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Re: manipulation : does the risk out weighs the benefit ?
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Re: manipulation : does the risk out weighs the benefit ? - September 22, 2003 12:03:00 PM
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DocZon
Posts: 70
Joined: April 19, 2003
From: Winchester, MA
Status: offline
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Surprised no one made mention of this article yet.
DocZon, Chiropractor
Arterial Dissections: Approximately 1 in 5.85 Million Cervical Manipulations," Study Says
--------------------------------------------------------------------------------
A paper1 published in the October 2 issue of the Canadian Medical Association Journal (CMAJ) by Scott Haldeman,DC, MD,PhD, Paul Carey, et al. ("Arterial Dissections following Cervical Manipulation: the Chiropractic Experience") reports that the chances of arterial dissection after cervical manipulation is approximately 1 in 5.85 million manipulations.
Specifically, the authors state:
"The likelihood that a chiropractor will be made aware of an arterial dissection following cervical manipulation is approximately 1:8.06 million office visits, 1:5.85 million cervical manipulations, 1:1430 chiropractic practice years and 1:48 chiropractic practice careers."
The authors note that their numbers are "significantly less than the estimates of 1:500,000 to 1:1 million cervical manipulations calculated from surveys of neurologists." 2,3,4
The Haldeman, Carey, et al. study reviewed malpractice data from the Canadian Chiropractic Protective Association (CCPA) between 1988 and 1997 on stroke claims following chiropractic manipulation. Extapolating from the data, its was determined that approximately 134.5 million cervical manipulations were performed by chiropractors covered by the CCPA. Of those, 43 cases of neurological symptoms were identified: 20 were minor (not diagnosed as stroke by neurologists), and 23 cases involved stroke or vertebral artery dissection.
A profile of the 23 people (ages 24 to 75) was compiled to see if they had preexisting conditions (hypertension, diabetes, migraine headaches) or behavior (smoking) that could be identified as complicating factors in their conditions. Of the 23, five were smokers; four suffered migraines; and four had hypertension. These numbers, however, were not sufficient to identify these factors as complications, nor has a recent review of the literature been able to identify those patients at greater risk for stroke after cervical manipulation.5
"This study is based on the most factual evidence available for determining the risk of stroke associated with neck adjustment," said Paul Carey,DC, one of the principal authors of the study, and president of the CCPA. Dr. Carey is in charge of the CCPA's claims, files and management.
"There has been much recent speculation about this risk, and some neurologists have expressed concern that the risk may be higher than previously believed," observed Dr. Carey. "This most recent study establishes such an extremely low degree of risk, that patients can feel confident about the safety of neck manipulation performed by chiropractors."
Dr. Carey said that the study supports recent research published in the Canadian Medical Association Journal by the Institute for Clinical Evaluative Studies, which found that the incidence of stroke associated with neck adjustment is so rare that it was not possible for the researchers to establish a meaningful rate of occurrence for the high number of cervical adjustments that are performed.
In the same issue of the of the CMAJ as the Haldeman, Carey, et al., study was the paper "Cervical Manipulation and Risk of Stroke" by Drs. Kapra and Bondy.6 They noted that the Haldeman, Carey, et al., study provided "important data about the association between stroke and specific chiropractic interventions," but opined that the "use of malpractice claims data is unlikely to lead to an accurate estimation of the risk of stroke."
Drs. Kapra and Bondy asserted that a "less biased estimate" of the risk factor was an Ontario case-control study using administrative data.7 That study set the risk of stroke for people under 45 years old at 1.3 per 100 000 chiropractic visits (there was no significant association for patients aged over 45 years).
Still, Kapra and Bonday state that the risk associated with cervical manipulation "is both small and inaccurately estimated ... smaller than that associated with many commonly used diagnostic tests or prescription drugs."
Kapra and Bonday recommend: "...given the potentially devastating consequences of arterial dissection, physicians and chiropractors should discuss this risk, however small it may be, with patients contemplating neck manipulation."
