A couple of months ago I found myself in a Twitter argument with a Chemist with 6,000 Imaginary friends, reminding me why you shouldn’t have substantive scientific arguments with the scientific illiterate with only 280 characters at your disposal. It also reminded me about the biases facing Chiropractors.
He posted a video of a Youtube Chiropractor who gets millions of views (I hate Youtube Chiropractors and will not be posting the video) and commented on, in my opinion, the buffoonish aspects of the Chiropractors antics.
The discussion inevitably led into the weird dichotomy that Chiropractics detractors hold onto:
Chiropractic adjustments are, at once, useless and completely incapable off effecting any physiological change that could produce positive health outcomes while simultaneously being able to kill you instantly and/or weeks after administered.
Has anyone alerted the Insurance companies yet?
By death they of course mean “Chiropractic’s Dark Secret”, stroke correlated with cervical manipulation, specifically vertebral artery dissection.
I put the term “Chiropractics Dark secret” in quotation marks because it’s supposed to be something we are hiding from the public, afraid to discuss openly. As if we were cult members starting to voice doubts about their leader and tenants, speaking of it in hushed tones. This is utter nonsense as we discussed this issue openly in 2000-2003 when I attended the Los Angeles College of Chiropractic and we were told that we *could*, in very rare instances, be the causative factor in vertebral artery dissection.
However, two decades is a long time ago in the world of science and we have gone from thinking that we could be the cause in rare instances to we are innocent, if not culpable from a med-legal standpoint, bystanders in the ongoing events presenting to our offices, as Australian Chiropractor Dr. Matthew Long describes. The charge that we are killing people left and right seems like something to study extensively and we have done just that, studying the biomechanics of arterial dissection and what the mechanism of injury could possibly be as I documented in this post . According to the most current research not only do we not generate enough force to tear a healthy artery, but an already torn artery presenting to our offices will not be made worse with a Chiropractic adjustment. This evidence has changed my views from when I started in my learning and career.
In other words, as the science changed, so did my belief. (Hint: This is how science is supposed to work.)
Coming armed with the latest research was nothing to the Twitter geniuses whose counter-arguments ranged from:
- Your sources suck (Spine and JMPT Sucks?)
- This one source was in a periodical that had to retract another article.
- Your articles are written by “a bunch of Chiropractors” as if the study of the biomechanics of spinal manipulation should be carried out not by spinal manipulations greatest utilizers. Perhaps “Better Homes and Garden” is up to the task.
- Katie May! Individuals were actually posting Time magazines Katie May article as a scientific retort
- Look at this article that shows this case study about someone getting a stroke after seeing a Chiropractor.
No less than three people posted this same article from South Korea (Where only the Equivalent of Medical Doctors can perform spinal manipulation) “A Case of Posterior Inferior Cerebellar Artery Infarction after Cervical Chiropractic Manipulation.” I will make the conclusion easy: Someone had an arterial dissection diagnosed 2 weeks after visiting a Chiropractor.
Evidence Based Chiropractor, and Devil to Subluxation only Chiropractors, Dr. Stephen Pearle, did a sufficient filet job in a letter to the editor, touching on points I said to the twitter Mob. Namely how the hell can you say a Chiropractic adjustment is associated with an arterial dissection half a month later in a country that doesn’t permit trained Chiropractors to practice?
Another article that was posted was this Gem: “Cervical artery dissection related to chiropractic manipulation: One institution’s experience.”
It showed that from 2008-2012 of the 141 patients that were seen with arterial dissections 12 patients with 16 dissections had had “prior” (When?) Chiropractic intervention. While some with axes to grind want us to upend the earth because 11.75% of their arterial dissection patients had previously been to a Chiropractor, unbiased observers might ask “What Characteristics do the 11.75% of patients share with the 89.25% of arterial dissections that Didn’t see a Chiropractor?” so that we could better diagnose an make the proper referral in the still rare but increasingly likely event that patients are coming into our offices with these strokes in progress.
As mentioned, the evidence has shifted away from us causing these events. As Dr. Long mentioned in the linked article above NSAIDS show an increased association, as much as three fold, with stroke but no one suggests curtailing their use. Furthermore Dr. Long in his latest post documented an Antibiotic-Stroke Connection, specifically fluoroquinolone antibiotics. Dr. Long quotes James S. Demetrious in the journal Chiropractic & Manual Therapies for the potential biomechanics causative agent for fluoroquinolone antibiotics:
Demetrious, J. S. (2018). Spontaneous cervical artery dissection: a fluoroquinolone induced connective tissue disorder? Chiropractic & Manual Therapies, 26(1), 1050–3.
