Adjustments, Strokes and Errors in Medicine
In both Canada and the United Stares, reports have appeared in the popular media suggesting that chiropractic “manipulation” of the cervical spine is associated with strokes. Some writers have suggested that such procedures be banned. These allegations require a swift and vigorous response.
Clinical Perceptions of the Risk of Vertebral Artery Dissection After Cervical Manipulation: The Effect of Referral Bias
The perceived risk after cervical manipulation by chiropractors and neurologists is related to the probability that a practitioner will be made aware of such an incident. The difference in the number of chiropractors (approximately 3,840 in 1997) and neurologists (approximately 4,000 in 1997) in active practice and the fact that each patient who has a stroke after manipulation will likely be seen by only one chiropractor but by three or more neurologists partly explains the difference in experience and the perception of risk of these two professions. This selection or referral bias is important in shaping the clinical opinions of the various disciplines and distorts discussion on the true incidence of these complications of cervical manipulation. The nature of this study, however, describes the likelihood that a clinician will be made aware of such an event and cannot be interpreted as describing the actual risk of stroke after manipulation.
BENEFITS AND RISKS OF SPINAL MANIPULATION
This chapter summarizes what has been learned from clinical trials about the benefits of spinal manipulation for specific problems and from case reports about the risks of spinal manipulation. In addition, findings of studies examining the ability of spinal manipulation to increase patient satisfaction, decrease cost, or increase cost-effectiveness of care are summarized.
Misuse of the Literature by Medical Authors in Discussing Spinal Manipulative Therapy Injury
It is impossible to accurately determine just how often non-chiropractors have been inaccurately reported in the medical literature as chiropractors, because, in many cases, it is not possible to communicate with the original author, who has either died or relocated.
Although medical authors have incorrectly ascribed non-chiropractic cases to chiropractic and/or chiropractors, no example was found in the medical literature where a case of manipulation iatrogenesis involving a chiropractor had been incorrectly ascribed to a medical or other practitioner.
We must not deny the existence of the possibility of injury after manual therapy. All steps should be taken to increase awareness of and minimize injury. Australian chiropractors have written on cervical spine injuries after manipulation therapy and necessary precautions since 1977 [2-19].
The greater number of Cases involving chiropractors (see Table 1) is to be expected because of the much greater number of manipulations performed by chiropractors [In the USA, 94% chiropractic, 4% osteopathy, and 2% medical [85-86]].
It has been clearly demonstrated that the literature of medical organizations, medical authors and respected, peer-reviewed, indexed journals have, on numerous occasions, misrepresented the facts regarding the identity of a practitioner of manual therapy associated with patient injury. Such biased reporting must influence the perception of chiropractic held by the reader, especially when cases of death [12-13, 21, 24-25, 27, 29, 32, 35, 37, 44, 49, 54-57]; tetraplegia [27, 30, 33, 40, 58-68] and neurological deficit [21, 23, 27-28, 31, 37-38, 41, 45, 48, 50-53, 58-68] are incorrectly reported as having been caused by chiropractic. Because of the unwarranted negative opinion generated in medical readers and the lay public alike, erroneous reporting is likely to result in hesitancy to refer to and underutilization of this important mode of health care delivery.
Is this misrepresentation accidental or is it intentionally mischievous? In many cases, the medical author(s) had access to the original reports, which clearly document the practitioner as a non-chiropractor, yet medical authors cited in this paper still published papers incorrectly implicating chiropractic. If the cases described here can be viewed as “using false representations to obtain unjust advantage or injure another” it qualifies as a definition of fraud [87].
In the public interest, reduction of incidents and accidents from manual therapy will be better served by a joint effort between knowledgeable chiropractors and medical practitioners than by the use of statements not based on fact.
A Risk Assessment of Cervical Manipulation vs. NSAIDs for the Treatment of Neck Pain
The best evidence indicates that cervical manipulation for neck pain is much safer than the use of NSAIDs, by as much as a factor of several hundred times.There is no evidence that indicates NSAID use is any more effective than cervical manipulation for neck pain.
