Question
QUESTION: Hi Dr G,  

I have some degenerating discs, one in my lower back, one in my neck, which both give me trouble quite regularly.  My chiropractor does not tell me when to come but I just go when I feel I need to, which has averaged about once every 2 weeks this past year, sometimes for lower back, sometimes for neck, sometimes both.  I do feel better most times, but not usually straight away.  Sometimes I think - well, if I didn't go see him it would have gone away on it's own anyway, but if I don't go it carries on hurting and in the end I go.  One thing that bothers me is that my back clicks on its own, and it didn't used to - I have heard of hypermobility so maybe my chiropractor has loosened me too much, I sometimes think there is no point going to be adjusted when my back will just wobble back and give me sharp pain again.  Last Sat I got a big neck spasm which gave me a bad headache and made me feel disorientated and tired too. Went and got my neck adjusted, afterwards felt more disorientated and a bit nauseous.  Next day, less dizzy but still bad headache.  My friends and family think I am making it worse by going there, but the human body degenerates with age so how would I know what state I'd be in if I didn't go?
(Q1) After treatments should I feel better straight away, or the next day or a couple of days after that?  
(Q2) Has my chiropractor made me hypermobile with too many treatments?  If so, how can I stop being hypermobile?
(Q3) Should I expect to feel worse for a while before feeling better after a neck adjustment? He said it was very locked up - the worst it had been for a long time.
Sorry it's long and thanks for your help.
Sue

ANSWER: Hi Sue,

The only way to know if you are benefiting from the manipulative treatment is to discontinue treatment for a while.  Most people feel good following treatment, and it should be that way.   There are some who find that they are sore for a day, and then feel good.  There is no clear explanation for this.  Usually, if all the DC performs is joint manipulation and fails to perform soft tissue therapy, there is greater likelihood for soreness.   There is little chance that the DC made you hypermobile.    My biggest concern for you is that you experienced dizziness and a bad headache.   Your DC must NOT do any cervical joint manipulation until you are completely clear of headaches and neck pain, and only when you can completely pass a thorough neurovascular examination.   The current research indicates that some people have neck pain and headaches because neck arteries such as the carotid artery or the deeper vertebral artery are in the process of dissecting, e.g. from an aneurysm or from degenerative changes to the vessel wall.   You - and your chiro - should read the latest summary on this topic:  Article URL http://www.chiroandosteo.com/content/18/1/22   
Ask your DC to read this article before working on you.   There is a chance that you were "locked up" and had "spasm" because your neck was reacting to a problem deeper in the neck, whether it be a vessel or an irritated/degenerated disc, and the spasm and locked/stiff joint is a symptom an not the treatable lesion (the target of treatment).   An analogous situation would be a patient with middle back spasm and a locked up feeling to middle thoracic joints when the true problem is that they have a gall bladder stone and inflammation.  What the experience in their middle back goes away when the gall stone is dissolved (or the gall bladder comes out).   Your chiropractor - who is held to be an expert in this arena - should always be cognizant of this with spine conditions.   Get a neurovascular exam.   Ask your DC to consider just doing some soft tissue work and exercises to see if that improves your symptoms.  Avoid high velocity neck manipulation until you learn more about your vascular status.   Run all this by your chiropractor.

'Hope this was helpful.

Dr. G


---------- FOLLOW-UP ----------

QUESTION: Yes, thank you very much.

Can you describe to me what a thorough neurovascular examination is please?  Does a chiropractor do it?

The document you referred me to about Vertebral artery dissection and stroke was a bit beyond me but I did understand that it would be extremely unlikely for that to be my problem, although if it was I'd be very worried!  I looked it up and on emedicine I found this:

Several risk factors have been associated with the development of VAD. These include the following:

   * Spinal manipulation10,11,2,3,6,12,13 - Has one of the best studied and strongest demonstrated associations with VAD (The Canadian Chiropractic Association, Canadian Federation of Chiropractic Regulatory Boards, Clinical Practice Guidelines Development Initiative, Guidelines Development Committee have specific recommendations on assessment of signs of impaired vertebral artery flow and recommendations for treating or not treating patients with suspected impaired flow.14 ) http://emedicine.medscape.com/article/761451-overview

Does that mean that a chiropractor treating your neck can cause strokes?  Or does it mean, before the chiropractor treats you he must be sure you don't have that condition?
Thanks again for your advice, much appreciated.
Sue

Answer
Sue,

The emedicine information is wrong.  It is outdated and does not heed current research.  Cassidy's study clearly demonstrated that the odds of getting a stroke in a chiropractic office is no different than the odds of getting a stroke in a primary care MD's  office (there's a ton of links to Cassidy's study, e.g. on www.masschiro.org).  There are so many things that are "associated" with getting a stroke: drinking alcohol, taking ibuprophen, smoking...  But nobody is making a big deal about these like they are about neck joint manipulation.  It's not that the chiropractor causes the stroke except in EXTREMELY RARE instances, so rare that it's barely worth discussing, and so rare that it's impossible to study.  The research indicates that the patients go to the chiropractor in the midst of an artery dissection that sooner or later will cause a stroke and the chiropractic manipulation may or may not speed it along.  It seems as though the person will get the stroke anyway, at the dentist, hairdresser, doing plumbing, or watching TV.  The issue for the chiropractor is that they must carefully assess the patient to consider if they are one of these people with a vessel disorder causing the neck and head pain.  Apparently in many cases it is impossible to know until the patient is much more symptomatic, e.g. with dizziness, speech difficulty, loss of balance.   Neurovascular exam involves checking reflexes, assessing nerve function such as pin-prick skin senation, eye movements, and listening to the sound of the carotid arteries in the neck, etc.  These are things your doctors know about.  There was a "2-minute neuro exam" highlighted at the end of Murphy's article (again, meant for a doctor to see).  In school, we were taught to do neck position tests for "artery insufficiency" as a screening test for potential stroke patients, but it's been proven that these tests are not sensitive and often show false positives, e.g. they cause a patient to get dizzy when their neck is extended and rotated but the patient is normal/healthy.   

'Hope this helps clear things up a bit..

Dr. G