These are the ingrained biases we face. NSAIDS show an increased association with stroke and fluoroquinolone has a potential mechanism more congruent with the biomechanics for arterial dissection than spinal manipulation yet curtailing their use is not tangibly dissuaded. Strokes via cerebra vascular events are frequently misdiagnosed in Emergency rooms yet the medical testing and useless intervention on the path to discovering the stroke are considered standard. Meanwhile a Chiropractor not immediately diagnosing a stroke and God forbid performing *ANY* therapy on a patient will be blamed for the Stroke itself. It is not impossible to see a situation where a Chiropractor taking an incomplete history, in which he fails to uncover recent NSAID or Antibiotic use, is blamed for the cerebrovascular catastrophe.
Upwards of 250 people die per day during surgery and tens of thousands die per year from legally prescribed medication in the United States however having achieved cultural authority Medical Doctors errors are treated as an acceptable statistic and Chiropractors errors are treated as an institutional failure of a profession that needs greater regulation.
Recognizing these biases are important, crying about it will do us no good. While the continued research is important it is of secondary importance to raising our diagnostic skills so that we catch these instances when they present themselves. We live in a world where, unfortunately and perhaps partially our fault, what we do is viewed with skepticism: even X-rays are viewed as unnecessary and a means of scaring patients into care with “routine” degeneration. We ask for more diagnostic testing its considered unnecessary, we fail to make the diagnosis we are held more accountable than “real” doctors. If God forbid we initiate any therapy we will be seen as the causative factor by the professions detractors, and the regulatory boards will nail you for history taking and failure to take good notes. And all the appeals to all the biomechanics science in the world will be difficult to prove when the blown up picture of a single mom who suffered a stroke “after” your adjustment is presented to a jury.
This isn’t to say that the failure to diagnose isn’t an onus we have, nor that a Chiropractic adjustment is entirely incapable of doing any harm.
That was jogged into my memory recently as I was discussing with a PT colleague (who performs spinal manipulations) working with one of the Chinese national teams about the mechanisms of killing someone Chuck Norris style. He mentioned “tearing the vertebral artery” and I disagreed saying there would have to be injury to the spinal cord as those Chuck Norris movies show you, death is near instantaneous when Chuck breaks your neck. As you can see, not all my discussions with colleagues are of an academic or serious nature.
The breaking of the neck brings up a recent case where I believe the Chiropractor Was negligent.
Obtaining relevant medical details from a newzine is difficult but as best as I can ascertain his spine was starting to undergo degrative fusion and a harsh adjustment with a drop piece caused fracturing and damaging to the cord. The Chiropractor in question did not take X-Rays of the neck, mishandled the patient after the disastrous adjustment, and was less than candid when the paramedics arrived. He screamed in pain following the adjustment, was improperly treated as he became a paraplegic, and succumbed to respiratory failure later.
In common parlance: The Chiropractor fucked up (*Probably).
Diagnosis:
Moving forward we have to come up with a means of diagnosing potential problems before they occur.
This starts with a good history, not only to screen for risk factors mentioned above like recent NSAID and Antibiotic use, but for red flags which can have you make a referral to the proper medical professional:
If we are still unsure of how to proceed you can also utilize a HINTs test, which appears more sensitive for stroke than early MRI in AVS.
If you are still somewhat unsure there is also appropriate imaging that can be utilized, as detailed in this article. Mentioned is Radiographs (X-Rays) that can detect stenosis like in the York Case but can not visualize soft tissue, and also Computed Tomography (CT), Magnetic Resonance Imaging (MRI) , Ultrasonography (US), and Angiography, all off which can be utilized for the detection of Arterial dissection.
And finally, and most importantly, if you do decide to initiate treatment document everything and if there is any immediate worsening of symptomatology make an immediate referral to emergency care facilities.
In an ideal world Chiropractic patients would walk through the door with Full Spine MRI’s (even better weight bearing MRI’s) but we don’t live in an ideal world.
You do, however, have the ability to have an ideal clinic, where patient are accepted to the best of your ability or referred out. Decreased cardiovascular fitness, increased medication use and generalized unhealthiness will increase these incidences in the future, especially in the young. As Chiropractors we have the tools to be able to catch and mitigate these disasters greatly.
Chiropractic Rōnin 