The Haleman, Carey, et al. paper concludes with a recommendation for future research:
"The only manner in which the real incidence of dissection following cervical manipulation can be established and the feasibility of screening patients determined is to carry out research in which both chiropractors and neurologists participate. Failure to cooperate in such research will result in confusing and conflicting information being given to patients and will reduce the likelihood that these complications can be avoided."
References
Haldeman S, Carey P, Townsend M, Papadopoulos C. Arterial dissections following cervical manipulation: the chiropractic experience. CMAJ 2001;165(7):905-6.
Lee KP, Carlini WG, McCormick GF, Albers GW. Neurologic complications following chiropractic manipulation. A survey of California neurologists. Neurology 1995;45:1213-5.
Norris JW, Beletsky V, Nadareishvili ZG, on behalf of the Canadian Stroke Consortium. Sudden neck movement and cervical artery dissection. CMAJ 2000;163(1):38-40.
Stroke after chiropractic manipulation, a "small but significant risk" study finds. American Heart Association News 1994;Feb 19:1-3.
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):785-94.
Kapra MK, Bondy SJ. Cervical manipulation and risk of stroke CMAJ 2001;165(7):907-8.
Rothwell DM, Bondy SJ, Williams JI. Chiropractic manipulation and stroke: a population-based case-control study. Stroke 2001;32:1054-60.
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Re: manipulation : does the risk out weighs the benefit ? - September 22, 2003 3:15:00 PM
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Diane
Posts: 1507
Joined: March 9, 2001
From: Vancouver, B.C., Canada
Status: offline
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[URL=http://www.chirobase.org/15News/neurol.htm]http://www.chirobase.org/15News/neurol.htm[/URL]
Diane
PS: Unfortunately the link doesn't go where it says it will. Here is the article:
Sorry, the link doesn't work, so here's what the link was supposed to go to:
Miscellaneous News Index | | | Chirobase Home Page
Canadian Neurologists Warn against Neck Manipulation
Brad Stewart, MD, FRCPC
Sixty-two clinical neurologists from across Canada, all certified members of the Royal College of
Physicians and Surgeons, have issued a warning to the
Canadian public and provincial governments about the dangers of neck manipulation. The signers
include private neurologists as well as chiefs of neurology
departments of major teaching hospitals. Calling their concerns significant, they warn that stroke
and death due to neck manipulation has been reported in the
scientific literature for over 50 years and that manipulation is one of the leading causes of stroke
in the under 45-age group. The neurologists express six
basic concerns:
They first call upon physicians to be more vigilant. All patients presenting with a stroke, especially
those less than 45, should be questioned about
recent neck manipulation. They advise that physicians need to make an immediate referral to a
neurologist for any patient with a history of neck
manipulation that is followed by symptoms of stroke.
They uge the public to recognize that symptoms such as sudden neck pain, visual disturbances
and nausea following neck manipulation are not
normal. They warn that under no circumstances should an individual allow their necks to be
manipulated if any of these symptoms are present.
They endorse the Inquest Jury recommendations into the death of Laurie Jean Mathiason of
Saskatoon, Saskatchewan, a 20-year-old woman who
died following a chiropractic neck manipulation. That Jury recommended that the "risk of stroke
and other inherent risks associated with chiropractic
treatment be visible and available in the reception area of every chiropractic facility."
They express concern that in a routine autopsy "the vertebral arteries in the neck are almost
never removed and examined." As it is these arteries that
are most often damaged by neck manipulation, they urge close inspection of the vertebral
arteries in all suspicious cases. Further, such cases should
be referred to the office of the regional coroner.
They urge all the provincial Ministries of Health to act upon the strong concerns expressed by the
Canadian Pediatric Community about neck
manipulation in the pediatric age group. They call for an "immediate banning of all spinal
manipulation of infants and children".
They call for an Inquiry into what they consider to be "endless non-scientific claims being made
as to the uses of neck manipulation."
Statement of Concern to the Canadian Public from Canadian Neurologists
Regarding the Debilitating and Fatal Damage Manipulation
of the Neck May Cause to the Nervous System
February 2002
We Canadian neurologists hereby express our strong concern and thereby issue this warning to
Canadians. The public must be made aware
that the neurological damage that can result subsequent to upper neck manipulation can be
debilitating and fatal.
