropractic practice. Part I. The occurrence of cerebrovascular accidents after manipulation to the neck in Denmark from 1978–1988. J Manipulative Physiol Ther 1996; 19: 371–7. Haldeman S, Kohlbeck FJ, McGregor M. Unpredictability of cerebrovascular ischemia associated with cervical spine manipulation. Spine 2002; 27: 49–55. Dziewas R, Konrad C, Dräger B et al. Cervical artery dissection – clinical features, risk factors, therapy and outcome in 126 patients. J Neurol 2003; 250: 1179–84. Presentation by Dr Preston Long DC to State of Connecticut. Connecticut State Board of Chiropractic Examiners. Hartford Connecticut. 25 October 2009. Anon. What's the harm in going to a chiropractor? What's the Harm 2009; http://whatstheharm.net/chiropractic.html (accessed October 2009). Ernst E. Vascular accidents after neck manipulation: cause or coincidence? Int J Clin Pract 2009; in press. Long PH. Stroke and spinal manipulation. J Quality Health Care 2004; 3: 8–10. Ernst E. Chiropractic: a critical evaluation. J Pain Symptom Manage 2008; 35: 544–62. Stevinson C, Honan W, Cooke B, Ernst E. Neurological complications of cervical spine manipulation. J Roy Soc Med 2001; 94: 107–10. Ernst E. Cerebrovascular complications associated with spinal manipulation. Phys Ther Rev 2004; 9: 5–15. Terrett AGJ. Current Concepts in Vertebrobasilar Complications following Spinal Manipulation, 2nd edn. Des Moines: JCMIC Group, 2001. Di Fabio RP. Manipulation of the cervical spine: risks and benefits. Physical Ther 1999; 79: 50–65. Alcantara J, Ohm J, Kunz D. The safety and effectiveness of pediatric chiropractic: a survey of chiropractors and parents in a practice-based research network. Explore (NY) 2009; 5: 290–5. Sweeney A, Doody C Manual therapy for the cervical spine and reported adverse effects: a survey of Irish Manipulative Physiotherapists. Man Ther 2010; 15: 32–6. Int J Clin Pract. 2010;64(10):1162-1165. © 2010 Blackwell Publishing Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 8, 2011 Report Share Posted July 8, 2011 Medical errors are the fourth leading cause of death in this country and if you add non-error deaths e.g., adverse drug events, hospital infections, surgical adverse events etc. some authors suggest medical care is the leading cause of death in this country.... VErn Saboe Chiropractic deaths Docs:I especially like their "Conclusion."Lyndon McGill, D.C.Salem, Oregonwww.SalemSpineClinic.comwww.EvolvingDaily.com Deaths after Chiropractic: A Review of Published Cases E. Ernst Posted: 08/30/2010; Int J Clin Pract. 2010;64(10):1162-1165. © 2010 Blackwell Publishing Abstract and Introduction Abstract Objective: The aim of this study was to summarise all cases in which chiropractic spinal manipulation was followed by death.Design: This study is a systematic review of case reports.Methods: Literature searches in four electronic databases with no restrictions of time or language.Main outcome measure: Death.Results: Twenty six fatalities were published in the medical literature and many more might have remained unpublished. The alleged pathology usually was a vascular accident involving the dissection of a vertebral artery.Conclusion: Numerous deaths have occurred after chiropractic manipulations. The risks of this treatment by far outweigh its benefit. Introduction Vascular accidents after upper spinal manipulation are a well-recognised problem (e.g.[1,2]). Dissection of a vertebral artery, caused by extension and rotation of the neck beyond the physiological range of motion, is thought to be the underlying mechanism.[2] Several deaths have been reported as a consequence. Some proponents of chiropractic seem to believe that the critical evaluation of this evidence amounts to a 'scare story' (Chairman of the UK General Chiropractic Council)[3] or to 'puffing up (the evidence) out of all proportion' (President of the British Chiropractic Association).[4] A responsible approach to serious therapeutic risks, however, requires an open discussion of the facts. In this review, I aimed to provide the basis for such a discussion by summarising all fatalities which occurred after chiropractic spinal manipulation and were published in the medical literature. Methods Electronic searches were conducted in the following electronic databases: Medline, Embase, AMED, Cochrane Library (September 2009). No restrictions of time or language were applied. Search terms were chiropractic, spinal manipulation, vascular accidents, stroke, death and fatality. In addition, our own departmental files and the bibliographies of the articles thus located were searched. Several experts were also contacted for further data. Case reports were included if they provided information on human patients who had died after receiving one or more treatments from a chiropractor. Data were extracted from the included articles according to predefined criteria (Table 1). Table 1. Published case reports of deaths after chiropractic treatments References Year of publication Victim Type of vascular accident Time between treatment and death Anon[5] 1934 Woman, age unknown Tear in left lateral sinus 2 weeks Pratt- and Berger[6] 1947 32-year-old man Thrombosis of basilar, left anterior-inferior cerebellar and right posterior-inferior arteries 24 h Pratt- and Berger[6] 1947 35-year-old woman Thrombosis of posterior-inferior cerebellar artery 10 h Anon[7] 1955 Woman, age unknown Intra-spinal bleeding and compression of spinal cord 18 h Ford and [8] 1956 37-year-old man Thrombosis of basilar, left-posterior cerebellar and left-posterior cerebral arteries 6 h Ford and [8] 1956 No information provided Thrombosis of basilar artery No information provided and Estridge[9] 1962 33-year-old woman Infarct of cerebellar and brainstem 3 days Lorenz and Vogelsang[10] 1972 39-year-old woman Thrombosis of basilar artery 58 days Schmitt[11] 1976 35-years-old woman Infarct of brainstem 1 h Krueger and Okazaki[12] 1980 25-year-old man Infarct of brainstem and cerebellum 48 h Sherman et al.[13] 1981 60-year-old woman Dissection of vertebral artery 4 days Ali Cherif et al.[14] 1983 51-year-old man Infarct of medulla oblongata 11 days Nielsen[15] 1984 34-year-old man Dissection of vertebral artery aneurysen 3 h Zak and Carmody[16] 1984 53-year-old man Left vertebral, posterior-inferior and superior cerebellar artery occlusion; cerebellar infarction 27 days Modde[17] 1985 26-year-old woman Dissection of vertebral artery 1 day Jentzen et al.[18] 1987 51-year-old man Infarct of cerebellum and brainstem No information provided Sherman et al.[20] 1987 37-year-old man Infarct of brainstem 3 days Mas et al.[19] 1989 35-year-old woman Dissecting aneurysm of vertebral artery 16 h Raskind and North[21] 1990 47-year-old woman Cerebellar haemorrheae No information provided Sullivan[22] 1992 41-year-old woman Haemorrhage in ventricular system 8 h Haynes[23] 1994 36-year-old woman Dissecting aneurysm of vertebral artery, thrombo-embolism No information provided s et al.[24] 1995 29-year-old woman Infarct of right hemisphere 3 days Klougart et al.[25] 1996 34-year-old man Unclear Few hours Haldeman et al.[26] 2002 Previously unpublished legal cases No information provided No information provided Haldeman et al.[26] 2002 Previously unpublished legal cases No information provided No information provided Dziewas et al.[27] 2003 No information provided No information provided No information provided Results Twenty-six fatalities were published since 1934 in 23 articles (Table 1).[5–27] Table 1. Published case reports of deaths after chiropractic treatments References Year of publication Victim Type of vascular accident Time between treatment and death Anon[5] 1934 Woman, age unknown Tear in left lateral sinus 2 weeks Pratt- and Berger[6] 1947 32-year-old man Thrombosis of basilar, left anterior-inferior cerebellar and right posterior-inferior arteries 24 h Pratt- and Berger[6] 1947 35-year-old woman Thrombosis of posterior-inferior cerebellar artery 10 h Anon[7] 1955 Woman, age unknown Intra-spinal bleeding and compression of spinal cord 18 h Ford and [8] 1956 37-year-old man Thrombosis of basilar, left-posterior cerebellar and left-posterior cerebral arteries 6 h Ford and [8] 1956 No information provided Thrombosis of basilar artery No information provided and Estridge[9] 1962 33-year-old woman Infarct of cerebellar and brainstem 3 days Lorenz and Vogelsang[10] 1972 39-year-old woman Thrombosis of basilar artery 58 days Schmitt[11] 1976 35-years-old woman Infarct of brainstem 1 h Krueger and Okazaki[12] 1980 25-year-old man Infarct of brainstem and cerebellum 48 h Sherman et al.[13] 1981 60-year-old woman Dissection of vertebral artery 4 days Ali Cherif et al.[14] 1983 51-year-old man Infarct of medulla oblongata 11 days Nielsen[15] 1984 34-year-old man Dissection of vertebral artery aneurysen 3 h Zak and Carmody[16] 1984 53-year-old man Left vertebral, posterior-inferior and superior cerebellar artery occlusion; cerebellar infarction 27 days Modde[17] 1985 26-year-old woman Dissection of vertebral artery 1 day Jentzen et al.[18] 1987 51-year-old man Infarct of cerebellum and brainstem No information provided Sherman et al.[20] 1987 37-year-old man Infarct of brainstem 3 days Mas et al.[19] 1989 35-year-old woman Dissecting aneurysm of vertebral artery 16 h Raskind and North[21] 1990 47-year-old woman Cerebellar haemorrheae No information provided Sullivan[22] 1992 41-year-old woman Haemorrhage in ventricular system 8 h Haynes[23] 1994 36-year-old woman Dissecting aneurysm of vertebral artery, thrombo-embolism No information provided s et al.[24] 1995 29-year-old woman Infarct of right hemisphere 3 days Klougart et al.[25] 1996 34-year-old man Unclear Few hours Haldeman et al.[26] 2002 Previously unpublished legal cases No information provided No information provided Haldeman et al.[26] 2002 Previously unpublished legal cases No information provided No information provided Dziewas et al.[27] 2003 No information provided No information provided No information provided Most of the victims were relatively young; 14 were below the age of 40. There was a slight majority of female patients. The type of complication associated with death frequently related to a vascular accident leading to thrombosis and cerebral infarction. The time between treatment and death ranged from 1 h to 58 days; in 10 cases, it was 1 day or less. Unfortunately, the published information was often incomplete. Many other fatalities seem to have remained unpublished. For instance, the testimony of the chiropractor Preston Long for a court in Connecticut recently listed the family names of nine victims: Mathiason, Solsbury, Mc Cornick, Venegas, Bedenbaugh, , Fawcett, Parisien, Standt. Long also states that 'many others [are] unknown hidden behind legal agreements of silence'.[28] A website names further North American fatalities: Epping (California), G. Fowden (Utah), Grainger (Alberta), Hoffman (land), Renate Dora Labonte (Ontario), (California), Pereyra (Connecticut), A. Roth (Ontario) and Lee Strohecker (Pennsylvania).[29] Discussion This systematic review demonstrates that numerous deaths have been associated with chiropractic. Usually high-velocity, short-lever thrusts of the upper spine with rotation are implicated. They are believed to cause vertebral arterial dissection in predisposed individuals which, in turn, can lead to a chain of events including stroke and death.[1,2,26,30] Many chiropractors claim that, because arterial dissection can also occur spontaneously, causality between the chiropractic intervention and arterial dissection is not proven. However, when carefully evaluating the known facts, one does arrive at the conclusion that causality is at least likely (e.g.[30,31]). Even if it were merely a remote possibility, the precautionary principle in healthcare would mean that neck manipulations should be considered unsafe until proven otherwise. Moreover, there is no good evidence for assuming that neck manipulation is an effective therapy for any medical condition.[32] Thus, the risk-benefit balance for chiropractic neck manipulation fails to be positive. Reliable estimates of the frequency of vascular accidents are prevented by the fact that under-reporting is known to be substantial. In a survey of UK neurologists, for instance, under-reporting of serious complications was 100%.[33] Those cases which are published often turn out to be incomplete. Of 40 case reports of serious adverse effects associated with spinal manipulation, nine failed to provide any information about the clinical outcome.[34] Incomplete reporting of outcomes might therefore further increase the true number of fatalities. Obviously, the present article is not aimed at providing incidence figures; this would require a different methodology entirely. To date, no reliable incidence data are available. This review is focussed on deaths after chiropractic, yet neck manipulations are, of course, used by other healthcare professionals as well. The reason for this focus is simple: chiropractors are more frequently associated with serious manipulation-related adverse effects than osteopaths, physiotherapists, doctors or other professionals. Of the 40 cases of serious adverse effects mentioned above, 28 can be traced back to a chiropractor and none to an osteopath.[34] A review of complications after spinal manipulations by any type of healthcare professional included three deaths related to osteopaths, nine to medical practitioners, none to a physiotherapist, one to a naturopath and 17 to chiropractors.[35] This article also summarised a total of 265 vascular accidents of which 142 were linked to chiropractors. Another review of complications after neck manipulations published by 1997 included 177 vascular accidents, 32 of which were fatal. The vast majority of these cases were associated with chiropractic and none with physiotherapy.[36] The most obvious explanation for the dominance of chiropractic is that chiropractors routinely employ high-velocity, short-lever thrusts on the upper spine with a rotational element, while the other healthcare professionals use them much more sparingly.[37,38] In conclusion, numerous deaths have been associated with chiropractic neck manipulations. There are reasons to suspect that under-reporting is substantial and reliable incidence figures do not exist. The risks of chiropractic neck manipulations by far outweigh their benefits. Healthcare professionals should advise the public accordingly. Sidebar What's Known Chiropractic upper spinal manipulation has repeatedly been associated with arterial dissection followed by stroke and, in some cases, death. What's New The article is the first systematic review of all fatalities reported in the medical literature. Twenty-six deaths are on record and many more seem to have remained unpublished. References Ernst E. Adverse effects of spinal manipulation: a systematic review. J R Soc Med 2007; 100: 330–8. Leon- A, Cuetter A, Ferrer G. Cervical spine manipulation: an alternative medical procedure with potentially fatal complications. South Med J 2007; 100: 201–3. Dixon P. Letter to the Editor. Adverse effects of spinal manipulation. J R Soc Med 2007; 100: 444. BJ. Letter to the Editor. Adverse effects of spinal manipulation. J R Soc Med 2007; 100: 444. Anon. Medicolegal. Malpractice: death resulting from chiropractic treatment for headache. J Am Med Assoc 1934; 103:1260, 1935; 105:1712–4, 1937; 109:233–4. Pratt- HR, Berger KE. Cerebellar and spinal injuries after chiropractic manipulation. J Am Med Assoc 1947; 133: 600–3. Anon. Medicolegal abstracts. Chiropractors: injury to spinal meninges during adjustments. J Am Med Assoc 1955; 159: 809. Ford FR, D. Thrombosis of the basilar artery with softenings in the cerebellum and brain stem due to manipulation of the neck; a report of two cases with one post-mortem examination, reasons are given to prove that damage to the vertebral arteries is responsible. Bull s Hopkins Hosp 1956; 98: 37–42. RA, Estridge MN. Neurologic complications of head and neck manipulations. JAMA 1962; 182: 528–31. Lorenz R, Vogelsang HG. Thrombosis of the basilar artery following chiropractic manipulation of the cervical spine. [in German] Thrombose der arteria basilaris nach chiropraktischen Manipulationen an der Halbwirbelsäule. Dtsch Med Wochenschr 1972; 97: 36–43. Schmitt HP. Rupturen und Thrombosen der Arteria vertebralis nach gedeckten mechanischen Insulten. Schweiz Arch Neurol Neurochir Psychiatry 1976; 119: 363–79. Krueger BR, Okazaki H. Vertebral-basilar distribution infarction following chiropractic cervical manipulation. Mayo Clin Proc 1980; 55: 322–32. Sherman DG, Hart RG, Easton JD. Abrupt change in head position and cerebral infarction. Stroke 1981; 12: 2–6. Ali Cherif A, Delpuech F, Habib M, Salamon G, Khalil R. Thrombose vertebro-basilaire apres manipulation du rachis cervical. A propos de deux cas. Ann de Med Phys 1983; 25: 459–65. Nielsen AA. Cerebrovascular insults caused by manipulation of the cervical spine. [in Danish]. Ugeskr Laeger 1984; 146: 3267–70. Zak SM, Carmody RF. Cerebellar infarction from chiropractic neck manipulation: case report and review of the literature. Ariz Med 1984; 41: 333–7. Modde PJ. Chiropractic Malpractice. Columbia, land: Hanrow Press. 1985: 269–70, 273–5, 311–8, 322–3, 329–31, 334–7. Jentzen JM, Amatuzio J, GF. Complications of cervical manipulation: a case report of fatal brainstem infarct with review of the mechanisms and predisposing factors. J Forensic Sci 1987; 32: 1089–94. Mas JL, Henin D, Bousser MG, Chain F, Haw JJ. Dissecting aneurysm of the vertebral artery and cervical manipulation: a case report with autopsy. Neurology 1989; 39: 512–5. Sherman MR, Smialek JE, Zane WE. Pathogenesis of vertebral artery occlusion following cervical spine manipulation. Arch Pathol Lab Med 1987; 111: 851–3. Raskind R, North CM. Vertebral artery injuries following chiropractic cervical spine manipulation--case reports. Angiology 1990; 41: 445–52. Sullivan EC. Brain stem stroke syndromes from cervical adjustments. Report on five cases. J Chiropr Res Clin Invest 1992; 8: 12–6. Haynes MJ. Stroke following cervical manipulation in Perth. Chiropr J Aust 1994; 24: 42–6. s M, Bohl J, Thömke F, Kallen K-J, Mahlzahn K, Wandel E. Dissection of the internal carotid artery after chiropractic manipulation of the neck. Neurology 1995; 45: 2284–6. Klougart N, Leboeuf-Yde C, Rasmussen LR. Safety in chiropractic practice. Part I. The occurrence of cerebrovascular accidents after manipulation to the neck in Denmark from 1978–1988. J Manipulative Physiol Ther 1996; 19: 371–7. Haldeman S, Kohlbeck FJ, McGregor M. Unpredictability of cerebrovascular ischemia associated with cervical spine manipulation. Spine 2002; 27: 49–55. Dziewas R, Konrad C, Dräger B et al. Cervical artery dissection – clinical features, risk factors, therapy and outcome in 126 patients. J Neurol 2003; 250: 1179–84. Presentation by Dr Preston Long DC to State of Connecticut. Connecticut State Board of Chiropractic Examiners. Hartford Connecticut. 25 October 2009. Anon. What's the harm in going to a chiropractor? What's the Harm 2009; http://whatstheharm.net/chiropractic.html (accessed October 2009). Ernst E. Vascular accidents after neck manipulation: cause or coincidence? Int J Clin Pract 2009; in press. Long PH. Stroke and spinal manipulation. J Quality Health Care 2004; 3: 8–10. Ernst E. Chiropractic: a critical evaluation. J Pain Symptom Manage 2008; 35: 544–62. Stevinson C, Honan W, Cooke B, Ernst E. Neurological complications of cervical spine manipulation. J Roy Soc Med 2001; 94: 107–10. Ernst E. Cerebrovascular complications associated with spinal manipulation. Phys Ther Rev 2004; 9: 5–15. Terrett AGJ. Current Concepts in Vertebrobasilar Complications following Spinal Manipulation, 2nd edn. Des Moines: JCMIC Group, 2001. Di Fabio RP. Manipulation of the cervical spine: risks and benefits. Physical Ther 1999; 79: 50–65. Alcantara J, Ohm J, Kunz D. The safety and effectiveness of pediatric chiropractic: a survey of chiropractors and parents in a practice-based research network. Explore (NY) 2009; 5: 290–5. Sweeney A, Doody C Manual therapy for the cervical spine and reported adverse effects: a survey of Irish Manipulative Physiotherapists. Man Ther 2010; 15: 32–6. Int J Clin Pract. 2010;64(10):1162-1165. © 2010 Blackwell Publishing Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 8, 2011 Report Share Posted July 8, 2011 I remember my dad reading an article in Time magazine to me many years ago that told about a bunch of doctors in L.A. going on strike, and during that time the death rate in the city went down significantly. True story! :-) Lyndon McGill, D.C. Salem, Oregon www.SalemSpineClinic.com www.EvolvingDaily.com On 7/8/2011 12:12 PM, Vern Saboe wrote: Medical errors are the fourth leading cause of death in this country and if you add non-error deaths e.g., adverse drug events, hospital infections, surgical adverse events etc. some authors suggest medical care is the leading cause of death in this country.... VErn Saboe Chiropractic deaths Docs: I especially like their "Conclusion." Lyndon McGill, D.C. Salem, Oregon www.SalemSpineClinic.com www.EvolvingDaily.com Deaths after Chiropractic: A Review of Published Cases E. Ernst Posted: 08/30/2010; Int J Clin Pract. 2010;64(10):1162-1165. © 2010 Blackwell Publishing Abstract and Introduction Abstract Objective: The aim of this study was to summarise all cases in which chiropractic spinal manipulation was followed by death. Design: This study is a systematic review of case reports. Methods: Literature searches in four electronic databases with no restrictions of time or language. Main outcome measure: Death. Results: Twenty six fatalities were published in the medical literature and many more might have remained unpublished. The alleged pathology usually was a vascular accident involving the dissection of a vertebral artery. Conclusion: Numerous deaths have occurred after chiropractic manipulations. The risks of this treatment by far outweigh its benefit. Introduction Vascular accidents after upper spinal manipulation are a well-recognised problem (e.g.[1,2]). Dissection of a vertebral artery, caused by extension and rotation of the neck beyond the physiological range of motion, is thought to be the underlying mechanism.[2] Several deaths have been reported as a consequence. Some proponents of chiropractic seem to believe that the critical evaluation of this evidence amounts to a 'scare story' (Chairman of the UK General Chiropractic Council)[3] or to 'puffing up (the evidence) out of all proportion' (President of the British Chiropractic Association).[4] A responsible approach to serious therapeutic risks, however, requires an open discussion of the facts. In this review, I aimed to provide the basis for such a discussion by summarising all fatalities which occurred after chiropractic spinal manipulation and were published in the medical literature. Methods Electronic searches were conducted in the following electronic databases: Medline, Embase, AMED, Cochrane Library (September 2009). No restrictions of time or language were applied. Search terms were chiropractic, spinal manipulation, vascular accidents, stroke, death and fatality. In addition, our own departmental files and the bibliographies of the articles thus located were searched. Several experts were also contacted for further data. Case reports were included if they provided information on human patients who had died after receiving one or more treatments from a chiropractor. Data were extracted from the included articles according to predefined criteria (Table 1). Table 1. Published case reports of deaths after chiropractic treatments References Year of publication Victim Type of vascular accident Time between treatment and death Anon[5] 1934 Woman, age unknown Tear in left lateral sinus 2 weeks Pratt- and Berger[6] 1947 32-year-old man Thrombosis of basilar, left anterior-inferior cerebellar and right posterior-inferior arteries 24 h Pratt- and Berger[6] 1947 35-year-old woman Thrombosis of posterior-inferior cerebellar artery 10 h Anon[7] 1955 Woman, age unknown Intra-spinal bleeding and compression of spinal cord 18 h Ford and [8] 1956 37-year-old man Thrombosis of basilar, left-posterior cerebellar and left-posterior cerebral arteries 6 h Ford and [8] 1956 No information provided Thrombosis of basilar artery No information provided and Estridge[9] 1962 33-year-old woman Infarct of cerebellar and brainstem 3 days Lorenz and Vogelsang[10] 1972 39-year-old woman Thrombosis of basilar artery 58 days Schmitt[11] 1976 35-years-old woman Infarct of brainstem 1 h Krueger and Okazaki[12] 1980 25-year-old man Infarct of brainstem and cerebellum 48 h Sherman et al.[13] 1981 60-year-old woman Dissection of vertebral artery 4 days Ali Cherif et al.[14] 1983 51-year-old man Infarct of medulla oblongata 11 days Nielsen[15] 1984 34-year-old man Dissection of vertebral artery aneurysen 3 h Zak and Carmody[16] 1984 53-year-old man Left vertebral, posterior-inferior and superior cerebellar artery occlusion; cerebellar infarction 27 days Modde[17] 1985 26-year-old woman Dissection of vertebral artery 1 day Jentzen et al.[18] 1987 51-year-old man Infarct of cerebellum and brainstem No information provided Sherman et al.[20] 1987 37-year-old man Infarct of brainstem 3 days Mas et al.[19] 1989 35-year-old woman Dissecting aneurysm of vertebral artery 16 h Raskind and North[21] 1990 47-year-old woman Cerebellar haemorrheae No information provided Sullivan[22] 1992 41-year-old woman Haemorrhage in ventricular system 8 h Haynes[23] 1994 36-year-old woman Dissecting aneurysm of vertebral artery, thrombo-embolism No information provided s et al.[24] 1995 29-year-old woman Infarct of right hemisphere 3 days Klougart et al.[25] 1996 34-year-old man Unclear Few hours Haldeman et al.[26] 2002 Previously unpublished legal cases No information provided No information provided Haldeman et al.[26] 2002 Previously unpublished legal cases No information provided No information provided Dziewas et al.[27] 2003 No information provided No information provided No information provided Results Twenty-six fatalities were published since 1934 in 23 articles (Table 1).[5–27] Table 1. Published case reports of deaths after chiropractic treatments References Year of publication Victim Type of vascular accident Time between treatment and death Anon[5] 1934 Woman, age unknown Tear in left lateral sinus 2 weeks Pratt- and Berger[6] 1947 32-year-old man Thrombosis of basilar, left anterior-inferior cerebellar and right posterior-inferior arteries 24 h Pratt- and Berger[6] 1947 35-year-old woman Thrombosis of posterior-inferior cerebellar artery 10 h Anon[7] 1955 Woman, age unknown Intra-spinal bleeding and compression of spinal cord 18 h Ford and [8] 1956 37-year-old man Thrombosis of basilar, left-posterior cerebellar and left-posterior cerebral arteries 6 h Ford and [8] 1956 No information provided Thrombosis of basilar artery No information provided and Estridge[9] 1962 33-year-old woman Infarct of cerebellar and brainstem 3 days Lorenz and Vogelsang[10] 1972 39-year-old woman Thrombosis of basilar artery 58 days Schmitt[11] 1976 35-years-old woman Infarct of brainstem 1 h Krueger and Okazaki[12] 1980 25-year-old man Infarct of brainstem and cerebellum 48 h Sherman et al.[13] 1981 60-year-old woman Dissection of vertebral artery 4 days Ali Cherif et al.[14] 1983 51-year-old man Infarct of medulla oblongata 11 days Nielsen[15] 1984 34-year-old man Dissection of vertebral artery aneurysen 3 h Zak and Carmody[16] 1984 53-year-old man Left vertebral, posterior-inferior and superior cerebellar artery occlusion; cerebellar infarction 27 days Modde[17] 1985 26-year-old woman Dissection of vertebral artery 1 day Jentzen et al.[18] 1987 51-year-old man Infarct of cerebellum and brainstem No information provided Sherman et al.[20] 1987 37-year-old man Infarct of brainstem 3 days Mas et al.[19] 1989 35-year-old woman Dissecting aneurysm of vertebral artery 16 h Raskind and North[21] 1990 47-year-old woman Cerebellar haemorrheae No information provided Sullivan[22] 1992 41-year-old woman Haemorrhage in ventricular system 8 h Haynes[23] 1994 36-year-old woman Dissecting aneurysm of vertebral artery, thrombo-embolism No information provided s et al.[24] 1995 29-year-old woman Infarct of right hemisphere 3 days Klougart et al.[25] 1996 34-year-old man Unclear Few hours Haldeman et al.[26] 2002 Previously unpublished legal cases No information provided No information provided Haldeman et al.[26] 2002 Previously unpublished legal cases No information provided No information provided Dziewas et al.[27] 2003 No information provided No information provided No information provided Most of the victims were relatively young; 14 were below the age of 40. There was a slight majority of female patients. The type of complication associated with death frequently related to a vascular accident leading to thrombosis and cerebral infarction. The time between treatment and death ranged from 1 h to 58 days; in 10 cases, it was 1 day or less. Unfortunately, the published information was often incomplete. Many other fatalities seem to have remained unpublished. For instance, the testimony of the chiropractor Preston Long for a court in Connecticut recently listed the family names of nine victims: Mathiason, Solsbury, Mc Cornick, Venegas, Bedenbaugh, , Fawcett, Parisien, Standt. Long also states that 'many others [are] unknown hidden behind legal agreements of silence'.[28] A website names further North American fatalities: Epping (California), G. Fowden (Utah), Grainger (Alberta), Hoffman (land), Renate Dora Labonte (Ontario), (California), Pereyra (Connecticut), A. Roth (Ontario) and Lee Strohecker (Pennsylvania).[29] Discussion This systematic review demonstrates that numerous deaths have been associated with chiropractic. Usually high-velocity, short-lever thrusts of the upper spine with rotation are implicated. They are believed to cause vertebral arterial dissection in predisposed individuals which, in turn, can lead to a chain of events including stroke and death.[1,2,26,30] Many chiropractors claim that, because arterial dissection can also occur spontaneously, causality between the chiropractic intervention and arterial dissection is not proven. However, when carefully evaluating the known facts, one does arrive at the conclusion that causality is at least likely (e.g.[30,31]). Even if it were merely a remote possibility, the precautionary principle in healthcare would mean that neck manipulations should be considered unsafe until proven otherwise. Moreover, there is no good evidence for assuming that neck manipulation is an effective therapy for any medical condition.[32] Thus, the risk-benefit balance for chiropractic neck manipulation fails to be positive. Reliable estimates of the frequency of vascular accidents are prevented by the fact that under-reporting is known to be substantial. In a survey of UK neurologists, for instance, under-reporting of serious complications was 100%.[33] Those cases which are published often turn out to be incomplete. Of 40 case reports of serious adverse effects associated with spinal manipulation, nine failed to provide any information about the clinical outcome.[34] Incomplete reporting of outcomes might therefore further increase the true number of fatalities. Obviously, the present article is not aimed at providing incidence figures; this would require a different methodology entirely. To date, no reliable incidence data are available. This review is focussed on deaths after chiropractic, yet neck manipulations are, of course, used by other healthcare professionals as well. The reason for this focus is simple: chiropractors are more frequently associated with serious manipulation-related adverse effects than osteopaths, physiotherapists, doctors or other professionals. Of the 40 cases of serious adverse effects mentioned above, 28 can be traced back to a chiropractor and none to an osteopath.[34] A review of complications after spinal manipulations by any type of healthcare professional included three deaths related to osteopaths, nine to medical practitioners, none to a physiotherapist, one to a naturopath and 17 to chiropractors.[35] This article also summarised a total of 265 vascular accidents of which 142 were linked to chiropractors. Another review of complications after neck manipulations published by 1997 included 177 vascular accidents, 32 of which were fatal. The vast majority of these cases were associated with chiropractic and none with physiotherapy.[36] The most obvious explanation for the dominance of chiropractic is that chiropractors routinely employ high-velocity, short-lever thrusts on the upper spine with a rotational element, while the other healthcare professionals use them much more sparingly.[37,38] In conclusion, numerous deaths have been associated with chiropractic neck manipulations. There are reasons to suspect that under-reporting is substantial and reliable incidence figures do not exist. The risks of chiropractic neck manipulations by far outweigh their benefits. Healthcare professionals should advise the public accordingly. Sidebar What's Known Chiropractic upper spinal manipulation has repeatedly been associated with arterial dissection followed by stroke and, in some cases, death. What's New The article is the first systematic review of all fatalities reported in the medical literature. Twenty-six deaths are on record and many more seem to have remained unpublished. References Ernst E. Adverse effects of spinal manipulation: a systematic review. J R Soc Med 2007; 100: 330–8. Leon- A, Cuetter A, Ferrer G. Cervical spine manipulation: an alternative medical procedure with potentially fatal complications. South Med J 2007; 100: 201–3. Dixon P. Letter to the Editor. Adverse effects of spinal manipulation. J R Soc Med 2007; 100: 444. BJ. Letter to the Editor. Adverse effects of spinal manipulation. J R Soc Med 2007; 100: 444. Anon. Medicolegal. Malpractice: death resulting from chiropractic treatment for headache. J Am Med Assoc 1934; 103:1260, 1935; 105:1712–4, 1937; 109:233–4. Pratt- HR, Berger KE. Cerebellar and spinal injuries after chiropractic manipulation. J Am Med Assoc 1947; 133: 600–3. Anon. Medicolegal abstracts. Chiropractors: injury to spinal meninges during adjustments. J Am Med Assoc 1955; 159: 809. Ford FR, D. Thrombosis of the basilar artery with softenings in the cerebellum and brain stem due to manipulation of the neck; a report of two cases with one post-mortem examination, reasons are given to prove that damage to the vertebral arteries is responsible. Bull s Hopkins Hosp 1956; 98: 37–42. RA, Estridge MN. Neurologic complications of head and neck manipulations. JAMA 1962; 182: 528–31. Lorenz R, Vogelsang HG. Thrombosis of the basilar artery following chiropractic manipulation of the cervical spine. [in German] Thrombose der arteria basilaris nach chiropraktischen Manipulationen an der Halbwirbelsäule. Dtsch Med Wochenschr 1972; 97: 36–43. Schmitt HP. Rupturen und Thrombosen der Arteria vertebralis nach gedeckten mechanischen Insulten. Schweiz Arch Neurol Neurochir Psychiatry 1976; 119: 363–79. Krueger BR, Okazaki H. Vertebral-basilar distribution infarction following chiropractic cervical manipulation. Mayo Clin Proc 1980; 55: 322–32. Sherman DG, Hart RG, Easton JD. Abrupt change in head position and cerebral infarction. Stroke 1981; 12: 2–6. Ali Cherif A, Delpuech F, Habib M, Salamon G, Khalil R. Thrombose vertebro-basilaire apres manipulation du rachis cervical. A propos de deux cas. Ann de Med Phys 1983; 25: 459–65. Nielsen AA. Cerebrovascular insults caused by manipulation of the cervical spine. [in Danish]. Ugeskr Laeger 1984; 146: 3267–70. Zak SM, Carmody RF. Cerebellar infarction from chiropractic neck manipulation: case report and review of the literature. Ariz Med 1984; 41: 333–7. Modde PJ. Chiropractic Malpractice. Columbia, land: Hanrow Press. 1985: 269–70, 273–5, 311–8, 322–3, 329–31, 334–7. Jentzen JM, Amatuzio J, GF. Complications of cervical manipulation: a case report of fatal brainstem infarct with review of the mechanisms and predisposing factors. J Forensic Sci 1987; 32: 1089–94. Mas JL, Henin D, Bousser MG, Chain F, Haw JJ. Dissecting aneurysm of the vertebral artery and cervical manipulation: a case report with autopsy. Neurology 1989; 39: 512–5. Sherman MR, Smialek JE, Zane WE. Pathogenesis of vertebral artery occlusion following cervical spine manipulation. Arch Pathol Lab Med 1987; 111: 851–3. Raskind R, North CM. Vertebral artery injuries following chiropractic cervical spine manipulation--case reports. Angiology 1990; 41: 445–52. Sullivan EC. Brain stem stroke syndromes from cervical adjustments. Report on five cases. J Chiropr Res Clin Invest 1992; 8: 12–6. Haynes MJ. Stroke following cervical manipulation in Perth. Chiropr J Aust 1994; 24: 42–6. s M, Bohl J, Thömke F, Kallen K-J, Mahlzahn K, Wandel E. Dissection of the internal carotid artery after chiropractic manipulation of the neck. Neurology 1995; 45: 2284–6. Klougart N, Leboeuf-Yde C, Rasmussen LR. Safety in chiropractic practice. Part I. The occurrence of cerebrovascular accidents after manipulation to the neck in Denmark from 1978–1988. J Manipulative Physiol Ther 1996; 19: 371–7. Haldeman S, Kohlbeck FJ, McGregor M. Unpredictability of cerebrovascular ischemia associated with cervical spine manipulation. Spine 2002; 27: 49–55. Dziewas R, Konrad C, Dräger B et al. Cervical artery dissection – clinical features, risk factors, therapy and outcome in 126 patients. J Neurol 2003; 250: 1179–84. Presentation by Dr Preston Long DC to State of Connecticut. Connecticut State Board of Chiropractic Examiners. Hartford Connecticut. 25 October 2009. Anon. What's the harm in going to a chiropractor? What's the Harm 2009; http://whatstheharm.net/chiropractic.html (accessed October 2009). Ernst E. Vascular accidents after neck manipulation: cause or coincidence? Int J Clin Pract 2009; in press. Long PH. Stroke and spinal manipulation. J Quality Health Care 2004; 3: 8–10. Ernst E. Chiropractic: a critical evaluation. J Pain Symptom Manage 2008; 35: 544–62. Stevinson C, Honan W, Cooke B, Ernst E. Neurological complications of cervical spine manipulation. J Roy Soc Med 2001; 94: 107–10. Ernst E. Cerebrovascular complications associated with spinal manipulation. Phys Ther Rev 2004; 9: 5–15. Terrett AGJ. Current Concepts in Vertebrobasilar Complications following Spinal Manipulation, 2nd edn. Des Moines: JCMIC Group, 2001. Di Fabio RP. Manipulation of the cervical spine: risks and benefits. Physical Ther 1999; 79: 50–65. Alcantara J, Ohm J, Kunz D. The safety and effectiveness of pediatric chiropractic: a survey of chiropractors and parents in a practice-based research network. Explore (NY) 2009; 5: 290–5. Sweeney A, Doody C Manual therapy for the cervical spine and reported adverse effects: a survey of Irish Manipulative Physiotherapists. Man Ther 2010; 15: 32–6. Int J Clin Pract. 2010;64(10):1162-1165. © 2010 Blackwell Publishing Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 8, 2011 Report Share Posted July 8, 2011 Dear Dr. Joe, We will once and forever catch a "break" when ALL of the chiropractic schools decide to teach ONLY instrument corrections of the cervical spine and permanently remove the stigma of tears of vascular structures due to vigorous rotational "adjustments". Herb Freeman D.C. Chiropractic deaths Docs:I especially like their "Conclusion."Lyndon McGill, D.C.Salem, Oregonwww.SalemSpineClinic.comwww.EvolvingDaily.com Deaths after Chiropractic: A Review of Published Cases E. Ernst Posted: 08/30/2010; Int J Clin Pract. 2010;64(10):1162-1165. © 2010 Blackwell Publishing Abstract and Introduction Abstract Objective: The aim of this study was to summarise all cases in which chiropractic spinal manipulation was followed by death.Design: This study is a systematic review of case reports.Methods: Literature searches in four electronic databases with no restrictions of time or language.Main outcome measure: Death.Results: Twenty six fatalities were published in the medical literature and many more might have remained unpublished. The alleged pathology usually was a vascular accident involving the dissection of a vertebral artery.Conclusion: Numerous deaths have occurred after chiropractic manipulations. The risks of this treatment by far outweigh its benefit. Introduction Vascular accidents after upper spinal manipulation are a well-recognised problem (e.g.[1,2]). Dissection of a vertebral artery, caused by extension and rotation of the neck beyond the physiological range of motion, is thought to be the underlying mechanism.[2] Several deaths have been reported as a consequence. Some proponents of chiropractic seem to believe that the critical evaluation of this evidence amounts to a 'scare story' (Chairman of the UK General Chiropractic Council)[3] or to 'puffing up (the evidence) out of all proportion' (President of the British Chiropractic Association).[4] A responsible approach to serious therapeutic risks, however, requires an open discussion of the facts. In this review, I aimed to provide the basis for such a discussion by summarising all fatalities which occurred after chiropractic spinal manipulation and were published in the medical literature. Methods Electronic searches were conducted in the following electronic databases: Medline, Embase, AMED, Cochrane Library (September 2009). No restrictions of time or language were applied. Search terms were chiropractic, spinal manipulation, vascular accidents, stroke, death and fatality. In addition, our own departmental files and the bibliographies of the articles thus located were searched. Several experts were also contacted for further data. Case reports were included if they provided information on human patients who had died after receiving one or more treatments from a chiropractor. Data were extracted from the included articles according to predefined criteria (Table 1). Table 1. Published case reports of deaths after chiropractic treatments References Year of publication Victim Type of vascular accident Time between treatment and death Anon[5] 1934 Woman, age unknown Tear in left lateral sinus 2 weeks Pratt- and Berger[6] 1947 32-year-old man Thrombosis of basilar, left anterior-inferior cerebellar and right posterior-inferior arteries 24 h Pratt- and Berger[6] 1947 35-year-old woman Thrombosis of posterior-inferior cerebellar artery 10 h Anon[7] 1955 Woman, age unknown Intra-spinal bleeding and compression of spinal cord 18 h Ford and [8] 1956 37-year-old man Thrombosis of basilar, left-posterior cerebellar and left-posterior cerebral arteries 6 h Ford and [8] 1956 No information provided Thrombosis of basilar artery No information provided and Estridge[9] 1962 33-year-old woman Infarct of cerebellar and brainstem 3 days Lorenz and Vogelsang[10] 1972 39-year-old woman Thrombosis of basilar artery 58 days Schmitt[11] 1976 35-years-old woman Infarct of brainstem 1 h Krueger and Okazaki[12] 1980 25-year-old man Infarct of brainstem and cerebellum 48 h Sherman et al.[13] 1981 60-year-old woman Dissection of vertebral artery 4 days Ali Cherif et al.[14] 1983 51-year-old man Infarct of medulla oblongata 11 days Nielsen[15] 1984 34-year-old man Dissection of vertebral artery aneurysen 3 h Zak and Carmody[16] 1984 53-year-old man Left vertebral, posterior-inferior and superior cerebellar artery occlusion; cerebellar infarction 27 days Modde[17] 1985 26-year-old woman Dissection of vertebral artery 1 day Jentzen et al.[18] 1987 51-year-old man Infarct of cerebellum and brainstem No information provided Sherman et al.[20] 1987 37-year-old man Infarct of brainstem 3 days Mas et al.[19] 1989 35-year-old woman Dissecting aneurysm of vertebral artery 16 h Raskind and North[21] 1990 47-year-old woman Cerebellar haemorrheae No information provided Sullivan[22] 1992 41-year-old woman Haemorrhage in ventricular system 8 h Haynes[23] 1994 36-year-old woman Dissecting aneurysm of vertebral artery, thrombo-embolism No information provided s et al.[24] 1995 29-year-old woman Infarct of right hemisphere 3 days Klougart et al.[25] 1996 34-year-old man Unclear Few hours Haldeman et al.[26] 2002 Previously unpublished legal cases No information provided No information provided Haldeman et al.[26] 2002 Previously unpublished legal cases No information provided No information provided Dziewas et al.[27] 2003 No information provided No information provided No information provided Results Twenty-six fatalities were published since 1934 in 23 articles (Table 1).[5-27] Table 1. Published case reports of deaths after chiropractic treatments References Year of publication Victim Type of vascular accident Time between treatment and death Anon[5] 1934 Woman, age unknown Tear in left lateral sinus 2 weeks Pratt- and Berger[6] 1947 32-year-old man Thrombosis of basilar, left anterior-inferior cerebellar and right posterior-inferior arteries 24 h Pratt- and Berger[6] 1947 35-year-old woman Thrombosis of posterior-inferior cerebellar artery 10 h Anon[7] 1955 Woman, age unknown Intra-spinal bleeding and compression of spinal cord 18 h Ford and [8] 1956 37-year-old man Thrombosis of basilar, left-posterior cerebellar and left-posterior cerebral arteries 6 h Ford and [8] 1956 No information provided Thrombosis of basilar artery No information provided and Estridge[9] 1962 33-year-old woman Infarct of cerebellar and brainstem 3 days Lorenz and Vogelsang[10] 1972 39-year-old woman Thrombosis of basilar artery 58 days Schmitt[11] 1976 35-years-old woman Infarct of brainstem 1 h Krueger and Okazaki[12] 1980 25-year-old man Infarct of brainstem and cerebellum 48 h Sherman et al.[13] 1981 60-year-old woman Dissection of vertebral artery 4 days Ali Cherif et al.[14] 1983 51-year-old man Infarct of medulla oblongata 11 days Nielsen[15] 1984 34-year-old man Dissection of vertebral artery aneurysen 3 h Zak and Carmody[16] 1984 53-year-old man Left vertebral, posterior-inferior and superior cerebellar artery occlusion; cerebellar infarction 27 days Modde[17] 1985 26-year-old woman Dissection of vertebral artery 1 day Jentzen et al.[18] 1987 51-year-old man Infarct of cerebellum and brainstem No information provided Sherman et al.[20] 1987 37-year-old man Infarct of brainstem 3 days Mas et al.[19] 1989 35-year-old woman Dissecting aneurysm of vertebral artery 16 h Raskind and North[21] 1990 47-year-old woman Cerebellar haemorrheae No information provided Sullivan[22] 1992 41-year-old woman Haemorrhage in ventricular system 8 h Haynes[23] 1994 36-year-old woman Dissecting aneurysm of vertebral artery, thrombo-embolism No information provided s et al.[24] 1995 29-year-old woman Infarct of right hemisphere 3 days Klougart et al.[25] 1996 34-year-old man Unclear Few hours Haldeman et al.[26] 2002 Previously unpublished legal cases No information provided No information provided Haldeman et al.[26] 2002 Previously unpublished legal cases No information provided No information provided Dziewas et al.[27] 2003 No information provided No information provided No information provided Most of the victims were relatively young; 14 were below the age of 40. There was a slight majority of female patients. The type of complication associated with death frequently related to a vascular accident leading to thrombosis and cerebral infarction. The time between treatment and death ranged from 1 h to 58 days; in 10 cases, it was 1 day or less. Unfortunately, the published information was often incomplete. Many other fatalities seem to have remained unpublished. For instance, the testimony of the chiropractor Preston Long for a court in Connecticut recently listed the family names of nine victims: Mathiason, Solsbury, Mc Cornick, Venegas, Bedenbaugh, , Fawcett, Parisien, Standt. Long also states that 'many others [are] unknown hidden behind legal agreements of silence'.[28] A website names further North American fatalities: Epping (California), G. Fowden (Utah), Grainger (Alberta), Hoffman (land), Renate Dora Labonte (Ontario), (California), Pereyra (Connecticut), A. Roth (Ontario) and Lee Strohecker (Pennsylvania).[29] Discussion This systematic review demonstrates that numerous deaths have been associated with chiropractic. Usually high-velocity, short-lever thrusts of the upper spine with rotation are implicated. They are believed to cause vertebral arterial dissection in predisposed individuals which, in turn, can lead to a chain of events including stroke and death.[1,2,26,30] Many chiropractors claim that, because arterial dissection can also occur spontaneously, causality between the chiropractic intervention and arterial dissection is not proven. However, when carefully evaluating the known facts, one does arrive at the conclusion that causality is at least likely (e.g.[30,31]). Even if it were merely a remote possibility, the precautionary principle in healthcare would mean that neck manipulations should be considered unsafe until proven otherwise. Moreover, there is no good evidence for assuming that neck manipulation is an effective therapy for any medical condition.[32] Thus, the risk-benefit balance for chiropractic neck manipulation fails to be positive. Reliable estimates of the frequency of vascular accidents are prevented by the fact that under-reporting is known to be substantial. In a survey of UK neurologists, for instance, under-reporting of serious complications was 100%.[33] Those cases which are published often turn out to be incomplete. Of 40 case reports of serious adverse effects associated with spinal manipulation, nine failed to provide any information about the clinical outcome.[34] Incomplete reporting of outcomes might therefore further increase the true number of fatalities. Obviously, the present article is not aimed at providing incidence figures; this would require a different methodology entirely. To date, no reliable incidence data are available. This review is focussed on deaths after chiropractic, yet neck manipulations are, of course, used by other healthcare professionals as well. The reason for this focus is simple: chiropractors are more frequently associated with serious manipulation-related adverse effects than osteopaths, physiotherapists, doctors or other professionals. Of the 40 cases of serious adverse effects mentioned above, 28 can be traced back to a chiropractor and none to an osteopath.[34] A review of complications after spinal manipulations by any type of healthcare professional included three deaths related to osteopaths, nine to medical practitioners, none to a physiotherapist, one to a naturopath and 17 to chiropractors.[35] This article also summarised a total of 265 vascular accidents of which 142 were linked to chiropractors. Another review of complications after neck manipulations published by 1997 included 177 vascular accidents, 32 of which were fatal. The vast majority of these cases were associated with chiropractic and none with physiotherapy.[36] The most obvious explanation for the dominance of chiropractic is that chiropractors routinely employ high-velocity, short-lever thrusts on the upper spine with a rotational element, while the other healthcare professionals use them much more sparingly.[37,38] In conclusion, numerous deaths have been associated with chiropractic neck manipulations. There are reasons to suspect that under-reporting is substantial and reliable incidence figures do not exist. The risks of chiropractic neck manipulations by far outweigh their benefits. Healthcare professionals should advise the public accordingly. Sidebar What's Known Chiropractic upper spinal manipulation has repeatedly been associated with arterial dissection followed by stroke and, in some cases, death. What's New The article is the first systematic review of all fatalities reported in the medical literature. Twenty-six deaths are on record and many more seem to have remained unpublished. References Ernst E. Adverse effects of spinal manipulation: a systematic review. J R Soc Med 2007; 100: 330-8. Leon- A, Cuetter A, Ferrer G. Cervical spine manipulation: an alternative medical procedure with potentially fatal complications. South Med J 2007; 100: 201-3. Dixon P. Letter to the Editor. Adverse effects of spinal manipulation. J R Soc Med 2007; 100: 444. BJ. Letter to the Editor. Adverse effects of spinal manipulation. J R Soc Med 2007; 100: 444. Anon. Medicolegal. Malpractice: death resulting from chiropractic treatment for headache. J Am Med Assoc 1934; 103:1260, 1935; 105:1712-4, 1937; 109:233-4. Pratt- HR, Berger KE. Cerebellar and spinal injuries after chiropractic manipulation. J Am Med Assoc 1947; 133: 600-3. Anon. Medicolegal abstracts. Chiropractors: injury to spinal meninges during adjustments. J Am Med Assoc 1955; 159: 809. Ford FR, D. Thrombosis of the basilar artery with softenings in the cerebellum and brain stem due to manipulation of the neck; a report of two cases with one post-mortem examination, reasons are given to prove that damage to the vertebral arteries is responsible. Bull s Hopkins Hosp 1956; 98: 37-42. RA, Estridge MN. Neurologic complications of head and neck manipulations. JAMA 1962; 182: 528-31. Lorenz R, Vogelsang HG. Thrombosis of the basilar artery following chiropractic manipulation of the cervical spine. [in German] Thrombose der arteria basilaris nach chiropraktischen Manipulationen an der Halbwirbelsäule. Dtsch Med Wochenschr 1972; 97: 36-43. Schmitt HP. Rupturen und Thrombosen der Arteria vertebralis nach gedeckten mechanischen Insulten. Schweiz Arch Neurol Neurochir Psychiatry 1976; 119: 363-79. Krueger BR, Okazaki H. Vertebral-basilar distribution infarction following chiropractic cervical manipulation. Mayo Clin Proc 1980; 55: 322-32. Sherman DG, Hart RG, Easton JD. Abrupt change in head position and cerebral infarction. Stroke 1981; 12: 2-6. Ali Cherif A, Delpuech F, Habib M, Salamon G, Khalil R. Thrombose vertebro-basilaire apres manipulation du rachis cervical. A propos de deux cas. Ann de Med Phys 1983; 25: 459-65. Nielsen AA. Cerebrovascular insults caused by manipulation of the cervical spine. [in Danish]. Ugeskr Laeger 1984; 146: 3267-70. Zak SM, Carmody RF. Cerebellar infarction from chiropractic neck manipulation: case report and review of the literature. Ariz Med 1984; 41: 333-7. Modde PJ. Chiropractic Malpractice. Columbia, land: Hanrow Press. 1985: 269-70, 273-5, 311-8, 322-3, 329-31, 334-7. Jentzen JM, Amatuzio J, GF. Complications of cervical manipulation: a case report of fatal brainstem infarct with review of the mechanisms and predisposing factors. J Forensic Sci 1987; 32: 1089-94. Mas JL, Henin D, Bousser MG, Chain F, Haw JJ. Dissecting aneurysm of the vertebral artery and cervical manipulation: a case report with autopsy. Neurology 1989; 39: 512-5. Sherman MR, Smialek JE, Zane WE. Pathogenesis of vertebral artery occlusion following cervical spine manipulation. Arch Pathol Lab Med 1987; 111: 851-3. Raskind R, North CM. Vertebral artery injuries following chiropractic cervical spine manipulation--case reports. Angiology 1990; 41: 445-52. Sullivan EC. Brain stem stroke syndromes from cervical adjustments. Report on five cases. J Chiropr Res Clin Invest 1992; 8: 12-6. Haynes MJ. Stroke following cervical manipulation in Perth. Chiropr J Aust 1994; 24: 42-6. s M, Bohl J, Thömke F, Kallen K-J, Mahlzahn K, Wandel E. Dissection of the internal carotid artery after chiropractic manipulation of the neck. Neurology 1995; 45: 2284-6. Klougart N, Leboeuf-Yde C, Rasmussen LR. Safety in chiropractic practice. Part I. The occurrence of cerebrovascular accidents after manipulation to the neck in Denmark from 1978-1988. J Manipulative Physiol Ther 1996; 19: 371-7. Haldeman S, Kohlbeck FJ, McGregor M. Unpredictability of cerebrovascular ischemia associated with cervical spine manipulation. Spine 2002; 27: 49-55. Dziewas R, Konrad C, Dräger B et al. Cervical artery dissection - clinical features, risk factors, therapy and outcome in 126 patients. J Neurol 2003; 250: 1179-84. Presentation by Dr Preston Long DC to State of Connecticut. Connecticut State Board of Chiropractic Examiners. Hartford Connecticut. 25 October 2009. Anon. What's the harm in going to a chiropractor? What's the Harm 2009; http://whatstheharm.net/chiropractic.html (accessed October 2009). Ernst E. Vascular accidents after neck manipulation: cause or coincidence? Int J Clin Pract 2009; in press. Long PH. Stroke and spinal manipulation. J Quality Health Care 2004; 3: 8-10. Ernst E. Chiropractic: a critical evaluation. J Pain Symptom Manage 2008; 35: 544-62. Stevinson C, Honan W, Cooke B, Ernst E. Neurological complications of cervical spine manipulation. J Roy Soc Med 2001; 94: 107-10. Ernst E. Cerebrovascular complications associated with spinal manipulation. Phys Ther Rev 2004; 9: 5-15. Terrett AGJ. Current Concepts in Vertebrobasilar Complications following Spinal Manipulation, 2nd edn. Des Moines: JCMIC Group, 2001. Di Fabio RP. Manipulation of the cervical spine: risks and benefits. Physical Ther 1999; 79: 50-65. Alcantara J, Ohm J, Kunz D. The safety and effectiveness of pediatric chiropractic: a survey of chiropractors and parents in a practice-based research network. Explore (NY) 2009; 5: 290-5. Sweeney A, Doody C Manual therapy for the cervical spine and reported adverse effects: a survey of Irish Manipulative Physiotherapists. Man Ther 2010; 15: 32-6. Int J Clin Pract. 2010;64(10):1162-1165. © 2010 Blackwell Publishing Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 8, 2011 Report Share Posted July 8, 2011 All, My perceptions may not be popular from what I see on this list, but I can't read the posts any longer without comment. I agree that iatrogenic, medical error and adverse drug rxns are a bigger cause of death than chiropractic manipulation. And altho I believe deaths from vascular accidents following high velocity adjusting, may only be assigned as a 'very low risk', I still think this issue needs statistical analysis. I think we as a profession would do better to lead the risk studies for obvious reasons. I also think this chart is poorly crafted and doesn't prove a thing well enough for me to quote any of the stats. During the beginning of my 2nd yr as a DC student, my beloved grand father died approximately 2-3 hours after a chiropractic high velocity adjustment. Cause of death was listed as 2 fold; abdominal anuerysm and stroke. He was 89, diabetic, high cholesterol, tho not over weight. He was active and danced every weekend with grandma. He had been seeing the same chiropractor for about a decade. The adjustments were getting increasingly more difficult for him to tolerate. He mentioned this to me as a student. I didn't know enough to advise him at the time. The ER doctors told our family it was most likely the high veolcity lumbar roll and the upper cervical adjusting that caused his death. He felt immediately dizzy after the adjustment, however he'd been getting dizzy after adjusting the last 3-4 times. He had mentioned it to the DC and was told it was 'normal' for his age according to my grandmother who attended appts with him. On this occasion, the dizziness didn't pass. And his legs got so weak, he could barely make to to the car. He passed out on the way home and my grandmother drove him straight to ER. He never regained consciousness. They had been married for over 50 yrs. It was a devastating thing for our family. I remember reading the ER reports as a 2nd yr DC student. Sobering. However, in 1982 there wasn't a lot of informed consent mandatory stuff going on. I have to admit, when it happens to a close family member, you will take notice. You will appreciate the absolute need to do a verbal and written signed consent form if you decide to adjust the high risk patients.After asking a few senior interns and my own clinic director, I appreciated how my grandpa's DC had failed to change adjusting procedures and take into account his failing health and risk factors. MY grandma was too distraught to sue. However, I did call the doctor and told him that in all probability, he killed my grandfather by not keeping current with risk factors. He said he was retiring the next yr. I told him not to wait. He did apologize and said in hindsight, he probably should've considered grandpa's health, but that he was so active, he had overlooked it. I give him this, he had the guts to apologize to grandma. No one in the family would sue him because he ponied up. I have always been and am still in support of mandatory informed consent. Written, signed and verbal. I am in support of our profession listening to public sentiment and dealing with it. I think our state association should work with either UWS, OHSU or both to design a statistical analysis of this perceived risk. We need to do it before others do it. That way we are pro-active and perceived as listening to public sentiment, public protection; instead of living in denial. Once stats prove otherwise de NILE is fine. Minga Guerrero DC Re: Chiropractic deaths Medical errors are the fourth leading cause of death in this country and if you add non-error deaths e.g., adverse drug events, hospital infections, surgical adverse events etc. some authors suggest medical care is the leading cause of death in this country.... VErn Saboe Chiropractic deaths Docs: I especially like their "Conclusion." Lyndon McGill, D.C. Salem, Oregon www.SalemSpineClinic.com www.EvolvingDaily.com Deaths after Chiropractic: A Review of Published Cases E. Ernst Posted: 08/30/2010; Int J Clin Pract. 