QuestionEven though you are probably right the following links coupled with what I was told by the physio is making me not go back to my chiropractor.This is what the physio was basing what he told me on and he told me to do a search on the net, I rather be wrong and not go to my chiropractor than go back and have the physio be proved right, I mean there are other treatments.
http://www.healthwatcher.net/chirowatch.com/cw-cervical.html
http://www.hfienberg.com/statstuff/chiro2.htm
http://www.ebm-first.com/?cat=5
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The text above is a follow-up to ...
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I have been seeing a chiropractor for the past week regarding a trapped nerve in my neck, I also have been seeing a physio theripist and what he had to say about chiropractors has got me worried.
He said the that manipulation of the neck is very bad for you and can cause brain tumors and brain damage over time.
He also said most chiropractors come from cananada and arent allowed practice there anymore, and that there have been quite a few horror stories relating to brain damage over there.
My chiropractor is registered under the chiropractic association of ireland, can you put my fear at ease?
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Mark,
As an addendum to my prior answer to your questions, I am providing this additional information which addresses the specific issue of concerns regarding chiropractic manipuluatio of the cervical spine and stroke.
The first is a a response I wrote which answered a previous question by another individual on this site, but which has some bearing on the question you raised:
A 2005 randomized trial published in the medical journal Spine found that of 280 participants, 85 had 212 adverse symptoms as a result of chiropractic manipulation of the cervical spine. Increased neck pain or stiffness was the most common symptom, reported by 25 of the participants. Less common were headache and radiating pain. Patients who received manipulation were more likely than those who received mobilization to have an adverse symptom occurring within 24 hours of treatment (reference: Hurwitz E, Morgenstern H, Vassilaki M et al. Frequency and Clinical Predictors of Adverse Reactions to Chiropractic Care in the UCLA Neck Pain Study. Spine 2005; 30: 1477-84.)
This study suggested that adverse reactions to chiropractic care for neck pain are common and that despite somewhat imprecise estimation, adverse reactions appear more likely to follow cervical spine manipulation than mobilization. The authors concluded that given the possible higher risk of adverse reactions and lack of demonstrated effectiveness of manipulation over mobilization, chiropractors should consider a conservative approach for applying manipulation to their patients, especially those with severe neck pain.
In my opinion, a safe option to thrust manipulations for individuals in whom thrusting techniques are not advisable or preferred would be mobilization techniques, as stated in the research study referenced above. Chiropractors are trained to employ a variety of joint mobilization and soft tissue techniques as an alternative or an adjunctive therapeutic approach to thrusting joint manipulation.
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Secondly, the following is a statement from the Foundation for Chiropractic Education and Research (fcer.org):
New Study Puts Stroke From Neck Adjustment at Less than 1 in 5 Million Adjustments
Toronto, October 12, 2001?A new Canadian study, reported in the October 2, 2001 issue of the Canadian Medical Association Journal (CMAJ), puts the risk of stroke following neck adjustment at 1 in every 5.85 million adjustments. The study, which is based on patient medical files and malpractice data from the Canadian Chiropractic Protective Association, evaluated all claims of stroke following chiropractic care for a ten year period between 1988 and 1997.
"This study is based on the most factual evidence available for determining the risk of stroke associated with neck adjustment," said Dr. Paul Carey, one of the principal authors of the study. "There has been much recent speculation about this risk, and some neurologists have expressed concern that the risk may be higher than previously believed. This study indicates that there is no cause for undue alarm, and that the risk may, in fact, be considerably lower than previously thought."
The study identified 23 reported cases of stroke following neck adjustments (also known as cervical manipulation), as diagnosed by the treating physician, over the ten year period. This was compared to the estimated 134.5 million neck adjustments performed by chiropractors in Canada over the same time frame.
Today抯 publication points out that earlier surveys of neurologists who reported stroke following chiropractic treatment were not rigorous, and did not review patient charts to determine the type of adjustment that was performed, or even whether an adjustment was performed during the chiropractic visit implicated in the stroke.
"Unnecessary alarm has been created by the release of unpublished data in the past based on flawed methodology," explained Carey. "While it is possible that the experience of chiropractors does not reflect all strokes that occur following neck adjustment, 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."
Carey pointed out that other very common treatments for headache, and neck and back pain carry much higher risks of serious complications.
He also noted that the study supports the recent research published in CMAJ by the Institute for Clinical Evaluative Studies which found that the incidence of stroke associated with neck adjustments is so rare, it was not possible for the researchers to establish a meaningful rate of occurrence despite the high number of cervical adjustments that are performed.
