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The Odd Myth That Chiropractors Cause Strokes, Revisited April 2, 2018 | Forum

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Admin Jun 25 '18

Let us begin a“Risk vs. Reward” discussion with the BENEFITS of cervical manipulation therapy.

If we talk about danger with an intervention, then we have to talk about the risk vs. reward ratio.

I want to start off with the benefits of cervical manipulation for neck pain specifically.

Each paper mentioned includes a short description of the conclusion for each paper cited. Again, each paper is cited in the reference section so that those of you that wish can easily review these papers independently on your own.

  1. Korthalis-de Bos IB, et. al. – “Manual therapy (spinal mobilization) is more effective and less costly for treating neck pain than physiotherapy or care by a general practitioner[10].”
  2. Dewitte V, et. al. – “Based on key features in subjective and clinical examination, patients with mechanical nociceptive pain probably arising from articular structures can be categorized into specific articular dysfunction patterns. Pending on these patterns, specific mobilization and manipulation techniques are warranted. The proposed patterns are illustrated in 3 case studies. This clinical algorithm is the corollary of empirical expertise and is complemented by in-depth discussions and knowledge exchange with international colleagues. Consequently, it is intended that a carefully targeted approach contributes to an increase in specificity and safety in the use of cervical mobilizations and manipulation techniques as valuable adjuncts to other manual therapy modalities[11].”
  3. Dunning JR, et. al. – “The combination of upper cervical and upper thoracic HVLA thrust manipulation is appreciably more effective in the short term than nonthrust mobilization in patients with mechanical neck pain[12].”
  4. Brontfort G, et. al. – “For participants with acute and subacute neck pain, SMT was more effective than medication in both the short and long term. However, a few instructional sessions of HEA resulted in similar outcomes at most time points[13].”
  5. Puentedura EJ, et. al. – The objective of the paper was as follows: “Thrust joint manipulation to the cervical spine has been shown to be effective in patients presenting with a primary report of neck pain. It would be useful for clinicians to have a decision-making tool, such as a clinical prediction rule, that could accurately identify which subgroup of patients would respond positively to cervical thrust joint manipulation.” In the results, they showed if 3 or more of the 4 attributes were present,” the probability of experiencing a successful outcome improved from 39% to 90%[14].”
  6. Yu H, et. al. – “Chiropractic management of atlantoaxial osteoarthritis yielded favorable outcomes for these 10 patients[15].”
  7. Puentedura EJ, et. al. – “Patients with neck pain who met 4 of 6 of the CPR criteria for successful treatment of neck pain with a thoracic spine thrust joint manipulation demonstrated a more favorable response when the thrust joint manipulation was directed to the cervical spine rather than the thoracic spine. Patients receiving cervical thrust joint manipulation also demonstrated fewer transient side-effects[16].”
  8. Miller J, et. al. – “Moderate quality evidence supports this treatment combination (cervical manual therapy combined with exercise) for pain reduction and improved quality of life over manual therapy alone for chronic neck pain; and suggests greater short-term pain reduction when compared to traditional care for acute whiplash[17].”
  9. Hurwitz EL, et. al. – “Our best evidence synthesis suggests that therapies involving manual therapy and exercise are more effective than alternative strategies for patients with neck pain[18].”
  10. Muller R, et. al. – “In patients with chronic spinal pain syndromes, spinal manipulation, if not contraindicated, may be the only treatment modality of the assessed regimens that provides broad and significant long-term benefit[19].”
  11. Zhu L, et. al. – “There was moderate level evidence to support the immediate effectiveness of cervical spine manipulation in treating people with cervical radiculopathy[20]
  12. Giles LG, et. al. – “The consistency of the results provides, despite some discussed shortcomings of this study, evidence that in patients with chronic spinal pain, manipulation, if not contraindicated, results in greater short-term improvement than acupuncture or medication[21].”
  13. Bronfort G, et. al. – “Our data synthesis suggests that recommendations can be made with some confidence regarding the use of spinal manipulative therapy and/or mobilization as a viable option for the treatment of both low back pain and neck pain[22].”

There you have a fairly thick list of research papers demonstrating the effectiveness of chiropractic adjustments for uncomplicated neck pain but neck pain is not the only reason to have a chiropractic adjustment delivered to the cervical region. Another very common reason for neck adjustments would be for the treatment of acute and chronic headaches.