2010;64(10):1162-1165. © 2010 Blackwell Publishing Abstract and Introduction Abstract Objective: The aim of this study was to summarise all cases in which chiropractic spinal manipulation was followed by death. Design: This study is a systematic review of case reports. Methods: Literature searches in four electronic databases with no restrictions of time or language. Main outcome measure: Death. Results: Twenty six fatalities were published in the medical literature and many more might have remained unpublished. The alleged pathology usually was a vascular accident involving the dissection of a vertebral artery. Conclusion: Numerous deaths have occurred after chiropractic manipulations. The risks of this treatment by far outweigh its benefit. Introduction Vascular accidents after upper spinal manipulation are a well-recognised problem (e.g.[1,2]). Dissection of a vertebral artery, caused by extension and rotation of the neck beyond the physiological range of motion, is thought to be the underlying mechanism.[2] Several deaths have been reported as a consequence. Some proponents of chiropractic seem to believe that the critical evaluation of this evidence amounts to a 'scare story' (Chairman of the UK General Chiropractic Council)[3] or to 'puffing up (the evidence) out of all proportion' (President of the British Chiropractic Association).[4] A responsible approach to serious therapeutic risks, however, requires an open discussion of the facts. In this review, I aimed to provide the basis for such a discussion by summarising all fatalities which occurred after chiropractic spinal manipulation and were published in the medical literature. Methods Electronic searches were conducted in the following electronic databases: Medline, Embase, AMED, Cochrane Library (September 2009). No restrictions of time or language were applied. Search terms were chiropractic, spinal manipulation, vascular accidents, stroke, death and fatality. In addition, our own departmental files and the bibliographies of the articles thus located were searched. Several experts were also contacted for further data. Case reports were included if they provided information on human patients who had died after receiving one or more treatments from a chiropractor. Data were extracted from the included articles according to predefined criteria (Table 1). Table 1. Published case reports of deaths after chiropractic treatments References Year of publication Victim Type of vascular accident Time between treatment and death Anon[5] 1934 Woman, age unknown Tear in left lateral sinus 2 weeks Pratt- and Berger[6] 1947 32-year-old man Thrombosis of basilar, left anterior-inferior cerebellar and right posterior-inferior arteries 24 h Pratt- and Berger[6] 1947 35-year-old woman Thrombosis of posterior-inferior cerebellar artery 10 h Anon[7] 1955 Woman, age unknown Intra-spinal bleeding and compression of spinal cord 18 h Ford and [8] 1956 37-year-old man Thrombosis of basilar, left-posterior cerebellar and left-posterior cerebral arteries 6 h Ford and [8] 1956 No information provided Thrombosis of basilar artery No information provided and Estridge[9] 1962 33-year-old woman Infarct of cerebellar and brainstem 3 days Lorenz and Vogelsang[10] 1972 39-year-old woman Thrombosis of basilar artery 58 days Schmitt[11] 1976 35-years-old woman Infarct of brainstem 1 h Krueger and Okazaki[12] 1980 25-year-old man Infarct of brainstem and cerebellum 48 h Sherman et al.[13] 1981 60-year-old woman Dissection of vertebral artery 4 days Ali Cherif et al.[14] 1983 51-year-old man Infarct of medulla oblongata 11 days Nielsen[15] 1984 34-year-old man Dissection of vertebral artery aneurysen 3 h Zak and Carmody[16] 1984 53-year-old man Left vertebral, posterior-inferior and superior cerebellar artery occlusion; cerebellar infarction 27 days Modde[17] 1985 26-year-old woman Dissection of vertebral artery 1 day Jentzen et al.[18] 1987 51-year-old man Infarct of cerebellum and brainstem No information provided Sherman et al.[20] 1987 37-year-old man Infarct of brainstem 3 days Mas et al.[19] 1989 35-year-old woman Dissecting aneurysm of vertebral artery 16 h Raskind and North[21] 1990 47-year-old woman Cerebellar haemorrheae No information provided Sullivan[22] 1992 41-year-old woman Haemorrhage in ventricular system 8 h Haynes[23] 1994 36-year-old woman Dissecting aneurysm of vertebral artery, thrombo-embolism No information provided s et al.[24] 1995 29-year-old woman Infarct of right hemisphere 3 days Klougart et al.[25] 1996 34-year-old man Unclear Few hours Haldeman et al.[26] 2002 Previously unpublished legal cases No information provided No information provided Haldeman et al.[26] 2002 Previously unpublished legal cases No information provided No information provided Dziewas et al.[27] 2003 No information provided No information provided No information provided Results Twenty-six fatalities were published since 1934 in 23 articles (Table 1).[5–27] Table 1. Published case reports of deaths after chiropractic treatments References Year of publication Victim Type of vascular accident Time between treatment and death Anon[5] 1934 Woman, age unknown Tear in left lateral sinus 2 weeks Pratt- and Berger[6] 1947 32-year-old man Thrombosis of basilar, left anterior-inferior cerebellar and right posterior-inferior arteries 24 h Pratt- and Berger[6] 1947 35-year-old woman Thrombosis of posterior-inferior cerebellar artery 10 h Anon[7] 1955 Woman, age unknown Intra-spinal bleeding and compression of spinal cord 18 h Ford and [8] 1956 37-year-old man Thrombosis of basilar, left-posterior cerebellar and left-posterior cerebral arteries 6 h Ford and [8] 1956 No information provided Thrombosis of basilar artery No information provided and Estridge[9] 1962 33-year-old woman Infarct of cerebellar and brainstem 3 days Lorenz and Vogelsang[10] 1972 39-year-old woman Thrombosis of basilar artery 58 days Schmitt[11] 1976 35-years-old woman Infarct of brainstem 1 h Krueger and Okazaki[12] 1980 25-year-old man Infarct of brainstem and cerebellum 48 h Sherman et al.[13] 1981 60-year-old woman Dissection of vertebral artery 4 days Ali Cherif et al.[14] 1983 51-year-old man Infarct of medulla oblongata 11 days Nielsen[15] 1984 34-year-old man Dissection of vertebral artery aneurysen 3 h Zak and Carmody[16] 1984 53-year-old man Left vertebral, posterior-inferior and superior cerebellar artery occlusion; cerebellar infarction 27 days Modde[17] 1985 26-year-old woman Dissection of vertebral artery 1 day Jentzen et al.[18] 1987 51-year-old man Infarct of cerebellum and brainstem No information provided Sherman et al.[20] 1987 37-year-old man Infarct of brainstem 3 days Mas et al.[19] 1989 35-year-old woman Dissecting aneurysm of vertebral artery 16 h Raskind and North[21] 1990 47-year-old woman Cerebellar haemorrheae No information provided Sullivan[22] 1992 41-year-old woman Haemorrhage in ventricular system 8 h Haynes[23] 1994 36-year-old woman Dissecting aneurysm of vertebral artery, thrombo-embolism No information provided s et al.[24] 1995 29-year-old woman Infarct of right hemisphere 3 days Klougart et al.[25] 1996 34-year-old man Unclear Few hours Haldeman et al.[26] 2002 Previously unpublished legal cases No information provided No information provided Haldeman et al.[26] 2002 Previously unpublished legal cases No information provided No information provided Dziewas et al.[27] 2003 No information provided No information provided No information provided Most of the victims were relatively young; 14 were below the age of 40. There was a slight majority of female patients. The type of complication associated with death frequently related to a vascular accident leading to thrombosis and cerebral infarction. The time between treatment and death ranged from 1 h to 58 days; in 10 cases, it was 1 day or less. Unfortunately, the published information was often incomplete. Many other fatalities seem to have remained unpublished. For instance, the testimony of the chiropractor Preston Long for a court in Connecticut recently listed the family names of nine victims: Mathiason, Solsbury, Mc Cornick, Venegas, Bedenbaugh, , Fawcett, Parisien, Standt. Long also states that 'many others [are] unknown hidden behind legal agreements of silence'.[28] A website names further North American fatalities: Epping (California), G. Fowden (Utah), Grainger (Alberta), Hoffman (land), Renate Dora Labonte (Ontario), (California), Pereyra (Connecticut), A. Roth (Ontario) and Lee Strohecker (Pennsylvania).[29] Discussion This systematic review demonstrates that numerous deaths have been associated with chiropractic. Usually high-velocity, short-lever thrusts of the upper spine with rotation are implicated. They are believed to cause vertebral arterial dissection in predisposed individuals which, in turn, can lead to a chain of events including stroke and death.[1,2,26,30] Many chiropractors claim that, because arterial dissection can also occur spontaneously, causality between the chiropractic intervention and arterial dissection is not proven. However, when carefully evaluating the known facts, one does arrive at the conclusion that causality is at least likely (e.g.[30,31]). Even if it were merely a remote possibility, the precautionary principle in healthcare would mean that neck manipulations should be considered unsafe until proven otherwise. Moreover, there is no good evidence for assuming that neck manipulation is an effective therapy for any medical condition.[32] Thus, the risk-benefit balance for chiropractic neck manipulation fails to be positive. Reliable estimates of the frequency of vascular accidents are prevented by the fact that under-reporting is known to be substantial. In a survey of UK neurologists, for instance, under-reporting of serious complications was 100%.[33] Those cases which are published often turn out to be incomplete. Of 40 case reports of serious adverse effects associated with spinal manipulation, nine failed to provide any information about the clinical outcome.[34] Incomplete reporting of outcomes might therefore further increase the true number of fatalities. Obviously, the present article is not aimed at providing incidence figures; this would require a different methodology entirely. To date, no reliable incidence data are available. This review is focussed on deaths after chiropractic, yet neck manipulations are, of course, used by other healthcare professionals as well. The reason for this focus is simple: chiropractors are more frequently associated with serious manipulation-related adverse effects than osteopaths, physiotherapists, doctors or other professionals. Of the 40 cases of serious adverse effects mentioned above, 28 can be traced back to a chiropractor and none to an osteopath.[34] A review of complications after spinal manipulations by any type of healthcare professional included three deaths related to osteopaths, nine to medical practitioners, none to a physiotherapist, one to a naturopath and 17 to chiropractors.[35] This article also summarised a total of 265 vascular accidents of which 142 were linked to chiropractors. Another review of complications after neck manipulations published by 1997 included 177 vascular accidents, 32 of which were fatal. The vast majority of these cases were associated with chiropractic and none with physiotherapy.[36] The most obvious explanation for the dominance of chiropractic is that chiropractors routinely employ high-velocity, short-lever thrusts on the upper spine with a rotational element, while the other healthcare professionals use them much more sparingly.[37,38] In conclusion, numerous deaths have been associated with chiropractic neck manipulations. There are reasons to suspect that under-reporting is substantial and reliable incidence figures do not exist. The risks of chiropractic neck manipulations by far outweigh their benefits. Healthcare professionals should advise the public accordingly. Sidebar What's Known Chiropractic upper spinal manipulation has repeatedly been associated with arterial dissection followed by stroke and, in some cases, death. What's New The article is the first systematic review of all fatalities reported in the medical literature. Twenty-six deaths are on record and many more seem to have remained unpublished. References Ernst E. Adverse effects of spinal manipulation: a systematic review. J R Soc Med 2007; 100: 330–8. Leon- A, Cuetter A, Ferrer G. Cervical spine manipulation: an alternative medical procedure with potentially fatal complications. South Med J 2007; 100: 201–3. Dixon P. Letter to the Editor. Adverse effects of spinal manipulation. J R Soc Med 2007; 100: 444. BJ. Letter to the Editor. Adverse effects of spinal manipulation. J R Soc Med 2007; 100: 444. Anon. Medicolegal. Malpractice: death resulting from chiropractic treatment for headache. J Am Med Assoc 1934; 103:1260, 1935; 105:1712–4, 1937; 109:233–4. Pratt- HR, Berger KE. Cerebellar and spinal injuries after chiropractic manipulation. J Am Med Assoc 1947; 133: 600–3. Anon. Medicolegal abstracts. Chiropractors: injury to spinal meninges during adjustments. J Am Med Assoc 1955; 159: 809. Ford FR, D. Thrombosis of the basilar artery with softenings in the cerebellum and brain stem due to manipulation of the neck; a report of two cases with one post-mortem examination, reasons are given to prove that damage to the vertebral arteries is responsible. Bull s Hopkins Hosp 1956; 98: 37–42. RA, Estridge MN. Neurologic complications of head and neck manipulations. JAMA 1962; 182: 528–31. Lorenz R, Vogelsang HG. Thrombosis of the basilar artery following chiropractic manipulation of the cervical spine. [in German] Thrombose der arteria basilaris nach chiropraktischen Manipulationen an der Halbwirbelsäule. Dtsch Med Wochenschr 1972; 97: 36–43. Schmitt HP. Rupturen und Thrombosen der Arteria vertebralis nach gedeckten mechanischen Insulten. Schweiz Arch Neurol Neurochir Psychiatry 1976; 119: 363–79. Krueger BR, Okazaki H. Vertebral-basilar distribution infarction following chiropractic cervical manipulation. Mayo Clin Proc 1980; 55: 322–32. Sherman DG, Hart RG, Easton JD. Abrupt change in head position and cerebral infarction. Stroke 1981; 12: 2–6. Ali Cherif A, Delpuech F, Habib M, Salamon G, Khalil R. Thrombose vertebro-basilaire apres manipulation du rachis cervical. A propos de deux cas. Ann de Med Phys 1983; 25: 459–65. Nielsen AA. Cerebrovascular insults caused by manipulation of the cervical spine. [in Danish]. Ugeskr Laeger 1984; 146: 3267–70. Zak SM, Carmody RF. Cerebellar infarction from chiropractic neck manipulation: case report and review of the literature. Ariz Med 1984; 41: 333–7. Modde PJ. Chiropractic Malpractice. Columbia, land: Hanrow Press. 1985: 269–70, 273–5, 311–8, 322–3, 329–31, 334–7. Jentzen JM, Amatuzio J, GF. Complications of cervical manipulation: a case report of fatal brainstem infarct with review of the mechanisms and predisposing factors. J Forensic Sci 1987; 32: 1089–94. Mas JL, Henin D, Bousser MG, Chain F, Haw JJ. Dissecting aneurysm of the vertebral artery and cervical manipulation: a case report with autopsy. Neurology 1989; 39: 512–5. Sherman MR, Smialek JE, Zane WE. Pathogenesis of vertebral artery occlusion following cervical spine manipulation. Arch Pathol Lab Med 1987; 111: 851–3. Raskind R, North CM. Vertebral artery injuries following chiropractic cervical spine manipulation--case reports. Angiology 1990; 41: 445–52. Sullivan EC. Brain stem stroke syndromes from cervical adjustments. Report on five cases. J Chiropr Res Clin Invest 1992; 8: 12–6. Haynes MJ. Stroke following cervical manipulation in Perth. Chiropr J Aust 1994; 24: 42–6. s M, Bohl J, Thömke F, Kallen K-J, Mahlzahn K, Wandel E. Dissection of the internal carotid artery after chiropractic manipulation of the neck. Neurology 1995; 45: 2284–6. Klougart N, Leboeuf-Yde C, Rasmussen LR. Safety in chiropractic practice. Part I. The occurrence of cerebrovascular accidents after manipulation to the neck in Denmark from 1978–1988. J Manipulative Physiol Ther 1996; 19: 371–7. Haldeman S, Kohlbeck FJ, McGregor M. Unpredictability of cerebrovascular ischemia associated with cervical spine manipulation. Spine 2002; 27: 49–55. Dziewas R, Konrad C, Dräger B et al. Cervical artery dissection – clinical features, risk factors, therapy and outcome in 126 patients. J Neurol 2003; 250: 1179–84. Presentation by Dr Preston Long DC to State of Connecticut. Connecticut State Board of Chiropractic Examiners. Hartford Connecticut. 25 October 2009. Anon. What's the harm in going to a chiropractor? What's the Harm 2009; http://whatstheharm.net/chiropractic.html (accessed October 2009). Ernst E. Vascular accidents after neck manipulation: cause or coincidence? Int J Clin Pract 2009; in press. Long PH. Stroke and spinal manipulation. J Quality Health Care 2004; 3: 8–10. Ernst E. Chiropractic: a critical evaluation. J Pain Symptom Manage 2008; 35: 544–62. Stevinson C, Honan W, Cooke B, Ernst E. Neurological complications of cervical spine manipulation. J Roy Soc Med 2001; 94: 107–10. Ernst E. Cerebrovascular complications associated with spinal manipulation. Phys Ther Rev 2004; 9: 5–15. Terrett AGJ. Current Concepts in Vertebrobasilar Complications following Spinal Manipulation, 2nd edn. Des Moines: JCMIC Group, 2001. Di Fabio RP. Manipulation of the cervical spine: risks and benefits. Physical Ther 1999; 79: 50–65. Alcantara J, Ohm J, Kunz D. The safety and effectiveness of pediatric chiropractic: a survey of chiropractors and parents in a practice-based research network. Explore (NY) 2009; 5: 290–5. Sweeney A, Doody C Manual therapy for the cervical spine and reported adverse effects: a survey of Irish Manipulative Physiotherapists. Man Ther 2010; 15: 32–6. Int J Clin Pract. 2010;64(10):1162-1165. © 2010 Blackwell Publishing Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 8, 2011 Report Share Posted July 8, 2011 Yes, that was a true story. It continues to amaze me how much the public forgives them. It is truly astounding. One of their major paths for side-stepping truth or fault is in their oath, when they all agree to 'never to speak in bad purpose about another doctor. That way, they can never make a judgement about another's work or outcome. Which is why/how we become such targets. (sigh). But it allows a patient to walk away, never knowing what, how, or sometimes if something, happened. Some of the injustices happening out there are so sad. It all became 'man's inhumanity to man' to me. Now they are calling it 'burn-out'! Guess I wasn't the only one noticing some problems!?! The fact that people are being programmed for three - THREE - spinal surgeries now, before the first cut is ever even done on the first one, just boggles my brain! At the same time, more and more people are showing up in my office as disgusted with the whole mess as I am. So I'm hopeful. Sunny Sunny Kierstyn, RN DC Fibromyalgia Care Center of Oregon 2677 Willakenzie Road, 7CEugene, Oregon, 97401541- 654-0850; Fx; 541- 654-0834www.drsunnykierstyn.com From: twogems@...Date: Fri, 8 Jul 2011 12:30:15 -0700Subject: Re: Chiropractic deaths I remember my dad reading an article in Time magazine to me many years ago that told about a bunch of doctors in L.A. going on strike, and during that time the death rate in the city went down significantly. True story! :-) Lyndon McGill, D.C. Salem, Oregon www.SalemSpineClinic.com www.EvolvingDaily.com On 7/8/2011 12:12 PM, Vern Saboe wrote: Medical errors are the fourth leading cause of death in this country and if you add non-error deaths e.g., adverse drug events, hospital infections, surgical adverse events etc. some authors suggest medical care is the leading cause of death in this country.... VErn Saboe Chiropractic deaths Docs: I especially like their "Conclusion." Lyndon McGill, D.C. Salem, Oregon www.SalemSpineClinic.com www.EvolvingDaily.com Deaths after Chiropractic: A Review of Published Cases E. Ernst Posted: 08/30/2010; Int J Clin Pract. 2010;64(10):1162-1165. © 2010 Blackwell Publishing Abstract and Introduction Abstract Objective: The aim of this study was to summarise all cases in which chiropractic spinal manipulation was followed by death. Design: This study is a systematic review of case reports. Methods: Literature searches in four electronic databases with no restrictions of time or language. Main outcome measure: Death. Results: Twenty six fatalities were published in the medical literature and many more might have remained unpublished. The alleged pathology usually was a vascular accident involving the dissection of a vertebral artery. Conclusion: Numerous deaths have occurred after chiropractic manipulations. The risks of this treatment by far outweigh its benefit. Introduction Vascular accidents after upper spinal manipulation are a well-recognised problem (e.g.[1,2]). Dissection of a vertebral artery, caused by extension and rotation of the neck beyond the physiological range of motion, is thought to be the underlying mechanism.[2] Several deaths have been reported as a consequence. Some proponents of chiropractic seem to believe that the critical evaluation of this evidence amounts to a 'scare story' (Chairman of the UK General Chiropractic Council)[3] or to 'puffing up (the evidence) out of all proportion' (President of the British Chiropractic Association).[4] A responsible approach to serious therapeutic risks, however, requires an open discussion of the facts. In this review, I aimed to provide the basis for such a discussion by summarising all fatalities which occurred after chiropractic spinal manipulation and were published in the medical literature. Methods Electronic searches were conducted in the following electronic databases: Medline, Embase, AMED, Cochrane Library (September 2009). No restrictions of time or language were applied. Search terms were chiropractic, spinal manipulation, vascular accidents, stroke, death and fatality. In addition, our own departmental files and the bibliographies of the articles thus located were searched. Several experts were also contacted for further data. Case reports were included if they provided information on human patients who had died after receiving one or more treatments from a chiropractor. Data were extracted from the included articles according to predefined criteria (Table 1). Table 1. Published case reports of deaths after chiropractic treatments References Year of publication Victim Type of vascular accident Time between treatment and death Anon[5] 1934 Woman, age unknown Tear in left lateral sinus 2 weeks Pratt- and Berger[6] 1947 32-year-old man Thrombosis of basilar, left anterior-inferior cerebellar and right posterior-inferior arteries 24 h Pratt- and Berger[6] 1947 35-year-old woman Thrombosis of posterior-inferior cerebellar artery 10 h Anon[7] 1955 Woman, age unknown Intra-spinal bleeding and compression of spinal cord 18 h Ford and [8] 1956 37-year-old man Thrombosis of basilar, left-posterior cerebellar and left-posterior cerebral arteries 6 h Ford and [8] 1956 No information provided Thrombosis of basilar artery No information provided and Estridge[9] 1962 33-year-old woman Infarct of cerebellar and brainstem 3 days Lorenz and Vogelsang[10] 1972 39-year-old woman Thrombosis of basilar artery 58 days Schmitt[11] 1976 35-years-old woman Infarct of brainstem 1 h Krueger and Okazaki[12] 1980 25-year-old man Infarct of brainstem and cerebellum 48 h Sherman et al.[13] 1981 60-year-old woman Dissection of vertebral artery 4 days Ali Cherif et al.[14] 1983 51-year-old man Infarct of medulla oblongata 11 days Nielsen[15] 1984 34-year-old man Dissection of vertebral artery aneurysen 3 h Zak and Carmody[16] 1984 53-year-old man Left vertebral, posterior-inferior and superior cerebellar artery occlusion; cerebellar infarction 27 days Modde[17] 1985 26-year-old woman Dissection of vertebral artery 1 day Jentzen et al.[18] 1987 51-year-old man Infarct of cerebellum and brainstem No information provided Sherman et al.[20] 1987 37-year-old man Infarct of brainstem 3 days Mas et al.[19] 1989 35-year-old woman Dissecting aneurysm of vertebral artery 16 h Raskind and North[21] 1990 47-year-old woman Cerebellar haemorrheae No information provided Sullivan[22] 1992 41-year-old woman Haemorrhage in ventricular system 8 h Haynes[23] 1994 36-year-old woman Dissecting aneurysm of vertebral artery, thrombo-embolism No information provided s et al.[24] 1995 29-year-old woman Infarct of right hemisphere 3 days Klougart et al.[25] 1996 34-year-old man Unclear Few hours Haldeman et al.[26] 2002 Previously unpublished legal cases No information provided No information provided Haldeman et al.[26] 2002 Previously unpublished legal cases No information provided No information provided Dziewas et al.[27] 2003 No information provided No information provided No information provided Results Twenty-six fatalities were published since 1934 in 23 articles (Table 1).[5–27] Table 1. Published case reports of deaths after chiropractic treatments References Year of publication Victim Type of vascular accident Time between treatment and death Anon[5] 1934 Woman, age unknown Tear in left lateral sinus 2 weeks Pratt- and Berger[6] 1947 32-year-old man Thrombosis of basilar, left anterior-inferior cerebellar and right posterior-inferior arteries 24 h Pratt- and Berger[6] 1947 35-year-old woman Thrombosis of posterior-inferior cerebellar artery 10 h Anon[7] 1955 Woman, age unknown Intra-spinal bleeding and compression of spinal cord 18 h Ford and [8] 1956 37-year-old man Thrombosis of basilar, left-posterior cerebellar and left-posterior cerebral arteries 6 h Ford and [8] 1956 No information provided Thrombosis of basilar artery No information provided and Estridge[9] 1962 33-year-old woman Infarct of cerebellar and brainstem 3 days Lorenz and Vogelsang[10] 1972 39-year-old woman Thrombosis of basilar artery 58 days Schmitt[11] 1976 35-years-old woman Infarct of brainstem 1 h Krueger and Okazaki[12] 1980 25-year-old man Infarct of brainstem and cerebellum 48 h Sherman et al.[13] 1981 60-year-old woman Dissection of vertebral artery 4 days Ali Cherif et al.[14] 1983 51-year-old man Infarct of medulla oblongata 11 days Nielsen[15] 1984 34-year-old man Dissection of vertebral artery aneurysen 3 h Zak and Carmody[16] 1984 53-year-old man Left vertebral, posterior-inferior and superior cerebellar artery occlusion; cerebellar infarction 27 days Modde[17] 1985 26-year-old woman Dissection of vertebral artery 1 day Jentzen et al.[18] 1987 51-year-old man Infarct of cerebellum and brainstem No information provided Sherman et al.[20] 1987 37-year-old man Infarct of brainstem 3 days Mas et al.[19] 1989 35-year-old woman Dissecting aneurysm of vertebral artery 16 h Raskind and North[21] 1990 47-year-old woman Cerebellar haemorrheae No information provided Sullivan[22] 1992 41-year-old woman Haemorrhage in ventricular system 8 h Haynes[23] 1994 36-year-old woman Dissecting aneurysm of vertebral artery, thrombo-embolism No information provided s et al.[24] 1995 29-year-old woman Infarct of right hemisphere 3 days Klougart et al.[25] 1996 34-year-old man Unclear Few hours Haldeman et al.[26] 2002 Previously unpublished legal cases No information provided No information provided Haldeman et al.[26] 2002 Previously unpublished legal cases No information provided No information provided Dziewas et al.[27] 2003 No information provided No information provided No information provided Most of the victims were relatively young; 14 were below the age of 40. There was a slight majority of female patients. The type of complication associated with death frequently related to a vascular accident leading to thrombosis and cerebral infarction. The time between treatment and death ranged from 1 h to 58 days; in 10 cases, it was 1 day or less. Unfortunately, the published information was often incomplete. Many other fatalities seem to have remained unpublished. For instance, the testimony of the chiropractor Preston Long for a court in Connecticut recently listed the family names of nine victims: Mathiason, Solsbury, Mc Cornick, Venegas, Bedenbaugh, , Fawcett, Parisien, Standt. Long also states that 'many others [are] unknown hidden behind legal agreements of silence'.[28] A website names further North American fatalities: Epping (California), G. Fowden (Utah), Grainger (Alberta), Hoffman (land), Renate Dora Labonte (Ontario), (California), Pereyra (Connecticut), A. Roth (Ontario) and Lee Strohecker (Pennsylvania).[29] Discussion This systematic review demonstrates that numerous deaths have been associated with chiropractic. Usually high-velocity, short-lever thrusts of the upper spine with rotation are implicated. They are believed to cause vertebral arterial dissection in predisposed individuals which, in turn, can lead to a chain of events including stroke and death.[1,2,26,30] Many chiropractors claim that, because arterial dissection can also occur spontaneously, causality between the chiropractic intervention and arterial dissection is not proven. However, when carefully evaluating the known facts, one does arrive at the conclusion that causality is at least likely (e.g.[30,31]). Even if it were merely a remote possibility, the precautionary principle in healthcare would mean that neck manipulations should be considered unsafe until proven otherwise. Moreover, there is no good evidence for assuming that neck manipulation is an effective therapy for any medical condition.[32] Thus, the risk-benefit balance for chiropractic neck manipulation fails to be positive. Reliable estimates of the frequency of vascular accidents are prevented by the fact that under-reporting is known to be substantial. In a survey of UK neurologists, for instance, under-reporting of serious complications was 100%.[33] Those cases which are published often turn out to be incomplete. Of 40 case reports of serious adverse effects associated with spinal manipulation, nine failed to provide any information about the clinical outcome.[34] Incomplete reporting of outcomes might therefore further increase the true number of fatalities. Obviously, the present article is not aimed at providing incidence figures; this would require a different methodology entirely. To date, no reliable incidence data are available. This review is focussed on deaths after chiropractic, yet neck manipulations are, of course, used by other healthcare professionals as well. The reason for this focus is simple: chiropractors are more frequently associated with serious manipulation-related adverse effects than osteopaths, physiotherapists, doctors or other professionals. Of the 40 cases of serious adverse effects mentioned above, 28 can be traced back to a chiropractor and none to an osteopath.[34] A review of complications after spinal manipulations by any type of healthcare professional included three deaths related to osteopaths, nine to medical practitioners, none to a physiotherapist, one to a naturopath and 17 to chiropractors.[35] This article also summarised a total of 265 vascular accidents of which 142 were linked to chiropractors. Another review of complications after neck manipulations published by 1997 included 177 vascular accidents, 32 of which were fatal. The vast majority of these cases were associated with chiropractic and none with physiotherapy.[36] The most obvious explanation for the dominance of chiropractic is that chiropractors routinely employ high-velocity, short-lever thrusts on the upper spine with a rotational element, while the other healthcare professionals use them much more sparingly.[37,38] In conclusion, numerous deaths have been associated with chiropractic neck manipulations. There are reasons to suspect that under-reporting is substantial and reliable incidence figures do not exist. The risks of chiropractic neck manipulations by far outweigh their benefits. Healthcare professionals should advise the public accordingly. Sidebar What's Known Chiropractic upper spinal manipulation has repeatedly been associated with arterial dissection followed by stroke and, in some cases, death. What's New The article is the first systematic review of all fatalities reported in the medical literature. Twenty-six deaths are on record and many more seem to have remained unpublished. References Ernst E. Adverse effects of spinal manipulation: a systematic review. J R Soc Med 2007; 100: 330–8. Leon- A, Cuetter A, Ferrer G. Cervical spine manipulation: an alternative medical procedure with potentially fatal complications. South Med J 2007; 100: 201–3. Dixon P. Letter to the Editor. Adverse effects of spinal manipulation. J R Soc Med 2007; 100: 444. BJ. Letter to the Editor. Adverse effects of spinal manipulation. J R Soc Med 2007; 100: 444. Anon. Medicolegal. Malpractice: death resulting from chiropractic treatment for headache. J Am Med Assoc 1934; 103:1260, 1935; 105:1712–4, 1937; 109:233–4. Pratt- HR, Berger KE. Cerebellar and spinal injuries after chiropractic manipulation. J Am Med Assoc 1947; 133: 600–3. Anon. Medicolegal abstracts. Chiropractors: injury to spinal meninges during adjustments. J Am Med Assoc 1955; 159: 809. Ford FR, D. Thrombosis of the basilar artery with softenings in the cerebellum and brain stem due to manipulation of the neck; a report of two cases with one post-mortem examination, reasons are given to prove that damage to the vertebral arteries is responsible. Bull s Hopkins Hosp 1956; 98: 37–42. RA, Estridge MN. Neurologic complications of head and neck manipulations. JAMA 1962; 182: 528–31. Lorenz R, Vogelsang HG. Thrombosis of the basilar artery following chiropractic manipulation of the cervical spine. [in German] Thrombose der arteria basilaris nach chiropraktischen Manipulationen an der Halbwirbelsäule. Dtsch Med Wochenschr 1972; 97: 36–43. Schmitt HP. Rupturen und Thrombosen der Arteria vertebralis nach gedeckten mechanischen Insulten. Schweiz Arch Neurol Neurochir Psychiatry 1976; 119: 363–79. Krueger BR, Okazaki H. Vertebral-basilar distribution infarction following chiropractic cervical manipulation. Mayo Clin Proc 1980; 55: 322–32. Sherman DG, Hart RG, Easton JD. Abrupt change in head position and cerebral infarction. Stroke 1981; 12: 2–6. Ali Cherif A, Delpuech F, Habib M, Salamon G, Khalil R. Thrombose vertebro-basilaire apres manipulation du rachis cervical. A propos de deux cas. Ann de Med Phys 1983; 25: 459–65. Nielsen AA. Cerebrovascular insults caused by manipulation of the cervical spine. [in Danish]. Ugeskr Laeger 1984; 146: 3267–70. Zak SM, Carmody RF. Cerebellar infarction from chiropractic neck manipulation: case report and review of the literature. Ariz Med 1984; 41: 333–7. Modde PJ. Chiropractic Malpractice. Columbia, land: Hanrow Press. 1985: 269–70, 273–5, 311–8, 322–3, 329–31, 334–7. Jentzen JM, Amatuzio J, GF. Complications of cervical manipulation: a case report of fatal brainstem infarct with review of the mechanisms and predisposing factors. J Forensic Sci 1987; 32: 1089–94. Mas JL, Henin D, Bousser MG, Chain F, Haw JJ. Dissecting aneurysm of the vertebral artery and cervical manipulation: a case report with autopsy. Neurology 1989; 39: 512–5. Sherman MR, Smialek JE, Zane WE. Pathogenesis of vertebral artery occlusion following cervical spine manipulation. Arch Pathol Lab Med 1987; 111: 851–3. Raskind R, North CM. Vertebral artery injuries following chiropractic cervical spine manipulation--case reports. Angiology 1990; 41: 445–52. Sullivan EC. Brain stem stroke syndromes from cervical adjustments. Report on five cases. J Chiropr Res Clin Invest 1992; 8: 12–6. Haynes MJ. Stroke following cervical manipulation in Perth. Chiropr J Aust 1994; 24: 42–6. s M, Bohl J, Thömke F, Kallen K-J, Mahlzahn K, Wandel E. Dissection of the internal carotid artery after chiropractic manipulation of the neck. Neurology 1995; 45: 2284–6. Klougart N, Leboeuf-Yde C, Rasmussen LR. Safety in chiropractic practice. Part I. The occurrence of cerebrovascular accidents after manipulation to the neck in Denmark from 1978–1988. J Manipulative Physiol Ther 1996; 19: 371–7. Haldeman S, Kohlbeck FJ, McGregor M. Unpredictability of cerebrovascular ischemia associated with cervical spine manipulation. Spine 2002; 27: 49–55. Dziewas R, Konrad C, Dräger B et al. Cervical artery dissection – clinical features, risk factors, therapy and outcome in 126 patients. J Neurol 2003; 250: 1179–84. Presentation by Dr Preston Long DC to State of Connecticut. Connecticut State Board of Chiropractic Examiners. Hartford Connecticut. 25 October 2009. Anon. What's the harm in going to a chiropractor? What's the Harm 2009; http://whatstheharm.net/chiropractic.html (accessed October 2009). Ernst E. Vascular accidents after neck manipulation: cause or coincidence? Int J Clin Pract 2009; in press. Long PH. Stroke and spinal manipulation. J Quality Health Care 2004; 3: 8–10. Ernst E. Chiropractic: a critical evaluation. J Pain Symptom Manage 2008; 35: 544–62. Stevinson C, Honan W, Cooke B, Ernst E. Neurological complications of cervical spine manipulation. J Roy Soc Med 2001; 94: 107–10. Ernst E. Cerebrovascular complications associated with spinal manipulation. Phys Ther Rev 2004; 9: 5–15. Terrett AGJ. Current Concepts in Vertebrobasilar Complications following Spinal Manipulation, 2nd edn. Des Moines: JCMIC Group, 2001. Di Fabio RP. Manipulation of the cervical spine: risks and benefits. Physical Ther 1999; 79: 50–65. Alcantara J, Ohm J, Kunz D. The safety and effectiveness of pediatric chiropractic: a survey of chiropractors and parents in a practice-based research network. Explore (NY) 2009; 5: 290–5. Sweeney A, Doody C Manual therapy for the cervical spine and reported adverse effects: a survey of Irish Manipulative Physiotherapists. Man Ther 2010; 15: 32–6. Int J Clin Pract. 2010;64(10):1162-1165. © 2010 Blackwell Publishing Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 8, 2011 Report Share Posted July 8, 2011  I am also in favor of informed consent both written and verbal documented in the chart. With that said would have informed consent have saved your grandfather? How is it that it was both the cervical adjustment and the lumbar roll that likely killed your grandfather. What would you have expected the doctor to have told your grandfather prior to performing a high velocity adjustment? This may cause a vertebral artery dissection and you may die? Considering the myriad of systematic reviews of the literature not the least of which was the recent (2008) 10 year (2000-2010) Bone and Joint Decade...Task Force on Neck Pain and Its Associated Disorders findings that validate the rarity of this occurrence. This review of 31, 878 citations (Haldeman and coworkers) found an association between chiropractic treatment and subsequent vertebrobasilar artery stroke in persons under the age of 45. However, the same association was found in patients visiting a general practitioner of medicine? We must inform patients of any "material risks" currently I don't believe the scientific evidence supports vertebral artery stroke secondary to SMT as such since the incidence is so very remote.....when the dentist injects you with that local anesthetic have any of you ever had the doctor discuss the fact that you could have an unforseen, non-predictable anaphylactic reaction and die? Or when the medics prescribe the various medications do you believe they also inform the patient of such verbally? Recall the conclusion that started this discussion from the paper (toliet) by Ernst that the benefits of spinal manipulation do not out weight the risks....crapola. Lastly, could not have been the case that your beloved grandfather presented to the chiropractor with neck pain low back pain because especially considering his health was in the process of stroke having pain due to a dissection in progress? To quote Haldeman relative to the cervical spine and verterbral arteries..."This is likely explained by patients with vertebrobasilar artery dissection-related neck pain or headache seeking care before having their stroke." ....any way I understand what you are saying and agree about informed consent but I do not agree that we need to tell our patients oh by the way this could kill you! How I handle the issue of stroke and informed consent is that stroke is referred to as a extremely rare occurence in my written informed consent but during my verbal communication PAR Conf. in the room with the new patient I inform them that research shows that you have a 300 to 400 greater chance of a serious side effect to taking an NSAID such as Advil than you have with anything I will be doing. Just two cents, Vern Saboe Chiropractic deaths Docs:I especially like their "Conclusion."Lyndon McGill, D.C.Salem, Oregonwww.SalemSpineClinic.comwww.EvolvingDaily.com Deaths after Chiropractic: A Review of Published Cases E. Ernst Posted: 08/30/2010; Int J Clin Pract. 2010;64(10):1162-1165. © 2010 Blackwell Publishing Abstract and Introduction Abstract Objective: The aim of this study was to summarise all cases in which chiropractic spinal manipulation was followed by death.Design: This study is a systematic review of case reports.Methods: Literature searches in four electronic databases with no restrictions of time or language.Main outcome measure: Death.Results: Twenty six fatalities were published in the medical literature and many more might have remained unpublished. The alleged pathology usually was a vascular accident involving the dissection of a vertebral artery.Conclusion: Numerous deaths have occurred after chiropractic manipulations. The risks of this treatment by far outweigh its benefit. Introduction Vascular accidents after upper spinal manipulation are a well-recognised problem (e.g.[1,2]). Dissection of a vertebral artery, caused by extension and rotation of the neck beyond the physiological range of motion, is thought to be the underlying mechanism.[2] Several deaths have been reported as a consequence. Some proponents of chiropractic seem to believe that the critical evaluation of this evidence amounts to a 'scare story' (Chairman of the UK General Chiropractic Council)[3] or to 'puffing up (the evidence) out of all proportion' (President of the British Chiropractic Association).[4] A responsible approach to serious therapeutic risks, however, requires an open discussion of the facts. In this review, I aimed to provide the basis for such a discussion by summarising all fatalities which occurred after chiropractic spinal manipulation and were published in the medical literature. Methods Electronic searches were conducted in the following electronic databases: Medline, Embase, AMED, Cochrane Library (September 2009). No restrictions of time or language were applied. Search terms were chiropractic, spinal manipulation, vascular accidents, stroke, death and fatality. In addition, our own departmental files and the bibliographies of the articles thus located were searched. Several experts were also contacted for further data. Case reports were included if they provided information on human patients who had died after receiving one or more treatments from a chiropractor. Data were extracted from the included articles according to predefined criteria (Table 1). Table 1. Published case reports of deaths after chiropractic treatments References Year of publication Victim Type of vascular accident Time between treatment and death Anon[5] 1934 Woman, age unknown Tear in left lateral sinus 2 weeks Pratt- and Berger[6] 1947 32-year-old man Thrombosis of basilar, left anterior-inferior cerebellar and right posterior-inferior arteries 24 h Pratt- and Berger[6] 1947 35-year-old woman Thrombosis of posterior-inferior cerebellar artery 10 h Anon[7] 1955 Woman, age unknown Intra-spinal bleeding and compression of spinal cord 18 h Ford and [8] 1956 37-year-old man Thrombosis of basilar, left-posterior cerebellar and left-posterior cerebral arteries 6 h Ford and [8] 1956 No information provided Thrombosis of basilar artery No information provided and Estridge[9] 1962 33-year-old woman Infarct of cerebellar and brainstem 3 days Lorenz and Vogelsang[10] 1972 39-year-old woman Thrombosis of basilar artery 58 days Schmitt[11] 1976 35-years-old woman Infarct of brainstem 1 h Krueger and Okazaki[12] 1980 25-year-old man Infarct of brainstem and cerebellum 48 h Sherman et al.[13] 1981 60-year-old woman Dissection of vertebral artery 4 days Ali Cherif et al.[14] 1983 51-year-old man Infarct of medulla oblongata 11 days Nielsen[15] 1984 34-year-old man Dissection of vertebral artery aneurysen 3 h Zak and Carmody[16] 1984 53-year-old man Left vertebral, posterior-inferior and superior cerebellar artery occlusion; cerebellar infarction 27 days Modde[17] 1985 26-year-old woman Dissection of vertebral artery 1 day Jentzen et al.[18] 1987 51-year-old man Infarct of cerebellum and brainstem No information provided Sherman et al.[20] 1987 37-year-old man Infarct of brainstem 3 days Mas et al.[19] 1989 35-year-old woman Dissecting aneurysm of vertebral artery 16 h Raskind and North[21] 1990 47-year-old woman Cerebellar haemorrheae No information provided Sullivan[22] 1992 41-year-old woman Haemorrhage in ventricular system 8 h Haynes[23] 1994 36-year-old woman Dissecting aneurysm of vertebral artery, thrombo-embolism No information provided s et al.[24] 1995 29-year-old woman Infarct of right hemisphere 3 days Klougart et al.[25] 1996 34-year-old man Unclear Few hours Haldeman et al.[26] 2002 Previously unpublished legal cases No information provided No information provided Haldeman et al.[26] 2002 Previously unpublished legal cases No information provided No information provided Dziewas et al.[27] 2003 No information provided No information provided No information provided Results Twenty-six fatalities were published since 1934 in 23 articles (Table 1).[5–27] Table 1. Published case reports of deaths after chiropractic treatments References Year of publication Victim Type of vascular accident Time between treatment and death Anon[5] 1934 Woman, age unknown Tear in left lateral sinus 2 weeks Pratt- and Berger[6] 1947 32-year-old man Thrombosis of basilar, left anterior-inferior cerebellar and right posterior-inferior arteries 24 h Pratt- and Berger[6] 1947 35-year-old woman Thrombosis of posterior-inferior cerebellar artery 10 h Anon[7] 1955 Woman, age unknown Intra-spinal bleeding and compression of spinal cord 18 h Ford and [8] 1956 37-year-old man Thrombosis of basilar, left-posterior cerebellar and left-posterior cerebral arteries 6 h Ford and [8] 1956 No information provided Thrombosis of basilar artery No information provided and Estridge[9] 1962 33-year-old woman Infarct of cerebellar and brainstem 3 days Lorenz and Vogelsang[10] 1972 39-year-old woman Thrombosis of basilar artery 58 days Schmitt[11] 1976 35-years-old woman Infarct of brainstem 1 h Krueger and Okazaki[12] 1980 25-year-old man Infarct of brainstem and cerebellum 48 h Sherman et al.[13] 1981 60-year-old woman Dissection of vertebral artery 4 days Ali Cherif et al.[14] 1983 51-year-old man Infarct of medulla oblongata 11 days Nielsen[15] 1984 34-year-old man Dissection of vertebral artery aneurysen 3 h Zak and Carmody[16] 1984 53-year-old man Left vertebral, posterior-inferior and superior cerebellar artery occlusion; cerebellar infarction 27 days Modde[17] 1985 26-year-old woman Dissection of vertebral artery 1 day Jentzen et al.[18] 1987 51-year-old man Infarct of cerebellum and brainstem No information provided Sherman et al.[20] 1987 37-year-old man Infarct of brainstem 3 days Mas et al.[19] 1989 35-year-old woman Dissecting aneurysm of vertebral artery 16 h Raskind and North[21] 1990 47-year-old woman Cerebellar haemorrheae No information provided Sullivan[22] 1992 41-year-old woman Haemorrhage in ventricular system 8 h Haynes[23] 1994 36-year-old woman Dissecting aneurysm of vertebral artery, thrombo-embolism No information provided s et al.[24] 1995 29-year-old woman Infarct of right hemisphere 3 days Klougart et al.[25] 1996 34-year-old man Unclear Few hours Haldeman et al.[26] 2002 Previously unpublished legal cases No information provided No information provided Haldeman et al.[26] 2002 Previously unpublished legal cases No information provided No information provided Dziewas et al.[27] 2003 No information provided No information provided No information provided Most of the victims were relatively young; 14 were below the age of 40. There was a slight majority of female patients. The type of complication associated with death frequently related to a vascular accident leading to thrombosis and cerebral infarction. The time between treatment and death ranged from 1 h to 58 days; in 10 cases, it was 1 day or less. Unfortunately, the published information was often incomplete. Many other fatalities seem to have remained unpublished. For instance, the testimony of the chiropractor Preston Long for a court in Connecticut recently listed the family names of nine victims: Mathiason, Solsbury, Mc Cornick, Venegas, Bedenbaugh, , Fawcett, Parisien, Standt. Long also states that 'many others [are] unknown hidden behind legal agreements of silence'.[28] A website names further North American fatalities: Epping (California), G. Fowden (Utah), Grainger (Alberta), Hoffman (land), Renate Dora Labonte (Ontario), (California), Pereyra (Connecticut), A. Roth (Ontario) and Lee Strohecker (Pennsylvania).[29] Discussion This systematic review demonstrates that numerous deaths have been associated with chiropractic. Usually high-velocity, short-lever thrusts of the upper spine with rotation are implicated. They are believed to cause vertebral arterial dissection in predisposed individuals which, in turn, can lead to a chain of events including stroke and death.[1,2,26,30] Many chiropractors claim that, because arterial dissection can also occur spontaneously, causality between the chiropractic intervention and arterial dissection is not proven. However, when carefully evaluating the known facts, one does arrive at the conclusion that causality is at least likely (e.g.[30,31]). Even if it were merely a remote possibility, the precautionary principle in healthcare would mean that neck manipulations should be considered unsafe until proven otherwise. Moreover, there is no good evidence for assuming that neck manipulation is an effective therapy for any medical condition.[32] Thus, the risk-benefit balance for chiropractic neck manipulation fails to be positive. Reliable estimates of the frequency of vascular accidents are prevented by the fact that under-reporting is known to be substantial. In a survey of UK neurologists, for instance, under-reporting of serious complications was 100%.[33] Those cases which are published often turn out to be incomplete. Of 40 case reports of serious adverse effects associated with spinal manipulation, nine failed to provide any information about the clinical outcome.[34] Incomplete reporting of outcomes might therefore further increase the true number of fatalities. Obviously, the present article is not aimed at providing incidence figures; this would require a different methodology entirely. To date, no reliable incidence data are available. This review is focussed on deaths after chiropractic, yet neck manipulations are, of course, used by other healthcare professionals as well. The reason for this focus is simple: chiropractors are more frequently associated with serious manipulation-related adverse effects than osteopaths, physiotherapists, doctors or other professionals. Of the 40 cases of serious adverse effects mentioned above, 28 can be traced back to a chiropractor and none to an osteopath.[34] A review of complications after spinal manipulations by any type of healthcare professional included three deaths related to osteopaths, nine to medical practitioners, none to a physiotherapist, one to a naturopath and 17 to chiropractors.[35] This article also summarised a total of 265 vascular accidents of which 142 were linked to chiropractors. Another review of complications after neck manipulations published by 1997 included 177 vascular accidents, 32 of which were fatal. The vast majority of these cases were associated with chiropractic and none with physiotherapy.[36] The most obvious explanation for the dominance of chiropractic is that chiropractors routinely employ high-velocity, short-lever thrusts on the upper spine with a rotational element, while the other healthcare professionals use them much more sparingly.[37,38] In conclusion, numerous deaths have been associated with chiropractic neck manipulations. There are reasons to suspect that under-reporting is substantial and reliable incidence figures do not exist. The risks of chiropractic neck manipulations by far outweigh their benefits. Healthcare professionals should advise the public accordingly. Sidebar What's Known Chiropractic upper spinal manipulation has repeatedly been associated with arterial dissection followed by stroke and, in some cases, death. What's New The article is the first systematic review of all fatalities reported in the medical literature. Twenty-six deaths are on record and many more seem to have remained unpublished. References Ernst E. Adverse effects of spinal manipulation: a systematic review. J R Soc Med 2007; 100: 330–8. Leon- A, Cuetter A, Ferrer G. Cervical spine manipulation: an alternative medical procedure with potentially fatal complications. South Med J 2007; 100: 201–3. Dixon P. Letter to the Editor. Adverse effects of spinal manipulation. J R Soc Med 2007; 100: 444. BJ. Letter to the Editor. Adverse effects of spinal manipulation. J R Soc Med 2007; 100: 444. Anon. Medicolegal. Malpractice: death resulting from chiropractic treatment for headache. J Am Med Assoc 1934; 103:1260, 1935; 105:1712–4, 1937; 109:233–4. Pratt- HR, Berger KE. Cerebellar and spinal injuries after chiropractic manipulation. J Am Med Assoc 1947; 133: 600–3. Anon. Medicolegal abstracts. Chiropractors: injury to spinal meninges during adjustments. J Am Med Assoc 1955; 159: 809. Ford FR, D. Thrombosis of the basilar artery with softenings in the cerebellum and brain stem due to manipulation of the neck; a report of two cases with one post-mortem examination, reasons are given to prove that damage to the vertebral arteries is responsible. Bull s Hopkins Hosp 1956; 98: 37–42. RA, Estridge MN. Neurologic complications of head and neck manipulations. JAMA 1962; 182: 528–31. Lorenz R, Vogelsang HG. Thrombosis of the basilar artery following chiropractic manipulation of the cervical spine. [in German] Thrombose der arteria basilaris nach chiropraktischen Manipulationen an der Halbwirbelsäule. Dtsch Med Wochenschr 1972; 97: 36–43. Schmitt HP. Rupturen und Thrombosen der Arteria vertebralis nach gedeckten mechanischen Insulten. Schweiz Arch Neurol Neurochir Psychiatry 1976; 119: 363–79. Krueger BR, Okazaki H. Vertebral-basilar distribution infarction following chiropractic cervical manipulation. Mayo Clin Proc 1980; 55: 322–32. Sherman DG, Hart RG, Easton JD. Abrupt change in head position and cerebral infarction. Stroke 1981; 12: 2–6. Ali Cherif A, Delpuech F, Habib M, Salamon G, Khalil R. Thrombose vertebro-basilaire apres manipulation du rachis cervical. A propos de deux cas. Ann de Med Phys 1983; 25: 459–65. Nielsen AA. Cerebrovascular insults caused by manipulation of the cervical spine. [in Danish]. Ugeskr Laeger 1984; 146: 3267–70. Zak SM, Carmody RF. Cerebellar infarction from chiropractic neck manipulation: case report and review of the literature. Ariz Med 1984; 41: 333–7. Modde PJ. Chiropractic Malpractice. Columbia, land: Hanrow Press. 1985: 269–70, 273–5, 311–8, 322–3, 329–31, 334–7. Jentzen JM, Amatuzio J, GF. Complications of cervical manipulation: a case report of fatal brainstem infarct with review of the mechanisms and predisposing factors. J Forensic Sci 1987; 32: 1089–94. Mas JL, Henin D, Bousser MG, Chain F, Haw JJ. Dissecting aneurysm of the vertebral artery and cervical manipulation: a case report with autopsy. Neurology 1989; 39: 512–5. Sherman MR, Smialek JE, Zane WE. Pathogenesis of vertebral artery occlusion following cervical spine manipulation. Arch Pathol Lab Med 1987; 111: 851–3. Raskind R, North CM. Vertebral artery injuries following chiropractic cervical spine manipulation--case reports. Angiology 1990; 41: 445–52. Sullivan EC. Brain stem stroke syndromes from cervical adjustments. Report on five cases. J Chiropr Res Clin Invest 1992; 8: 12–6. Haynes MJ. Stroke following cervical manipulation in Perth. Chiropr J Aust 1994; 24: 42–6. s M, Bohl J, Thömke F, Kallen K-J, Mahlzahn K, Wandel E. Dissection of the internal carotid artery after chiropractic manipulation of the neck. Neurology 1995; 45: 2284–6. Klougart N, Leboeuf-Yde C, Rasmussen LR. Safety in chiropractic practice. Part I. The occurrence of cerebrovascular accidents after manipulation to the neck in Denmark from 1978–1988. J Manipulative Physiol Ther 1996; 19: 371–7. Haldeman S, Kohlbeck FJ, McGregor M. Unpredictability of cerebrovascular ischemia associated with cervical spine manipulation. Spine 2002; 27: 49–55. Dziewas R, Konrad C, Dräger B et al. Cervical artery dissection – clinical features, risk factors, therapy and outcome in 126 patients. J Neurol 2003; 250: 1179–84. Presentation by Dr Preston Long DC to State of Connecticut. Connecticut State Board of Chiropractic Examiners. Hartford Connecticut. 25 October 2009. Anon. What's the harm in going to a chiropractor? What's the Harm 2009; http://whatstheharm.net/chiropractic.html (accessed October 2009). Ernst E. Vascular accidents after neck manipulation: cause or coincidence? Int J Clin Pract 2009; in press. Long PH. Stroke and spinal manipulation. J Quality Health Care 2004; 3: 8–10. Ernst E. Chiropractic: a critical evaluation. J Pain Symptom Manage 2008; 35: 544–62. Stevinson C, Honan W, Cooke B, Ernst E. Neurological complications of cervical spine manipulation. J Roy Soc Med 2001; 94: 107–10. Ernst E. Cerebrovascular complications associated with spinal manipulation. Phys Ther Rev 2004; 9: 5–15. Terrett AGJ. Current Concepts in Vertebrobasilar Complications following Spinal Manipulation, 2nd edn. Des Moines: JCMIC Group, 2001. Di Fabio RP. Manipulation of the cervical spine: risks and benefits. Physical Ther 1999; 79: 50–65. Alcantara J, Ohm J, Kunz D. The safety and effectiveness of pediatric chiropractic: a survey of chiropractors and parents in a practice-based research network. Explore (NY) 2009; 5: 290–5. Sweeney A, Doody C Manual therapy for the cervical spine and reported adverse effects: a survey of Irish Manipulative Physiotherapists. Man Ther 2010; 15: 32–6. Int J Clin Pract. 