Adjustment/risk

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Adjustment/risk

 

 

adjustment-risk1The 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.

 

 

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 in the individual vertebral segments. Also used is the term "Vertebral Disarticulations" which describes the out of place nature of the individual vertebrae.

 

DIVERSIFIED METHOD: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 spinal adjustment system. 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. *(see Hondras MA, Long C, et. al., "A Randomized Controlled Trial Comparing 2 Types of Spinal Manipulation and Minimal Conservative Medical Care for Adults 55 Years and Older with Subacture or Chronic Low Back Pain," JMPT, Vol. 32 (5), June 2009. Upshot: Participants who received spinal manipulation had improvements on average in functional status over those who received minimal conservative medical care.)

 

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.

 

adjustment-risk2Risks: 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).

 


The carotid arteries in the front of the neck bring 80% of the blood to the brain, 40% each side. The vertebral arteries in the back of the neck are so named because the weave through the vertebrae and up into the brain. They bring the remaining 20% of the blood to the brain, 10% on each side. Very rarely, if a chiropractic adjustment is hard enough, it might aggravate an existing tear or flaw in one or both of the vertebral arteries. This type of vertebral "adjustment" of the cervical spine requires a rotational vector in the motion. *Be advised: Dr. Haberstroh NEVER used any rotation in his cervical spine maneuvers and has never had any stroke issues with all the patients he has treated in 30 years. (see Rubinstein SM, et. al., "Predictors of Adverse Events Following Chiropractic Care for Patients with Neck Pain,"
J of Manip. and Physiol. Therapeutics, Vol. 31(2, March, 2008-*Biggest predictor was rotation of the neck.) The bulk of the available studies on cervicogenic strokes suggest that the vertebral arteries are most often weak and susceptible to injury with ANY kind of rotation or hyperextension. That is to say, the patients already had deformities in these crucial vessles that may or may not have had clinical symptoms. Oddly, in the literature, there are numerous articles published showing that hairdressing salons have a history of stroking patients while the client has their head in extreme extension during shampooing. In those cases, there is no rotational movement, just hyperextension and still, strokes can and do happen. If you are still concerned, feel free to access the sites listed below or even access the WEB yourself and do some research. Chiropractic, despite it's one main risk factor, is still considered one of the safest mainstream health care modalities going. In sum, Dr. H utilizes a "COUPLED REDUCTION" type of cervical thrust such that the vector of motion is ACROSS the joint; consistent with the normal coupled motion of the neck; not around the joint. The neck, when bending laterally also shows rotation of each segment in the opposite direction. Taking this factor into account, the Coupled Reduction facilitates the adjustment consistent with normal dual motion aspects of the vertebrae themselves. 

 

See also:  Wuest S, Symons B, et.al., "Preliminary Report: Biomechanics of Vertebral Artery Segments C1-C6 During Cervical Spinal Manipulation," JMPT, Vol. 33,#4, May 2010. *upshot here is that the findings from this new study suggest that the textbook mechanics of the vertebral artery(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 vertebrae movements may play a crucial role in VA mechanics during neck manipulation. Add to that, the engineering strains during cervcial spinal manip. were LOWER than those obtained during simple range of motion testing.

 

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:

 


 

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.

 


© Copyright The Chiropractic Journal

 



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.

 


 

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.

 

 

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

 


 

In response to the horrible Alan Alda narrated PBS special on "Alternative Healing," the ACA Research Director submitted this article to PBS which, among other things, addresses the issue of stroke with chiropractic manipulation.

 

Response to PBS Documentary
See References
by Anthony L. Rosner, Ph.D.
FCER Director of Research and Education
June 18, 2002
Pat Mitchell, President & CEO
Public Broadcasting Service
1320 Braddock Place
Alexandria, Virginia 22314


Dear Ms. Mitchell:
I am writing to you as the Director of Research and Education of the Foundation for Chiropractic Education and Research, which for over half a century has been the premier organization supporting research and postgraduate study in areas pertaining to the theory and practice of chiropractic healthcare. Perhaps even more importantly, I also write to you as a former subscriber to PBS, which in my and most others' perceptions is an organization whose hallmarks have been both freedom from commercial bias and the capacity to deliver objective, informative news to the public worldwide.