The Validity of the Extension-rotation Test as a Clinical Screening Procedure Before Neck Manipulation: A Secondary Analysis
We were unable to demonstrate that the extension-rotation test is a valid clinical screening procedure to detect decreased blood flow in the vertebral artery. The value of this test for screening patients at risk of stroke after cervical manipulation is questionable.
Safety in Chiropractic Practice, Part I: The Occurrence of Cerebrovascular Accidents After Manipulation to the Neck in Denmark from 1978–1988
Although the incidence of CVA after chiropractic SMT was confirmed to be low, there seems to be sufficient evidence to justify a firm policy statement cautioning against upper cervical rotation as a technique of first choice.
Manipulation and Mobilization of the Cervical Spine: A Systematic Review of the Literature
Cervical spine manipulation and mobilization probably provide at least short-term benefits for some patients with neck pain and headaches. Although the complication rate of manipulation is small, the potential for adverse outcomes must be considered because of the possibility of permanent impairment or death.
Safety in Chiropractic Practice Part II: Treatment to the Upper Neck and the Rate of Cerebrovascular Incidents
Although there seems to be a link between upper cervical rotation manipulative techniques and cerebrovascular incidents, treatment to the lower neck and the use of other techniques are implicated as well.
Tissue Plasminogen Activator in a Vertebral Artery Dissection
To our knowledge, this is the first reported case of intravenous tissue plasminogen activator use in acute vertebral artery dissection.
Vertebral Artery Flow and Spinal Manipulation. A Randomized, Controlled and Observer Blinded Study
To the best of our knowledge, this is the first study comparing flow velocity in the vertebral artery before and after spinal manipulative therapy. We found no significant changes in otherwise healthy subjects with a biomechanical dysfunction of the cervical spine. Major changes in peak flow velocity might in theory explain the pathophysiology of cerebrovascular accidents after spinal manipulative therapy. However, in uncomplicated spinal manipulative therapy, this potential risk factor was not prevalent.
Efficacy and Risks of Chiropractic Manipulation: What Does the Evidence Suggest?
This review article drew upon the appropriateness studies conducted at RAND, which indicated efficacy of manipulation for acute or sub-acute low back pain, neck pain, and muscle-tension-type headaches. The article also reported the low risk of serious complications from lumbar and cervical manipulations. According to the literature review, the estimated risk for serious complications from cervical manipulation is 6.39 per 10 million manipulations. For lumbar manipulation, it is 1 per 100 million manipulations. These estimates compare favorably to other forms of therapy, such as cervical spine surgery or nonsteroidal anti-inflammatory drugs (NSAIDS). The risk from manipulation is low and compares favorably to other forms of therapy for the same conditions (e.g., 15.6 complications per 1000 cervical spine surgeries, 3.2 per 1000 subjects for nonsteroidal anti-inflammatory drugs)
Risk Factors and Precipitating Neck Movements Causing Vertebrobasilar Artery Dissection After Cervical Trauma and Spinal Manipulation
The literature does not assist in the identification of the offending mechanical trauma, neck movement, or type of manipulation precipitating vertebrobasilar artery dissection or the identification of the patient at risk. Thus, given the current status of the literature, it is impossible to advise patients or physicians about how to avoid vertebrobasilar artery dissection when considering cervical manipulation or about specific sports or exercises that result in neck movement or trauma.
Effect of Premanipulative Tests on Vertebral Artery and Internal Carotid Artery Blood Flow: A Pilot Study
Screening procedures that use rotation and extension may be useful tests of the adequacy of collateral circulation. A larger study is needed to determine whether subjects testing positive significantly differ from those testing negative.
Vertebral Artery Volume Flow in Human Beings
This appears to be the first in vivo Doppler study on human vertebral artery volume blood flow. Our results indicate that in symptom-free subjects there is no change in vertebral artery perfusion during rotation in spite of significant changes in flow velocity. This finding, as well as the observed changes in flow velocity reported by others, may be explained by a positional change in the vertebral artery diameter. In addition, we have investigated volume blood flow in the vertebral arteries before or after spinal manipulation therapy but found no significant changes.