2010;64(10):1162-1165. © 2010 Blackwell Publishing Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 8, 2011 Report Share Posted July 8, 2011 Ahhhh Herb, Can't quite agree with you there, good friend. Cervical stairstep with figure 8 is an excellent to avoid the HVLA, provide an excellent cervical adjustment and protect the patient all at the same time. AND they can teach instrument adjusting! ;'-)) SunnySunny Kierstyn, RN DC Fibromyalgia Care Center of Oregon 2677 Willakenzie Road, 7CEugene, Oregon, 97401541- 654-0850; Fx; 541- 654-0834www.drsunnykierstyn.com spinetree@...; Oregondcs From: hbf4747@...Date: Fri, 8 Jul 2011 17:44:22 -0700Subject: Re: Chiropractic deaths Dear Dr. Joe, We will once and forever catch a "break" when ALL of the chiropractic schools decide to teach ONLY instrument corrections of the cervical spine and permanently remove the stigma of tears of vascular structures due to vigorous rotational "adjustments". Herb Freeman D.C. Chiropractic deaths Docs:I especially like their "Conclusion."Lyndon McGill, D.C.Salem, Oregonwww.SalemSpineClinic.comwww.EvolvingDaily.com Deaths after Chiropractic: A Review of Published Cases E. Ernst Posted: 08/30/2010; Int J Clin Pract. 2010;64(10):1162-1165. © 2010 Blackwell Publishing Abstract and Introduction Abstract Objective: The aim of this study was to summarise all cases in which chiropractic spinal manipulation was followed by death.Design: This study is a systematic review of case reports.Methods: Literature searches in four electronic databases with no restrictions of time or language.Main outcome measure: Death.Results: Twenty six fatalities were published in the medical literature and many more might have remained unpublished. The alleged pathology usually was a vascular accident involving the dissection of a vertebral artery.Conclusion: Numerous deaths have occurred after chiropractic manipulations. The risks of this treatment by far outweigh its benefit. Introduction Vascular accidents after upper spinal manipulation are a well-recognised problem (e.g.[1,2]). Dissection of a vertebral artery, caused by extension and rotation of the neck beyond the physiological range of motion, is thought to be the underlying mechanism.[2] Several deaths have been reported as a consequence. Some proponents of chiropractic seem to believe that the critical evaluation of this evidence amounts to a 'scare story' (Chairman of the UK General Chiropractic Council)[3] or to 'puffing up (the evidence) out of all proportion' (President of the British Chiropractic Association).[4] A responsible approach to serious therapeutic risks, however, requires an open discussion of the facts. In this review, I aimed to provide the basis for such a discussion by summarising all fatalities which occurred after chiropractic spinal manipulation and were published in the medical literature. Methods Electronic searches were conducted in the following electronic databases: Medline, Embase, AMED, Cochrane Library (September 2009). No restrictions of time or language were applied. Search terms were chiropractic, spinal manipulation, vascular accidents, stroke, death and fatality. In addition, our own departmental files and the bibliographies of the articles thus located were searched. Several experts were also contacted for further data. Case reports were included if they provided information on human patients who had died after receiving one or more treatments from a chiropractor. Data were extracted from the included articles according to predefined criteria (Table 1). Table 1. Published case reports of deaths after chiropractic treatments References Year of publication Victim Type of vascular accident Time between treatment and death Anon[5] 1934 Woman, age unknown Tear in left lateral sinus 2 weeks Pratt- and Berger[6] 1947 32-year-old man Thrombosis of basilar, left anterior-inferior cerebellar and right posterior-inferior arteries 24 h Pratt- and Berger[6] 1947 35-year-old woman Thrombosis of posterior-inferior cerebellar artery 10 h Anon[7] 1955 Woman, age unknown Intra-spinal bleeding and compression of spinal cord 18 h Ford and [8] 1956 37-year-old man Thrombosis of basilar, left-posterior cerebellar and left-posterior cerebral arteries 6 h Ford and [8] 1956 No information provided Thrombosis of basilar artery No information provided and Estridge[9] 1962 33-year-old woman Infarct of cerebellar and brainstem 3 days Lorenz and Vogelsang[10] 1972 39-year-old woman Thrombosis of basilar artery 58 days Schmitt[11] 1976 35-years-old woman Infarct of brainstem 1 h Krueger and Okazaki[12] 1980 25-year-old man Infarct of brainstem and cerebellum 48 h Sherman et al.[13] 1981 60-year-old woman Dissection of vertebral artery 4 days Ali Cherif et al.[14] 1983 51-year-old man Infarct of medulla oblongata 11 days Nielsen[15] 1984 34-year-old man Dissection of vertebral artery aneurysen 3 h Zak and Carmody[16] 1984 53-year-old man Left vertebral, posterior-inferior and superior cerebellar artery occlusion; cerebellar infarction 27 days Modde[17] 1985 26-year-old woman Dissection of vertebral artery 1 day Jentzen et al.[18] 1987 51-year-old man Infarct of cerebellum and brainstem No information provided Sherman et al.[20] 1987 37-year-old man Infarct of brainstem 3 days Mas et al.[19] 1989 35-year-old woman Dissecting aneurysm of vertebral artery 16 h Raskind and North[21] 1990 47-year-old woman Cerebellar haemorrheae No information provided Sullivan[22] 1992 41-year-old woman Haemorrhage in ventricular system 8 h Haynes[23] 1994 36-year-old woman Dissecting aneurysm of vertebral artery, thrombo-embolism No information provided s et al.[24] 1995 29-year-old woman Infarct of right hemisphere 3 days Klougart et al.[25] 1996 34-year-old man Unclear Few hours Haldeman et al.[26] 2002 Previously unpublished legal cases No information provided No information provided Haldeman et al.[26] 2002 Previously unpublished legal cases No information provided No information provided Dziewas et al.[27] 2003 No information provided No information provided No information provided Results Twenty-six fatalities were published since 1934 in 23 articles (Table 1).[5-27] Table 1. Published case reports of deaths after chiropractic treatments References Year of publication Victim Type of vascular accident Time between treatment and death Anon[5] 1934 Woman, age unknown Tear in left lateral sinus 2 weeks Pratt- and Berger[6] 1947 32-year-old man Thrombosis of basilar, left anterior-inferior cerebellar and right posterior-inferior arteries 24 h Pratt- and Berger[6] 1947 35-year-old woman Thrombosis of posterior-inferior cerebellar artery 10 h Anon[7] 1955 Woman, age unknown Intra-spinal bleeding and compression of spinal cord 18 h Ford and [8] 1956 37-year-old man Thrombosis of basilar, left-posterior cerebellar and left-posterior cerebral arteries 6 h Ford and [8] 1956 No information provided Thrombosis of basilar artery No information provided and Estridge[9] 1962 33-year-old woman Infarct of cerebellar and brainstem 3 days Lorenz and Vogelsang[10] 1972 39-year-old woman Thrombosis of basilar artery 58 days Schmitt[11] 1976 35-years-old woman Infarct of brainstem 1 h Krueger and Okazaki[12] 1980 25-year-old man Infarct of brainstem and cerebellum 48 h Sherman et al.[13] 1981 60-year-old woman Dissection of vertebral artery 4 days Ali Cherif et al.[14] 1983 51-year-old man Infarct of medulla oblongata 11 days Nielsen[15] 1984 34-year-old man Dissection of vertebral artery aneurysen 3 h Zak and Carmody[16] 1984 53-year-old man Left vertebral, posterior-inferior and superior cerebellar artery occlusion; cerebellar infarction 27 days Modde[17] 1985 26-year-old woman Dissection of vertebral artery 1 day Jentzen et al.[18] 1987 51-year-old man Infarct of cerebellum and brainstem No information provided Sherman et al.[20] 1987 37-year-old man Infarct of brainstem 3 days Mas et al.[19] 1989 35-year-old woman Dissecting aneurysm of vertebral artery 16 h Raskind and North[21] 1990 47-year-old woman Cerebellar haemorrheae No information provided Sullivan[22] 1992 41-year-old woman Haemorrhage in ventricular system 8 h Haynes[23] 1994 36-year-old woman Dissecting aneurysm of vertebral artery, thrombo-embolism No information provided s et al.[24] 1995 29-year-old woman Infarct of right hemisphere 3 days Klougart et al.[25] 1996 34-year-old man Unclear Few hours Haldeman et al.[26] 2002 Previously unpublished legal cases No information provided No information provided Haldeman et al.[26] 2002 Previously unpublished legal cases No information provided No information provided Dziewas et al.[27] 2003 No information provided No information provided No information provided Most of the victims were relatively young; 14 were below the age of 40. There was a slight majority of female patients. The type of complication associated with death frequently related to a vascular accident leading to thrombosis and cerebral infarction. The time between treatment and death ranged from 1 h to 58 days; in 10 cases, it was 1 day or less. Unfortunately, the published information was often incomplete. Many other fatalities seem to have remained unpublished. For instance, the testimony of the chiropractor Preston Long for a court in Connecticut recently listed the family names of nine victims: Mathiason, Solsbury, Mc Cornick, Venegas, Bedenbaugh, , Fawcett, Parisien, Standt. Long also states that 'many others [are] unknown hidden behind legal agreements of silence'.[28] A website names further North American fatalities: Epping (California), G. Fowden (Utah), Grainger (Alberta), Hoffman (land), Renate Dora Labonte (Ontario), (California), Pereyra (Connecticut), A. Roth (Ontario) and Lee Strohecker (Pennsylvania).[29] Discussion This systematic review demonstrates that numerous deaths have been associated with chiropractic. Usually high-velocity, short-lever thrusts of the upper spine with rotation are implicated. They are believed to cause vertebral arterial dissection in predisposed individuals which, in turn, can lead to a chain of events including stroke and death.[1,2,26,30] Many chiropractors claim that, because arterial dissection can also occur spontaneously, causality between the chiropractic intervention and arterial dissection is not proven. However, when carefully evaluating the known facts, one does arrive at the conclusion that causality is at least likely (e.g.[30,31]). Even if it were merely a remote possibility, the precautionary principle in healthcare would mean that neck manipulations should be considered unsafe until proven otherwise. Moreover, there is no good evidence for assuming that neck manipulation is an effective therapy for any medical condition.[32] Thus, the risk-benefit balance for chiropractic neck manipulation fails to be positive. Reliable estimates of the frequency of vascular accidents are prevented by the fact that under-reporting is known to be substantial. In a survey of UK neurologists, for instance, under-reporting of serious complications was 100%.[33] Those cases which are published often turn out to be incomplete. Of 40 case reports of serious adverse effects associated with spinal manipulation, nine failed to provide any information about the clinical outcome.[34] Incomplete reporting of outcomes might therefore further increase the true number of fatalities. Obviously, the present article is not aimed at providing incidence figures; this would require a different methodology entirely. To date, no reliable incidence data are available. This review is focussed on deaths after chiropractic, yet neck manipulations are, of course, used by other healthcare professionals as well. The reason for this focus is simple: chiropractors are more frequently associated with serious manipulation-related adverse effects than osteopaths, physiotherapists, doctors or other professionals. Of the 40 cases of serious adverse effects mentioned above, 28 can be traced back to a chiropractor and none to an osteopath.[34] A review of complications after spinal manipulations by any type of healthcare professional included three deaths related to osteopaths, nine to medical practitioners, none to a physiotherapist, one to a naturopath and 17 to chiropractors.[35] This article also summarised a total of 265 vascular accidents of which 142 were linked to chiropractors. Another review of complications after neck manipulations published by 1997 included 177 vascular accidents, 32 of which were fatal. The vast majority of these cases were associated with chiropractic and none with physiotherapy.[36] The most obvious explanation for the dominance of chiropractic is that chiropractors routinely employ high-velocity, short-lever thrusts on the upper spine with a rotational element, while the other healthcare professionals use them much more sparingly.[37,38] In conclusion, numerous deaths have been associated with chiropractic neck manipulations. There are reasons to suspect that under-reporting is substantial and reliable incidence figures do not exist. The risks of chiropractic neck manipulations by far outweigh their benefits. Healthcare professionals should advise the public accordingly. Sidebar What's Known Chiropractic upper spinal manipulation has repeatedly been associated with arterial dissection followed by stroke and, in some cases, death. What's New The article is the first systematic review of all fatalities reported in the medical literature. Twenty-six deaths are on record and many more seem to have remained unpublished. References Ernst E. Adverse effects of spinal manipulation: a systematic review. J R Soc Med 2007; 100: 330-8. Leon- A, Cuetter A, Ferrer G. Cervical spine manipulation: an alternative medical procedure with potentially fatal complications. South Med J 2007; 100: 201-3. Dixon P. Letter to the Editor. Adverse effects of spinal manipulation. J R Soc Med 2007; 100: 444. BJ. Letter to the Editor. Adverse effects of spinal manipulation. J R Soc Med 2007; 100: 444. Anon. Medicolegal. Malpractice: death resulting from chiropractic treatment for headache. J Am Med Assoc 1934; 103:1260, 1935; 105:1712-4, 1937; 109:233-4. Pratt- HR, Berger KE. Cerebellar and spinal injuries after chiropractic manipulation. J Am Med Assoc 1947; 133: 600-3. Anon. Medicolegal abstracts. Chiropractors: injury to spinal meninges during adjustments. J Am Med Assoc 1955; 159: 809. Ford FR, D. Thrombosis of the basilar artery with softenings in the cerebellum and brain stem due to manipulation of the neck; a report of two cases with one post-mortem examination, reasons are given to prove that damage to the vertebral arteries is responsible. Bull s Hopkins Hosp 1956; 98: 37-42. RA, Estridge MN. Neurologic complications of head and neck manipulations. JAMA 1962; 182: 528-31. Lorenz R, Vogelsang HG. Thrombosis of the basilar artery following chiropractic manipulation of the cervical spine. [in German] Thrombose der arteria basilaris nach chiropraktischen Manipulationen an der Halbwirbelsäule. Dtsch Med Wochenschr 1972; 97: 36-43. Schmitt HP. Rupturen und Thrombosen der Arteria vertebralis nach gedeckten mechanischen Insulten. Schweiz Arch Neurol Neurochir Psychiatry 1976; 119: 363-79. Krueger BR, Okazaki H. Vertebral-basilar distribution infarction following chiropractic cervical manipulation. Mayo Clin Proc 1980; 55: 322-32. Sherman DG, Hart RG, Easton JD. Abrupt change in head position and cerebral infarction. Stroke 1981; 12: 2-6. Ali Cherif A, Delpuech F, Habib M, Salamon G, Khalil R. Thrombose vertebro-basilaire apres manipulation du rachis cervical. A propos de deux cas. Ann de Med Phys 1983; 25: 459-65. Nielsen AA. Cerebrovascular insults caused by manipulation of the cervical spine. [in Danish]. Ugeskr Laeger 1984; 146: 3267-70. Zak SM, Carmody RF. Cerebellar infarction from chiropractic neck manipulation: case report and review of the literature. Ariz Med 1984; 41: 333-7. Modde PJ. Chiropractic Malpractice. Columbia, land: Hanrow Press. 1985: 269-70, 273-5, 311-8, 322-3, 329-31, 334-7. Jentzen JM, Amatuzio J, GF. Complications of cervical manipulation: a case report of fatal brainstem infarct with review of the mechanisms and predisposing factors. J Forensic Sci 1987; 32: 1089-94. Mas JL, Henin D, Bousser MG, Chain F, Haw JJ. Dissecting aneurysm of the vertebral artery and cervical manipulation: a case report with autopsy. Neurology 1989; 39: 512-5. Sherman MR, Smialek JE, Zane WE. Pathogenesis of vertebral artery occlusion following cervical spine manipulation. Arch Pathol Lab Med 1987; 111: 851-3. Raskind R, North CM. Vertebral artery injuries following chiropractic cervical spine manipulation--case reports. Angiology 1990; 41: 445-52. Sullivan EC. Brain stem stroke syndromes from cervical adjustments. Report on five cases. J Chiropr Res Clin Invest 1992; 8: 12-6. Haynes MJ. Stroke following cervical manipulation in Perth. Chiropr J Aust 1994; 24: 42-6. s M, Bohl J, Thömke F, Kallen K-J, Mahlzahn K, Wandel E. Dissection of the internal carotid artery after chiropractic manipulation of the neck. Neurology 1995; 45: 2284-6. Klougart N, Leboeuf-Yde C, Rasmussen LR. Safety in chiropractic practice. Part I. The occurrence of cerebrovascular accidents after manipulation to the neck in Denmark from 1978-1988. J Manipulative Physiol Ther 1996; 19: 371-7. Haldeman S, Kohlbeck FJ, McGregor M. Unpredictability of cerebrovascular ischemia associated with cervical spine manipulation. Spine 2002; 27: 49-55. Dziewas R, Konrad C, Dräger B et al. Cervical artery dissection - clinical features, risk factors, therapy and outcome in 126 patients. J Neurol 2003; 250: 1179-84. Presentation by Dr Preston Long DC to State of Connecticut. Connecticut State Board of Chiropractic Examiners. Hartford Connecticut. 25 October 2009. Anon. What's the harm in going to a chiropractor? What's the Harm 2009; http://whatstheharm.net/chiropractic.html (accessed October 2009). Ernst E. Vascular accidents after neck manipulation: cause or coincidence? Int J Clin Pract 2009; in press. Long PH. Stroke and spinal manipulation. J Quality Health Care 2004; 3: 8-10. Ernst E. Chiropractic: a critical evaluation. J Pain Symptom Manage 2008; 35: 544-62. Stevinson C, Honan W, Cooke B, Ernst E. Neurological complications of cervical spine manipulation. J Roy Soc Med 2001; 94: 107-10. Ernst E. Cerebrovascular complications associated with spinal manipulation. Phys Ther Rev 2004; 9: 5-15. Terrett AGJ. Current Concepts in Vertebrobasilar Complications following Spinal Manipulation, 2nd edn. Des Moines: JCMIC Group, 2001. Di Fabio RP. Manipulation of the cervical spine: risks and benefits. Physical Ther 1999; 79: 50-65. Alcantara J, Ohm J, Kunz D. The safety and effectiveness of pediatric chiropractic: a survey of chiropractors and parents in a practice-based research network. Explore (NY) 2009; 5: 290-5. Sweeney A, Doody C Manual therapy for the cervical spine and reported adverse effects: a survey of Irish Manipulative Physiotherapists. Man Ther 2010; 15: 32-6. Int J Clin Pract. 2010;64(10):1162-1165. © 2010 Blackwell Publishing Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 8, 2011 Report Share Posted July 8, 2011 Hi Minga, That consent is SO important ... it was disappointing during the talks of the Informed Consent section of the Education Manual for Evidenced Based Chiropractic. It was the consensus then that a written one was 'encouraged' but not required. As I recall, the subject is coming up this year (month?) for review by the OBCE Board. Maybe we can move down the road on it this time. Sunny Sunny Kierstyn, RN DC Fibromyalgia Care Center of Oregon 2677 Willakenzie Road, 7CEugene, Oregon, 97401541- 654-0850; Fx; 541- 654-0834www.drsunnykierstyn.com From: AboWoman@...Date: Fri, 8 Jul 2011 20:57:46 -0400Subject: Re: Chiropractic deaths All, My perceptions may not be popular from what I see on this list, but I can't read the posts any longer without comment. I agree that iatrogenic, medical error and adverse drug rxns are a bigger cause of death than chiropractic manipulation. And altho I believe deaths from vascular accidents following high velocity adjusting, may only be assigned as a 'very low risk', I still think this issue needs statistical analysis. I think we as a profession would do better to lead the risk studies for obvious reasons. I also think this chart is poorly crafted and doesn't prove a thing well enough for me to quote any of the stats. During the beginning of my 2nd yr as a DC student, my beloved grand father died approximately 2-3 hours after a chiropractic high velocity adjustment. Cause of death was listed as 2 fold; abdominal anuerysm and stroke. He was 89, diabetic, high cholesterol, tho not over weight. He was active and danced every weekend with grandma. He had been seeing the same chiropractor for about a decade. The adjustments were getting increasingly more difficult for him to tolerate. He mentioned this to me as a student. I didn't know enough to advise him at the time. The ER doctors told our family it was most likely the high veolcity lumbar roll and the upper cervical adjusting that caused his death. He felt immediately dizzy after the adjustment, however he'd been getting dizzy after adjusting the last 3-4 times. He had mentioned it to the DC and was told it was 'normal' for his age according to my grandmother who attended appts with him. On this occasion, the dizziness didn't pass. And his legs got so weak, he could barely make to to the car. He passed out on the way home and my grandmother drove him straight to ER. He never regained consciousness. They had been married for over 50 yrs. It was a devastating thing for our family. I remember reading the ER reports as a 2nd yr DC student. Sobering. However, in 1982 there wasn't a lot of informed consent mandatory stuff going on. I have to admit, when it happens to a close family member, you will take notice. You will appreciate the absolute need to do a verbal and written signed consent form if you decide to adjust the high risk patients.After asking a few senior interns and my own clinic director, I appreciated how my grandpa's DC had failed to change adjusting procedures and take into account his failing health and risk factors. MY grandma was too distraught to sue. However, I did call the doctor and told him that in all probability, he killed my grandfather by not keeping current with risk factors. He said he was retiring the next yr. I told him not to wait. He did apologize and said in hindsight, he probably should've considered grandpa's health, but that he was so active, he had overlooked it. I give him this, he had the guts to apologize to grandma. No one in the family would sue him because he ponied up. I have always been and am still in support of mandatory informed consent. Written, signed and verbal. I am in support of our profession listening to public sentiment and dealing with it. I think our state association should work with either UWS, OHSU or both to design a statistical analysis of this perceived risk. We need to do it before others do it. That way we are pro-active and perceived as listening to public sentiment, public protection; instead of living in denial. Once stats prove otherwise de NILE is fine. Minga Guerrero DC Re: Chiropractic deaths Medical errors are the fourth leading cause of death in this country and if you add non-error deaths e.g., adverse drug events, hospital infections, surgical adverse events etc. some authors suggest medical care is the leading cause of death in this country.... VErn Saboe Chiropractic deaths Docs: I especially like their "Conclusion." Lyndon McGill, D.C. Salem, Oregon www.SalemSpineClinic.com www.EvolvingDaily.com Deaths after Chiropractic: A Review of Published Cases E. Ernst Posted: 08/30/2010; Int J Clin Pract. 2010;64(10):1162-1165. © 2010 Blackwell Publishing Abstract and Introduction Abstract Objective: The aim of this study was to summarise all cases in which chiropractic spinal manipulation was followed by death. Design: This study is a systematic review of case reports. Methods: Literature searches in four electronic databases with no restrictions of time or language. Main outcome measure: Death. Results: Twenty six fatalities were published in the medical literature and many more might have remained unpublished. The alleged pathology usually was a vascular accident involving the dissection of a vertebral artery. Conclusion: Numerous deaths have occurred after chiropractic manipulations. The risks of this treatment by far outweigh its benefit. Introduction Vascular accidents after upper spinal manipulation are a well-recognised problem (e.g.[1,2]). Dissection of a vertebral artery, caused by extension and rotation of the neck beyond the physiological range of motion, is thought to be the underlying mechanism.[2] Several deaths have been reported as a consequence. Some proponents of chiropractic seem to believe that the critical evaluation of this evidence amounts to a 'scare story' (Chairman of the UK General Chiropractic Council)[3] or to 'puffing up (the evidence) out of all proportion' (President of the British Chiropractic Association).[4] A responsible approach to serious therapeutic risks, however, requires an open discussion of the facts. In this review, I aimed to provide the basis for such a discussion by summarising all fatalities which occurred after chiropractic spinal manipulation and were published in the medical literature. Methods Electronic searches were conducted in the following electronic databases: Medline, Embase, AMED, Cochrane Library (September 2009). No restrictions of time or language were applied. Search terms were chiropractic, spinal manipulation, vascular accidents, stroke, death and fatality. In addition, our own departmental files and the bibliographies of the articles thus located were searched. Several experts were also contacted for further data. Case reports were included if they provided information on human patients who had died after receiving one or more treatments from a chiropractor. Data were extracted from the included articles according to predefined criteria (Table 1). Table 1. Published case reports of deaths after chiropractic treatments References Year of publication Victim Type of vascular accident Time between treatment and death Anon[5] 1934 Woman, age unknown Tear in left lateral sinus 2 weeks Pratt- and Berger[6] 1947 32-year-old man Thrombosis of basilar, left anterior-inferior cerebellar and right posterior-inferior arteries 24 h Pratt- and Berger[6] 1947 35-year-old woman Thrombosis of posterior-inferior cerebellar artery 10 h Anon[7] 1955 Woman, age unknown Intra-spinal bleeding and compression of spinal cord 18 h Ford and [8] 1956 37-year-old man Thrombosis of basilar, left-posterior cerebellar and left-posterior cerebral arteries 6 h Ford and [8] 1956 No information provided Thrombosis of basilar artery No information provided and Estridge[9] 1962 33-year-old woman Infarct of cerebellar and brainstem 3 days Lorenz and Vogelsang[10] 1972 39-year-old woman Thrombosis of basilar artery 58 days Schmitt[11] 1976 35-years-old woman Infarct of brainstem 1 h Krueger and Okazaki[12] 1980 25-year-old man Infarct of brainstem and cerebellum 48 h Sherman et al.[13] 1981 60-year-old woman Dissection of vertebral artery 4 days Ali Cherif et al.[14] 1983 51-year-old man Infarct of medulla oblongata 11 days Nielsen[15] 1984 34-year-old man Dissection of vertebral artery aneurysen 3 h Zak and Carmody[16] 1984 53-year-old man Left vertebral, posterior-inferior and superior cerebellar artery occlusion; cerebellar infarction 27 days Modde[17] 1985 26-year-old woman Dissection of vertebral artery 1 day Jentzen et al.[18] 1987 51-year-old man Infarct of cerebellum and brainstem No information provided Sherman et al.[20] 1987 37-year-old man Infarct of brainstem 3 days Mas et al.[19] 1989 35-year-old woman Dissecting aneurysm of vertebral artery 16 h Raskind and North[21] 1990 47-year-old woman Cerebellar haemorrheae No information provided Sullivan[22] 1992 41-year-old woman Haemorrhage in ventricular system 8 h Haynes[23] 1994 36-year-old woman Dissecting aneurysm of vertebral artery, thrombo-embolism No information provided s et al.[24] 1995 29-year-old woman Infarct of right hemisphere 3 days Klougart et al.[25] 1996 34-year-old man Unclear Few hours Haldeman et al.[26] 2002 Previously unpublished legal cases No information provided No information provided Haldeman et al.[26] 2002 Previously unpublished legal cases No information provided No information provided Dziewas et al.[27] 2003 No information provided No information provided No information provided Results Twenty-six fatalities were published since 1934 in 23 articles (Table 1).[5–27] Table 1. Published case reports of deaths after chiropractic treatments References Year of publication Victim Type of vascular accident Time between treatment and death Anon[5] 1934 Woman, age unknown Tear in left lateral sinus 2 weeks Pratt- and Berger[6] 1947 32-year-old man Thrombosis of basilar, left anterior-inferior cerebellar and right posterior-inferior arteries 24 h Pratt- and Berger[6] 1947 35-year-old woman Thrombosis of posterior-inferior cerebellar artery 10 h Anon[7] 1955 Woman, age unknown Intra-spinal bleeding and compression of spinal cord 18 h Ford and [8] 1956 37-year-old man Thrombosis of basilar, left-posterior cerebellar and left-posterior cerebral arteries 6 h Ford and [8] 1956 No information provided Thrombosis of basilar artery No information provided and Estridge[9] 1962 33-year-old woman Infarct of cerebellar and brainstem 3 days Lorenz and Vogelsang[10] 1972 39-year-old woman Thrombosis of basilar artery 58 days Schmitt[11] 1976 35-years-old woman Infarct of brainstem 1 h Krueger and Okazaki[12] 1980 25-year-old man Infarct of brainstem and cerebellum 48 h Sherman et al.[13] 1981 60-year-old woman Dissection of vertebral artery 4 days Ali Cherif et al.[14] 1983 51-year-old man Infarct of medulla oblongata 11 days Nielsen[15] 1984 34-year-old man Dissection of vertebral artery aneurysen 3 h Zak and Carmody[16] 1984 53-year-old man Left vertebral, posterior-inferior and superior cerebellar artery occlusion; cerebellar infarction 27 days Modde[17] 1985 26-year-old woman Dissection of vertebral artery 1 day Jentzen et al.[18] 1987 51-year-old man Infarct of cerebellum and brainstem No information provided Sherman et al.[20] 1987 37-year-old man Infarct of brainstem 3 days Mas et al.[19] 1989 35-year-old woman Dissecting aneurysm of vertebral artery 16 h Raskind and North[21] 1990 47-year-old woman Cerebellar haemorrheae No information provided Sullivan[22] 1992 41-year-old woman Haemorrhage in ventricular system 8 h Haynes[23] 1994 36-year-old woman Dissecting aneurysm of vertebral artery, thrombo-embolism No information provided s et al.[24] 1995 29-year-old woman Infarct of right hemisphere 3 days Klougart et al.[25] 1996 34-year-old man Unclear Few hours Haldeman et al.[26] 2002 Previously unpublished legal cases No information provided No information provided Haldeman et al.[26] 2002 Previously unpublished legal cases No information provided No information provided Dziewas et al.[27] 2003 No information provided No information provided No information provided Most of the victims were relatively young; 14 were below the age of 40. There was a slight majority of female patients. The type of complication associated with death frequently related to a vascular accident leading to thrombosis and cerebral infarction. The time between treatment and death ranged from 1 h to 58 days; in 10 cases, it was 1 day or less. Unfortunately, the published information was often incomplete. Many other fatalities seem to have remained unpublished. For instance, the testimony of the chiropractor Preston Long for a court in Connecticut recently listed the family names of nine victims: Mathiason, Solsbury, Mc Cornick, Venegas, Bedenbaugh, , Fawcett, Parisien, Standt. Long also states that 'many others [are] unknown hidden behind legal agreements of silence'.[28] A website names further North American fatalities: Epping (California), G. Fowden (Utah), Grainger (Alberta), Hoffman (land), Renate Dora Labonte (Ontario), (California), Pereyra (Connecticut), A. Roth (Ontario) and Lee Strohecker (Pennsylvania).[29] Discussion This systematic review demonstrates that numerous deaths have been associated with chiropractic. Usually high-velocity, short-lever thrusts of the upper spine with rotation are implicated. They are believed to cause vertebral arterial dissection in predisposed individuals which, in turn, can lead to a chain of events including stroke and death.[1,2,26,30] Many chiropractors claim that, because arterial dissection can also occur spontaneously, causality between the chiropractic intervention and arterial dissection is not proven. However, when carefully evaluating the known facts, one does arrive at the conclusion that causality is at least likely (e.g.[30,31]). Even if it were merely a remote possibility, the precautionary principle in healthcare would mean that neck manipulations should be considered unsafe until proven otherwise. Moreover, there is no good evidence for assuming that neck manipulation is an effective therapy for any medical condition.[32] Thus, the risk-benefit balance for chiropractic neck manipulation fails to be positive. Reliable estimates of the frequency of vascular accidents are prevented by the fact that under-reporting is known to be substantial. In a survey of UK neurologists, for instance, under-reporting of serious complications was 100%.[33] Those cases which are published often turn out to be incomplete. Of 40 case reports of serious adverse effects associated with spinal manipulation, nine failed to provide any information about the clinical outcome.[34] Incomplete reporting of outcomes might therefore further increase the true number of fatalities. Obviously, the present article is not aimed at providing incidence figures; this would require a different methodology entirely. To date, no reliable incidence data are available. This review is focussed on deaths after chiropractic, yet neck manipulations are, of course, used by other healthcare professionals as well. The reason for this focus is simple: chiropractors are more frequently associated with serious manipulation-related adverse effects than osteopaths, physiotherapists, doctors or other professionals. Of the 40 cases of serious adverse effects mentioned above, 28 can be traced back to a chiropractor and none to an osteopath.[34] A review of complications after spinal manipulations by any type of healthcare professional included three deaths related to osteopaths, nine to medical practitioners, none to a physiotherapist, one to a naturopath and 17 to chiropractors.[35] This article also summarised a total of 265 vascular accidents of which 142 were linked to chiropractors. Another review of complications after neck manipulations published by 1997 included 177 vascular accidents, 32 of which were fatal. The vast majority of these cases were associated with chiropractic and none with physiotherapy.[36] The most obvious explanation for the dominance of chiropractic is that chiropractors routinely employ high-velocity, short-lever thrusts on the upper spine with a rotational element, while the other healthcare professionals use them much more sparingly.[37,38] In conclusion, numerous deaths have been associated with chiropractic neck manipulations. There are reasons to suspect that under-reporting is substantial and reliable incidence figures do not exist. The risks of chiropractic neck manipulations by far outweigh their benefits. Healthcare professionals should advise the public accordingly. Sidebar What's Known Chiropractic upper spinal manipulation has repeatedly been associated with arterial dissection followed by stroke and, in some cases, death. What's New The article is the first systematic review of all fatalities reported in the medical literature. Twenty-six deaths are on record and many more seem to have remained unpublished. References Ernst E. Adverse effects of spinal manipulation: a systematic review. J R Soc Med 2007; 100: 330–8. Leon- A, Cuetter A, Ferrer G. Cervical spine manipulation: an alternative medical procedure with potentially fatal complications. South Med J 2007; 100: 201–3. Dixon P. Letter to the Editor. Adverse effects of spinal manipulation. J R Soc Med 2007; 100: 444. BJ. Letter to the Editor. Adverse effects of spinal manipulation. J R Soc Med 2007; 100: 444. Anon. Medicolegal. Malpractice: death resulting from chiropractic treatment for headache. J Am Med Assoc 1934; 103:1260, 1935; 105:1712–4, 1937; 109:233–4. Pratt- HR, Berger KE. Cerebellar and spinal injuries after chiropractic manipulation. J Am Med Assoc 1947; 133: 600–3. Anon. Medicolegal abstracts. Chiropractors: injury to spinal meninges during adjustments. J Am Med Assoc 1955; 159: 809. Ford FR, D. Thrombosis of the basilar artery with softenings in the cerebellum and brain stem due to manipulation of the neck; a report of two cases with one post-mortem examination, reasons are given to prove that damage to the vertebral arteries is responsible. Bull s Hopkins Hosp 1956; 98: 37–42. RA, Estridge MN. Neurologic complications of head and neck manipulations. JAMA 1962; 182: 528–31. Lorenz R, Vogelsang HG. Thrombosis of the basilar artery following chiropractic manipulation of the cervical spine. [in German] Thrombose der arteria basilaris nach chiropraktischen Manipulationen an der Halbwirbelsäule. Dtsch Med Wochenschr 1972; 97: 36–43. Schmitt HP. Rupturen und Thrombosen der Arteria vertebralis nach gedeckten mechanischen Insulten. Schweiz Arch Neurol Neurochir Psychiatry 1976; 119: 363–79. Krueger BR, Okazaki H. Vertebral-basilar distribution infarction following chiropractic cervical manipulation. Mayo Clin Proc 1980; 55: 322–32. Sherman DG, Hart RG, Easton JD. Abrupt change in head position and cerebral infarction. Stroke 1981; 12: 2–6. Ali Cherif A, Delpuech F, Habib M, Salamon G, Khalil R. Thrombose vertebro-basilaire apres manipulation du rachis cervical. A propos de deux cas. Ann de Med Phys 1983; 25: 459–65. Nielsen AA. Cerebrovascular insults caused by manipulation of the cervical spine. [in Danish]. Ugeskr Laeger 1984; 146: 3267–70. Zak SM, Carmody RF. Cerebellar infarction from chiropractic neck manipulation: case report and review of the literature. Ariz Med 1984; 41: 333–7. Modde PJ. Chiropractic Malpractice. Columbia, land: Hanrow Press. 1985: 269–70, 273–5, 311–8, 322–3, 329–31, 334–7. Jentzen JM, Amatuzio J, GF. Complications of cervical manipulation: a case report of fatal brainstem infarct with review of the mechanisms and predisposing factors. J Forensic Sci 1987; 32: 1089–94. Mas JL, Henin D, Bousser MG, Chain F, Haw JJ. Dissecting aneurysm of the vertebral artery and cervical manipulation: a case report with autopsy. Neurology 1989; 39: 512–5. Sherman MR, Smialek JE, Zane WE. Pathogenesis of vertebral artery occlusion following cervical spine manipulation. Arch Pathol Lab Med 1987; 111: 851–3. Raskind R, North CM. Vertebral artery injuries following chiropractic cervical spine manipulation--case reports. Angiology 1990; 41: 445–52. Sullivan EC. Brain stem stroke syndromes from cervical adjustments. Report on five cases. J Chiropr Res Clin Invest 1992; 8: 12–6. Haynes MJ. Stroke following cervical manipulation in Perth. Chiropr J Aust 1994; 24: 42–6. s M, Bohl J, Thömke F, Kallen K-J, Mahlzahn K, Wandel E. Dissection of the internal carotid artery after chiropractic manipulation of the neck. Neurology 1995; 45: 2284–6. Klougart N, Leboeuf-Yde C, Rasmussen LR. Safety in chiropractic practice. Part I. The occurrence of cerebrovascular accidents after manipulation to the neck in Denmark from 1978–1988. J Manipulative Physiol Ther 1996; 19: 371–7. Haldeman S, Kohlbeck FJ, McGregor M. Unpredictability of cerebrovascular ischemia associated with cervical spine manipulation. Spine 2002; 27: 49–55. Dziewas R, Konrad C, Dräger B et al. Cervical artery dissection – clinical features, risk factors, therapy and outcome in 126 patients. J Neurol 2003; 250: 1179–84. Presentation by Dr Preston Long DC to State of Connecticut. Connecticut State Board of Chiropractic Examiners. Hartford Connecticut. 25 October 2009. Anon. What's the harm in going to a chiropractor? What's the Harm 2009; http://whatstheharm.net/chiropractic.html (accessed October 2009). Ernst E. Vascular accidents after neck manipulation: cause or coincidence? Int J Clin Pract 2009; in press. Long PH. Stroke and spinal manipulation. J Quality Health Care 2004; 3: 8–10. Ernst E. Chiropractic: a critical evaluation. J Pain Symptom Manage 2008; 35: 544–62. Stevinson C, Honan W, Cooke B, Ernst E. Neurological complications of cervical spine manipulation. J Roy Soc Med 2001; 94: 107–10. Ernst E. Cerebrovascular complications associated with spinal manipulation. Phys Ther Rev 2004; 9: 5–15. Terrett AGJ. Current Concepts in Vertebrobasilar Complications following Spinal Manipulation, 2nd edn. Des Moines: JCMIC Group, 2001. Di Fabio RP. Manipulation of the cervical spine: risks and benefits. Physical Ther 1999; 79: 50–65. Alcantara J, Ohm J, Kunz D. The safety and effectiveness of pediatric chiropractic: a survey of chiropractors and parents in a practice-based research network. Explore (NY) 2009; 5: 290–5. Sweeney A, Doody C Manual therapy for the cervical spine and reported adverse effects: a survey of Irish Manipulative Physiotherapists. Man Ther 2010; 15: 32–6. Int J Clin Pract. 2010;64(10):1162-1165. © 2010 Blackwell Publishing Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 8, 2011 Report Share Posted July 8, 2011 Hi Minga, My heartfelt sympathy regarding your grandfather. . That must have been tough going through WSCC after that. Thank you for sharing to educate all of us. Elliott Mantell Sent via BlackBerry by AT & T Re: Chiropractic deaths Medical errors are the fourth leading cause of death in this country and if you add non-error deaths e.g., adverse drug events, hospital infections, surgical adverse events etc. some authors suggest medical care is the leading cause of death in this country.... VErn Saboe Chiropractic deaths Docs: I especially like their " Conclusion. " Lyndon McGill, D.C. Salem, Oregon www.SalemSpineClinic.com www.EvolvingDaily.com Deaths after Chiropractic: A Review of Published Cases E. Ernst Posted: 08/30/2010; Int J Clin Pract. 2010;64(10):1162-1165. © 2010 Blackwell Publishing Abstract and Introduction Abstract Objective: The aim of this study was to summarise all cases in which chiropractic spinal manipulation was followed by death. Design: This study is a systematic review of case reports. Methods: Literature searches in four electronic databases with no restrictions of time or language. Main outcome measure: Death. Results: Twenty six fatalities were published in the medical literature and many more might have remained unpublished. The alleged pathology usually was a vascular accident involving the dissection of a vertebral artery. Conclusion: Numerous deaths have occurred after chiropractic manipulations. The risks of this treatment by far outweigh its benefit. Introduction Vascular accidents after upper spinal manipulation are a well-recognised problem (e.g.[1,2]). Dissection of a vertebral artery, caused by extension and rotation of the neck beyond the physiological range of motion, is thought to be the underlying mechanism.[2] Several deaths have been reported as a consequence. Some proponents of chiropractic seem to believe that the critical evaluation of this evidence amounts to a 'scare story' (Chairman of the UK General Chiropractic Council)[3] or to 'puffing up (the evidence) out of all proportion' (President of the British Chiropractic Association).[4] A responsible approach to serious therapeutic risks, however, requires an open discussion of the facts. In this review, I aimed to provide the basis for such a discussion by summarising all fatalities which occurred after chiropractic spinal manipulation and were published in the medical literature. Methods Electronic searches were conducted in the following electronic databases: Medline, Embase, AMED, Cochrane Library (September 2009). No restrictions of time or language were applied. Search terms were chiropractic, spinal manipulation, vascular accidents, stroke, death and fatality. In addition, our own departmental files and the bibliographies of the articles thus located were searched. Several experts were also contacted for further data. Case reports were included if they provided information on human patients who had died after receiving one or more treatments from a chiropractor. Data were extracted from the included articles according to predefined criteria (Table 1). Table 1. Published case reports of deaths after chiropractic treatments References Year of publication Victim Type of vascular accident Time between treatment and death Anon[5] 1934 Woman, age unknown Tear in left lateral sinus 2 weeks Pratt- and Berger[6] 1947 32-year-old man Thrombosis of basilar, left anterior-inferior cerebellar and right posterior-inferior arteries 24 h Pratt- and Berger[6] 1947 35-year-old woman Thrombosis of posterior-inferior cerebellar artery 10 h Anon[7] 1955 Woman, age unknown Intra-spinal bleeding and compression of spinal cord 18 h Ford and [8] 1956 37-year-old man Thrombosis of basilar, left-posterior cerebellar and left-posterior cerebral arteries 6 h Ford and [8] 1956 No information provided Thrombosis of basilar artery No information provided and Estridge[9] 1962 33-year-old woman Infarct of cerebellar and brainstem 3 days Lorenz and Vogelsang[10] 1972 39-year-old woman Thrombosis of basilar artery 58 days Schmitt[11] 1976 35-years-old woman Infarct of brainstem 1 h Krueger and Okazaki[12] 1980 25-year-old man Infarct of brainstem and cerebellum 48 h Sherman et al.[13] 1981 60-year-old woman Dissection of vertebral artery 4 days Ali Cherif et al.[14] 1983 51-year-old man Infarct of medulla oblongata 11 days Nielsen[15] 1984 34-year-old man Dissection of vertebral artery aneurysen 3 h Zak and Carmody[16] 1984 53-year-old man Left vertebral, posterior-inferior and superior cerebellar artery occlusion; cerebellar infarction 27 days Modde[17] 1985 26-year-old woman Dissection of vertebral artery 1 day Jentzen et al.[18] 1987 51-year-old man Infarct of cerebellum and brainstem No information provided Sherman et al.[20] 1987 37-year-old man Infarct of brainstem 3 days Mas et al.[19] 1989 35-year-old woman Dissecting aneurysm of vertebral artery 16 h Raskind and North[21] 1990 47-year-old woman Cerebellar haemorrheae No information provided Sullivan[22] 1992 41-year-old woman Haemorrhage in ventricular system 8 h Haynes[23] 1994 36-year-old woman Dissecting aneurysm of vertebral artery, thrombo-embolism No information provided s et al.[24] 1995 29-year-old woman Infarct of right hemisphere 3 days Klougart et al.[25] 1996 34-year-old man Unclear Few hours Haldeman et al.[26] 2002 Previously unpublished legal cases No information provided No information provided Haldeman et al.[26] 2002 Previously unpublished legal cases No information provided No information provided Dziewas et al.[27] 2003 No information provided No information provided No information provided Results Twenty-six fatalities were published since 1934 in 23 articles (Table 1).[5–27] Table 1. Published case reports of deaths after chiropractic treatments References Year of publication Victim Type of vascular accident Time between treatment and death Anon[5] 1934 Woman, age unknown Tear in left lateral sinus 2 weeks Pratt- and Berger[6] 1947 32-year-old man Thrombosis of basilar, left anterior-inferior cerebellar and right posterior-inferior arteries 24 h Pratt- and Berger[6] 1947 35-year-old woman Thrombosis of posterior-inferior cerebellar artery 10 h Anon[7] 1955 Woman, age unknown Intra-spinal bleeding and compression of spinal cord 18 h Ford and [8] 1956 37-year-old man Thrombosis of basilar, left-posterior cerebellar and left-posterior cerebral arteries 6 h Ford and [8] 1956 No information provided Thrombosis of basilar artery No information provided and Estridge[9] 1962 33-year-old woman Infarct of cerebellar and brainstem 3 days Lorenz and Vogelsang[10] 1972 39-year-old woman Thrombosis of basilar artery 58 days Schmitt[11] 1976 35-years-old woman Infarct of brainstem 1 h Krueger and Okazaki[12] 1980 25-year-old man Infarct of brainstem and cerebellum 48 h Sherman et al.[13] 1981 60-year-old woman Dissection of vertebral artery 4 days Ali Cherif et al.[14] 1983 51-year-old man Infarct of medulla oblongata 11 days Nielsen[15] 1984 34-year-old man Dissection of vertebral artery aneurysen 3 h Zak and Carmody[16] 1984 53-year-old man Left vertebral, posterior-inferior and superior cerebellar artery occlusion; cerebellar infarction 27 days Modde[17] 1985 26-year-old woman Dissection of vertebral artery 1 day Jentzen et al.[18] 1987 51-year-old man Infarct of cerebellum and brainstem No information provided Sherman et al.[20] 1987 37-year-old man Infarct of brainstem 3 days Mas et al.[19] 1989 35-year-old woman Dissecting aneurysm of vertebral artery 16 h Raskind and North[21] 1990 47-year-old woman Cerebellar haemorrheae No information provided Sullivan[22] 1992 41-year-old woman Haemorrhage in ventricular system 8 h Haynes[23] 1994 36-year-old woman Dissecting aneurysm of vertebral artery, thrombo-embolism No information provided s et al.[24] 1995 29-year-old woman Infarct of right hemisphere 3 days Klougart et al.[25] 1996 34-year-old man Unclear Few hours Haldeman et al.[26] 2002 Previously unpublished legal cases No information provided No information provided Haldeman et al.[26] 2002 Previously unpublished legal cases No information provided No information provided Dziewas et al.[27] 2003 No information provided No information provided No information provided Most of the victims were relatively young; 14 were below the age of 40. There was a slight majority of female patients. The type of complication associated with death frequently related to a vascular accident leading to thrombosis and cerebral infarction. The time between treatment and death ranged from 1 h to 58 days; in 10 cases, it was 1 day or less. Unfortunately, the published information was often incomplete. Many other fatalities seem to have remained unpublished. For instance, the testimony of the chiropractor Preston Long for a court in Connecticut recently listed the family names of nine victims: Mathiason, Solsbury, Mc Cornick, Venegas, Bedenbaugh, , Fawcett, Parisien, Standt. Long also states that 'many others [are] unknown hidden behind legal agreements of silence'.[28] A website names further North American fatalities: Epping (California), G. Fowden (Utah), Grainger (Alberta), Hoffman (land), Renate Dora Labonte (Ontario), (California), Pereyra (Connecticut), A. Roth (Ontario) and Lee Strohecker (Pennsylvania).[29] Discussion This systematic review demonstrates that numerous deaths have been associated with chiropractic. Usually high-velocity, short-lever thrusts of the upper spine with rotation are implicated. They are believed to cause vertebral arterial dissection in predisposed individuals which, in turn, can lead to a chain of events including stroke and death.[1,2,26,30] Many chiropractors claim that, because arterial dissection can also occur spontaneously, causality between the chiropractic intervention and arterial dissection is not proven. However, when carefully evaluating the known facts, one does arrive at the conclusion that causality is at least likely (e.g.[30,31]). Even if it were merely a remote possibility, the precautionary principle in healthcare would mean that neck manipulations should be considered unsafe until proven otherwise. Moreover, there is no good evidence for assuming that neck manipulation is an effective therapy for any medical condition.[32] Thus, the risk-benefit balance for chiropractic neck manipulation fails to be positive. Reliable estimates of the frequency of vascular accidents are prevented by the fact that under-reporting is known to be substantial. In a survey of UK neurologists, for instance, under-reporting of serious complications was 100%.[33] Those cases which are published often turn out to be incomplete. Of 40 case reports of serious adverse effects associated with spinal manipulation, nine failed to provide any information about the clinical outcome.[34] Incomplete reporting of outcomes might therefore further increase the true number of fatalities. Obviously, the present article is not aimed at providing incidence figures; this would require a different methodology entirely. To date, no reliable incidence data are available. This review is focussed on deaths after chiropractic, yet neck manipulations are, of course, used by other healthcare professionals as well. The reason for this focus is simple: chiropractors are more frequently associated with serious manipulation-related adverse effects than osteopaths, physiotherapists, doctors or other professionals. Of the 40 cases of serious adverse effects mentioned above, 28 can be traced back to a chiropractor and none to an osteopath.[34] A review of complications after spinal manipulations by any type of healthcare professional included three deaths related to osteopaths, nine to medical practitioners, none to a physiotherapist, one to a naturopath and 17 to chiropractors.[35] This article also summarised a total of 265 vascular accidents of which 142 were linked to chiropractors. Another review of complications after neck manipulations published by 1997 included 177 vascular accidents, 32 of which were fatal. The vast majority of these cases were associated with chiropractic and none with physiotherapy.[36] The most obvious explanation for the dominance of chiropractic is that chiropractors routinely employ high-velocity, short-lever thrusts on the upper spine with a rotational element, while the other healthcare professionals use them much more sparingly.[37,38] In conclusion, numerous deaths have been associated with chiropractic neck manipulations. There are reasons to suspect that under-reporting is substantial and reliable incidence figures do not exist. The risks of chiropractic neck manipulations by far outweigh their benefits. Healthcare professionals should advise the public accordingly. Sidebar What's Known Chiropractic upper spinal manipulation has repeatedly been associated with arterial dissection followed by stroke and, in some cases, death. What's New The article is the first systematic review of all fatalities reported in the medical literature. Twenty-six deaths are on record and many more seem to have remained unpublished. References Ernst E. Adverse effects of spinal manipulation: a systematic review. J R Soc Med 2007; 100: 330–8. Leon- A, Cuetter A, Ferrer G. Cervical spine manipulation: an alternative medical procedure with potentially fatal complications. South Med J 2007; 100: 201–3. Dixon P. Letter to the Editor. Adverse effects of spinal manipulation. J R Soc Med 2007; 100: 444. BJ. Letter to the Editor. Adverse effects of spinal manipulation. J R Soc Med 2007; 100: 444. Anon. Medicolegal. Malpractice: death resulting from chiropractic treatment for headache. J Am Med Assoc 1934; 103:1260, 1935; 105:1712–4, 1937; 109:233–4. Pratt- HR, Berger KE. Cerebellar and spinal injuries after chiropractic manipulation. J Am Med Assoc 1947; 133: 600–3. Anon. Medicolegal abstracts. Chiropractors: injury to spinal meninges during adjustments. J Am Med Assoc 1955; 159: 809. Ford FR, D. Thrombosis of the basilar artery with softenings in the cerebellum and brain stem due to manipulation of the neck; a report of two cases with one post-mortem examination, reasons are given to prove that damage to the vertebral arteries is responsible. Bull s Hopkins Hosp 1956; 98: 37–42. RA, Estridge MN. Neurologic complications of head and neck manipulations. JAMA 1962; 182: 528–31. Lorenz R, Vogelsang HG. Thrombosis of the basilar artery following chiropractic manipulation of the cervical spine. [in German] Thrombose der arteria basilaris nach chiropraktischen Manipulationen an der Halbwirbelsäule. Dtsch Med Wochenschr 1972; 97: 36–43. Schmitt HP. Rupturen und Thrombosen der Arteria vertebralis nach gedeckten mechanischen Insulten. Schweiz Arch Neurol Neurochir Psychiatry 1976; 119: 363–79. Krueger BR, Okazaki H. Vertebral-basilar distribution infarction following chiropractic cervical manipulation. Mayo Clin Proc 1980; 55: 322–32. Sherman DG, Hart RG, Easton JD. Abrupt change in head position and cerebral infarction. Stroke 1981; 12: 2–6. Ali Cherif A, Delpuech F, Habib M, Salamon G, Khalil R. Thrombose vertebro-basilaire apres manipulation du rachis cervical. A propos de deux cas. Ann de Med Phys 1983; 25: 459–65. Nielsen AA. Cerebrovascular insults caused by manipulation of the cervical spine. [in Danish]. Ugeskr Laeger 1984; 146: 3267–70. Zak SM, Carmody RF. Cerebellar infarction from chiropractic neck manipulation: case report and review of the literature. Ariz Med 1984; 41: 333–7. Modde PJ. Chiropractic Malpractice. Columbia, land: Hanrow Press. 1985: 269–70, 273–5, 311–8, 322–3, 329–31, 334–7. Jentzen JM, Amatuzio J, GF. Complications of cervical manipulation: a case report of fatal brainstem infarct with review of the mechanisms and predisposing factors. J Forensic Sci 1987; 32: 1089–94. Mas JL, Henin D, Bousser MG, Chain F, Haw JJ. Dissecting aneurysm of the vertebral artery and cervical manipulation: a case report with autopsy. Neurology 1989; 39: 512–5. Sherman MR, Smialek JE, Zane WE. Pathogenesis of vertebral artery occlusion following cervical spine manipulation. Arch Pathol Lab Med 1987; 111: 851–3. Raskind R, North CM. Vertebral artery injuries following chiropractic cervical spine manipulation--case reports. Angiology 1990; 41: 445–52. Sullivan EC. Brain stem stroke syndromes from cervical adjustments. Report on five cases. J Chiropr Res Clin Invest 1992; 8: 12–6. Haynes MJ. Stroke following cervical manipulation in Perth. Chiropr J Aust 1994; 24: 42–6. s M, Bohl J, Thömke F, Kallen K-J, Mahlzahn K, Wandel E. Dissection of the internal carotid artery after chiropractic manipulation of the neck. Neurology 1995; 45: 2284–6. Klougart N, Leboeuf-Yde C, Rasmussen LR. Safety in chiropractic practice. Part I. The occurrence of cerebrovascular accidents after manipulation to the neck in Denmark from 1978–1988. J Manipulative Physiol Ther 1996; 19: 371–7. Haldeman S, Kohlbeck FJ, McGregor M. Unpredictability of cerebrovascular ischemia associated with cervical spine manipulation. Spine 2002; 27: 49–55. Dziewas R, Konrad C, Dräger B et al. Cervical artery dissection – clinical features, risk factors, therapy and outcome in 126 patients. J Neurol 2003; 250: 1179–84. Presentation by Dr Preston Long DC to State of Connecticut. Connecticut State Board of Chiropractic Examiners. Hartford Connecticut. 25 October 2009. Anon. What's the harm in going to a chiropractor? What's the Harm 2009; http://whatstheharm.net/chiropractic.html (accessed October 2009). Ernst E. Vascular accidents after neck manipulation: cause or coincidence? Int J Clin Pract 2009; in press. Long PH. Stroke and spinal manipulation. J Quality Health Care 2004; 3: 8–10. Ernst E. Chiropractic: a critical evaluation. J Pain Symptom Manage 2008; 35: 544–62. Stevinson C, Honan W, Cooke B, Ernst E. Neurological complications of cervical spine manipulation. J Roy Soc Med 2001; 94: 107–10. Ernst E. Cerebrovascular complications associated with spinal manipulation. Phys Ther Rev 2004; 9: 5–15. Terrett AGJ. Current Concepts in Vertebrobasilar Complications following Spinal Manipulation, 2nd edn. Des Moines: JCMIC Group, 2001. Di Fabio RP. Manipulation of the cervical spine: risks and benefits. Physical Ther 1999; 79: 50–65. Alcantara J, Ohm J, Kunz D. The safety and effectiveness of pediatric chiropractic: a survey of chiropractors and parents in a practice-based research network. Explore (NY) 2009; 5: 290–5. Sweeney A, Doody C Manual therapy for the cervical spine and reported adverse effects: a survey of Irish Manipulative Physiotherapists. Man Ther 2010; 15: 32–6. Int J Clin Pract. 