(Editor’s note: The following is the Foundation for Vertebral Subluxation position statement regarding Chiropractic and stroke.)
There is no human experimental evidence that chiropractic adjustments or neck manipulations are causally related to strokes. The claims and statements that have been made and that have been interpreted by plaintiff attorneys and plaintiff experts to contend a link are based largely on anecdotes, case reports, and case controlled studies.
A multitude of systematic distortions (biases) may effect the results and conclusions drawn from case-control studies. Other criteria must be used to determine whether a purported association is actually causative because an association does not prove causation. At this point in time due to the rarity with which vertebrobasilar accidents occur within this population, experimental evidence in humans and prospective cohort studies examining the hypothesis that chiropractic adjustments cause stroke – do not exist. In fact, recent research shows no evidence of excess risk of VBA stroke associated with chiropractic care as compared to primary care.
Regarding advising on risks – a risk should be disclosed if a reasonable patient in what the doctor knows or should know to be the patient’s position, would be likely to attach significance to the risk or cluster of risks in deciding whether to forego the proposed therapy. Patients and doctors must make this decision based upon appropriate information. Since there is no human experimental evidence that chiropractic adjustments or neck manipulations are causally related to strokes, it is inappropriate to require a doctor to suggest that such a risk exists.
Further, chiropractors utilize a number of techniques to address joint dysfunction and vertebral subluxation. Many techniques do not employ the type of manipulation that has been alleged to be a factor in vertebrobasilar accidents. This adds to the inappropriate nature of such a disclosure.
{ 20 comments… read them below or add one }
But surely most of the claims made for chiropractic treatment is based on “anecdotes, case reports, and case controlled studies.”
How do you balance arguing for the requirement of experimental evidence demonstrating the risk, but are willing to go with poor evidence when assessing the possible benefits of chiropractic? If we follow your logic regarding patient choice, you ought to not make any beyond very limit claims for chiropractic when discussing someone’s treatment with them.
Aren’t you letting your own biases creep in?
Can you comment on this piece of research that concludes “Numerous deaths have occurred after chiropractic manipulations. The risks of this treatment by far outweigh its benefit”
URL: http://www.ncbi.nlm.nih.gov/pubmed/20642715
@Matt- In 115 years, I would contend that millions of people have received chiropractic adjustments, and the best this study could find was 26 deaths associated with chiropractic adjustments? Seriously? If I used that same logic against you regarding vaccines, you would laugh at me.
@Beacon- Read today’s post: http://theatlasoflife.com/2010/07/27/dr-christopher-kents-response-to-the-gccs-ruling-on-vertebral-subluxation-in-the-uk/
I know RCTs are the ONLY way to know if something is true, and that you have way more clinical experience than I do. So please, continue to educate me on the best way help my patients. You know best.
Tell that to my patients who have had strokes after having their necks “cracked” by a chiropracter. Only 3 in 5 years, but how many should there be?
So I wonder why more people don’t cry foul over having a VBAI after visiting a primary care physician, but they do after visiting a chiropractor. If these people are getting strokes after getting their neck “cracked” as you say, how soon after? Immediately? a day later? a week later? What was their health like? Would they have had a stroke anyway, no matter if they got “cracked” or if they were turning their head to back out of their driveway?
I’m not saying it’s not possible, or that it has never happened. But to say it is an outright risk of a chiropractic adjustment, especially when many chiropractors use very gentle methods of adjusting a cervical vertebra, is a lie. There are too many factors involved in having a stroke to blame it solely on a chiropractic adjustment.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2271108/
I am so grateful for chiropractic and all it has HELPED with in our family!
I’ve already read that. I don’t really see how it can be seen as a response to the point I raised. On the one hand you are dismissing evidence because it is not robust enough; on the other you are accepting it. You seem to be doing this because it suits you as a Chiropractic; how do you legitimise this double standard to others and yourself?
@Beacon- I’m a Chiropractor, not a chiropractic. you raise the point about a double standard, but you missed the point in the post I referred you to. Practice based results are results enough for me. That’s not skewing the evidence to suit me… I don’t need an RCT to prove that the sky is blue. And I don’t need an RCT to prove to me that chiropractic works for someone who’s had countless surgeries and is on 10 different meds, only to get their life back as a result of chiropractic, which I’ve seen. I guess I should tell that patient it’s all in her head because I don’t have an RCT to prove chiropractic helped her, right? Again, I assume you have more experience caring for patients in some form or another than I do, so I’m sure you can correct me if I’m wrong.
I can pull stats from a number of chiropractors and show you positive results, though I’m sure you’ll discount it because it’s not a RCT. But, people with your line of thinking will often accept the fact that chiropractic causes stroke without the RCT to prove it. Funny… I guess that would be a double standard as well, right?
Great blog Dr. Brandon. Keep doing what your doing, and dont take anything the “skeptics” say personally.
Regardless of what is said by them, most human beings will ALWAYS make health decisions based on results and how they feel – not on some statistic they find in a medical journal. Those that do, are the ones you will find on 10 different medications by the age of 60.
Because of this, chiropractic has thrived, is thriving and will always thrive in the future.
