I have attempted to understand the current
situation, which draws an association between
cerebrovascular arterial (CVA) events and
cervical
spine manipulation. I am clearly not an
expert in this field but have attempted to
search databases, read various research
studies, and attend multiple chiropractic
research conferences that have discussed
cervical manipulation and risk of stroke.
So far what has clearly been shown is that
the risk is so small that any possible study
to properly study the phenomena would take
about 25 million subjects. The reason is that
the incident appears to be so rare, that it
is hard to differentiate between causal and
coincidental factors. The coincidence factor
is rare also; to the degree that research is
showing in some cases seeing a visit to a
chiropractor might reduce the incidence of
stroke as compared to common incidental or
trivial causes.
So what are we at this time as chiropractors are
left with? Apparently as healthcare
practitioners we are responsible to
differentiate when a patient presents in our
office whether or not they might be having a
stroke in progress and making sure they are
referred both immediately and appropriately.
Part of the difficulty is that many factors
associated with stroke in progress are
reasons why patients seek our care.
What are some factors that we can use to
differentiate patient care and the need for
referrals?
Be cautious to watch for patient dizziness,
drop attacks, blurred vision, difficulty
speaking, swallowing, or walking, along with
nausea, numbness, and nystagmus. Since a
subset of patients treated by chiropractic
care can receive relief from the above
symptoms what is important in this
differential diagnosis is a mix of ALL of
these symptoms in one patient.
We need to be concerned when a patient tells
us "I have a pain in my neck and/or head
unlike anything I have ever had before." Also
we will need to increase any investigation if
the patient has posterior head pain that is
throbbing, steady or sharp, called a
"thunderclap headache."
In an effort to keep SOT chiropractors
advised of the most current events that may
affect our practices this newsletter will
feature:
1. A recent article in Dynamic
Chiropractic entitled, "Chiropractic and
Stroke Risk: Setting the Record Straight."
2. An abstract of an article and comment
published in the October 1, 200t issue of
Spine entitled, "Safety of Chiropractic
Manipulation of the Cervical Spine: A
Prospective National Survey"
3. "Migraine With Aura Increases Risk for
Ischemic Stroke" discussed in a prior SOT
Research Update.
4. CEvantive University associated with Foundation
of Chiropractic Education and Research (FCER) offers a free 2-
hour course on stroke and manipulation.
5. NCMIC has a new monograph Current Concepts in Spinal
Manipulation and Cervical Arterial Incidents - 2006.
6. The Benefits Outweigh the Risks for Patients Undergoing
Chiropractic Care for Neck Pain: A Prospective, Multicenter, Cohort
Study. JMPT. July 2007.
7. Haneline MT, Rosner AL. The etiology of cervical artery
dissection. Journal of Chiropractic Medicine. Sep 2007; 6(3): 110-120.
8. Cassidy JD, Boyle
E, Côté P, He Y, Hogg-Johnson S, Silver FL, Bondy SJ. Risk
of vertebrobasilar stroke and chiropractic care: results of a
population-based case-control and case-crossover study. Spine. 2008 Feb
15;33(4 Suppl):S176-83.
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Chiropractic and Stroke Risk: Setting the Record
Straight
Dynamic Chiropractic, September 24, 2007, Volume 25, Issue 20
A groundbreaking study on vertebral artery
dissection (VAD) and stroke following
chiropractic office visits is pending
publication in Spine and the European Spine
Journal. The study, conducted as part of the
Bone and Joint Decade 2000-2010 Task Force on
Neck Pain and Its Associated Disorders,
looked at the association between
chiropractic office visits and the incidence
of vertebral artery strokes.
"Current research suggests that dissections
are probably multifactorial in origin," said
Task Force President Scott Haldeman, DC, MD,
PhD. "They appear to occur in a person with a
genetic predisposition to arterial
dissection. They also appear to require a
second factor such as viral infection or
possibly estrogen. They can then be triggered
by a minor head movement, including
activities of daily living, an adjustment or
an examination of the neck."
Chiropractic
and Stroke Risk: Setting the Record Straight · click here
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Safety of Chiropractic Manipulation of the Cervical
Spine: A Prospective National Survey
Thiel HW, Bolton JE, Docherty S, Portlock JC. Spine.
32(21):2375-2378, October 1, 2007.
Objective. To estimate the risk of serious
and relatively minor adverse events following
chiropractic manipulation of the cervical
spine by a sample of U.K. chiropractors.