Chiropractors see headache patients in their offices daily and research shows us those patients are in the right place for the best, non-pharmacological treatment of the complaint. In fact, I have an episode of this Chiropractic Forward Podcast (https://www.chiropracticforward.com) that dealt with a paper showing the effectiveness of chiropractic for headaches.

It was Episode 006 and is linked below.

CF 006: With Dr. Tyce Hergert: Astounding Expert Information On Immediate Headache Relief

Here is a listing of papers demonstrating the benefits of cervical manipulation for headaches. Each paper mentioned includes a short description of the conclusion for each paper cited. Again, each paper is cited in the reference section so that those of you that wish can easily review these papers independently on your own.

  1. Malo-Urries M, et. al. – “Upper cervical translatoric spinal mobilization intervention increased upper, and exhibited a tendency to improve general, cervical range of motion and induce immediate headache relief in subjects with cervicogenic headache[23].”
  2. Espi-Lopez GV, et. al. – “In short, manual therapy techniques and manipulation applied to the suboccipital region for four weeks or more showed great improvement and in effectiveness for several aspects that measure the quality of life of a patient having suffered from tension type headaches[24].”
  3. Dunning J, et. al. – “Six to eight sessions of upper cervical and upper thoracic manipulation were shown to be more effective than mobilization and exercise in patients with cervicogenic headache, and the effects were maintained at 3 months[12].”
  4. Hurwitz EL, et. al. – “Utilization and expenditures for headache treatment increased from 2000 to 2009 across all provider groups. MD care represented the majority of total allowed charges in this study. MD care and DC care, alone or in combination, were overall the least expensive patterns of headache care. Risk-adjusted charges were significantly less for DC-only care[25].”
  5. Bronfort G, et. al. – “SMT appears to have a better effect than massage for cervicogenic headache. It also appears that SMT has an effect comparable to commonly used first-line prophylactic prescription medications for tension-type headache and migraine headache[26].”
  6. Bronfort G, et. al. – “Chiropractic is effective in acute, subacute, and chronic low back pain, migraines and headaches originating from the neck, for the treatment of some forms of dizziness, extremity and joint issues, as well as mid back and acute and subacute neck pain[27].
  7. Tuchin PJ, et. al. – “The results of this study support previous results showing that some people report significant improvement in migraines after chiropractic spinal manipulative therapy. A high percentage (>80%) of participants reported stress as a major factor for their migraines. It appears probable that chiropractic care has an effect on the physical conditions related to stress and that in these people the effects of the migraine are reduced[28].”
  8. McCrory D, et. al. – “Cervical spinal manipulation was associated with improvement in headache outcomes in two trials involving patients with neck pain and/or neck dysfunction and headache. Manipulation appeared to result in immediate improvement in headache severity when used to treat episodes of cervicogenic headache when compared with an attention-placebo control. Furthermore, when compared to soft-tissue therapies (massage), a course of manipulation treatments resulted in sustained improvement in headache frequency and severity[29].”

Many headache patients present to chiropractors after a considerable amount of time spent taking headache and migraine medications. Medications do not come without consequences. Certainly when taken long-term. Not only have these patients spent a considerable amount of time on medication, they often have endured botox injections, steroid injections, and worse before finally going to the chiropractor.

It is a fact that patients should have the GUARANTEE of the best treatment that does the LEAST amount of harm.

It is a fact that patients should have the GUARANTEE of the best treatment that does the LEAST amount of harm.

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In that spirit, and considering that chiropractic is safe, effective, and non-pharmacologic, it makes sense that the medical field should actually PROMOTE Chiropractic as a viable, if not valuable, treatment for headaches and migraines rather than dismiss it as ineffectual and dangerous.

Having demonstrated study upon study validating the effectiveness and benefits of cervical manipulation for neck pain (acute, subacute, and chronic) as well as for headaches (chronic, acute, subacute, tension-type, cervicogenic, and migraines), we can now focus attention on research papers having to do with the risk of stroke instance (lack of risk) as a direct result of cervical chiropractic adjustments.

But first, where would you think the idea of the Chiropractors Cause Strokes myth might come from? I believe there are at least a few root sources.

