Is Getting a Chiropractic Cervical Adjustment "Almost Like Getting Hanged"?

The Blog site "Science Based Medicine" has a recent post (among its considerable collection of nonsense) that again brings up the topic of stroke related to chiropractic manipulation, and nitpicks another large study that found no significant relationship between the two

https://www.sciencebasedmedicine.org/chiropractic-and-stroke-the-question-is-not-answered/#disqus_thread

What really bugs me is that the author of the post, Dr. Crislip, once again repeats his accusation that chiropractic cervical manipulation applies 40% of the force that is applied to the neck during hanging.  

Here's his original "calculation":

https://www.sciencebasedmedicine.org/chiropractic-and-stroke-evaluation-of-one-paper/

My response below totally debunks this nonsense, and I'm awaiting his reply to my evidence. Meanwhile, I've managed to raise the ire of some "chiro-skeptics". Our discussion so-far is below:

My comments are in Bold

Responses to my comments are in italics

Bill Lauretti, DC • a day ago

Perhaps, Dr. Crislip, if you have such compelling objections to the study recently published in Chiropractic and Manual Therapies you should compose concise a Letter to the Editor and send it to that journal, so that it can be published and responded to by the authors. I think that's the way "Science Based Medicine" is supposed to work.

Oh, and please stop comparing the force applied during a cervical manipulation to the force applied during a hanging. If you actually read the article where you got your data for the force applied during a manipulation, you would realize that the force was measured against a rigid force plate, during a mock manipulation that is nothing at all like a cervical manipulation (it's more like a forceful prone thoracic manipulation).

"For manual force applications, each operator performed 10 force applications at 5-second intervals on a 10 × 10 sensor mat (each sensor 1 cm2, Sensor Products Inc, Hanover, NJ) mounted on a rigid surface. All operators contacted the mat using a reinforced single hypothenar hand orientation."

http://www.sciencedirect.com/s...

as referenced in the Aetna policy you reference in your article.

Bill Lauretti, DC
Associate Professor,
New York Chiropractic College

Windriven  Bill Lauretti, DC • a day ago

Hmmm ... Chiropractic and Manual Therapies seems to have an impact factor indistinguishable from background noise. Who would have guessed it had an editor with whom to correspond? Moreover, why bother to correspond with anyone associated with chiropractic subluxation, the cornerstone of your particular brand of quackery? You can put on a white coat, style yourself 'doctor' or 'professor' but at least one of us knows this to be intellectual silliness.

That said, SBM has its own mission. The 'study' in question was illustrative rather than central to the essay.

"[P]lease stop comparing the force applied during a cervical manipulation to the force applied during a hanging"

Yes, I would imagine that is bad for business. And your whining about force measured against a 'rigid force plate' betrays your ignorance of physics. The body of the subject represents significant inertial mass. Unless you are suggesting that this HVLA maneuver uses sufficient force to actually move the body (!) there is nothing objectionable about using a rigid force plate. That would be precisely the correct way to measure energy that would otherwise be absorbed by tissues in and around the cervical spine.

Bill Lauretti  Windriven • a day ago

Regarding the force measurements, my point was that the article Dr. Crislip indirectly referenced measured the force that would be applied during one type of thoracic spine manipulation, and has absolutely nothing to do with the force applied during a cervical spine manipulation which uses a completely different technique.

The article referenced below did measure the forces applied during a cervical manipulation, and found the mean peak force during a cervical rotational manipulation was 40.5 newtons, considerably below the 264 newtons that Crislip claims in his article. So we're not applying "40% of the force applied during a hanging" as Crislip states--it's actually more like 6%--but of course, that's not nearly as scary a story to tell.

As for the journal Chiropractic and Manual Therapies, it is a peer reviewed, indexed journal and the accepted route to criticizing published papers is to write the journal and allow for a public debate in its pages, not by writing snarky remarks on a blog. Regarding Impact Factors, it's interesting to note that the original Cassidy study that caused Crislip so much consternation was published in the journal Spine, which has one of the highest Impact Factors of any specialty journal.

You say that "SBM has its own mission". Yes, judging from the contemptuous tone of your posting above and its complete irrelevance to any scientific inquiry, it seems to me that its mission is more focused on ridicule and bullying than on Science.

Another comment here says that Dr. Crislip acknowledges his errors and corrects them, and that we chiropractors can learn from him. I am awaiting my lesson.

GN Kawchuk, W Herzog. Biomechanical characterization (fingerprinting) of five novel methods of cervical spine manipulation. J Manipulative Physiol Ther, 16 (1993), pp. 573–577

WLU Mod  Bill Lauretti • a day ago

And my point was that there is no well-demonstrated rationale for cervical spine manipulation. How much force does it take to sever or tear an artery in the neck?

As for the journal Chiropractic and Manual Therapies, it is a peer reviewed, indexed journal and the accepted route to criticizing published papers is to write the journal and allow for a public debate in its pages, not by writing snarky remarks on a blog. Regarding Impact Factors, it's interesting to note that the original Cassidy study that caused Crislip so much consternation was published in the journal Spine, which has one of the highest Impact Factors of any specialty journal

 Andrew Wakefield published his work in The Lancet.

  seems to me that its mission is more focused on ridicule and bullying than on Science

Perhaps that is because you are a chiropractor, and the article you consider to be "ridicule and bullying" directly attacks your professional pride and income. And ethics. And scientific acumen. Possibly why you keep bringing up distractions like tone and the irrelevant opening factoid. You've said little about the risk of strokes due to chiropractic, haven't discussed the positive evidence for stroke and chiropractic, and haven't provided a rationale for any reason to manipulate the cervical spine.

But yeah - the way Dr. Crislip discusses one way of measuring force on the neck, that's just the worst.

