CHIROPRACTIC Adjustments, Beneficial Effects & Safety Issues

The chiropractic "adjustment" is a physical maneuver, usually done by hand, by the treating chiropractor on a patient's spine. This "adjustment" is the main tool in the chiropractic arsenal for effecting a treatment on a patient. Other phrases used that mean essentially the same thing are; spinal joint reduction, manipulation of the spine or cavitation of a spinal joint. The reason chiropractors put so much emphasis on the spine is because, the human spine is our "portal of entry" into a person's body. Surgeons use a scalpal to effect their portal of entry; internists most often use medications as their portal; chiropractors use their hands (usually)externally on the spine, to effect changes inside the body. The affects these "adjustments" of the spine have on the patient's entire body are profound. By adjusting spinal vertebrae back to their normal position, chiropractors can not only relieve local back pain that often arises at that site, but can also affect spinal nerves, sympathetic nerves and thus effect changes throughout the entire body. *Revisit the Interactive 3-D person seen on our HOME PAGE.

The actual adjustment, or spinal manipulation, or reduction of a pathomechanical segment (see subluxation)is a process of applying a quick but gentle pressure force to the "subluxated" vertebral segment to correct the motion of that segment and return it to it's normal motion and placement with the surrounding vertebrae. *Other terms for Subluxation include "Pathomechanics" which describes a pathology of the movement (or lackthereof) in the individual vertebral segments. Also used is the term "Vertebral Disarticulations" which describes the out of place nature of the individual vertebrae. The most common method of applying an adjustment is called the Diversified Method. This is what Dr. Haberstroh uses and it is quite effective. Diversified technique is often described as a "high velocity, low amplitude" maneuver. This means, the actual movement by the chiropractor must be faster than the typical human reflex (about 300 miliseconds) but not too deep. Which means the adjustment is very fast, but there is just enough force initiated in the vertebral segment for slight physical movement without hurting the patient. There are about 30 main systems of chiropractic adjustments in use today with a number of other more esoteric systems in use by a small minority of chiropractors.  Most of these systems have a positive effect on reducing subluxations and balancing a patient's musculo-skeletal system. "Diversified" is the oldest and most commonly used. Research has shown us that spinal manipulation (adjustements) to be the most effective treatment modality for many conditions including the common, everyday back pain syndrome. Adjustments are effective because they correct many of the structural, biomechanical, muscular and sometimes neurological abnormalities in and around the spine that cause a great number of health problems with people. A recent article (see Spinal Manipulation Alters EMG . . . article cited below) demonstrated for us, just how effective manipulation of the spine is for reducing muscular tension. Bear in mind that all muscles in the body must attach to bones. In the human spine, this muscular attachment realtiy is vetted via several layers of overlapping musculature up and down the entire spine that supports the spine and helps hold up the body. Muscle tension = muscle imbalance. Chiropractors always seek to reduce muscle tension. There are several ways to do this: electrical stimulation, massage, trigger point therapy, stretch therapy and manipulation of the spinal segments.

People always ask me, "Dr. H, does the chiropractic adjustment hurt?" The answer is 99% of the time no, it doesn't hurt. There is the odd occasion where there is so much swelling, so much muscle spasm, and/or the patient simply cannot relax for the adjustment, that there is a small bit of pain associated with that particular adjustment. The spinal joints are coated with slick hyaline cartiledge. With a properly vectored adjustment, these gliding joints move freely and quickly back into place. This also barring issues like advanced osteoarthritis or fused vertebrae. As we mention elsewhere on this WEB site, chiropractors utilize many other treatment modalities to help their patients such as nutrition, homeopathy, rehabitiation, electrical stimulation, intersegmental traction, postural instruction to name just a few. Nevertheless, the chiropractic adjustment, in whatever form it is rendered, is still the primary tool we all use to help our patients and correct spinal pathomechanics (subluxations).