The study, titled "Arterial dissections following cervical manipulation: the chiropractic experience" was authored by Scott Haldeman, DC, MD, PhD, FRCP; Paul Carey, DC; Murray Townsend, BSc, DC; and Costa Papadopoulos, MHA, CHE.
This release was prepared by the Canadian Chiropractic Protective Association (CCPA). It is distributed by FCER with permission of CCPA.
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Additionally, this is also a statement from FCER:
Response to Rothwell Study in Stroke
By Anthony L. Rosner, Ph.D.
Within recent years, a long series of publications have attempted to single out chiropractic as a significant causative factor of cervical artery dissections and strokes. These not only have appeared in the medical journals [1-7] but in the widely circulated lay press as well [8]. I and other members of the chiropractic research community have found ourselves increasingly preoccupied with having to craft responses to all of these reports [9,10].
The latest study, from the University of Toronto and the Sunnybrook and Women's College Health Sciences Centre and published in Stroke, has turned the heat up a notch or two. It presents 582 cases with a diagnosis of vertebrobasilar dissection (VBA) or occlusion over the 6-year period from January 1993 through December 1998, age and sex matching these to 4 controls each lacking this diagnosis from the Ontario population. The study documents use of chiropractic services from public health insurance billing records. Of those patients aged less than 45 years, VBA cases appeared to be 5 times more likely than controls to have visited a chiropractor within 1 week of the VBA, although no significant associations were found for those aged >45 years. In the younger cohort, BA cases were 5 times as likely to have had 3 or more visits with a cervical diagnosis in the month before the actual occurrence of the VBA [11].
Unfortunately, this argument appears to be somewhat of a red herring. It also suffers from a paucity of numbers, for when the focus is reduced to the most heralded cohort of the study (patients aged less than 45 years), only 6 had cervical manipulations within 1 week of their VBA against a background figure of 1 from a matched cohort which did not have a vascular event. That would leave 5 incidences that would appear to be attributable to the chiropractic visit over a 5-year period, or 1 per year.
The fact remains that Rothwell's own data clearly indicate that vast preponderance (over 95%) of VBA stroke victims did not visit the chiropractor's office within the year preceding the vascular event, and nearly another 3% saw a chiropractor from 1 month to 1 year preceding the stroke [9] What needs to be emphasized is that no less than 68 everyday activities have been shown to disrupt cerebral circulation [12-14]. Among those activities, 18 (childbirth, interventions by surgeon or anesthetist during surgery, calisthenics, yoga, overhead work, neck extension during radiography, neck extension for a bleeding nose, turning the head while driving a vehicle, archery, wrestling, emergency resuscitation, star gazing, sleeping position, swimming, rap dancing, fitness exercise, beauty parlor events, and Tai Chi) have actually been associated with vascular accidents but are decidedly non-manipulative [14].
Assuming that VBAs are the result of blunt trauma may actually exonerate most cervical adjustments as the causative agent. Peak elongations of the vertebral artery during neck manipulative treatments have recently been shown to be at most about 11% of the elongations observed at the arterial failure limit; in fact, these elongations are consistently lower than those seen during routine range of motion and diagnostic testing [15]. What is becoming more and more apparent is that VBAs must be considered to be the result of cumulative events over an extended period of time rather than recent visits to the chiropractor.
Simply expressed, this argument states that a subset of stroke patients who had sought chiropractic treatment for neck pain were already well on the way to experiencing a VBA accident. Rothwell's study omitted the most obvious and convincing control group--which would have been to include a cohort of patients with neck pain seeking treatment by practitioners other than chiropractors, such as allopathic physicians. Like a perfect sham procedure in a clinical trial, this particular control would have accounted for all variables except the fact that the patient visited a chiropractor rather than another practitioner. Clearly, this design would have more directly tracked the development of VBAs and avoided the highly conjectural and suspiciously political attempt to lay the blame directly to chiropractic manipulation, as has been done in the studies of inferior design cited earlier [1-7]
Instead of becoming too obsessed with Rothwell's single-digit numbers of cases and to put this matter in the proper perspective, one should be forever cognizant of the fact that death rates following cervical manipulation calculate to be anywhere between 1/100-1/400 the rates seen in the use of NSAIDs for similar conditions [16,17] Death rates from lumbar spine operations have been reported to be 300 times higher than the rate produced by cerebrovascular accidents in spinal manipulation [18,19]. For cervical surgeries, recent death rates have been estimated to be 700-fold greater [19]. As Rome has pointed out,12 risks for "virtually all" medical procedures ranging from the taking of blood samples [20], use of vitamins [21], drugs [21], "natural" medications [22], and vaccinations [23] are routinely accepted by the public as a matter of course.