Bill Lauretti: 

OK, here's some evidence for the use of chiropractic manipulation/mobilization of the cervical spine:

 Neck Pain: A comprehensive review published in the journal Spine (High impact factor, remember) found that manipulation, mobilization and supervised exercises were all “Likely Helpful” in treating non-traumatic neck pain (all treatments incorporated in most chiropractors’ treatment plans). In contrast, NSAIDs and other drugs had “Not Enough Evidence to Make a Determination” of effectiveness.

http://www.ncbi.nlm.nih.gov./pubmed/18204393

 For headache, one review found that “The RCTs suggest that massage therapy, physiotherapy, relaxation and chiropractic spinal manipulative therapy might be equally effective as propranolol and topiramate in the prophylactic management of migraine” (all treatments incorporated in most chiropractors’ treatment plans).

http://www.ncbi.nlm.nih.gov./pmc/articles/PMC3072494/

Another review published in Chiropractic and Osteopathy (yeah, that journal again…) found that “spinal manipulation/mobilization is effective in adults for… migraine and cervicogenic headache; cervicogenic dizziness”.

http://www.ncbi.nlm.nih.gov./pmc/articles/PMC2841070/

 Another recent review concluded “Strong recommendations were made for the treatment of chronic neck pain with manipulation, manual therapy, and exercise in combination with other modalities. Moderate recommendations were made for the treatment of acute neck pain with manipulation and mobilization in combination with other modalities. “

http://www.ncbi.nlm.nih.gov/pubmed/24262386

 Although the evidence supporting a chiropractic approach to headaches and neck pain is less than compelling, there is at least as much evidence in its favor as for other commonly used treatments, including all common pharmacological approaches.  If you disagree, I invite you to share with me all the randomized controlled trials you find supporting the use of acetaminophen, NSAIDs, muscle relaxants, steroids and opioid narcotics, all of which are commonly prescribed for these conditions.  It is clear that any major risks of cervical manipulation are extremely rare—likely in the realm of one per million treatments or so. Compare this risk with the considerable risk of overdose from acetaminophen (the leading cause of acute liver failure in the western world), the risk of bleeding ulcers from NSAIDs (deaths from GI toxicity of NSAIDs is the 15th most common cause of death in the US), the high risk of abuse and addiction from muscle relaxants and narcotics (opioid overdoses kill 15,000 people per year, more than the number of deaths from cocaine and heroin combined). 

Lest I am again accused of bringing up “distractions”, the sparse evidence of effectiveness and significant risks of so-called “conventional” treatments for these conditions are very real and very relevant—it’s what goes on in the real world every day.  For example, one recent study found that more than half of adults with migraines had been prescribed a narcotic painkiller, such as OxyContin and Vicodin; 16 percent of children and teenagers with migraines had been prescribed a narcotic painkiller.

http://consumer.healthday.com/general-health-information-16/doctor-news-206/too-many-migraine-sufferers-given-narcotic-painkillers-barbiturates-700452.html

 In answer to your other question, “How much force does it take to sever or tear an artery in the neck?” The answer is it takes approximately 8.2-8.8 N of force, and a strain of 53-62% of its original resting length.  Rapid movements like neck manipulation generate peak strains of 12.9%, considerably within the artery’s tolerance and similar to the strains on the artery during ordinary ranges of motion.

http://www.ncbi.nlm.nih.gov/pubmed/?term=25457973

 So, if you’d all like to continue having an intelligent, evidence-based discussion, I look forward to doing so.  If you intend to regress to ad hominum attacks and insults, let’s not waste each other’s time.  Meanwhile, I’m still awaiting Dr. Crislip’s correction to his “hangman’s” accusations.

 WLU Mod  Bill Lauretti • 20 hours ago

Question - are there any that find cervical manipulation is superior to massage, which doesn't carry the risk of lethal stroke or paraplegia?

Interestingly, the only one that considers cervical manipulation without examining other treatment options appears to be the J Manipulative Physiol Ther. That's a chiropractic mouthpiece, right?

Further, I would recommend massage over any pharmacological treatment, bar perhaps OTC painkillers and the like, which nicely balance safety, efficacy and convenience.

How much force does it take to sever or tear an artery if it has a bulge, weakness or congenital flaw in it by the way? Can you identify people who have bulges, weaknesses or congenital flaws in the arteries emerging from their cervical spine? And do you warn customers as part of your routine intake procedures of the low but serious risks of cervical spine adjustment potentially causing life-long paralysis?

Bill Lauretti  WLU • 19 hours ago

OK, it's clear you've chosen to ignore all my points. Cervical manipulation places no more strain on the vertebral artery than turning your head, so why would you assume massage is safer? And there are a few studies that have found manipulation more effective than mobilization or massage for some types of neck pain and headache (I would find the references, but it's obvious you won't bother reading them anyway).

I'm glad you would at least recommend massage (many MDs still don't). However, how can you justify the blanket statement that OTC painkillers (presumably NSAIDs) "nicely balance" safety and efficacy? Do you have any actual evidence of that? And are you saying that you never prescribe anything stronger for your patients with neck pain or headaches? My invitation to share relevant RCTs has apparently gone unanswered.

How much force does it take to tear a weakend artery? In some cases, about as much as it gets when the patient turns his head to back out of his driveway in the morning. No, there is no way to positively identify pre-existing artery flaws, although a thorough history and physical exam can go a long way toward raising suspicion (a skill I teach my students very carefully).

How do you identify these patients with arterial flaws when they come to your office before you send them off for a massage? Or do you?

Yes, I do recommend getting informed consent from all patients, including discussing the remote risks of arterial dissection when appropriate. Do you get informed consent before every procedure or prescription that has a 1/million risk of significant harm?