Thanks Jeremy! Believe me, I don’t take it personally… in fact I enjoy the debate. I agree with you. We wouldn’t have been around for 115 years as a profession if what we did was simply smoke and mirrors.
The issue isn’t that there aren’t any RCTs; the issue is that there are RCTs and they don’t show an effect. I’m glad that you concede you are adopting a double standard, however.
The issue was I don’t need RCTs to prove chiropractic works. I see it everyday in practice. And the fact there aren’t any RCTs is a flat out lie. The following proves that much.
http://www.nature.com/jhh/journal/v21/n5/full/1002133a.html
Interesting. Do you have the full text? I’d like to read this pilot study in full.
Here you go Beacon.
http://nucalispinalcare.com/pdf/1.pdf
Many thanks. The study definitely suggests a larger trial would be worthwhile. I’m a little concerned by some of the elements of the paper though. It doesn’t discuss the covariance used, and I think in a fully-fledged study one would need more detail on the manner in which the treatment and sham treatment were given to ensure that they were genuinely identical; i.e. that there was nothing in the manner of the practitioner that would give away which group the patient is in, or even that would have an effect on the outcome separate to the adjustment itself. We know that one of the things that drives the placebo effect is the level of attention a patient gets (e.g. an hour spent with a homeopath vs. a fifteen minute appointment with a GP) and it is easy to imagine a chiropractor being somewhat apathetic in applying a sham treatment. I’m not saying that was definitely the case in the pilot study, merely that it is a possibility that needs eradicating in the protocol of the main study.
I also found it odd that there was no discussion of the vertebral arteries as a possible mechanism that would link a misaligned atlas with high blood pressure. Perhaps I am being naive, but this seems intuitively obvious.
Do you happen to know if the study went ahead in full?
The NUCCA adjustment is so gentle and light, that performing a sham adjustment wouldn’t be very difficult at all, just to let you know.
That study came out in 2007, but the same study on a larger scale is currently being conducted at Palmer College of Chiropractic. I believe they received a grant from the NIH to conduct that study, if I’m not mistaken.
I agree with you about the vertebral arteries. But at the end of the study they suggested more studies to figure out the exact mechanism, so maybe they will come to that conclusion outright.
This phenomenon is something that chiropractors have known for years. In fact, when I took physiology in chiro school, this was actually one of our lab assignments. We had a doc that would adjust several students’ C1s, and we recorded pre- and post-blood pressure. The post reading was always much less than before.
Some of the RCTs that I’ve seen regarding chiropractic, aren’t even chiropractic, but osteopathic manipulations. That’s why I dispute the results of many of those RCTs. General manipulations don’t have lasting effects, but specific C1 adjustments do. That’s what we do in our office, and we see unbelievable amounts of healing in all our patients, like allergies, ear infections, high blood pressure, trigeminal neuralgia, depression, etc., etc. Our goal is not to “treat” those symptoms, but reduction in symptoms just happens. No RCTs to prove that to you, but like I said before, just from practice based results, I know what we do is effective. I don’t need an RCT to know that. Heck, I’ve experienced amazing results personally and within my family, and that has been proof enough for me.
Right now, I can think of several good studies being conducted using upper cervical chiropractic (like NUCCA) that are having great results (autism, multiple sclerosis, etc.). Obviously the studies are not out yet, but within the next few years, people will start to see that upper cervical chiropractic has a much different effect on overall health than generalized spinal manipulations. It’s like comparing apples and oranges, to be honest.
Keep in mind that RCT’s are not the only type of valid study. Case studies are a very important part of a profession’s literature and they shouldn’t be written off as “merely anecdotal.” It is important to note that the chiropractic profession doesn’t benefit from the same level of sponsorship that the medical profession does… finding the funding to conduct RCT’s is a lot more difficult for a chiropractic research department than it is when, for example, Pfizer foots the bill. Also, controlling the variables in a chiropractic study is a lot more difficult than it is in a medication study as an example.
Chiropractic research is an ever-growing aspect of the profession and it has a long way to go with an uphill battle to fight against the challenges of the studies themselves, gaining funding, and the blindness of skeptics who latch onto anti-chiropractic dogma without another thought about the evidence or the realities of the situation.
Here is an easy litmus test to prove the point that, regardless of what naysayers would like you to believe, that chiropractic is safe: just ask the insurance companies. Doctors of chiropractic in the USA have the lowest malpractice insurance premiums of all the major healthcare professions. My malpractice coverage is about 25% of what a general family practitioner pays, and it’s about 1/40 of what an OBGYN would pay, if even that. The insurers do not lose money on their insurance policies, so this is pretty good proof of safety above and beyond what the researchers are arguing about. Chiropractic adjustments are still safer than taking an aspirin.
Great points Dr. Agocs!
As long as rumors about the safety of chiropractic exist, we must work to educate the general public. The Foundation for Chiropractic Progress is doing a great job with campaigns by Jerry Rice and others. Every doctor DC needs to post articles proving efficacy of chiropractic and the fallacy of the stroke connection onto their website and work to educate the public, one patient at a time. In time, the public will come to know that chiropractic is the safest and most effective health care system available.