The very first article on a subject related to alternative medicine with a 2015 date that I came across is a case-report. I am afraid it will not delight our chiropractic friends who tend to deny that their main therapy can cause serious problems.
In this paper, US doctors tell the story of a young woman who developed headache, vomiting, diplopia, dizziness, and ataxia following a neck manipulation by her chiropractor. A computed tomography scan of the head was ordered and it revealed an infarct in the inferior half of the left cerebellar hemisphere and compression of the fourth ventricle causing moderately severe, acute obstructive hydrocephalus. Magnetic resonance angiography showed severe narrowing and low flow in the intracranial segment of the left distal vertebral artery. The patient was treated with mannitol and a ventriculostomy. Following these interventions, she made an excellent functional recovery.
The authors of the case-report draw the following conclusions: This report illustrates the potential hazards associated with neck trauma, including chiropractic manipulation. The vertebral arteries are at risk for aneurysm formation and/or dissection, which can cause acute stroke.
I can already hear the counter-arguments: this is not evidence, it’s an anecdote; the evidence from the Cassidy study shows there is no such risk!
Indeed the Cassidy study concluded that vertebral artery accident (VBA) stroke is a very rare event in the population. The increased risks of VBA stroke associated with chiropractic and primary care physician visits is likely due to patients with headache and neck pain from VBA dissection seeking care before their stroke. We found no evidence of excess risk of VBA stroke associated chiropractic care compared to primary care. That, of course, was what chiropractors longed to hear (and it is the main basis for their denial of risk) – so much so that Cassidy et al published the same results a second time (most experts feel that this is a violation of publication ethics).
But repeating arguments does not make them more true. What we should not forget is that the Cassidy study was but one of several case-control studies investigating this subject. And the totality of all such studies does not deny an association between neck manipulation and stroke.
Much more important is the fact that a re-analysis of the Cassidy data found that prior studies grossly misclassified cases of cervical dissection and mistakenly dismissed a causal association with manipulation. The authors of this new paper found a classification error of cases by Cassidy et al and they re-analysed the Cassidy data, which reported no association between spinal manipulation and cervical artery dissection (odds ratio [OR] 5 1.12, 95% CI .77-1.63). These re-calculated results reveal an odds ratio of 2.15 (95% CI.98-4.69). For patients less than 45 years of age, the OR was 6.91 (95% CI 2.59-13.74). The authors of the re-analysis conclude as follows: If our estimates of case misclassification are applicable outside the VA population, ORs for the association between SMT exposure and CAD are likely to be higher than those reported using the Rothwell/Cassidy strategy, particularly among younger populations. Future epidemiologic studies of this association should prioritize the accurate classification of cases and SMT exposure.
I think they are correct; but my conclusion of all this would be more pragmatic and much simpler: UNTIL WE HAVE CONVINCING EVIDENCE TO THE CONTRARY, WE HAVE TO ASSUME THAT CHIROPRACTIC NECK MANIPULATION CAN CAUSE A STROKE.
This is nothing new. Unfortunately, as with many medical procedures, there are risks. You can go into surgery to have a kidney stone removed and you can die. You can be sedated during a dental tooth extraction and never awake. There are some risks with chiropractic manipulation, but the reality is there are far far fewer risks with manipulation than other medical procedures. You can probably count on one hand how many people have a stroke following chiropractic manipulation each year. It’s not something to take lightly in any way, but the risks are incredibly low. I have been a doctor of chiropractic since 2008 and have adjusted thousands of people, and in that time I have “injured” two or three people, the worse being muscle strain.
Students are taught have to adjust the spine in a very gentle and careful way. Methods have changed significantly, and the forces applied for spinal manipulation have be minimized greatly.
Millions of chiropractic adjustments occur daily throughout the U.S., and few experience even a muscle strain. On the other hand, botched medical procedures kill in the tens of thousands of people each year. There is barely a reason to even be discussing this.
With all due respect, Jayson, I think you are committing a category error along the lines: All animals make mistakes that cause harm to other animals; the few mistakes made in chiropractic adjustments are so insignificant that there is barely a reason to even be discussing them.
Air travel is the safest means of transport simply because each and every accident is fully investigated and (usually) the whole industry is mandated to make upgrades to their products and services based on inescapable evidence. Your argument is similar to: Well, cars cause so many more deaths and injuries than aircraft therefore why even bother to investigate or discuss aircraft accidents?
The focus should never be placed on all the things that happened to turn out well; the primary focus must remain firmly placed on reducing the number of things that go catastrophically wrong. Please read:
http://en.wikipedia.org/wiki/Survivorship_bias
An interesting response. Well, we all have our biases. No one, not even the best scientist-advocate, is free of subjectivity, born of experience and values. Those values and experiences don’t necessarily invalidate their views, do they? I’m not a practitioner, but I am supportive of manual medicine, generally and not without reservations. I fully and freely admit that I have derived benefit from upper-cervical manipulation and that I know many others who have too. Whilst these experiences aren’t on the same par as, say, an RCT, they help to inform my views, as do your views together with the scientific literature.
But the chiros already have such a system! Chiropractic Patient Incident Reporting and Learning System has been running for a while, building up an anonymous database of incidents, the harms and what caused them so that chiros can be learn from mistakes made and bad practices and patients can be better protected in the future.
