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Experts Say Risks of Chiropractic Neck Cracking Outweigh Benefits

An article appearing in the British Medical Journal (BMJ) questioning the safety of chiropractic neck adjustments has reopened the debate on the safety of these treatments

According to this article appearing in the Daily Mail, experts issued new alarms last week about what is popularly known as "neck cracking" and similar manipulations typically carried out by chiropractors because they have been known to trigger "catastrophic" health problems such as a strokes. Some doctors say there are serious side-effects linked to these manipulations and are asking professional organizations representing both chiropractors and osteopaths to advise their members that the risks are too great to justify continued use of these manipulations.

"The non-superiority of manipulation to alternative treatments, coupled with concerns regarding safety, renders cervical spine manipulation unnecessary and inadvisable," the report states.

In the article, Neil O'Connell, from the Central Texas Spine Institute and his colleagues argue that cervical spine manipulation "may carry the potential for serious neurovascular complications."

The injuries can occur when the lining of the vertebral artery, which is located at the back of the neck and supplies blood to the brain, is torn, resulting in a stroke.

O'Connell states that studies "provide consistent evidence of an association between neurovascular injury and recent exposure to cervical manipulation."

He refers to a review of randomized trials of neck manipulation by the international medical review body known as the Cochrane Collaboration which found that, when used as a stand-alone treatment, the risky practice results in only moderate short-term pain relief. Because other high quality trials found that this kind of neck manipulation is no better than other treatments such as physical exercise, they believe the risks of using it for neck pain outweigh the potential benefits.

They conclude: "The potential for catastrophic events and the clear absence of unique benefit lead to the inevitable conclusion that manipulation of the cervical spine should be abandoned as part of conservative care for neck pain."

At present, there is considerable debate within the chiropractic community about how to handle the stroke risk which is associated with neck manipulation. For instance, Professor David Cassidy from the University of Toronto, writing in the same edition of the BMJ, believes cervical spine manipulation should not be abandoned as a treatment for neck pain. He points to high quality evidence that "clearly suggests that manipulation benefits patients with neck pain" and raises doubt about any direct relation between manipulation and stroke.

However, he does want to see more research into the pros and cons of this and other techniques in order to identify safer and more effective treatments.

While doctors like to say the risk factor is quite low, various studies turn up numbers anywhere from one in 40,000 treatments to one in 10 million. Experts say the reason why there is such a large spread between these numbers is that there has been very little systematic study of the frequency of strokes; large malpractice insurers won't reveal how many cases they know about; and a large majority of cases that medical doctors see are not reported in scientific journals. 

However, professional organizations in some countries, such as Canada, have already taken steps to protect patients. The Canadian Chiropractic Association published a consent form in 1993 which stated, in part: "Doctors of chiropractic, medical doctors, and physical therapists using manual therapy treatments for patients with neck problems such as yours are required to explain that there have been rare cases of injury to a vertebral artery as a result of treatment. Such an injury has been known to cause stroke, sometimes with serious neurological injury. The chances of this happening are extremely remote, approximately 1 per 1 million treatments. Appropriate tests will be performed on you to help identify if you may be susceptible to that kind of injury. . . . [27]."

Stephen Barrett, MD, of Quackwatch, calls this form a step in the right direction but believes it doesn't go far enough.  "A proper consent should disclose that (a) the risk is unknown; (b) alternative treatments may be available; (c) in many cases, neck symptoms will go away without treatment; (d) certain types of neck manipulation carry a higher risk than others; and (e) claims that spinal manipulation can remedy systemic diseases, boost immunity, improve general health, or prolong life have neither scientific justification nor a plausible rationale."

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