2010;64(10):1162-1165. © 2010 Blackwell Publishing Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 9, 2011 Report Share Posted July 9, 2011 Well Said, Minga I have also seen a case, where a patient had a stroke immediately following chiro upper cerv adj, luckily, I was not the doctor. Minga's case shows a preventable death, a pt who was getting dizzy after adjustments, and the doc continued to do the same thing. As a profession, we need to look at how we can reduce the risk. I use low force neck adjusting, and only do rotational cervical moves, on those who request them, or on whom the low force adj isn't doing the job Marc Marc Heller, DC mheller@... www.MarcHellerDC.com On 7/8/2011 5:57 PM, AboWoman@... wrote: > All, My perceptions may not be popular from what I see on this list, > but I can't read the posts any longer without comment. > I agree that iatrogenic, medical error and adverse drug rxns are a > bigger cause of death than chiropractic manipulation. And altho I > believe deaths from vascular accidents following high velocity > adjusting, may only be assigned as a 'very low risk', I still think > this issue needs statistical analysis. I think we as a profession > would do better to lead the risk studies for obvious reasons. I also > think this chart is poorly crafted and doesn't prove a thing well > enough for me to quote any of the stats. > During the beginning of my 2nd yr as a DC student, my beloved grand > father died approximately 2-3 hours after a chiropractic high velocity > adjustment. Cause of death was listed as 2 fold; abdominal anuerysm > and stroke. He was 89, diabetic, high cholesterol, tho not over > weight. He was active and danced every weekend with grandma. He had > been seeing the same chiropractor for about a decade. The adjustments > were getting increasingly more difficult for him to tolerate. He > mentioned this to me as a student. I didn't know enough to advise him > at the time. The ER doctors told our family it was most likely the > high veolcity lumbar roll and the upper cervical adjusting that caused > his death. He felt immediately dizzy after the adjustment, however > he'd been getting dizzy after adjusting the last 3-4 times. He had > mentioned it to the DC and was told it was 'normal' for his age > according to my grandmother who attended appts with him. > On this occasion, the dizziness didn't pass. And his legs got so weak, > he could barely make to to the car. He passed out on the way home and > my grandmother drove him straight to ER. He never regained > consciousness. They had been married for over 50 yrs. It was a > devastating thing for our family. I remember reading the ER reports as > a 2nd yr DC student. Sobering. However, in 1982 there wasn't a lot of > informed consent mandatory stuff going on._I have to admit, when it > happens to a close family member, you will take notice_. You will > appreciate the absolute need to do a verbal and written signed consent > form if you decide to adjust the high risk patients.After asking a few > senior interns and my own clinic director, I appreciated how my > grandpa's DC had failed to change adjusting procedures and take into > account his failing health and risk factors. MY grandma was too > distraught to sue. However, I did call the doctor and told him that in > all probability, he killed my grandfather by not keeping current with > risk factors. He said he was retiring the next yr. I told him not to > wait. He did apologize and said in hindsight, he probably should've > considered grandpa's health, but that he was so active, he had > overlooked it. I give him this, he had the guts to apologize to > grandma. No one in the family would sue him because he ponied up. > I have always been and am still in support of mandatory informed > consent. Written, signed and verbal. I am in support of our profession > listening to public sentiment and dealing with it. I think our state > association should work with either UWS, OHSU or both to design a > statistical analysis of this perceived risk. We need to do it before > others do it. That way we are pro-active and perceived as listening to > public sentiment, public protection; instead of living in denial. > Once stats prove otherwise de NILE is fine. > Minga Guerrero DC > > > > Re: Chiropractic deaths > > Medical errors are the fourth leading cause of death in this country > and if you add non-error deaths e.g., adverse drug events, hospital > infections, surgical adverse events etc. some authors suggest medical > care is the leading cause of death in this country.... > VErn Saboe > > * Chiropractic deaths > > Docs: > > I especially like their " Conclusion. " > > Lyndon McGill, D.C. > Salem, Oregon > www.SalemSpineClinic.com > www.EvolvingDaily.com > > > <http://www3.interscience.wiley.com/journal/117980488/home> > > > Deaths after Chiropractic: A Review of Published Cases > > E. Ernst > Posted: 08/30/2010; Int J Clin > Pract. 2010;64(10):1162-1165. © 2010 Blackwell Publishing > > > Abstract and Introduction > > > Abstract > > *Objective:* The aim of this study was to summarise all cases in > which chiropractic spinal manipulation was followed by death. > *Design:* This study is a systematic review of case reports. > *Methods:* Literature searches in four electronic databases with > no restrictions of time or language. > *Main outcome measure:* Death. > *Results:* Twenty six fatalities were published in the medical > literature and many more might have remained unpublished. The > alleged pathology usually was a vascular accident involving the > dissection of a vertebral artery. > *Conclusion:* Numerous deaths have occurred after chiropractic > manipulations. The risks of this treatment by far outweigh its > benefit. > > > Introduction > > Vascular accidents after upper spinal manipulation are a > well-recognised problem (e.g.^[1,2] ). Dissection of a vertebral > artery, caused by extension and rotation of the neck beyond the > physiological range of motion, is thought to be the underlying > mechanism.^[2] Several deaths have been reported as a consequence. > Some proponents of chiropractic seem to believe that the critical > evaluation of this evidence amounts to a 'scare story' (Chairman > of the UK General Chiropractic Council)^[3] or to 'puffing up (the > evidence) out of all proportion' (President of the British > Chiropractic Association).^[4] A responsible approach to serious > therapeutic risks, however, requires an open discussion of the facts. > In this review, I aimed to provide the basis for such a discussion > by summarising all fatalities which occurred after chiropractic > spinal manipulation and were published in the medical literature. > > > Methods > > Electronic searches were conducted in the following electronic > databases: Medline, Embase, AMED, Cochrane Library (September > 2009). No restrictions of time or language were applied. Search > terms were chiropractic, spinal manipulation, vascular accidents, > stroke, death and fatality. In addition, our own departmental > files and the bibliographies of the articles thus located were > searched. Several experts were also contacted for further data. > Case reports were included if they provided information on human > patients who had died after receiving one or more treatments from > a chiropractor. Data were extracted from the included articles > according to predefined criteria (Table 1). > > > Table 1. Published case reports of deaths after > chiropractic treatments > > References Year of publication Victim Type of vascular > accident Time between treatment and death > Anon^[5] 1934 Woman, age unknown Tear in left lateral sinus 2 > weeks > Pratt- and Berger^[6] 1947 32-year-old man Thrombosis of > basilar, left anterior-inferior cerebellar and right > posterior-inferior arteries 24 h > Pratt- and Berger^[6] 1947 35-year-old woman Thrombosis > of posterior-inferior cerebellar artery 10 h > Anon^[7] 1955 Woman, age unknown Intra-spinal bleeding and > compression of spinal cord 18 h > Ford and ^[8] 1956 37-year-old man Thrombosis of basilar, > left-posterior cerebellar and left-posterior cerebral arteries 6 h > Ford and ^[8] 1956 No information provided Thrombosis of > basilar artery No information provided > and Estridge^[9] 1962 33-year-old woman Infarct of > cerebellar and brainstem 3 days > Lorenz and Vogelsang^[10] 1972 39-year-old woman Thrombosis of > basilar artery 58 days > Schmitt^[11] 1976 35-years-old woman Infarct of brainstem 1 h > Krueger and Okazaki^[12] 1980 25-year-old man Infarct of > brainstem and cerebellum 48 h > Sherman et al.^[13] 1981 60-year-old woman Dissection of > vertebral artery 4 days > Ali Cherif et al.^[14] 1983 51-year-old man Infarct of medulla > oblongata 11 days > Nielsen^[15] 1984 34-year-old man Dissection of vertebral > artery aneurysen 3 h > Zak and Carmody^[16] 1984 53-year-old man Left vertebral, > posterior-inferior and superior cerebellar artery occlusion; > cerebellar infarction 27 days > Modde^[17] 1985 26-year-old woman Dissection of vertebral > artery 1 day > Jentzen et al.^[18] 1987 51-year-old man Infarct of cerebellum > and brainstem No information provided > Sherman et al.^[20] 1987 37-year-old man Infarct of brainstem > 3 days > Mas et al.^[19] 1989 35-year-old woman Dissecting aneurysm of > vertebral artery 16 h > Raskind and North^[21] 1990 47-year-old woman Cerebellar > haemorrheae No information provided > Sullivan^[22] 1992 41-year-old woman Haemorrhage in ventricular > system 8 h > Haynes^[23] 1994 36-year-old woman Dissecting aneurysm of > vertebral artery, thrombo-embolism No information provided > s et al.^[24] 1995 29-year-old woman Infarct of right > hemisphere 3 days > Klougart et al.^[25] 1996 34-year-old man Unclear Few hours > Haldeman et al.^[26] 2002 Previously unpublished legal cases No > information provided No information provided > Haldeman et al.^[26] 2002 Previously unpublished legal cases No > information provided No information provided > Dziewas et al.^[27] 2003 No information provided No information > provided No information provided > > > Results > > Twenty-six fatalities were published since 1934 in 23 articles > (Table 1).^[5–27] > > > Table 1. Published case reports of deaths after > chiropractic treatments > > References Year of publication Victim Type of vascular > accident Time between treatment and death > Anon^[5] 1934 Woman, age unknown Tear in left lateral sinus 2 > weeks > Pratt- and Berger^[6] 1947 32-year-old man Thrombosis of > basilar, left anterior-inferior cerebellar and right > posterior-inferior arteries 24 h > Pratt- and Berger^[6] 1947 35-year-old woman Thrombosis > of posterior-inferior cerebellar artery 10 h > Anon^[7] 1955 Woman, age unknown Intra-spinal bleeding and > compression of spinal cord 18 h > Ford and ^[8] 1956 37-year-old man Thrombosis of basilar, > left-posterior cerebellar and left-posterior cerebral arteries 6 h > Ford and ^[8] 1956 No information provided Thrombosis of > basilar artery No information provided > and Estridge^[9] 1962 33-year-old woman Infarct of > cerebellar and brainstem 3 days > Lorenz and Vogelsang^[10] 1972 39-year-old woman Thrombosis of > basilar artery 58 days > Schmitt^[11] 1976 35-years-old woman Infarct of brainstem 1 h > Krueger and Okazaki^[12] 1980 25-year-old man Infarct of > brainstem and cerebellum 48 h > Sherman et al.^[13] 1981 60-year-old woman Dissection of > vertebral artery 4 days > Ali Cherif et al.^[14] 1983 51-year-old man Infarct of medulla > oblongata 11 days > Nielsen^[15] 1984 34-year-old man Dissection of vertebral > artery aneurysen 3 h > Zak and Carmody^[16] 1984 53-year-old man Left vertebral, > posterior-inferior and superior cerebellar artery occlusion; > cerebellar infarction 27 days > Modde^[17] 1985 26-year-old woman Dissection of vertebral > artery 1 day > Jentzen et al.^[18] 1987 51-year-old man Infarct of cerebellum > and brainstem No information provided > Sherman et al.^[20] 1987 37-year-old man Infarct of brainstem > 3 days > Mas et al.^[19] 1989 35-year-old woman Dissecting aneurysm of > vertebral artery 16 h > Raskind and North^[21] 1990 47-year-old woman Cerebellar > haemorrheae No information provided > Sullivan^[22] 1992 41-year-old woman Haemorrhage in ventricular > system 8 h > Haynes^[23] 1994 36-year-old woman Dissecting aneurysm of > vertebral artery, thrombo-embolism No information provided > s et al.^[24] 1995 29-year-old woman Infarct of right > hemisphere 3 days > Klougart et al.^[25] 1996 34-year-old man Unclear Few hours > Haldeman et al.^[26] 2002 Previously unpublished legal cases No > information provided No information provided > Haldeman et al.^[26] 2002 Previously unpublished legal cases No > information provided No information provided > Dziewas et al.^[27] 2003 No information provided No information > provided No information provided > > Most of the victims were relatively young; 14 were below the age > of 40. There was a slight majority of female patients. The type of > complication associated with death frequently related to a > vascular accident leading to thrombosis and cerebral infarction. > The time between treatment and death ranged from 1 h to 58 days; > in 10 cases, it was 1 day or less. Unfortunately, the published > information was often incomplete. > Many other fatalities seem to have remained unpublished. For > instance, the testimony of the chiropractor Preston Long for a > court in Connecticut recently listed the family names of nine > victims: Mathiason, Solsbury, Mc Cornick, Venegas, Bedenbaugh, > , Fawcett, Parisien, Standt. Long also states that 'many > others [are] unknown hidden behind legal agreements of > silence'.^[28] A website names further North American fatalities: > Epping (California), G. Fowden (Utah), Grainger > (Alberta), Hoffman (land), Renate Dora Labonte (Ontario), > (California), Pereyra (Connecticut), > A. Roth (Ontario) and Lee Strohecker (Pennsylvania).^[29] > > > Discussion > > This systematic review demonstrates that numerous deaths have been > associated with chiropractic. Usually high-velocity, short-lever > thrusts of the upper spine with rotation are implicated. They are > believed to cause vertebral arterial dissection in predisposed > individuals which, in turn, can lead to a chain of events > including stroke and death.^[1,2,26,30] > Many chiropractors claim that, because arterial dissection can > also occur spontaneously, causality between the chiropractic > intervention and arterial dissection is not proven. However, when > carefully evaluating the known facts, one does arrive at the > conclusion that causality is at least likely (e.g.^[30,31] ). Even > if it were merely a remote possibility, the precautionary > principle in healthcare would mean that neck manipulations should > be considered unsafe until proven otherwise. Moreover, there is no > good evidence for assuming that neck manipulation is an effective > therapy for any medical condition.^[32] Thus, the risk-benefit > balance for chiropractic neck manipulation fails to be positive. > Reliable estimates of the frequency of vascular accidents are > prevented by the fact that under-reporting is known to be > substantial. In a survey of UK neurologists, for instance, > under-reporting of serious complications was 100%.^[33] Those > cases which are published often turn out to be incomplete. Of 40 > case reports of serious adverse effects associated with spinal > manipulation, nine failed to provide any information about the > clinical outcome.^[34] Incomplete reporting of outcomes might > therefore further increase the true number of fatalities. > Obviously, the present article is not aimed at providing incidence > figures; this would require a different methodology entirely. To > date, no reliable incidence data are available. > This review is focussed on deaths after chiropractic, yet neck > manipulations are, of course, used by other healthcare > professionals as well. The reason for this focus is simple: > chiropractors are more frequently associated with serious > manipulation-related adverse effects than osteopaths, > physiotherapists, doctors or other professionals. Of the 40 cases > of serious adverse effects mentioned above, 28 can be traced back > to a chiropractor and none to an osteopath.^[34] A review of > complications after spinal manipulations by any type of healthcare > professional included three deaths related to osteopaths, nine to > medical practitioners, none to a physiotherapist, one to a > naturopath and 17 to chiropractors.^[35] This article also > summarised a total of 265 vascular accidents of which 142 were > linked to chiropractors. Another review of complications after > neck manipulations published by 1997 included 177 vascular > accidents, 32 of which were fatal. The vast majority of these > cases were associated with chiropractic and none with > physiotherapy.^[36] The most obvious explanation for the dominance > of chiropractic is that chiropractors routinely employ > high-velocity, short-lever thrusts on the upper spine with a > rotational element, while the other healthcare professionals use > them much more sparingly.^[37,38] > In conclusion, numerous deaths have been associated with > chiropractic neck manipulations. There are reasons to suspect that > under-reporting is substantial and reliable incidence figures do > not exist. The risks of chiropractic neck manipulations by far > outweigh their benefits. Healthcare professionals should advise > the public accordingly. > > > Sidebar > > > What's Known > > Chiropractic upper spinal manipulation has repeatedly been > associated with arterial dissection followed by stroke and, in > some cases, death. > > > What's New > > The article is the first systematic review of all fatalities > reported in the medical literature. Twenty-six deaths are on > record and many more seem to have remained unpublished. > > > References > > 1. Ernst E. Adverse effects of spinal manipulation: a > systematic review. /J R Soc Med/ 2007; 100: 330–8. > 2. Leon- A, Cuetter A, Ferrer G. Cervical spine > manipulation: an alternative medical procedure with > potentially fatal complications. /South Med J/ 2007; 100: > 201–3. > 3. Dixon P. Letter to the Editor. Adverse effects of spinal > manipulation. /J R Soc Med/ 2007; 100: 444. > 4. BJ. Letter to the Editor. Adverse effects of spinal > manipulation. /J R Soc Med/ 2007; 100: 444. > 5. Anon. Medicolegal. Malpractice: death resulting from > chiropractic treatment for headache. /J Am Med Assoc/ 1934; > 103:1260, 1935; 105:1712–4, 1937; 109:233–4. > 6. Pratt- HR, Berger KE. Cerebellar and spinal injuries > after chiropractic manipulation. /J Am Med Assoc/ 1947; 133: > 600–3. > 7. Anon. Medicolegal abstracts. Chiropractors: injury to spinal > meninges during adjustments. /J Am Med Assoc/ 1955; 159: 809. > 8. Ford FR, D. Thrombosis of the basilar artery with > softenings in the cerebellum and brain stem due to > manipulation of the neck; a report of two cases with one > post-mortem examination, reasons are given to prove that > damage to the vertebral arteries is responsible. /Bull s > Hopkins Hosp/ 1956; 98: 37–42. > 9. RA, Estridge MN. Neurologic complications of head and > neck manipulations. /JAMA/ 1962; 182: 528–31. > 10. Lorenz R, Vogelsang HG. Thrombosis of the basilar artery > following chiropractic manipulation of the cervical spine. > [in German] Thrombose der arteria basilaris nach > chiropraktischen Manipulationen an der Halbwirbelsäule. > /Dtsch Med Wochenschr/ 1972; 97: 36–43. > 11. Schmitt HP. Rupturen und Thrombosen der Arteria vertebralis > nach gedeckten mechanischen Insulten. /Schweiz Arch Neurol > Neurochir Psychiatry/ 1976; 119: 363–79. > 12. Krueger BR, Okazaki H. Vertebral-basilar distribution > infarction following chiropractic cervical manipulation. > /Mayo Clin Proc/ 1980; 55: 322–32. > 13. Sherman DG, Hart RG, Easton JD. Abrupt change in head > position and cerebral infarction. /Stroke/ 1981; 12: 2–6. > 14. Ali Cherif A, Delpuech F, Habib M, Salamon G, Khalil R. > Thrombose vertebro-basilaire apres manipulation du rachis > cervical. A propos de deux cas. /Ann de Med Phys/ 1983; 25: > 459–65. > 15. Nielsen AA. Cerebrovascular insults caused by manipulation > of the cervical spine. [in Danish]. /Ugeskr Laeger/ 1984; > 146: 3267–70. > 16. Zak SM, Carmody RF. Cerebellar infarction from chiropractic > neck manipulation: case report and review of the literature. > /Ariz Med/ 1984; 41: 333–7. > 17. Modde PJ. /Chiropractic Malpractice/. Columbia, land: > Hanrow Press. 1985: 269–70, 273–5, 311–8, 322–3, 329–31, 334–7. > 18. Jentzen JM, Amatuzio J, GF. Complications of > cervical manipulation: a case report of fatal brainstem > infarct with review of the mechanisms and predisposing > factors. /J Forensic Sci/ 1987; 32: 1089–94. > 19. Mas JL, Henin D, Bousser MG, Chain F, Haw JJ. Dissecting > aneurysm of the vertebral artery and cervical manipulation: > a case report with autopsy. /Neurology/ 1989; 39: 512–5. > 20. Sherman MR, Smialek JE, Zane WE. Pathogenesis of vertebral > artery occlusion following cervical spine manipulation. > /Arch Pathol Lab Med/ 1987; 111: 851–3. > 21. Raskind R, North CM. Vertebral artery injuries following > chiropractic cervical spine manipulation--case reports. > /Angiology/ 1990; 41: 445–52. > 22. Sullivan EC. Brain stem stroke syndromes from cervical > adjustments. Report on five cases. /J Chiropr Res Clin > Invest/ 1992; 8: 12–6. > 23. Haynes MJ. Stroke following cervical manipulation in Perth. > /Chiropr J Aust/ 1994; 24: 42–6. > 24. s M, Bohl J, Thömke F, Kallen K-J, Mahlzahn K, Wandel > E. Dissection of the internal carotid artery after > chiropractic manipulation of the neck. /Neurology/ 1995; 45: > 2284–6. > 25. Klougart N, Leboeuf-Yde C, Rasmussen LR. Safety in > chiropractic practice. Part I. The occurrence of > cerebrovascular accidents after manipulation to the neck in > Denmark from 1978–1988. /J Manipulative Physiol Ther/ 1996; > 19: 371–7. > 26. Haldeman S, Kohlbeck FJ, McGregor M. Unpredictability of > cerebrovascular ischemia associated with cervical spine > manipulation. /Spine/ 2002; 27: 49–55. > 27. Dziewas R, Konrad C, Dräger B et al. Cervical artery > dissection – clinical features, risk factors, therapy and > outcome in 126 patients. /J Neurol/ 2003; 250: 1179–84. > 28. Presentation by Dr Preston Long DC to State of Connecticut. > Connecticut State Board of Chiropractic Examiners. Hartford > Connecticut. 25 October 2009. > 29. Anon. What's the harm in going to a chiropractor? /What's > the Harm/ 2009; http://whatstheharm.net/chiropractic.html > (accessed October 2009). > 30. Ernst E. Vascular accidents after neck manipulation: cause > or coincidence? /Int J Clin Pract/ 2009; in press. > 31. Long PH. Stroke and spinal manipulation. /J Quality Health > Care/ 2004; 3: 8–10. > 32. Ernst E. Chiropractic: a critical evaluation. /J Pain > Symptom Manage/ 2008; 35: 544–62. > 33. Stevinson C, Honan W, Cooke B, Ernst E. Neurological > complications of cervical spine manipulation. /J Roy Soc > Med/ 2001; 94: 107–10. > 34. Ernst E. Cerebrovascular complications associated with > spinal manipulation. /Phys Ther Rev/ 2004; 9: 5–15. > 35. Terrett AGJ. /Current Concepts in Vertebrobasilar > Complications following Spinal Manipulation/, 2nd edn. Des > Moines: JCMIC Group, 2001. > 36. Di Fabio RP. Manipulation of the cervical spine: risks and > benefits. /Physical Ther/ 1999; 79: 50–65. > 37. Alcantara J, Ohm J, Kunz D. The safety and effectiveness of > pediatric chiropractic: a survey of chiropractors and > parents in a practice-based research network. /Explore (NY)/ > 2009; 5: 290–5. > 38. Sweeney A, Doody C Manual therapy for the cervical spine and > reported adverse effects: a survey of Irish Manipulative > Physiotherapists. /Man Ther/ 2010; 15: 32–6. > > Int J Clin Pract. 2010;64(10):1162-1165. © 2010 Blackwell Publishing > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 9, 2011 Report Share Posted July 9, 2011  Doctors, For those of you who have tried an instrument assisted cervical correction and feel it was unsuccessful first check the upper thoracic area for hyperkyphosis and release it then check the cervicals for a head forward posture which tells you that you are dealing facet compression, that should be reduced using a vertebral distraction pump, then correct for rotation using your instrument and you'll see the ease with which correction occurs. Herb Freeman D.C. * Chiropractic deaths>> Docs:>> I especially like their "Conclusion.">> Lyndon McGill, D.C.> Salem, Oregon> www.SalemSpineClinic.com> www.EvolvingDaily.com>>> <http://www3.interscience.wiley.com/journal/117980488/home>>>> Deaths after Chiropractic: A Review of Published Cases>> E. Ernst> Posted: 08/30/2010; Int J Clin> Pract. 2010;64(10):1162-1165. © 2010 Blackwell Publishing>>> Abstract and Introduction>>> Abstract>> *Objective:* The aim of this study was to summarise all cases in> which chiropractic spinal manipulation was followed by death.> *Design:* This study is a systematic review of case reports.> *Methods:* Literature searches in four electronic databases with> no restrictions of time or language.> *Main outcome measure:* Death.> *Results:* Twenty six fatalities were published in the medical> literature and many more might have remained unpublished. The> alleged pathology usually was a vascular accident involving the> dissection of a vertebral artery.> *Conclusion:* Numerous deaths have occurred after chiropractic> manipulations. The risks of this treatment by far outweigh its> benefit.>>> Introduction>> Vascular accidents after upper spinal manipulation are a> well-recognised problem (e.g.^[1,2] ). Dissection of a vertebral> artery, caused by extension and rotation of the neck beyond the> physiological range of motion, is thought to be the underlying> mechanism.^[2] Several deaths have been reported as a consequence.> Some proponents of chiropractic seem to believe that the critical> evaluation of this evidence amounts to a 'scare story' (Chairman> of the UK General Chiropractic Council)^[3] or to 'puffing up (the> evidence) out of all proportion' (President of the British> Chiropractic Association).^[4] A responsible approach to serious> therapeutic risks, however, requires an open discussion of the facts.> In this review, I aimed to provide the basis for such a discussion> by summarising all fatalities which occurred after chiropractic> spinal manipulation and were published in the medical literature.>>> Methods>> Electronic searches were conducted in the following electronic> databases: Medline, Embase, AMED, Cochrane Library (September> 2009). No restrictions of time or language were applied. Search> terms were chiropractic, spinal manipulation, vascular accidents,> stroke, death and fatality. In addition, our own departmental> files and the bibliographies of the articles thus located were> searched. Several experts were also contacted for further data.> Case reports were included if they provided information on human> patients who had died after receiving one or more treatments from> a chiropractor. Data were extracted from the included articles> according to predefined criteria (Table 1).>>> Table 1. Published case reports of deaths after> chiropractic treatments>> References Year of publication Victim Type of vascular> accident Time between treatment and death> Anon^[5] 1934 Woman, age unknown Tear in left lateral sinus 2> weeks> Pratt- and Berger^[6] 1947 32-year-old man Thrombosis of> basilar, left anterior-inferior cerebellar and right> posterior-inferior arteries 24 h> Pratt- and Berger^[6] 1947 35-year-old woman Thrombosis> of posterior-inferior cerebellar artery 10 h> Anon^[7] 1955 Woman, age unknown Intra-spinal bleeding and> compression of spinal cord 18 h> Ford and ^[8] 1956 37-year-old man Thrombosis of basilar,> left-posterior cerebellar and left-posterior cerebral arteries 6 h> Ford and ^[8] 1956 No information provided Thrombosis of> basilar artery No information provided> and Estridge^[9] 1962 33-year-old woman Infarct of> cerebellar and brainstem 3 days> Lorenz and Vogelsang^[10] 1972 39-year-old woman Thrombosis of> basilar artery 58 days> Schmitt^[11] 1976 35-years-old woman Infarct of brainstem 1 h> Krueger and Okazaki^[12] 1980 25-year-old man Infarct of> brainstem and cerebellum 48 h> Sherman et al.^[13] 1981 60-year-old woman Dissection of> vertebral artery 4 days> Ali Cherif et al.^[14] 1983 51-year-old man Infarct of medulla> oblongata 11 days> Nielsen^[15] 1984 34-year-old man Dissection of vertebral> artery aneurysen 3 h> Zak and Carmody^[16] 1984 53-year-old man Left vertebral,> posterior-inferior and superior cerebellar artery occlusion;> cerebellar infarction 27 days> Modde^[17] 1985 26-year-old woman Dissection of vertebral> artery 1 day> Jentzen et al.^[18] 1987 51-year-old man Infarct of cerebellum> and brainstem No information provided> Sherman et al.^[20] 1987 37-year-old man Infarct of brainstem> 3 days> Mas et al.^[19] 1989 35-year-old woman Dissecting aneurysm of> vertebral artery 16 h> Raskind and North^[21] 1990 47-year-old woman Cerebellar> haemorrheae No information provided> Sullivan^[22] 1992 41-year-old woman Haemorrhage in ventricular> system 8 h> Haynes^[23] 1994 36-year-old woman Dissecting aneurysm of> vertebral artery, thrombo-embolism No information provided> s et al.^[24] 1995 29-year-old woman Infarct of right> hemisphere 3 days> Klougart et al.^[25] 1996 34-year-old man Unclear Few hours> Haldeman et al.^[26] 2002 Previously unpublished legal cases No> information provided No information provided> Haldeman et al.^[26] 2002 Previously unpublished legal cases No> information provided No information provided> Dziewas et al.^[27] 2003 No information provided No information> provided No information provided>>> Results>> Twenty-six fatalities were published since 1934 in 23 articles> (Table 1).^[5–27]>>> Table 1. Published case reports of deaths after> chiropractic treatments>> References Year of publication Victim Type of vascular> accident Time between treatment and death> Anon^[5] 1934 Woman, age unknown Tear in left lateral sinus 2> weeks> Pratt- and Berger^[6] 1947 32-year-old man Thrombosis of> basilar, left anterior-inferior cerebellar and right> posterior-inferior arteries 24 h> Pratt- and Berger^[6] 1947 35-year-old woman Thrombosis> of posterior-inferior cerebellar artery 10 h> Anon^[7] 1955 Woman, age unknown Intra-spinal bleeding and> compression of spinal cord 18 h> Ford and ^[8] 1956 37-year-old man Thrombosis of basilar,> left-posterior cerebellar and left-posterior cerebral arteries 6 h> Ford and ^[8] 1956 No information provided Thrombosis of> basilar artery No information provided> and Estridge^[9] 1962 33-year-old woman Infarct of> cerebellar and brainstem 3 days> Lorenz and Vogelsang^[10] 1972 39-year-old woman Thrombosis of> basilar artery 58 days> Schmitt^[11] 1976 35-years-old woman Infarct of brainstem 1 h> Krueger and Okazaki^[12] 1980 25-year-old man Infarct of> brainstem and cerebellum 48 h> Sherman et al.^[13] 1981 60-year-old woman Dissection of> vertebral artery 4 days> Ali Cherif et al.^[14] 1983 51-year-old man Infarct of medulla> oblongata 11 days> Nielsen^[15] 1984 34-year-old man Dissection of vertebral> artery aneurysen 3 h> Zak and Carmody^[16] 1984 53-year-old man Left vertebral,> posterior-inferior and superior cerebellar artery occlusion;> cerebellar infarction 27 days> Modde^[17] 1985 26-year-old woman Dissection of vertebral> artery 1 day> Jentzen et al.^[18] 1987 51-year-old man Infarct of cerebellum> and brainstem No information provided> Sherman et al.^[20] 1987 37-year-old man Infarct of brainstem> 3 days> Mas et al.^[19] 1989 35-year-old woman Dissecting aneurysm of> vertebral artery 16 h> Raskind and North^[21] 1990 47-year-old woman Cerebellar> haemorrheae No information provided> Sullivan^[22] 1992 41-year-old woman Haemorrhage in ventricular> system 8 h> Haynes^[23] 1994 36-year-old woman Dissecting aneurysm of> vertebral artery, thrombo-embolism No information provided> s et al.^[24] 1995 29-year-old woman Infarct of right> hemisphere 3 days> Klougart et al.^[25] 1996 34-year-old man Unclear Few hours> Haldeman et al.^[26] 2002 Previously unpublished legal cases No> information provided No information provided> Haldeman et al.^[26] 2002 Previously unpublished legal cases No> information provided No information provided> Dziewas et al.^[27] 2003 No information provided No information> provided No information provided>> Most of the victims were relatively young; 14 were below the age> of 40. There was a slight majority of female patients. The type of> complication associated with death frequently related to a> vascular accident leading to thrombosis and cerebral infarction.> The time between treatment and death ranged from 1 h to 58 days;> in 10 cases, it was 1 day or less. Unfortunately, the published> information was often incomplete.> Many other fatalities seem to have remained unpublished. For> instance, the testimony of the chiropractor Preston Long for a> court in Connecticut recently listed the family names of nine> victims: Mathiason, Solsbury, Mc Cornick, Venegas, Bedenbaugh,> , Fawcett, Parisien, Standt. Long also states that 'many> others [are] unknown hidden behind legal agreements of> silence'.^[28] A website names further North American fatalities:> Epping (California), G. Fowden (Utah), Grainger> (Alberta), Hoffman (land), Renate Dora Labonte (Ontario),> (California), Pereyra (Connecticut), > A. Roth (Ontario) and Lee Strohecker (Pennsylvania).^[29]>>> Discussion>> This systematic review demonstrates that numerous deaths have been> associated with chiropractic. Usually high-velocity, short-lever> thrusts of the upper spine with rotation are implicated. They are> believed to cause vertebral arterial dissection in predisposed> individuals which, in turn, can lead to a chain of events> including stroke and death.^[1,2,26,30]> Many chiropractors claim that, because arterial dissection can> also occur spontaneously, causality between the chiropractic> intervention and arterial dissection is not proven. However, when> carefully evaluating the known facts, one does arrive at the> conclusion that causality is at least likely (e.g.^[30,31] ). Even> if it were merely a remote possibility, the precautionary> principle in healthcare would mean that neck manipulations should> be considered unsafe until proven otherwise. Moreover, there is no> good evidence for assuming that neck manipulation is an effective> therapy for any medical condition.^[32] Thus, the risk-benefit> balance for chiropractic neck manipulation fails to be positive.> Reliable estimates of the frequency of vascular accidents are> prevented by the fact that under-reporting is known to be> substantial. In a survey of UK neurologists, for instance,> under-reporting of serious complications was 100%.^[33] Those> cases which are published often turn out to be incomplete. Of 40> case reports of serious adverse effects associated with spinal> manipulation, nine failed to provide any information about the> clinical outcome.^[34] Incomplete reporting of outcomes might> therefore further increase the true number of fatalities.> Obviously, the present article is not aimed at providing incidence> figures; this would require a different methodology entirely. To> date, no reliable incidence data are available.> This review is focussed on deaths after chiropractic, yet neck> manipulations are, of course, used by other healthcare> professionals as well. The reason for this focus is simple:> chiropractors are more frequently associated with serious> manipulation-related adverse effects than osteopaths,> physiotherapists, doctors or other professionals. Of the 40 cases> of serious adverse effects mentioned above, 28 can be traced back> to a chiropractor and none to an osteopath.^[34] A review of> complications after spinal manipulations by any type of healthcare> professional included three deaths related to osteopaths, nine to> medical practitioners, none to a physiotherapist, one to a> naturopath and 17 to chiropractors.^[35] This article also> summarised a total of 265 vascular accidents of which 142 were> linked to chiropractors. Another review of complications after> neck manipulations published by 1997 included 177 vascular> accidents, 32 of which were fatal. The vast majority of these> cases were associated with chiropractic and none with> physiotherapy.^[36] The most obvious explanation for the dominance> of chiropractic is that chiropractors routinely employ> high-velocity, short-lever thrusts on the upper spine with a> rotational element, while the other healthcare professionals use> them much more sparingly.^[37,38]> In conclusion, numerous deaths have been associated with> chiropractic neck manipulations. There are reasons to suspect that> under-reporting is substantial and reliable incidence figures do> not exist. The risks of chiropractic neck manipulations by far> outweigh their benefits. Healthcare professionals should advise> the public accordingly.>>> Sidebar>>> What's Known>> Chiropractic upper spinal manipulation has repeatedly been> associated with arterial dissection followed by stroke and, in> some cases, death.>>> What's New>> The article is the first systematic review of all fatalities> reported in the medical literature. Twenty-six deaths are on> record and many more seem to have remained unpublished.>>> References>> 1. Ernst E. Adverse effects of spinal manipulation: a> systematic review. /J R Soc Med/ 2007; 100: 330–8.> 2. Leon- A, Cuetter A, Ferrer G. Cervical spine> manipulation: an alternative medical procedure with> potentially fatal complications. /South Med J/ 2007; 100:> 201–3.> 3. Dixon P. Letter to the Editor. Adverse effects of spinal> manipulation. /J R Soc Med/ 2007; 100: 444.> 4. BJ. Letter to the Editor. Adverse effects of spinal> manipulation. /J R Soc Med/ 2007; 100: 444.> 5. Anon. Medicolegal. Malpractice: death resulting from> chiropractic treatment for headache. /J Am Med Assoc/ 1934;> 103:1260, 1935; 105:1712–4, 1937; 109:233–4.> 6. Pratt- HR, Berger KE. Cerebellar and spinal injuries> after chiropractic manipulation. /J Am Med Assoc/ 1947; 133:> 600–3.> 7. Anon. Medicolegal abstracts. Chiropractors: injury to spinal> meninges during adjustments. /J Am Med Assoc/ 1955; 159: 809.> 8. Ford FR, D. Thrombosis of the basilar artery with> softenings in the cerebellum and brain stem due to> manipulation of the neck; a report of two cases with one> post-mortem examination, reasons are given to prove that> damage to the vertebral arteries is responsible. /Bull s> Hopkins Hosp/ 1956; 98: 37–42.> 9. RA, Estridge MN. Neurologic complications of head and> neck manipulations. /JAMA/ 1962; 182: 528–31.> 10. Lorenz R, Vogelsang HG. Thrombosis of the basilar artery> following chiropractic manipulation of the cervical spine.> [in German] Thrombose der arteria basilaris nach> chiropraktischen Manipulationen an der Halbwirbelsäule.> /Dtsch Med Wochenschr/ 1972; 97: 36–43.> 11. Schmitt HP. Rupturen und Thrombosen der Arteria vertebralis> nach gedeckten mechanischen Insulten. /Schweiz Arch Neurol> Neurochir Psychiatry/ 1976; 119: 363–79.> 12. Krueger BR, Okazaki H. Vertebral-basilar distribution> infarction following chiropractic cervical manipulation.> /Mayo Clin Proc/ 1980; 55: 322–32.> 13. Sherman DG, Hart RG, Easton JD. Abrupt change in head> position and cerebral infarction. /Stroke/ 1981; 12: 2–6.> 14. Ali Cherif A, Delpuech F, Habib M, Salamon G, Khalil R.> Thrombose vertebro-basilaire apres manipulation du rachis> cervical. A propos de deux cas. /Ann de Med Phys/ 1983; 25:> 459–65.> 15. Nielsen AA. Cerebrovascular insults caused by manipulation> of the cervical spine. [in Danish]. /Ugeskr Laeger/ 1984;> 146: 3267–70.> 16. Zak SM, Carmody RF. Cerebellar infarction from chiropractic> neck manipulation: case report and review of the literature.> /Ariz Med/ 1984; 41: 333–7.> 17. Modde PJ. /Chiropractic Malpractice/. Columbia, land:> Hanrow Press. 1985: 269–70, 273–5, 311–8, 322–3, 329–31, 334–7.> 18. Jentzen JM, Amatuzio J, GF. Complications of> cervical manipulation: a case report of fatal brainstem> infarct with review of the mechanisms and predisposing> factors. /J Forensic Sci/ 1987; 32: 1089–94.> 19. Mas JL, Henin D, Bousser MG, Chain F, Haw JJ. Dissecting> aneurysm of the vertebral artery and cervical manipulation:> a case report with autopsy. /Neurology/ 1989; 39: 512–5.> 20. Sherman MR, Smialek JE, Zane WE. Pathogenesis of vertebral> artery occlusion following cervical spine manipulation.> /Arch Pathol Lab Med/ 1987; 111: 851–3.> 21. Raskind R, North CM. Vertebral artery injuries following> chiropractic cervical spine manipulation--case reports.> /Angiology/ 1990; 41: 445–52.> 22. Sullivan EC. Brain stem stroke syndromes from cervical> adjustments. Report on five cases. /J Chiropr Res Clin> Invest/ 1992; 8: 12–6.> 23. Haynes MJ. Stroke following cervical manipulation in Perth.> /Chiropr J Aust/ 1994; 24: 42–6.> 24. s M, Bohl J, Thömke F, Kallen K-J, Mahlzahn K, Wandel> E. Dissection of the internal carotid artery after> chiropractic manipulation of the neck. /Neurology/ 1995; 45:> 2284–6.> 25. Klougart N, Leboeuf-Yde C, Rasmussen LR. Safety in> chiropractic practice. Part I. The occurrence of> cerebrovascular accidents after manipulation to the neck in> Denmark from 1978–1988. /J Manipulative Physiol Ther/ 1996;> 19: 371–7.> 26. Haldeman S, Kohlbeck FJ, McGregor M. Unpredictability of> cerebrovascular ischemia associated with cervical spine> manipulation. /Spine/ 2002; 27: 49–55.> 27. Dziewas R, Konrad C, Dräger B et al. Cervical artery> dissection – clinical features, risk factors, therapy and> outcome in 126 patients. /J Neurol/ 2003; 250: 1179–84.> 28. Presentation by Dr Preston Long DC to State of Connecticut.> Connecticut State Board of Chiropractic Examiners. Hartford> Connecticut. 25 October 2009.> 29. Anon. What's the harm in going to a chiropractor? /What's> the Harm/ 2009; http://whatstheharm.net/chiropractic.html> (accessed October 2009).> 30. Ernst E. Vascular accidents after neck manipulation: cause> or coincidence? /Int J Clin Pract/ 2009; in press.> 31. Long PH. Stroke and spinal manipulation. /J Quality Health> Care/ 2004; 3: 8–10.> 32. Ernst E. Chiropractic: a critical evaluation. /J Pain> Symptom Manage/ 2008; 35: 544–62.> 33. Stevinson C, Honan W, Cooke B, Ernst E. Neurological> complications of cervical spine manipulation. /J Roy Soc> Med/ 2001; 94: 107–10.> 34. Ernst E. Cerebrovascular complications associated with> spinal manipulation. /Phys Ther Rev/ 2004; 9: 5–15.> 35. Terrett AGJ. /Current Concepts in Vertebrobasilar> Complications following Spinal Manipulation/, 2nd edn. Des> Moines: JCMIC Group, 2001.> 36. Di Fabio RP. Manipulation of the cervical spine: risks and> benefits. /Physical Ther/ 1999; 79: 50–65.> 37. Alcantara J, Ohm J, Kunz D. The safety and effectiveness of> pediatric chiropractic: a survey of chiropractors and> parents in a practice-based research network. /Explore (NY)/> 2009; 5: 290–5.> 38. Sweeney A, Doody C Manual therapy for the cervical spine and> reported adverse effects: a survey of Irish Manipulative> Physiotherapists. /Man Ther/ 2010; 15: 32–6.>> Int J Clin Pract. 2010;64(10):1162-1165. © 2010 Blackwell Publishing>>> Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 11, 2011 Report Share Posted July 11, 2011 Thanks Vern! This is also my understanding of the research. This so-called science article about Chiro deaths is almost a year old and is NOT good science. I am sadden that several Docs on this list are misinformed and ready to submit and give up one of our most powerful tools! Certainly, any powerful tool must be used with the upmost care and applied with a high level of skill and respect. The lesson from the tragic case of one of our member's grandfather speaks to this. The Chiro care this older gentle received may have contributed to his other wise long and active life. M Kalb MS DCAuthor of Winning at Aging Wellness Chiropractor and Health Coachwww.DrKalb.com 541.488.3001 On Jul 8, 2011, at 9:26 PM, Vern Saboe wrote:  I am also in favor of informed consent both written and verbal documented in the chart. With that said would have informed consent have saved your grandfather? How is it that it was both the cervical adjustment and the lumbar roll that likely killed your grandfather. What would you have expected the doctor to have told your grandfather prior to performing a high velocity adjustment? This may cause a vertebral artery dissection and you may die? Considering the myriad of systematic reviews of the literature not the least of which was the recent (2008) 10 year (2000-2010) Bone and Joint Decade...Task Force on Neck Pain and Its Associated Disorders findings that validate the rarity of this occurrence. This review of 31, 878 citations (Haldeman and coworkers) found an association between chiropractic treatment and subsequent vertebrobasilar artery stroke in persons under the age of 45. However, the same association was found in patients visiting a general practitioner of medicine? We must inform patients of any "material risks" currently I don't believe the scientific evidence supports vertebral artery stroke secondary to SMT as such since the incidence is so very remote.....when the dentist injects you with that local anesthetic have any of you ever had the doctor discuss the fact that you could have an unforseen, non-predictable anaphylactic reaction and die? Or when the medics prescribe the various medications do you believe they also inform the patient of such verbally? Recall the conclusion that started this discussion from the paper (toliet) by Ernst that the benefits of spinal manipulation do not out weight the risks....crapola. Lastly, could not have been the case that your beloved grandfather presented to the chiropractor with neck pain low back pain because especially considering his health was in the process of stroke having pain due to a dissection in progress? To quote Haldeman relative to the cervical spine and verterbral arteries..."This is likely explained by patients with vertebrobasilar artery dissection-related neck pain or headache seeking care before having their stroke." ....any way I understand what you are saying and agree about informed consent but I do not agree that we need to tell our patients oh by the way this could kill you! How I handle the issue of stroke and informed consent is that stroke is referred to as a extremely rare occurence in my written informed consent but during my verbal communication PAR Conf. in the room with the new patient I inform them that research shows that you have a 300 to 400 greater chance of a serious side effect to taking an NSAID such as Advil than you have with anything I will be doing. Just two cents, Vern Saboe Chiropractic deaths Docs:I especially like their "Conclusion."Lyndon McGill, D.C.Salem, Oregonwww.SalemSpineClinic.comwww.EvolvingDaily.com <Wiley_pub2-logo-2lines.gif> Deaths after Chiropractic: A Review of Published Cases E. Ernst Posted: 08/30/2010; Int J Clin Pract. 2010;64(10):1162-1165. © 2010 Blackwell Publishing Abstract and Introduction Abstract Objective: The aim of this study was to summarise all cases in which chiropractic spinal manipulation was followed by death.Design: This study is a systematic review of case reports.Methods: Literature searches in four electronic databases with no restrictions of time or language.Main outcome measure: Death.Results: Twenty six fatalities were published in the medical literature and many more might have remained unpublished. The alleged pathology usually was a vascular accident involving the dissection of a vertebral artery.Conclusion: Numerous deaths have occurred after chiropractic manipulations. The risks of this treatment by far outweigh its benefit. Introduction Vascular accidents after upper spinal manipulation are a well-recognised problem (e.g.[1,2]). Dissection of a vertebral artery, caused by extension and rotation of the neck beyond the physiological range of motion, is thought to be the underlying mechanism.[2] Several deaths have been reported as a consequence. Some proponents of chiropractic seem to believe that the critical evaluation of this evidence amounts to a 'scare story' (Chairman of the UK General Chiropractic Council)[3] or to 'puffing up (the evidence) out of all proportion' (President of the British Chiropractic Association).[4] A responsible approach to serious therapeutic risks, however, requires an open discussion of the facts. In this review, I aimed to provide the basis for such a discussion by summarising all fatalities which occurred after chiropractic spinal manipulation and were published in the medical literature. Methods Electronic searches were conducted in the following electronic databases: Medline, Embase, AMED, Cochrane Library (September 2009). No restrictions of time or language were applied. Search terms were chiropractic, spinal manipulation, vascular accidents, stroke, death and fatality. In addition, our own departmental files and the bibliographies of the articles thus located were searched. Several experts were also contacted for further data. Case reports were included if they provided information on human patients who had died after receiving one or more treatments from a chiropractor. Data were extracted from the included articles according to predefined criteria (Table 1). Table 1. Published case reports of deaths after chiropractic treatments References Year of publication Victim Type of vascular accident Time between treatment and death Anon[5] 1934 Woman, age unknown Tear in left lateral sinus 2 weeks Pratt- and Berger[6] 1947 32-year-old man Thrombosis of basilar, left anterior-inferior cerebellar and right posterior-inferior arteries 24 h Pratt- and Berger[6] 1947 35-year-old woman Thrombosis of posterior-inferior cerebellar artery 10 h Anon[7] 1955 Woman, age unknown Intra-spinal bleeding and compression of spinal cord 18 h Ford and [8] 1956 37-year-old man Thrombosis of basilar, left-posterior cerebellar and left-posterior cerebral arteries 6 h Ford and [8] 1956 No information provided Thrombosis of basilar artery No information provided and Estridge[9] 1962 33-year-old woman Infarct of cerebellar and brainstem 3 days Lorenz and Vogelsang[10] 1972 39-year-old woman Thrombosis of basilar artery 58 days Schmitt[11] 1976 35-years-old woman Infarct of brainstem 1 h Krueger and Okazaki[12] 1980 25-year-old man Infarct of brainstem and cerebellum 48 h Sherman et al.[13] 1981 60-year-old woman Dissection of vertebral artery 4 days Ali Cherif et al.[14] 1983 51-year-old man Infarct of medulla oblongata 11 days Nielsen[15] 1984 34-year-old man Dissection of vertebral artery aneurysen 3 h Zak and Carmody[16] 1984 53-year-old man Left vertebral, posterior-inferior and superior cerebellar artery occlusion; cerebellar infarction 27 days Modde[17] 1985 26-year-old woman Dissection of vertebral artery 1 day Jentzen et al.[18] 1987 51-year-old man Infarct of cerebellum and brainstem No information provided Sherman et al.[20] 1987 37-year-old man Infarct of brainstem 3 days Mas et al.[19] 1989 35-year-old woman Dissecting aneurysm of vertebral artery 16 h Raskind and North[21] 1990 47-year-old woman Cerebellar haemorrheae No information provided Sullivan[22] 1992 41-year-old woman Haemorrhage in ventricular system 8 h Haynes[23] 1994 36-year-old woman Dissecting aneurysm of vertebral artery, thrombo-embolism No information provided s et al.[24] 1995 29-year-old woman Infarct of right hemisphere 3 days Klougart et al.[25] 1996 34-year-old man Unclear Few hours Haldeman et al.[26] 2002 Previously unpublished legal cases No information provided No information provided Haldeman et al.[26] 2002 Previously unpublished legal cases No information provided No information provided Dziewas et al.[27] 2003 No information provided No information provided No information provided Results Twenty-six fatalities were published since 1934 in 23 articles (Table 1).[5–27] Table 1. Published case reports of deaths after chiropractic treatments References Year of publication Victim Type of vascular accident Time between treatment and death Anon[5] 1934 Woman, age unknown Tear in left lateral sinus 2 weeks Pratt- and Berger[6] 1947 32-year-old man Thrombosis of basilar, left anterior-inferior cerebellar and right posterior-inferior arteries 24 h Pratt- and Berger[6] 1947 35-year-old woman Thrombosis of posterior-inferior cerebellar artery 10 h Anon[7] 1955 Woman, age unknown Intra-spinal bleeding and compression of spinal cord 18 h Ford and [8] 1956 37-year-old man Thrombosis of basilar, left-posterior cerebellar and left-posterior cerebral arteries 6 h Ford and [8] 1956 No information provided Thrombosis of basilar artery No information provided and Estridge[9] 1962 33-year-old woman Infarct of cerebellar and brainstem 3 days Lorenz and Vogelsang[10] 1972 39-year-old woman Thrombosis of basilar artery 58 days Schmitt[11] 1976 35-years-old woman Infarct of brainstem 1 h Krueger and Okazaki[12] 1980 25-year-old man Infarct of brainstem and cerebellum 48 h Sherman et al.[13] 1981 60-year-old woman Dissection of vertebral artery 4 days Ali Cherif et al.[14] 1983 51-year-old man Infarct of medulla oblongata 11 days Nielsen[15] 1984 34-year-old man Dissection of vertebral artery aneurysen 3 h Zak and Carmody[16] 1984 53-year-old man Left vertebral, posterior-inferior and superior cerebellar artery occlusion; cerebellar infarction 27 days Modde[17] 1985 26-year-old woman Dissection of vertebral artery 1 day Jentzen et al.[18] 1987 51-year-old man Infarct of cerebellum and brainstem No information provided Sherman et al.[20] 1987 37-year-old man Infarct of brainstem 3 days Mas et al.[19] 1989 35-year-old woman Dissecting aneurysm of vertebral artery 16 h Raskind and North[21] 1990 47-year-old woman Cerebellar haemorrheae No information provided Sullivan[22] 1992 41-year-old woman Haemorrhage in ventricular system 8 h Haynes[23] 1994 36-year-old woman Dissecting aneurysm of vertebral artery, thrombo-embolism No information provided s et al.[24] 1995 29-year-old woman Infarct of right hemisphere 3 days Klougart et al.[25] 1996 34-year-old man Unclear Few hours Haldeman et al.[26] 2002 Previously unpublished legal cases No information provided No information provided Haldeman et al.[26] 2002 Previously unpublished legal cases No information provided No information provided Dziewas et al.[27] 2003 No information provided No information provided No information provided Most of the victims were relatively young; 14 were below the age of 40. There was a slight majority of female patients. The type of complication associated with death frequently related to a vascular accident leading to thrombosis and cerebral infarction. The time between treatment and death ranged from 1 h to 58 days; in 10 cases, it was 1 day or less. Unfortunately, the published information was often incomplete. Many other fatalities seem to have remained unpublished. For instance, the testimony of the chiropractor Preston Long for a court in Connecticut recently listed the family names of nine victims: Mathiason, Solsbury, Mc Cornick, Venegas, Bedenbaugh, , Fawcett, Parisien, Standt. Long also states that 'many others [are] unknown hidden behind legal agreements of silence'.[28] A website names further North American fatalities: Epping (California), G. Fowden (Utah), Grainger (Alberta), Hoffman (land), Renate Dora Labonte (Ontario), (California), Pereyra (Connecticut), A. Roth (Ontario) and Lee Strohecker (Pennsylvania).[29] Discussion This systematic review demonstrates that numerous deaths have been associated with chiropractic. Usually high-velocity, short-lever thrusts of the upper spine with rotation are implicated. They are believed to cause vertebral arterial dissection in predisposed individuals which, in turn, can lead to a chain of events including stroke and death.[1,2,26,30] Many chiropractors claim that, because arterial dissection can also occur spontaneously, causality between the chiropractic intervention and arterial dissection is not proven. However, when carefully evaluating the known facts, one does arrive at the conclusion that causality is at least likely (e.g.[30,31]). Even if it were merely a remote possibility, the precautionary principle in healthcare would mean that neck manipulations should be considered unsafe until proven otherwise. Moreover, there is no good evidence for assuming that neck manipulation is an effective therapy for any medical condition.[32] Thus, the risk-benefit balance for chiropractic neck manipulation fails to be positive. Reliable estimates of the frequency of vascular accidents are prevented by the fact that under-reporting is known to be substantial. In a survey of UK neurologists, for instance, under-reporting of serious complications was 100%.[33] Those cases which are published often turn out to be incomplete. Of 40 case reports of serious adverse effects associated with spinal manipulation, nine failed to provide any information about the clinical outcome.[34] Incomplete reporting of outcomes might therefore further increase the true number of fatalities. Obviously, the present article is not aimed at providing incidence figures; this would require a different methodology entirely. To date, no reliable incidence data are available. This review is focussed on deaths after chiropractic, yet neck manipulations are, of course, used by other healthcare professionals as well. The reason for this focus is simple: chiropractors are more frequently associated with serious manipulation-related adverse effects than osteopaths, physiotherapists, doctors or other professionals. Of the 40 cases of serious adverse effects mentioned above, 28 can be traced back to a chiropractor and none to an osteopath.[34] A review of complications after spinal manipulations by any type of healthcare professional included three deaths related to osteopaths, nine to medical practitioners, none to a physiotherapist, one to a naturopath and 17 to chiropractors.[35] This article also summarised a total of 265 vascular accidents of which 142 were linked to chiropractors. Another review of complications after neck manipulations published by 1997 included 177 vascular accidents, 32 of which were fatal. The vast majority of these cases were associated with chiropractic and none with physiotherapy.[36] The most obvious explanation for the dominance of chiropractic is that chiropractors routinely employ high-velocity, short-lever thrusts on the upper spine with a rotational element, while the other healthcare professionals use them much more sparingly.[37,38] In conclusion, numerous deaths have been associated with chiropractic neck manipulations. There are reasons to suspect that under-reporting is substantial and reliable incidence figures do not exist. The risks of chiropractic neck manipulations by far outweigh their benefits. Healthcare professionals should advise the public accordingly. Sidebar What's Known Chiropractic upper spinal manipulation has repeatedly been associated with arterial dissection followed by stroke and, in some cases, death. What's New The article is the first systematic review of all fatalities reported in the medical literature. Twenty-six deaths are on record and many more seem to have remained unpublished. References Ernst E. Adverse effects of spinal manipulation: a systematic review. J R Soc Med 2007; 100: 330–8. Leon- A, Cuetter A, Ferrer G. Cervical spine manipulation: an alternative medical procedure with potentially fatal complications. South Med J 2007; 100: 201–3. Dixon P. Letter to the Editor. Adverse effects of spinal manipulation. J R Soc Med 2007; 100: 444. BJ. Letter to the Editor. Adverse effects of spinal manipulation. J R Soc Med 2007; 100: 444. Anon. Medicolegal. Malpractice: death resulting from chiropractic treatment for headache. J Am Med Assoc 1934; 103:1260, 1935; 105:1712–4, 1937; 109:233–4. Pratt- HR, Berger KE. Cerebellar and spinal injuries after chiropractic manipulation. J Am Med Assoc 1947; 133: 600–3. Anon. Medicolegal abstracts. Chiropractors: injury to spinal meninges during adjustments. J Am Med Assoc 1955; 159: 809. Ford FR, D. Thrombosis of the basilar artery with softenings in the cerebellum and brain stem due to manipulation of the neck; a report of two cases with one post-mortem examination, reasons are given to prove that damage to the vertebral arteries is responsible. Bull s Hopkins Hosp 1956; 98: 37–42. RA, Estridge MN. Neurologic complications of head and neck manipulations. JAMA 1962; 182: 528–31. Lorenz R, Vogelsang HG. Thrombosis of the basilar artery following chiropractic manipulation of the cervical spine. [in German] Thrombose der arteria basilaris nach chiropraktischen Manipulationen an der Halbwirbelsäule. Dtsch Med Wochenschr 1972; 97: 36–43. Schmitt HP. Rupturen und Thrombosen der Arteria vertebralis nach gedeckten mechanischen Insulten. Schweiz Arch Neurol Neurochir Psychiatry 1976; 119: 363–79. Krueger BR, Okazaki H. Vertebral-basilar distribution infarction following chiropractic cervical manipulation. Mayo Clin Proc 1980; 55: 322–32. Sherman DG, Hart RG, Easton JD. Abrupt change in head position and cerebral infarction. Stroke 1981; 12: 2–6. Ali Cherif A, Delpuech F, Habib M, Salamon G, Khalil R. Thrombose vertebro-basilaire apres manipulation du rachis cervical. A propos de deux cas. Ann de Med Phys 1983; 25: 459–65. Nielsen AA. Cerebrovascular insults caused by manipulation of the cervical spine. [in Danish]. Ugeskr Laeger 1984; 146: 3267–70. Zak SM, Carmody RF. Cerebellar infarction from chiropractic neck manipulation: case report and review of the literature. Ariz Med 1984; 41: 333–7. Modde PJ. Chiropractic Malpractice. Columbia, land: Hanrow Press. 