We make the following recommendations for the attention of the Canadian public, the
practitioners of manipulation, the medical community,
the provincial Ministries of Health and the health care professional regulatory bodies.
Our concerns are significant. Stroke and death due to neck manipulation has been reported in the
scientific literature for over 50 years
[1-10]. New deaths, in the past few years, have been reported to the Canadian Stroke
Consortium [11]. The Canadian Stroke Consortium
recently published a major prospective study [12]. The latest data from the Stroke Consortium
indicates that "more than 100 cases of
dissection per year are associated with neck manipulation." [13] The resulting stroke and
debilitation from such a large number is very
significant.
A recent study by the Institute of Clinical Evaluative Sciences (ICES Ontario) indicates that
patients with posterior circulation strokes under
the age of 45 are 5 times more likely than controls to have visited a chiropractor within one week
of the event [14].
Concern #1: Physicians need greater diagnostic awareness of the
neurological complications that may result from neck manipulation,
Many physicians are not aware of the risks associated with neck manipulation and thus fail to
undertake the appropriate investigations [15]
A history of neck manipulation or severe neck pain accompanied by signs or symptoms of stroke
should prompt an immediate referral to a
neurologist for examination and appropriate investigation.
Multiple neurological complications can result subsequent to neck manipulation. The most
dramatic is arterial dissection leading to stroke
and death. Cervical manipulation most commonly causes stroke occurring in the back part of the
brain. This can be particularly disabling as
it can affect such basic functions as swallowing, speaking and walking.
We recommend that the neurology community undertake an educational program for primary
care and emergency room physicians to
increase diagnostic awareness of the dangers of neck manipulation and its multiple neurological
complications.
Concern #2: There is an urgent need for the public to be
fully and properly informed of the dangers of neck manipulation.
Members of the public are largely unaware of the complications of neck manipulation.
Well-documented complications include damage to
the nerves in the neck, compression of the spinal cord by unstable discs, tearing of the arteries in
the neck, stroke and death.
The most significant complication of manipulation is stroke secondary to torn arteries in the neck.
The first symptom may be sudden neck
pain following neck manipulation [12]. Patients often ignore this pain, as it may have been neck
pain that prompted the visit in the first place.
Other important symptoms suggestive of stroke include visual disturbances, nausea, dizziness,
poor co-ordination, and weakness or
numbness on one side of the body. The onset of these symptoms should prompt an immediate
medical assessment. Under no circumstances
should an individual allow their necks to be manipulated if any of these symptoms are present.
We recommend that the medical community undertake an information campaign to increase
public awareness of the risks of neck
manipulation. Special attention should be paid to increasing awareness of the symptoms of
stroke following manipulation.
Concern #3: The individual patient needs to be
fully and directly aware that serious risks do exist.
We endorse the major recommendations of the 1998 inquest into the manipulation-induced
death of Laurie Jean Mathiason of Saskatoon,
Saskatchewan. This Inquest recommended that the "risk of stroke and other inherent risks
associated with chiropractic treatment be visible
and available in the reception area of every chiropractic facility." [16]
We further recommend that other practitioners of manipulation therapy, including
physiotherapists, should have a warning posted in their
offices about the risks of neck manipulation.
Qualified epidemiologists, medical scientists and legal experts should develop a patient
information form that it truly reflective of the risks.
This should be presented to every patient. This should include up to date scientific information on
the risks per individual patient rather than
dated, non-scientific claims that significantly underestimate the risk to the individual patient.
Concern #4: We are concerned that current
autopsy procedures fail to diagnose all cases.
In the course of a routine autopsy, the vertebral arteries in the neck are almost never removed
and examined. Cases of death due to neck
manipulation have been missed [17]. It is important to know the true incidence.
As there may be a significant time delay between manipulation and stroke, any person dying of
stroke within three months of a neck
manipulation should have their carotid and/or vertebral arteries examined by a pathologist. This
is especially important in those patients
under the age of 45 in whom a clear cause for stroke cannot be identified [14].
Suspicious cases should be reported to the office of the regional Coroner. This will allow a better
estimate of the true incidence of stroke and
death secondary to cervical manipulation.
