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Petition to stop neck manipulation

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Petition to stop neck manipulation - August 20, 2005 9:57:00 PM   


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I never realized until I talked to the author of this petition from Australia that in Asian countries, barbers routinely crack necks along with the shave and a haircut! Furthermore, it is rumored (according to a PT I know) that in Burma at least, this tradition is a colonial one, left as a dangerous legacy by the British!

Ram, the author, acquired a vertebral artery dissection 4 years ago. His petition is to stop neck manipulation being done by chiros, barbers and osteopaths. I wish he would add PTs and MDs, but it's too late now.. besides, he thinks PTs and MDs are less apt to cause a VAD because of how infrequently we use neck manipulation as a technique, and how likely we are to try anything but... first.

I urge everyone to support this petition and put a stop to strokes caused in this manner.
Thank you,
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Re: Petition to stop neck manipulation - August 20, 2005 10:50:00 PM   


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How many CVA claims are made against chiropractors, PTs, MDs, or DOs each year? How many manipualtions are performed?

How can you compare manipulations from barbers to manipulations by chiros and PTs?

Seriously, are you approaching this from an evidence based perspective, or personal bias?

(in reply to Diane)
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Re: Petition to stop neck manipulation - August 20, 2005 10:59:00 PM   


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Buddy, I doubt any of your questions matter to anyone who has had a stroke from a neck manipulation. Personal bias, sure. Guilty as charged. Want to see neck manip in the garbage can of history where it belongs.Regardless of who does it, or overutilizes it.

(in reply to Diane)
Post #: 3
Re: Petition to stop neck manipulation - August 20, 2005 11:21:00 PM   

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Quite honestly, there are so many ways to manipulate a neck...I can't imagine I do it the same way a barber in vietnam does (or whatever).

Who or what official body would you turn the petition into...the manipulation police or perhaps the President of Earth?
There are perhaps one MILLION more deaths yearly by way of cigarette smoke...and that ain't illegal. What about not wearing a helmet while riding a motorcycle?

Hey, I say "stop neck manipulation by barbers"


Dr. Wagner DO
Moderator of Medical Complexity Forum

(in reply to Diane)
Post #: 4
Re: Petition to stop neck manipulation - August 20, 2005 11:29:00 PM   


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Hello Wagner,
If you link through to [URL=]this page[/URL] (accessible by clicking on "view current signatures" from the first link), you'll see the people who've already signed it, including me. There are three pages of signatures. The number of signatures per page depends on how lengthy the comments are. Scroll down to the bottom to pick up the fist two pages. Feel free to sign the petition and make a comment about it yourself, or just lurk the petition.. :)

Sure would be nice if people read it before starting to get steamed.

(in reply to Diane)
Post #: 5
Re: Petition to stop neck manipulation - August 21, 2005 2:59:00 AM   


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I'm all for putting warnings on treatments. As long as every profession does it for something with equal relative risk.

The petition should say manipulation done by anyone not just DOs, DCs, and barbers... please include PTs and MDs if you are going to do one.

(in reply to Diane)
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Re: Petition to stop neck manipulation - August 21, 2005 3:40:00 AM   


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Now we have the wisdom gven to us from our ancestors...e.g. it is not good to crack your knuckles. How is this different from cracking your neck i.e. if it is bad for your knuckles which can result in arthritis then why it is ok for the poor neck?! Forcefully cracking your neck done by any professions is not OK!

(in reply to Diane)
Post #: 7
Re: Petition to stop neck manipulation - August 21, 2005 5:48:00 AM   


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I read a study a while ago that found absolutely no increase in the incidence of arthitis among long-term knuckle crackers. Sorry, I don't have the reference.

As for Cx manipulation, as far as I am aware, there is considerable evidence that incidences of vertebral artery transection are usually associated with higher amplitude rotational thrusts to the upper Cx spine, particularly when performed in extension (and in certain systemic diseases).

My osteopathic training has always cautioned against such an approach to Cx manipulation and has carefully taught minimal leverage, multivector type lock-up with a thrust predominately into sidebending. When done well the thrust amplitude is less than a cm and involves far less force than a sneeze. As far as I know, I don't think there has been a single case of stroke caused by an Australian osteopath. The same cannot be said of other Australian practitioners doing Cx manipulation.

This doesn't mean that I think it is a necessary approach to neck pain. For one, there are less aggressive ways to get the same result, and the literature supports this. Perhaps we should be paying more attention to that. However, I have to agree with Wags that there are many different ways to manipulate a neck and some of them are far, far more dangerous than others, and some practitioners are far less skillful than others. Is banning the solution? - I don't know. Certainly there needs to be greater education, both publicly and professionally though.