1985: 269–70, 273–5, 311–8, 322–3, 329–31, 334–7. Jentzen JM, Amatuzio J, GF. Complications of cervical manipulation: a case report of fatal brainstem infarct with review of the mechanisms and predisposing factors. J Forensic Sci 1987; 32: 1089–94. Mas JL, Henin D, Bousser MG, Chain F, Haw JJ. Dissecting aneurysm of the vertebral artery and cervical manipulation: a case report with autopsy. Neurology 1989; 39: 512–5. Sherman MR, Smialek JE, Zane WE. Pathogenesis of vertebral artery occlusion following cervical spine manipulation. Arch Pathol Lab Med 1987; 111: 851–3. Raskind R, North CM. Vertebral artery injuries following chiropractic cervical spine manipulation--case reports. Angiology 1990; 41: 445–52. Sullivan EC. Brain stem stroke syndromes from cervical adjustments. Report on five cases. J Chiropr Res Clin Invest 1992; 8: 12–6. Haynes MJ. Stroke following cervical manipulation in Perth. Chiropr J Aust 1994; 24: 42–6. s M, Bohl J, Thömke F, Kallen K-J, Mahlzahn K, Wandel E. Dissection of the internal carotid artery after chiropractic manipulation of the neck. Neurology 1995; 45: 2284–6. Klougart N, Leboeuf-Yde C, Rasmussen LR. Safety in chiropractic practice. Part I. The occurrence of cerebrovascular accidents after manipulation to the neck in Denmark from 1978–1988. J Manipulative Physiol Ther 1996; 19: 371–7. Haldeman S, Kohlbeck FJ, McGregor M. Unpredictability of cerebrovascular ischemia associated with cervical spine manipulation. Spine 2002; 27: 49–55. Dziewas R, Konrad C, Dräger B et al. Cervical artery dissection – clinical features, risk factors, therapy and outcome in 126 patients. J Neurol 2003; 250: 1179–84. Presentation by Dr Preston Long DC to State of Connecticut. Connecticut State Board of Chiropractic Examiners. Hartford Connecticut. 25 October 2009. Anon. What's the harm in going to a chiropractor? What's the Harm 2009; http://whatstheharm.net/chiropractic.html (accessed October 2009). Ernst E. Vascular accidents after neck manipulation: cause or coincidence? Int J Clin Pract 2009; in press. Long PH. Stroke and spinal manipulation. J Quality Health Care 2004; 3: 8–10. Ernst E. Chiropractic: a critical evaluation. J Pain Symptom Manage 2008; 35: 544–62. Stevinson C, Honan W, Cooke B, Ernst E. Neurological complications of cervical spine manipulation. J Roy Soc Med 2001; 94: 107–10. Ernst E. Cerebrovascular complications associated with spinal manipulation. Phys Ther Rev 2004; 9: 5–15. Terrett AGJ. Current Concepts in Vertebrobasilar Complications following Spinal Manipulation, 2nd edn. Des Moines: JCMIC Group, 2001. Di Fabio RP. Manipulation of the cervical spine: risks and benefits. Physical Ther 1999; 79: 50–65. Alcantara J, Ohm J, Kunz D. The safety and effectiveness of pediatric chiropractic: a survey of chiropractors and parents in a practice-based research network. Explore (NY) 2009; 5: 290–5. Sweeney A, Doody C Manual therapy for the cervical spine and reported adverse effects: a survey of Irish Manipulative Physiotherapists. Man Ther 2010; 15: 32–6. Int J Clin Pract. 2010;64(10):1162-1165. © 2010 Blackwell Publishing Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 11, 2011 Report Share Posted July 11, 2011  Minga, Thank you for sharing this deeply personal experience of your grandfather's death. It shows your great personal strength to continue in school and to have the practice you do. It is also a valuable teach to us al. Thank you. Christian Mathisen, DC, CCWFN 3654 S Pacific Hwy Medford, OR 97501 cmathdc@... Chiropractic deaths Docs:I especially like their "Conclusion."Lyndon McGill, D.C.Salem, Oregonwww.SalemSpineClinic.comwww.EvolvingDaily.com Deaths after Chiropractic: A Review of Published Cases E. Ernst Posted: 08/30/2010; Int J Clin Pract. 2010;64(10):1162-1165. © 2010 Blackwell Publishing Abstract and Introduction Abstract Objective: The aim of this study was to summarise all cases in which chiropractic spinal manipulation was followed by death.Design: This study is a systematic review of case reports.Methods: Literature searches in four electronic databases with no restrictions of time or language.Main outcome measure: Death.Results: Twenty six fatalities were published in the medical literature and many more might have remained unpublished. The alleged pathology usually was a vascular accident involving the dissection of a vertebral artery.Conclusion: Numerous deaths have occurred after chiropractic manipulations. The risks of this treatment by far outweigh its benefit. Introduction Vascular accidents after upper spinal manipulation are a well-recognised problem (e.g.[1,2]). Dissection of a vertebral artery, caused by extension and rotation of the neck beyond the physiological range of motion, is thought to be the underlying mechanism.[2] Several deaths have been reported as a consequence. Some proponents of chiropractic seem to believe that the critical evaluation of this evidence amounts to a 'scare story' (Chairman of the UK General Chiropractic Council)[3] or to 'puffing up (the evidence) out of all proportion' (President of the British Chiropractic Association).[4] A responsible approach to serious therapeutic risks, however, requires an open discussion of the facts. In this review, I aimed to provide the basis for such a discussion by summarising all fatalities which occurred after chiropractic spinal manipulation and were published in the medical literature. Methods Electronic searches were conducted in the following electronic databases: Medline, Embase, AMED, Cochrane Library (September 2009). No restrictions of time or language were applied. Search terms were chiropractic, spinal manipulation, vascular accidents, stroke, death and fatality. In addition, our own departmental files and the bibliographies of the articles thus located were searched. Several experts were also contacted for further data. Case reports were included if they provided information on human patients who had died after receiving one or more treatments from a chiropractor. Data were extracted from the included articles according to predefined criteria (Table 1). Table 1. Published case reports of deaths after chiropractic treatments References Year of publication Victim Type of vascular accident Time between treatment and death Anon[5] 1934 Woman, age unknown Tear in left lateral sinus 2 weeks Pratt- and Berger[6] 1947 32-year-old man Thrombosis of basilar, left anterior-inferior cerebellar and right posterior-inferior arteries 24 h Pratt- and Berger[6] 1947 35-year-old woman Thrombosis of posterior-inferior cerebellar artery 10 h Anon[7] 1955 Woman, age unknown Intra-spinal bleeding and compression of spinal cord 18 h Ford and [8] 1956 37-year-old man Thrombosis of basilar, left-posterior cerebellar and left-posterior cerebral arteries 6 h Ford and [8] 1956 No information provided Thrombosis of basilar artery No information provided and Estridge[9] 1962 33-year-old woman Infarct of cerebellar and brainstem 3 days Lorenz and Vogelsang[10] 1972 39-year-old woman Thrombosis of basilar artery 58 days Schmitt[11] 1976 35-years-old woman Infarct of brainstem 1 h Krueger and Okazaki[12] 1980 25-year-old man Infarct of brainstem and cerebellum 48 h Sherman et al.[13] 1981 60-year-old woman Dissection of vertebral artery 4 days Ali Cherif et al.[14] 1983 51-year-old man Infarct of medulla oblongata 11 days Nielsen[15] 1984 34-year-old man Dissection of vertebral artery aneurysen 3 h Zak and Carmody[16] 1984 53-year-old man Left vertebral, posterior-inferior and superior cerebellar artery occlusion; cerebellar infarction 27 days Modde[17] 1985 26-year-old woman Dissection of vertebral artery 1 day Jentzen et al.[18] 1987 51-year-old man Infarct of cerebellum and brainstem No information provided Sherman et al.[20] 1987 37-year-old man Infarct of brainstem 3 days Mas et al.[19] 1989 35-year-old woman Dissecting aneurysm of vertebral artery 16 h Raskind and North[21] 1990 47-year-old woman Cerebellar haemorrheae No information provided Sullivan[22] 1992 41-year-old woman Haemorrhage in ventricular system 8 h Haynes[23] 1994 36-year-old woman Dissecting aneurysm of vertebral artery, thrombo-embolism No information provided s et al.[24] 1995 29-year-old woman Infarct of right hemisphere 3 days Klougart et al.[25] 1996 34-year-old man Unclear Few hours Haldeman et al.[26] 2002 Previously unpublished legal cases No information provided No information provided Haldeman et al.[26] 2002 Previously unpublished legal cases No information provided No information provided Dziewas et al.[27] 2003 No information provided No information provided No information provided Results Twenty-six fatalities were published since 1934 in 23 articles (Table 1).[5–27] Table 1. Published case reports of deaths after chiropractic treatments References Year of publication Victim Type of vascular accident Time between treatment and death Anon[5] 1934 Woman, age unknown Tear in left lateral sinus 2 weeks Pratt- and Berger[6] 1947 32-year-old man Thrombosis of basilar, left anterior-inferior cerebellar and right posterior-inferior arteries 24 h Pratt- and Berger[6] 1947 35-year-old woman Thrombosis of posterior-inferior cerebellar artery 10 h Anon[7] 1955 Woman, age unknown Intra-spinal bleeding and compression of spinal cord 18 h Ford and [8] 1956 37-year-old man Thrombosis of basilar, left-posterior cerebellar and left-posterior cerebral arteries 6 h Ford and [8] 1956 No information provided Thrombosis of basilar artery No information provided and Estridge[9] 1962 33-year-old woman Infarct of cerebellar and brainstem 3 days Lorenz and Vogelsang[10] 1972 39-year-old woman Thrombosis of basilar artery 58 days Schmitt[11] 1976 35-years-old woman Infarct of brainstem 1 h Krueger and Okazaki[12] 1980 25-year-old man Infarct of brainstem and cerebellum 48 h Sherman et al.[13] 1981 60-year-old woman Dissection of vertebral artery 4 days Ali Cherif et al.[14] 1983 51-year-old man Infarct of medulla oblongata 11 days Nielsen[15] 1984 34-year-old man Dissection of vertebral artery aneurysen 3 h Zak and Carmody[16] 1984 53-year-old man Left vertebral, posterior-inferior and superior cerebellar artery occlusion; cerebellar infarction 27 days Modde[17] 1985 26-year-old woman Dissection of vertebral artery 1 day Jentzen et al.[18] 1987 51-year-old man Infarct of cerebellum and brainstem No information provided Sherman et al.[20] 1987 37-year-old man Infarct of brainstem 3 days Mas et al.[19] 1989 35-year-old woman Dissecting aneurysm of vertebral artery 16 h Raskind and North[21] 1990 47-year-old woman Cerebellar haemorrheae No information provided Sullivan[22] 1992 41-year-old woman Haemorrhage in ventricular system 8 h Haynes[23] 1994 36-year-old woman Dissecting aneurysm of vertebral artery, thrombo-embolism No information provided s et al.[24] 1995 29-year-old woman Infarct of right hemisphere 3 days Klougart et al.[25] 1996 34-year-old man Unclear Few hours Haldeman et al.[26] 2002 Previously unpublished legal cases No information provided No information provided Haldeman et al.[26] 2002 Previously unpublished legal cases No information provided No information provided Dziewas et al.[27] 2003 No information provided No information provided No information provided Most of the victims were relatively young; 14 were below the age of 40. There was a slight majority of female patients. The type of complication associated with death frequently related to a vascular accident leading to thrombosis and cerebral infarction. The time between treatment and death ranged from 1 h to 58 days; in 10 cases, it was 1 day or less. Unfortunately, the published information was often incomplete. Many other fatalities seem to have remained unpublished. For instance, the testimony of the chiropractor Preston Long for a court in Connecticut recently listed the family names of nine victims: Mathiason, Solsbury, Mc Cornick, Venegas, Bedenbaugh, , Fawcett, Parisien, Standt. Long also states that 'many others [are] unknown hidden behind legal agreements of silence'.[28] A website names further North American fatalities: Epping (California), G. Fowden (Utah), Grainger (Alberta), Hoffman (land), Renate Dora Labonte (Ontario), (California), Pereyra (Connecticut), A. Roth (Ontario) and Lee Strohecker (Pennsylvania).[29] Discussion This systematic review demonstrates that numerous deaths have been associated with chiropractic. Usually high-velocity, short-lever thrusts of the upper spine with rotation are implicated. They are believed to cause vertebral arterial dissection in predisposed individuals which, in turn, can lead to a chain of events including stroke and death.[1,2,26,30] Many chiropractors claim that, because arterial dissection can also occur spontaneously, causality between the chiropractic intervention and arterial dissection is not proven. However, when carefully evaluating the known facts, one does arrive at the conclusion that causality is at least likely (e.g.[30,31]). Even if it were merely a remote possibility, the precautionary principle in healthcare would mean that neck manipulations should be considered unsafe until proven otherwise. Moreover, there is no good evidence for assuming that neck manipulation is an effective therapy for any medical condition.[32] Thus, the risk-benefit balance for chiropractic neck manipulation fails to be positive. Reliable estimates of the frequency of vascular accidents are prevented by the fact that under-reporting is known to be substantial. In a survey of UK neurologists, for instance, under-reporting of serious complications was 100%.[33] Those cases which are published often turn out to be incomplete. Of 40 case reports of serious adverse effects associated with spinal manipulation, nine failed to provide any information about the clinical outcome.[34] Incomplete reporting of outcomes might therefore further increase the true number of fatalities. Obviously, the present article is not aimed at providing incidence figures; this would require a different methodology entirely. To date, no reliable incidence data are available. This review is focussed on deaths after chiropractic, yet neck manipulations are, of course, used by other healthcare professionals as well. The reason for this focus is simple: chiropractors are more frequently associated with serious manipulation-related adverse effects than osteopaths, physiotherapists, doctors or other professionals. Of the 40 cases of serious adverse effects mentioned above, 28 can be traced back to a chiropractor and none to an osteopath.[34] A review of complications after spinal manipulations by any type of healthcare professional included three deaths related to osteopaths, nine to medical practitioners, none to a physiotherapist, one to a naturopath and 17 to chiropractors.[35] This article also summarised a total of 265 vascular accidents of which 142 were linked to chiropractors. Another review of complications after neck manipulations published by 1997 included 177 vascular accidents, 32 of which were fatal. The vast majority of these cases were associated with chiropractic and none with physiotherapy.[36] The most obvious explanation for the dominance of chiropractic is that chiropractors routinely employ high-velocity, short-lever thrusts on the upper spine with a rotational element, while the other healthcare professionals use them much more sparingly.[37,38] In conclusion, numerous deaths have been associated with chiropractic neck manipulations. There are reasons to suspect that under-reporting is substantial and reliable incidence figures do not exist. The risks of chiropractic neck manipulations by far outweigh their benefits. Healthcare professionals should advise the public accordingly. Sidebar What's Known Chiropractic upper spinal manipulation has repeatedly been associated with arterial dissection followed by stroke and, in some cases, death. What's New The article is the first systematic review of all fatalities reported in the medical literature. Twenty-six deaths are on record and many more seem to have remained unpublished. References Ernst E. Adverse effects of spinal manipulation: a systematic review. J R Soc Med 2007; 100: 330–8. Leon- A, Cuetter A, Ferrer G. Cervical spine manipulation: an alternative medical procedure with potentially fatal complications. South Med J 2007; 100: 201–3. Dixon P. Letter to the Editor. Adverse effects of spinal manipulation. J R Soc Med 2007; 100: 444. BJ. Letter to the Editor. Adverse effects of spinal manipulation. J R Soc Med 2007; 100: 444. Anon. Medicolegal. Malpractice: death resulting from chiropractic treatment for headache. J Am Med Assoc 1934; 103:1260, 1935; 105:1712–4, 1937; 109:233–4. Pratt- HR, Berger KE. Cerebellar and spinal injuries after chiropractic manipulation. J Am Med Assoc 1947; 133: 600–3. Anon. Medicolegal abstracts. Chiropractors: injury to spinal meninges during adjustments. J Am Med Assoc 1955; 159: 809. Ford FR, D. Thrombosis of the basilar artery with softenings in the cerebellum and brain stem due to manipulation of the neck; a report of two cases with one post-mortem examination, reasons are given to prove that damage to the vertebral arteries is responsible. Bull s Hopkins Hosp 1956; 98: 37–42. RA, Estridge MN. Neurologic complications of head and neck manipulations. JAMA 1962; 182: 528–31. Lorenz R, Vogelsang HG. Thrombosis of the basilar artery following chiropractic manipulation of the cervical spine. [in German] Thrombose der arteria basilaris nach chiropraktischen Manipulationen an der Halbwirbelsäule. Dtsch Med Wochenschr 1972; 97: 36–43. Schmitt HP. Rupturen und Thrombosen der Arteria vertebralis nach gedeckten mechanischen Insulten. Schweiz Arch Neurol Neurochir Psychiatry 1976; 119: 363–79. Krueger BR, Okazaki H. Vertebral-basilar distribution infarction following chiropractic cervical manipulation. Mayo Clin Proc 1980; 55: 322–32. Sherman DG, Hart RG, Easton JD. Abrupt change in head position and cerebral infarction. Stroke 1981; 12: 2–6. Ali Cherif A, Delpuech F, Habib M, Salamon G, Khalil R. Thrombose vertebro-basilaire apres manipulation du rachis cervical. A propos de deux cas. Ann de Med Phys 1983; 25: 459–65. Nielsen AA. Cerebrovascular insults caused by manipulation of the cervical spine. [in Danish]. Ugeskr Laeger 1984; 146: 3267–70. Zak SM, Carmody RF. Cerebellar infarction from chiropractic neck manipulation: case report and review of the literature. Ariz Med 1984; 41: 333–7. Modde PJ. Chiropractic Malpractice. Columbia, land: Hanrow Press. 1985: 269–70, 273–5, 311–8, 322–3, 329–31, 334–7. Jentzen JM, Amatuzio J, GF. Complications of cervical manipulation: a case report of fatal brainstem infarct with review of the mechanisms and predisposing factors. J Forensic Sci 1987; 32: 1089–94. Mas JL, Henin D, Bousser MG, Chain F, Haw JJ. Dissecting aneurysm of the vertebral artery and cervical manipulation: a case report with autopsy. Neurology 1989; 39: 512–5. Sherman MR, Smialek JE, Zane WE. Pathogenesis of vertebral artery occlusion following cervical spine manipulation. Arch Pathol Lab Med 1987; 111: 851–3. Raskind R, North CM. Vertebral artery injuries following chiropractic cervical spine manipulation--case reports. Angiology 1990; 41: 445–52. Sullivan EC. Brain stem stroke syndromes from cervical adjustments. Report on five cases. J Chiropr Res Clin Invest 1992; 8: 12–6. Haynes MJ. Stroke following cervical manipulation in Perth. Chiropr J Aust 1994; 24: 42–6. s M, Bohl J, Thömke F, Kallen K-J, Mahlzahn K, Wandel E. Dissection of the internal carotid artery after chiropractic manipulation of the neck. Neurology 1995; 45: 2284–6. Klougart N, Leboeuf-Yde C, Rasmussen LR. Safety in chiropractic practice. Part I. The occurrence of cerebrovascular accidents after manipulation to the neck in Denmark from 1978–1988. J Manipulative Physiol Ther 1996; 19: 371–7. Haldeman S, Kohlbeck FJ, McGregor M. Unpredictability of cerebrovascular ischemia associated with cervical spine manipulation. Spine 2002; 27: 49–55. Dziewas R, Konrad C, Dräger B et al. Cervical artery dissection – clinical features, risk factors, therapy and outcome in 126 patients. J Neurol 2003; 250: 1179–84. Presentation by Dr Preston Long DC to State of Connecticut. Connecticut State Board of Chiropractic Examiners. Hartford Connecticut. 25 October 2009. Anon. What's the harm in going to a chiropractor? What's the Harm 2009; http://whatstheharm.net/chiropractic.html (accessed October 2009). Ernst E. Vascular accidents after neck manipulation: cause or coincidence? Int J Clin Pract 2009; in press. Long PH. Stroke and spinal manipulation. J Quality Health Care 2004; 3: 8–10. Ernst E. Chiropractic: a critical evaluation. J Pain Symptom Manage 2008; 35: 544–62. Stevinson C, Honan W, Cooke B, Ernst E. Neurological complications of cervical spine manipulation. J Roy Soc Med 2001; 94: 107–10. Ernst E. Cerebrovascular complications associated with spinal manipulation. Phys Ther Rev 2004; 9: 5–15. Terrett AGJ. Current Concepts in Vertebrobasilar Complications following Spinal Manipulation, 2nd edn. Des Moines: JCMIC Group, 2001. Di Fabio RP. Manipulation of the cervical spine: risks and benefits. Physical Ther 1999; 79: 50–65. Alcantara J, Ohm J, Kunz D. The safety and effectiveness of pediatric chiropractic: a survey of chiropractors and parents in a practice-based research network. Explore (NY) 2009; 5: 290–5. Sweeney A, Doody C Manual therapy for the cervical spine and reported adverse effects: a survey of Irish Manipulative Physiotherapists. Man Ther 2010; 15: 32–6. Int J Clin Pract. 2010;64(10):1162-1165. © 2010 Blackwell Publishing Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 11, 2011 Report Share Posted July 11, 2011 I would say I too support Vern's commentary and way of handling informed consent. I am not ready to throw out HVA because of some junk science that is motivated by the reach for economic gain and raw power. I can respect Minga's concerns but on the other hand I have worked for nearly 30years as a DC. Part of this time was spent in three different very busy chiropractic clinics in three different states and I haves never seen a CVA case yet. They are rare indeed in my experience and according to credible evidence. I will inform the patient accordingly.  And then I will 'adjust the dog out of them '--if x-rays and exam indicate the need. Schneider DCPDXOn Mon, Jul 11, 2011 at 7:45 AM, Kalb <drjohnkalb@...> wrote:  Thanks Vern! This is also my understanding of the research. This so-called science article about Chiro dI eaths is almost a year old and is NOT good science. I am sadden that several Docs on this list are misinformed and ready to submit and give up one of our most powerful tools! Certainly, any powerful tool must be used with the upmost care and applied with a high level of skill and respect. The lesson from the tragic case of one of our member's grandfather speaks to this. The Chiro care this older gentle received may have contributed to his other wise long and active life. M Kalb MS DCAuthor of Winning at Aging  Wellness Chiropractor and Health Coachwww.DrKalb.com  541.488.3001 On Jul 8, 2011, at 9:26 PM, Vern Saboe wrote:   I am also in favor of informed consent both written and verbal documented in the chart. With that said would have informed consent have saved your grandfather? How is it that it was both the cervical adjustment and the lumbar roll that likely killed your grandfather. What would you have expected the doctor to have told your grandfather prior to performing a high velocity adjustment? This may cause a vertebral artery dissection and you may die? Considering the myriad of systematic reviews of the literature not the least of which was the recent (2008) 10 year (2000-2010) Bone and Joint Decade...Task Force on Neck Pain and Its Associated Disorders findings that validate the rarity of this occurrence. This review of 31, 878 citations (Haldeman and coworkers) found an association between chiropractic treatment and subsequent vertebrobasilar artery stroke in persons under the age of 45. However, the same association was found in patients visiting a general practitioner of medicine? We must inform patients of any " material risks " currently I don't believe the scientific evidence supports vertebral artery stroke secondary to SMT as such since the incidence is so very remote.....when the dentist injects you with that local anesthetic have any of you ever had the doctor discuss the fact that you could have an unforseen, non-predictable anaphylactic reaction and die? Or when the medics prescribe the various medications do you believe they also inform the patient of such verbally? Recall the conclusion that started this discussion from the paper (toliet) by Ernst that the benefits of spinal manipulation do not out weight the risks....crapola.  Lastly, could not have been the case that your beloved grandfather presented to the chiropractor with neck pain low back pain because especially considering his health was in the process of stroke having pain due to a dissection in progress? To quote Haldeman relative to the cervical spine and verterbral arteries... " This is likely explained by patients with vertebrobasilar artery dissection-related neck pain or headache seeking care before having their stroke. "   ....any way I understand what you are saying and agree about informed consent but I do not agree that we need to tell our patients oh by the way this could kill you! How I handle the issue of stroke and informed consent is that stroke is referred to as a extremely rare occurence in my written informed consent but during my verbal communication PAR Conf. in the room with the new patient I inform them that research shows that you have a 300 to 400 greater chance of a serious side effect to taking an NSAID such as Advil than you have with anything I will be doing.  Just two cents,  Vern Saboe Chiropractic deaths Docs:I especially like their " Conclusion. " Lyndon McGill, D.C.Salem, Oregonwww.SalemSpineClinic.comwww.EvolvingDaily.com  <Wiley_pub2-logo-2lines.gif> Deaths after Chiropractic: A Review of Published Cases E. Ernst Posted: 08/30/2010; Int J Clin Pract. 2010;64(10):1162-1165. © 2010 Blackwell Publishing Abstract and Introduction Abstract Objective: The aim of this study was to summarise all cases in which chiropractic spinal manipulation was followed by death.Design: This study is a systematic review of case reports.Methods: Literature searches in four electronic databases with no restrictions of time or language.Main outcome measure: Death.Results: Twenty six fatalities were published in the medical literature and many more might have remained unpublished. The alleged pathology usually was a vascular accident involving the dissection of a vertebral artery.Conclusion: Numerous deaths have occurred after chiropractic manipulations. The risks of this treatment by far outweigh its benefit. Introduction Vascular accidents after upper spinal manipulation are a well-recognised problem (e.g.[1,2]). Dissection of a vertebral artery, caused by extension and rotation of the neck beyond the physiological range of motion, is thought to be the underlying mechanism.[2] Several deaths have been reported as a consequence. Some proponents of chiropractic seem to believe that the critical evaluation of this evidence amounts to a 'scare story' (Chairman of the UK General Chiropractic Council)[3] or to 'puffing up (the evidence) out of all proportion' (President of the British Chiropractic Association).[4] A responsible approach to serious therapeutic risks, however, requires an open discussion of the facts. In this review, I aimed to provide the basis for such a discussion by summarising all fatalities which occurred after chiropractic spinal manipulation and were published in the medical literature. Methods Electronic searches were conducted in the following electronic databases: Medline, Embase, AMED, Cochrane Library (September 2009). No restrictions of time or language were applied. Search terms were chiropractic, spinal manipulation, vascular accidents, stroke, death and fatality. In addition, our own departmental files and the bibliographies of the articles thus located were searched. Several experts were also contacted for further data. Case reports were included if they provided information on human patients who had died after receiving one or more treatments from a chiropractor. Data were extracted from the included articles according to predefined criteria (Table 1). Table 1. Published case reports of deaths after chiropractic treatments References Year of publication Victim Type of vascular accident Time between treatment and death Anon[5] 1934 Woman, age unknown Tear in left lateral sinus 2 weeks Pratt- and Berger[6] 1947 32-year-old man Thrombosis of basilar, left anterior-inferior cerebellar and right posterior-inferior arteries 24 h Pratt- and Berger[6] 1947 35-year-old woman Thrombosis of posterior-inferior cerebellar artery 10 h Anon[7] 1955 Woman, age unknown Intra-spinal bleeding and compression of spinal cord 18 h Ford and [8] 1956 37-year-old man Thrombosis of basilar, left-posterior cerebellar and left-posterior cerebral arteries 6 h Ford and [8] 1956 No information provided Thrombosis of basilar artery No information provided and Estridge[9] 1962 33-year-old woman Infarct of cerebellar and brainstem 3 days Lorenz and Vogelsang[10] 1972 39-year-old woman Thrombosis of basilar artery 58 days Schmitt[11] 1976 35-years-old woman Infarct of brainstem 1 h Krueger and Okazaki[12] 1980 25-year-old man Infarct of brainstem and cerebellum 48 h Sherman et al.[13] 1981 60-year-old woman Dissection of vertebral artery 4 days Ali Cherif et al.[14] 1983 51-year-old man Infarct of medulla oblongata 11 days Nielsen[15] 1984 34-year-old man Dissection of vertebral artery aneurysen 3 h Zak and Carmody[16] 1984 53-year-old man Left vertebral, posterior-inferior and superior cerebellar artery occlusion; cerebellar infarction 27 days Modde[17] 1985 26-year-old woman Dissection of vertebral artery 1 day Jentzen et al.[18] 1987 51-year-old man Infarct of cerebellum and brainstem No information provided Sherman et al.[20] 1987 37-year-old man Infarct of brainstem 3 days Mas et al.[19] 1989 35-year-old woman Dissecting aneurysm of vertebral artery 16 h Raskind and North[21] 1990 47-year-old woman Cerebellar haemorrheae No information provided Sullivan[22] 1992 41-year-old woman Haemorrhage in ventricular system 8 h Haynes[23] 1994 36-year-old woman Dissecting aneurysm of vertebral artery, thrombo-embolism No information provided s et al.[24] 1995 29-year-old woman Infarct of right hemisphere 3 days Klougart et al.[25] 1996 34-year-old man Unclear Few hours Haldeman et al.[26] 2002 Previously unpublished legal cases No information provided No information provided Haldeman et al.[26] 2002 Previously unpublished legal cases No information provided No information provided Dziewas et al.[27] 2003 No information provided No information provided No information provided Results Twenty-six fatalities were published since 1934 in 23 articles (Table 1).[5–27] Table 1. Published case reports of deaths after chiropractic treatments References Year of publication Victim Type of vascular accident Time between treatment and death Anon[5] 1934 Woman, age unknown Tear in left lateral sinus 2 weeks Pratt- and Berger[6] 1947 32-year-old man Thrombosis of basilar, left anterior-inferior cerebellar and right posterior-inferior arteries 24 h Pratt- and Berger[6] 1947 35-year-old woman Thrombosis of posterior-inferior cerebellar artery 10 h Anon[7] 1955 Woman, age unknown Intra-spinal bleeding and compression of spinal cord 18 h Ford and [8] 1956 37-year-old man Thrombosis of basilar, left-posterior cerebellar and left-posterior cerebral arteries 6 h Ford and [8] 1956 No information provided Thrombosis of basilar artery No information provided and Estridge[9] 1962 33-year-old woman Infarct of cerebellar and brainstem 3 days Lorenz and Vogelsang[10] 1972 39-year-old woman Thrombosis of basilar artery 58 days Schmitt[11] 1976 35-years-old woman Infarct of brainstem 1 h Krueger and Okazaki[12] 1980 25-year-old man Infarct of brainstem and cerebellum 48 h Sherman et al.[13] 1981 60-year-old woman Dissection of vertebral artery 4 days Ali Cherif et al.[14] 1983 51-year-old man Infarct of medulla oblongata 11 days Nielsen[15] 1984 34-year-old man Dissection of vertebral artery aneurysen 3 h Zak and Carmody[16] 1984 53-year-old man Left vertebral, posterior-inferior and superior cerebellar artery occlusion; cerebellar infarction 27 days Modde[17] 1985 26-year-old woman Dissection of vertebral artery 1 day Jentzen et al.[18] 1987 51-year-old man Infarct of cerebellum and brainstem No information provided Sherman et al.[20] 1987 37-year-old man Infarct of brainstem 3 days Mas et al.[19] 1989 35-year-old woman Dissecting aneurysm of vertebral artery 16 h Raskind and North[21] 1990 47-year-old woman Cerebellar haemorrheae No information provided Sullivan[22] 1992 41-year-old woman Haemorrhage in ventricular system 8 h Haynes[23] 1994 36-year-old woman Dissecting aneurysm of vertebral artery, thrombo-embolism No information provided s et al.[24] 1995 29-year-old woman Infarct of right hemisphere 3 days Klougart et al.[25] 1996 34-year-old man Unclear Few hours Haldeman et al.[26] 2002 Previously unpublished legal cases No information provided No information provided Haldeman et al.[26] 2002 Previously unpublished legal cases No information provided No information provided Dziewas et al.[27] 2003 No information provided No information provided No information provided Most of the victims were relatively young; 14 were below the age of 40. There was a slight majority of female patients. The type of complication associated with death frequently related to a vascular accident leading to thrombosis and cerebral infarction. The time between treatment and death ranged from 1 h to 58 days; in 10 cases, it was 1 day or less. Unfortunately, the published information was often incomplete. Many other fatalities seem to have remained unpublished. For instance, the testimony of the chiropractor Preston Long for a court in Connecticut recently listed the family names of nine victims: Mathiason, Solsbury, Mc Cornick, Venegas, Bedenbaugh, , Fawcett, Parisien, Standt. Long also states that 'many others [are] unknown hidden behind legal agreements of silence'.[28] A website names further North American fatalities: Epping (California), G. Fowden (Utah), Grainger (Alberta), Hoffman (land), Renate Dora Labonte (Ontario), (California), Pereyra (Connecticut), A. Roth (Ontario) and Lee Strohecker (Pennsylvania).[29] Discussion This systematic review demonstrates that numerous deaths have been associated with chiropractic. Usually high-velocity, short-lever thrusts of the upper spine with rotation are implicated. They are believed to cause vertebral arterial dissection in predisposed individuals which, in turn, can lead to a chain of events including stroke and death.[1,2,26,30] Many chiropractors claim that, because arterial dissection can also occur spontaneously, causality between the chiropractic intervention and arterial dissection is not proven. However, when carefully evaluating the known facts, one does arrive at the conclusion that causality is at least likely (e.g.[30,31]). Even if it were merely a remote possibility, the precautionary principle in healthcare would mean that neck manipulations should be considered unsafe until proven otherwise. Moreover, there is no good evidence for assuming that neck manipulation is an effective therapy for any medical condition.[32] Thus, the risk-benefit balance for chiropractic neck manipulation fails to be positive. Reliable estimates of the frequency of vascular accidents are prevented by the fact that under-reporting is known to be substantial. In a survey of UK neurologists, for instance, under-reporting of serious complications was 100%.[33] Those cases which are published often turn out to be incomplete. Of 40 case reports of serious adverse effects associated with spinal manipulation, nine failed to provide any information about the clinical outcome.[34] Incomplete reporting of outcomes might therefore further increase the true number of fatalities. Obviously, the present article is not aimed at providing incidence figures; this would require a different methodology entirely. To date, no reliable incidence data are available. This review is focussed on deaths after chiropractic, yet neck manipulations are, of course, used by other healthcare professionals as well. The reason for this focus is simple: chiropractors are more frequently associated with serious manipulation-related adverse effects than osteopaths, physiotherapists, doctors or other professionals. Of the 40 cases of serious adverse effects mentioned above, 28 can be traced back to a chiropractor and none to an osteopath.[34] A review of complications after spinal manipulations by any type of healthcare professional included three deaths related to osteopaths, nine to medical practitioners, none to a physiotherapist, one to a naturopath and 17 to chiropractors.[35] This article also summarised a total of 265 vascular accidents of which 142 were linked to chiropractors. Another review of complications after neck manipulations published by 1997 included 177 vascular accidents, 32 of which were fatal. The vast majority of these cases were associated with chiropractic and none with physiotherapy.[36] The most obvious explanation for the dominance of chiropractic is that chiropractors routinely employ high-velocity, short-lever thrusts on the upper spine with a rotational element, while the other healthcare professionals use them much more sparingly.[37,38] In conclusion, numerous deaths have been associated with chiropractic neck manipulations. There are reasons to suspect that under-reporting is substantial and reliable incidence figures do not exist. The risks of chiropractic neck manipulations by far outweigh their benefits. Healthcare professionals should advise the public accordingly. Sidebar What's Known Chiropractic upper spinal manipulation has repeatedly been associated with arterial dissection followed by stroke and, in some cases, death. What's New The article is the first systematic review of all fatalities reported in the medical literature. Twenty-six deaths are on record and many more seem to have remained unpublished. References Ernst E. Adverse effects of spinal manipulation: a systematic review. J R Soc Med 2007; 100: 330–8. Leon- A, Cuetter A, Ferrer G. Cervical spine manipulation: an alternative medical procedure with potentially fatal complications. South Med J 2007; 100: 201–3. Dixon P. Letter to the Editor. Adverse effects of spinal manipulation. J R Soc Med 2007; 100: 444. BJ. Letter to the Editor. Adverse effects of spinal manipulation. J R Soc Med 2007; 100: 444. Anon. Medicolegal. Malpractice: death resulting from chiropractic treatment for headache. J Am Med Assoc 1934; 103:1260, 1935; 105:1712–4, 1937; 109:233–4. Pratt- HR, Berger KE. Cerebellar and spinal injuries after chiropractic manipulation. J Am Med Assoc 1947; 133: 600–3. Anon. Medicolegal abstracts. Chiropractors: injury to spinal meninges during adjustments. J Am Med Assoc 1955; 159: 809. Ford FR, D. Thrombosis of the basilar artery with softenings in the cerebellum and brain stem due to manipulation of the neck; a report of two cases with one post-mortem examination, reasons are given to prove that damage to the vertebral arteries is responsible. Bull s Hopkins Hosp 1956; 98: 37–42. RA, Estridge MN. Neurologic complications of head and neck manipulations. JAMA 1962; 182: 528–31. Lorenz R, Vogelsang HG. Thrombosis of the basilar artery following chiropractic manipulation of the cervical spine. [in German] Thrombose der arteria basilaris nach chiropraktischen Manipulationen an der Halbwirbelsäule. Dtsch Med Wochenschr 1972; 97: 36–43. Schmitt HP. Rupturen und Thrombosen der Arteria vertebralis nach gedeckten mechanischen Insulten. Schweiz Arch Neurol Neurochir Psychiatry 1976; 119: 363–79. Krueger BR, Okazaki H. Vertebral-basilar distribution infarction following chiropractic cervical manipulation. Mayo Clin Proc 1980; 55: 322–32. Sherman DG, Hart RG, Easton JD. Abrupt change in head position and cerebral infarction. Stroke 1981; 12: 2–6. Ali Cherif A, Delpuech F, Habib M, Salamon G, Khalil R. Thrombose vertebro-basilaire apres manipulation du rachis cervical. A propos de deux cas. Ann de Med Phys 1983; 25: 459–65. Nielsen AA. Cerebrovascular insults caused by manipulation of the cervical spine. [in Danish]. Ugeskr Laeger 1984; 146: 3267–70. Zak SM, Carmody RF. Cerebellar infarction from chiropractic neck manipulation: case report and review of the literature. Ariz Med 1984; 41: 333–7. Modde PJ. Chiropractic Malpractice. Columbia, land: Hanrow Press. 1985: 269–70, 273–5, 311–8, 322–3, 329–31, 334–7. Jentzen JM, Amatuzio J, GF. Complications of cervical manipulation: a case report of fatal brainstem infarct with review of the mechanisms and predisposing factors. J Forensic Sci 1987; 32: 1089–94. Mas JL, Henin D, Bousser MG, Chain F, Haw JJ. Dissecting aneurysm of the vertebral artery and cervical manipulation: a case report with autopsy. Neurology 1989; 39: 512–5. Sherman MR, Smialek JE, Zane WE. Pathogenesis of vertebral artery occlusion following cervical spine manipulation. Arch Pathol Lab Med 1987; 111: 851–3. Raskind R, North CM. Vertebral artery injuries following chiropractic cervical spine manipulation--case reports. Angiology 1990; 41: 445–52. Sullivan EC. Brain stem stroke syndromes from cervical adjustments. Report on five cases. J Chiropr Res Clin Invest 1992; 8: 12–6. Haynes MJ. Stroke following cervical manipulation in Perth. Chiropr J Aust 1994; 24: 42–6. s M, Bohl J, Thömke F, Kallen K-J, Mahlzahn K, Wandel E. Dissection of the internal carotid artery after chiropractic manipulation of the neck. Neurology 1995; 45: 2284–6. Klougart N, Leboeuf-Yde C, Rasmussen LR. Safety in chiropractic practice. Part I. The occurrence of cerebrovascular accidents after manipulation to the neck in Denmark from 1978–1988. J Manipulative Physiol Ther 1996; 19: 371–7. Haldeman S, Kohlbeck FJ, McGregor M. Unpredictability of cerebrovascular ischemia associated with cervical spine manipulation. Spine 2002; 27: 49–55. Dziewas R, Konrad C, Dräger B et al. Cervical artery dissection – clinical features, risk factors, therapy and outcome in 126 patients. J Neurol 2003; 250: 1179–84. Presentation by Dr Preston Long DC to State of Connecticut. Connecticut State Board of Chiropractic Examiners. Hartford Connecticut. 25 October 2009. Anon. What's the harm in going to a chiropractor? What's the Harm 2009; http://whatstheharm.net/chiropractic.html (accessed October 2009). Ernst E. Vascular accidents after neck manipulation: cause or coincidence? Int J Clin Pract 2009; in press. Long PH. Stroke and spinal manipulation. J Quality Health Care 2004; 3: 8–10. Ernst E. Chiropractic: a critical evaluation. J Pain Symptom Manage 2008; 35: 544–62. Stevinson C, Honan W, Cooke B, Ernst E. Neurological complications of cervical spine manipulation. J Roy Soc Med 2001; 94: 107–10. Ernst E. Cerebrovascular complications associated with spinal manipulation. Phys Ther Rev 2004; 9: 5–15. Terrett AGJ. Current Concepts in Vertebrobasilar Complications following Spinal Manipulation, 2nd edn. Des Moines: JCMIC Group, 2001. Di Fabio RP. Manipulation of the cervical spine: risks and benefits. Physical Ther 1999; 79: 50–65. Alcantara J, Ohm J, Kunz D. The safety and effectiveness of pediatric chiropractic: a survey of chiropractors and parents in a practice-based research network. Explore (NY) 2009; 5: 290–5. Sweeney A, Doody C Manual therapy for the cervical spine and reported adverse effects: a survey of Irish Manipulative Physiotherapists. Man Ther 2010; 15: 32–6. Int J Clin Pract. 2010;64(10):1162-1165. © 2010 Blackwell Publishing  -- Schneider DC PDX Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 11, 2011 Report Share Posted July 11, 2011 Your pretty much “on the money†. There has been cadaver and pig studies Walter Herzog performed a study on the normal forces on the vertebral artery during a diversified style adjustment/manipulation of the cervical spine using a piezoelectric sensor in the vertebral arteries. They then subjected dissected vertebral arteries to mechanical stress until they failed tore/dissected. As I recall they found that the force needed to cause the mechanical failure of the vessels was some 10Xs the force generated on the vertebral artery during an adjustment.  This fits with the work of Caplan (Stroke 16:1030-1038, 1985) who’s found that normal as in healthy vessels of the head and neck are particularly resistant to trauma. They reviewed the literature of individuals who suffered significant and severe cervical spinal trauma as in severe enough (50 cases) that they died and found only three cases of vertebral artery injury.  Getting back to are wonderful medical colleague Ernst he reports 26 deaths in 75 years of chiropractic practice in other words supposedly due to chiropractic spinal manipulation or an average of 1/3 deaths per year.  I believe it is estimated that about 250 million chiropractic visits occur in the US each year and then you have Canada and Europe oh…and the rest of the world.  The figures are incredibly infinitesimal when compared to the iatrogenesis of modern medicine which kills between 230,000-280,000 folks yearly!  Lastly, correct me if I wrong but all of the high quality clinical trials supporting what we do are pretty much all relative to diversified (high velocity low amplitude) spinal adjustments manipulation by hand not instruments yes most are relative to low back but the research is mounding for the cervical spine as well….Yes, I use an Activator and an arthrostim for a minority of my patients but my principle mode of treatment is a diversified chiropractic adjustment because that’s what the research supports and what I’ve found to work for 30 years….lastly, when it comes to instrumental versus adjustments by hand an very new couple of research papers document the cavitation of the zygoaphyseal joints with diversified adjusting and these same authors note the development of intra-articular adhesions with spinal fixations….instruments simply cannot cause joint cavitation significantly enough to break up those adhesions……is so please cite the research….the instruments work on a reflexogenic bases and have their useful place….second place in me-book…. Just me-two cents worth, Vern SAboe From: [mailto:msmith@...] Sent: Monday, July 11, 2011 4:54 PM Schneider; KalbCc: Vern Saboe; ; AboWoman@...Subject: RE: Chiropractic deaths Wouldn't a meaningful study be to compare the incidence of elderly patients visiting their general practitioner complaining of neck pain or headache within several days of dying from a vertebrobasilar vascular tear? Or even the incidence of patients complaining of neck pain prior to dying from such a condition?? Have there been any post mortem studies with interviews of family and friends? Have there been any cadaver studies showing that a short thrust cervical adjustment can or is capable of causing a dissection in cadaver tissue? If the " risk " is so low, at what point would it become recognized as coincidence as opposed to causation? I know it sounds good to say that the chiropractic adjustment that many believe is violent anyway " caused " the condition, but what's the actual evidence? Here are some of the symptoms of the condition--many of which I would think might cause a long time chiropractic patient to schedule an appointment for an adjustment. Have there been any known incidences where an elderly patient has suffered such an event within days of getting an arthrostim manipulation? Probably no studies done, perhaps because the assumption is that " obviously " wouldn't cause a dissection. But there are some reports of people having the condition a short time after having a massage. Did the massage cause it, or was the person seeing a or their massage therapist precisely because they were suffering some of the recognized symptoms of the condition: Difficulty swallowingDifficulty walkingDouble vision or vision lossHeadacheHearing lossNausea and vomitingNeck acheNumbness or tingling Poor coordination Sleepiness or even apparent sleep from which the person can not be awakenedSlurred speech Stroke or transient ischemic attackVertigo (sensation of things spinning around)Perhaps the informed consent ought to be just as strong in favor of warning the patient that while they might just be having neck pain or a headache, there's a small chance they might also be suffering the beginnings of a full blown stroke. Perhaps before adjusting such an elderly patient, the above laundry list should be reviewed with the patient to find out if they recently experienced any of the preceding symptoms? Or to routinely tell them to immediately call you if they experience any of those symptoms within a day of seeing you? I don't know. I'm just asking. G. Gatti, Gatti, Maier, Sayer, Thayer, & Associates1781 Liberty St. SESalem, OR 973021-(800) 289-3443 msmith@... From: [mailto: ] On Behalf Of SchneiderSent: Monday, July 11, 2011 3:48 PM KalbCc: Vern Saboe; ; AboWoman@...Subject: Re: Chiropractic deaths I would say I too support Vern's commentary and way of handling informed consent. I am not ready to throw out HVA because of some junk science that is motivated by the reach for economic gain and raw power. I can respect Minga's concerns but on the other hand I have worked for nearly 30years as a DC. Part of this time was spent in three different very busy chiropractic clinics in three different states and I haves never seen a CVA case yet. They are rare indeed in my experience and according to credible evidence. I will inform the patient accordingly. And then I will 'adjust the dog out of them '--if x-rays and exam indicate the need. Schneider DCPDXOn Mon, Jul 11, 2011 at 7:45 AM, Kalb <drjohnkalb@...> wrote: Thanks Vern! This is also my understanding of the research. This so-called science article about Chiro dI eaths is almost a year old and is NOT good science. I am sadden that several Docs on this list are misinformed and ready to submit and give up one of our most powerful tools! Certainly, any powerful tool must be used with the upmost care and applied with a high level of skill and respect. The lesson from the tragic case of one of our member's grandfather speaks to this. The Chiro care this older gentle received may have contributed to his other wise long and active life. M Kalb MS DCAuthor of Winning at Aging Wellness Chiropractor and Health Coachwww.DrKalb.com 541.488.3001 On Jul 8, 2011, at 9:26 PM, Vern Saboe wrote:  I am also in favor of informed consent both written and verbal documented in the chart. With that said would have informed consent have saved your grandfather? How is it that it was both the cervical adjustment and the lumbar roll that likely killed your grandfather. What would you have expected the doctor to have told your grandfather prior to performing a high velocity adjustment? This may cause a vertebral artery dissection and you may die? Considering the myriad of systematic reviews of the literature not the least of which was the recent (2008) 10 year (2000-2010) Bone and Joint Decade...Task Force on Neck Pain and Its Associated Disorders findings that validate the rarity of this occurrence. This review of 31, 878 citations (Haldeman and coworkers) found an association between chiropractic treatment and subsequent vertebrobasilar artery stroke in persons under the age of 45. However, the same association was found in patients visiting a general practitioner of medicine? We must inform patients of any " material risks " currently I don't believe the scientific evidence supports vertebral artery stroke secondary to SMT as such since the incidence is so very remote.....when the dentist injects you with that local anesthetic have any of you ever had the doctor discuss the fact that you could have an unforseen, non-predictable anaphylactic reaction and die? Or when the medics prescribe the various medications do you believe they also inform the patient of such verbally? Recall the conclusion that started this discussion from the paper (toliet) by Ernst that the benefits of spinal manipulation do not out weight the risks....crapola. Lastly, could not have been the case that your beloved grandfather presented to the chiropractor with neck pain low back pain because especially considering his health was in the process of stroke having pain due to a dissection in progress? To quote Haldeman relative to the cervical spine and verterbral arteries... " This is likely explained by patients with vertebrobasilar artery dissection-related neck pain or headache seeking care before having their stroke. " ...any way I understand what you are saying and agree about informed consent but I do not agree that we need to tell our patients oh by the way this could kill you! How I handle the issue of stroke and informed consent is that stroke is referred to as a extremely rare occurence in my written informed consent but during my verbal communication PAR Conf. in the room with the new patient I inform them that research shows that you have a 300 to 400 greater chance of a serious side effect to taking an NSAID such as Advil than you have with anything I will be doing. Just two cents, Vern Saboe Chiropractic deaths Docs:I especially like their " Conclusion. " Lyndon McGill, D.C.Salem, Oregonwww.SalemSpineClinic.comwww.EvolvingDaily.com <Wiley_pub2-logo-2lines.gif> Deaths after Chiropractic: A Review of Published CasesE. ErnstPosted: 08/30/2010; Int J Clin Pract. 2010;64(10):1162-1165. © 2010 Blackwell PublishingAbstract and IntroductionAbstractObjective: The aim of this study was to summarise all cases in which chiropractic spinal manipulation was followed by death.Design: This study is a systematic review of case reports.Methods: Literature searches in four electronic databases with no restrictions of time or language.Main outcome measure: Death.Results: Twenty six fatalities were published in the medical literature and many more might have remained unpublished. The alleged pathology usually was a vascular accident involving the dissection of a vertebral artery.Conclusion: Numerous deaths have occurred after chiropractic manipulations. The risks of this treatment by far outweigh its benefit.IntroductionVascular accidents after upper spinal manipulation are a well-recognised problem (e.g.[1,2]). Dissection of a vertebral artery, caused by extension and rotation of the neck beyond the physiological range of motion, is thought to be the underlying mechanism.[2] Several deaths have been reported as a consequence. Some proponents of chiropractic seem to believe that the critical evaluation of this evidence amounts to a 'scare story' (Chairman of the UK General Chiropractic Council)[3] or to 'puffing up (the evidence) out of all proportion' (President of the British Chiropractic Association).[4] A responsible approach to serious therapeutic risks, however, requires an open discussion of the facts.In this review, I aimed to provide the basis for such a discussion by summarising all fatalities which occurred after chiropractic spinal manipulation and were published in the medical literature.MethodsElectronic searches were conducted in the following electronic databases: Medline, Embase, AMED, Cochrane Library (September 2009). No restrictions of time or language were applied. Search terms were chiropractic, spinal manipulation, vascular accidents, stroke, death and fatality. In addition, our own departmental files and the bibliographies of the articles thus located were searched. Several experts were also contacted for further data. Case reports were included if they provided information on human patients who had died after receiving one or more treatments from a chiropractor. Data were extracted from the included articles according to predefined criteria (Table 1).Table 1. Published case reports of deaths after chiropractic treatmentsReferencesYear of publicationVictimType of vascular accidentTime between treatment and deathAnon[5] 1934Woman, age unknownTear in left lateral sinus2 weeksPratt- and Berger[6] 194732-year-old manThrombosis of basilar, left anterior-inferior cerebellar and right posterior-inferior arteries24 hPratt- and Berger[6] 194735-year-old womanThrombosis of posterior-inferior cerebellar artery10 hAnon[7] 1955Woman, age unknownIntra-spinal bleeding and compression of spinal cord18 hFord and [8] 195637-year-old manThrombosis of basilar, left-posterior cerebellar and left-posterior cerebral arteries6 hFord and [8] 1956No information providedThrombosis of basilar arteryNo information provided and Estridge[9] 196233-year-old womanInfarct of cerebellar and brainstem3 daysLorenz and Vogelsang[10] 197239-year-old womanThrombosis of basilar artery58 daysSchmitt[11] 197635-years-old womanInfarct of brainstem1 hKrueger and Okazaki[12] 198025-year-old manInfarct of brainstem and cerebellum48 hSherman et al.[13] 198160-year-old womanDissection of vertebral artery4 daysAli Cherif et al.[14] 198351-year-old manInfarct of medulla oblongata11 daysNielsen[15] 198434-year-old manDissection of vertebral artery aneurysen3 hZak and Carmody[16] 198453-year-old manLeft vertebral, posterior-inferior and superior cerebellar artery occlusion; cerebellar infarction27 daysModde[17] 198526-year-old womanDissection of vertebral artery1 dayJentzen et al.[18] 198751-year-old manInfarct of cerebellum and brainstemNo information providedSherman et al.[20] 198737-year-old manInfarct of brainstem3 daysMas et al.[19] 198935-year-old womanDissecting aneurysm of vertebral artery16 hRaskind and North[21] 199047-year-old womanCerebellar haemorrheaeNo information providedSullivan[22] 199241-year-old womanHaemorrhage in ventricular system8 hHaynes[23] 199436-year-old womanDissecting aneurysm of vertebral artery, thrombo-embolismNo information provideds et al.[24] 199529-year-old womanInfarct of right hemisphere3 daysKlougart et al.[25] 199634-year-old manUnclearFew hoursHaldeman et al.[26] 2002Previously unpublished legal casesNo information providedNo information providedHaldeman et al.[26] 2002Previously unpublished legal casesNo information providedNo information providedDziewas et al.[27] 2003No information providedNo information providedNo information providedResultsTwenty-six fatalities were published since 1934 in 23 articles (Table 1).