Concern #5: Provincial Ministries of Health should ackowledge and
act upon the strong concerns and recommendations of the scientific
pediatric community regarding so-called "pediatric chiropractic."
Chiropractors in Canada perform cervical manipulation in children for the "treatment" of infantile
colic, inner ear infections, bedwetting and a
myriad of other paediatric illnesses. Chiropractic authorities claim that parents should bring their
new-born baby to a chiropractor "as soon
as possible after birth." [18] Such claims and recommendations have no scientific basis and only
expose infants and children to unwarranted
neck manipulation.
Strong concerns have been expressed by the Chiefs of Paediatrics of our Canadian Hospitals [19]
and by the Canadian Paediatric Society
regarding chiropractic manipulation on the spines of infants and children [20].
Paralysis and other complications in infants and children following cervical neck manipulation have
occurred [21]. Death has also been
reported [23].
We strongly recommend that each provincial Ministry of Health order the immediate banning of all
spinal manipulation of
infants and children.
Concern #6: We express our strong concern about the many non-scientific claims
made as to the conditions that purportedly may benefit from neck manipulaltion.
There are endless non-scientific claims being made as to the uses of neck manipulation. The
public must be made aware that the very great
majority of these claims have little or no evidence to support them.
We call upon the responsible governmental health authorities to conduct a full inquiry into the
dubious claims being made. Representatives
of all concerned parties should be brought together in such an inquiry. This should include an
examination of the information being taught at
all schools and courses dealing with manipulation therapy.
References
1.Pratt-Thomas HR, Berger KE: Cerebellar and spinal injuries after chiropractic manipulation.
Death case. J Amer Med Assoc 1947;
133(9):600-3
2.York v. Daniels. Medicolegal abstracts. Chiropractors Injury to spinal meninges during
adjustments. Death case. J. Amer. Med Assoc.
1955; 159 (8) 809
3.Smith RA, Estridge MN. Neurological complications of head and neck manipulations. (Death
case) J. Amer. med. Assoc. 1962; 182 (5)
527-31
4.Lorenz R, Vogelsang HG Thrombose der arteria basilaris nach chiroprakitschen manipulationen.
Death case. Deutsche Med. Wochenschrift
1972; 97:36-43
5.Beatty RA. Dissecting hematoma of the internal carotid artery following chiropractic cervical
manipulation. J. Trauma 1977; 17 (3): 248-9
6.Easton JD, Sherman DG. Cervical manipulation and stroke. Stroke 1977; 8(5) 594-7
7.Nyberg-Hansen R, Loken AC, Tenstad O. Brainstem lesions with coma for five years following
manipulation of the cervical spine. Death
case. J. Neurol 1978; 218: 97-105
8.Zak SM, Carmody RF. Cerebellar infarction from chiropractic neck manipulation: Death case.
Case report and review of the literature. Ariz.
Med. 1984; 41 (5) 333-7
9.Mas JL, Henin D, Bousser MG et al. Dissecting aneurysm of the vertebral artery and cervical
manipulation. Death case. A case report with
autopsy. Neurology 1989; 39 (4) 512-5
10.Sullivan EC. Brain stem stroke syndromes from cervical adjustments. Report on five cases.
Death case. J. Chiro Res. & Clin. Investigation
1992; 8 (1) 12-16
11.Norris JW, Beletsky V. SPONTADS data. Canadian Stroke Consortium. 2001
12.Norris JW, Beletsky V. Zurab G. Nadareishvili. Sudden Neck Movement and cervical artery
dissection. C.M.A.J. 2000 (07) 163. 38-40
13.SPONTADS. Canadian Stroke Consortium. May 2001
14.Rothwell DM, Bondy SJ, Williams I. Case control study of chiropractic manipulation and stroke.
Stroke 2001 (5) 1054-1060
15.Chan M. Nadareishvili Z. Norris. J. Diagnostic Strategies in Young Patients With Ischemic
Stroke. Can J Neurol. Sci 2000; 27; 120-124
16.July recommendations. Inquest concerning the death of Laurie Jean Mathiason. September
1998. Saskatoon, Saskatchewan. Canada.
17.D.C.F. Ontario.