Vertebral Artery Flow and Cervical Manipulation: An Experimental Study
We present an experimental model for investigations of vertebral artery hemodynamics during biomechanical interventions. We found a modest and transient effect of cervical manipulation on vertebral artery volume flow. The model may have further applications in future biomechanical research, for example, to determine whether any of several spinal manipulative techniques imposes less strain on the vertebral artery, thereby reducing possible future cerebrovascular accidents after such treatment.
Is There a Role for Premanipulative Testing Before Cervical Manipulation?
It appears that a positive premanipulative test is not an absolute contraindication to manipulation of the cervical spine. If the test is able to identify patients at risk for cerebrovascular accidents, we suggest patients with a reproducible positive test should be referred for a duplex examination of the vertebral artery flow. If duplex flow is normal, the patient should be eligible for cervical manipulation despite the positive premanipulative test.
Vertebral Artery Dissection Causing Stroke in Sport
Five cases of vertebral arterial dissection occurring in sport are presented. These cases emphasise the diagnostic and management difficulties in this setting. Stroke in sport, although uncommon, is predominantly due to arterial dissection in either the vertebral or carotid arteries. Physicians involved in athlete care need to be aware of this diagnosis.
Vertebral Artery Dissection and Migraine Headaches in Children
Strokes of the posterior circulation are uncommon in childhood. In vertebrobasilar insults, vertebral artery dissection remains a rare diagnosis. We report the case of an 8-year-old boy with a history of migraine headaches who presented with acute cerebellar signs and agitation following multiple infarctions of bilateral cerebellar hemispheres. Vertebral angiography demonstrated dissection of the left vertebral artery with occlusion of the basilar artery just distal to its origin.
Risk factors for vertebral artery dissection are reviewed, with emphasis on association with migraine headaches. A review of imaging studies for the diagnosis of dissection is also presented. This case demonstrates the importance of considering arterial wall dissection in pediatric patients with a history of atypical migraines associated with new neurologic findings.
Vertebral Artery Dissection: Warning Symptoms, Clinical Features and Prognosis in 26 Patients
Our findings show that VA dissection affects mainly middle age persons and involves both sexes equally. Headache and/or neck pain followed by vertigo or unilateral facial paresthesia is an important warning sign that may precede onset of stroke by several days. Although the majority of patients will have excellent prognosis, this was less likely in patients presenting with subarachnoid hemorrhage or bilateral VA dissection. Recurrence rate was low.
Unpredictability of Cerebrovascular Ischemia Associated with Cervical Spine Manipulation Therapy: A Review of Sixty-four Cases After Cervical Spine Manipulation
Cerebrovascular accidents after manipulation appear to be unpredictable and should be considered an inherent, idiosyncratic, and rare complication of this treatment approach.
Transcranial Sonography and Vertebrobasilar Insufficiency
This illustrates a case of extra-arterial mechanical compression of the vertebral arteries documented by transcranial Doppler sonography procedures. Brainstem symptoms were correlated with a documented perfusion deficit during cervical positional testing. This case also demonstrated that spinal manipulative therapy may be safely used on patients with vertebrobasilar insufficiency when the biomechanics and related flow studies are elucidated.
Vertebral Arteries and Cervical Rotation: Modeling and Magnetic Resonance Angiography Studies
The results of this study do not support the hypothesis that lumen narrowing of vertebral arteries generally occurs during contralateral cervical rotation and that stenosis when it occurs is due to stretching of the vessel. It seems that when stenosis happens it is mainly due to localized compression, usually at the level of the C2 transverse foramen. Factors that may influence the degree of stenosis are the amount of atlanto-axial rotation and the concomitant C1/C2 contralateral lateral flexion, the intraluminal pressure and how well developed the curves are of the atlanto-axial segment.
Uneventful Upper Cervical Manipulation in the Presence of a Damaged Vertebral Artery
This case report demonstrates that vigorous manipulation of the upper cervical spine is possible without injuring an already damaged vertebral artery. It is suggested that the line of drive used during the single manipulation, almost pure lateral flexion with slight rotation, was responsible for the apparent innocuous response. Guidelines for the evaluation and management of vertebral artery dissection are reviewed. Because it is currently impossible to identify patients at risk of having a dissected vertebral artery with standard in-office examination procedures, rotational manipulation of the upper cervical spine should be abandoned by all practitioners, and schools should remove such techniques from their curriculums.