Thus it was with equal parts of incredulity, dismay and horror that I and the public experienced your broadcast on June 4 of "A Different Way to Heal," an episode of Scientific American Frontiers. From the slurs of Robert Baratz [representing an anti-fraud organization whose statements on chiropractic have been officially discredited1] to the testimony of a former disenchanted chiropractor to the deliberately orchestrated terminology used by your lead narrator Alan Alda, you could not have further denigrated the term "scientific" had you tried. Instead of serving as the font of documented scientific information from the best peer-reviewed medical literature, your program relied upon hearsay, biases, and opinions from clearly prejudiced sources and as such transformed itself into a petri dish of fetid disinformation of the first magnitude. I am frankly amazed that a program and broadcasting network of your stature should have failed so spectacularly in one of the primary tenets of research--which is of course to conduct a balanced, detailed review of available information which has appeared in the refereed scientific literature for the past 25 years.

To begin, it is curious that you should have chosen a former and disgruntled chiropractor to provide the lion's share of primary reference information regarding the chiropractic clinical experience to the public. We know nothing about the circumstances under which John Badanes left the profession--nor was the public given at least an equal exposure to a chiropractor in current practice who represents the thinking of the majority of the profession to provide the necessary clinical perspective. Your heavy reliance upon Badanes' testimony was as absurd as counting upon the retired astronaut John Glenn as the primary source of information on the recent upgrade of the Hubble telescope from the space shuttle Discovery.

Instead, you elected to instill in the viewer a malevolent, pseudo-science stereotype of a treatment which, in Alan Alda's own terminology, is "illogical," "violent," and designed to overcome "some kind of blockage of some life force that was coming in from the universe" in an endeavor in which "it's easy not only for the patient to be fooled but the chiropractor too." Rather than describing the attributes of a new treatment which is what your program series is presumed to accomplish, you chose to desecrate it instead. What was, in fact, your primary objective here?

Rather than continue under your program's unmistakable impression that chiropractic healthcare is more based upon religious zealotry than scientific principles, I wish to immediately direct your attention to the enclosed reprint from no less a source than the Annals of Internal Medicine--presumably where the derivative material for a program that calls itself "Scientific American Frontiers" should have begun rather than ended as requisite material that had to be imported from your viewing public. In the reprint you will notice that, in contrast to what Alan Alda may have concluded, chiropractic care is at the crossroads of alternative and mainstream medicine, increasingly viewed as effective "by many in the medical profession." Rather than being "totally based upon a religious belief system" as Robert Baratz would have led us to believe in your program, this particular article clearly states that "much of the positive evolution of chiropractic can be ascribed to a quarter century-long research effort focused on the core chiropractic procedure of spinal manipulation. This effort has helped bring spinal manipulation out of the investigational category to become one of the most studied forms of conservative treatment for spinal pain."2  In the interest of acquainting you with merely a fraction of the vital information omitted on your program, I would first like to orient you to some important background material regarding chiropractic care and then take up a few of the more troubling aspects of your broadcast. In the interests of both objective reporting and the sharing of credible information in publicly funded media, I would expect that you will be able to respond appropriately to this material.

 


General Comments:
Chiropractic is recognized and licensed in every state and province in North America, as well as in 76 nations representing the European, Asian, Latin American, Caribbean, Eastern Mediterranean, and Pacific domains.3 The increasing acceptance of chiropractic as a legitimate health care profession has occurred in part through the increasing emphasis on research by professional organizations and the colleges with funding by outside agencies. It also stems from the accrediting and review of educational curricula at chiropractic colleges around the world, 16 of which are accredited in the United States by the Council for Chiropractic Education [CCE]. The CCE has had accrediting agency status with the U.S. Department of Education since 1974 and with the Council on Postsecondary Accreditation since 1976. The minimum content of hours required for CCE accreditation is 4,200 and ranges from 4,400 to 5,220 hours at colleges nationwide.2 In fact, the didactic basic science and clinical science hours among chiropractic colleges around the United States compares closely with the corresponding averages obtained from medical schools nationwide.4