Summary of Background Data. The risk of a
serious adverse event following chiropractic
manipulation of the cervical spine is largely
unknown. Estimates range from 1 in 200,000 to
1 in several million cervical spine
manipulations.
Methods. We studied treatment outcomes
obtained from 19,722 patients. Manipulation
was defined as the application of a
high-velocity/low-amplitude or mechanically
assisted thrust to the cervical spine.
Serious adverse events, defined as "referred
to hospital A&E and/or severe onset/worsening
of symptoms immediately after treatment
and/or resulted in persistent or significant
disability/incapacity," and minor adverse
events reported by patients as a worsening of
presenting symptoms or onset of new symptoms,
were recorded immediately, and up to 7 days,
after treatment.
Results. Data were obtained from 28,807
treatment consultations and 50,276 cervical
spine manipulations. There were no reports of
serious adverse events. This translates to an
estimated risk of a serious adverse event of,
at worse [almost equal to]1 per 10,000
treatment consultations immediately after
cervical spine manipulation, [almost equal
to]2 per 10,000 treatment consultations up to
7 days after treatment and [almost equal to]6
per 100,000 cervical spine manipulations.
Minor side effects with a possible neurologic
involvement were more common. The highest
risk immediately after treatment was
fainting/dizziness/light-headedness in, at
worse [almost equal to]16 per 1000 treatment
consultations. Up to 7 days after treatment,
these risks were headache in, at worse
[almost equal to]4 per 100, numbness/tingling
in upper limbs in, at worse [almost equal
to]15 per 1000 and
fainting/dizziness/light-headedness in, at
worse [almost equal to]13 per 1000 treatment
consultations.
Conclusion. 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.
Safety
of Chiropractic Manipulation of the Cervical Spine: A Prospective
National Survey. · click here
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Safety of Chiropractic Manipulation of the Cervical
Spine: A Prospective National Survey.
Comment: Paul Shekelle, MD, PhD, RAND Corporation
This paper is a good first step at trying to
build the evidence base for one of the most
vexing concerns about cervical spine
manipulation, the possibility of serious
adverse events. Data from 377 chiropractors
in Britain gathered reports from treating
19,722 patients who received more than 50,000
cervical spine manipulations. No serious
adverse events were reported. This is
reassuring.
However, it is concerning that only about a
third of chiropractors in Britain
participated in the data collection;
therefore, the safety of cervical spine
manipulations performed by the other two
thirds of British chiropractors is unknown.
Also, for the chiropractors who did
participate, no follow-up data were available
for 413 treatment consultations. Even though
this a small percentage of the total number
of treatment consultations, a serious adverse
event in a small number of these, even one
serious adverse event, would be cause for a
major revision of the conclusion.
What's needed now is for possible adverse
events of cervical spine manipulation to be
gathered the same way it is for adverse
events of surgery: on every patient and every
clinician. Then we'll really start to
understand just how low the risk might be.
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Migraine with Aura Increases Risk for Ischemic Stroke
Medscape Medical News 2007
August 14, 2007 - New research suggests that
women who have recent onset of migraine with
visual aura have an almost 7-fold increased
risk for ischemic stroke. Results from the
Stroke Prevention in Young Women Study found
the risk for first-ever ischemic stroke was
highest among women who reported new onset
(within the past year) of probable migraine
with visual aura (PMVA).
Key points to take from the article:
1. "...risk for first-ever ischemic stroke
was highest among women who reported new
onset (within the past year) of probable
migraine with visual aura... "
2. "Women who had probable migraine with
visual symptoms who also smoked and used oral
contraceptives (OCs) had seven times the risk
of stroke than women who had probable
migraine with visual symptoms alone,"
3. In this study the group that had
probable migraine with visual aura (PMVA) who
smoked and used OCs had a 10-fold increased
risk for stroke compared with women with no
history of migraine, who did not smoke or use
OCs.
Main point: The doctor should be cautious
with HVLA (typical diversified type) cervical
adjustment with women with PMVA who smoke and
take OCs, possibly even exercise caution with
cervical stairstep adjustments and consider
investigating co-treatment with a
neurologist, if clinically indicated.
To access following link you will need to
open an account with Medscape, which is free
and only takes minutes.
Migraine
with Aura Increases Risk for Ischemic Stroke
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The Benefits Outweigh the Risks for Patients
Undergoing Chiropractic Care for Neck Pain: A Prospective, Multicenter,
Cohort Study
Rubinstein SM, Leboeuf-Yde C, Knol DL, de Koekkoek TE,
Pfeifle CE, van Tulder MW. J Manip Physiological Therapeutics. Jul
2007;30(6): 408-18.