(in reply to Diane)
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Re: Petition to stop neck manipulation - August 21, 2005 6:19:00 AM   


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I also wonder if the artery would have transected anyway, eventually, given the fragility of the inner layers found in some people who have not been manipulated. Who knows.
I am not cluey on this procedure, but I have heard of doctors and chiros (mind you, this is anecdotal) who have manipulated through range; ie high velocity all the way. The last person I saw in hospital described five attempts, all through range before it was abandoned due to brain stem symptoms. I know this is NOT routine practice, but the fact this occurs is scary. (By the way, she eventually recovered, but it took five months before her balance was restored. She had no intention to sue - she figured 'he was doing his best'.)
People happily self-crack their own necks; I wonder if this works better because they have control and it is an active process?


(in reply to Diane)
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Re: Petition to stop neck manipulation - August 21, 2005 6:48:00 AM   


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Nari, if you watch someone crack there own neck you notice that is almost always a sidebending thrust that cavitates the contralateral side- very little or no rotation involved. This is a commonly used osteopathic style of Cx manipulation. You also notice that they keep doing it because it doesn't resolve the problem.


(in reply to Diane)
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Re: Petition to stop neck manipulation - August 21, 2005 8:25:00 AM   
Alex Brenner PT MPT OCS


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The barbers in Korea also manipulate the neck after the cut. A few years ago a soldier was killed after he was manipulated by a Korean barber. Pretty weird.

I dont agree to ban PTs from performing cervical manipulation as it has been shown to be an effective treatment. Luke R's post above is right on.

Diane, more people have died from taking over the counter NSAIDs than people have died from cervical manipulation.


Alex Brenner, PT, MPT, OCS

(in reply to Diane)
Post #: 11
Re: Petition to stop neck manipulation - August 21, 2005 8:45:00 AM   


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I get slightly confused when I read the term "manipulation." I know the procedures that I was taught... but I don't know what anyone else is doing when they do "manipulation."

I don't know how to describe in writing, but the high velocity aspect isn't occurring with a gross active range of motion component with what I was taught. The high velocity aspect is just occurring at the vertebral level. The best description I can think of would be like when accessory movements are manually assessed - except the manipulation is just quite a bit quicker. I'm not going to say that the procedures that I were taught would not lead to a vertebral artery dissection, but there is a pretty big difference in the cervical spine positioning that I was taught and for example, the position the cervical spine is in for a hair wash at a hairdresser.

I can get my c-spine to cavitate just by getting on my horse, getting him into his gait and then relax my neck muscles and let my head drop forward or to the left or right or sometimes rotated. The only force is the ground reaction forces that come up his legs, hmmm, combined with the force of gravity in the position I let my head go into.

I do think that manipulation does have a time and a place and a purpose. The scary aspect is that there is not a definitive test that is highly sensitive, highly specific or highly valid that can give us comfort that the vertebral artery is structurally sound prior to beginning the procedure.

(in reply to Diane)
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Re: Petition to stop neck manipulation - August 21, 2005 10:07:00 AM   


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Wow, I find myself participating less and less here, and this is a perfect example as to why. Rationality tossed to the wind.


Greg Priest, DC, DABCO

(in reply to Diane)
Post #: 13
Re: Petition to stop neck manipulation - August 21, 2005 10:18:00 AM   


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Risk vs. reward,

gentle ossilations, suboccipital release, grade 1-grade 4 manips, exercise have been shown to be just as effective (sorry don't have the link) and none carry the possiblity of death. I think it becomes an informed consent problem. If we told our patients that come in with neck pain or headaches "ok you have the choice between two treatments, both of which can be very effective in resolving your complaints, with the one technique you may percieve improvements more rapidly than with the other but on very rare occasions, people die" I know I would choose option #2.


(in reply to Diane)
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Re: Petition to stop neck manipulation - August 21, 2005 10:52:00 AM   
Bill Egan


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Currently there is no evidence that shows cervical manipulation is superior to mobilization. The risk for serious adverse events following cervical manipulation is exteremely low. However, a recent study showed increased odds of temporary side effects following cervical manipulation compared to mobilization. See below. I agree with others that a sensible position is to attempt to treat first with mobilzation, muscle energy, or other procedures. At the same time, we should not abandon the practice of cervical manipulation, nor make it illegal, except for barbers.


Spine. 2005 Jul 1;30(13):1477-84.

Frequency and clinical predictors of adverse reactions to chiropractic care in
the UCLA neck pain study.

Hurwitz EL, Morgenstern H, Vassilaki M, Chiang LM.

Department of Epidemiology, UCLA School of Public Health, Los Angeles, CA
90095-1772, USA.