Safety: People are also concerned with safety issues regarding adjustments. In study after study, it has been shown that chiropractic adjustments, especially those with no rotary component (like what Dr. H uses), do not stress the vertebral arteries and hence do not cause the patient to stroke after a cervical (neck) adjustment. Nor do people often suffer from the more widely used term, VBI-vertebro-basilar incident. This could include dizziness after an adjustment or syncope, vertigo or headaches.  Interestingly, a great CASE STUDY was published recently on Spinal Cord Compression. This article was written by several chiropractors (Murphy, D.R., et.al, "Manipulation in the Presence of Cervical Spinal Cord Compression," JMPT, Vol. 29 (3), April, 2006)and demonstrates that manipulative reductions of the spine can be safe and effective even in the presence of a space occpying lesion that was pressing in on the spinal cord itself. We've had cases like that at this very office.

Risks: Chiropractic manipulation of the neck (cervical spine) is still considered controversial by some. The literature is divided as to the exact risk percentage with regard to chiropractors causing strokes. This again, is the main criticism of chiropractic: that it is unsafe to manually manipulate the cervical spine for fear of lacerating a vertebral artery and thus throwing clots up into the brain. Admittedly, it does happen. How often remains the point of contension. As the LINKS below will show you, it is an extremely rare event. One in  8 million adjustments according to one study, one in about 500,000 neck adjustments in another. Understand the anatomy we are talking about here: See the figure at right>

Note both the Carotid Artery (larger, in front)
and the Verebral Artery (smaller, in rear).

Other risks: Rarely, a patient is in some additional pain after their first couple of treatments. This is an uncommon occurrance and it is impossible to tell who it may be. It is of no consequence and for those patients, most often is the case where the recommended treatment begins to take effect shortly after the start of a program and the pain subsides in due time. See Rubinestein S, et.al., "The Benefits Outweigh the Risks for Patients Undergoing Chiropractic Care for Neck Pain: A Prospective, Multicenter, Cohort Study," JMPT, Vol 30(6), July-August 2007 p408-418.

Consider the article written by Christopher Kent, DC for "THE CHIROPRACTIC JOURNAL," JUNE, 1997:

 

Read and respected by more doctors of chiropractic than any other professional publication in the world. A publication of the World Chiropractic Alliance