  • You guessed it: our old friend the American Medical Association and their state association underlings. This group deemed it unethical to refer to chiropractors or accept referrals FROM chiropractors. They tried to run us out of business by conducting conferences about chiropractic and generating literature that was anti-chiropractic. They then dispersed the misinformation down through the channels of the state medical associations all the way out to the medical doctors, nurses, and medical field profession out in the field, and then ultimately to their patient bases. The “Chiropractors Cause Strokes” myth was well within their ability to propagate. When your initiative is to rid the Earth of the chiropractic profession, you take advantage of what you can. The Federal Court decision in Wilk vs. AMA shows the AMA did just that.
  • The other likely culprit in my estimation would be patients visiting medical professionals after having been to a chiropractor and having suffering a stroke sometime afterward. I did not say chiropractors “causing” strokes. Research shows us that people are going to chiropractors already suffering arterial tears that are sometimes spontaneous in nature and almost impossible to diagnose in an in-office setting. While chiropractors have a high level of education, there are many out there that are simply untrained at catching red flags and making the proper referral. Other times, patients present with very common symptoms and there are no red flags present whatsoever. The chiropractor treats the patient thinking they are going to help improve a neck complaint or a headache while in reality they may be exacerbating a tear. When the patient reaches the medical professional, the link is easy to make for the uninformed: chiropractors causes strokes.
  • Ignorance – The simple lack of knowledge regarding the body of evidence and research that is available on the topic perpetuates the myth. It is clear the benefits are present. It is clear the risks are not. End of story. But if one is ignorant of the literature, then Chiropractors Cause Strokes is plausible (if not likely) in their minds.

I find it interesting and helpful to relate ideas in medical terms. Many times, when one is learning about topics they are unfamiliar with, it helps to familiarize the material by relating it in terms they better understand. Have you ever watched a commercial for a new medicine or pill and, at the end of the commercial, the narrator runs through an obstacle course of side effects and possible harms?

If you have seen those commercials, then it’s crystal clear that prescription medication can be scary and risky but what about more benign, over-the-counter medications?

Briefly, let us discuss some of the other treatment risks patients commonly face with traditional medical interventions.

  • Data obtained from the U.S. Centers for Disease Control and Prevention show that more than 300 people die annually as a result of acetaminophen poisoning.
  • Beginning in 2006, according to the CDC, the number of people who died after accidentally taking too much acetaminophen surpassed the number who died from intentionally overdosing to commit suicide.
  • NSAIDS such as Ibuprofen and Acetaminophen cause at least 16,000 deaths per year and send 100,000 people to the ER in the United States every year.

It is clear that there is risk with ANY sort of intervention when it comes to the living, breathing, constantly changing, human body. There is risk when one chooses to cross the street, walk in a rainstorm, or climb a ladder.

It is clear that there is risk with ANY sort of intervention when it comes to the living, breathing, constantly changing, human body. There is risk when one chooses to cross the street, walk in a rainstorm, or climb a ladder.

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Most do not let these minimal risks control their decisions or instill fear into their hearts so that they refuse to take an action.

The majority of the population subconsciously realizes a risk, understands minimal odds, and takes action accordingly.

What follows is a listing of the papers exploring the RISKS of adverse events as a result of cervical manipulation. Each paper mentioned includes a short description of the conclusion for each paper cited. Each of these papers is referenced in the citation section at the end of this article and can be reviewed independently.

