A recent, balanced report in the Canadian Medical Association Journal, states that “neck manipulation as a therapeutic strategy for head and neck pain is common and may be effective” and concludes that until methods of identification of “high risk” populations improves, chiropractors should inform all patients of possible serious complications before neck manipulation (informed-consent).
Dr. Scott Haldeman et al. wrote a follow–up article to the Canadian Stroke Consortium piece cited above. They reviewed 10 years worth of malpractice claim files in Canada for its 4500 chiropractors. They found: “The likelihood that a chiropractor will be made aware of an arterial dissection following cervical manipulation is approximately 1:8.06 million office visits, 1:5.85 million cervical manipulations, 1:1430 chiropractic practice years and 1:48 chiropractic practice careers. This is significantly less than the estimates of 1:500,000–1 million cervical manipulations calculated from surveys of neurologists”.
It is now becoming apparent that chiropractors may have prematurely accepted the notion that cervical adjusting/manipulation could be a “causative” event for VAD. That was a reasonable and professional response to case studies and reports in the peer-reviewed medical literature, which was often based on a pattern of medical mis-reporting later documented by Terrett.
The recently published “Current Concepts: Spinal Manipulation and Cervical Arterial Incidents 2005” (NCMIC) concludes in its Executive Summary: “Unfortunately, opinion rather than fact has tended to dominate discussions regarding CVAs and chiropractic, even though there has been no definitive evidence that chiropractic adjustments (actually) cause strokes. The good news is that this monograph notes that a causative relationship between chiropractic manipulation and stroke is unlikely. There is an associative relationship between the two because people may go to chiropractors for relief of stroke-related symptoms.”
It also recommends that chiropractors pay close attention when patients present with sudden onset of headache/neck/face pain that's different than the patient has had before. If so, evaluate for a history of: Drugs/medication (smoking, oral contraceptives); Physical trauma (which may have damaged arterial structures); Connective tissue diseases (autosomal dominant polycystic kidney disease, Ehlers-Danlos type IV, Marfan Syndrome, Fibromuscular Dystrophy); Genitourinary system (frequent urinary tract infection, hematuria); Nervous system (dysarthria, dysphagia, visual changes, dizziness, confusion, giddiness and vertigo); Cardiovascular system (stroke, TIAs, mitral prolapse, aortic dilation, hypertension).
More and more the reports of stroke caused by chiropractic manipulation are proving false. When further examined, the reports show that these unfortunate events are caused by lay persons tying to mimic specific chiropractic manipulations, as reported in Emergency Medicine.
I read with interest the article by Chen et al (2006) "Vertebral artery dissection and cerebellar infarction following chiropractic manipulation". On communication with Dr. Chen, it was clarified that this manipulation was performed by an individual who graduated from a college associated with Chinese herbs. This individual did not graduate from an accredited chiropractic college, nor is he licensed to practise chiropractic by any other means. As the manipulation was not done by a qualified chiropractor, it was misleading to identify this as a chiropractic adjustment. Similar to the fact that only qualified surgeons can perform surgeries, only qualified chiropractors can perform chiropractic manipulation.
In addition, the authors report that chiropractors perform adjustments without acknowledging relevant risks. This statement is also false. Chiropractors are duly trained to identify risk factors for spinal manipulation and, in many jurisdictions, are required to obtain informed consent. Emerg Med J 2007; 24: 146.
An Evidence Basis for your Referrals
Recommendation 7: For patients who do not improve with self-care options, clinicians should consider the addition of non-pharmacologic therapy with proven benefits for acute low back pain, spinal manipulation; for chronic or subacute low back pain, intensive interdisciplinary rehabilitation, exercise therapy, acupuncture, massage therapy, spinal manipulation, yoga, cognitive-behavioral therapy, or progressive relaxation (weak recommendation, moderate-quality evidence).
Ann Intern Med. 2007;147:478-491.
Spine. 32(21):2375-2378, October 1, 2007
If you've ever heard certain sources claiming that chiropractic spinal manipulation/adjustment of the neck region can be unsafe or downright dangerous, a new study published in the internationally respected journal Spine should help put you at ease. U.K. researchers set out to evaluate the true risk of chiropractic manipulation of the cervical spine (neck region). After reviewing data from over 50,000 cervical manipulations, researchers found no reports of serious adverse events. Researchers concluded, "… the risk of a serious adverse event, immediately or up to 7 days after treatment, was low to very low". Of course, doctors of chiropractic have known for over 100 years that chiropractic manipulation of the spine and joints of the body is not only highly effective, but also extremely safe for their patients.
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A comparison between chiropractic management and pain clinic management for chronic low-back pain in a national health service outpatient clinic.
Private Practice, Oldham, United Kingdom.
OBJECTIVES: To compare outcomes in perception of pain and disability for a group of patients suffering with chronic low-back pain (CLBP) when managed in a hospital by either a regional pain clinic or a chiropractor. DESIGN: The study was a pragmatic, randomized, controlled trial. SETTING: The trial was performed at a National Health Service (NHS) hospital outpatient clinic (pain clinic) in the United Kingdom. SUBJECTS AND INTERVENTIONS: Patients with CLBP (i.e., symptom duration of >12 weeks) referred to a regional pain clinic (outpatient hospital clinic) were assessed and randomized to either chiropractic or pain-clinic management for a period of 8 weeks. The study was pragmatic, allowing for normal treatment protocols to be used. Treatment was administered in an NHS hospital setting. OUTCOME MEASURES: The Roland-Morris Disability Questionnaire (RMDQ) and Numerical Rating Scale were used to assess changes in perceived disability and pain. Mean values at weeks 0, 2, 4, 6, and 8 were calculated. The mean differences between week 0 and week 8 were compared across the two treatment groups using Student's t-tests. Ninety-five percent (95%) confidence intervals (CIs) for the differences between groups were calculated. RESULTS: Randomization placed 12 patients in the pain clinic and 18 in the chiropractic group, of which 11 and 16, respectively, completed the trial. At 8 weeks, the mean improvement in RMDQ was 5.5 points greater for the chiropractic group (decrease in disability by 5.9) than for the pain-clinic group (0.36) (95% CI 2.0 points to 9.0 points; p = 0.004). Reduction in mean pain intensity at week 8 was 1.8 points greater for the chiropractic group than for the pain-clinic group (p = 0.023). Conclusions: This study suggests that chiropractic management administered in an NHS setting may be effective for reducing levels of disability and perceived pain during the period of treatment for a subpopulation of patients with CLBP.
