Chiropractic neck manipulation can cause stroke

Chiropractic neck manipulation can cause stroke

Chiropractic neck manipulation can cause stroke
Published Wednesday 07 January 2015
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.
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http://www.baylorhealth.edu/Documents/BUMC%20Proceedings/2015%20Vol%2028/No%201/28_1_Jones_VAD.pdf
Ref: Jones J, Jones C, Nugent K. Vertebral artery dissection after a chiropractor neck manipulation. Proc (Bayl Univ Med Cent). 2015 Jan;28(1):88-90.
Re the classification error of cases by Cassidy et al, I hope that the American Chiropractic Association will be mailing the 16,600 neurologists – to whom it sent the original paper – notifying them of that error:
Npl on Wednesday 07 January 2015 at 13:48
since chiropractic seems to be rather unknown in our parts, how does the “parent discipline” osteopathy fare?
I would be interested if the proven benefits with back pain (wikipedia) are superior to say, a regular massage (in place of a placebo). This for example could be added to regular medicine if it turns out favorable.
(Sorry to bring up something potentially off-topic / off-quack)
Jayson on Wednesday 07 January 2015 at 15:03
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.
Edzard on Wednesday 07 January 2015 at 15:18
“This is nothing new”…the re-analysis and the fact that the Cassidy results are wrong are both new.
“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.” … in both instances, there is evidence that the interventions normally generate more good than harm. Not so with chiropractic upper spinal manipulation.
” the reality is there are far far fewer risks with manipulation than other medical procedures”…how do you know? there is no monitoring system!
” 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”… the plural of anecdote is anecdotes, not evidence.
“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”….any evidence for that?
“. On the other hand, botched medical procedures kill in the tens of thousands of people each year”…classical fallacy.
Grandma on Wednesday 07 January 2015 at 15:23
The difference is obvious. Someone who dies during a science-based medical procedure has undergone real treatment, the person who has a stroke after chiropractic “treatment” is simply the victim of pseudo-scientific nonsense. Of course there are cases of malpractice, but real medicine has systems in place to address these.
Pete Attkins on Wednesday 07 January 2015 at 16:14
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:
Jackie on Tuesday 20 January 2015 at 00:36
“You can probably count on one hand how many people have a stroke following chiropractic manipulation each year.” When I had my vertebral artery dissection due to a chiropractic adjustment (at 25 years old, no pre-existing conditions, still no medical conditions that would indicate such a thing), my doctor in the hospital I stayed at for 2 weeks, told me that he had seen 8 people already that year who had had stroke due to chiropractic manipulation. I was the 9th. It was June. The year was only half over. This was in a semi-small city/hospital. Pretty sure the numbers are MUCH higher than that. Just go look at the facebook groups created for survivors…
Marianne Mattix on Wednesday 11 November 2015 at 23:26
Even if they don’t cause stroke(which they can). There are many other adverse events they can cause such as nerve and arterial stretches, herniated discs, and brachial plexus injuries. I speak from personal experience. Cervical thrust manipulation ruined my life. I went to see a chiropractor for low back pain and all he did was turn my head to one side and pulled then the other side. I asked why he was pulling on my head when it was my back that I was having trouble with? He responded that the type of therapy he used treats the whole spine. When I left and had been home for about an hour I experienced the worst headache I’d ever had. He called to find out why I didn’t return for my next treatment and when I told him why, he told me to please come in so he could talk to me. He told me that my subluxations in all areas of my spine were so severe that things would get worse before they got better. After the 4th visit I could hardly walk due to dizziness, had the worst head and neck pain in my life, was vomiting, and felt like I had a virus attacking every muscle in my body. Called my G.P. Who sent me straight to the e.r. I had an arterial and nerve stretch, herniated disc with annular tear at c-6-c7, and a brachial plexus injury. I went through horrific treatments and surgeries and had my life turned upside down. Every Chiropractor who has a degree from the Chiropractic college in Georgia, whose founding member is a crook and a half and belongs in prison, should have their licenses stripped. There are reputable chiropractors out there but the quacks from this group need sent to prison. They make false claims and mislead the public. They are also predatory and many are scamming medicaid and regular insurance companies. The problem is that most sue these quacks but have to sign hush waivers basically.
Ieva Zagante on Monday 07 December 2015 at 13:04
Jayson, unless you provide evidence, that your students are really taught to be careful …, and I do not mean only manipulation itself, but also ability to recognise serious conditions, like, e.g. kidney problems in young persons (they may have worse osteoporosis than an old lady), Marfan’s syndrome, cancers (primary or secondary), because these may lead to trauma….
And then: if kidney stone can be removed only by operation (depends on composition, form, state of the kidney), then operation must be done, whereas neck manipulations is far from the only thing you can subject your body to.
And, by the way, do you teach your students to leave alone patients who are simply to stressed and need some rest?
Björn Geir on Monday 12 January 2015 at 06:34
@ William
If you have followed the blog for the past days you may have noticed that Dr. Ernst has been busy with something more interesting than answering your arguments, which are groundless.
 
The woman had Poland’s syndrome according to the older text. This is not a connective tissue disorder. It is a congenital malformation involving unilateral non-development of the pectoral musculature and hand deformity. It is not related to a detectable genetic defect and only very rarely seems familial. The most likely cause being a disturbance of the ipsilateral subclavian vasculature in the developing fetus. It is not associated with neck or head abnormalities. Therefore it is quite adequate to state in the 2015 definitive publication that the woman had no significant previous medical history.
I see no problem with this.
 
Dr. Ernst did not state that this was a “new” case history. He only wrote that the paper he came across was dated 2015. The publication date is January 2015. Of course the case happened before that. It is quite common for clinicians to present interesting cases first as posters or short talks at conferences. A booklet is usually published beforehand with the different presentations numbered for reference and an abstract of the poster or talk. This text can often also be found online as you seem to have done The work is then usually written up as an article, changes made to reflect points of critique and suggestions from the audience (one form of peer review) and published in a journal or, as in this case, in the institution’s proceedings. The text you cut and paste is obviously from the prior list of conference abstracts. It is easy to imagine the bombardment of questions after the presentation, regarding the significance of Poland’s syndrome to the injury and the author decided, after reading up on the matter, that it was not significant to the case history.
I see no problem with this either.

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