18.Chiropractic and Children: Infants and Toddlers. Ontario Chiropractic Association. Distributed
from Canadian Memorial Chiropractic
College, Toronto. 2001.
19.A Statement by the Chairman of the Departments of Pediatrics of Pediatric Hospitals in
Canada. August 1994.
20.Spiegelblatt L. Francoeur E. Letter correspondence. Professor Michael de Robertis. York
University. Canadian Pediatric Society. 1988 Nov.
17.
21.Shafir. J. Pediatrics 1992; 120:226-9
22.Nickerson HJ, Silberman TL. Journal of Pediatrics 1992. Letter.
23.Klin Padiatr. 2001 March-April; 213(2): 76-85
Dr. Stewart practices clinical neurology in Edmonton, Canada. He can be reached at (780)
413-1710. The other signers were Drs. P. Ashby, Peter Bailey,
Pierre Bourque, Carol Boyle, Vera Bril, Richard Camiciolli , Martin del Campo, Robert Chen, Martin
A. Chepesiuk, Joseph Y. Chu, David R. Craig, Franscois
Delisle, Farouk Dindar, Francis Dominique, J.R. Donat, Draga Jichici, Ali Esmail, Mark S.
Freedman, John Falconer, Dean Foti, Mark Gewal, E. Gene
Gibson, A.J. Gomori, A. Guberman, Stanley Hashimoto Doug Hobson, Peter Humphreys, Trevor
Hurwitz, Reginald Hutchings, Harold Jacobs, Nathalie
Jette, Jack Jhamandas, Wendy Johnson, John D. Kay, Ralph Kern, Edwin Klimek, Morton C.
Knazan, Israel Libman, Liesly Lee, William J. Logan, Keith
Meloff, Liette Muresan, Garry Moddel, Mike Nicolle, Robert Nelson, John J. Peacock, C. Elizabeth
Pringle, George Rice, Ashfaq Shuaib, Barry Sinclair,
Ranjit Singh, Elout Starreveld, Brad Stewart, Dwight Stewart, John Stewart, Grant Stotts, Peter Stys,
Barry Tessler, Brian Thiessen, Chao Tai, Bob Yufe,
Christopher Voll, and Sharon Whiting.
Miscellaneous News Index | | | Chirobase Home Page
This article was posted on March 13, 2002.
[This message has been edited by Diane (edited September 22, 2003).]
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Re: manipulation : does the risk out weighs the benefit ? - September 23, 2003 5:34:00 AM
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teston
Posts: 38
Joined: August 27, 2003
Status: offline
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[URL=http://www.pbs.org/saf/1210/video/watchonline.htm]http://www.pbs.org/saf/1210/video/watchonline.htm[/URL]
Go here and click on "Adjusting the Joints". I bet there will be some PT's that are shocked by the force of the manipulations.
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Re: manipulation : does the risk out weighs the benefit ? - September 23, 2003 9:17:00 AM
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OAK
Posts: 184
Joined: September 1, 2003
Status: offline
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That was a very well done video. They truely captured the essence of the Chiropratic profession.
I did not like how generally the term "neck manipulation" was used. It was very unfair of the MD to state that all "neck manipulations" were dangerous. There are literally 100's of different ways to perform a cervical manipulation. If one specific medication is found to be harmful and is taken off the market (which has happened numberous times) is it fair to declare that ALL medications are harmful.
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Re: manipulation : does the risk out weighs the benefit ? - September 23, 2003 8:10:00 PM
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coloradojulie
Posts: 413
Joined: November 10, 2002
From: colorado usa
Status: offline
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My My!!! What a video.... some of these chiros on this site who spend a great deal of energy arguing with us...might want to contact Alan Alda and PBS instead!
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Re: manipulation : does the risk out weighs the benefit ? - September 23, 2003 9:38:00 PM
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Sam B
Posts: 73
Joined: August 6, 2003
Status: offline
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Ditto Julie. Absolutely shocking that sidelying closing thrust to the neck. I actually recoiled in my chair. Maybe the noise was from the table too. PBS obviously chose that manipulation for impact, to show their opinion of some of the techniques. Every technique shown was forceful and loud, except the activator, which looked like one might as well tap the patient or flick open a ball-point pen for the same effect. It seems their opinions were expressed very clearly by the way the material was presented and the closing remarks. I am sure that many evidence based chiropractors out there would be upset by this material.
