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As I approached my weekly task to write my contribution to this blog, it occurred to me that there has been a bit of news that somehow none of the regular contributors has written about. Moreover, it strikes me as a particularly appropriate topic after Sam Homola’s post on Friday about upper cervical chiropractic manipulation, sometimes called NUCCA (National Upper Cervical Chiropractic Association). We’ve discussed the complications of neck manipulation by chiropractors before, specifically strokes due to injury to a vertebral artery. (Remember the tragic case of Katie May, a young model who died after chiropractic neck manipulation?) It turns out that there are other ways to die from a chiropractic neck manipulation. Witness the case of John Lawlor. First reported over a month ago, the story is that John Lawlor died following a chiropractic adjustment:

A chiropractor has been arrested on suspicion of manslaughter after a retired bank manager died following treatment for backache. John Lawler, 80, was undergoing routine treatment at a private clinic when he lost consciousness and appeared to have become paralysed from the shoulders down. He was taken straight to hospital but died the next day as a result of a ‘traumatic spinal cord injury.’ His wife of 55 years, Joan Lawler, 81, was in the chiropractor’s clinic with her husband and witnessed the incident. Police are investigating to establish whether or not criminal negligence was a factor in his death. Dr Arleen Scholten, 40, the chiropractor who treated Mr Lawler, was arrested by police on suspicion of manslaughter and released pending further inquiries.

The reaction of the authorities regulating chiropractic in the UK was—shall we say?—less than heartening:

The investigating committee of the General Chiropractic Council met on September 28 to decide whether or not to issue an interim suspension order against Dr Scholten. It decided to allow her to continue to practise. Speaking from her home in Tollerton, near York, Dr Scholten said yesterday: ‘I’ve been told not to comment at this time.’

Because of course a council of chiropractors won’t act, and of course Scholten is a true believer:

Writing about her life and personal philosophy on her company website, she comments: ‘Chiropractic is a lifestyle for our family. This includes good nutrition, regular exercise, plenty of time outdoors, little screen time and regular chiropractic care. ‘Yes, all five of us are adjusted regularly. Our children were all adjusted the day they were born, two were homebirths and I continue to check their spines regularly. There is a saying in chiropractic, ‘If the twig is bent so grows the tree’. ‘I will forever be dedicated to sharing the health benefits of chiropractic. I am passionate about the science of human wellness and feel morally obligated to educate my patients on ways to increase health and well-being through eating, thinking and moving, in ways congruent with our bodies.’

So she’s been adjusting the spines of her children since the day they were born? That’s some serious dedication to her quackery.

A vertebral fracture, followed by gross mismanagement

Two weeks ago, the results of the coroner’s inquest into the death of Mr. Lawlor were revealed. Specifically, Mr. Lawlor suffered a broken neck:

A MAN suffered a broken neck while being treated by a York chiropractor for an aching leg, an inquest heard today. John Lawler’s widow Joan told how her husband was on a treatment table at Chiropractic 1st in The Mount in August 2017 when things started to go wrong. She said he started shouting at chiropractor Dr Arleen Scholten: “You are hurting me. You are hurting me.” Then he began moaning and then said: “I can’t feel my arms.” Mrs Lawler said Dr Scholten tried to turn him over and then manoeuvred him into a chair next to the treatment table but he had become unresponsive.

What happened next is that Ms. Scholten called an ambulance. She wondered if he had had a stroke, which tells me that she at least recognized the possibility of vertebral artery injury from neck manipulation. She dismissed the possibility because “his features were symmetrical.” She also noted that his lips were blue, but that he was breathing. It would be obvious to any physician that he was not getting enough oxygen.

After the ambulance arrived, the paramedics gave Mr. Lawlor oxygen, treated him, and rushed him to York Hospital, after which he was later transferred to Leeds General Infirmary. There, he underwent an MRI, and his wife was told that the results indicated that he had suffered a broken neck. The doctors also told her that he was now a paraplegic and required a 14 hour operation to stabilize the spine. However, he “just faded away” and died the next day.