With over 65,000 licensed practitioners in the United States, chiropractic has taken its place as the foremost profession through which spinal manipulations have been administered--largely in the treatment of back pain but increasingly for other disorders such as neck pain; headache; cumulative trauma disorders in the extremities; infantile colic; enuresis; otitis media; asthma; and GI dysfunctions [These will be cited below.] Indeed, it has been estimated that the total number of chiropractic office visits nationwide each year is 250 million,5 with 94% of all spinal manipulations administered by chiropractors.6

What may not as well-known as it should is that the practice of chiropractic includes a complete physical examination and establishing a diagnosis. The aim is to establish biomechanical and neurological integrity through an assortment of noninvasive measures, many [but not all] of which are manual. These would include manipulation, mobilization, soft-tissue and nonforce techniques, exercise and rehabilitation, and occasionally such educational programs as nutritional counseling or wellness care.

With regards to back pain, the efficacy and effectiveness of these procedures have been reviewed repeatedly by carefully structured guidelines, developed both within the profession7 and by multidisciplinary panels representing the U.S.8 and no less than 10 other countries worldwide.9 According to Meeker and Haldeman, 73 randomized clinical trials comparing spinal manipulation with either placebos or other treatments in the management of back pain have been published in the scientific literature--almost all appearing within the past 25 years.2 Meta-analyses addressing acute low-back pain10,11 have also been published, supporting the appropriateness of spinal manipulation in managing acute low-back pain. According to a systematic review by van Tulder:

"There is limited evidence that manipulation is more effective than a placebo treatment."
Although contradictory results did not allow van Tulder to compare manipulation to other physiotherapeutic applications, there was no such uncertainty regarding chronic low-back pain. Here van Tulder unequivocally states that:
"There is strong evidence that manipulation is more effective than a placebo treatment....There is moderate evidence that manipulation is more effective for chronic LBP than usual care by the general practitioner, bed-rest, analgesics, and massage."11

Specific Concerns:
The barrage of derogatory language in your broadcast as described above smacks of opportunism in the first order. Its statement that those chiropractors who perform leg length checks actually attempt to elongate the bone is as absurd as it is fear-mongering. It also creates the impression that the use of the NervoScope in thermography is widespread, when in fact it has been regarded as merely "investigational" by guidelines intended to represent the bulk of practicing chiropractors within the United States.7 Finally, your broadcast neglected to cite any number of studies published in a journal included in the Index Medicus which for over a quarter of a century have indicated that chiropractic treatments not only match the medical alternatives for treating such diverse conditions as back pain,12 carpal tunnel syndrome,13 cervicogenic, migraine and tension-type headache,14-17 dysmenorrhea,18 premenstrual syndrome,19 infantile colic,20 enuresis,21 and even ear infections,22 but do so for longer durations after treatment and without the common, injurious or even fatal side of medications.
In light of Robert Baratz' emphatic alarms about the "dangers" of spinal manipulation and the indication from the program's host that "20% of all strokes caused by artery damage could [italics mine] be a result of neck manipulation," your assertions are in serious need of retooling with more definitive information as follows:

*To begin, the term "could" is conjectural only. As many as 68 everyday activities have been shown to disrupt cerebral circulation, 18 of which have actually been associated with vascular accidents but are decidedly non-manipulative. Such activities would include childbirth; interventions by surgeons or anesthetists during surgery; calisthenics; yoga; turning the head while driving a vehicle, undergoing x-rays, or treating a bleeding nose; star gazing; swimming; rap dancing; and beauty parlor events.23

*A review of over half a dozen peer-reviewed published scientific papers puts the risk of cerebrovascular accidents [including stroke] associated with spinal manipulation at anywhere from 1 per 400,00024 to 1 per 5.85M cervical manipulations, the latter figure representing the most rigorously derived frequency.25 On the other hand, the risk of deaths from the use of such medicines as nonsteroidal anti-inflammatory agents [NSAIDs] or from surgery to treat many of the same conditions as those managed by chiropractors is 40026 to 70027 times greater; yet warnings pertaining to the use of these particular options do not seem to have been mentioned by any of the individuals in your program. In fact, rates of spontaneous arterial dissections have been reported on an annual basis to be 1.5-3 per 100,000,28-30 substantially larger than most rates of severe strokes that have been associated with [let alone caused by] cervical manipulation.