Internal Forces Sustained by the Vertebral Artery During Spinal Manipulative Therapy
SMT resulted in strains sustained internally by the VA that were similar to those experienced during neck ROM testing and VBI screening. These strains were almost an order of magnitude lower than those required to mechanically disrupt the VA. We conclude that under normal circumstances, a single, typical (high-velocity/low-amplitude) SMT thrust is very unlikely to tear or otherwise mechanically disrupt the VA.
Is Cervical Spinal Manipulation Dangerous?
The present case adds to the list of CVAs after cervical manipulation. However, it also illustrates that such complications may leave the patient completely asymptomatic, allowing a normal life despite a severe pathologic condition demonstrated by MR. The outcome of many cases reported by Terrett1 [6] was not available, but in 27 out of 183 patients there was a complete recovery, and 15 had an almost complete recovery. Conversely, 33 out of the 183 patients had a fatal CVA after cervical manipulation. Therefore, the treatment is certainly not without serious risk. However, the fear of CVAs seems greatly exaggerated, considering the low number of reported cases compared to the amount of treatment given and in view of the higher rate of complications with many generally accepted treatments. It is tempting to speculate that the widespread fear of cervical manipulation within the medical profession is more a political than a factual issue.
Association of Internal Carotid Artery Dissection and Chiropractic Manipulation
The medical literature does not support a clear causal relationship between CMT and ICAD. Reported cases are exceedingly scarce, and none support clear cause and effect.
Vertebrobasilar Ischemia and Spinal Manipulation
I have presented the diagnosis and evaluation of vertebrobasilar ischemia. One case resulted from self-manipulation to the cervical spine, and a second case was due to a spinal strain. Cerebral vascular Doppler examination, a thorough history, and a physical examination indicated a need for spinal manipulative therapy, even though the functional vascular test did not.
Serial cerebrovascular Doppler sonography documented the improvement of peak systolic flow; however, because of the 13-month duration in the first patient, there is some question about the amount of time, even though the symptomatic picture improved considerably within 24 hours. In the second patient, the repeat study was performed within 4 days.
I am not recommending the use of cervical spine manipulation in patients that exhibit vertebrobasilar ischemia. I do, however, feel chiropractic physicians in general successfully treat substantial amounts of dizziness and light-headedness, which have resulted from irritation to the apophyseal joints and possibly stimulus to the sympathetic nervous system resulting in ischemia.
Further, a nonrotator type of manipulative technique, which has been described, should be employed in high-risk patients. In addition, continuous wave Doppler and duplex Doppler sonography were shown to be an excellent method to rule out possible vertebrobasilar arterial ischemia that can result from something more serious than a spasm of the vertebral or carotid arteries.
Motor Vehicle Accidents: The Most Common Cause of Traumatic Vertebrobasilar Ischemia
Traumatic vertebrobasilar ischemia is most often due to MVAs; the diagnosis is often missed, in part because of the delay between injury and onset of symptoms and, in part, we hypothesize, because of reluctance of doctors to be involved in medicolegal cases.
Spontaneous Cervical Artery Dissections and Implications for Homocysteine
As shown in Table 1, the annual incidence of spontaneous VADs in hospital settings has been estimated to occur at the rate of 1 to 1.5 per 100,000 patients. [15] The corresponding VAD incidence rate in community settings has been reported to be twice as high. [16,17] Using an estimated value of 10 from the literature to represent an average number of manipulations per patient per episode, [23] it becomes apparent that the proposed exposure rate for CVAs attributed to spinal manipulation is equivalent to the spontaneous rates for cervical arterial dissections as reported. [15-17] If the threat of stroke or stroke-like symptoms is to be properly assessed, therefore, at least half our attention needs to be directed toward the spontaneous events instead of primarily or solely on spinal manipulation.