There are a number of issues regarding this case. The first, of course, is a question that immediately came to mind: Why on earth would a chiropractor choose manipulation of the cervical spine to treat an “aching leg”? Another question that immediately comes to mind is: Why would a chiropractor treat an 80-year-old man with cervical spine manipulation? Edzard Ernst, who has commented several times on this case, provided a likely answer:

One might be surprised to hear that the chiropractor manipulated the neck of a patient who consulted her not because of neck pain but because of a condition seemingly unrelated to the neck. This is an issue that comes up regularly and which is therefore important; some people might be aware that it is dangerous to see a chiropractor when suffering from neck pain because he/she is bound to manipulate the neck. By contrast, most people would probably think it is ok to consult a chiropractor when suffering from lower back pain, because manipulations in that region is far less risky. The truth, however, is that chiropractors have been taught that the spine is one organ and one entity. Thus they tend to check for subluxations (or whatever name they give to the non-existing condition they all aim to treat) in every region of the spine. If they find one in the neck – and they usually do – they would ‘adjust’ it, meaning they would apply one or more high-velocity, low-amplitude thrusts and manipulate the neck. This could well be, I think, how the chiropractor in the case that is before the court at present came to manipulate the neck of her patient. And this might be how poor Mr Lawler lost his life.

Of course, the reason I also ask why a chiropractor manipulated an old man’s neck is because it’s quite possible that Mr. Lawlor had significant osteoporosis, which is common in the elderly. In that case, as Ernst further explains, it could be argued that manipulation of the neck with normal force could have resulted in the fracture that paralyzed and ultimately killed Mr. Lawlor and that Ms. Scholten wasn’t to blame. On the other hand, it could just as well be argued that she was obligated to check Mr. Lawlor for evidence of osteoporosis or other conditions (such as atherosclerosis if the vertebral arteries) that would put him at a higher risk for complications from cervical manipulation. Indeed, he makes a very persuasive argument that Scholten likely didn’t provide true informed consent by cautioning him about the risk of stroke or neck fracture due to high intensity manipulation. As he put it, “In my view, any clinician applying a potentially harmful therapy has the obligation to make sure there are no contra-indications to it. If that all is so, the chiropractor might have been both negligent and reckless”.

Ernst published a statement from the Lawlor family that was quite telling:

There were several events that went very wrong with John’s chiropractic treatment, before, during, and after the actual manipulation that broke his neck. Firstly, John thought he was being treated by a medically qualified doctor, when he was not. Furthermore, he had not given informed consent to this treatment. The chiropractor diagnosed so-called ‘vertebral subluxation complex’ which she aimed to treat by manipulating his neck. We heard this week from medical experts that John had ossified ligaments in his spine, where previously flexible ligaments had turned to bone and become rigid. This condition is not uncommon, and is present in about 10% of those over 50. It would have showed on an X-ray or other imaging technique. The chiropractor did not ask for any images before commencing treatment and was seemingly unaware of the risks of doing a manual manipulation on an elderly patient. It has become clear that the chiropractor did the manipulation incorrectly, and broke these rigid ligaments during a so-called ‘drop table’ manipulation, causing discs in the cervical spine to rupture and the spinal cord to become crushed. Although these manipulations are done frequently by chiropractors, we have heard that the force applied to his neck by the chiropractor would have had to have been “significant”. Immediately John reported loss of sensation and paralysis in his arms. At this stage the only safe and appropriate response was to leave him on the treatment bed and await the arrival of the paramedics, and provide an accurate history to the ambulance controller and paramedics. The chiropractor, in fact, manhandled John from the treatment bed into a chair; then tipped his head backwards and gave “mouth to mouth” breaths. She provided an inaccurate and misleading history to the paramedic and ambulance controller, causing the paramedic to treat the incident as “medical” not “traumatic” and to transport John downstairs to the ambulance without stabilising his neck. If the paramedics had been given the full and accurate story, they would have stabilised his neck in situ and transported him on a scoop stretcher – and he would have subsequently survived.

In general, it’s arguable to me whether Mr. Lawlor would have survived if this had been done. What is not arguable, however, is that the mismanagement of the aftermath of his spine fracture by Ms. Scholten greatly reduced his chances of survival or of recovering neurologic function with proper treatment, and that immobilizing his cervical spine would have maximized his chances of survival and recovery of at least some function. Also disturbing is how Mr. Lawlor had thought that he was being treated by a medically qualified doctor. I’m not sure if this meant that he thought Ms. Scholten was a medical doctor or that he considered chiropractors to be “medically qualified doctors”. This confusion, however, is a not uncommon consequence of how chirpractors like to call themselves “doctors” or even “chiropractic physicians” as part of their self-image and marketing.

Ernst also published the findings of the coroner’s inquest:

Mr Lawler died because of a tear and dislocation of the C4/C5 intervertebral disc caused by considerable external force.

The pathologist’s report also shows that the deceased’s ligaments holding the vertebrae of the upper spine in place were ossified.