Do cervical adjustments cause strokes? In his book "Galileo's Revenge," attorney Peter Huber describes "junk science" as "A hodgepodge of biased data, spurious inference, and logical legerdemain...It is a catalog of every conceivable kind of error: data dredging, wishful thinking, truculent dogmatism, and, now and again, outright fraud." (1) An excellent example of "junk science" is the popular notion that chiropractic adjustments cause strokes. Although individual case reports of adverse events following "manipulation" have been reported in the medical literature for decades, recent exposes in the popular media seem to have led some gullible patients (and more than a few chiropractors) to accept this premise at face value. Careful examination will reveal that these individuals have fallen prey to a classic case of "junk science." A common error in logic is equating correlation with cause and effect. The fact that a temporal relationship exists between two events does not mean that one caused the other. As Keating explained, "To mistake temporal contiguity of two phenomena for causation is a classic fallacy of reasoning known as 'post hoc, ergo propter hoc,' from the Latin meaning 'after this, therefore caused by this.'" (2) Simple examples of the "post hoc, ergo propter hoc" fallacy include the notions that germs cause disease, or rats cause garbage. Consider the application of this fallacy in the case of chiropractic adjustments and strokes. Lee attempted to obtain an estimate of how often practicing neurologists in California encountered unexpected strokes, myelopathies, or radiculopathies following "chiropractic manipulation." Neurologists were asked the number of patients evaluated over the preceding two years who suffered a neurologic complication within 24 hours of receiving a "chiropractic manipulation." 55 strokes were reported. The author stated, "Patients, physicians, and chiropractors should be aware of the risk of neurologic complications associated with chiropractic manipulation." (3) What's wrong with this picture? Let's change "neurologic complications" to automobile accidents. Would it be reasonable to suggest that if 55 patients over the last two years had car accidents within 24 hours of seeing a chiropractor that the D.C. caused the accidents? Want to see how absurd this can get? Change "neurologic complications" to ice cream consumption. Or sleep. Or orgasm. Is there anything we can do that would either strengthen or weaken a case of alleged causality? Yes. If we have reliable reporting, we can compare the number of times the event in question (in this case, strokes) occurs as a random event to the number of times the event occurs following the putative causative event (in this case, a "chiropractic manipulation"). In a letter to the editor of JMPT, Myler posed an interesting question: "I was curious how the risk of fatal stroke after cervical manipulation, placed at 0.00025% compared with the risk of (fatal) stroke in the general population of the United States." (4) According to data obtained from the National Center for Health Statistics, the mortality rate from stroke was calculated to be 0.00057%. If Myler's data is accurate, the risk of death from stroke after cervical manipulation is less than half the risk of fatal stroke in the general population! But is Myler's data accurate? His 0.00025% figure is from a paper by Dabbs and Lauretti. (5) Their estimate is probably as good as any, since the basis for it was a reasonably comprehensive review of literature. Yet, there is potentially conflicting information which must be considered. Jaskoviak reported that not a single case of vertebral artery stroke occurred in approximately five million cervical "manipulations" at The National College of Chiropractic Clinic from 1965 to 1980. (6) Not one. Osteopathic authors Vick et al reported that from 1923 to 1993, there were only 185 reports of injury out of "several hundred million treatments." (7) All of the figures which I found concerning stroke following "manipulation" involve estimates, not hard data. In the "Back Letter" it was wisely observed that, "In scientific terms, all these figures are rough guesses at best... There is currently no accurate data on the total number of cervical manipulations performed every year or the total number of complications. Both figures would be necessary to arrive at an accurate estimate. In addition, none of the studies in the medical literature adequately control for other risk factors and co-morbidities." (8) But we're not finished yet. Leboeuf-Yde et al suggested that there may be an over-reporting of "spinal manipulative therapy" related injuries. The authors reported cases involving two fatal strokes, a heart attack, a bleeding basilar aneurysm, paresis of an arm and a leg, and cauda equina syndrome which occurred in individuals who were considering chiropractic care, yet because of chance, did not receive it. (9) Had these events been temporally related to a chiropractic office visit, it is likely that they would have been inappropriately attributed to the chiropractic care. Furthermore, there are cases of strokes attributed to chiropractic care where the "operator" was not a chiropractor at all. Terrett observed that "manipulations" administered by a Kung Fu practitioner, GPs, osteopaths, physiotherapists, a wife, a blind masseur, and an Indian barber were incorrectly attributed to chiropractors. (10) As Terrett wrote, "The words chiropractic and chiropractor have been incorrectly used in numerous publications dealing with SMT injury by medical authors, respected medical journals and medical organizations. In many cases, this is not accidental; the authors had access to original reports that identified the practitioner involved as a non-chiropractor. The true incidence of such reporting cannot be determined. Such reporting adversely affects the reader's opinion of chiropractic and chiropractors." Alas, we're still not done. Another error made in these reports is failure to differentiate "cervical manipulation" from specific chiropractic adjustment. They're simply not the same. Klougart et al published risk estimates which reveal differences depending upon the type of technique used by the chiropractor. (11) There is simply no competent evidence that specific chiropractic adjustments, or even "cervical manipulations" cause strokes. This conclusion begs the question, "What about screening tests to identify patients at risk?" More smoke and mirrors. After examining 12 patients with dizziness reproduced by extension-rotation and 20 healthy controls with Doppler ultrasound of the vertebral arteries, Cote et al concluded, "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." (12) Terrett noted, "There is also no evidence which suggests that positive tests have any correlation to future VBS (vertebrobasilar stroke) and SMT (spinal manipulative therapy)." (13) Despite this, attorneys continue to file stroke related lawsuits against chiropractors, and muckrakers masquerading as journalists stir the emotions of the populace. It is time to put the misconception that chiropractic adjustments cause strokes to rest. It's junk science. References 1. Huber PW: "Galileo's Revenge. Junk Science in the Courtroom." Basic Books. 1991. Page 3. 2. Keating JC Jr: "Toward a Philosophy of the Science of Chiropractic." Stockton Foundation for Chiropractic Research, 1992. Page 189. 3. Lee K: "Neurologic complications following chiropractic manipulation: a survey of California neurologists." Neurology 1995;45:1213. 4. Myler L: Letter to the editor. JMPT 1996;19:357. 5. Debbs V, Lauretti WJ: "A risk assessment of cervical manipulation vs. VSAIDS for the treatment of neck pain." JMPT 1995;18:530. 6. Jaskoviac P: "Complications arising from manipulation of the cervical spine." JMPT 1980;3:213. 7. Vick D, McKay C, Zengerie C: "The safety of manipulative treatment: review of the literature from 1925 to 1993." JAOA 1996;96:113. 8. "What about serious complications of cervical manipulation?" The Back Letter 1996;11:115. 9. Leboeuf-Yde C, Rasmussen LR, Klougart N: "The risk of over-reporting spinal manipulative therapy-induced injuries; a description of some cases that failed to burden the statistics." JMPT 1996;19:536. 10. Terrett AGJ: "Misuse of the literature by medical authors in discussing spinal manipulative therapy injury." JMPT 1995;18:203. 11. Klougart N, Leboeuf-Yde C, Rasmussen LR: JMPT 1996;19:371. 12. Cote P, Kreitz B, Cassidy J, Thiel H: "The validity of the extension-rotation test as a clinical screening procedure before neck manipulation: a secondary analysis." JMPT 1996;19:159. 13. Terrett AGJ: "Vertebrobasilar stroke following manipulation." NCMIC, Des Moines, 1996. Page 32.