The Stroke Issue: Paucity of Valid Data, Plethora of Unsubstantiated Conjecture
Chiropractic can be proud of its exemplary standards in the areas of informed consent and the allocation of funding for research to study issues of safety. As a responsible, ethical, and caring profession, chiropractic must continue to look into the issue regarding the potential risk of chiropractic adjustment. At this time, it cannot be scientifically stated that there is no risk of VBA dissection from chiropractic cervical adjustment. It can, and in my opinion must, be scientifically stated that there is neither valid evidence of a causal relationship between chiropractic cervical adjustment and VBA dissection nor any valid data to estimate a risk of VBA dissection associated with chiropractic cervical adjustment. It can also be stated that the data that are available regarding the total number of adjustments performed each year, the total number of VBA dissections and occlusions that occur in the absence of chiropractic adjustment each year, and the data that indicate a chiropractic cervical adjustment represents less force to the vertebral artery than movement within the normal range of motion make it more logical to assume a temporal rather than causal link between these 2 events.
How Common Are Side Effects of Spinal Manipulation And Can These Side Effects Be Predicted?
Little scientific support is available concerning usual and unusual reactions after spinal manipulation although such reactions are very common in clinical practice. Fifty-nine manipulative therapists were requested to enroll 15 consecutive patients attending for their first visit to receive spinal manipulation. These patients were asked to complete a questionnaire after this first visit that asked for possible risk factors for spinal manipulation and asked about any side effects after the manipulation. The participating practitioners were asked to note medical diagnosis, manipulated spinal region, number of treated areas and type of additional treatment. Four hundred and sixty five valuable responses were analysed. Two hundred and eighty three patients (60.9%) reported at least one post-manipulative reaction. The most common were headache (19.8%), stiffness (19.5%), local discomfort (15.2%), radiating discomfort (12.1%) and fatigue (12.1%).
Defining the Effect of Cervical Manipulation on Vertebral Artery Integrity: Establishment of an Animal Model
For the first time, an animal model has been established that permits direct interrogation of the internal structures of the vertebral artery. This model can also be manipulated to create “preexisting” vascular injuries that are thought to be possible prerequisites for cerebrovascular injury associated with manipulation. As a result, an experimental platform has been established that is capable of providing investigators of all backgrounds with the ability to quantify biologic and mechanical outcomes of cervical manipulation.
Cervical Artery Dissection A Comparison of Highly Dynamic Mechanisms: Manipulation Versus Motor Vehicle Collision
Perceived causation of reported cases of cervical artery dissection is more frequently attributed to chiropractic manipulative therapy procedures than to motor vehicle collision related injuries, even though the comparative biomechanical evidence makes such causation unlikely. The direct evidence suggests that the healthy vertebral artery is not at risk from properly performed chiropractic manipulative procedures.
Is It Time To Stop Functional Pre-manipulation Testing of the Cervical Spine?
The combined extended and rotated cervical spine position has been postulated to affect vertebral artery blood flow by primarily causing a narrowing of the vessel lumen, usually within the artery contralateral to the side of head rotation. The production of brainstem symptoms during the manoeuvre has generally been considered to be a positive test result. As a consequence, functional pre-manipulation testing of the cervical spine has been part of clinical screening undertaken by chiropractors and other manual practitioners to rule out the risk of possible injury to the vertebral artery.
Cerebrovascular Accident Without Chiropractic Manipulation: A Case Report
It is imperative to avoid overstating the risk of CVA after cervical spinal manipulation, yet it is equally crucial to recognize it as a direct or indirect clinical possibility. Clinical apathy can arise from assuming that as there is no conclusive proof for CVAs as a consequence of cervical manipulation. It remains essential for both the patient’s health and the profession’s future that we remain vigilant—vigilant not only regarding knowledge concerning the potential presence of CVAs in progress, their underlying causative, and/or contributing factors, but arguably more importantly, with respect to the clinical diversity with which they may present. Thoughts linger concerning the possible legal consequences, which may subsequently have occurred, should spinal manipulation have taken place the day of consultation for this particular patient.