STUDY DESIGN: Randomized clinical trial. OBJECTIVES: To document the types and
frequencies of adverse reactions associated with the most common chiropractic
treatments for neck pain, and to identify possible clinical predictors of
adverse reactions to chiropractic treatment. SUMMARY OF BACKGROUND DATA:
Chiropractic care is frequently sought by patients for relief from neck pain;
however, adverse reactions related to its primary modes of treatment have not
been well examined. METHODS: A total of 336 patients with neck pain presenting
to 4 southern California health care clinics were randomized in a balanced 2 x 2
x 2 factorial design to manipulation with or without heat, and with or without
electrical muscle stimulation (EMS); and mobilization with or without heat and
with or without EMS. Discomfort or unpleasant reactions from chiropractic care
were self-assessed at 2 weeks after the randomization/baseline visit. RESULTS:
Of the 280 participants (83%) who responded, 85 (30.4%) had 212 adverse symptoms
as a result of chiropractic care. Increased neck pain or stiffness was the most
common symptom, reported by 25% of the participants. Less common were headache
and radiating pain. Patients randomized to manipulation were more likely than
those randomized to mobilization to have an adverse symptom occurring within 24
hours of treatment (adjusted odds ratio [OR] = 1.44, 95% confidence interval
[CI] = 0.83, 2.49). Heat and EMS were only weakly associated with adverse
symptoms (heat: OR = 0.94, 95% CI = 0.54, 1.62; EMS: OR = 1.09, 95% CI = 0.63,
1.89). Moderate-to-severe neck disability at baseline was strongly associated
with adverse neurologic symptoms (OR = 5.70, 95% CI = 1.49, 21.80). CONCLUSIONS:
Our results suggest that adverse reactions to chiropractic care for neck pain
are common and that despite somewhat imprecise estimation, adverse reactions
appear more likely to follow cervical spine manipulation than mobilization.
Given the possible higher risk of adverse reactions and lack of demonstrated
effectiveness of manipulation over mobilization, chiropractors should consider a
conservative approach for applying manipulation to their patients, especially
those with severe neck pain.

(in reply to Diane)
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Re: Petition to stop neck manipulation - August 21, 2005 11:45:00 AM   


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A truly interesting thread. Good points on all sides, but has anyone thought about the selection criteria of patients to be manipulated? To catagorically ban an accepted and viable treatment option is ludicrous (sp). How many patients have we as therapists seen through the years who have adverse reactions to a specific treatment. If we are honest, we have all had a few. None with catastophic results but nonetheless adverse. Did we stop using that technique for the rest of our treatment careers? Probably not because it was beneficial for the vast majority. One would think a little insight, common sense and understanding of cultural differences might be in order.
I think we all need to take a deep breath, meditate for a bit and come back ready to have friendly open and thoughtful discussions of issues that we have control over and also will advance our professions individually and as a whole to help the peopel we treat.
If you want to lighten your day, check this out.

(in reply to Diane)
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Re: Petition to stop neck manipulation - August 21, 2005 11:47:00 AM   


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Thanks Bill.

(in reply to Diane)
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Re: Petition to stop neck manipulation - August 21, 2005 12:28:00 PM   


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Just to add another country to the list:
it's regularly done in Turkey also.


(in reply to Diane)
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Re: Petition to stop neck manipulation - August 21, 2005 12:59:00 PM   


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Falls, if you take a moment to read the petition, what is being asked for is informed consent.

[QUOTE] To: All Presidents, Prime Ministers, Congressmen & Health Ministers of all countries

We the undersigned, make a Global appeal to all Presidents, Prime Ministers, Congressmen & Ministers for Health in all countries, to introduce and support a legislation warning the public about the serious dangers of neck manipulation by Chiropractors, Osteopaths and Barbers. Such manipulations could result in a stroke & place a patient?s life at risk.

The medical profession, especially neurologists have been very active globally in pointing out that neck manipulations can sometimes result in a brain stem stroke caused by damaging the vertebral or carotid arteries or both.

The VAD Club is made up of lucky survivors of Vertebral and Carotid Artery Dissections. Such dissections are caused by a variety of factors, one of which is Chiropractic manipulation of the neck, the dangers of which warrant patients being forewarned.

Any legislated warning will arm a patient with sufficient information as to the risks of any manipulations of the neck area and avoid a possible accident that could lead to a stroke.

We are not suggesting that neck manipulations will always cause a stroke.

We are saying that Neck Manipulation can sometimes cause a stroke, also known these days as a brain attack, requiring the public to be cautioned by practitioners before they perform any neck manipulation to ease neck pain or migraine head aches.

Similar to all cigarette packs carrying Government Health Warnings like



we would like to see a warning displayed prominently in all Chiropractor's Offices and Treatment rooms which says

Government Health Warning


The Undersigned [/QUOTE]It's less than I'd really like to see, but it's a start.

(in reply to Diane)
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Re: Petition to stop neck manipulation - August 21, 2005 12:59:00 PM   


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There is no use debating this issue. The issue it too polarized.

If you've had a bad reaction or know someone who has, you will be against it no matter what.

If you use the procedure in practice, you will argue for the procedure no matter what.

Then you have the "I know someone who knows someone that heard from a neighbor that their cousin was hurt by manipulation" people who will be against it based on that and their ignorance.

The person that said patient selection is important had a good point. I rarely manipulate the c-spine unless the person has an subjective complaint or they requestion the procedure and objective findings are present. Informed consent is also important.

Diane, let's ban NSAIDs, cigarettes, alcohol, and elective surgeries while we're at it. Oh wait, chiropractors and barbers dont use these, so I guess it's ok.

(in reply to Diane)
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