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Chiropractors Don't Raise Stroke Risk, Study Says
CAROLINE ALPHONSO

>From Saturday's Globe and Mail

January 19, 2008 at 12:53 AM EST

TORONTO — A Canadian study indicates there is no increased risk related to chiropractic treatment in the heated debate about whether neck adjustments can trigger a rare type of stroke. Researchers say patients are no more likely to suffer a stroke following a visit to a chiropractor than they would after stepping into their family doctor's office. The findings, published today in the journal Spine, help shed light on earlier studies that had cast a cloud on the chiropractic profession and suggested that their actions resulted in some patients suffering a stroke after treatment.

“We didn't see any increased association between chiropractic care and usual family physician care, and the stroke,” said Frank Silver, one of the researchers and also a professor of medicine at the University of Toronto and director of the University Health Network stroke program.

“The association occurs because patients tend to seek care when they're having neck pain or headache, and sometimes they go to a chiropractor, sometimes they go to a physician. But we didn't see an increased likelihood of them having this type of stroke after seeing a chiropractor.”

A rare cause for stroke, arterial dissection occurs when one of the neck arteries supplying blood to the brain is torn. A stroke can occur when a clot, formed on the torn membrane, is dislodged and subsequently travels to the brain, blocking circulation. The two neck arteries are  usceptible to compression with neck rotation. But it is rare. It occurs spontaneously, or after minimal neck movements, such as looking backward to reverse a car. Critics charge that the twisting and pulling of the neck frequently done by chiropractors can damage arteries, leading occasionally to stroke. However, a research paper published in 2001 in the Canadian Medical Association Journal found there is only a one-in-5.85-million risk that a chiropractic neck adjustment will cause a stroke.

In this study, the Canadian team looked at nine years of data in Ontario, and found only 818 patients with this kind of stroke. Unlike the previous study in 2001that investigated the relationship betweenchiropractic visits and vertebra l artery stroke, researchers in this study also studied visits to family doctors that preceded this kind of stroke. Dr. Silver said researchers were looking for an increased association between chiropractic care and stroke. Although they found this association, they also discovered it to be the same as when patients visited a family doctor. The researchers say the association is likely explained by patients seeking medical or chiropractic services for their neck pain rather than these services causing the stroke. In other words, patients had already damaged the artery before seeking help from either a medical doctor or a chiropractor, and then the stroke occurred after the visit. The research paper says the results should be interpreted cautiously. Although the study provides the best data to date on the relationship between neck manipulation and vertebral artery stroke, researchers have not ruled out that in rare circumstances neck manipulation can be a potential cause of some strokes. Co-author David Cassidy, a senior scientist at the
University Health Network and a professor of epidemiology at the University of Toronto, said: “If someone says ‘Has it ever happened that a chiropractor has caused a stroke?' I can't say it's never happened. But if it's happening, it's not happening at a greater risk than when it is in a GP office.”