[5–27] Table 1. Published case reports of deaths after chiropractic treatmentsReferencesYear of publicationVictimType of vascular accidentTime between treatment and deathAnon[5] 1934Woman, age unknownTear in left lateral sinus2 weeksPratt- and Berger[6] 194732-year-old manThrombosis of basilar, left anterior-inferior cerebellar and right posterior-inferior arteries24 hPratt- and Berger[6] 194735-year-old womanThrombosis of posterior-inferior cerebellar artery10 hAnon[7] 1955Woman, age unknownIntra-spinal bleeding and compression of spinal cord18 hFord and [8] 195637-year-old manThrombosis of basilar, left-posterior cerebellar and left-posterior cerebral arteries6 hFord and [8] 1956No information providedThrombosis of basilar arteryNo information provided and Estridge[9] 196233-year-old womanInfarct of cerebellar and brainstem3 daysLorenz and Vogelsang[10] 197239-year-old womanThrombosis of basilar artery58 daysSchmitt[11] 197635-years-old womanInfarct of brainstem1 hKrueger and Okazaki[12] 198025-year-old manInfarct of brainstem and cerebellum48 hSherman et al.[13] 198160-year-old womanDissection of vertebral artery4 daysAli Cherif et al.[14] 198351-year-old manInfarct of medulla oblongata11 daysNielsen[15] 198434-year-old manDissection of vertebral artery aneurysen3 hZak and Carmody[16] 198453-year-old manLeft vertebral, posterior-inferior and superior cerebellar artery occlusion; cerebellar infarction27 daysModde[17] 198526-year-old womanDissection of vertebral artery1 dayJentzen et al.[18] 198751-year-old manInfarct of cerebellum and brainstemNo information providedSherman et al.[20] 198737-year-old manInfarct of brainstem3 daysMas et al.[19] 198935-year-old womanDissecting aneurysm of vertebral artery16 hRaskind and North[21] 199047-year-old womanCerebellar haemorrheaeNo information providedSullivan[22] 199241-year-old womanHaemorrhage in ventricular system8 hHaynes[23] 199436-year-old womanDissecting aneurysm of vertebral artery, thrombo-embolismNo information provideds et al.[24] 199529-year-old womanInfarct of right hemisphere3 daysKlougart et al.[25] 199634-year-old manUnclearFew hoursHaldeman et al.[26] 2002Previously unpublished legal casesNo information providedNo information providedHaldeman et al.[26] 2002Previously unpublished legal casesNo information providedNo information providedDziewas et al.[27] 2003No information providedNo information providedNo information providedMost of the victims were relatively young; 14 were below the age of 40. There was a slight majority of female patients. The type of complication associated with death frequently related to a vascular accident leading to thrombosis and cerebral infarction. The time between treatment and death ranged from 1 h to 58 days; in 10 cases, it was 1 day or less. Unfortunately, the published information was often incomplete.Many other fatalities seem to have remained unpublished. For instance, the testimony of the chiropractor Preston Long for a court in Connecticut recently listed the family names of nine victims: Mathiason, Solsbury, Mc Cornick, Venegas, Bedenbaugh, , Fawcett, Parisien, Standt. Long also states that 'many others [are] unknown hidden behind legal agreements of silence'.[28] A website names further North American fatalities: Epping (California), G. Fowden (Utah), Grainger (Alberta), Hoffman (land), Renate Dora Labonte (Ontario), (California), Pereyra (Connecticut), A. Roth (Ontario) and Lee Strohecker (Pennsylvania).[29] DiscussionThis systematic review demonstrates that numerous deaths have been associated with chiropractic. Usually high-velocity, short-lever thrusts of the upper spine with rotation are implicated. They are believed to cause vertebral arterial dissection in predisposed individuals which, in turn, can lead to a chain of events including stroke and death.[1,2,26,30] Many chiropractors claim that, because arterial dissection can also occur spontaneously, causality between the chiropractic intervention and arterial dissection is not proven. However, when carefully evaluating the known facts, one does arrive at the conclusion that causality is at least likely (e.g.[30,31]). Even if it were merely a remote possibility, the precautionary principle in healthcare would mean that neck manipulations should be considered unsafe until proven otherwise. Moreover, there is no good evidence for assuming that neck manipulation is an effective therapy for any medical condition.[32] Thus, the risk-benefit balance for chiropractic neck manipulation fails to be positive.Reliable estimates of the frequency of vascular accidents are prevented by the fact that under-reporting is known to be substantial. In a survey of UK neurologists, for instance, under-reporting of serious complications was 100%.[33] Those cases which are published often turn out to be incomplete. Of 40 case reports of serious adverse effects associated with spinal manipulation, nine failed to provide any information about the clinical outcome.[34] Incomplete reporting of outcomes might therefore further increase the true number of fatalities. Obviously, the present article is not aimed at providing incidence figures; this would require a different methodology entirely. To date, no reliable incidence data are available.This review is focussed on deaths after chiropractic, yet neck manipulations are, of course, used by other healthcare professionals as well. The reason for this focus is simple: chiropractors are more frequently associated with serious manipulation-related adverse effects than osteopaths, physiotherapists, doctors or other professionals. Of the 40 cases of serious adverse effects mentioned above, 28 can be traced back to a chiropractor and none to an osteopath.[34] A review of complications after spinal manipulations by any type of healthcare professional included three deaths related to osteopaths, nine to medical practitioners, none to a physiotherapist, one to a naturopath and 17 to chiropractors.[35] This article also summarised a total of 265 vascular accidents of which 142 were linked to chiropractors. Another review of complications after neck manipulations published by 1997 included 177 vascular accidents, 32 of which were fatal. The vast majority of these cases were associated with chiropractic and none with physiotherapy.[36] The most obvious explanation for the dominance of chiropractic is that chiropractors routinely employ high-velocity, short-lever thrusts on the upper spine with a rotational element, while the other healthcare professionals use them much more sparingly.[37,38] In conclusion, numerous deaths have been associated with chiropractic neck manipulations. There are reasons to suspect that under-reporting is substantial and reliable incidence figures do not exist. The risks of chiropractic neck manipulations by far outweigh their benefits. Healthcare professionals should advise the public accordingly.SidebarWhat's KnownChiropractic upper spinal manipulation has repeatedly been associated with arterial dissection followed by stroke and, in some cases, death.What's NewThe article is the first systematic review of all fatalities reported in the medical literature. Twenty-six deaths are on record and many more seem to have remained unpublished.ReferencesErnst E. Adverse effects of spinal manipulation: a systematic review. J R Soc Med 2007; 100: 330–8. Leon- A, Cuetter A, Ferrer G. Cervical spine manipulation: an alternative medical procedure with potentially fatal complications. South Med J 2007; 100: 201–3. Dixon P. Letter to the Editor. Adverse effects of spinal manipulation. J R Soc Med 2007; 100: 444. BJ. Letter to the Editor. Adverse effects of spinal manipulation. J R Soc Med 2007; 100: 444. Anon. Medicolegal. Malpractice: death resulting from chiropractic treatment for headache. J Am Med Assoc 1934; 103:1260, 1935; 105:1712–4, 1937; 109:233–4. Pratt- HR, Berger KE. Cerebellar and spinal injuries after chiropractic manipulation. J Am Med Assoc 1947; 133: 600–3. Anon. Medicolegal abstracts. Chiropractors: injury to spinal meninges during adjustments. J Am Med Assoc 1955; 159: 809. Ford FR, D. Thrombosis of the basilar artery with softenings in the cerebellum and brain stem due to manipulation of the neck; a report of two cases with one post-mortem examination, reasons are given to prove that damage to the vertebral arteries is responsible. Bull s Hopkins Hosp 1956; 98: 37–42. RA, Estridge MN. Neurologic complications of head and neck manipulations. JAMA 1962; 182: 528–31. Lorenz R, Vogelsang HG. Thrombosis of the basilar artery following chiropractic manipulation of the cervical spine. [in German] Thrombose der arteria basilaris nach chiropraktischen Manipulationen an der Halbwirbelsäule. Dtsch Med Wochenschr 1972; 97: 36–43. Schmitt HP. Rupturen und Thrombosen der Arteria vertebralis nach gedeckten mechanischen Insulten. Schweiz Arch Neurol Neurochir Psychiatry 1976; 119: 363–79. Krueger BR, Okazaki H. Vertebral-basilar distribution infarction following chiropractic cervical manipulation. Mayo Clin Proc 1980; 55: 322–32. Sherman DG, Hart RG, Easton JD. Abrupt change in head position and cerebral infarction. Stroke 1981; 12: 2–6. Ali Cherif A, Delpuech F, Habib M, Salamon G, Khalil R. Thrombose vertebro-basilaire apres manipulation du rachis cervical. A propos de deux cas. Ann de Med Phys 1983; 25: 459–65. Nielsen AA. Cerebrovascular insults caused by manipulation of the cervical spine. [in Danish]. Ugeskr Laeger 1984; 146: 3267–70. Zak SM, Carmody RF. Cerebellar infarction from chiropractic neck manipulation: case report and review of the literature. Ariz Med 1984; 41: 333–7. Modde PJ. Chiropractic Malpractice. Columbia, land: Hanrow Press. 1985: 269–70, 273–5, 311–8, 322–3, 329–31, 334–7. Jentzen JM, Amatuzio J, GF. Complications of cervical manipulation: a case report of fatal brainstem infarct with review of the mechanisms and predisposing factors. J Forensic Sci 1987; 32: 1089–94. Mas JL, Henin D, Bousser MG, Chain F, Haw JJ. Dissecting aneurysm of the vertebral artery and cervical manipulation: a case report with autopsy. Neurology 1989; 39: 512–5. Sherman MR, Smialek JE, Zane WE. Pathogenesis of vertebral artery occlusion following cervical spine manipulation. Arch Pathol Lab Med 1987; 111: 851–3. Raskind R, North CM. Vertebral artery injuries following chiropractic cervical spine manipulation--case reports. Angiology 1990; 41: 445–52. Sullivan EC. Brain stem stroke syndromes from cervical adjustments. Report on five cases. J Chiropr Res Clin Invest 1992; 8: 12–6. Haynes MJ. Stroke following cervical manipulation in Perth. Chiropr J Aust 1994; 24: 42–6. s M, Bohl J, Thömke F, Kallen K-J, Mahlzahn K, Wandel E. Dissection of the internal carotid artery after chiropractic manipulation of the neck. Neurology 1995; 45: 2284–6. Klougart N, Leboeuf-Yde C, Rasmussen LR. Safety in chiropractic practice. Part I. The occurrence of cerebrovascular accidents after manipulation to the neck in Denmark from 1978–1988. J Manipulative Physiol Ther 1996; 19: 371–7. Haldeman S, Kohlbeck FJ, McGregor M. Unpredictability of cerebrovascular ischemia associated with cervical spine manipulation. Spine 2002; 27: 49–55. Dziewas R, Konrad C, Dräger B et al. Cervical artery dissection – clinical features, risk factors, therapy and outcome in 126 patients. J Neurol 2003; 250: 1179–84. Presentation by Dr Preston Long DC to State of Connecticut. Connecticut State Board of Chiropractic Examiners. Hartford Connecticut. 25 October 2009. Anon. What's the harm in going to a chiropractor? What's the Harm 2009; http://whatstheharm.net/chiropractic.html (accessed October 2009). Ernst E. Vascular accidents after neck manipulation: cause or coincidence? Int J Clin Pract 2009; in press. Long PH. Stroke and spinal manipulation. J Quality Health Care 2004; 3: 8–10. Ernst E. Chiropractic: a critical evaluation. J Pain Symptom Manage 2008; 35: 544–62. Stevinson C, Honan W, Cooke B, Ernst E. Neurological complications of cervical spine manipulation. J Roy Soc Med 2001; 94: 107–10. Ernst E. Cerebrovascular complications associated with spinal manipulation. Phys Ther Rev 2004; 9: 5–15. Terrett AGJ. Current Concepts in Vertebrobasilar Complications following Spinal Manipulation, 2nd edn. Des Moines: JCMIC Group, 2001. Di Fabio RP. Manipulation of the cervical spine: risks and benefits. Physical Ther 1999; 79: 50–65. Alcantara J, Ohm J, Kunz D. The safety and effectiveness of pediatric chiropractic: a survey of chiropractors and parents in a practice-based research network. Explore (NY) 2009; 5: 290–5. Sweeney A, Doody C Manual therapy for the cervical spine and reported adverse effects: a survey of Irish Manipulative Physiotherapists. Man Ther 2010; 15: 32–6. Int J Clin Pract. 2010;64(10):1162-1165. © 2010 Blackwell Publishing Error! Filename not specified. -- Schneider DC PDX Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 11, 2011 Report Share Posted July 11, 2011 Vern, I wanted to reply to your post. Let me see if I can adress some of your comments: 1. With that said would have informed consent have saved your grandfather? maybe, but we'll never know. He was never given the opportunity to review any risks. It would have at least given him the knowledge to make an informed decision as to whether he wanted to risk an aneurysm or stroke in order to relieve what he thought was spine pain. This was my main point. I am not opposed to HVLA anywhere. 2. Lastly, could not have been the case that your beloved grandfather presented to the chiropractor with neck pain low back pain because especially considering his health was in the process of stroke having pain due to a dissection in progress? Maybe, but there's absolutely no way to know. And that is a very mute point at this time. To some degree, when DCs make that comment, I look at it as an excuse to deflect a negligence in diagnosis or informed consent. He's long dead. My point is this : the DC should've known my grandpa was at a higher risk for stroke and aneurysm due to his health profile. He had not taken any x-rays. He had given diagnostic clues to the DC that were overlooked. Dizziness following HVLA of the neck. There was no VBI test. HVLA does have risks and we as a profession need to address that. If a patient is "in the process of stroke" perhaps an HVLA to the C-spine is contraindicated? 3. .....when the dentist injects you with that local anesthetic have any of you ever had the doctor discuss the fact that you could have an unforseen, non-predictable anaphylactic reaction and die? Or when the medics prescribe the various medications do you believe they also inform the patient of such verbally? This is not an argument I'd ever make. With this rationale, when a surgery is performed, if the risk is low enough, like say 1-5%, then why should they bother to let us know at all? After all, dentists & chiropractors don't. I never cared for that reasoning. My MD went over risk factors before injecting me with meds. My dentist screened for allergies prior to injecting me and the forms he gave me to sign had stuff about shock. I agree that not all do that. 4. What would you have expected the doctor to have told your grandfather prior to performing a high velocity adjustment? I would've expected him to do a thorough exam prior to using HVLA. once he found that my grandpa was in his late 80's, diabetic, high blood pressure etc, I would expect him to say, "This is the treatment I think would work to help relieve your pain. XYZ. Although the risk for HVLA in the C-spine does have a risk for stroke, sprain, and temporary pain, the risk is low in most cases. With the conditions you have, the risk may be higher." At that point, if the patient asks what are the effects of a stroke, the doctor can reivew stroke symptoms so if the patient experiences any of them he/she knows to go to a hospital. My grandma was almost home before she turned around to drive an extra 30 min to the hospital. SHe didn't realize the risk. He may have bled out anyway, but if the DC had been on top of it, maybe he would not have died on that day. The patient has then agreed to the risks and taken personal responsibility with all the knowledge he/she deserves. If the patient declines HVLA, hopefully the doctor knows other methods that can delete the symptoms with less risk. There are many adjustive options for patients. 5. However, the same association was found in patients visiting a general practitioner of medicine? The biggest difference here is that patients seeing a DC have been moved beyond normal range of motion with an impact applied to the VBA at this end range of motion. I would need to see if the patients that saw MDs were receiving manip or extreme ROM prior to the stroke, what was done to see if there was a correlation. Regardless, when you look at straight biomechanics, an artery that's begun to dissect is weaker. It may not stand up to the force of HVLA. In my opinion, an HVLA on an artery that's begun to dissect, could progress. We need to take these things into consideration and figure a way to change public opinion on this. Whether it's with producing our own stats thru competant science or compiling current research and doing a public media message, I don't know. But we can't deny public perceptions. We must not ignore them. 6. I agree that the paper presented was not one I'd use. I thought the stats were flawed and useless and I said as much in my email. Minga Re: Chiropractic deaths I would say I too support Vern's commentary and way of handling informed consent. I am not ready to throw out HVA because of some junk science that is motivated by the reach for economic gain and raw power. I can respect Minga's concerns but on the other hand I have worked for nearly 30years as a DC. Part of this time was spent in three different very busy chiropractic clinics in three different states and I haves never seen a CVA case yet. They are rare indeed in my experience and according to credible evidence. I will inform the patient accordingly. And then I will 'adjust the dog out of them '--if x-rays and exam indicate the need. Schneider DC PDX On Mon, Jul 11, 2011 at 7:45 AM, Kalb <drjohnkalb@...> wrote: Thanks Vern! This is also my understanding of the research. This so-called science article about Chiro dI eaths is almost a year old and is NOT good science. I am sadden that several Docs on this list are misinformed and ready to submit and give up one of our most powerful tools! Certainly, any powerful tool must be used with the upmost care and applied with a high level of skill and respect. The lesson from the tragic case of one of our member's grandfather speaks to this. The Chiro care this older gentle received may have contributed to his other wise long and active life. M Kalb MS DC Author of Winning at Aging Wellness Chiropractor and Health Coach www.DrKalb.com 541.488.3001 On Jul 8, 2011, at 9:26 PM, Vern Saboe wrote:  I am also in favor of informed consent both written and verbal documented in the chart. With that said would have informed consent have saved your grandfather? How is it that it was both the cervical adjustment and the lumbar roll that likely killed your grandfather. What would you have expected the doctor to have told your grandfather prior to performing a high velocity adjustment? This may cause a vertebral artery dissection and you may die? Considering the myriad of systematic reviews of the literature not the least of which was the recent (2008) 10 year (2000-2010) Bone and Joint Decade...Task Force on Neck Pain and Its Associated Disorders findings that validate the rarity of this occurrence. This review of 31, 878 citations (Haldeman and coworkers) found an association between chiropractic treatment and subsequent vertebrobasilar artery stroke in persons under the age of 45. However, the same association was found in patients visiting a general practitioner of medicine? We must inform patients of any "material risks" currently I don't believe the scientific evidence supports vertebral artery stroke secondary to SMT as such since the incidence is so very remote.....when the dentist injects you with that local anesthetic have any of you ever had the doctor discuss the fact that you could have an unforseen, non-predictable anaphylactic reaction and die? Or when the medics prescribe the various medications do you believe they also inform the patient of such verbally? Recall the conclusion that started this discussion from the paper (toliet) by Ernst that the benefits of spinal manipulation do not out weight the risks....crapola. Lastly, could not have been the case that your beloved grandfather presented to the chiropractor with neck pain low back pain because especially considering his health was in the process of stroke having pain due to a dissection in progress? To quote Haldeman relative to the cervical spine and verterbral arteries..."This is likely explained by patients with vertebrobasilar artery dissection-related neck pain or headache seeking care before having their stroke." ....any way I understand what you are saying and agree about informed consent but I do not agree that we need to tell our patients oh by the way this could kill you! How I handle the issue of stroke and informed consent is that stroke is referred to as a extremely rare occurence in my written informed consent but during my verbal communication PAR Conf. in the room with the new patient I inform them that research shows that you have a 300 to 400 greater chance of a serious side effect to taking an NSAID such as Advil than you have with anything I will be doing. Just two cents, Vern Saboe Chiropractic deaths Docs: I especially like their "Conclusion." Lyndon McGill, D.C. Salem, Oregon www.SalemSpineClinic.com www.EvolvingDaily.com <Wiley_pub2-logo-2lines.gif> Deaths after Chiropractic: A Review of Published Cases E. Ernst Posted: 08/30/2010; Int J Clin Pract. 2010;64(10):1162-1165. © 2010 Blackwell Publishing Abstract and Introduction Abstract Objective: The aim of this study was to summarise all cases in which chiropractic spinal manipulation was followed by death. Design: This study is a systematic review of case reports. Methods: Literature searches in four electronic databases with no restrictions of time or language. Main outcome measure: Death. Results: Twenty six fatalities were published in the medical literature and many more might have remained unpublished. The alleged pathology usually was a vascular accident involving the dissection of a vertebral artery. Conclusion: Numerous deaths have occurred after chiropractic manipulations. The risks of this treatment by far outweigh its benefit. Introduction Vascular accidents after upper spinal manipulation are a well-recognised problem (e.g.[1,2]). Dissection of a vertebral artery, caused by extension and rotation of the neck beyond the physiological range of motion, is thought to be the underlying mechanism.[2] Several deaths have been reported as a consequence. Some proponents of chiropractic seem to believe that the critical evaluation of this evidence amounts to a 'scare story' (Chairman of the UK General Chiropractic Council)[3] or to 'puffing up (the evidence) out of all proportion' (President of the British Chiropractic Association).[4] A responsible approach to serious therapeutic risks, however, requires an open discussion of the facts. In this review, I aimed to provide the basis for such a discussion by summarising all fatalities which occurred after chiropractic spinal manipulation and were published in the medical literature. Methods Electronic searches were conducted in the following electronic databases: Medline, Embase, AMED, Cochrane Library (September 2009). No restrictions of time or language were applied. Search terms were chiropractic, spinal manipulation, vascular accidents, stroke, death and fatality. In addition, our own departmental files and the bibliographies of the articles thus located were searched. Several experts were also contacted for further data. Case reports were included if they provided information on human patients who had died after receiving one or more treatments from a chiropractor. Data were extracted from the included articles according to predefined criteria (Table 1). Table 1. Published case reports of deaths after chiropractic treatments References Year of publication Victim Type of vascular accident Time between treatment and death Anon[5] 1934 Woman, age unknown Tear in left lateral sinus 2 weeks Pratt- and Berger[6] 1947 32-year-old man Thrombosis of basilar, left anterior-inferior cerebellar and right posterior-inferior arteries 24 h Pratt- and Berger[6] 1947 35-year-old woman Thrombosis of posterior-inferior cerebellar artery 10 h Anon[7] 1955 Woman, age unknown Intra-spinal bleeding and compression of spinal cord 18 h Ford and [8] 1956 37-year-old man Thrombosis of basilar, left-posterior cerebellar and left-posterior cerebral arteries 6 h Ford and [8] 1956 No information provided Thrombosis of basilar artery No information provided and Estridge[9] 1962 33-year-old woman Infarct of cerebellar and brainstem 3 days Lorenz and Vogelsang[10] 1972 39-year-old woman Thrombosis of basilar artery 58 days Schmitt[11] 1976 35-years-old woman Infarct of brainstem 1 h Krueger and Okazaki[12] 1980 25-year-old man Infarct of brainstem and cerebellum 48 h Sherman et al.[13] 1981 60-year-old woman Dissection of vertebral artery 4 days Ali Cherif et al.[14] 1983 51-year-old man Infarct of medulla oblongata 11 days Nielsen[15] 1984 34-year-old man Dissection of vertebral artery aneurysen 3 h Zak and Carmody[16] 1984 53-year-old man Left vertebral, posterior-inferior and superior cerebellar artery occlusion; cerebellar infarction 27 days Modde[17] 1985 26-year-old woman Dissection of vertebral artery 1 day Jentzen et al.[18] 1987 51-year-old man Infarct of cerebellum and brainstem No information provided Sherman et al.[20] 1987 37-year-old man Infarct of brainstem 3 days Mas et al.[19] 1989 35-year-old woman Dissecting aneurysm of vertebral artery 16 h Raskind and North[21] 1990 47-year-old woman Cerebellar haemorrheae No information provided Sullivan[22] 1992 41-year-old woman Haemorrhage in ventricular system 8 h Haynes[23] 1994 36-year-old woman Dissecting aneurysm of vertebral artery, thrombo-embolism No information provided s et al.[24] 1995 29-year-old woman Infarct of right hemisphere 3 days Klougart et al.[25] 1996 34-year-old man Unclear Few hours Haldeman et al.[26] 2002 Previously unpublished legal cases No information provided No information provided Haldeman et al.[26] 2002 Previously unpublished legal cases No information provided No information provided Dziewas et al.[27] 2003 No information provided No information provided No information provided Results Twenty-six fatalities were published since 1934 in 23 articles (Table 1).[5–27] Table 1. Published case reports of deaths after chiropractic treatments References Year of publication Victim Type of vascular accident Time between treatment and death Anon[5] 1934 Woman, age unknown Tear in left lateral sinus 2 weeks Pratt- and Berger[6] 1947 32-year-old man Thrombosis of basilar, left anterior-inferior cerebellar and right posterior-inferior arteries 24 h Pratt- and Berger[6] 1947 35-year-old woman Thrombosis of posterior-inferior cerebellar artery 10 h Anon[7] 1955 Woman, age unknown Intra-spinal bleeding and compression of spinal cord 18 h Ford and [8] 1956 37-year-old man Thrombosis of basilar, left-posterior cerebellar and left-posterior cerebral arteries 6 h Ford and [8] 1956 No information provided Thrombosis of basilar artery No information provided and Estridge[9] 1962 33-year-old woman Infarct of cerebellar and brainstem 3 days Lorenz and Vogelsang[10] 1972 39-year-old woman Thrombosis of basilar artery 58 days Schmitt[11] 1976 35-years-old woman Infarct of brainstem 1 h Krueger and Okazaki[12] 1980 25-year-old man Infarct of brainstem and cerebellum 48 h Sherman et al.[13] 1981 60-year-old woman Dissection of vertebral artery 4 days Ali Cherif et al.[14] 1983 51-year-old man Infarct of medulla oblongata 11 days Nielsen[15] 1984 34-year-old man Dissection of vertebral artery aneurysen 3 h Zak and Carmody[16] 1984 53-year-old man Left vertebral, posterior-inferior and superior cerebellar artery occlusion; cerebellar infarction 27 days Modde[17] 1985 26-year-old woman Dissection of vertebral artery 1 day Jentzen et al.[18] 1987 51-year-old man Infarct of cerebellum and brainstem No information provided Sherman et al.[20] 1987 37-year-old man Infarct of brainstem 3 days Mas et al.[19] 1989 35-year-old woman Dissecting aneurysm of vertebral artery 16 h Raskind and North[21] 1990 47-year-old woman Cerebellar haemorrheae No information provided Sullivan[22] 1992 41-year-old woman Haemorrhage in ventricular system 8 h Haynes[23] 1994 36-year-old woman Dissecting aneurysm of vertebral artery, thrombo-embolism No information provided s et al.[24] 1995 29-year-old woman Infarct of right hemisphere 3 days Klougart et al.[25] 1996 34-year-old man Unclear Few hours Haldeman et al.[26] 2002 Previously unpublished legal cases No information provided No information provided Haldeman et al.[26] 2002 Previously unpublished legal cases No information provided No information provided Dziewas et al.[27] 2003 No information provided No information provided No information provided Most of the victims were relatively young; 14 were below the age of 40. There was a slight majority of female patients. The type of complication associated with death frequently related to a vascular accident leading to thrombosis and cerebral infarction. The time between treatment and death ranged from 1 h to 58 days; in 10 cases, it was 1 day or less. Unfortunately, the published information was often incomplete. Many other fatalities seem to have remained unpublished. For instance, the testimony of the chiropractor Preston Long for a court in Connecticut recently listed the family names of nine victims: Mathiason, Solsbury, Mc Cornick, Venegas, Bedenbaugh, , Fawcett, Parisien, Standt. Long also states that 'many others [are] unknown hidden behind legal agreements of silence'.[28] A website names further North American fatalities: Epping (California), G. Fowden (Utah), Grainger (Alberta), Hoffman (land), Renate Dora Labonte (Ontario), (California), Pereyra (Connecticut), A. Roth (Ontario) and Lee Strohecker (Pennsylvania).[29] Discussion This systematic review demonstrates that numerous deaths have been associated with chiropractic. Usually high-velocity, short-lever thrusts of the upper spine with rotation are implicated. They are believed to cause vertebral arterial dissection in predisposed individuals which, in turn, can lead to a chain of events including stroke and death.[1,2,26,30] Many chiropractors claim that, because arterial dissection can also occur spontaneously, causality between the chiropractic intervention and arterial dissection is not proven. However, when carefully evaluating the known facts, one does arrive at the conclusion that causality is at least likely (e.g.[30,31]). Even if it were merely a remote possibility, the precautionary principle in healthcare would mean that neck manipulations should be considered unsafe until proven otherwise. Moreover, there is no good evidence for assuming that neck manipulation is an effective therapy for any medical condition.[32] Thus, the risk-benefit balance for chiropractic neck manipulation fails to be positive. Reliable estimates of the frequency of vascular accidents are prevented by the fact that under-reporting is known to be substantial. In a survey of UK neurologists, for instance, under-reporting of serious complications was 100%.[33] Those cases which are published often turn out to be incomplete. Of 40 case reports of serious adverse effects associated with spinal manipulation, nine failed to provide any information about the clinical outcome.[34] Incomplete reporting of outcomes might therefore further increase the true number of fatalities. Obviously, the present article is not aimed at providing incidence figures; this would require a different methodology entirely. To date, no reliable incidence data are available. This review is focussed on deaths after chiropractic, yet neck manipulations are, of course, used by other healthcare professionals as well. The reason for this focus is simple: chiropractors are more frequently associated with serious manipulation-related adverse effects than osteopaths, physiotherapists, doctors or other professionals. Of the 40 cases of serious adverse effects mentioned above, 28 can be traced back to a chiropractor and none to an osteopath.[34] A review of complications after spinal manipulations by any type of healthcare professional included three deaths related to osteopaths, nine to medical practitioners, none to a physiotherapist, one to a naturopath and 17 to chiropractors.[35] This article also summarised a total of 265 vascular accidents of which 142 were linked to chiropractors. Another review of complications after neck manipulations published by 1997 included 177 vascular accidents, 32 of which were fatal. The vast majority of these cases were associated with chiropractic and none with physiotherapy.[36] The most obvious explanation for the dominance of chiropractic is that chiropractors routinely employ high-velocity, short-lever thrusts on the upper spine with a rotational element, while the other healthcare professionals use them much more sparingly.[37,38] In conclusion, numerous deaths have been associated with chiropractic neck manipulations. There are reasons to suspect that under-reporting is substantial and reliable incidence figures do not exist. The risks of chiropractic neck manipulations by far outweigh their benefits. Healthcare professionals should advise the public accordingly. Sidebar What's Known Chiropractic upper spinal manipulation has repeatedly been associated with arterial dissection followed by stroke and, in some cases, death. What's New The article is the first systematic review of all fatalities reported in the medical literature. Twenty-six deaths are on record and many more seem to have remained unpublished. References Ernst E. Adverse effects of spinal manipulation: a systematic review. J R Soc Med 2007; 100: 330–8. Leon- A, Cuetter A, Ferrer G. Cervical spine manipulation: an alternative medical procedure with potentially fatal complications. South Med J 2007; 100: 201–3. Dixon P. Letter to the Editor. Adverse effects of spinal manipulation. J R Soc Med 2007; 100: 444. BJ. Letter to the Editor. Adverse effects of spinal manipulation. J R Soc Med 2007; 100: 444. Anon. Medicolegal. Malpractice: death resulting from chiropractic treatment for headache. J Am Med Assoc 1934; 103:1260, 1935; 105:1712–4, 1937; 109:233–4. Pratt- HR, Berger KE. Cerebellar and spinal injuries after chiropractic manipulation. J Am Med Assoc 1947; 133: 600–3. Anon. Medicolegal abstracts. Chiropractors: injury to spinal meninges during adjustments. J Am Med Assoc 1955; 159: 809. Ford FR, D. Thrombosis of the basilar artery with softenings in the cerebellum and brain stem due to manipulation of the neck; a report of two cases with one post-mortem examination, reasons are given to prove that damage to the vertebral arteries is responsible. Bull s Hopkins Hosp 1956; 98: 37–42. RA, Estridge MN. Neurologic complications of head and neck manipulations. JAMA 1962; 182: 528–31. Lorenz R, Vogelsang HG. Thrombosis of the basilar artery following chiropractic manipulation of the cervical spine. [in German] Thrombose der arteria basilaris nach chiropraktischen Manipulationen an der Halbwirbelsäule. Dtsch Med Wochenschr 1972; 97: 36–43. Schmitt HP. Rupturen und Thrombosen der Arteria vertebralis nach gedeckten mechanischen Insulten. Schweiz Arch Neurol Neurochir Psychiatry 1976; 119: 363–79. Krueger BR, Okazaki H. Vertebral-basilar distribution infarction following chiropractic cervical manipulation. Mayo Clin Proc 1980; 55: 322–32. Sherman DG, Hart RG, Easton JD. Abrupt change in head position and cerebral infarction. Stroke 1981; 12: 2–6. Ali Cherif A, Delpuech F, Habib M, Salamon G, Khalil R. Thrombose vertebro-basilaire apres manipulation du rachis cervical. A propos de deux cas. Ann de Med Phys 1983; 25: 459–65. Nielsen AA. Cerebrovascular insults caused by manipulation of the cervical spine. [in Danish]. Ugeskr Laeger 1984; 146: 3267–70. Zak SM, Carmody RF. Cerebellar infarction from chiropractic neck manipulation: case report and review of the literature. Ariz Med 1984; 41: 333–7. Modde PJ. Chiropractic Malpractice. Columbia, land: Hanrow Press. 1985: 269–70, 273–5, 311–8, 322–3, 329–31, 334–7. Jentzen JM, Amatuzio J, GF. Complications of cervical manipulation: a case report of fatal brainstem infarct with review of the mechanisms and predisposing factors. J Forensic Sci 1987; 32: 1089–94. Mas JL, Henin D, Bousser MG, Chain F, Haw JJ. Dissecting aneurysm of the vertebral artery and cervical manipulation: a case report with autopsy. Neurology 1989; 39: 512–5. Sherman MR, Smialek JE, Zane WE. Pathogenesis of vertebral artery occlusion following cervical spine manipulation. Arch Pathol Lab Med 1987; 111: 851–3. Raskind R, North CM. Vertebral artery injuries following chiropractic cervical spine manipulation--case reports. Angiology 1990; 41: 445–52. Sullivan EC. Brain stem stroke syndromes from cervical adjustments. Report on five cases. J Chiropr Res Clin Invest 1992; 8: 12–6. Haynes MJ. Stroke following cervical manipulation in Perth. Chiropr J Aust 1994; 24: 42–6. s M, Bohl J, Thömke F, Kallen K-J, Mahlzahn K, Wandel E. Dissection of the internal carotid artery after chiropractic manipulation of the neck. Neurology 1995; 45: 2284–6. Klougart N, Leboeuf-Yde C, Rasmussen LR. Safety in chiropractic practice. Part I. The occurrence of cerebrovascular accidents after manipulation to the neck in Denmark from 1978–1988. J Manipulative Physiol Ther 1996; 19: 371–7. Haldeman S, Kohlbeck FJ, McGregor M. Unpredictability of cerebrovascular ischemia associated with cervical spine manipulation. Spine 2002; 27: 49–55. Dziewas R, Konrad C, Dräger B et al. Cervical artery dissection – clinical features, risk factors, therapy and outcome in 126 patients. J Neurol 2003; 250: 1179–84. Presentation by Dr Preston Long DC to State of Connecticut. Connecticut State Board of Chiropractic Examiners. Hartford Connecticut. 25 October 2009. Anon. What's the harm in going to a chiropractor? What's the Harm 2009; http://whatstheharm.net/chiropractic.html (accessed October 2009). Ernst E. Vascular accidents after neck manipulation: cause or coincidence? Int J Clin Pract 2009; in press. Long PH. Stroke and spinal manipulation. J Quality Health Care 2004; 3: 8–10. Ernst E. Chiropractic: a critical evaluation. J Pain Symptom Manage 2008; 35: 544–62. Stevinson C, Honan W, Cooke B, Ernst E. Neurological complications of cervical spine manipulation. J Roy Soc Med 2001; 94: 107–10. Ernst E. Cerebrovascular complications associated with spinal manipulation. Phys Ther Rev 2004; 9: 5–15. Terrett AGJ. Current Concepts in Vertebrobasilar Complications following Spinal Manipulation, 2nd edn. Des Moines: JCMIC Group, 2001. Di Fabio RP. Manipulation of the cervical spine: risks and benefits. Physical Ther 1999; 79: 50–65. Alcantara J, Ohm J, Kunz D. The safety and effectiveness of pediatric chiropractic: a survey of chiropractors and parents in a practice-based research network. Explore (NY) 2009; 5: 290–5. Sweeney A, Doody C Manual therapy for the cervical spine and reported adverse effects: a survey of Irish Manipulative Physiotherapists. Man Ther 2010; 15: 32–6. Int J Clin Pract. 2010;64(10):1162-1165. © 2010 Blackwell Publishing -- Schneider DC PDX Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 11, 2011 Report Share Posted July 11, 2011  Dr. Kalb, Far from being misinformed I am being kept very well informed by my son who is frequently involved testifying in law suits where ham handed D.C.'s have caused serious injury to patients by overly vigorous manual manipulations. The news of the majority of these lawsuits do not reach us for one reason or another. I am certainly not suggesting that we give up corrections of the cervical spine(I don't know what gave you that impression) I'm saying that people like Arlon Fuhr, Collocca, Brimhall and Allan Creed have been very successful in teaching D.C.'s for decades without resorting to rotational moves with outstanding results. Herb Freeman D.C. Chiropractic deaths Docs:I especially like their "Conclusion."Lyndon McGill, D.C.Salem, Oregonwww.SalemSpineClinic.comwww.EvolvingDaily.com <Wiley_pub2-logo-2lines.gif> Deaths after Chiropractic: A Review of Published Cases E. Ernst Posted: 08/30/2010; Int J Clin Pract. 2010;64(10):1162-1165. © 2010 Blackwell Publishing Abstract and Introduction Abstract Objective: The aim of this study was to summarise all cases in which chiropractic spinal manipulation was followed by death.Design: This study is a systematic review of case reports.Methods: Literature searches in four electronic databases with no restrictions of time or language.Main outcome measure: Death.Results: Twenty six fatalities were published in the medical literature and many more might have remained unpublished. The alleged pathology usually was a vascular accident involving the dissection of a vertebral artery.Conclusion: Numerous deaths have occurred after chiropractic manipulations. The risks of this treatment by far outweigh its benefit. Introduction Vascular accidents after upper spinal manipulation are a well-recognised problem (e.g.[1,2]). Dissection of a vertebral artery, caused by extension and rotation of the neck beyond the physiological range of motion, is thought to be the underlying mechanism.[2] Several deaths have been reported as a consequence. Some proponents of chiropractic seem to believe that the critical evaluation of this evidence amounts to a 'scare story' (Chairman of the UK General Chiropractic Council)[3] or to 'puffing up (the evidence) out of all proportion' (President of the British Chiropractic Association).[4] A responsible approach to serious therapeutic risks, however, requires an open discussion of the facts. In this review, I aimed to provide the basis for such a discussion by summarising all fatalities which occurred after chiropractic spinal manipulation and were published in the medical literature. Methods Electronic searches were conducted in the following electronic databases: Medline, Embase, AMED, Cochrane Library (September 2009). No restrictions of time or language were applied. Search terms were chiropractic, spinal manipulation, vascular accidents, stroke, death and fatality. In addition, our own departmental files and the bibliographies of the articles thus located were searched. Several experts were also contacted for further data. Case reports were included if they provided information on human patients who had died after receiving one or more treatments from a chiropractor. Data were extracted from the included articles according to predefined criteria (Table 1). Table 1. Published case reports of deaths after chiropractic treatments References Year of publication Victim Type of vascular accident Time between treatment and death Anon[5] 1934 Woman, age unknown Tear in left lateral sinus 2 weeks Pratt- and Berger[6] 1947 32-year-old man Thrombosis of basilar, left anterior-inferior cerebellar and right posterior-inferior arteries 24 h Pratt- and Berger[6] 1947 35-year-old woman Thrombosis of posterior-inferior cerebellar artery 10 h Anon[7] 1955 Woman, age unknown Intra-spinal bleeding and compression of spinal cord 18 h Ford and [8] 1956 37-year-old man Thrombosis of basilar, left-posterior cerebellar and left-posterior cerebral arteries 6 h Ford and [8] 1956 No information provided Thrombosis of basilar artery No information provided and Estridge[9] 1962 33-year-old woman Infarct of cerebellar and brainstem 3 days Lorenz and Vogelsang[10] 1972 39-year-old woman Thrombosis of basilar artery 58 days Schmitt[11] 1976 35-years-old woman Infarct of brainstem 1 h Krueger and Okazaki[12] 1980 25-year-old man Infarct of brainstem and cerebellum 48 h Sherman et al.[13] 1981 60-year-old woman Dissection of vertebral artery 4 days Ali Cherif et al.[14] 1983 51-year-old man Infarct of medulla oblongata 11 days Nielsen[15] 1984 34-year-old man Dissection of vertebral artery aneurysen 3 h Zak and Carmody[16] 1984 53-year-old man Left vertebral, posterior-inferior and superior cerebellar artery occlusion; cerebellar infarction 27 days Modde[17] 1985 26-year-old woman Dissection of vertebral artery 1 day Jentzen et al.[18] 1987 51-year-old man Infarct of cerebellum and brainstem No information provided Sherman et al.[20] 1987 37-year-old man Infarct of brainstem 3 days Mas et al.[19] 1989 35-year-old woman Dissecting aneurysm of vertebral artery 16 h Raskind and North[21] 1990 47-year-old woman Cerebellar haemorrheae No information provided Sullivan[22] 1992 41-year-old woman Haemorrhage in ventricular system 8 h Haynes[23] 1994 36-year-old woman Dissecting aneurysm of vertebral artery, thrombo-embolism No information provided s et al.[24] 1995 29-year-old woman Infarct of right hemisphere 3 days Klougart et al.[25] 1996 34-year-old man Unclear Few hours Haldeman et al.[26] 2002 Previously unpublished legal cases No information provided No information provided Haldeman et al.[26] 2002 Previously unpublished legal cases No information provided No information provided Dziewas et al.[27] 2003 No information provided No information provided No information provided Results Twenty-six fatalities were published since 1934 in 23 articles (Table 1).[5–27] Table 1. Published case reports of deaths after chiropractic treatments References Year of publication Victim Type of vascular accident Time between treatment and death Anon[5] 1934 Woman, age unknown Tear in left lateral sinus 2 weeks Pratt- and Berger[6] 1947 32-year-old man Thrombosis of basilar, left anterior-inferior cerebellar and right posterior-inferior arteries 24 h Pratt- and Berger[6] 1947 35-year-old woman Thrombosis of posterior-inferior cerebellar artery 10 h Anon[7] 1955 Woman, age unknown Intra-spinal bleeding and compression of spinal cord 18 h Ford and [8] 1956 37-year-old man Thrombosis of basilar, left-posterior cerebellar and left-posterior cerebral arteries 6 h Ford and [8] 1956 No information provided Thrombosis of basilar artery No information provided and Estridge[9] 1962 33-year-old woman Infarct of cerebellar and brainstem 3 days Lorenz and Vogelsang[10] 1972 39-year-old woman Thrombosis of basilar artery 58 days Schmitt[11] 1976 35-years-old woman Infarct of brainstem 1 h Krueger and Okazaki[12] 1980 25-year-old man Infarct of brainstem and cerebellum 48 h Sherman et al.[13] 1981 60-year-old woman Dissection of vertebral artery 4 days Ali Cherif et al.[14] 1983 51-year-old man Infarct of medulla oblongata 11 days Nielsen[15] 1984 34-year-old man Dissection of vertebral artery aneurysen 3 h Zak and Carmody[16] 1984 53-year-old man Left vertebral, posterior-inferior and superior cerebellar artery occlusion; cerebellar infarction 27 days Modde[17] 1985 26-year-old woman Dissection of vertebral artery 1 day Jentzen et al.[18] 1987 51-year-old man Infarct of cerebellum and brainstem No information provided Sherman et al.[20] 1987 37-year-old man Infarct of brainstem 3 days Mas et al.[19] 1989 35-year-old woman Dissecting aneurysm of vertebral artery 16 h Raskind and North[21] 1990 47-year-old woman Cerebellar haemorrheae No information provided Sullivan[22] 1992 41-year-old woman Haemorrhage in ventricular system 8 h Haynes[23] 1994 36-year-old woman Dissecting aneurysm of vertebral artery, thrombo-embolism No information provided s et al.[24] 1995 29-year-old woman Infarct of right hemisphere 3 days Klougart et al.[25] 1996 34-year-old man Unclear Few hours Haldeman et al.[26] 2002 Previously unpublished legal cases No information provided No information provided Haldeman et al.[26] 2002 Previously unpublished legal cases No information provided No information provided Dziewas et al.[27] 2003 No information provided No information provided No information provided Most of the victims were relatively young; 14 were below the age of 40. There was a slight majority of female patients. The type of complication associated with death frequently related to a vascular accident leading to thrombosis and cerebral infarction. The time between treatment and death ranged from 1 h to 58 days; in 10 cases, it was 1 day or less. Unfortunately, the published information was often incomplete. Many other fatalities seem to have remained unpublished. For instance, the testimony of the chiropractor Preston Long for a court in Connecticut recently listed the family names of nine victims: Mathiason, Solsbury, Mc Cornick, Venegas, Bedenbaugh, , Fawcett, Parisien, Standt. Long also states that 'many others [are] unknown hidden behind legal agreements of silence'.[28] A website names further North American fatalities: Epping (California), G. Fowden (Utah), Grainger (Alberta), Hoffman (land), Renate Dora Labonte (Ontario), (California), Pereyra (Connecticut), A. Roth (Ontario) and Lee Strohecker (Pennsylvania).[29] Discussion This systematic review demonstrates that numerous deaths have been associated with chiropractic. Usually high-velocity, short-lever thrusts of the upper spine with rotation are implicated. They are believed to cause vertebral arterial dissection in predisposed individuals which, in turn, can lead to a chain of events including stroke and death.[1,2,26,30] Many chiropractors claim that, because arterial dissection can also occur spontaneously, causality between the chiropractic intervention and arterial dissection is not proven. However, when carefully evaluating the known facts, one does arrive at the conclusion that causality is at least likely (e.g.[30,31]). Even if it were merely a remote possibility, the precautionary principle in healthcare would mean that neck manipulations should be considered unsafe until proven otherwise. Moreover, there is no good evidence for assuming that neck manipulation is an effective therapy for any medical condition.[32] Thus, the risk-benefit balance for chiropractic neck manipulation fails to be positive. Reliable estimates of the frequency of vascular accidents are prevented by the fact that under-reporting is known to be substantial. In a survey of UK neurologists, for instance, under-reporting of serious complications was 100%.[33] Those cases which are published often turn out to be incomplete. Of 40 case reports of serious adverse effects associated with spinal manipulation, nine failed to provide any information about the clinical outcome.[34] Incomplete reporting of outcomes might therefore further increase the true number of fatalities. Obviously, the present article is not aimed at providing incidence figures; this would require a different methodology entirely. To date, no reliable incidence data are available. This review is focussed on deaths after chiropractic, yet neck manipulations are, of course, used by other healthcare professionals as well. The reason for this focus is simple: chiropractors are more frequently associated with serious manipulation-related adverse effects than osteopaths, physiotherapists, doctors or other professionals. Of the 40 cases of serious adverse effects mentioned above, 28 can be traced back to a chiropractor and none to an osteopath.[34] A review of complications after spinal manipulations by any type of healthcare professional included three deaths related to osteopaths, nine to medical practitioners, none to a physiotherapist, one to a naturopath and 17 to chiropractors.[35] This article also summarised a total of 265 vascular accidents of which 142 were linked to chiropractors. Another review of complications after neck manipulations published by 1997 included 177 vascular accidents, 32 of which were fatal. The vast majority of these cases were associated with chiropractic and none with physiotherapy.[36] The most obvious explanation for the dominance of chiropractic is that chiropractors routinely employ high-velocity, short-lever thrusts on the upper spine with a rotational element, while the other healthcare professionals use them much more sparingly.[37,38] In conclusion, numerous deaths have been associated with chiropractic neck manipulations. There are reasons to suspect that under-reporting is substantial and reliable incidence figures do not exist. The risks of chiropractic neck manipulations by far outweigh their benefits. Healthcare professionals should advise the public accordingly. Sidebar What's Known Chiropractic upper spinal manipulation has repeatedly been associated with arterial dissection followed by stroke and, in some cases, death. What's New The article is the first systematic review of all fatalities reported in the medical literature. Twenty-six deaths are on record and many more seem to have remained unpublished. References Ernst E. Adverse effects of spinal manipulation: a systematic review. J R Soc Med 2007; 100: 330–8. Leon- A, Cuetter A, Ferrer G. Cervical spine manipulation: an alternative medical procedure with potentially fatal complications. South Med J 2007; 100: 201–3. Dixon P. Letter to the Editor. Adverse effects of spinal manipulation. J R Soc Med 2007; 100: 444. BJ. Letter to the Editor. Adverse effects of spinal manipulation. J R Soc Med 2007; 100: 444. Anon. Medicolegal. Malpractice: death resulting from chiropractic treatment for headache. J Am Med Assoc 1934; 103:1260, 1935; 105:1712–4, 1937; 109:233–4. Pratt- HR, Berger KE. Cerebellar and spinal injuries after chiropractic manipulation. J Am Med Assoc 1947; 133: 600–3. Anon. Medicolegal abstracts. Chiropractors: injury to spinal meninges during adjustments. J Am Med Assoc 1955; 159: 809. Ford FR, D. Thrombosis of the basilar artery with softenings in the cerebellum and brain stem due to manipulation of the neck; a report of two cases with one post-mortem examination, reasons are given to prove that damage to the vertebral arteries is responsible. Bull s Hopkins Hosp 1956; 98: 37–42. RA, Estridge MN. Neurologic complications of head and neck manipulations. JAMA 1962; 182: 528–31. Lorenz R, Vogelsang HG. Thrombosis of the basilar artery following chiropractic manipulation of the cervical spine. [in German] Thrombose der arteria basilaris nach chiropraktischen Manipulationen an der Halbwirbelsäule. Dtsch Med Wochenschr 1972; 97: 36–43. Schmitt HP. Rupturen und Thrombosen der Arteria vertebralis nach gedeckten mechanischen Insulten. Schweiz Arch Neurol Neurochir Psychiatry 1976; 119: 363–79. Krueger BR, Okazaki H. Vertebral-basilar distribution infarction following chiropractic cervical manipulation. Mayo Clin Proc 1980; 55: 322–32. Sherman DG, Hart RG, Easton JD. Abrupt change in head position and cerebral infarction. Stroke 1981; 12: 2–6. Ali Cherif A, Delpuech F, Habib M, Salamon G, Khalil R. Thrombose vertebro-basilaire apres manipulation du rachis cervical. A propos de deux cas. Ann de Med Phys 1983; 25: 459–65. Nielsen AA. Cerebrovascular insults caused by manipulation of the cervical spine. [in Danish]. Ugeskr Laeger 1984; 146: 3267–70. Zak SM, Carmody RF. Cerebellar infarction from chiropractic neck manipulation: case report and review of the literature. Ariz Med 1984; 41: 333–7. Modde PJ. Chiropractic Malpractice. Columbia, land: Hanrow Press. 1985: 269–70, 273–5, 311–8, 322–3, 329–31, 334–7. Jentzen JM, Amatuzio J, GF. Complications of cervical manipulation: a case report of fatal brainstem infarct with review of the mechanisms and predisposing factors. J Forensic Sci 1987; 32: 1089–94. Mas JL, Henin D, Bousser MG, Chain F, Haw JJ. Dissecting aneurysm of the vertebral artery and cervical manipulation: a case report with autopsy. Neurology 1989; 39: 512–5. Sherman MR, Smialek JE, Zane WE. Pathogenesis of vertebral artery occlusion following cervical spine manipulation. Arch Pathol Lab Med 1987; 111: 851–3. Raskind R, North CM. Vertebral artery injuries following chiropractic cervical spine manipulation--case reports. Angiology 1990; 41: 445–52. Sullivan EC. Brain stem stroke syndromes from cervical adjustments. Report on five cases. J Chiropr Res Clin Invest 1992; 8: 12–6. Haynes MJ. Stroke following cervical manipulation in Perth. Chiropr J Aust 1994; 24: 42–6. s M, Bohl J, Thömke F, Kallen K-J, Mahlzahn K, Wandel E. Dissection of the internal carotid artery after chiropractic manipulation of the neck. Neurology 1995; 45: 2284–6. Klougart N, Leboeuf-Yde C, Rasmussen LR. Safety in chiropractic practice. Part I. The occurrence of cerebrovascular accidents after manipulation to the neck in Denmark from 1978–1988. J Manipulative Physiol Ther 1996; 19: 371–7. Haldeman S, Kohlbeck FJ, McGregor M. Unpredictability of cerebrovascular ischemia associated with cervical spine manipulation. Spine 2002; 27: 49–55. Dziewas R, Konrad C, Dräger B et al. Cervical artery dissection – clinical features, risk factors, therapy and outcome in 126 patients. J Neurol 2003; 250: 1179–84. Presentation by Dr Preston Long DC to State of Connecticut. Connecticut State Board of Chiropractic Examiners. Hartford Connecticut. 25 October 2009. Anon. What's the harm in going to a chiropractor? What's the Harm 2009; http://whatstheharm.net/chiropractic.html (accessed October 2009). Ernst E. Vascular accidents after neck manipulation: cause or coincidence? Int J Clin Pract 2009; in press. Long PH. Stroke and spinal manipulation. J Quality Health Care 2004; 3: 8–10. Ernst E. Chiropractic: a critical evaluation. J Pain Symptom Manage 2008; 35: 544–62. Stevinson C, Honan W, Cooke B, Ernst E. Neurological complications of cervical spine manipulation. J Roy Soc Med 2001; 94: 107–10. Ernst E. Cerebrovascular complications associated with spinal manipulation. Phys Ther Rev 2004; 9: 5–15. Terrett AGJ. Current Concepts in Vertebrobasilar Complications following Spinal Manipulation, 2nd edn. Des Moines: JCMIC Group, 2001. Di Fabio RP. Manipulation of the cervical spine: risks and benefits. Physical Ther 1999; 79: 50–65. Alcantara J, Ohm J, Kunz D. The safety and effectiveness of pediatric chiropractic: a survey of chiropractors and parents in a practice-based research network. Explore (NY) 2009; 5: 290–5. Sweeney A, Doody C Manual therapy for the cervical spine and reported adverse effects: a survey of Irish Manipulative Physiotherapists. Man Ther 2010; 15: 32–6. Int J Clin Pract. 2010;64(10):1162-1165. © 2010 Blackwell Publishing Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 11, 2011 Report Share Posted July 11, 2011  Hi Herb, I love the heck out of you and your son I consider both of you good friends and a wonderful resource and trust me I pick his incredible brain frequently. Just a couple of comments. First, this discussion was about death secondary to chiropractic treatment not mild, moderate, or serious injury supposedly secondary to chiropractic adjustments. Second, in regards to the doctors you list who have successfully taught I presume from the list instrumental light force therapy understood but, where is the scientific research that supports what they are teaching is actually doing what they say it does? In short where are the well designed controlled clinical trials, or well designed experimental studies that actually addressed reliability, validity, positive predictive value, discriminability, sensitivity and specificity? Or well-designed large controlled observational clinical studies (case-control, cohort studies etc.). In my opinion and many world chiropractic and medical authorities agree and now even the State or Oregon agree that at least for low back pain/uncomplicated injury HVLA spinal adjustments/manipulations by hand do. No we don't have to fall into the trap of our materialistic medical counter-parts that if our treatment interventions cannot be fully explained (e.g.vital force or life force) then it is epi-phenomenal and thus, irrelevant. As long as there is no patient safety issue it is enough that that procedure obtains the wanted outcomes (Les Feinberg's Tech comes to mind, I have no idea how it works and I don't care) but we must have evidence that support that whatever procedure we use in fact does what we say it does (outcomes). At some point we as a profession have to make a reasonable attempt at separating what really provides the outcomes (non-baloney) we say they do from those that simply don't (baloney) and be willing to discard that baloney procedure, test, substance or device... Cheers, Vern Chiropractic deaths Docs:I especially like their "Conclusion."Lyndon McGill, D.C.Salem, Oregonwww.SalemSpineClinic.comwww.EvolvingDaily.com <Wiley_pub2-logo-2lines.gif> Deaths after Chiropractic: A Review of Published Cases E. Ernst Posted: 08/30/2010; Int J Clin Pract. 