Interesting point made by the "ex-chiropractor" regarding a self affirming/ self referential loop. One can believe in any form of chiropractic (or PT) it does not matter; you test and find what you expect to find, and the treatment works for what you find, so that confirms that your own initial opinion/ diagnosis was correct. I am sure that this exists in almost all forms of treatment in PT and medicine too, not just Chiropractic... when we find something that "works" we can always find a diagnosis that affirms need for the performance of a technique/ treatment that we know "works" This is prevalent in the MacKensie approach, Williams flexion, pelvic obliquity corrections, or almost any system that does not rely heavily on clinical reasoning/ scientific study for validity as the basis for indicated treatment.
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Re: manipulation : does the risk out weighs the benefit ? - September 23, 2003 9:48:00 PM
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touchiba
Posts: 101
Joined: November 11, 2002
From: PA
Status: offline
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Yeah, the noise made was definately from the table.
Also, I love how they interview all the idiots in the profession. They go right to the lowest common denominator. As for the ex chiro, well, he is a grad of one of the not so good schools and therefore bases all of his opinions on the crap he was taught there.
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Re: manipulation : does the risk out weighs the benefit ? - September 24, 2003 6:21:00 AM
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mcap56
Posts: 619
Joined: October 26, 2002
From: New York, NY
Status: offline
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Sam:
I have stated some of my concerns with the McKenzie method. However, your statement is baseless. One of the most important principles of the system is that you do not treat anyone based on medical diagnosis. The syndromes have models of pathology, but no specific pathology is assumed in your determination of treatment.
And, to their credit, they have produced more research and study than any other spinal treatment group in PT. The Lastlett study for the SIJ is just such an example.
mcap
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Re: manipulation : does the risk out weighs the benefit ? - September 24, 2003 8:00:00 AM
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nrl
Posts: 121
Joined: May 23, 2002
From: israel
Status: offline
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Dear OAK,
Just saw a post from a few days ago about the risk of MVA and driving.
This is a demagogic question/statement of the “billion Chinese can’t be wrong” category.
I drive because it’s a necessity of life, or rather the life I live. I do my best to reduce the risk of me having a MVA in the way I drive and in some public work I do aimed at alleviating the awareness to safe driving . The far tOo high risk of MVA should not send me to do all things that I think might be hazardous.
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Re: manipulation : does the risk out weighs the benefit ? - September 24, 2003 9:00:00 AM
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touchiba
Posts: 101
Joined: November 11, 2002
From: PA
Status: offline
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"I do my best to reduce the risk of me having a MVA in the way I drive and in some public work I do aimed at alleviating the awareness to safe driving."
Great, but how does this sound:
I do my best to reduce the risk of me causing a CVA in the way I adjust and in research I do aimed at increasing my ability to adjust safer.
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Re: manipulation : does the risk out weighs the benefit ? - September 25, 2003 8:55:00 AM
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OAK
Posts: 184
Joined: September 1, 2003
Status: offline
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"I drive because it’s a necessity of life"
Translation: Risking death (a serious MVA) is a necessity of life.
That doesn't make sense. The reason you drive is because the risk of an accident is so low that it is not reasonalbe to avoid driving. Just like no reasonable person would avoid leaving their house for fear of getting struck by lightening (also a higher risk than a cervical manipulation complication).
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Re: manipulation : does the risk out weighs the benefit ? - September 25, 2003 1:14:00 PM
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nrl
Posts: 121
Joined: May 23, 2002
From: israel
Status: offline
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"because the risk of an accident is so low " - apparently you haven't tried driving in my country.
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Re: manipulation : does the risk out weighs the benefit ? - September 25, 2003 7:47:00 PM
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hmgross
Posts: 292
Joined: February 28, 2003
From: Minnesota
Status: offline
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Good video, did anyone else check out the theraputic touch video as well?
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