Looking for symptoms of a stroke caused by a tear inside a neck artery can be difficult. Just because a person has a neck pain or headache doesn't mean it's going to lead to a stroke, Dr. Silver cautioned. Some of the symptoms include double vision associated with pain, droopy eyelids, numbness down one side of the body and dizziness.

@Opinion on this article:

The most recent study by Cassidy et al. looked at all residents of Ontario Canada over a 9-year period (1993-2002). This represents the equivalent of 109 million person-years of observation. Their design looked at not only visitations to chiropractors in the period preceding the stroke, but also visits to their primary care physician (PCP). The idea in this design is that a PCP, in their work-up of patients, is unlikely to subject them to any maneuver that might produce a stroke. So the proportion of people who did have a stroke and who had recently seen their PCP should represent the background rate of VBA stroke in the population. In total they found 818 VBA strokes that met criteria. And the results were interesting. There was an increased odds ratio for the stroke patients in terms of having seen a chiropractor in the period prior to the stroke (OR=1.37; 95% CI 1.04-1.91). But the OR for seeing the PCP was about the same. In fact, there was a slightly stronger association. They theorized that patients with a VBA dissection are likely to consult with PCP or their chiropractors because of the symptoms. Thus, the confounder is identified and, although this study does not absolve CMT of all culpability in all cases of stroke, in the words of the authors, ". . . [CMT] is unlikely to be a major cause of these rare events."

 This study can be considered the definitive study on the subject and clearly is going to be welcome news to DCs everywhere. I would recommend every DC obtain a copy.

 References

 1.         Cassidy JD, Boyle E, Cote P, et al., "Risk of vertebrobasilar stroke and chiropractic care: Results of a population-based case-control and case-crossover study," Spine 2008;33:S176-S83.

2.         Coulter ID, Hurwitz EL, Adams AH, et al.,"The appropriateness of manipulation and mobilization of the cervical spine," 1 ed. Santa Monica: The RAND Corporation, 1996.

3.         Lazarou J, Pomeranz BH, Corey PN.,"Incidence of adverse drug reactions in hospitalized patients: a meta-analysis of prospective studies," JAMA 1998;279:1200-5.

4.         Moore TJ, Cohen MR, Furberg CD,"Serious adverse drug events reported to the Food and Drug Administration," 1998-2005. Arch Int Med 2007;167:1752-9.

5.         Rothwell DM, Bondy SJ, Williams JI,"Chiropractic manipulation and stroke: a population-based case-control study," Stroke 2001;32:1054-60.

6.         Smith WS, Johnston SC, Skalabrin EJ, et al, "Spinal manipulative therapy is an independent risk factor for vertebral artery dissection," Neurology 2003;60:1424-8.

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The Crack Sound: Not to worry. That sound is not the bones grinding against each other; it is carbon dioxide coming out of solution. It's exactly the same sound and physics as oppening a can of soda. The joints of the body are surrounded by fluid filled sacks called bursa. When a joint has become subluxated, out of its normal alignment, the sac gets pulled and the fluid dynamics change such that a high velocity adjustment causes the release of CO2. Don't worry, it's harmless! (see Brodeur, R., "The Audible Release Associated with Joint Manipulation," JMPT Vol. 18 (3): 155-64, March 1995 . Also revisit Reggers, JW, Pollard, HP, "Analysis of Zygapophyseal Joint Cracking During Chiropractic Manipulation," JMPT Vol. 18 (2): 65-71, Feb. 1995.)

>Studies also show that low back adjustments are extremely safe and effective.  See various references below regarding safety and effectiveness of chiropractic treatment:

*JMPT= Journal of Manipulative and Physilogical Therapeutics

Lynton GF, Giles DC, Reinhold M, "Chronic Spinal Pain: A Randomized Clinical Trial Comparing Medication, Acupuncture, and Spinal Manipulation," Spine, July, 2003, 28 (14): 1490-1502. In this, the latest addition to our article list: meds, needle acupuncture and manipulation (by chiropracators) were all compared. Results: The highest proportion of early asymptomatic recoveries were found for manipulation (27.3%), followed by acupuncture (9.4%) and then meds (5%). Good Stuff! Additionally, there was a 47% improvement in overall general health status for the chiropractic spinal manipulation group. Very Good Stuff!!  Now, check out the next article . . .