*Death rates due to medication side effects have been estimated by the Institute of Medicine to range from 230,000-280,000 per year.31 Those caused by commonly used NSAIDs [such as ibuprofen] have been reported to approach an annual rate of 16,00032--dwarfing any estimates of chiropractic fatalities by several orders of magnitude.
*Experiments with arterial models at the University of Calgary have shown that peak elongations of the vertebral artery during neck manipulations are at most 11% of the elongations that would be seen at the arterial failure limits; in fact, these elongations are consistently lower than those seen during routine diagnostic tests.33
*The common musculoskeletal conditions routinely diagnosed and treated by chiropractors were shown in one study to have eluded first-year medical orthopedic residents, who failed a validated competency examination by two independent means of assessment.34,35
Clearly, the chiropractic profession remains deeply concerned about and is actively researching the occurrences of any cerebrovascular accidents ever to occur with manipulations, which remains a phenomenon rarer than most activities in daily life. What is already becoming more and more apparent is that vertebral artery failures need to be regarded as the result of cumulative events such as those I have mentioned above rather than by what Robert Baratz and Alan Alda repeatedly referred to as traumatic and twisting maneuvers applied by chiropractors to the neck. What makes far more sense and of far greater value to the patient would be to continue to pursue productive research, hopefully with cooperation between the chiropractic and medical professions.

The attainment of that goal is obviously hampered by your program. The facts that randomized clinical trials support both the efficacy and safety of chiropractic treatment not only for managing back pain but for headaches, carpal tunnel syndrome, infantile colic and bedwetting problems as well2 should be shared with your audience as well if they are to be given truly meaningful medical advice on treatment options, the centerpiece of which should quite simply be the risk-to-benefit ratio. Guidelines of no less than 11 nations have recognized the effectiveness of chiropractic as a viable treatment option for millions of patients.8,9 Until this type of information can be freely shared with your audience as well, they are being seriously misled by the one-sided and ill-conceived presentation in your June 4 broadcast.

Your proliferation of the egregiously corrupted information that I have outlined in your June 4 broadcast is an affront to both the letter and spirit of publicly supported broadcasting, which one would have thought was originally conceived to be unencumbered by corporate interests and thus uniquely suited to review topics of public concern in an objective and detailed manner. I would invite you to indicate to me whether you believe that the core support of PBS derives from any other principles and whether I have overlooked anything in my assessment of public broadcasting's purpose--of which PBS is meant to be a proud example.

In the interest of responsible public broadcasting everywhere, to say nothing of public healthcare and the unwarranted damage that your remarks threaten to do to chiropractic care, I am requesting in the strongest terms your retraction or qualification of the June 4 presentation and your creation of an opportunity to allow the most [rather than the least] responsible caregivers in a viable and scientifically documented healthcare profession to present their side of the story which, when the day is done, may in fact represent the majority opinion.36-38

Sincerely yours,


Anthony L. Rosner, Ph.D.
Director of Research and Education
Foundation for Chiropractic Education and Research