  1. Cassidy JD, et. al. – Spanning over a nine year time period and 109,020,875 person-years, the researchers included visits to chiropractors AND primary practitioners. There was no statistical difference between the likelihood of vertebral artery dissection after having seen a primary medical doctor vs. after having seen a chiropractor. The only possible conclusions are 1) Chiropractors and medical doctors are causing strokes on rare occasion. 2) Patients are presenting to the offices of chiropractors and medical doctors seeking relief from symptoms of a vertebral arterial dissection already in progress. Obviously the medical professionals are not manipulating the cervical region so option number one makes the least sense. Cassidy’s conclusion was as follows, “This suggests that patients with undiagnosed vertebral artery dissection are seeking clinical care for headache and neck pain before having a VBA stroke.”
  2. Cassidy JD, Pronfort G, Hartvigsen J, et. al. – This article appeared in the British Medical Journal in 2012. “The effectiveness of manipulation for neck pain has been examined in several high quality systematic reviews, evidence based clinical guidelines, and health technology assessment reports. When combined with recent randomized trial results, this evidence supports including manipulation as a treatment option for neck pain,…..We say no to abandoning manipulation and yes to more rigorous research on the benefits and harms of this and other common interventions for neck pain[30].”
  3. Kosloff TM, et. al. – We found no significant association between exposure to chiropractic care and the risk of VBA (vertebrobasilar artery system) stroke. We conclude that manipulation is an unlikely cause of VBA stroke. The positive association between PCP visits and VBA stroke is most likely due to patient decisions to seek care for the symptoms (headache and neck pain) of arterial dissection. We further conclude that using chiropractic visits as a measure of exposure to manipulation may result in unreliable estimates of the strength of association with the occurrence of VBA stroke[31].”
  4. Buzzatti L, et. al. – “….the displacement induced with the present technique seems not to be able to endanger vital structure on the Spinal Cord and the Vertebral Artery.   This study also adds to a better comprehension of the kinematic of the atlanto-axial segment during the performance of HVLA manipulation[32].”
  5. Whedon JM, et. al. – “Among Medicare B beneficiaries aged 66 to 99 years with neck pain, incidence of vertebrobasilar stroke was extremely low.  Small differences in risk between patients who saw a chiropractor and those who saw a primary care physician are probably not clinically significant[33].”
  6. Achalandabaso A, et. al. – “Our data show no changes in any of the studied damage markers. Although this study examined the outcomes in an asymptomatic population, lower cervical and thoracic manipulative techniques seem to be safe manual therapies techniques which cause no harm to the health of the subject. These data may be used as evidence of the safe application of spinal manipulation to healthy subjects. Further studies with a large sample size and a patient population are needed to corroborate the innocuous effects of spinal manipulation[34].”
  7. Quesnele JJ, et. al. – “There were no significant changes in blood flow or velocity in the vertebral arteries of healthy young male adults after various head positions and cervical spine manipulations[35].”
  8. Tuchin P, et. al. – “The evidence for causality of vertebral artery dissection from chiropractic is weak[36].”
  9. Symons BP, et. al. – “We conclude that under normal circumstances, a single typical (high-velocity/low-amplitude) SMT thrust is very unlikely to mechanically disrupt the VA[37].”
  10. Church EW, et. al. – “Our analysis shows a small association between chiropractic neck manipulation and cervical artery dissection (CAD). This relationship may be explained by the high risk of bias and confounding in the available studies, and in particular by the known association of neck pain with CAD and with chiropractic manipulation. There is no convincing evidence to support a causal link between chiropractic manipulation and CAD. Belief in a causal link may have significant negative consequences such as numerous episodes of litigation[38].”

A methodical, logical, and systematic stroll through the body of literature shows without a doubt there is indeed incredible benefit in the use of cervical manipulative treatments for neck pain and headaches & migraine complaints while there is no more risk of stroke from treating with a chiropractor vs. treating with a medical profession.

I want this article to be the final word on this Chiropractors Cause Strokes myth. I want it to be the “end all, be all” on the topic but I have lived long enough to know better and have experienced twenty years within the chiropractic profession. I know this information will not change the attitudes of many. But, if this article can be a reference point for learning more about the topic and can be a tool for educating others about this myth, then I will have fulfilled my function.

In conclusion, the benefit and effectiveness has been proven, the risks have been disproven, and the “Chiropractors Cause Strokes” myth is ONCE AND FOR ALL officially and completely DEBUNKED.

In conclusion, the benefit and effectiveness has been proven, the risks have been disproven, and the “Chiropractors Cause Strokes” myth is ONCE AND FOR ALL officially and completely DEBUNKED.

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In conclusion, the benefit and effectiveness has been proven, the risks have been disproven, and the “Chiropractors Cause Strokes” myth is ONCE AND FOR ALL officially and completely DEBUNKED.

If you would like Dr. Jeff Williams to give this presentation at your seminar or event, please send us an email at dr.williams@chiropracticforward.com for booking and availability.

Listen to our series of podcasts accompanying this blog:




https://www.chiropracticforward.com/blog-post/debunked-the-odd-myth-that-chiropractors-cause-strokes-revisited/

The Forum post is edited by Admin Jul 5 '19
Admin
Admin May 24 '19

https://jnnp.bmj.com/content/80/2/171


Triple and quadruple spontaneous cervical artery dissection: presenting characteristics and long-term outcome
  1. M Arnold1,2,
  2. G M De Marchis2,
  3. C Stapf1,
  4. R W Baumgartner3,
  5. K Nedeltchev2,
  6. F Buffon1,
  7. A Galimanis2,
  8. H Sarikaya3,
  9. H P Mattle2,
  10. M G Bousser1
Author affiliations Abstract

Background: Spontaneous cervicocephalic artery dissection (sCAD) of more than two cervical arteries is rare.

