The efficacy of spinal manipulative therapy (SMT) has been a topic
of research for more than 20 years now and has subsequently been recognized as
such in at least four countries which has led to increased integration of
chiropractors into mainstream healthcare.[1] This
greater predominance has led to questions regarding the possibility of
complications due to SMT, especially with respect to manipulation of the cervical
spine (neck).
This was never more prevalent than after two tragic events
following chiropractic care in Canada in the 1990s which
spurred rabid media attention and an adamant stance by the neurology community
to avoid cervical manipulation as a treatment for neck pain.[2] These
events have no less been the provocative factor for the publication of several
case reports in which chiropractors have been incorrectly identified as the
practitioner responsible for injuries related to SMT.[3] This
fact is inescapable when reviewing two articles published in the Journal
of Neurology where the authors cite 46 cases involving stroke and/or
vertebral artery dissection due to “chiropractic manipulation”.
Truth be told only FOUR (4) of the cases involved chiropractors the remaining
42 cases (91%) of injury due to cervical manipulation were induced by 25
-orthopedists, 6 -physical therapists, 1 -neurologist, 2 -Primary Care
Physicians, 1 -homeopath, 2 -“health practitioners”, and the rest “remained
unreported”.[4][5][6] Admittedly
there is inherent risk, albeit minimal, associated with neck manipulation but
all forms of therapeutic intervention come with risk and some are far greater
than SMT.
Take for instance the most common “quick fix” for
musculoskeletal pain, non-steroidal anti-inflammatories [NSAIDs] (i.e. Advil,
Aleve, Motrin, Tylenol). Medical studies published during the 1990s found
that hospitalizations due to gastrointestinal complications from NSAIDs range
from 32,000 - 103,000 while NSAID related deaths average out at 9,850 ANNUALLY
in the United States alone![7][8][9] In
fact the Food and Drug Administration reports that the largest cause of drug
overdose in the United States is acetaminophen (Tylenol) which by itself is
responsible for 56,000 emergency room visits, 2,600 hospitalizations, and 458
deaths due to acute liver failure EVERY YEAR![10] The one-year
risks of experiencing complications due to prolonged NSAID use are
simply staggering: [11]
Severe gastrointestinal bleeding:
-
Adults younger than 45 = 1 in 2,100
-
Adults older than 75 = 1 in 110
Death:
-
Adults younger than 45 = 1 in 12,353
-
Adults older than 75 = 1 in 647
These non-prescription pain relievers have become an accepted form
of musculoskeletal pain relief yet their catastrophic effects have never been
as scrutinized as spinal manipulative therapy which has been scientifically
proven to be more effective in relieving neck pain and headache[12] with statistically
infinitesimal risk of serious adverse reaction.
A population based study published in Neurology in
2006 discovered that over a 16 year period (1987-2003) the incidence rate of strokes
due to arterial dissection (ICAD and VAD) affected only 0.97 - 1.72 residents per
100,000 annually within the defined community (Olmsted County, MN).[13] These
findings regarded the population in general since reliable epidemiological data was not available. A
subsequent population-based case control and case-crossover study conducted by
members of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its
Associated Disorders was published in SPINE in
2008 which investigated the association between chiropractic care and stroke
due to arterial dissection and compared it to primary care physician (PCP)
treatment for the same issue.[14] This
study examined ALL residents of Ontario
(109,020,875 person years), Canada’s most populous province over a nine (9)
year period (1993-2002). The researchers found only 818 cases of
stroke due to arterial dissection that met the study’s inclusion/exclusion
criteria. Overall, 4.4% (n=36) of the cases had visited a chiropractor and
51.0% (417) had only visited a PCP 30 days prior to hospital
admission for stroke related to arterial dissection. It should be noted though
that of the 36 cases noted above, only 16 cases (2.0%) were exclusively
chiropractic visits 20 (2.4%) had visited both a chiropractor and PCP with the
remaining 365 cases having consulted no one for care prior to hospitalization
due to stroke. In the end the researchers came to the following conclusions:
-
Stroke due to arterial dissection within the population is a RARE EVENT.
- Of the
453 cases that did consult either a chiropractor or PCP prior to
hospitalization, the chief complaint upon presentation was neck pain and
headache. The researchers concluded that this similarity was due to an arterial
dissection IN PROGRESS which led these patients to seek relief of their pain.