Oh! Wait. The data are confidential and not made public and I don’t think it’s used much. As I understand it, not even the statutory regulator has access to it…
Alan Henness wrote: “As I understand it, not even the statutory regulator has access to it…”
That’s my understanding, too. Also, the regulator (the General Chiropractic Council – GCC) seems to have dug a hole for itself when it claimed the following in 2006:
QUOTE
“*IF* chiropractors are to provide a safe clinical experience for patients then a reporting procedure needs to be put in place, within the clinics and within the profession as a whole, which allows for adverse events and near misses to be shared on an anonymised basis so that we can all learn from them.”
Since we know that the CPIRLS is being under-utilised, it would appear that the GCC’s recommendations for patient safety are not being fully met. Further, since a large part of the GCC’s remit is to protect patients, you have to wonder why it’s not developed its own robust adverse event event reporting system during the 14 years that it has existed.
Is this the same case history? Sounds the same except Ernst, Jones (the author) and Blue Wode left a few things out. By the way, the case report is over 3 years old, not new for 2015.Just dredging old injuries up. The woman had a connective tissue disease that should have been a red flag toward aggressive SMT. Jones doesn’t mention that the second time around.
#207 VERTEBRAL ARTERY DISSECTION AFTER CHIROPRACTOR VISIT
Jones J TTUHSC, Lubbock, TX. Case Report: Vertebral artery aneurysms/dissections occur in both men and women at an average age of 48. They are more common in patients with a history of connective tissue diseases, such as Marfan’s Syndrome or Ehlers- Danlos. They are also associated with neck trauma or manipulation, such as chiropractic maneuvers, sports, yoga, coughing, falls, and ceiling painting. One in 20,000 spinal manipulations results in an aneurysm/dissection and cerebrovascular accident. There is coexistent subarachnoid hemorrhage in 50-66% of adult cases. We present the case of a young woman with a ver- tebral artery dissection after a chiropractor visit. A 38-yr-old woman with a past medical history of Poland’s Syndrome presented with complaints of headache, nausea/vomiting, blurry vision, diplopia, dizziness, and ataxia for two to three weeks which developed after a recent visit to her chiropractor. Her level of consciousness was also decreased. She was not taking any medications on admission and denied tobacco, alcohol, and illicit drug use. On physical exam, vital signs stable. The patient was drowsy but aroused to sternal rub. She was not oriented and followed simple commands poorly. She demonstrated nystagmus to the left and left sided weakness. CBC and elec- trolyte panel were normal. Urine drug screen and a hypercoagulable workup were negative. CT showed an acute left cerebellar process with extensive edema, mass effect, obstructive hydrocephalus, and possible tonsillar herni- ation. A VP shunt was placed. Subsequent MRI showed an acute left cere- bellar infarct, involving the posterior inferior cerebellar artery territory and the anterior inferior cerebral artery territory with hydrocephalus and pneu- moventricle. MRA of the head and neck showed low flow and severe nar- rowing at the intracranial segment of the left distal vertebral artery near the basilar artery. The patient received mannitol for 7 days and gradually became more alert and responsive. At discharge, her limb strength and sensation were at baseline, but had some residual left-sided facial weakness and impaired sensation. Vertebral artery aneurysms/dissections are known complications of spinal manipulation procedures. The differential diagnosis for patients who present with headache, nausea, diplopia, and ataxia should always in- clude vertebral artery aneurysms, especially if there is a recent history of a chiropractic visit.
Chiropractors have been warned by national organisations of risks associated with CMT long before this old case history was recycled.
I am also 31 and had a stroke immediately after a neck manipulation. I literally had a stroke on the chiropractic table. Before this I was 10% bodyfat, ate a really clean diet, all my blood was was good (was approved for life insurance just before) worked out 5 days a week etc.
The people in ICU at the hopistal told me that they see 1-2 cases a month of stroke after visit a chiropractor. I have experience pain relief from chiropractic for my lower back etc… I tell people not get their neck adjusted anymore.
If this is such b.s. then why are there young and healthy people that have this happen? I have no study to back it up, besides the fact that I had a stroke in the office immediately after the adjustment.
I, too, am sorry to hear about the devastating consequences arising from your chiropractic encounter. FYI, there is a new website in Australia that’s just been set up which is inviting victims of neck manipulation injuries to contact it: http://www.neckdamage.org/
The site also carries a survey aimed at medical doctors and surgeons in an effort to find out how many people are being injured by neck manipulation.
In Manitoba Canada, we have formed a Group called the Manitoba Chiropractic Stroke Survivors and are petitioning our provincial government to apply conditions, restrictions and limitations on high velocity low amplitude manipulation of the vertebrae – in particular the cervical vertebrae. Our provincial government is in the process of assessing and allocating “reserved acts” to profession specific health care providers through profession specific regulations. Reserved acts are considered to be acts that pose a significant risk of harm to the public and high velocity low amplitude manipulation of the spinal vertebrae is one of those “reserved acts”. The government has assured our Group that we will be given the opportunity to present our position. If it is at all possible that you might be of some assistance in formulating and presenting out position it would be very much appreciated.
And taking an aspirin can cause gastrointestinal hemorrhage.
Almost every intervention carries risks. We have to inform ourselves of the risks to reduce the likelihood of any serious complications from whatever intervention that we make.
It does not mean that we do not do those interventions anymore but it does mean that we must drive to ensure that the risks are as low as possible and that the patient is aware of the risks however low
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