2010;64(10):1162-1165. © 2010 Blackwell Publishing Abstract and Introduction Abstract Objective: The aim of this study was to summarise all cases in which chiropractic spinal manipulation was followed by death.Design: This study is a systematic review of case reports.Methods: Literature searches in four electronic databases with no restrictions of time or language.Main outcome measure: Death.Results: Twenty six fatalities were published in the medical literature and many more might have remained unpublished. The alleged pathology usually was a vascular accident involving the dissection of a vertebral artery.Conclusion: Numerous deaths have occurred after chiropractic manipulations. The risks of this treatment by far outweigh its benefit. Introduction Vascular accidents after upper spinal manipulation are a well-recognised problem (e.g.[1,2]). Dissection of a vertebral artery, caused by extension and rotation of the neck beyond the physiological range of motion, is thought to be the underlying mechanism.[2] Several deaths have been reported as a consequence. Some proponents of chiropractic seem to believe that the critical evaluation of this evidence amounts to a 'scare story' (Chairman of the UK General Chiropractic Council)[3] or to 'puffing up (the evidence) out of all proportion' (President of the British Chiropractic Association).[4] A responsible approach to serious therapeutic risks, however, requires an open discussion of the facts. In this review, I aimed to provide the basis for such a discussion by summarising all fatalities which occurred after chiropractic spinal manipulation and were published in the medical literature. Methods Electronic searches were conducted in the following electronic databases: Medline, Embase, AMED, Cochrane Library (September 2009). No restrictions of time or language were applied. Search terms were chiropractic, spinal manipulation, vascular accidents, stroke, death and fatality. In addition, our own departmental files and the bibliographies of the articles thus located were searched. Several experts were also contacted for further data. Case reports were included if they provided information on human patients who had died after receiving one or more treatments from a chiropractor. Data were extracted from the included articles according to predefined criteria (Table 1). Table 1. Published case reports of deaths after chiropractic treatments References Year of publication Victim Type of vascular accident Time between treatment and death Anon[5] 1934 Woman, age unknown Tear in left lateral sinus 2 weeks Pratt- and Berger[6] 1947 32-year-old man Thrombosis of basilar, left anterior-inferior cerebellar and right posterior-inferior arteries 24 h Pratt- and Berger[6] 1947 35-year-old woman Thrombosis of posterior-inferior cerebellar artery 10 h Anon[7] 1955 Woman, age unknown Intra-spinal bleeding and compression of spinal cord 18 h Ford and [8] 1956 37-year-old man Thrombosis of basilar, left-posterior cerebellar and left-posterior cerebral arteries 6 h Ford and [8] 1956 No information provided Thrombosis of basilar artery No information provided and Estridge[9] 1962 33-year-old woman Infarct of cerebellar and brainstem 3 days Lorenz and Vogelsang[10] 1972 39-year-old woman Thrombosis of basilar artery 58 days Schmitt[11] 1976 35-years-old woman Infarct of brainstem 1 h Krueger and Okazaki[12] 1980 25-year-old man Infarct of brainstem and cerebellum 48 h Sherman et al.[13] 1981 60-year-old woman Dissection of vertebral artery 4 days Ali Cherif et al.[14] 1983 51-year-old man Infarct of medulla oblongata 11 days Nielsen[15] 1984 34-year-old man Dissection of vertebral artery aneurysen 3 h Zak and Carmody[16] 1984 53-year-old man Left vertebral, posterior-inferior and superior cerebellar artery occlusion; cerebellar infarction 27 days Modde[17] 1985 26-year-old woman Dissection of vertebral artery 1 day Jentzen et al.[18] 1987 51-year-old man Infarct of cerebellum and brainstem No information provided Sherman et al.[20] 1987 37-year-old man Infarct of brainstem 3 days Mas et al.[19] 1989 35-year-old woman Dissecting aneurysm of vertebral artery 16 h Raskind and North[21] 1990 47-year-old woman Cerebellar haemorrheae No information provided Sullivan[22] 1992 41-year-old woman Haemorrhage in ventricular system 8 h Haynes[23] 1994 36-year-old woman Dissecting aneurysm of vertebral artery, thrombo-embolism No information provided s et al.[24] 1995 29-year-old woman Infarct of right hemisphere 3 days Klougart et al.[25] 1996 34-year-old man Unclear Few hours Haldeman et al.[26] 2002 Previously unpublished legal cases No information provided No information provided Haldeman et al.[26] 2002 Previously unpublished legal cases No information provided No information provided Dziewas et al.[27] 2003 No information provided No information provided No information provided Results Twenty-six fatalities were published since 1934 in 23 articles (Table 1).[5–27] Table 1. Published case reports of deaths after chiropractic treatments References Year of publication Victim Type of vascular accident Time between treatment and death Anon[5] 1934 Woman, age unknown Tear in left lateral sinus 2 weeks Pratt- and Berger[6] 1947 32-year-old man Thrombosis of basilar, left anterior-inferior cerebellar and right posterior-inferior arteries 24 h Pratt- and Berger[6] 1947 35-year-old woman Thrombosis of posterior-inferior cerebellar artery 10 h Anon[7] 1955 Woman, age unknown Intra-spinal bleeding and compression of spinal cord 18 h Ford and [8] 1956 37-year-old man Thrombosis of basilar, left-posterior cerebellar and left-posterior cerebral arteries 6 h Ford and [8] 1956 No information provided Thrombosis of basilar artery No information provided and Estridge[9] 1962 33-year-old woman Infarct of cerebellar and brainstem 3 days Lorenz and Vogelsang[10] 1972 39-year-old woman Thrombosis of basilar artery 58 days Schmitt[11] 1976 35-years-old woman Infarct of brainstem 1 h Krueger and Okazaki[12] 1980 25-year-old man Infarct of brainstem and cerebellum 48 h Sherman et al.[13] 1981 60-year-old woman Dissection of vertebral artery 4 days Ali Cherif et al.[14] 1983 51-year-old man Infarct of medulla oblongata 11 days Nielsen[15] 1984 34-year-old man Dissection of vertebral artery aneurysen 3 h Zak and Carmody[16] 1984 53-year-old man Left vertebral, posterior-inferior and superior cerebellar artery occlusion; cerebellar infarction 27 days Modde[17] 1985 26-year-old woman Dissection of vertebral artery 1 day Jentzen et al.[18] 1987 51-year-old man Infarct of cerebellum and brainstem No information provided Sherman et al.[20] 1987 37-year-old man Infarct of brainstem 3 days Mas et al.[19] 1989 35-year-old woman Dissecting aneurysm of vertebral artery 16 h Raskind and North[21] 1990 47-year-old woman Cerebellar haemorrheae No information provided Sullivan[22] 1992 41-year-old woman Haemorrhage in ventricular system 8 h Haynes[23] 1994 36-year-old woman Dissecting aneurysm of vertebral artery, thrombo-embolism No information provided s et al.[24] 1995 29-year-old woman Infarct of right hemisphere 3 days Klougart et al.[25] 1996 34-year-old man Unclear Few hours Haldeman et al.[26] 2002 Previously unpublished legal cases No information provided No information provided Haldeman et al.[26] 2002 Previously unpublished legal cases No information provided No information provided Dziewas et al.[27] 2003 No information provided No information provided No information provided Most of the victims were relatively young; 14 were below the age of 40. There was a slight majority of female patients. The type of complication associated with death frequently related to a vascular accident leading to thrombosis and cerebral infarction. The time between treatment and death ranged from 1 h to 58 days; in 10 cases, it was 1 day or less. Unfortunately, the published information was often incomplete. Many other fatalities seem to have remained unpublished. For instance, the testimony of the chiropractor Preston Long for a court in Connecticut recently listed the family names of nine victims: Mathiason, Solsbury, Mc Cornick, Venegas, Bedenbaugh, , Fawcett, Parisien, Standt. Long also states that 'many others [are] unknown hidden behind legal agreements of silence'.[28] A website names further North American fatalities: Epping (California), G. Fowden (Utah), Grainger (Alberta), Hoffman (land), Renate Dora Labonte (Ontario), (California), Pereyra (Connecticut), A. Roth (Ontario) and Lee Strohecker (Pennsylvania).[29] Discussion This systematic review demonstrates that numerous deaths have been associated with chiropractic. Usually high-velocity, short-lever thrusts of the upper spine with rotation are implicated. They are believed to cause vertebral arterial dissection in predisposed individuals which, in turn, can lead to a chain of events including stroke and death.[1,2,26,30] Many chiropractors claim that, because arterial dissection can also occur spontaneously, causality between the chiropractic intervention and arterial dissection is not proven. However, when carefully evaluating the known facts, one does arrive at the conclusion that causality is at least likely (e.g.[30,31]). Even if it were merely a remote possibility, the precautionary principle in healthcare would mean that neck manipulations should be considered unsafe until proven otherwise. Moreover, there is no good evidence for assuming that neck manipulation is an effective therapy for any medical condition.[32] Thus, the risk-benefit balance for chiropractic neck manipulation fails to be positive. Reliable estimates of the frequency of vascular accidents are prevented by the fact that under-reporting is known to be substantial. In a survey of UK neurologists, for instance, under-reporting of serious complications was 100%.[33] Those cases which are published often turn out to be incomplete. Of 40 case reports of serious adverse effects associated with spinal manipulation, nine failed to provide any information about the clinical outcome.[34] Incomplete reporting of outcomes might therefore further increase the true number of fatalities. Obviously, the present article is not aimed at providing incidence figures; this would require a different methodology entirely. To date, no reliable incidence data are available. This review is focussed on deaths after chiropractic, yet neck manipulations are, of course, used by other healthcare professionals as well. The reason for this focus is simple: chiropractors are more frequently associated with serious manipulation-related adverse effects than osteopaths, physiotherapists, doctors or other professionals. Of the 40 cases of serious adverse effects mentioned above, 28 can be traced back to a chiropractor and none to an osteopath.[34] A review of complications after spinal manipulations by any type of healthcare professional included three deaths related to osteopaths, nine to medical practitioners, none to a physiotherapist, one to a naturopath and 17 to chiropractors.[35] This article also summarised a total of 265 vascular accidents of which 142 were linked to chiropractors. Another review of complications after neck manipulations published by 1997 included 177 vascular accidents, 32 of which were fatal. The vast majority of these cases were associated with chiropractic and none with physiotherapy.[36] The most obvious explanation for the dominance of chiropractic is that chiropractors routinely employ high-velocity, short-lever thrusts on the upper spine with a rotational element, while the other healthcare professionals use them much more sparingly.[37,38] In conclusion, numerous deaths have been associated with chiropractic neck manipulations. There are reasons to suspect that under-reporting is substantial and reliable incidence figures do not exist. The risks of chiropractic neck manipulations by far outweigh their benefits. Healthcare professionals should advise the public accordingly. Sidebar What's Known Chiropractic upper spinal manipulation has repeatedly been associated with arterial dissection followed by stroke and, in some cases, death. What's New The article is the first systematic review of all fatalities reported in the medical literature. Twenty-six deaths are on record and many more seem to have remained unpublished. References Ernst E. Adverse effects of spinal manipulation: a systematic review. J R Soc Med 2007; 100: 330–8. Leon- A, Cuetter A, Ferrer G. Cervical spine manipulation: an alternative medical procedure with potentially fatal complications. South Med J 2007; 100: 201–3. Dixon P. Letter to the Editor. Adverse effects of spinal manipulation. J R Soc Med 2007; 100: 444. BJ. Letter to the Editor. Adverse effects of spinal manipulation. J R Soc Med 2007; 100: 444. Anon. Medicolegal. Malpractice: death resulting from chiropractic treatment for headache. J Am Med Assoc 1934; 103:1260, 1935; 105:1712–4, 1937; 109:233–4. Pratt- HR, Berger KE. Cerebellar and spinal injuries after chiropractic manipulation. J Am Med Assoc 1947; 133: 600–3. Anon. Medicolegal abstracts. Chiropractors: injury to spinal meninges during adjustments. J Am Med Assoc 1955; 159: 809. Ford FR, D. Thrombosis of the basilar artery with softenings in the cerebellum and brain stem due to manipulation of the neck; a report of two cases with one post-mortem examination, reasons are given to prove that damage to the vertebral arteries is responsible. Bull s Hopkins Hosp 1956; 98: 37–42. RA, Estridge MN. Neurologic complications of head and neck manipulations. JAMA 1962; 182: 528–31. Lorenz R, Vogelsang HG. Thrombosis of the basilar artery following chiropractic manipulation of the cervical spine. [in German] Thrombose der arteria basilaris nach chiropraktischen Manipulationen an der Halbwirbelsäule. Dtsch Med Wochenschr 1972; 97: 36–43. Schmitt HP. Rupturen und Thrombosen der Arteria vertebralis nach gedeckten mechanischen Insulten. Schweiz Arch Neurol Neurochir Psychiatry 1976; 119: 363–79. Krueger BR, Okazaki H. Vertebral-basilar distribution infarction following chiropractic cervical manipulation. Mayo Clin Proc 1980; 55: 322–32. Sherman DG, Hart RG, Easton JD. Abrupt change in head position and cerebral infarction. Stroke 1981; 12: 2–6. Ali Cherif A, Delpuech F, Habib M, Salamon G, Khalil R. Thrombose vertebro-basilaire apres manipulation du rachis cervical. A propos de deux cas. Ann de Med Phys 1983; 25: 459–65. Nielsen AA. Cerebrovascular insults caused by manipulation of the cervical spine. [in Danish]. Ugeskr Laeger 1984; 146: 3267–70. Zak SM, Carmody RF. Cerebellar infarction from chiropractic neck manipulation: case report and review of the literature. Ariz Med 1984; 41: 333–7. Modde PJ. Chiropractic Malpractice. Columbia, land: Hanrow Press. 1985: 269–70, 273–5, 311–8, 322–3, 329–31, 334–7. Jentzen JM, Amatuzio J, GF. Complications of cervical manipulation: a case report of fatal brainstem infarct with review of the mechanisms and predisposing factors. J Forensic Sci 1987; 32: 1089–94. Mas JL, Henin D, Bousser MG, Chain F, Haw JJ. Dissecting aneurysm of the vertebral artery and cervical manipulation: a case report with autopsy. Neurology 1989; 39: 512–5. Sherman MR, Smialek JE, Zane WE. Pathogenesis of vertebral artery occlusion following cervical spine manipulation. Arch Pathol Lab Med 1987; 111: 851–3. Raskind R, North CM. Vertebral artery injuries following chiropractic cervical spine manipulation--case reports. Angiology 1990; 41: 445–52. Sullivan EC. Brain stem stroke syndromes from cervical adjustments. Report on five cases. J Chiropr Res Clin Invest 1992; 8: 12–6. Haynes MJ. Stroke following cervical manipulation in Perth. Chiropr J Aust 1994; 24: 42–6. s M, Bohl J, Thömke F, Kallen K-J, Mahlzahn K, Wandel E. Dissection of the internal carotid artery after chiropractic manipulation of the neck. Neurology 1995; 45: 2284–6. Klougart N, Leboeuf-Yde C, Rasmussen LR. Safety in chiropractic practice. Part I. The occurrence of cerebrovascular accidents after manipulation to the neck in Denmark from 1978–1988. J Manipulative Physiol Ther 1996; 19: 371–7. Haldeman S, Kohlbeck FJ, McGregor M. Unpredictability of cerebrovascular ischemia associated with cervical spine manipulation. Spine 2002; 27: 49–55. Dziewas R, Konrad C, Dräger B et al. Cervical artery dissection – clinical features, risk factors, therapy and outcome in 126 patients. J Neurol 2003; 250: 1179–84. Presentation by Dr Preston Long DC to State of Connecticut. Connecticut State Board of Chiropractic Examiners. Hartford Connecticut. 25 October 2009. Anon. What's the harm in going to a chiropractor? What's the Harm 2009; http://whatstheharm.net/chiropractic.html (accessed October 2009). Ernst E. Vascular accidents after neck manipulation: cause or coincidence? Int J Clin Pract 2009; in press. Long PH. Stroke and spinal manipulation. J Quality Health Care 2004; 3: 8–10. Ernst E. Chiropractic: a critical evaluation. J Pain Symptom Manage 2008; 35: 544–62. Stevinson C, Honan W, Cooke B, Ernst E. Neurological complications of cervical spine manipulation. J Roy Soc Med 2001; 94: 107–10. Ernst E. Cerebrovascular complications associated with spinal manipulation. Phys Ther Rev 2004; 9: 5–15. Terrett AGJ. Current Concepts in Vertebrobasilar Complications following Spinal Manipulation, 2nd edn. Des Moines: JCMIC Group, 2001. Di Fabio RP. Manipulation of the cervical spine: risks and benefits. Physical Ther 1999; 79: 50–65. Alcantara J, Ohm J, Kunz D. The safety and effectiveness of pediatric chiropractic: a survey of chiropractors and parents in a practice-based research network. Explore (NY) 2009; 5: 290–5. Sweeney A, Doody C Manual therapy for the cervical spine and reported adverse effects: a survey of Irish Manipulative Physiotherapists. Man Ther 2010; 15: 32–6. Int J Clin Pract. 2010;64(10):1162-1165. © 2010 Blackwell Publishing Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 11, 2011 Report Share Posted July 11, 2011  Hi Vern, If you contact Arlon he will happily supply you with more than enough data to justify the methods that he teaches. Incidentally it is just that data that has permitted him to work with patients at the VA hospital in Phoenix. Herb Chiropractic deaths Docs:I especially like their "Conclusion."Lyndon McGill, D.C.Salem, Oregonwww.SalemSpineClinic.comwww.EvolvingDaily.com <Wiley_pub2-logo-2lines.gif> Deaths after Chiropractic: A Review of Published Cases E. Ernst Posted: 08/30/2010; Int J Clin Pract. 2010;64(10):1162-1165. © 2010 Blackwell Publishing Abstract and Introduction Abstract Objective: The aim of this study was to summarise all cases in which chiropractic spinal manipulation was followed by death.Design: This study is a systematic review of case reports.Methods: Literature searches in four electronic databases with no restrictions of time or language.Main outcome measure: Death.Results: Twenty six fatalities were published in the medical literature and many more might have remained unpublished. The alleged pathology usually was a vascular accident involving the dissection of a vertebral artery.Conclusion: Numerous deaths have occurred after chiropractic manipulations. The risks of this treatment by far outweigh its benefit. Introduction Vascular accidents after upper spinal manipulation are a well-recognised problem (e.g.[1,2]). Dissection of a vertebral artery, caused by extension and rotation of the neck beyond the physiological range of motion, is thought to be the underlying mechanism.[2] Several deaths have been reported as a consequence. Some proponents of chiropractic seem to believe that the critical evaluation of this evidence amounts to a 'scare story' (Chairman of the UK General Chiropractic Council)[3] or to 'puffing up (the evidence) out of all proportion' (President of the British Chiropractic Association).[4] A responsible approach to serious therapeutic risks, however, requires an open discussion of the facts. In this review, I aimed to provide the basis for such a discussion by summarising all fatalities which occurred after chiropractic spinal manipulation and were published in the medical literature. Methods Electronic searches were conducted in the following electronic databases: Medline, Embase, AMED, Cochrane Library (September 2009). No restrictions of time or language were applied. Search terms were chiropractic, spinal manipulation, vascular accidents, stroke, death and fatality. In addition, our own departmental files and the bibliographies of the articles thus located were searched. Several experts were also contacted for further data. Case reports were included if they provided information on human patients who had died after receiving one or more treatments from a chiropractor. Data were extracted from the included articles according to predefined criteria (Table 1). Table 1. Published case reports of deaths after chiropractic treatments References Year of publication Victim Type of vascular accident Time between treatment and death Anon[5] 1934 Woman, age unknown Tear in left lateral sinus 2 weeks Pratt- and Berger[6] 1947 32-year-old man Thrombosis of basilar, left anterior-inferior cerebellar and right posterior-inferior arteries 24 h Pratt- and Berger[6] 1947 35-year-old woman Thrombosis of posterior-inferior cerebellar artery 10 h Anon[7] 1955 Woman, age unknown Intra-spinal bleeding and compression of spinal cord 18 h Ford and [8] 1956 37-year-old man Thrombosis of basilar, left-posterior cerebellar and left-posterior cerebral arteries 6 h Ford and [8] 1956 No information provided Thrombosis of basilar artery No information provided and Estridge[9] 1962 33-year-old woman Infarct of cerebellar and brainstem 3 days Lorenz and Vogelsang[10] 1972 39-year-old woman Thrombosis of basilar artery 58 days Schmitt[11] 1976 35-years-old woman Infarct of brainstem 1 h Krueger and Okazaki[12] 1980 25-year-old man Infarct of brainstem and cerebellum 48 h Sherman et al.[13] 1981 60-year-old woman Dissection of vertebral artery 4 days Ali Cherif et al.[14] 1983 51-year-old man Infarct of medulla oblongata 11 days Nielsen[15] 1984 34-year-old man Dissection of vertebral artery aneurysen 3 h Zak and Carmody[16] 1984 53-year-old man Left vertebral, posterior-inferior and superior cerebellar artery occlusion; cerebellar infarction 27 days Modde[17] 1985 26-year-old woman Dissection of vertebral artery 1 day Jentzen et al.[18] 1987 51-year-old man Infarct of cerebellum and brainstem No information provided Sherman et al.[20] 1987 37-year-old man Infarct of brainstem 3 days Mas et al.[19] 1989 35-year-old woman Dissecting aneurysm of vertebral artery 16 h Raskind and North[21] 1990 47-year-old woman Cerebellar haemorrheae No information provided Sullivan[22] 1992 41-year-old woman Haemorrhage in ventricular system 8 h Haynes[23] 1994 36-year-old woman Dissecting aneurysm of vertebral artery, thrombo-embolism No information provided s et al.[24] 1995 29-year-old woman Infarct of right hemisphere 3 days Klougart et al.[25] 1996 34-year-old man Unclear Few hours Haldeman et al.[26] 2002 Previously unpublished legal cases No information provided No information provided Haldeman et al.[26] 2002 Previously unpublished legal cases No information provided No information provided Dziewas et al.[27] 2003 No information provided No information provided No information provided Results Twenty-six fatalities were published since 1934 in 23 articles (Table 1).[5–27] Table 1. Published case reports of deaths after chiropractic treatments References Year of publication Victim Type of vascular accident Time between treatment and death Anon[5] 1934 Woman, age unknown Tear in left lateral sinus 2 weeks Pratt- and Berger[6] 1947 32-year-old man Thrombosis of basilar, left anterior-inferior cerebellar and right posterior-inferior arteries 24 h Pratt- and Berger[6] 1947 35-year-old woman Thrombosis of posterior-inferior cerebellar artery 10 h Anon[7] 1955 Woman, age unknown Intra-spinal bleeding and compression of spinal cord 18 h Ford and [8] 1956 37-year-old man Thrombosis of basilar, left-posterior cerebellar and left-posterior cerebral arteries 6 h Ford and [8] 1956 No information provided Thrombosis of basilar artery No information provided and Estridge[9] 1962 33-year-old woman Infarct of cerebellar and brainstem 3 days Lorenz and Vogelsang[10] 1972 39-year-old woman Thrombosis of basilar artery 58 days Schmitt[11] 1976 35-years-old woman Infarct of brainstem 1 h Krueger and Okazaki[12] 1980 25-year-old man Infarct of brainstem and cerebellum 48 h Sherman et al.[13] 1981 60-year-old woman Dissection of vertebral artery 4 days Ali Cherif et al.[14] 1983 51-year-old man Infarct of medulla oblongata 11 days Nielsen[15] 1984 34-year-old man Dissection of vertebral artery aneurysen 3 h Zak and Carmody[16] 1984 53-year-old man Left vertebral, posterior-inferior and superior cerebellar artery occlusion; cerebellar infarction 27 days Modde[17] 1985 26-year-old woman Dissection of vertebral artery 1 day Jentzen et al.[18] 1987 51-year-old man Infarct of cerebellum and brainstem No information provided Sherman et al.[20] 1987 37-year-old man Infarct of brainstem 3 days Mas et al.[19] 1989 35-year-old woman Dissecting aneurysm of vertebral artery 16 h Raskind and North[21] 1990 47-year-old woman Cerebellar haemorrheae No information provided Sullivan[22] 1992 41-year-old woman Haemorrhage in ventricular system 8 h Haynes[23] 1994 36-year-old woman Dissecting aneurysm of vertebral artery, thrombo-embolism No information provided s et al.[24] 1995 29-year-old woman Infarct of right hemisphere 3 days Klougart et al.[25] 1996 34-year-old man Unclear Few hours Haldeman et al.[26] 2002 Previously unpublished legal cases No information provided No information provided Haldeman et al.[26] 2002 Previously unpublished legal cases No information provided No information provided Dziewas et al.[27] 2003 No information provided No information provided No information provided Most of the victims were relatively young; 14 were below the age of 40. There was a slight majority of female patients. The type of complication associated with death frequently related to a vascular accident leading to thrombosis and cerebral infarction. The time between treatment and death ranged from 1 h to 58 days; in 10 cases, it was 1 day or less. Unfortunately, the published information was often incomplete. Many other fatalities seem to have remained unpublished. For instance, the testimony of the chiropractor Preston Long for a court in Connecticut recently listed the family names of nine victims: Mathiason, Solsbury, Mc Cornick, Venegas, Bedenbaugh, , Fawcett, Parisien, Standt. Long also states that 'many others [are] unknown hidden behind legal agreements of silence'.[28] A website names further North American fatalities: Epping (California), G. Fowden (Utah), Grainger (Alberta), Hoffman (land), Renate Dora Labonte (Ontario), (California), Pereyra (Connecticut), A. Roth (Ontario) and Lee Strohecker (Pennsylvania).[29] Discussion This systematic review demonstrates that numerous deaths have been associated with chiropractic. Usually high-velocity, short-lever thrusts of the upper spine with rotation are implicated. They are believed to cause vertebral arterial dissection in predisposed individuals which, in turn, can lead to a chain of events including stroke and death.[1,2,26,30] Many chiropractors claim that, because arterial dissection can also occur spontaneously, causality between the chiropractic intervention and arterial dissection is not proven. However, when carefully evaluating the known facts, one does arrive at the conclusion that causality is at least likely (e.g.[30,31]). Even if it were merely a remote possibility, the precautionary principle in healthcare would mean that neck manipulations should be considered unsafe until proven otherwise. Moreover, there is no good evidence for assuming that neck manipulation is an effective therapy for any medical condition.[32] Thus, the risk-benefit balance for chiropractic neck manipulation fails to be positive. Reliable estimates of the frequency of vascular accidents are prevented by the fact that under-reporting is known to be substantial. In a survey of UK neurologists, for instance, under-reporting of serious complications was 100%.[33] Those cases which are published often turn out to be incomplete. Of 40 case reports of serious adverse effects associated with spinal manipulation, nine failed to provide any information about the clinical outcome.[34] Incomplete reporting of outcomes might therefore further increase the true number of fatalities. Obviously, the present article is not aimed at providing incidence figures; this would require a different methodology entirely. To date, no reliable incidence data are available. This review is focussed on deaths after chiropractic, yet neck manipulations are, of course, used by other healthcare professionals as well. The reason for this focus is simple: chiropractors are more frequently associated with serious manipulation-related adverse effects than osteopaths, physiotherapists, doctors or other professionals. Of the 40 cases of serious adverse effects mentioned above, 28 can be traced back to a chiropractor and none to an osteopath.[34] A review of complications after spinal manipulations by any type of healthcare professional included three deaths related to osteopaths, nine to medical practitioners, none to a physiotherapist, one to a naturopath and 17 to chiropractors.[35] This article also summarised a total of 265 vascular accidents of which 142 were linked to chiropractors. Another review of complications after neck manipulations published by 1997 included 177 vascular accidents, 32 of which were fatal. The vast majority of these cases were associated with chiropractic and none with physiotherapy.[36] The most obvious explanation for the dominance of chiropractic is that chiropractors routinely employ high-velocity, short-lever thrusts on the upper spine with a rotational element, while the other healthcare professionals use them much more sparingly.[37,38] In conclusion, numerous deaths have been associated with chiropractic neck manipulations. There are reasons to suspect that under-reporting is substantial and reliable incidence figures do not exist. The risks of chiropractic neck manipulations by far outweigh their benefits. Healthcare professionals should advise the public accordingly. Sidebar What's Known Chiropractic upper spinal manipulation has repeatedly been associated with arterial dissection followed by stroke and, in some cases, death. What's New The article is the first systematic review of all fatalities reported in the medical literature. Twenty-six deaths are on record and many more seem to have remained unpublished. References Ernst E. Adverse effects of spinal manipulation: a systematic review. J R Soc Med 2007; 100: 330–8. Leon- A, Cuetter A, Ferrer G. Cervical spine manipulation: an alternative medical procedure with potentially fatal complications. South Med J 2007; 100: 201–3. Dixon P. Letter to the Editor. Adverse effects of spinal manipulation. J R Soc Med 2007; 100: 444. BJ. Letter to the Editor. Adverse effects of spinal manipulation. J R Soc Med 2007; 100: 444. Anon. Medicolegal. Malpractice: death resulting from chiropractic treatment for headache. J Am Med Assoc 1934; 103:1260, 1935; 105:1712–4, 1937; 109:233–4. Pratt- HR, Berger KE. Cerebellar and spinal injuries after chiropractic manipulation. J Am Med Assoc 1947; 133: 600–3. Anon. Medicolegal abstracts. Chiropractors: injury to spinal meninges during adjustments. J Am Med Assoc 1955; 159: 809. Ford FR, D. Thrombosis of the basilar artery with softenings in the cerebellum and brain stem due to manipulation of the neck; a report of two cases with one post-mortem examination, reasons are given to prove that damage to the vertebral arteries is responsible. Bull s Hopkins Hosp 1956; 98: 37–42. RA, Estridge MN. Neurologic complications of head and neck manipulations. JAMA 1962; 182: 528–31. Lorenz R, Vogelsang HG. Thrombosis of the basilar artery following chiropractic manipulation of the cervical spine. [in German] Thrombose der arteria basilaris nach chiropraktischen Manipulationen an der Halbwirbelsäule. Dtsch Med Wochenschr 1972; 97: 36–43. Schmitt HP. Rupturen und Thrombosen der Arteria vertebralis nach gedeckten mechanischen Insulten. Schweiz Arch Neurol Neurochir Psychiatry 1976; 119: 363–79. Krueger BR, Okazaki H. Vertebral-basilar distribution infarction following chiropractic cervical manipulation. Mayo Clin Proc 1980; 55: 322–32. Sherman DG, Hart RG, Easton JD. Abrupt change in head position and cerebral infarction. Stroke 1981; 12: 2–6. Ali Cherif A, Delpuech F, Habib M, Salamon G, Khalil R. Thrombose vertebro-basilaire apres manipulation du rachis cervical. A propos de deux cas. Ann de Med Phys 1983; 25: 459–65. Nielsen AA. Cerebrovascular insults caused by manipulation of the cervical spine. [in Danish]. Ugeskr Laeger 1984; 146: 3267–70. Zak SM, Carmody RF. Cerebellar infarction from chiropractic neck manipulation: case report and review of the literature. Ariz Med 1984; 41: 333–7. Modde PJ. Chiropractic Malpractice. Columbia, land: Hanrow Press. 1985: 269–70, 273–5, 311–8, 322–3, 329–31, 334–7. Jentzen JM, Amatuzio J, GF. Complications of cervical manipulation: a case report of fatal brainstem infarct with review of the mechanisms and predisposing factors. J Forensic Sci 1987; 32: 1089–94. Mas JL, Henin D, Bousser MG, Chain F, Haw JJ. Dissecting aneurysm of the vertebral artery and cervical manipulation: a case report with autopsy. Neurology 1989; 39: 512–5. Sherman MR, Smialek JE, Zane WE. Pathogenesis of vertebral artery occlusion following cervical spine manipulation. Arch Pathol Lab Med 1987; 111: 851–3. Raskind R, North CM. Vertebral artery injuries following chiropractic cervical spine manipulation--case reports. Angiology 1990; 41: 445–52. Sullivan EC. Brain stem stroke syndromes from cervical adjustments. Report on five cases. J Chiropr Res Clin Invest 1992; 8: 12–6. Haynes MJ. Stroke following cervical manipulation in Perth. Chiropr J Aust 1994; 24: 42–6. s M, Bohl J, Thömke F, Kallen K-J, Mahlzahn K, Wandel E. Dissection of the internal carotid artery after chiropractic manipulation of the neck. Neurology 1995; 45: 2284–6. Klougart N, Leboeuf-Yde C, Rasmussen LR. Safety in chiropractic practice. Part I. The occurrence of cerebrovascular accidents after manipulation to the neck in Denmark from 1978–1988. J Manipulative Physiol Ther 1996; 19: 371–7. Haldeman S, Kohlbeck FJ, McGregor M. Unpredictability of cerebrovascular ischemia associated with cervical spine manipulation. Spine 2002; 27: 49–55. Dziewas R, Konrad C, Dräger B et al. Cervical artery dissection – clinical features, risk factors, therapy and outcome in 126 patients. J Neurol 2003; 250: 1179–84. Presentation by Dr Preston Long DC to State of Connecticut. Connecticut State Board of Chiropractic Examiners. Hartford Connecticut. 25 October 2009. Anon. What's the harm in going to a chiropractor? What's the Harm 2009; http://whatstheharm.net/chiropractic.html (accessed October 2009). Ernst E. Vascular accidents after neck manipulation: cause or coincidence? Int J Clin Pract 2009; in press. Long PH. Stroke and spinal manipulation. J Quality Health Care 2004; 3: 8–10. Ernst E. Chiropractic: a critical evaluation. J Pain Symptom Manage 2008; 35: 544–62. Stevinson C, Honan W, Cooke B, Ernst E. Neurological complications of cervical spine manipulation. J Roy Soc Med 2001; 94: 107–10. Ernst E. Cerebrovascular complications associated with spinal manipulation. Phys Ther Rev 2004; 9: 5–15. Terrett AGJ. Current Concepts in Vertebrobasilar Complications following Spinal Manipulation, 2nd edn. Des Moines: JCMIC Group, 2001. Di Fabio RP. Manipulation of the cervical spine: risks and benefits. Physical Ther 1999; 79: 50–65. Alcantara J, Ohm J, Kunz D. The safety and effectiveness of pediatric chiropractic: a survey of chiropractors and parents in a practice-based research network. Explore (NY) 2009; 5: 290–5. Sweeney A, Doody C Manual therapy for the cervical spine and reported adverse effects: a survey of Irish Manipulative Physiotherapists. Man Ther 2010; 15: 32–6. Int J Clin Pract. 2010;64(10):1162-1165. © 2010 Blackwell Publishing Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 11, 2011 Report Share Posted July 11, 2011  Understood Herb, I would indeed like to see the "data" or evidence. With that said I really can't help asking the question (have for years) if indeed Activator tech has all this high level evidence supporting its efficacy lets say for lower back pain patients, why is it that in non-of the evidence based guidelines produced here in the US has it not even been mentioned? These groups review hundreds to thousands of research articles generally only accepting the studies of high quality yet Activator nor any other instrumental adjusting device has ever been mentioned at least not to my knowledge. Alternatively HVLA spinal adjustments/manipulations by hand are and have? Oregon's new Low Back Pain Guidelines which I wrote a response too representing the Oregon Chiropractic Association accept HVLA spinal adjustments/manipulations as a level I first non-pharmacological intervention for acute low back pain...the only one by the way. Exercise therapy, massage, acupunture, yoga, cognitive-behavioral therapy, progressive relaxation, intensive interdisciplinary rehabilitation didn't make the cut, only HVLA spinal adustments by hand did! There was absolutely no mention of light force thrusting instruments such as Activator why? Vern Chiropractic deaths Docs:I especially like their "Conclusion."Lyndon McGill, D.C.Salem, Oregonwww.SalemSpineClinic.comwww.EvolvingDaily.com <Wiley_pub2-logo-2lines.gif> Deaths after Chiropractic: A Review of Published Cases E. Ernst Posted: 08/30/2010; Int J Clin Pract. 2010;64(10):1162-1165. © 2010 Blackwell Publishing Abstract and Introduction Abstract Objective: The aim of this study was to summarise all cases in which chiropractic spinal manipulation was followed by death.Design: This study is a systematic review of case reports.Methods: Literature searches in four electronic databases with no restrictions of time or language.Main outcome measure: Death.Results: Twenty six fatalities were published in the medical literature and many more might have remained unpublished. The alleged pathology usually was a vascular accident involving the dissection of a vertebral artery.Conclusion: Numerous deaths have occurred after chiropractic manipulations. The risks of this treatment by far outweigh its benefit. Introduction Vascular accidents after upper spinal manipulation are a well-recognised problem (e.g.[1,2]). Dissection of a vertebral artery, caused by extension and rotation of the neck beyond the physiological range of motion, is thought to be the underlying mechanism.[2] Several deaths have been reported as a consequence. Some proponents of chiropractic seem to believe that the critical evaluation of this evidence amounts to a 'scare story' (Chairman of the UK General Chiropractic Council)[3] or to 'puffing up (the evidence) out of all proportion' (President of the British Chiropractic Association).[4] A responsible approach to serious therapeutic risks, however, requires an open discussion of the facts. In this review, I aimed to provide the basis for such a discussion by summarising all fatalities which occurred after chiropractic spinal manipulation and were published in the medical literature. Methods Electronic searches were conducted in the following electronic databases: Medline, Embase, AMED, Cochrane Library (September 2009). No restrictions of time or language were applied. Search terms were chiropractic, spinal manipulation, vascular accidents, stroke, death and fatality. In addition, our own departmental files and the bibliographies of the articles thus located were searched. Several experts were also contacted for further data. Case reports were included if they provided information on human patients who had died after receiving one or more treatments from a chiropractor. Data were extracted from the included articles according to predefined criteria (Table 1). Table 1. Published case reports of deaths after chiropractic treatments References Year of publication Victim Type of vascular accident Time between treatment and death Anon[5] 1934 Woman, age unknown Tear in left lateral sinus 2 weeks Pratt- and Berger[6] 1947 32-year-old man Thrombosis of basilar, left anterior-inferior cerebellar and right posterior-inferior arteries 24 h Pratt- and Berger[6] 1947 35-year-old woman Thrombosis of posterior-inferior cerebellar artery 10 h Anon[7] 1955 Woman, age unknown Intra-spinal bleeding and compression of spinal cord 18 h Ford and [8] 1956 37-year-old man Thrombosis of basilar, left-posterior cerebellar and left-posterior cerebral arteries 6 h Ford and [8] 1956 No information provided Thrombosis of basilar artery No information provided and Estridge[9] 1962 33-year-old woman Infarct of cerebellar and brainstem 3 days Lorenz and Vogelsang[10] 1972 39-year-old woman Thrombosis of basilar artery 58 days Schmitt[11] 1976 35-years-old woman Infarct of brainstem 1 h Krueger and Okazaki[12] 1980 25-year-old man Infarct of brainstem and cerebellum 48 h Sherman et al.[13] 1981 60-year-old woman Dissection of vertebral artery 4 days Ali Cherif et al.[14] 1983 51-year-old man Infarct of medulla oblongata 11 days Nielsen[15] 1984 34-year-old man Dissection of vertebral artery aneurysen 3 h Zak and Carmody[16] 1984 53-year-old man Left vertebral, posterior-inferior and superior cerebellar artery occlusion; cerebellar infarction 27 days Modde[17] 1985 26-year-old woman Dissection of vertebral artery 1 day Jentzen et al.[18] 1987 51-year-old man Infarct of cerebellum and brainstem No information provided Sherman et al.[20] 1987 37-year-old man Infarct of brainstem 3 days Mas et al.[19] 1989 35-year-old woman Dissecting aneurysm of vertebral artery 16 h Raskind and North[21] 1990 47-year-old woman Cerebellar haemorrheae No information provided Sullivan[22] 1992 41-year-old woman Haemorrhage in ventricular system 8 h Haynes[23] 1994 36-year-old woman Dissecting aneurysm of vertebral artery, thrombo-embolism No information provided s et al.[24] 1995 29-year-old woman Infarct of right hemisphere 3 days Klougart et al.[25] 1996 34-year-old man Unclear Few hours Haldeman et al.[26] 2002 Previously unpublished legal cases No information provided No information provided Haldeman et al.[26] 2002 Previously unpublished legal cases No information provided No information provided Dziewas et al.[27] 2003 No information provided No information provided No information provided Results Twenty-six fatalities were published since 1934 in 23 articles (Table 1).[5–27] Table 1. Published case reports of deaths after chiropractic treatments References Year of publication Victim Type of vascular accident Time between treatment and death Anon[5] 1934 Woman, age unknown Tear in left lateral sinus 2 weeks Pratt- and Berger[6] 1947 32-year-old man Thrombosis of basilar, left anterior-inferior cerebellar and right posterior-inferior arteries 24 h Pratt- and Berger[6] 1947 35-year-old woman Thrombosis of posterior-inferior cerebellar artery 10 h Anon[7] 1955 Woman, age unknown Intra-spinal bleeding and compression of spinal cord 18 h Ford and [8] 1956 37-year-old man Thrombosis of basilar, left-posterior cerebellar and left-posterior cerebral arteries 6 h Ford and [8] 1956 No information provided Thrombosis of basilar artery No information provided and Estridge[9] 1962 33-year-old woman Infarct of cerebellar and brainstem 3 days Lorenz and Vogelsang[10] 1972 39-year-old woman Thrombosis of basilar artery 58 days Schmitt[11] 1976 35-years-old woman Infarct of brainstem 1 h Krueger and Okazaki[12] 1980 25-year-old man Infarct of brainstem and cerebellum 48 h Sherman et al.[13] 1981 60-year-old woman Dissection of vertebral artery 4 days Ali Cherif et al.[14] 1983 51-year-old man Infarct of medulla oblongata 11 days Nielsen[15] 1984 34-year-old man Dissection of vertebral artery aneurysen 3 h Zak and Carmody[16] 1984 53-year-old man Left vertebral, posterior-inferior and superior cerebellar artery occlusion; cerebellar infarction 27 days Modde[17] 1985 26-year-old woman Dissection of vertebral artery 1 day Jentzen et al.[18] 1987 51-year-old man Infarct of cerebellum and brainstem No information provided Sherman et al.[20] 1987 37-year-old man Infarct of brainstem 3 days Mas et al.[19] 1989 35-year-old woman Dissecting aneurysm of vertebral artery 16 h Raskind and North[21] 1990 47-year-old woman Cerebellar haemorrheae No information provided Sullivan[22] 1992 41-year-old woman Haemorrhage in ventricular system 8 h Haynes[23] 1994 36-year-old woman Dissecting aneurysm of vertebral artery, thrombo-embolism No information provided s et al.[24] 1995 29-year-old woman Infarct of right hemisphere 3 days Klougart et al.[25] 1996 34-year-old man Unclear Few hours Haldeman et al.[26] 2002 Previously unpublished legal cases No information provided No information provided Haldeman et al.[26] 2002 Previously unpublished legal cases No information provided No information provided Dziewas et al.[27] 2003 No information provided No information provided No information provided Most of the victims were relatively young; 14 were below the age of 40. There was a slight majority of female patients. The type of complication associated with death frequently related to a vascular accident leading to thrombosis and cerebral infarction. The time between treatment and death ranged from 1 h to 58 days; in 10 cases, it was 1 day or less. Unfortunately, the published information was often incomplete. Many other fatalities seem to have remained unpublished. For instance, the testimony of the chiropractor Preston Long for a court in Connecticut recently listed the family names of nine victims: Mathiason, Solsbury, Mc Cornick, Venegas, Bedenbaugh, , Fawcett, Parisien, Standt. Long also states that 'many others [are] unknown hidden behind legal agreements of silence'.[28] A website names further North American fatalities: Epping (California), G. Fowden (Utah), Grainger (Alberta), Hoffman (land), Renate Dora Labonte (Ontario), (California), Pereyra (Connecticut), A. Roth (Ontario) and Lee Strohecker (Pennsylvania).[29] Discussion This systematic review demonstrates that numerous deaths have been associated with chiropractic. Usually high-velocity, short-lever thrusts of the upper spine with rotation are implicated. They are believed to cause vertebral arterial dissection in predisposed individuals which, in turn, can lead to a chain of events including stroke and death.[1,2,26,30] Many chiropractors claim that, because arterial dissection can also occur spontaneously, causality between the chiropractic intervention and arterial dissection is not proven. However, when carefully evaluating the known facts, one does arrive at the conclusion that causality is at least likely (e.g.[30,31]). Even if it were merely a remote possibility, the precautionary principle in healthcare would mean that neck manipulations should be considered unsafe until proven otherwise. Moreover, there is no good evidence for assuming that neck manipulation is an effective therapy for any medical condition.[32] Thus, the risk-benefit balance for chiropractic neck manipulation fails to be positive. Reliable estimates of the frequency of vascular accidents are prevented by the fact that under-reporting is known to be substantial. In a survey of UK neurologists, for instance, under-reporting of serious complications was 100%.[33] Those cases which are published often turn out to be incomplete. Of 40 case reports of serious adverse effects associated with spinal manipulation, nine failed to provide any information about the clinical outcome.[34] Incomplete reporting of outcomes might therefore further increase the true number of fatalities. Obviously, the present article is not aimed at providing incidence figures; this would require a different methodology entirely. To date, no reliable incidence data are available. This review is focussed on deaths after chiropractic, yet neck manipulations are, of course, used by other healthcare professionals as well. The reason for this focus is simple: chiropractors are more frequently associated with serious manipulation-related adverse effects than osteopaths, physiotherapists, doctors or other professionals. Of the 40 cases of serious adverse effects mentioned above, 28 can be traced back to a chiropractor and none to an osteopath.[34] A review of complications after spinal manipulations by any type of healthcare professional included three deaths related to osteopaths, nine to medical practitioners, none to a physiotherapist, one to a naturopath and 17 to chiropractors.[35] This article also summarised a total of 265 vascular accidents of which 142 were linked to chiropractors. Another review of complications after neck manipulations published by 1997 included 177 vascular accidents, 32 of which were fatal. The vast majority of these cases were associated with chiropractic and none with physiotherapy.[36] The most obvious explanation for the dominance of chiropractic is that chiropractors routinely employ high-velocity, short-lever thrusts on the upper spine with a rotational element, while the other healthcare professionals use them much more sparingly.[37,38] In conclusion, numerous deaths have been associated with chiropractic neck manipulations. There are reasons to suspect that under-reporting is substantial and reliable incidence figures do not exist. The risks of chiropractic neck manipulations by far outweigh their benefits. Healthcare professionals should advise the public accordingly. Sidebar What's Known Chiropractic upper spinal manipulation has repeatedly been associated with arterial dissection followed by stroke and, in some cases, death. What's New The article is the first systematic review of all fatalities reported in the medical literature. Twenty-six deaths are on record and many more seem to have remained unpublished. References Ernst E. Adverse effects of spinal manipulation: a systematic review. J R Soc Med 2007; 100: 330–8. Leon- A, Cuetter A, Ferrer G. Cervical spine manipulation: an alternative medical procedure with potentially fatal complications. South Med J 2007; 100: 201–3. Dixon P. Letter to the Editor. Adverse effects of spinal manipulation. J R Soc Med 2007; 100: 444. BJ. Letter to the Editor. Adverse effects of spinal manipulation. J R Soc Med 2007; 100: 444. Anon. Medicolegal. Malpractice: death resulting from chiropractic treatment for headache. J Am Med Assoc 1934; 103:1260, 1935; 105:1712–4, 1937; 109:233–4. Pratt- HR, Berger KE. Cerebellar and spinal injuries after chiropractic manipulation. J Am Med Assoc 1947; 133: 600–3. Anon. Medicolegal abstracts. Chiropractors: injury to spinal meninges during adjustments. J Am Med Assoc 1955; 159: 809. Ford FR, D. Thrombosis of the basilar artery with softenings in the cerebellum and brain stem due to manipulation of the neck; a report of two cases with one post-mortem examination, reasons are given to prove that damage to the vertebral arteries is responsible. Bull s Hopkins Hosp 1956; 98: 37–42. RA, Estridge MN. Neurologic complications of head and neck manipulations. JAMA 1962; 182: 528–31. Lorenz R, Vogelsang HG. Thrombosis of the basilar artery following chiropractic manipulation of the cervical spine. [in German] Thrombose der arteria basilaris nach chiropraktischen Manipulationen an der Halbwirbelsäule. Dtsch Med Wochenschr 1972; 97: 36–43. Schmitt HP. Rupturen und Thrombosen der Arteria vertebralis nach gedeckten mechanischen Insulten. Schweiz Arch Neurol Neurochir Psychiatry 1976; 119: 363–79. Krueger BR, Okazaki H. Vertebral-basilar distribution infarction following chiropractic cervical manipulation. Mayo Clin Proc 1980; 55: 322–32. Sherman DG, Hart RG, Easton JD. Abrupt change in head position and cerebral infarction. Stroke 1981; 12: 2–6. Ali Cherif A, Delpuech F, Habib M, Salamon G, Khalil R. Thrombose vertebro-basilaire apres manipulation du rachis cervical. A propos de deux cas. Ann de Med Phys 1983; 25: 459–65. Nielsen AA. Cerebrovascular insults caused by manipulation of the cervical spine. [in Danish]. Ugeskr Laeger 1984; 146: 3267–70. Zak SM, Carmody RF. Cerebellar infarction from chiropractic neck manipulation: case report and review of the literature. Ariz Med 1984; 41: 333–7. Modde PJ. Chiropractic Malpractice. Columbia, land: Hanrow Press. 1985: 269–70, 273–5, 311–8, 322–3, 329–31, 334–7. Jentzen JM, Amatuzio J, GF. Complications of cervical manipulation: a case report of fatal brainstem infarct with review of the mechanisms and predisposing factors. J Forensic Sci 1987; 32: 1089–94. Mas JL, Henin D, Bousser MG, Chain F, Haw JJ. Dissecting aneurysm of the vertebral artery and cervical manipulation: a case report with autopsy. Neurology 1989; 39: 512–5. Sherman MR, Smialek JE, Zane WE. Pathogenesis of vertebral artery occlusion following cervical spine manipulation. Arch Pathol Lab Med 1987; 111: 851–3. Raskind R, North CM. Vertebral artery injuries following chiropractic cervical spine manipulation--case reports. Angiology 1990; 41: 445–52. Sullivan EC. Brain stem stroke syndromes from cervical adjustments. Report on five cases. J Chiropr Res Clin Invest 1992; 8: 12–6. Haynes MJ. Stroke following cervical manipulation in Perth. Chiropr J Aust 1994; 24: 42–6. s M, Bohl J, Thömke F, Kallen K-J, Mahlzahn K, Wandel E. Dissection of the internal carotid artery after chiropractic manipulation of the neck. Neurology 1995; 45: 2284–6. Klougart N, Leboeuf-Yde C, Rasmussen LR. Safety in chiropractic practice. Part I. The occurrence of cerebrovascular accidents after manipulation to the neck in Denmark from 1978–1988. J Manipulative Physiol Ther 1996; 19: 371–7. Haldeman S, Kohlbeck FJ, McGregor M. Unpredictability of cerebrovascular ischemia associated with cervical spine manipulation. Spine 2002; 27: 49–55. Dziewas R, Konrad C, Dräger B et al. Cervical artery dissection – clinical features, risk factors, therapy and outcome in 126 patients. J Neurol 2003; 250: 1179–84. Presentation by Dr Preston Long DC to State of Connecticut. Connecticut State Board of Chiropractic Examiners. Hartford Connecticut. 25 October 2009. Anon. What's the harm in going to a chiropractor? What's the Harm 2009; http://whatstheharm.net/chiropractic.html (accessed October 2009). Ernst E. Vascular accidents after neck manipulation: cause or coincidence? Int J Clin Pract 2009; in press. Long PH. Stroke and spinal manipulation. J Quality Health Care 2004; 3: 8–10. Ernst E. Chiropractic: a critical evaluation. J Pain Symptom Manage 2008; 35: 544–62. Stevinson C, Honan W, Cooke B, Ernst E. Neurological complications of cervical spine manipulation. J Roy Soc Med 2001; 94: 107–10. Ernst E. Cerebrovascular complications associated with spinal manipulation. Phys Ther Rev 2004; 9: 5–15. Terrett AGJ. Current Concepts in Vertebrobasilar Complications following Spinal Manipulation, 2nd edn. Des Moines: JCMIC Group, 2001. Di Fabio RP. Manipulation of the cervical spine: risks and benefits. Physical Ther 1999; 79: 50–65. Alcantara J, Ohm J, Kunz D. The safety and effectiveness of pediatric chiropractic: a survey of chiropractors and parents in a practice-based research network. Explore (NY) 2009; 5: 290–5. Sweeney A, Doody C Manual therapy for the cervical spine and reported adverse effects: a survey of Irish Manipulative Physiotherapists. Man Ther 2010; 15: 32–6. Int J Clin Pract. 2010;64(10):1162-1165. © 2010 Blackwell Publishing Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 12, 2011 Report Share Posted July 12, 2011 Herb - I get what you are saying and I can see the value it. You have a deeply held belief about the value of instrument adjusting and a great concern for our profession and how it is perceived by the public. You feel that rotational adjusting will be blamed for any negative outcome whether or not it is actually to the cause. Is this correct? I do respect your opinion. I would rather keep seeking to find the truth and educate our patients and the public and not give in because of misunderstanding and misinformation that the public is feed to discredit us. I will need to find the latest reference but it is my understanding that stroke after HVLA upper cervical adjusting is no more likely then after seeing a GP, it is in the range of approx. 1 in a million. I do respect you and your right to practice as you feel is best and it's my opinion is that properly done and screened, rotary adjustments are safe and effective and worth "fighting" the good fight to maintain. M Kalb MS DCAuthor of Winning at Aging Wellness Chiropractor and Health Coachwww.DrKalb.com 541.488.3001 On Jul 12, 2011, at 7:15 AM, BERNICE FREEMAN wrote:  Vern, Firstly D.C.'s have always been empiricists and it wasn't until the start of the B.J. Palmer clinic in the 20's that medically examined patients' were adjusted and then reexamined by the medical staff that a continuous stream of positive reports of the benefits healthwise of upper cervical adjusting were given to the profession ( I still have some of those records). More recently NUCCA and Chiropractic Biophysics have done their own research. I cannot tell you where they have been published but they certainly validate and prove that we as a profession no longer have to utilize rotational adjustments. Regardless of where or who has caused it any cervical injury from manipulation the blame will be laid at our door and billboards saying "Chiropractic Kills" will continue to appear. This is why I hope to see the schools make the switch to instrument assisted adjusting. Herb Freeman D.C. Chiropractic deaths Docs:I especially like their "Conclusion."Lyndon McGill, D.C.Salem, Oregonwww.SalemSpineClinic.comwww.EvolvingDaily.com <Wiley_pub2-logo-2lines.gif> Deaths after Chiropractic: A Review of Published Cases E. Ernst Posted: 08/30/2010; Int J Clin Pract. 2010;64(10):1162-1165. © 2010 Blackwell Publishing Abstract and Introduction Abstract Objective: The aim of this study was to summarise all cases in which chiropractic spinal manipulation was followed by death.Design: This study is a systematic review of case reports.Methods: Literature searches in four electronic databases with no restrictions of time or language.Main outcome measure: Death.Results: Twenty six fatalities were published in the medical literature and many more might have remained unpublished. The alleged pathology usually was a vascular accident involving the dissection of a vertebral artery.Conclusion: Numerous deaths have occurred after chiropractic manipulations. The risks of this treatment by far outweigh its benefit. Introduction Vascular accidents after upper spinal manipulation are a well-recognised problem (e.g.[1,2]). Dissection of a vertebral artery, caused by extension and rotation of the neck beyond the physiological range of motion, is thought to be the underlying mechanism.[2] Several deaths have been reported as a consequence. Some proponents of chiropractic seem to believe that the critical evaluation of this evidence amounts to a 'scare story' (Chairman of the UK General Chiropractic Council)[3] or to 'puffing up (the evidence) out of all proportion' (President of the British Chiropractic Association).