- There
is an association between chiropractic care and arterial dissection-related
stroke within residents under the age of 45 but chiropractic care DOES NOT
exhibit any excess risk of eliciting a stroke.
- There
is an association in PCP care and arterial dissection-related stroke in ALL AGE
GROUPS.
-
Currently there exists no valid screening procedure to identify the risk of
stroke in a person presenting with neck pain and/or headache.
The substantive nature of this data is enlightening but in no way
exhausts the need for further investigation into this rare yet life altering
event. A collaborative effort between chiropractors and neurologists during
future research is needed in order to derive a feasible screening method and
eliminate the confusing and conflicting information currently being given to
patients regarding the treatment of neck pain and headache.
[1] Haldeman, Scott, Paul Carey, Murray Townsend, and Costa Papadopoulos.
"Arterial Dissections following Cervical Manipulation the Chiropractic
Experience." Canadian Medical Association Journal 165.7
(2001): 905-06. Print.
[2] Cassidy, David, Eleanor Boyle, Pierre Cote, Helen He,
Sheilah Hogg-Johnson, Frank L. Silver, and Susan J. Bondy. "Risk of
Vertebrobasilar Stroke and Chiropractic Care." Spine 33.4S
(2008): 000. Print.
[3] Terrett, AG. "Misuse of the Literature by Medical
Authors in Discussing Spinal Manipulative Therapy Injury." Journal
of Manipulative and Physiological Therapeutics 18.4 (1995): 203-10.
Print.
[4] Murphy, Donald. “Primary Spine Practitioner Training
Session III: Putting it all Together.” Community Spine Pathway Training.
Burgundy Basin Inn, Rochester. 3&4 May 2014. Lecture.
[5] Hufnagel, A., Alexander Hammers, Paul-Walter Schonle,
Klaus-Dieter Bohm, and Georg Leonhardt. "Stroke following
Chiropractic Manipulation of the Cervical Spine." Journal of
Neurology 246(8) (1999): 683-88. Print.
[6] Reuter, U., M. Hamling, I. Kavuk, K. M. Einhaupl, and
E. Schielke. "Vertebral Artery Dissections after Chiropractic Neck
Manipulation in Germany over Three Years." Journal of Neurology 253(6)
(2006): 724-30. Print.
[7] Risser, Amanda, Deirdre Donovan, John Heintzman, and Tanya Page.
"NSAID Prescribing Precautions." American Family Physician 80.12
(2009): 1371-378. American Academy of Family Physicians. American Family
Physician, 15 Dec. 2009. Web. 08 May 2014.
<http://www.aafp.org/afp/2009/1215/p1371.html#afp20091215p1371-b13>.
[8] Wolfe, Micheal, David
Lichtenstein, and Gurkirpal Singh. "Gastrointestinal Toxicity of
Nonsteroidal Anti-inflammatory Drugs." New England Journal of
Medicine 340;24 (1999): 1888-899. Print.
[9] Tarone RE, Blot WJ,
McLaughlin JK. Nonselective non-aspirin nonsteroidal anti-inflammatory drugs
and gastrointestinal bleeding. Am J Ther. 2004;11(1):17–25.
[10] June 29-30, 2009: Joint Meeting of the Drug Safety and Risk Management
Advisory Committee with the Anesthetic and Life Support Drugs Advisory
Committee and the Nonprescription Drugs Advisory Committee: Meeting
Announcement http://www.fda.gov/AdvisoryCommittees/Calendar/ucm143083.htm).
[11] Blower AL, Brooks A, Fenn GC, et al. Emergency admissions for upper
gastrointestinal disease and their relation to NSAID use. Aliment Pharm
Ther. 1997;11(2):283–291.
[12] Association, American Chiropractic. "Benefits and Risks of Neck
Pain Treatments." Acatoday.org. American Chiropractic
Association, n.d. Web. 13 May 2014. <http://www.acatoday.org/pdf/Benefits_Risks_Neck_Pain_Treatments.pdf>.
[13] Lee, VH, Brown RD Jr, Mandrekar JN, et al. Incidence and outcome of
cervical artery dissection: a population-based study. Neurology 2006;67: 1809-12
[14]Cassidy, David, Eleanor Boyle, Pierre Cote, Helen He, Sheilah
Hogg-Johnson, Frank L. Silver, and Susan J. Bondy. "Risk of
Vertebrobasilar Stroke and Chiropractic Care." Spine 33.4S
(2008): 000. Print.