Inappropriate Use of the Title Chiropractor and the Term Chiropractic Manipulation in the Peer-reviewed Biomedical Literature
The results of this study suggest that the words ‘chiropractor’ and ‘chiropractic manipulation’ are often used inappropriately by European biomedical researchers in relation to the reporting of injuries associated with cervical spine manipulation. Furthermore, the findings of this year-long prospective review provide further preliminary evidence, beyond that already provided by Terrett [6], that the inappropriate use of the title ‘chiropractor’ and term ‘chiropractic manipulation’ may be a significant source of over-reporting of the link between chiropractic care and injury. Editors of peer-reviewed scientific journals were amenable to publishing ‘letters to editors’, and to a lesser extent ‘corrections’, pertaining to original research that had inappropriately used the title ‘chiropractor’ and/or term ‘chiropractic manipulation’.
The Benefits Outweigh the Risks for Patients Undergoing Chiropractic Care for Neck Pain: A Prospective, Multicenter, Cohort Study
Despite the fact that adverse events following treatment are common, and in some cases severe in intensity, this study shows that the benefits of chiropractic care for neck pain seem to outweigh the potential risks.
Safety of Chiropractic Manipulation of the Cervical Spine: A Prospective National Survey
Although minor side effects following cervical spine manipulation were relatively common, the risk of a serious adverse event, immediately or up to 7 days after treatment, was low to very low.
Examining Vertebrobasilar Artery Stroke in Two Canadian Provinces
The annual incidence rate of VBA strokes was fairly stable in Ontario and Saskatchewan between 1993 and 2004, except for 2000 when a sharp increase was observed. The increase in the incidence rate of VBA stroke could not be explained by a proportional increase in exposure to chiropractors at the ecological level of analysis. It may have been a reporting bias, influenced by media attention resulting from a coroner’s inquest into a death from VBA stroke after chiropractic care.
Risk of Vertebrobasilar Stroke and Chiropractic Care: Results of a Population-based Case-control and Case-crossover Study
VBA stroke is a very rare event in the population. There was an association between chiropractic services and subsequent vertebrobasilar artery stroke in persons under 45 years of age, but a similar association was also observed among patients receiving general practitioner services. This is likely explained by patients with vertebrobasilar artery dissection-related neck pain or headache seeking care before having their stroke.
Patients With Symptoms and Signs of Stroke Presenting to a Rural Chiropractic Practice
Patients with symptoms and signs of stroke may infrequently present to chiropractic physicians for evaluation and treatment. Prevention, screening, early identification of stroke symptoms and signs, and referral for prompt treatment are cornerstones of the national stroke policy as espoused by the Centers for Disease Control. Chiropractic physicians have opportunities for practice-related health education initiatives focusing on the role of health and wellness in stroke prevention and for prompt lifesaving referral of emergency presentations.
Microstructural Damage in Arterial Tissue Exposed to Repeated Tensile Strains
Cadaveric arterial tissues of New Zealand white rabbit with similar size, structure, and mechanical properties of human vertebral artery did not exhibit histologically identifiable microdamage when exposed to repeated mechanical loading equivalent to the strains observed in human vertebral artery during chiropractic cervical spine manipulative therapy.
Strokes: Causalities and Logical Fallacies
Twenty three years ago, while trying to fall asleep, I turned my head to one side. The right side of my body went numb and the room started swirling. I remember the ambulance ride and the sheer panic of not being able to feel or move my arms and legs. Yes, I am a stroke patient, and there is absolutely no doubt in my mind that had the event occurred while I was on a chiropractic table rather than lying in bed, the stroke would have been attributed to receiving chiropractic care. Since then, I’ve read the accounts that have appeared in the popular media suggesting that “chiropractic manipulation” of the cervical spine is associated with strokes. I’ve also reviewed all of the literature that I could that has addressed the purported relationship between chiropractic cervical adjustments and strokes. (A comprehensive review is beyond the scope of this brief article; however, resources are available for the interested reader.)
