Journal reference: Ernst E. Deaths after chiropractic: a review of published cases. Int J Clin Pract, July 2010; 64(8): 1162-5 ^[1]

Link: http://dx.doi.org/10.1111/j.1742-1241.2010.02352.x

Published: 16 June 2010

Evidence cookie says...

Chiropractic, specifically, high-velocity, short-lever thrusts of the upper spine with rotation is associated with numerous deaths. Most of the deaths were secondary to vascular accidents of the vertebrobasilar system. There is no good evidence for this therapy for any medical condition. General practitioners should advice their patients considering chiropractic therapy to avoid upper cervical manipulation.

Article details:

Study design:

systematic review of case studies

Study aim:

to summarise all cases in which chiropractic spinal manipulation was followed by death

Study conclusion:

Numerous deaths have occurred after chiropractic manipulations. The risks of this treatment by far outweigh its benefit. ^[1]

Critical appraisal:

Are the trial results valid?

Internal validity: Wikipedia

Is it unlikely that important, relevant studies were missed?

Yes.

• electronic searches of a number of databases
• bibliographies of articles searched
• several experts were contacted for further data

Were the criteria used to select articles for inclusion appropriate?

Yes.

• case reports included if they provided information on human patients who had died after receiving one or more treatments from a chiropractor

Were the included studies sufficiently valid for the type of question asked?

Yes.

• only qualitative exploration of the data was intended

Were the results similar from study to study?

N/A

What were the results?

Outcomes:

• 26 fatalities were published since 1934 (to September 2009)
• most of the victims were relatively young; 14 below the age of 40
• the type complication associated with death frequently related to a vascular accident leading to thrombosis and cerebral infarction
• the time between treatment and death ranged from 1 h to 58 days; in 10 cases, it was 1 day or less
• many other fatalities seem to have remain unpublished

Will the results help me care for my patient?

External validity: Wikipedia

Are the participants different to my patient?

• range of patients, many young receiving community chiropractic treatment

Is the treatment feasible?

N/A

Were all the clinically important outcomes considered?

• the cases looked specifically at death
• cerebrovascular accidents not resulting in death were not included in this systematic review
• it is probable that the systematic review substantially under-estimates the burden of death (due to unpublished reports) and serious adverse outcomes
• this limitation, however, strengthens rather than weakens the conclusion

Are the treatment benefits worth the potential harms/costs?

• chiropractic, specifically, high-velocity, short-lever thrusts of the upper spine with rotation is associated with numerous deaths
• there is no good evidence that it is effective therapy for any medical condition
• this particular form of therapy is not worth the potential harms

Study weaknesses (summary)

• published case studies likely grossly under-represent the true number of cases
• review of deaths following chiropractic only; other serious outcomes not resulting in death not reviewed
• study methodology cannot be used to calculate estimates of incidence
• although causation is implicated, it cannot be assumed by this review

Study strengths (summary)

• provides a summary of all the case reports in the medical literature
• the limitation of evidence is likely to be a gross under-estimate; the study conclusion is unlikely to be incorrect

Biases and conflicts of interests

• nil declared and none seem obvious

Clinical relevance to primary health care

Chiropractic treatment of the upper cervical spine, specifically, high-velocity, short-lever thrusts with rotation has been reportedly associated with vascular injury and occasionally death.

This systematic review of all published case studies of death following chiropractic, confirms this association. Almost all of the deaths resulted from a vascular accident of the vertebrobasilar system.  This study was not designed to estimate an incidence figure.

Given that there is no good evidence that chiropractic treatment of the upper cervical spine is effective therapy for any condition, the potential harm far outweighs the benefit.  General practitioners should advice their patients considering chiropractic therapy to avoid upper cervical manipulation.

References

1. Ernst E. Deaths after chiropractic: a review of published cases. Int J Clin Pract, July 2010; 64(8): 1162-5