Patients and methods: Vascular and potential sCAD risk factors, triggering events, clinical and neuroimaging findings, and outcome of patients with multiple sCAD were studied. Patients were drawn from prospective hospital-based sCAD registries.

Results: Of 740 consecutive patients with sCAD, 11 (1.5%) had three, and one had four (0.1%) sCAD. Eight of these 12 patients were women. One patient had additional dissections of the celiac trunk and hepatic artery. Vascular risk factors included hypertension (n = 1), hypercholesterolaemia (n = 6), current smoking (n = 5) and migraine (n = 6). No patient had a family history of sCAD, fibromuscular dysplasia (FMD) or connective tissue disease. SCAD was preceded by a minor trauma in five and infection in four patients. Clinical manifestations included ischaemic stroke (n = 8), transient ischaemic attack (n = 3), headache (n = 9), neck pain (n = 4), Horner syndrome (n = 5), pulsatile tinnitus (n = 2) and dysgeusia (n = 1). Brain MRI revealed ischaemic infarcts that affected one vessel territory in seven and two territories in two patients. The 3-month outcome was favourable (modified Rankin scale score 0–1) in 10 patients (83%). No new recurrent stroke or sCAD occurred during a mean follow-up of 50 (SD 29) months.

Conclusion: Multiple sCAD occurred preferentially in women and caused clinical symptoms and signs mainly in one vascular territory. In none of the patients was FMD or any other underlying arteriopathy apparent. The majority of multiple sCAD was preceded by a minor trauma or infection. Clinical outcome was favourable in most patients, and long-term prognosis benign. The data suggest that transient vasculopathy may be a major mechanism for multiple sCAD.

http://dx.doi.org/10.1136/jnnp.2008.155226



Admin
Admin May 30 '19


Case misclassification in studies of spinal manipulation and arterial dissection

J Stroke Cerebrovasc Dis. 2014 Sep;23(8):2031-2035. doi: 10.1016/j.jstrokecerebrovasdis.2014.03.007. Epub 2014 Jul 30.
Cai X, Razmara A, Paulus JK, Switkowski K, Fariborz PJ, Goryachev SD, D’Avolio L, Feldmann E, Thaler DE.

Abstract
BACKGROUND:
Spinal manipulation has been associated with cervical arterial dissection and stroke but a causal relationship has been questioned by population-based studies. Earlier studies identified cases using International Classification of Diseases Ninth Revision (ICD-9) codes specific to anatomic stroke location rather than stroke etiology. We hypothesize that case misclassification occurred in these previous studies and an underestimation of the strength of the association. We also predicted that case misclassification would differ by patient age.

METHODS:
We identified cases in the Veterans Health Administration database using the same strategy as the prior studies. The electronic medical record was then screened for the word “dissection.” The presence of atraumatic dissection was determined by medical record review by a neurologist.

RESULTS:
Of 3690 patients found by ICD-9 codes over a 30-month period, 414 (11.2%) had confirmed cervical artery dissection with a positive predictive value of 10.5% (95% confidence interval [CI] 9.6%-11.5%). The positive predictive value was higher in patients less than 45 years of age vs 45 years of age or older (41% vs 9%, P < .001). We reanalyzed a previous study, which reported no association between spinal manipulation and cervical artery dissection (odds ratio [OR] = 1.12, 95% CI .77-1.63) and recalculated an odds ratio of 2.15 (95% CI .98-4.69). For patients less than 45 years of age, the OR was 6.91 (95% CI 2.59-13.74).

CONCLUSIONS:
Prior studies grossly misclassified cases of cervical dissection and mistakenly dismissed a causal association with manipulation. Our study indicates that the OR for spinal manipulation exposure in cervical artery dissection is higher than previously reported.

Copyright © 2014 National Stroke Association. Published by Elsevier Inc. All rights reserved.

PubMed Reference




https://www.integrative-archives.com/2014/09/case-misclassification-in-studies-of-spinal-manipulation-and-arterial-dissection/

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