Preliminary Report: Biomechanics of Vertebral Artery Segments C1-C6 During Cervical Spinal Manipulation
Although general conclusions should not be drawn from these preliminary results, the findings of this study suggest that textbook mechanics of the VA may not hold, that VA strains may not be predictable from neck movements alone, and that fascial connections within the transverse foramina and coupled vertebra movements may play a crucial role in VA mechanics during neck manipulation. Furthermore, the engineering strains during cervical spinal manipulations were lower than those obtained during range of motion testing, suggesting that neck manipulations impart stretches on the VA that are well within the normal physiologic range of neck motion.
Current Understanding of the Relationship Between Cervical Manipulation and Stroke: What Does It Mean for the Chiropractic Profession?
The current understanding of the relationship between CMT and VADS provides new responsibilities and new opportunities. The response the chiropractic profession takes to these responsibilities and opportunities will impact its continued maturation and will help to limit suffering among its patients and the public at large. While current evidence suggests that CMT is associated with but not causally related to VADS, it can be expected that patients with undetected VADS will continue to see chiropractic physicians and it is essential that focused attention be made in an attempt at detection of this uncommon but potentially devastating disorder. In addition, the profession would do well to engage in a public health campaign designed to educate the public about VADS to increase recognition of the early signs of this disorder.
A Population-Based Case-Series of Ontario Patients Who Develop a Vertebrobasilar Artery Stroke After Seeing a Chiropractor
Our population-based analysis suggests that VBA stroke patients who consulted a chiropractor the year before their stroke are older than previously documented in clinical case series. We did not find that women were more commonly affected than men. Moreover, we found that most patients had at least one cardio- or cerebrovascular comorbidity. Our analysis suggests that relying on case series or surveys of health care professionals may provide a biased view of who develops a VBA stroke.
The Safety of Cervical Manipulation: Putting Stroke Risk in Perspective, Part 1
Several studies have attempted to link chiropractic manipulation to adverse events, the most serious and widely studied being strokes following dissections of the vertebral artery. [1-6] To begin to shed light on this problem, several retrospective studies against large population bases have been conducted. As shown in Table 1, [7-15] a large sampling of such studies indicates that the number of serious complications or cerebrovascular accidents (CVAs), as established by researchers from both the chiropractic and medical professions, ranges from one case per 400,000 manipulations to zero in 5 million.
Vertebral Artery Dissection in a Patient Practicing Self-manipulation of the Neck
It is critical for doctors of chiropractic to exercise proper clinical evaluation and treatment when addressing their patients, specifically when dealing with suspected VAD. This case report should serve as a reminder that recognizing “red flags” is critical to a proper diagnosis. By taking a proper history, realizing the warning signs, and performing the right action plan (ie, immediate referral to an emergency department), the chiropractic doctor and intern contributed to the preservation of this patient’s life.
Risk Factors and Clinical Presentation of Craniocervical Arterial Dissection: A Prospective Study
This study will provide descriptive and comparative data on intrinsic and extrinsic risk factors for craniocervical arterial dissection and outline the typical clinical presentation, including the nature of early presenting features which might assist practitioners to identify those patients for whom vigorous manual therapy of the neck is inappropriate and alert them to those for whom immediate urgent medical care should be sought.
Vertebral Artery Strains During High-speed, Low amplitude Cervical Spinal Manipulation
Spinal manipulative therapy (SMT) has been recognized as an effective treatment modality for many back, neck and musculoskeletal problems. One of the major issues of the use of SMT is its safety, especially with regards to neck manipulation and the risk of stroke. The vast majority of these accidents involve the vertebro-basilar system, specifically the vertebral artery (VA) between C2/C1. However, the mechanics of this region of the VA during SMT are unexplored. Here, we present first ever data on the mechanics of this region during cervical SMT performed by clinicians. VA strains obtained during SMT are significantly smaller than those obtained during diagnostic and range of motion testing, and are much smaller than failure strains. We conclude from this work that cervical SMT performed by trained clinicians does not appear to place undue strain on VA, and thus does not seem to be a factor in vertebro-basilar injuries.
Internal Carotid Artery Strains During High-Speed, Low-Amplitude Spinal Manipulations of the Neck
This study showed that maximal ICA strains imparted by cervical spinal manipulative treatments were well within the normal ROM. Chiropractic manipulation of the neck did not cause strains to the ICA in excess of those experienced during normal everyday movements. Therefore, cervical spinal manipulative therapy as performed by the trained clinicians in this study, did not appear to place undue strain on the ICA and thus does not seem to be a factor in ICA injuries.