[4] A responsible approach to serious therapeutic risks, however, requires an open discussion of the facts. In this review, I aimed to provide the basis for such a discussion by summarising all fatalities which occurred after chiropractic spinal manipulation and were published in the medical literature. Methods Electronic searches were conducted in the following electronic databases: Medline, Embase, AMED, Cochrane Library (September 2009). No restrictions of time or language were applied. Search terms were chiropractic, spinal manipulation, vascular accidents, stroke, death and fatality. In addition, our own departmental files and the bibliographies of the articles thus located were searched. Several experts were also contacted for further data. Case reports were included if they provided information on human patients who had died after receiving one or more treatments from a chiropractor. Data were extracted from the included articles according to predefined criteria (Table 1). Table 1. Published case reports of deaths after chiropractic treatments References Year of publication Victim Type of vascular accident Time between treatment and death Anon[5] 1934 Woman, age unknown Tear in left lateral sinus 2 weeks Pratt- and Berger[6] 1947 32-year-old man Thrombosis of basilar, left anterior-inferior cerebellar and right posterior-inferior arteries 24 h Pratt- and Berger[6] 1947 35-year-old woman Thrombosis of posterior-inferior cerebellar artery 10 h Anon[7] 1955 Woman, age unknown Intra-spinal bleeding and compression of spinal cord 18 h Ford and [8] 1956 37-year-old man Thrombosis of basilar, left-posterior cerebellar and left-posterior cerebral arteries 6 h Ford and [8] 1956 No information provided Thrombosis of basilar artery No information provided and Estridge[9] 1962 33-year-old woman Infarct of cerebellar and brainstem 3 days Lorenz and Vogelsang[10] 1972 39-year-old woman Thrombosis of basilar artery 58 days Schmitt[11] 1976 35-years-old woman Infarct of brainstem 1 h Krueger and Okazaki[12] 1980 25-year-old man Infarct of brainstem and cerebellum 48 h Sherman et al.[13] 1981 60-year-old woman Dissection of vertebral artery 4 days Ali Cherif et al.[14] 1983 51-year-old man Infarct of medulla oblongata 11 days Nielsen[15] 1984 34-year-old man Dissection of vertebral artery aneurysen 3 h Zak and Carmody[16] 1984 53-year-old man Left vertebral, posterior-inferior and superior cerebellar artery occlusion; cerebellar infarction 27 days Modde[17] 1985 26-year-old woman Dissection of vertebral artery 1 day Jentzen et al.[18] 1987 51-year-old man Infarct of cerebellum and brainstem No information provided Sherman et al.[20] 1987 37-year-old man Infarct of brainstem 3 days Mas et al.[19] 1989 35-year-old woman Dissecting aneurysm of vertebral artery 16 h Raskind and North[21] 1990 47-year-old woman Cerebellar haemorrheae No information provided Sullivan[22] 1992 41-year-old woman Haemorrhage in ventricular system 8 h Haynes[23] 1994 36-year-old woman Dissecting aneurysm of vertebral artery, thrombo-embolism No information provided s et al.[24] 1995 29-year-old woman Infarct of right hemisphere 3 days Klougart et al.[25] 1996 34-year-old man Unclear Few hours Haldeman et al.[26] 2002 Previously unpublished legal cases No information provided No information provided Haldeman et al.[26] 2002 Previously unpublished legal cases No information provided No information provided Dziewas et al.[27] 2003 No information provided No information provided No information provided Results Twenty-six fatalities were published since 1934 in 23 articles (Table 1).[5–27] Table 1. Published case reports of deaths after chiropractic treatments References Year of publication Victim Type of vascular accident Time between treatment and death Anon[5] 1934 Woman, age unknown Tear in left lateral sinus 2 weeks Pratt- and Berger[6] 1947 32-year-old man Thrombosis of basilar, left anterior-inferior cerebellar and right posterior-inferior arteries 24 h Pratt- and Berger[6] 1947 35-year-old woman Thrombosis of posterior-inferior cerebellar artery 10 h Anon[7] 1955 Woman, age unknown Intra-spinal bleeding and compression of spinal cord 18 h Ford and [8] 1956 37-year-old man Thrombosis of basilar, left-posterior cerebellar and left-posterior cerebral arteries 6 h Ford and [8] 1956 No information provided Thrombosis of basilar artery No information provided and Estridge[9] 1962 33-year-old woman Infarct of cerebellar and brainstem 3 days Lorenz and Vogelsang[10] 1972 39-year-old woman Thrombosis of basilar artery 58 days Schmitt[11] 1976 35-years-old woman Infarct of brainstem 1 h Krueger and Okazaki[12] 1980 25-year-old man Infarct of brainstem and cerebellum 48 h Sherman et al.[13] 1981 60-year-old woman Dissection of vertebral artery 4 days Ali Cherif et al.[14] 1983 51-year-old man Infarct of medulla oblongata 11 days Nielsen[15] 1984 34-year-old man Dissection of vertebral artery aneurysen 3 h Zak and Carmody[16] 1984 53-year-old man Left vertebral, posterior-inferior and superior cerebellar artery occlusion; cerebellar infarction 27 days Modde[17] 1985 26-year-old woman Dissection of vertebral artery 1 day Jentzen et al.[18] 1987 51-year-old man Infarct of cerebellum and brainstem No information provided Sherman et al.[20] 1987 37-year-old man Infarct of brainstem 3 days Mas et al.[19] 1989 35-year-old woman Dissecting aneurysm of vertebral artery 16 h Raskind and North[21] 1990 47-year-old woman Cerebellar haemorrheae No information provided Sullivan[22] 1992 41-year-old woman Haemorrhage in ventricular system 8 h Haynes[23] 1994 36-year-old woman Dissecting aneurysm of vertebral artery, thrombo-embolism No information provided s et al.[24] 1995 29-year-old woman Infarct of right hemisphere 3 days Klougart et al.[25] 1996 34-year-old man Unclear Few hours Haldeman et al.[26] 2002 Previously unpublished legal cases No information provided No information provided Haldeman et al.[26] 2002 Previously unpublished legal cases No information provided No information provided Dziewas et al.[27] 2003 No information provided No information provided No information provided Most of the victims were relatively young; 14 were below the age of 40. There was a slight majority of female patients. The type of complication associated with death frequently related to a vascular accident leading to thrombosis and cerebral infarction. The time between treatment and death ranged from 1 h to 58 days; in 10 cases, it was 1 day or less. Unfortunately, the published information was often incomplete. Many other fatalities seem to have remained unpublished. For instance, the testimony of the chiropractor Preston Long for a court in Connecticut recently listed the family names of nine victims: Mathiason, Solsbury, Mc Cornick, Venegas, Bedenbaugh, , Fawcett, Parisien, Standt. Long also states that 'many others [are] unknown hidden behind legal agreements of silence'.[28] A website names further North American fatalities: Epping (California), G. Fowden (Utah), Grainger (Alberta), Hoffman (land), Renate Dora Labonte (Ontario), (California), Pereyra (Connecticut), A. Roth (Ontario) and Lee Strohecker (Pennsylvania).[29] Discussion This systematic review demonstrates that numerous deaths have been associated with chiropractic. Usually high-velocity, short-lever thrusts of the upper spine with rotation are implicated. They are believed to cause vertebral arterial dissection in predisposed individuals which, in turn, can lead to a chain of events including stroke and death.[1,2,26,30] Many chiropractors claim that, because arterial dissection can also occur spontaneously, causality between the chiropractic intervention and arterial dissection is not proven. However, when carefully evaluating the known facts, one does arrive at the conclusion that causality is at least likely (e.g.[30,31]). Even if it were merely a remote possibility, the precautionary principle in healthcare would mean that neck manipulations should be considered unsafe until proven otherwise. Moreover, there is no good evidence for assuming that neck manipulation is an effective therapy for any medical condition.[32] Thus, the risk-benefit balance for chiropractic neck manipulation fails to be positive. Reliable estimates of the frequency of vascular accidents are prevented by the fact that under-reporting is known to be substantial. In a survey of UK neurologists, for instance, under-reporting of serious complications was 100%.[33] Those cases which are published often turn out to be incomplete. Of 40 case reports of serious adverse effects associated with spinal manipulation, nine failed to provide any information about the clinical outcome.[34] Incomplete reporting of outcomes might therefore further increase the true number of fatalities. Obviously, the present article is not aimed at providing incidence figures; this would require a different methodology entirely. To date, no reliable incidence data are available. This review is focussed on deaths after chiropractic, yet neck manipulations are, of course, used by other healthcare professionals as well. The reason for this focus is simple: chiropractors are more frequently associated with serious manipulation-related adverse effects than osteopaths, physiotherapists, doctors or other professionals. Of the 40 cases of serious adverse effects mentioned above, 28 can be traced back to a chiropractor and none to an osteopath.[34] A review of complications after spinal manipulations by any type of healthcare professional included three deaths related to osteopaths, nine to medical practitioners, none to a physiotherapist, one to a naturopath and 17 to chiropractors.[35] This article also summarised a total of 265 vascular accidents of which 142 were linked to chiropractors. Another review of complications after neck manipulations published by 1997 included 177 vascular accidents, 32 of which were fatal. The vast majority of these cases were associated with chiropractic and none with physiotherapy.[36] The most obvious explanation for the dominance of chiropractic is that chiropractors routinely employ high-velocity, short-lever thrusts on the upper spine with a rotational element, while the other healthcare professionals use them much more sparingly.[37,38] In conclusion, numerous deaths have been associated with chiropractic neck manipulations. There are reasons to suspect that under-reporting is substantial and reliable incidence figures do not exist. The risks of chiropractic neck manipulations by far outweigh their benefits. Healthcare professionals should advise the public accordingly. Sidebar What's Known Chiropractic upper spinal manipulation has repeatedly been associated with arterial dissection followed by stroke and, in some cases, death. What's New The article is the first systematic review of all fatalities reported in the medical literature. Twenty-six deaths are on record and many more seem to have remained unpublished. References Ernst E. Adverse effects of spinal manipulation: a systematic review. J R Soc Med 2007; 100: 330–8. Leon- A, Cuetter A, Ferrer G. Cervical spine manipulation: an alternative medical procedure with potentially fatal complications. South Med J 2007; 100: 201–3. Dixon P. Letter to the Editor. Adverse effects of spinal manipulation. J R Soc Med 2007; 100: 444. BJ. Letter to the Editor. Adverse effects of spinal manipulation. J R Soc Med 2007; 100: 444. Anon. Medicolegal. Malpractice: death resulting from chiropractic treatment for headache. J Am Med Assoc 1934; 103:1260, 1935; 105:1712–4, 1937; 109:233–4. Pratt- HR, Berger KE. Cerebellar and spinal injuries after chiropractic manipulation. J Am Med Assoc 1947; 133: 600–3. Anon. Medicolegal abstracts. Chiropractors: injury to spinal meninges during adjustments. J Am Med Assoc 1955; 159: 809. Ford FR, D. Thrombosis of the basilar artery with softenings in the cerebellum and brain stem due to manipulation of the neck; a report of two cases with one post-mortem examination, reasons are given to prove that damage to the vertebral arteries is responsible. Bull s Hopkins Hosp 1956; 98: 37–42. RA, Estridge MN. Neurologic complications of head and neck manipulations. JAMA 1962; 182: 528–31. Lorenz R, Vogelsang HG. Thrombosis of the basilar artery following chiropractic manipulation of the cervical spine. [in German] Thrombose der arteria basilaris nach chiropraktischen Manipulationen an der Halbwirbelsäule. Dtsch Med Wochenschr 1972; 97: 36–43. Schmitt HP. Rupturen und Thrombosen der Arteria vertebralis nach gedeckten mechanischen Insulten. Schweiz Arch Neurol Neurochir Psychiatry 1976; 119: 363–79. Krueger BR, Okazaki H. Vertebral-basilar distribution infarction following chiropractic cervical manipulation. Mayo Clin Proc 1980; 55: 322–32. Sherman DG, Hart RG, Easton JD. Abrupt change in head position and cerebral infarction. Stroke 1981; 12: 2–6. Ali Cherif A, Delpuech F, Habib M, Salamon G, Khalil R. Thrombose vertebro-basilaire apres manipulation du rachis cervical. A propos de deux cas. Ann de Med Phys 1983; 25: 459–65. Nielsen AA. Cerebrovascular insults caused by manipulation of the cervical spine. [in Danish]. Ugeskr Laeger 1984; 146: 3267–70. Zak SM, Carmody RF. Cerebellar infarction from chiropractic neck manipulation: case report and review of the literature. Ariz Med 1984; 41: 333–7. Modde PJ. Chiropractic Malpractice. Columbia, land: Hanrow Press. 1985: 269–70, 273–5, 311–8, 322–3, 329–31, 334–7. Jentzen JM, Amatuzio J, GF. Complications of cervical manipulation: a case report of fatal brainstem infarct with review of the mechanisms and predisposing factors. J Forensic Sci 1987; 32: 1089–94. Mas JL, Henin D, Bousser MG, Chain F, Haw JJ. Dissecting aneurysm of the vertebral artery and cervical manipulation: a case report with autopsy. Neurology 1989; 39: 512–5. Sherman MR, Smialek JE, Zane WE. Pathogenesis of vertebral artery occlusion following cervical spine manipulation. Arch Pathol Lab Med 1987; 111: 851–3. Raskind R, North CM. Vertebral artery injuries following chiropractic cervical spine manipulation--case reports. Angiology 1990; 41: 445–52. Sullivan EC. Brain stem stroke syndromes from cervical adjustments. Report on five cases. J Chiropr Res Clin Invest 1992; 8: 12–6. Haynes MJ. Stroke following cervical manipulation in Perth. Chiropr J Aust 1994; 24: 42–6. s M, Bohl J, Thömke F, Kallen K-J, Mahlzahn K, Wandel E. Dissection of the internal carotid artery after chiropractic manipulation of the neck. Neurology 1995; 45: 2284–6. Klougart N, Leboeuf-Yde C, Rasmussen LR. Safety in chiropractic practice. Part I. The occurrence of cerebrovascular accidents after manipulation to the neck in Denmark from 1978–1988. J Manipulative Physiol Ther 1996; 19: 371–7. Haldeman S, Kohlbeck FJ, McGregor M. Unpredictability of cerebrovascular ischemia associated with cervical spine manipulation. Spine 2002; 27: 49–55. Dziewas R, Konrad C, Dräger B et al. Cervical artery dissection – clinical features, risk factors, therapy and outcome in 126 patients. J Neurol 2003; 250: 1179–84. Presentation by Dr Preston Long DC to State of Connecticut. Connecticut State Board of Chiropractic Examiners. Hartford Connecticut. 25 October 2009. Anon. What's the harm in going to a chiropractor? What's the Harm 2009; http://whatstheharm.net/chiropractic.html (accessed October 2009). Ernst E. Vascular accidents after neck manipulation: cause or coincidence? Int J Clin Pract 2009; in press. Long PH. Stroke and spinal manipulation. J Quality Health Care 2004; 3: 8–10. Ernst E. Chiropractic: a critical evaluation. J Pain Symptom Manage 2008; 35: 544–62. Stevinson C, Honan W, Cooke B, Ernst E. Neurological complications of cervical spine manipulation. J Roy Soc Med 2001; 94: 107–10. Ernst E. Cerebrovascular complications associated with spinal manipulation. Phys Ther Rev 2004; 9: 5–15. Terrett AGJ. Current Concepts in Vertebrobasilar Complications following Spinal Manipulation, 2nd edn. Des Moines: JCMIC Group, 2001. Di Fabio RP. Manipulation of the cervical spine: risks and benefits. Physical Ther 1999; 79: 50–65. Alcantara J, Ohm J, Kunz D. The safety and effectiveness of pediatric chiropractic: a survey of chiropractors and parents in a practice-based research network. Explore (NY) 2009; 5: 290–5. Sweeney A, Doody C Manual therapy for the cervical spine and reported adverse effects: a survey of Irish Manipulative Physiotherapists. Man Ther 2010; 15: 32–6. Int J Clin Pract. 2010;64(10):1162-1165. © 2010 Blackwell Publishing Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 12, 2011 Report Share Posted July 12, 2011 Hi All, Thanks Vern for the opportunity to mention that the next NMT Quick-Care Level A seminar is in Portland at the Red Lion Convention Center on July 20-31. This is the new format for learning and practicing NMT that is incredibly easy to learn and apply. Supplement the great mechanistic procedures you offer your patients with this revolutionary system of “informational medicineâ€. You will find that NMT Quick-Care provides you with a simple way of correcting allergies, autoimmune inflammation, chronic pain, emotional suffering, and more. Applied in the form of a therapeutic dialog, with patient responses monitored by muscle response testing, NMT Quick-Care is a powerful way of indentifying and correcting the informational basis of disease and failure to heal. It is an efficient way to induce the mind-body to update its awareness of changes in its internal and external environment that have been misperceived or overlooked and to redirect mind-body function to unlock the innate healing process. You all know about the hypothalamic-pituitary-adrenal axis and how thoughts and beliefs contribute to this key regulatory system of the mind-body. Now you have an immediate and direct way of assessing and correcting neurological organization of the mind-body to optimize HPA axis induction of the healing process; to address what D.D. and B.J. called “Quality Interferenceâ€. NMT allows you to address the “other half†of the problem of interference with the expression of Innate Intelligence. Check out the NMT website www.nmt.md for more information on registration, testimonials from patients and students of NMT. Hope to see a few of you there. S. Feinberg, D.C. From: [mailto: ] On Behalf Of Vern SaboeSent: Monday, July 11, 2011 8:30 PM Kalb; ; BERNICE FREEMANSubject: Re: Chiropractic deaths  Hi Herb, I love the heck out of you and your son I consider both of you good friends and a wonderful resource and trust me I pick his incredible brain frequently. Just a couple of comments. First, this discussion was about death secondary to chiropractic treatment not mild, moderate, or serious injury supposedly secondary to chiropractic adjustments. Second, in regards to the doctors you list who have successfully taught I presume from the list instrumental light force therapy understood but, where is the scientific research that supports what they are teaching is actually doing what they say it does? In short where are the well designed controlled clinical trials, or well designed experimental studies that actually addressed reliability, validity, positive predictive value, discriminability, sensitivity and specificity? Or well-designed large controlled observational clinical studies (case-control, cohort studies etc.). In my opinion and many world chiropractic and medical authorities agree and now even the State or Oregon agree that at least for low back pain/uncomplicated injury HVLA spinal adjustments/manipulations by hand do. No we don't have to fall into the trap of our materialistic medical counter-parts that if our treatment interventions cannot be fully explained (e.g.vital force or life force) then it is epi-phenomenal and thus, irrelevant. As long as there is no patient safety issue it is enough that that procedure obtains the wanted outcomes (Les Feinberg's Tech comes to mind, I have no idea how it works and I don't care) but we must have evidence that support that whatever procedure we use in fact does what we say it does (outcomes). At some point we as a profession have to make a reasonable attempt at separating what really provides the outcomes (non-baloney) we say they do from those that simply don't (baloney) and be willing to discard that baloney procedure, test, substance or device... Cheers, Vern Chiropractic deaths Docs:I especially like their " Conclusion. " Lyndon McGill, D.C.Salem, Oregonwww.SalemSpineClinic.comwww.EvolvingDaily.com <Wiley_pub2-logo-2lines.gif> Deaths after Chiropractic: A Review of Published CasesE. ErnstPosted: 08/30/2010; Int J Clin Pract. 2010;64(10):1162-1165. © 2010 Blackwell PublishingAbstract and IntroductionAbstractObjective: The aim of this study was to summarise all cases in which chiropractic spinal manipulation was followed by death.Design: This study is a systematic review of case reports.Methods: Literature searches in four electronic databases with no restrictions of time or language.Main outcome measure: Death.Results: Twenty six fatalities were published in the medical literature and many more might have remained unpublished. The alleged pathology usually was a vascular accident involving the dissection of a vertebral artery.Conclusion: Numerous deaths have occurred after chiropractic manipulations. The risks of this treatment by far outweigh its benefit.IntroductionVascular accidents after upper spinal manipulation are a well-recognised problem (e.g.[1,2]). Dissection of a vertebral artery, caused by extension and rotation of the neck beyond the physiological range of motion, is thought to be the underlying mechanism.[2] Several deaths have been reported as a consequence. Some proponents of chiropractic seem to believe that the critical evaluation of this evidence amounts to a 'scare story' (Chairman of the UK General Chiropractic Council)[3] or to 'puffing up (the evidence) out of all proportion' (President of the British Chiropractic Association).[4] A responsible approach to serious therapeutic risks, however, requires an open discussion of the facts.In this review, I aimed to provide the basis for such a discussion by summarising all fatalities which occurred after chiropractic spinal manipulation and were published in the medical literature.MethodsElectronic searches were conducted in the following electronic databases: Medline, Embase, AMED, Cochrane Library (September 2009). No restrictions of time or language were applied. Search terms were chiropractic, spinal manipulation, vascular accidents, stroke, death and fatality. In addition, our own departmental files and the bibliographies of the articles thus located were searched. Several experts were also contacted for further data. Case reports were included if they provided information on human patients who had died after receiving one or more treatments from a chiropractor. Data were extracted from the included articles according to predefined criteria (Table 1).Table 1. Published case reports of deaths after chiropractic treatmentsReferencesYear of publicationVictimType of vascular accidentTime between treatment and deathAnon[5] 1934Woman, age unknownTear in left lateral sinus2 weeksPratt- and Berger[6] 194732-year-old manThrombosis of basilar, left anterior-inferior cerebellar and right posterior-inferior arteries24 hPratt- and Berger[6] 194735-year-old womanThrombosis of posterior-inferior cerebellar artery10 hAnon[7] 1955Woman, age unknownIntra-spinal bleeding and compression of spinal cord18 hFord and [8] 195637-year-old manThrombosis of basilar, left-posterior cerebellar and left-posterior cerebral arteries6 hFord and [8] 1956No information providedThrombosis of basilar arteryNo information provided and Estridge[9] 196233-year-old womanInfarct of cerebellar and brainstem3 daysLorenz and Vogelsang[10] 197239-year-old womanThrombosis of basilar artery58 daysSchmitt[11] 197635-years-old womanInfarct of brainstem1 hKrueger and Okazaki[12] 198025-year-old manInfarct of brainstem and cerebellum48 hSherman et al.[13] 198160-year-old womanDissection of vertebral artery4 daysAli Cherif et al.[14] 198351-year-old manInfarct of medulla oblongata11 daysNielsen[15] 198434-year-old manDissection of vertebral artery aneurysen3 hZak and Carmody[16] 198453-year-old manLeft vertebral, posterior-inferior and superior cerebellar artery occlusion; cerebellar infarction27 daysModde[17] 198526-year-old womanDissection of vertebral artery1 dayJentzen et al.[18] 198751-year-old manInfarct of cerebellum and brainstemNo information providedSherman et al.[20] 198737-year-old manInfarct of brainstem3 daysMas et al.[19] 198935-year-old womanDissecting aneurysm of vertebral artery16 hRaskind and North[21] 199047-year-old womanCerebellar haemorrheaeNo information providedSullivan[22] 199241-year-old womanHaemorrhage in ventricular system8 hHaynes[23] 199436-year-old womanDissecting aneurysm of vertebral artery, thrombo-embolismNo information provideds et al.[24] 199529-year-old womanInfarct of right hemisphere3 daysKlougart et al.[25] 199634-year-old manUnclearFew hoursHaldeman et al.[26] 2002Previously unpublished legal casesNo information providedNo information providedHaldeman et al.[26] 2002Previously unpublished legal casesNo information providedNo information providedDziewas et al.[27] 2003No information providedNo information providedNo information providedResultsTwenty-six fatalities were published since 1934 in 23 articles (Table 1).[5–27] Table 1. Published case reports of deaths after chiropractic treatmentsReferencesYear of publicationVictimType of vascular accidentTime between treatment and deathAnon[5] 1934Woman, age unknownTear in left lateral sinus2 weeksPratt- and Berger[6] 194732-year-old manThrombosis of basilar, left anterior-inferior cerebellar and right posterior-inferior arteries24 hPratt- and Berger[6] 194735-year-old womanThrombosis of posterior-inferior cerebellar artery10 hAnon[7] 1955Woman, age unknownIntra-spinal bleeding and compression of spinal cord18 hFord and [8] 195637-year-old manThrombosis of basilar, left-posterior cerebellar and left-posterior cerebral arteries6 hFord and [8] 1956No information providedThrombosis of basilar arteryNo information provided and Estridge[9] 196233-year-old womanInfarct of cerebellar and brainstem3 daysLorenz and Vogelsang[10] 197239-year-old womanThrombosis of basilar artery58 daysSchmitt[11] 197635-years-old womanInfarct of brainstem1 hKrueger and Okazaki[12] 198025-year-old manInfarct of brainstem and cerebellum48 hSherman et al.[13] 198160-year-old womanDissection of vertebral artery4 daysAli Cherif et al.[14] 198351-year-old manInfarct of medulla oblongata11 daysNielsen[15] 198434-year-old manDissection of vertebral artery aneurysen3 hZak and Carmody[16] 198453-year-old manLeft vertebral, posterior-inferior and superior cerebellar artery occlusion; cerebellar infarction27 daysModde[17] 198526-year-old womanDissection of vertebral artery1 dayJentzen et al.[18] 198751-year-old manInfarct of cerebellum and brainstemNo information providedSherman et al.[20] 198737-year-old manInfarct of brainstem3 daysMas et al.[19] 198935-year-old womanDissecting aneurysm of vertebral artery16 hRaskind and North[21] 199047-year-old womanCerebellar haemorrheaeNo information providedSullivan[22] 199241-year-old womanHaemorrhage in ventricular system8 hHaynes[23] 199436-year-old womanDissecting aneurysm of vertebral artery, thrombo-embolismNo information provideds et al.[24] 199529-year-old womanInfarct of right hemisphere3 daysKlougart et al.[25] 199634-year-old manUnclearFew hoursHaldeman et al.[26] 2002Previously unpublished legal casesNo information providedNo information providedHaldeman et al.[26] 2002Previously unpublished legal casesNo information providedNo information providedDziewas et al.[27] 2003No information providedNo information providedNo information providedMost of the victims were relatively young; 14 were below the age of 40. There was a slight majority of female patients. The type of complication associated with death frequently related to a vascular accident leading to thrombosis and cerebral infarction. The time between treatment and death ranged from 1 h to 58 days; in 10 cases, it was 1 day or less. Unfortunately, the published information was often incomplete.Many other fatalities seem to have remained unpublished. For instance, the testimony of the chiropractor Preston Long for a court in Connecticut recently listed the family names of nine victims: Mathiason, Solsbury, Mc Cornick, Venegas, Bedenbaugh, , Fawcett, Parisien, Standt. Long also states that 'many others [are] unknown hidden behind legal agreements of silence'.[28] A website names further North American fatalities: Epping (California), G. Fowden (Utah), Grainger (Alberta), Hoffman (land), Renate Dora Labonte (Ontario), (California), Pereyra (Connecticut), A. Roth (Ontario) and Lee Strohecker (Pennsylvania).[29] DiscussionThis systematic review demonstrates that numerous deaths have been associated with chiropractic. Usually high-velocity, short-lever thrusts of the upper spine with rotation are implicated. They are believed to cause vertebral arterial dissection in predisposed individuals which, in turn, can lead to a chain of events including stroke and death.[1,2,26,30] Many chiropractors claim that, because arterial dissection can also occur spontaneously, causality between the chiropractic intervention and arterial dissection is not proven. However, when carefully evaluating the known facts, one does arrive at the conclusion that causality is at least likely (e.g.[30,31]). Even if it were merely a remote possibility, the precautionary principle in healthcare would mean that neck manipulations should be considered unsafe until proven otherwise. Moreover, there is no good evidence for assuming that neck manipulation is an effective therapy for any medical condition.[32] Thus, the risk-benefit balance for chiropractic neck manipulation fails to be positive.Reliable estimates of the frequency of vascular accidents are prevented by the fact that under-reporting is known to be substantial. In a survey of UK neurologists, for instance, under-reporting of serious complications was 100%.[33] Those cases which are published often turn out to be incomplete. Of 40 case reports of serious adverse effects associated with spinal manipulation, nine failed to provide any information about the clinical outcome.[34] Incomplete reporting of outcomes might therefore further increase the true number of fatalities. Obviously, the present article is not aimed at providing incidence figures; this would require a different methodology entirely. To date, no reliable incidence data are available.This review is focussed on deaths after chiropractic, yet neck manipulations are, of course, used by other healthcare professionals as well. The reason for this focus is simple: chiropractors are more frequently associated with serious manipulation-related adverse effects than osteopaths, physiotherapists, doctors or other professionals. Of the 40 cases of serious adverse effects mentioned above, 28 can be traced back to a chiropractor and none to an osteopath.[34] A review of complications after spinal manipulations by any type of healthcare professional included three deaths related to osteopaths, nine to medical practitioners, none to a physiotherapist, one to a naturopath and 17 to chiropractors.[35] This article also summarised a total of 265 vascular accidents of which 142 were linked to chiropractors. Another review of complications after neck manipulations published by 1997 included 177 vascular accidents, 32 of which were fatal. The vast majority of these cases were associated with chiropractic and none with physiotherapy.[36] The most obvious explanation for the dominance of chiropractic is that chiropractors routinely employ high-velocity, short-lever thrusts on the upper spine with a rotational element, while the other healthcare professionals use them much more sparingly.[37,38] In conclusion, numerous deaths have been associated with chiropractic neck manipulations. There are reasons to suspect that under-reporting is substantial and reliable incidence figures do not exist. The risks of chiropractic neck manipulations by far outweigh their benefits. Healthcare professionals should advise the public accordingly.SidebarWhat's KnownChiropractic upper spinal manipulation has repeatedly been associated with arterial dissection followed by stroke and, in some cases, death.What's NewThe article is the first systematic review of all fatalities reported in the medical literature. Twenty-six deaths are on record and many more seem to have remained unpublished.ReferencesErnst E. Adverse effects of spinal manipulation: a systematic review. J R Soc Med 2007; 100: 330–8. Leon- A, Cuetter A, Ferrer G. Cervical spine manipulation: an alternative medical procedure with potentially fatal complications. South Med J 2007; 100: 201–3. Dixon P. Letter to the Editor. Adverse effects of spinal manipulation. J R Soc Med 2007; 100: 444. BJ. Letter to the Editor. Adverse effects of spinal manipulation. J R Soc Med 2007; 100: 444. Anon. Medicolegal. Malpractice: death resulting from chiropractic treatment for headache. J Am Med Assoc 1934; 103:1260, 1935; 105:1712–4, 1937; 109:233–4. Pratt- HR, Berger KE. Cerebellar and spinal injuries after chiropractic manipulation. J Am Med Assoc 1947; 133: 600–3. Anon. Medicolegal abstracts. Chiropractors: injury to spinal meninges during adjustments. J Am Med Assoc 1955; 159: 809. Ford FR, D. Thrombosis of the basilar artery with softenings in the cerebellum and brain stem due to manipulation of the neck; a report of two cases with one post-mortem examination, reasons are given to prove that damage to the vertebral arteries is responsible. Bull s Hopkins Hosp 1956; 98: 37–42. RA, Estridge MN. Neurologic complications of head and neck manipulations. JAMA 1962; 182: 528–31. Lorenz R, Vogelsang HG. Thrombosis of the basilar artery following chiropractic manipulation of the cervical spine. [in German] Thrombose der arteria basilaris nach chiropraktischen Manipulationen an der Halbwirbelsäule. Dtsch Med Wochenschr 1972; 97: 36–43. Schmitt HP. Rupturen und Thrombosen der Arteria vertebralis nach gedeckten mechanischen Insulten. Schweiz Arch Neurol Neurochir Psychiatry 1976; 119: 363–79. Krueger BR, Okazaki H. Vertebral-basilar distribution infarction following chiropractic cervical manipulation. Mayo Clin Proc 1980; 55: 322–32. Sherman DG, Hart RG, Easton JD. Abrupt change in head position and cerebral infarction. Stroke 1981; 12: 2–6. Ali Cherif A, Delpuech F, Habib M, Salamon G, Khalil R. Thrombose vertebro-basilaire apres manipulation du rachis cervical. A propos de deux cas. Ann de Med Phys 1983; 25: 459–65. Nielsen AA. Cerebrovascular insults caused by manipulation of the cervical spine. [in Danish]. Ugeskr Laeger 1984; 146: 3267–70. Zak SM, Carmody RF. Cerebellar infarction from chiropractic neck manipulation: case report and review of the literature. Ariz Med 1984; 41: 333–7. Modde PJ. Chiropractic Malpractice. Columbia, land: Hanrow Press. 1985: 269–70, 273–5, 311–8, 322–3, 329–31, 334–7. Jentzen JM, Amatuzio J, GF. Complications of cervical manipulation: a case report of fatal brainstem infarct with review of the mechanisms and predisposing factors. J Forensic Sci 1987; 32: 1089–94. Mas JL, Henin D, Bousser MG, Chain F, Haw JJ. Dissecting aneurysm of the vertebral artery and cervical manipulation: a case report with autopsy. Neurology 1989; 39: 512–5. Sherman MR, Smialek JE, Zane WE. Pathogenesis of vertebral artery occlusion following cervical spine manipulation. Arch Pathol Lab Med 1987; 111: 851–3. Raskind R, North CM. Vertebral artery injuries following chiropractic cervical spine manipulation--case reports. Angiology 1990; 41: 445–52. Sullivan EC. Brain stem stroke syndromes from cervical adjustments. Report on five cases. J Chiropr Res Clin Invest 1992; 8: 12–6. Haynes MJ. Stroke following cervical manipulation in Perth. Chiropr J Aust 1994; 24: 42–6. s M, Bohl J, Thömke F, Kallen K-J, Mahlzahn K, Wandel E. Dissection of the internal carotid artery after chiropractic manipulation of the neck. Neurology 1995; 45: 2284–6. Klougart N, Leboeuf-Yde C, Rasmussen LR. Safety in chiropractic practice. Part I. The occurrence of cerebrovascular accidents after manipulation to the neck in Denmark from 1978–1988. J Manipulative Physiol Ther 1996; 19: 371–7. Haldeman S, Kohlbeck FJ, McGregor M. Unpredictability of cerebrovascular ischemia associated with cervical spine manipulation. Spine 2002; 27: 49–55. Dziewas R, Konrad C, Dräger B et al. Cervical artery dissection – clinical features, risk factors, therapy and outcome in 126 patients. J Neurol 2003; 250: 1179–84. Presentation by Dr Preston Long DC to State of Connecticut. Connecticut State Board of Chiropractic Examiners. Hartford Connecticut. 25 October 2009. Anon. What's the harm in going to a chiropractor? What's the Harm 2009; http://whatstheharm.net/chiropractic.html (accessed October 2009). Ernst E. Vascular accidents after neck manipulation: cause or coincidence? Int J Clin Pract 2009; in press. Long PH. Stroke and spinal manipulation. J Quality Health Care 2004; 3: 8–10. Ernst E. Chiropractic: a critical evaluation. J Pain Symptom Manage 2008; 35: 544–62. Stevinson C, Honan W, Cooke B, Ernst E. Neurological complications of cervical spine manipulation. J Roy Soc Med 2001; 94: 107–10. Ernst E. Cerebrovascular complications associated with spinal manipulation. Phys Ther Rev 2004; 9: 5–15. Terrett AGJ. Current Concepts in Vertebrobasilar Complications following Spinal Manipulation, 2nd edn. Des Moines: JCMIC Group, 2001. Di Fabio RP. Manipulation of the cervical spine: risks and benefits. Physical Ther 1999; 79: 50–65. Alcantara J, Ohm J, Kunz D. The safety and effectiveness of pediatric chiropractic: a survey of chiropractors and parents in a practice-based research network. Explore (NY) 2009; 5: 290–5. Sweeney A, Doody C Manual therapy for the cervical spine and reported adverse effects: a survey of Irish Manipulative Physiotherapists. Man Ther 2010; 15: 32–6. Int J Clin Pract. 2010;64(10):1162-1165. © 2010 Blackwell Publishing Error! Filename not specified. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 12, 2011 Report Share Posted July 12, 2011 Hi Charlie, Thanks for noticing the typo. The NMT Quick-Care seminar is July 29-31. S. Feinberg, D.C. From: Charlie Caughlin [mailto:caughlindrc@...] Sent: Tuesday, July 12, 2011 9:32 AMfeinberg@...Subject: RE: Chiropractic deaths Les are those dates correct?Dr. A Caughlin DC CAC155 NW 1st Ave Day, Or. 97845 office 541-575-1063 fax 541-575-5554vsaboe@...; drjohnkalb@...; Oregondcs ; hbf4747@...From: feinberg@...Date: Tue, 12 Jul 2011 09:22:07 -0700Subject: RE: Chiropractic deaths Hi All, Thanks Vern for the opportunity to mention that the next NMT Quick-Care Level A seminar is in Portland at the Red Lion Convention Center on July 20-31. This is the new format for learning and practicing NMT that is incredibly easy to learn and apply. Supplement the great mechanistic procedures you offer your patients with this revolutionary system of “informational medicineâ€. You will find that NMT Quick-Care provides you with a simple way of correcting allergies, autoimmune inflammation, chronic pain, emotional suffering, and more. Applied in the form of a therapeutic dialog, with patient responses monitored by muscle response testing, NMT Quick-Care is a powerful way of indentifying and correcting the informational basis of disease and failure to heal. It is an efficient way to induce the mind-body to update its awareness of changes in its internal and external environment that have been misperceived or overlooked and to redirect mind-body function to unlock the innate healing process. You all know about the hypothalamic-pituitary-adrenal axis and how thoughts and beliefs contribute to this key regulatory system of the mind-body. Now you have an immediate and direct way of assessing and correcting neurological organization of the mind-body to optimize HPA axis induction of the healing process; to address what D.D. and B.J. called “Quality Interferenceâ€. NMT allows you to address the “other half†of the problem of interference with the expression of Innate Intelligence. Check out the NMT website www.nmt.md for more information on registration, testimonials from patients and students of NMT. Hope to see a few of you there. S. Feinberg, D.C. From: [mailto: ] On Behalf Of Vern SaboeSent: Monday, July 11, 2011 8:30 PM Kalb; ; BERNICE FREEMANSubject: Re: Chiropractic deaths  Hi Herb, I love the heck out of you and your son I consider both of you good friends and a wonderful resource and trust me I pick his incredible brain frequently. Just a couple of comments. First, this discussion was about death secondary to chiropractic treatment not mild, moderate, or serious injury supposedly secondary to chiropractic adjustments. Second, in regards to the doctors you list who have successfully taught I presume from the list instrumental light force therapy understood but, where is the scientific research that supports what they are teaching is actually doing what they say it does? In short where are the well designed controlled clinical trials, or well designed experimental studies that actually addressed reliability, validity, positive predictive value, discriminability, sensitivity and specificity? Or well-designed large controlled observational clinical studies (case-control, cohort studies etc.). In my opinion and many world chiropractic and medical authorities agree and now even the State or Oregon agree that at least for low back pain/uncomplicated injury HVLA spinal adjustments/manipulations by hand do. No we don't have to fall into the trap of our materialistic medical counter-parts that if our treatment interventions cannot be fully explained (e.g.vital force or life force) then it is epi-phenomenal and thus, irrelevant. As long as there is no patient safety issue it is enough that that procedure obtains the wanted outcomes (Les Feinberg's Tech comes to mind, I have no idea how it works and I don't care) but we must have evidence that support that whatever procedure we use in fact does what we say it does (outcomes). At some point we as a profession have to make a reasonable attempt at separating what really provides the outcomes (non-baloney) we say they do from those that simply don't (baloney) and be willing to discard that baloney procedure, test, substance or device... Cheers, Vern Chiropractic deaths Docs:I especially like their " Conclusion. " Lyndon McGill, D.C.Salem, Oregonwww.SalemSpineClinic.comwww.EvolvingDaily.com <Wiley_pub2-logo-2lines.gif> Deaths after Chiropractic: A Review of Published CasesE. ErnstPosted: 08/30/2010; Int J Clin Pract. 2010;64(10):1162-1165. © 2010 Blackwell PublishingAbstract and IntroductionAbstractObjective: The aim of this study was to summarise all cases in which chiropractic spinal manipulation was followed by death.Design: This study is a systematic review of case reports.Methods: Literature searches in four electronic databases with no restrictions of time or language.Main outcome measure: Death.Results: Twenty six fatalities were published in the medical literature and many more might have remained unpublished. The alleged pathology usually was a vascular accident involving the dissection of a vertebral artery.Conclusion: Numerous deaths have occurred after chiropractic manipulations. The risks of this treatment by far outweigh its benefit.IntroductionVascular accidents after upper spinal manipulation are a well-recognised problem (e.g.[1,2]). Dissection of a vertebral artery, caused by extension and rotation of the neck beyond the physiological range of motion, is thought to be the underlying mechanism.[2] Several deaths have been reported as a consequence. Some proponents of chiropractic seem to believe that the critical evaluation of this evidence amounts to a 'scare story' (Chairman of the UK General Chiropractic Council)[3] or to 'puffing up (the evidence) out of all proportion' (President of the British Chiropractic Association).[4] A responsible approach to serious therapeutic risks, however, requires an open discussion of the facts.In this review, I aimed to provide the basis for such a discussion by summarising all fatalities which occurred after chiropractic spinal manipulation and were published in the medical literature.MethodsElectronic searches were conducted in the following electronic databases: Medline, Embase, AMED, Cochrane Library (September 2009). No restrictions of time or language were applied. Search terms were chiropractic, spinal manipulation, vascular accidents, stroke, death and fatality. In addition, our own departmental files and the bibliographies of the articles thus located were searched. Several experts were also contacted for further data. Case reports were included if they provided information on human patients who had died after receiving one or more treatments from a chiropractor. Data were extracted from the included articles according to predefined criteria (Table 1).Table 1. Published case reports of deaths after chiropractic treatmentsReferencesYear of publicationVictimType of vascular accidentTime between treatment and deathAnon[5] 1934Woman, age unknownTear in left lateral sinus2 weeksPratt- and Berger[6] 194732-year-old manThrombosis of basilar, left anterior-inferior cerebellar and right posterior-inferior arteries24 hPratt- and Berger[6] 194735-year-old womanThrombosis of posterior-inferior cerebellar artery10 hAnon[7] 1955Woman, age unknownIntra-spinal bleeding and compression of spinal cord18 hFord and [8] 195637-year-old manThrombosis of basilar, left-posterior cerebellar and left-posterior cerebral arteries6 hFord and [8] 1956No information providedThrombosis of basilar arteryNo information provided and Estridge[9] 196233-year-old womanInfarct of cerebellar and brainstem3 daysLorenz and Vogelsang[10] 197239-year-old womanThrombosis of basilar artery58 daysSchmitt[11] 197635-years-old womanInfarct of brainstem1 hKrueger and Okazaki[12] 198025-year-old manInfarct of brainstem and cerebellum48 hSherman et al.[13] 198160-year-old womanDissection of vertebral artery4 daysAli Cherif et al.[14] 198351-year-old manInfarct of medulla oblongata11 daysNielsen[15] 198434-year-old manDissection of vertebral artery aneurysen3 hZak and Carmody[16] 198453-year-old manLeft vertebral, posterior-inferior and superior cerebellar artery occlusion; cerebellar infarction27 daysModde[17] 198526-year-old womanDissection of vertebral artery1 dayJentzen et al.[18] 198751-year-old manInfarct of cerebellum and brainstemNo information providedSherman et al.[20] 198737-year-old manInfarct of brainstem3 daysMas et al.[19] 198935-year-old womanDissecting aneurysm of vertebral artery16 hRaskind and North[21] 199047-year-old womanCerebellar haemorrheaeNo information providedSullivan[22] 199241-year-old womanHaemorrhage in ventricular system8 hHaynes[23] 199436-year-old womanDissecting aneurysm of vertebral artery, thrombo-embolismNo information provideds et al.[24] 199529-year-old womanInfarct of right hemisphere3 daysKlougart et al.[25] 199634-year-old manUnclearFew hoursHaldeman et al.[26] 2002Previously unpublished legal casesNo information providedNo information providedHaldeman et al.[26] 2002Previously unpublished legal casesNo information providedNo information providedDziewas et al.[27] 2003No information providedNo information providedNo information providedResultsTwenty-six fatalities were published since 1934 in 23 articles (Table 1).[5–27] Table 1. Published case reports of deaths after chiropractic treatmentsReferencesYear of publicationVictimType of vascular accidentTime between treatment and deathAnon[5] 1934Woman, age unknownTear in left lateral sinus2 weeksPratt- and Berger[6] 194732-year-old manThrombosis of basilar, left anterior-inferior cerebellar and right posterior-inferior arteries24 hPratt- and Berger[6] 194735-year-old womanThrombosis of posterior-inferior cerebellar artery10 hAnon[7] 1955Woman, age unknownIntra-spinal bleeding and compression of spinal cord18 hFord and [8] 195637-year-old manThrombosis of basilar, left-posterior cerebellar and left-posterior cerebral arteries6 hFord and [8] 1956No information providedThrombosis of basilar arteryNo information provided and Estridge[9] 196233-year-old womanInfarct of cerebellar and brainstem3 daysLorenz and Vogelsang[10] 197239-year-old womanThrombosis of basilar artery58 daysSchmitt[11] 197635-years-old womanInfarct of brainstem1 hKrueger and Okazaki[12] 198025-year-old manInfarct of brainstem and cerebellum48 hSherman et al.[13] 198160-year-old womanDissection of vertebral artery4 daysAli Cherif et al.[14] 198351-year-old manInfarct of medulla oblongata11 daysNielsen[15] 198434-year-old manDissection of vertebral artery aneurysen3 hZak and Carmody[16] 198453-year-old manLeft vertebral, posterior-inferior and superior cerebellar artery occlusion; cerebellar infarction27 daysModde[17] 198526-year-old womanDissection of vertebral artery1 dayJentzen et al.[18] 198751-year-old manInfarct of cerebellum and brainstemNo information providedSherman et al.[20] 198737-year-old manInfarct of brainstem3 daysMas et al.[19] 198935-year-old womanDissecting aneurysm of vertebral artery16 hRaskind and North[21] 199047-year-old womanCerebellar haemorrheaeNo information providedSullivan[22] 199241-year-old womanHaemorrhage in ventricular system8 hHaynes[23] 199436-year-old womanDissecting aneurysm of vertebral artery, thrombo-embolismNo information provideds et al.[24] 199529-year-old womanInfarct of right hemisphere3 daysKlougart et al.[25] 199634-year-old manUnclearFew hoursHaldeman et al.[26] 2002Previously unpublished legal casesNo information providedNo information providedHaldeman et al.[26] 2002Previously unpublished legal casesNo information providedNo information providedDziewas et al.[27] 2003No information providedNo information providedNo information providedMost of the victims were relatively young; 14 were below the age of 40. There was a slight majority of female patients. The type of complication associated with death frequently related to a vascular accident leading to thrombosis and cerebral infarction. The time between treatment and death ranged from 1 h to 58 days; in 10 cases, it was 1 day or less. Unfortunately, the published information was often incomplete.Many other fatalities seem to have remained unpublished. For instance, the testimony of the chiropractor Preston Long for a court in Connecticut recently listed the family names of nine victims: Mathiason, Solsbury, Mc Cornick, Venegas, Bedenbaugh, , Fawcett, Parisien, Standt. Long also states that 'many others [are] unknown hidden behind legal agreements of silence'.[28] A website names further North American fatalities: Epping (California), G. Fowden (Utah), Grainger (Alberta), Hoffman (land), Renate Dora Labonte (Ontario), (California), Pereyra (Connecticut), A. Roth (Ontario) and Lee Strohecker (Pennsylvania).[29] DiscussionThis systematic review demonstrates that numerous deaths have been associated with chiropractic. Usually high-velocity, short-lever thrusts of the upper spine with rotation are implicated. They are believed to cause vertebral arterial dissection in predisposed individuals which, in turn, can lead to a chain of events including stroke and death.[1,2,26,30] Many chiropractors claim that, because arterial dissection can also occur spontaneously, causality between the chiropractic intervention and arterial dissection is not proven. However, when carefully evaluating the known facts, one does arrive at the conclusion that causality is at least likely (e.g.[30,31]). Even if it were merely a remote possibility, the precautionary principle in healthcare would mean that neck manipulations should be considered unsafe until proven otherwise. Moreover, there is no good evidence for assuming that neck manipulation is an effective therapy for any medical condition.[32] Thus, the risk-benefit balance for chiropractic neck manipulation fails to be positive.Reliable estimates of the frequency of vascular accidents are prevented by the fact that under-reporting is known to be substantial. In a survey of UK neurologists, for instance, under-reporting of serious complications was 100%.[33] Those cases which are published often turn out to be incomplete. Of 40 case reports of serious adverse effects associated with spinal manipulation, nine failed to provide any information about the clinical outcome.[34] Incomplete reporting of outcomes might therefore further increase the true number of fatalities. Obviously, the present article is not aimed at providing incidence figures; this would require a different methodology entirely. To date, no reliable incidence data are available.This review is focussed on deaths after chiropractic, yet neck manipulations are, of course, used by other healthcare professionals as well. The reason for this focus is simple: chiropractors are more frequently associated with serious manipulation-related adverse effects than osteopaths, physiotherapists, doctors or other professionals. Of the 40 cases of serious adverse effects mentioned above, 28 can be traced back to a chiropractor and none to an osteopath.[34] A review of complications after spinal manipulations by any type of healthcare professional included three deaths related to osteopaths, nine to medical practitioners, none to a physiotherapist, one to a naturopath and 17 to chiropractors.[35] This article also summarised a total of 265 vascular accidents of which 142 were linked to chiropractors. Another review of complications after neck manipulations published by 1997 included 177 vascular accidents, 32 of which were fatal. The vast majority of these cases were associated with chiropractic and none with physiotherapy.[36] The most obvious explanation for the dominance of chiropractic is that chiropractors routinely employ high-velocity, short-lever thrusts on the upper spine with a rotational element, while the other healthcare professionals use them much more sparingly.[37,38] In conclusion, numerous deaths have been associated with chiropractic neck manipulations. There are reasons to suspect that under-reporting is substantial and reliable incidence figures do not exist. The risks of chiropractic neck manipulations by far outweigh their benefits. Healthcare professionals should advise the public accordingly.SidebarWhat's KnownChiropractic upper spinal manipulation has repeatedly been associated with arterial dissection followed by stroke and, in some cases, death.What's NewThe article is the first systematic review of all fatalities reported in the medical literature. Twenty-six deaths are on record and many more seem to have remained unpublished.ReferencesErnst E. Adverse effects of spinal manipulation: a systematic review. J R Soc Med 2007; 100: 330–8. Leon- A, Cuetter A, Ferrer G. Cervical spine manipulation: an alternative medical procedure with potentially fatal complications. South Med J 2007; 100: 201–3. Dixon P. Letter to the Editor. Adverse effects of spinal manipulation. J R Soc Med 2007; 100: 444. BJ. Letter to the Editor. Adverse effects of spinal manipulation. J R Soc Med 2007; 100: 444. Anon. Medicolegal. Malpractice: death resulting from chiropractic treatment for headache. J Am Med Assoc 1934; 103:1260, 1935; 105:1712–4, 1937; 109:233–4. Pratt- HR, Berger KE. Cerebellar and spinal injuries after chiropractic manipulation. J Am Med Assoc 1947; 133: 600–3. Anon. Medicolegal abstracts. Chiropractors: injury to spinal meninges during adjustments. J Am Med Assoc 1955; 159: 809. Ford FR, D. Thrombosis of the basilar artery with softenings in the cerebellum and brain stem due to manipulation of the neck; a report of two cases with one post-mortem examination, reasons are given to prove that damage to the vertebral arteries is responsible. Bull s Hopkins Hosp 1956; 98: 37–42. RA, Estridge MN. Neurologic complications of head and neck manipulations. JAMA 1962; 182: 528–31. Lorenz R, Vogelsang HG. Thrombosis of the basilar artery following chiropractic manipulation of the cervical spine. [in German] Thrombose der arteria basilaris nach chiropraktischen Manipulationen an der Halbwirbelsäule. Dtsch Med Wochenschr 1972; 97: 36–43. Schmitt HP. Rupturen und Thrombosen der Arteria vertebralis nach gedeckten mechanischen Insulten. Schweiz Arch Neurol Neurochir Psychiatry 1976; 119: 363–79. Krueger BR, Okazaki H. Vertebral-basilar distribution infarction following chiropractic cervical manipulation. Mayo Clin Proc 1980; 55: 322–32. Sherman DG, Hart RG, Easton JD. Abrupt change in head position and cerebral infarction. Stroke 1981; 12: 2–6. Ali Cherif A, Delpuech F, Habib M, Salamon G, Khalil R. Thrombose vertebro-basilaire apres manipulation du rachis cervical. A propos de deux cas. Ann de Med Phys 1983; 25: 459–65. Nielsen AA. Cerebrovascular insults caused by manipulation of the cervical spine. [in Danish]. Ugeskr Laeger 1984; 146: 3267–70. Zak SM, Carmody RF. Cerebellar infarction from chiropractic neck manipulation: case report and review of the literature. Ariz Med 1984; 41: 333–7. Modde PJ. Chiropractic Malpractice. Columbia, land: Hanrow Press. 1985: 269–70, 273–5, 311–8, 322–3, 329–31, 334–7. Jentzen JM, Amatuzio J, GF. Complications of cervical manipulation: a case report of fatal brainstem infarct with review of the mechanisms and predisposing factors. J Forensic Sci 1987; 32: 1089–94. Mas JL, Henin D, Bousser MG, Chain F, Haw JJ. Dissecting aneurysm of the vertebral artery and cervical manipulation: a case report with autopsy. Neurology 1989; 39: 512–5. Sherman MR, Smialek JE, Zane WE. Pathogenesis of vertebral artery occlusion following cervical spine manipulation. Arch Pathol Lab Med 1987; 111: 851–3. Raskind R, North CM. Vertebral artery injuries following chiropractic cervical spine manipulation--case reports. Angiology 1990; 41: 445–52. Sullivan EC. Brain stem stroke syndromes from cervical adjustments. Report on five cases. J Chiropr Res Clin Invest 1992; 8: 12–6. Haynes MJ. Stroke following cervical manipulation in Perth. Chiropr J Aust 1994; 24: 42–6. s M, Bohl J, Thömke F, Kallen K-J, Mahlzahn K, Wandel E. Dissection of the internal carotid artery after chiropractic manipulation of the neck. Neurology 1995; 45: 2284–6. Klougart N, Leboeuf-Yde C, Rasmussen LR. Safety in chiropractic practice. Part I. The occurrence of cerebrovascular accidents after manipulation to the neck in Denmark from 1978–1988. J Manipulative Physiol Ther 1996; 19: 371–7. Haldeman S, Kohlbeck FJ, McGregor M. Unpredictability of cerebrovascular ischemia associated with cervical spine manipulation. Spine 2002; 27: 49–55. Dziewas R, Konrad C, Dräger B et al. Cervical artery dissection – clinical features, risk factors, therapy and outcome in 126 patients. J Neurol 2003; 250: 1179–84. Presentation by Dr Preston Long DC to State of Connecticut. Connecticut State Board of Chiropractic Examiners. Hartford Connecticut. 25 October 2009. Anon. What's the harm in going to a chiropractor? What's the Harm 2009; http://whatstheharm.net/chiropractic.html (accessed October 2009). Ernst E. Vascular accidents after neck manipulation: cause or coincidence? Int J Clin Pract 2009; in press. Long PH. Stroke and spinal manipulation. J Quality Health Care 2004; 3: 8–10. Ernst E. Chiropractic: a critical evaluation. J Pain Symptom Manage 2008; 35: 544–62. Stevinson C, Honan W, Cooke B, Ernst E. Neurological complications of cervical spine manipulation. J Roy Soc Med 2001; 94: 107–10. Ernst E. Cerebrovascular complications associated with spinal manipulation. Phys Ther Rev 2004; 9: 5–15. Terrett AGJ. Current Concepts in Vertebrobasilar Complications following Spinal Manipulation, 2nd edn. Des Moines: JCMIC Group, 2001. Di Fabio RP. Manipulation of the cervical spine: risks and benefits. Physical Ther 1999; 79: 50–65. Alcantara J, Ohm J, Kunz D. The safety and effectiveness of pediatric chiropractic: a survey of chiropractors and parents in a practice-based research network. Explore (NY) 2009; 5: 290–5. Sweeney A, Doody C Manual therapy for the cervical spine and reported adverse effects: a survey of Irish Manipulative Physiotherapists. Man Ther 2010; 15: 32–6. Int J Clin Pract. 2010;64(10):1162-1165. © 2010 Blackwell Publishing Error! Filename not specified. Quote Link to comment Share on other sites More sharing options...
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