This is a common abnormality in elderly patients and limits the range of movement of the neck.

There was no adequately informed consent by Mr Lawler.

Mr Lawler seemed to have been under the impression that the chiropractor, who used the ‘Dr’ title, was a medical doctor.

There is no reason to assume that the treatment of Mr Lawler’s neck would be effective for his pain located in his leg.

The chiropractor used an ‘activator’ which applies only little and well-controlled force. However, she also employed a ‘drop table’ which applies a larger and not well-controlled force.

Chiropractic “drop tables”: Therapeutic tables or dangerous devices?

Oddly enough, I wasn’t familiar with chiropractic drop table techniques. So I did what I always do when I come across a technique with which I’m not familiar; I did a bit of searching on Google. It didn’t take me long to find a number of videos to help educate me, and some of them are scary.

This first video, for example, doesn’t show cervical manipulation itself, just the table, but the chiropractor states that the table is used for patients who have mobility issues and are hard to move. It also augments the force of the chiropractic manipulation:



Here’s one in which the chiropractors are explaining how the cervical drop table works:



And here’s a video by the company that makes a chiropractic drop table showing how the table works and touting its features:



As you can see from this video, there’s an actual pneumatic mechanism that augments the force of the adjustments:



And this one, too, with the cervical drop demonstration starting at around the 3:30, 4:45, and 10:50 marks:



Next up is a scary one:



And:



And:



I could go on, but you get the idea.

Cervical spine manipulation and serious complications: How common?

How common are injuries like this? Like the estimates for strokes as a complication of chiropractic neck manipulation, estimates vary. A recent review of the practice from the Manitoba Health Professionals Advisory Council identified a total of 159 references: 86 case reports/case series, 37 reviews of the literature, 9 randomized controlled trials, 6 surveys/qualitative studies, 5 case-control studies, 2 retrospective studies, 2 prospective studies and 12 others. The review noted that serious adverse events are rare, but that minor adverse events are common. Minor adverse events range from transient neurological symptoms, headache, increased neck pain or stiffness, fatigue, dizziness or imbalance, extremity weakness, tinnitus, depression, anxiety, nausea and vomiting, blurred vision, and confusion. (Personally, I would consider depression, anxiety, and confusion not to be “minor” adverse events.) Serious adverse events include the aforementioned vertebral artery dissection and stroke complicating manipulation, as well as transient ischemic events (the so-called “mini-stroke” in which the neurologic symptoms are transient), nerve or spinal cord damage, disc injury and/or herniation, fracture or subluxation of vertebrae, and musculoskeletal injuries.

But how common are these serious adverse events? The incidence rates for all serious adverse events following cervical spine manipulation are reported to range from one in 10,000 to one in several million cervical spine manipulations (CSMs) although the literature does appear to agree that that serious adverse events are likely underreported. According to the executive summary, the “best available estimate of incidence of vertebral artery dissection of occlusion attributable to CSM is approximately 1.3 cases for every 100,000 persons <45 years of age receiving CSM within 1 week of manipulative therapy,” and the current “best incidence estimate for vertebral dissection-caused stroke associated with CSM is 0.97 residents per 100,000.” The report also looked at risk factors for serious adverse events, concluding that a number of factors can place patients at a higher risk for these serious complications, including “vertebral artery abnormalities or insufficiency, atherosclerotic or other vascular disease, hypertension, connective tissue disorders, receiving multiple manipulations in the last 4 weeks, receiving a first CSM treatment, visiting a primary care physician, and younger age.” The report also noted that “patients who have experienced prior cervical trauma or neck pain may be at particularly higher risk of experiencing an adverse cerebrovascular event after CSM.”

The conclusion:

The current debate around CSM is notably polarized. Many authors stated that the risk of CSM does not outweigh the benefit, while others maintained that CSM is safe—especially in comparison to conventional treatments—and effective for treating certain conditions, particularly neck pain and headache. Because the current state of the literature may not yet be robust enough to inform definitive prohibitory or permissive policies around the application of CSM, an interim approach that balances both perspectives may involve the implementation of a harm-reduction strategy to mitigate potential harms of CSM until the evidence is more concrete. As noted by authors in the literature, approaches might include ensuring manual therapists are providing informed consent before treatment; that patients are provided with resources to aid in early recognition of a serious adverse event; and that regulatory bodies ensure the establishment of consistent definitions of adverse events for effective reporting and surveillance, institute rigorous protocol for identifying high-risk patients, and create detailed guidelines for appropriate application and contraindications of CSM. Most authors indicated that manipulation of the upper cervical spine should be reserved for carefully selected musculoskeletal conditions and that CSM should not be utilized in circumstances where there has not yet been sufficient evidence to establish benefit.