The Quality of Reports on Cervical Arterial Dissection Following Cervical Spinal Manipulation
This paper examined the quality of literature describing an association between cSMT and CAD. Case reports represented the majority of this literature. Since these reports may contribute to further understanding CADs as they relate to manual therapy, it is important that they are of the highest quality. This study has demonstrated that the literature infrequently reports useful data toward understanding the association between cSMT, CADs and stroke. As a result, the value of these reports toward informing our understanding of the relation between cSMT and CAD is minimal. We suggest that through the systematic collection of data features presented in this paper, a clearer clinical picture of the association between cSMT and CAD would be possible. This study lays the groundwork for developing a universal reporting tool for adverse events related to cSMT.
Risk of Traumatic Injury Associated with Chiropractic Spinal Manipulation in Medicare Part B Beneficiaries Aged 66-99
Among Medicare beneficiaries aged 66-99 with an office visit risk for a neuromusculoskeletal problem, risk of injury to the head, neck or trunk within 7 days was 76% lower among subjects with a chiropractic office visit as compared to those who saw a primary care physician.
Elongated Styloid Processes and Calcified Stylohyoid Ligaments in a Patient With Neck Pain: Implications for Manual Therapy Practice
Neck pain in the presence of elongated styloid processes (ESPs) and calcified stylohyoid ligaments (CSLs) can be associated with Eagle syndrome, which can include ipsilateral head and neck pain, odynophagia, dysphagia, and cerebrovascular symptoms. This case, initially thought to be Eagle syndrome, highlights proper diagnostic workup for this condition and presents potential contraindications to consider with regard to cervical spine manipulation in such patients. Manual therapy precautions pertaining to cervical spine manipulation may be appropriate in cases involving ESPs and calcified stylohyoid ligaments.
Recognition of Spontaneous Vertebral Artery Dissection Preempting Spinal Manipulative Therapy: A Patient Presenting With Neck Pain and Headache for Chiropractic Care
This case highlights the potential for patients with vertebral artery dissection to present with nonspecific musculoskeletal complaints. Neurological symptoms may not manifest initially, but their sudden onset indicates the possibility of an ischemic cerebrovascular event. We suggest that early recognition and emergent referral for this patient avoided potential exacerbation of an evolving pre-existing condition and resulted in timely anticoagulation treatment.
Identification of Internal Carotid Artery Dissection in Chiropractic Practice
Even though ICAD is uncommon, it is not considered rare and DCs may encounter patients with this condition in their practices. When identified, the chiropractic management of ICAD patients involves immediate referral to an appropriate medical specialist. Unwarranted delay may result in progression of the ICAD even in the absence of any treatment. In addition to urgent referral, it is recommended that any identified ICAD patient not receive cervical manipulation, as a few case reports have correlated worsening of the condition with the intervention. [34, 35] Moreover, any form of excessive or abrupt cervical motion may dislodge an embolus. Unfortunately, ICAD may be completely asymptomatic or symptoms may appear to be benign (e.g., headache, neck pain, or cervicogenic dizziness). Consequently, the condition may be nearly impossible to identify, at least in its early stage. There is currently no credible evidence to support the opinion that cervical manipulation causes ICAD. [4] However, a close temporal relationship between the chiropractic manipulation and the onset of symptoms may give the appearance of a causative relationship. As a result, medical neurologists may report this to patients who develop ICAD subsequent to chiropractic manipulation. [36, 37]
There are no pre-manipulation screening tests available that are capable of reliably identifying patients who are likely to develop cervical artery dissection. Realizing that ICAD is often difficult and sometimes impossible to diagnose, DCs should be aware of the information summarized in Table 1 and consider it in patients who are candidates for cervical manipulation, especially in cases involving new, severe, or unusual headache and/or neck pain. When ICAD is suspected, the patient should be immediately referred to an appropriate medical specialist for evaluation and possible treatment.