Muller R, Lynton GF, Giles DC, "Long Term Follow-up of a Randomized Clinical Trial Assessing the Efficacy of Medication, Acupuncture, and Spinal Manipulation for Chronic Mechanical Spinal Pain Syndromes," JMPT, Jan. 2005, Vol 28 (1).  As you can plainly see, these are the same three authors from the previous article following up on their own study. In the 2003 study, it was shown that chiropractic manipulation was more effective for short term relief. In this study, the authors were able to show, "In patients with CHRONIC spinal pain syndromes, spinal manipulation, may be the only treatment modality of the assessed regimens that provided broad and significant long-term benefit." Very good news for chiropractors and our patients. Interestingly, the authors identified an incidential finding in this study; "These authors also note that chronic mechanical spinal pain syndromes "compromised immune function." To sum up, "In this study and in two prior hosptial studies, those treated by chiropractic derived more short-term and long term benefit and satisfaction than those treated by hospital therapists." Very Good Stuff!

NB: A recent article in the Journal of Manipulative and Physiologic Therapeutics tells us that patients who receive chiropractic care, including manipulative therapy, had a 60.2% decrease in hospital admissions, 59% less hospital days and 62% less outpatient surgeries and procedures as well as 85% less pharmaceutical costs. Makes you think. See  Richard L. Sarnat, MDa, James Winterstein, DCb, Jerrilyn A. Cambron, DC, PhDc, "Clinical Utilization and Cost Outcomes From an Integrative Medicine Independent Physician Association: An Additional 3-Year Update," Volume 30, Issue 4, Pages 263-269 (May 2007).

Triano, J., Kawchuk, G., et.al., "Current Concepts: Spinal Manipulation and cervical arterial incidents 2005," NCMIC Chiropractic Solutions, 2005. *A derivative work based on Terrett's original monograph and updated with the most recent research on the subject.

Terrett, A., "Vertebrobasilar Stroke Following Manipulation," National Chiropractic Mutual Insurance Company Press, 1996.

Lowe,T., "Degenerative Disc Disease and Low Back Pain," Spine Universe, 2000.

Smith, J. Medical Library, "Low Back Pain," The Thompson Corporation, 1999-2003

Waddell, G., "The Back Pain Revolution," Churchil-Livingstone, 2nd Ed., 2004

DeVocht JW, Pickar JG, Wilder DG, "Spinal Manipulation Alters Electromyographic Activity of Paraspinal Muscles: A Descriptive Study", JMPT, Vol. 28 (7), Sept. 2005

Song, XJ, Gan, Qm et. al., "Spinal Manipulation Reduces Pain and Hyperalgesia after Lumbar Intervertebral Foramen Inflamation in the Rat," JMPT, Vol. 29, #1 (Jan, 2006), pg. 5-13.

Teodorczyk, JA, Injeyan, HS, et.al., "Spinal Manipulative Therapy Reduces Inflamatory Cytokines but NOT Substance P Production in Normal Subjects," JMPT, Vol. 29 (1/06), #1, pg. 14-21.

Excoffon, SG, Wallace, H, "Chiropractic and Rehabilitative Management of a Patient with Progressive Lumbar Disc Injury, Spondylolisthesis, and Spondyloptosis," JMPT, Vol. 29(1/06), #1, pg. 66-71.

Segura RM, Penas CF, et.al. "Immediate Effects on Neck Pain and Active Range of Motion After a Single Cervical High-Velocity Low-Amplitude Manipulation in Subjects Presenting with Mechanical Neck Pain: A Randomized Controlled Trial," JMPT, Vol. 29, (7), Pg. 511. 

Healthy Living Fact Sheet: Is Chiropractic Safe?
Chiropractic & Stroke: Key Messages
What are the Risks of Chiropractic Neck Adjustments?                                                        By William J. Lauretti, DC
Chiropractic Manipulation & Cervical Artery Dissection                                                    JACA article By Michael T. Haneline, DC, MPH and Gary Lewkovich, DC

(More Literature citations coming as we research them, please be patient. Thank you) *this page is still under construction.