Personally, I’m of the opinion that high-velocity, low-amplitude cervical spine manipulation like that performed by chiropractors should never be done because there is no robust evidence that it is effective for anything and, in the absence of efficacy, even the very small risk of very serious adverse events ranging from artery dissection to stroke to vertebral fracture (all of which can lead to major disability and even death), is unacceptable. A second part of the report that is spot on is that, if CSM isn’t going to be banned outright, harm mitigation should involve rigorous protocols and genuine informed consent. There’s where the General Chiropractic Council in the UK should come in.

The General Chiropractic Council: Putting the fox in charge of guarding the henhouse

Here’s where the story stands right now. Ms. Scholten is still practicing, as I learned in a story about the case published last Friday. Before I get into that part, I can’t help but note a new revelation in this story, namely that Mr. Lawlor’s GP had recommended a course of physiotherapy, not chiropractic. However, there were waiting lists for both NHS and private physiotherapists; so Mr. Lawlor made an appointment to see Ms. Scholten.

Also:

I don’t think Mum actually knew there was a difference between a physio and a chiropractor,’ says their youngest daughter Clare, 49, an executive in a London publishing house. ‘I wouldn’t have been that aware of the differences either. I was only vaguely aware that Dad was going for a spot of physio.’ Joan certainly assumed that ‘Dr Scholten’ was a medical doctor. ‘You do, don’t you? Particularly that generation,’ says David, 55, the couple’s eldest child who works in finance. ‘You see certificates on the wall and you think, “These are people who know what they are doing.” You put yourself into their hands.’

In addition:

‘For one, she used a stick, an “activator”, which is a small hand-held device that delivers a force to the spine. We heard the sound it would make during the inquest. It was like a thud. There was a sense that a lot of it was for show.’ Yet it was the table-drop treatment which did the damage. This wasn’t the first time John had had it. At an appointment the previous day (he’d had five sessions, although only three were ‘hands on’) Mrs Scholten had carried out this procedure, too. David adds: ‘Dad was shocked by that. Mum was shocked by it. They didn’t like it at all but they went off after with no ill effect, so Dad assumed it must be doing some good.’

Now here’s where the issue with regulation comes in and it’s a key reason why we at SBM so strongly oppose the licensure of quack professions:

They [Mr. Lawlor’s family] had hoped that the coroner would record a verdict of unlawful killing. Coroner Jonathan Heath instead recorded a narrative conclusion that Mr Lawler suffered spinal injuries while undergoing chiropractor adjustment and died from respiratory depression. However, he did say he would ask the chiropractic regulatory authorities to consider first aid training for chiropractors. He is also calling on the General Chiropractic Council (GCC) to bring in pre-treatment imaging, such as X-rays or scans, to protect the vulnerable. ‘We’ve since discovered that some chiropractors won’t treat patients of Dad’s age, or certainly not without doing scans first. He had a history of degenerative disease, too. He’d had some rods inserted in his lower back in 2009. He should not have been treated, quite simply.’

According to the story, the General Chiropractic Council is still reviewing the case. Ms. Scholten was indeed arrested and barred from practicing, but with the coroner’s final ruling, there are no longer any charges against Ms. Scholten, and she can continue to practice. Suspiciously, contrary to the usual practice of the GCC, it is conducting its hearings in private and wouldn’t allow Mr. Lawlor’s son David to attend, leading him to say:

Suspension hearings are normally open to the public but, on the day, they said I couldn’t be there. I find that unacceptable. This is a different world. It seems to be a little self-regulatory chiropractic bubble, where chiropractors regulate chiropractors.

That is, of course, exactly the problem with giving legal status to pseudoscience and quackery. The laws establishing licensure of chiropractors, acupuncturists, naturopaths, and the like inevitably also create boards to regulate and discipline these quacks, and who’s on the board? Members of the same quack profession. That leads to the boards that regulate these quack professions to turn into exactly that, little quack bubbles that regulate quacks. Thus far, the GCC has done next to nothing, and it wouldn’t surprise me if Ms. Scholten’s actions of having undergone a first aid course and altering her website to make it clear that she is not a medical doctor will satisfy the Council.

Patients like John Lawlor are just collateral damage to the licensure of quackery.