________________________________________
REFERENCES:
1)  Inglis BD, Fraser B, Penfold BR. Chiropractic in New Zealand, Report of A Commission of Inquiry. Wellington, NEW ZEALAND: Government Printer, 1979.
2)  Meeker WC, Haldeman S. Chiropractic: A profession at the crossroads of mainstream and alternative medicine. Annals of Internal Medicine 2002; 136(3): 216-227.
3)  Chapman-Smith D. The chiropractic profession. West Des Moines, IA: NCMIC Group Inc., 2000.
4)  Coulter I, Adams A, Coggan P, Wilkes M, Gonyea M. A comparative study of chiropractic and medical education. Alternative Therapies in Health and Medicine 1998; 4(5): 64-75.
5)  Haldeman S, Kohlbeck FJ, McGregor M. Risk factors and precipitating neck movements causing vertebrobasilar artery dissection after cervical trauma and spinal manipulation. Spine 1999; 24(8): 785-794.
6)  Shekelle P, Adams AH, Chassin MR, Hurwitz EL, Phillips RB, Brook RH. The appropriateness of spinal manipulation for low-back pain: Project overview and literature review. RAND: Santa Monica, CA, 1991. Monograph No. R-4025/1-CCR-FCER.
7)  Haldeman S, Chapman-Smith D, Peterson DM Jr. Guidelines for chiropractic quality assurance and practice parameters. In Proceedings of a Consensus Conference Commissioned by the Congress of Chiropractic State Associations, held at the Mercy Conference Center, Burlingame, CA, January 25-30, 1992. Gaithersburg, MD: Aspen, 1993.
8)  Bigos S, Bowyer O, Braen G, et al. Acute low back pain in adults. Clinical practice guideline No. 14. AHCPR Publication No. 95-0642. Rockville, MD: Agency for Health Care Policy and Research, Public Health Service, U.S. Department of Health and Human Services. December 1994.
9)  Koes BW, van Tulder MW, Ostelo R, Burton AK, Waddell G. Clinical guidelines for the management of low back pain on primary care. Spine 2001; 26(22): 2504-2514.
10)  Koes BW, Assendelft WJJ, van der Heijden GJMG, Bouter LM. Spinal manipulation for low-back pain: An updated systematic review of randomized clinical trials. Spine 21(24): 2860-2871.
11)  van Tulder M, Koes BW, Bouter LM. Conservative treatment of acute and chronic nonspecific low back pain: A systematic review of randomized controlled trials of the most common interventions. Spine 1997; 22(18): 2128-2156.
12)  Giles LGF, Muller R. Chronic spinal pain syndromes: A clinical pilot trial comparing acupuncture, a nonsteroidal anti-inflammatory drug, and spinal manipulation. Journal of Manipulative and Physiological Therapeutics 1999; 22(6): 376-381.
13)  Davis PT, Hulbert JR, Kassak KM, Meyer JJ. Comparative efficacy of conservative medical and chiropractic treatments for carpal tunnel syndrome: A randomized clinical trial. Journal of Manipulative and Physiological Therapeutics 1998; 21(5): 317-326.
14)  Boline PD, Kassak K, Bronfort G, Nelson C, Anderson AV. Spinal manipulation vs. amitriptyline for the treatment of chronic tension-type headache: A randomized clinical trial. Journal of Manipulative and Physiological Therapeutics 1995; 18(5): 148-154.
15)  Nilsson N, Christensen HW, Hartvigsen J. The effect of spinal manipulation in the treatment of cervicogenic headache. Journal of Manipulative and Physiological Therapeutics 1997; 20(5): 326-330.
16)  Nelson CF, Bronfort G, Evans R, Boline P, Goldsmith C, Anderson AV. The efficacy of spinal manipulation, amiltriptyline, and the combination of both therapies for the prophylaxis of migraine headache. Journal of Manipulative and Physiological Therapeutics 1998; 21(8): 511-519.
17)   Bronfort G. Efficacy of spinal manipulation for chronic headache: A systematic review. Journal of Manipulative and Physiological Therapeutics 2001; 24(7): 457-466.
18)  Kokjohn K, Schmid DM, Triano JJ, Brennan PC. The effect of spinal manipulation on pain and prostaglandin levels in women with primary dysmenorrhea. Journal of Manipulative and Physiological Therapeutics 1992; 15(5): 279-285.