Objective: This study describes both positive clinical
outcomes and adverse events in patients treated for neck pain by a
chiropractor.
Methods: This study was a prospective, multicenter,
observational cohort study. Patients with neck pain of any duration who
fulfilled the inclusion criteria were recruited in a practice-based
study. Data were collected on the patients and from the chiropractors
at baseline, the first 3 visits, and at 3 and 12 months. Clinical
outcome measures included (1) neck pain in the 24 hours preceding the
visit, (2) neck disability, (3) treatment satisfaction, (4) global
assessment, and (5) adverse events. Recovery was defined as "completely
improved" or "much better" using the global assessment scale. An
adverse event was defined as either a new related complaint or a
worsening of the presenting or existing complaint by >30% based upon
an 11-point numerical rating scale.
Results: In all, 79 chiropractors participated, recruiting
529 subjects, representing 4891 treatment consultations. Follow-up was
possible for 90% and 92%, respectively, at 3 and 12 months. Most
patients had chronic, recurrent complaints; mild to moderate disability
of the neck; and a mild amount of pain at baseline; and two thirds had
sought previous care for the presenting complaint in the preceding 6
months. Adverse events after any of the first 3 treatments were
reported by 56%, and 13% of the study population reported these events
to be severe in intensity.
The most common adverse events affected the
musculoskeletal system or were pain related, whereas symptoms such as
tiredness, dizziness, nausea, or ringing in the ears were uncommon
(<8%). Only 5 subjects (1%) reported to be much worse at 12 months.
No serious adverse events were recorded during the study period. Of the
patients who returned for a fourth visit, approximately half reported
to be recovered, whereas approximately two thirds of the cohort were
recovered at 3 and 12 months.
Conclusion: Adverse events may be common, but are rarely
severe in intensity. Most of the patients report recovery, particularly
in the long term. Therefore, the benefits of chiropractic care for neck
pain seem to outweigh the potential risks
The
Benefits Outweigh the Risks for Patients Undergoing Chiropractic Care
for Neck Pain: A Prospective, Multicenter, Cohort Study - Full Text pdf
· click here
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The etiology of cervical artery dissection
Haneline MT, Rosner AL. Journal of Chiropractic
Medicine. Sep 2007; 6(3): 110-120.
The etiology of cervical artery dissection (CAD) is unclear,
although a number of risk factors have been reported to be associated
with the condition. On rare occasions, patients experience CAD after
cervical spine manipulation, making knowledge about the cervical
arteries, the predisposing factors, and the pathogenesis of the
condition of interest to chiropractors. This commentary reports on the
relevant anatomy of the cervical arteries, developmental features of
CAD, epidemiology of the condition, and mechanisms of dissection.
The analysis of CAD risk factors is confusing, however,
because many people are exposed to mechanical events and known
pathophysiological associations without ever experiencing dissection.
No cause-and-effect relationship has been established between cervical
spine manipulation and CAD, but it seems that cervical manipulation may
be capable of triggering dissection in a susceptible patient or
contributing to the evolution of an already existing CAD.
Despite the many risk factors that have been proposed as
possible causes of CAD, it is still unknown which of them actually
predispose patients to CAD after cervical spine manipulation.
Haneline
MT, Rosner AL. The etiology of cervical artery dissection. Journal of
Chiropractic Medicine. Sep 2007; 6(3): 110-120. · Free Full Text
pdf
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The important point of this newsletter is
that while it is unlikely that chiropractic
cervical spine manipulation may cause a CVA
we must be aware of patients that may present
with a stroke in progress or with significant
findings warranting a referral for a
neurological consultation and possible even an immediate referral to
the local
emergency room.
Sacro Occipital Technique Organization - USA
is a non-profit, professional organization formed to promote the
awareness, understanding and utilization of the Sacro
Occipital Technique method of chiropractic as founded and
developed by Dr. Major Bertrand DeJarnette.
The SOTO-USA family all looks forward to
seeing you in Dallas, Texas for the October
2008 Clinical Symposium. It will be a great opportunity
learn an evidence based approach for SOT or advance your SOT training
with
with integrative classes in SOT and Cranial Manipulative Care. For
those interested in working with the dental profession treating TMD
this symposium will be
leading the way.
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