19)  Walsh MJ, Polus BI. A randomized, placebo-controlled clinical trial on the efficacy of chiropractic therapy on premenstrual syndrome. Journal of Manipulative and Physiological Therapeutics 1999; 22(9): 582-585.
20)  Wiberg JMM, Nordsteen J, Nilsson N. The short-term effect of spinal manipulation in the treatment of infantile colic: A randomized controlled trial with a blinded observer. Journal of Manipulative and Physiological Therapeutics 1999; 22(8): 517-522.
21)  Reed WR, Beavers S, Reddy SK, Kern G. Chiropractic management of primary nocturnal enuresis. Journal of Manipulative and Physiological Therapeutics 1994; 17(9): 596-600.
22)  Froehle RM. Ear infection: A retrospective study examining improvement from chiropractic care and analyzing for influencing factors. Journal of Manipulative and Physiological Therapeutics 1996; 19(3): 169-177.
23)  Rome PL. Perspective: An overview of comparative considerations of cerebrovascular accidents. Chiropractic Journal of Australia 1999; 29(3): 87-102.
24)  Dvorak J, Orelli F. How dangerous is manipulation of the cervical spine? Manual Medicine 1985; 2: 1-4.
25)  Haldeman S, Carey P, Townsend M, Papadopoulos C. Arterial dissections following cervical manipulation: The chiropractic experience. Canadian Medical Association Journal 2001; 165(7): 905-906.
26)  Dabbs V, Lauretti W. A risk assessment of cervical manipulation vs NSAIDs for the treatment of neck pain. Journal of Manipulative and Physiological Therapeutics 1995; 18(8): 530-536.
27)  Deyo RA, Cherkin DC, Loesser JD, Bigos SJ, Ciol MA. Morbidity and mortality in association with operations on the lumbar spine: The influence of age, diagnosis, and procedure. Journal of Bone and Joint Surgery Am 1992; 74(4): 536-543.
28)  Shievink WT, Mokri, B, O'Fallon WM. Recurrent spontaneous cervical-artery dissection. New England Journal of Medicine 1994; 330: 393-397.
29)  Shievink WT, Mokri B, Whisnant JP. Internal carotid artery dissection in a community: Rochester, Minnesota, 1987-1992. Stroke 1993; 24: 1678-1680.
30)  Giroud M, Fayolle H, Andre N, Dumas R, Becker F, Martin D, Baudoin N, Krause D. Incidence of internal carotid artery dissection in the community of Dijon [Letter]. Journal of Neurology and Neurosurgical Psychiatry 1994; 57: 1443.
31)  Schuster M, McGlynn E. Brook R. How good is the quality of health care in the United States? Milbank Quarterly 1998; 76: 517-563.
32)  Wolfe MM, Lichenstein, DR, Singh G. Gastrointestinal toxicity of nonsteroidal antiinflammatory drugs. New England Journal of Medicine 1999; 340(24): 1888-1899.
33)  Herzog W, Symonds B. Forces and elongations of the vertebral artery during range of motion testing, diagnostic procedures, and neck manipulative treatments. Proceedings of the World Federation of Chiropractic 6th Biennial Congress, Paris, FRANCE, May 21-26, 2001, pp. 199-200.
34)  Freeman KB, Bernstein J. The adequacy of medical school education in musculoskeletal medicine. Journal of Bone and Joint Surgery Am 1998; 80-A(10): 1421-1427.
35)  Freedman KB, Bernstein J. Educational deficiencies in musculoskeletal medicine. Journal of Bone and Joint Surgery 2002; 84-A(4): 604-608.
36)  Eisenberg DM, Kessler RC, Foster C, Norlock FE, Calkins DR, Delbanco TL. Unconventional medicine in the United States: Prevalence, costs, and patterns of use. New England Journal of Medicine 1993; 328(4): 246-252.
37)  Eisenberg DM, Davis RB, Ettner SL, Appel S, Wilkey S, Van Rompay M, Kessler RC. Trends in alternative medicine use in the United States, 1990-1997. Journal of the American Medical Association 1998; 280(18): 1569-1575.
38)  Astin JA. Why patients use alternative medicine. Journal of the American Medical Association 1998; 279(19): 1548-1553.
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