Until these lifestyle risks are properly bundled into a study of the proper design, the public will continue to misunderstand the true etiology of vertebrobasilar artery accidents, being led instead to chase arguably less than 3% of the total number of reported VBAs down a rabbit hole which has been labeled "The Chiropractor's Office." One also hopes that having to respond to this increasing number of studies based on a paucity of cases does not become the centerpiece of the chiropractic agenda.
REFERENCE:
1. Lee KP, Carlini WG, McCormick GF, Albers GF. Neurologic complications following chiropractic manipulation: A survey of California neurologists. Neurology 1995; 45: 1213-1215.
2. Hufnagal A, Hammers A, Schonle P-W, Bohm K-D, Leonhardt G. Stroke following chiropractic manipulation of the cervical spine. Journal of Neurology 1999; 246: 683-686.
3. Bin Saeed A, Shuaib A, Al-Sulatti G, Emery D. Vertebral artery dissection: Warning symptoms, clinical features and prognosis in 26 patients. The Canadian Journal of Neurological Sciences 2000; 27: 292-296.
4. Ernst E. Prospective investigations into the safety of spinal manipulation. Journal of Pain and Symptom Management 2001; 21(3): 238-242.
5. Stevinson C, Honan W, Cooke B, Ernst E. Neurological complications of cerivcal spine manipulation. Journal of the Royal Society of Medicine 2001; 94: 107-109.
6. Schievink WI. Spontaneous dissection of the carotid and vertebral arteries. New England Journal of Medicine 2001; 344(12): 898-906.
7. Vickers A, Zollman C. ABC of complementary medicine: The manipulative therapies: Osteopathy and chiropractic. British Medical Journal 1999; 319: 1176-1179.
8. Brody J. When simple actions ravage arteries. New York Times, April 3, 2001.
9. Chapman-Smith D. Safety and effectiveness of cervical manipulation: Addressing the gap between perception and reality. The Chiropractic Report 2001; 15(3): 1-4; 6-8.
10. Rosner A. Response to vertebral artery dissection study. April 10, 2001. http://www.fcer.org.
11. Rothwell DM, Bondy SJ, Williams JI. Chiropractic manipulation and stroke: A population-based case-control study. Stroke 2001; 32: 1054-1060.
12. Rome PL. Perspective: An overview of comparative considerations of cerebrovascular accidents. Chiropractic Journal of Australia 1999; 29(3): 87-102.
13. Terrett AGL. Vascular accidents from cervical spine manipulation. Journal of the Australian Chiropractic Association 1987; 17: 15-24.
14. Terrett AGL. Vertebral stroke following manipulation. West Des Moines, IA: National Chiropractic Mutual Insurance Company, 1996.
15. Herzog W, Symonds B. Forces and elongations of the vertebral artery during range of motion testing, diagnostic procedures, and neck manipulative treatments. Proceedings of the World Federation of Chiropractic 6th Biennial Congress, Paris, FRANCE, May 21-26, 2001, pp. 199-200.\r
16. Dabbs V, Lauretti W. A risk assessment of cervical manipulation vs NSAIDs for the treatment of neck pain. Journal of Manipulative and Physiological Therapeutics 1995; 18(8): 530-536.
17. Gabriel SE, Jaakkimainen L, Bombardier C. Risk of serious gastrointestinal complications related to the use of nonsteroidal anti-inflammatory drugs: A meta-analysis. Annals of Internal Medicine 1991; 115: 787-796.
18. Deyo RA, Cherkin DC, Loesser JD, Bigos SJ, Ciol MA. Morbidity and mortality in association with operations on the lumbar spine. Journal of Bone and Joint Surgery 1992; 74A: 536-543.
19. Boullet R. Treatment of sciatica: A comparative survey of the complications of surgical treatment and nucleolysis with chymopapain. Clinical Orthopedics 1990; 251: 144-152.
20. Horowitz SH. Peripheral nerve injury and causalgia secondary to routine venipuncture. Neurology 1994; 44: 962-964.
21. Caswell A [ed]. MIMS Annual, Australian edition, 22nd edition. St. Leonards, New South Wales: MediMedia Publishing, 1998.
22. Anonymous. Readers' Q & A. Australian Medicine 1998; October 5:18.
23. Burgess MA, McIntyre PB, Heath TC. Rethinking contraindications to vaccination. Medical Journal of Australia 1998; 168: 476-477.
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Finally, it bears mentioning that the chiropractic profession does not deny that there is a potential risk to any therapeutic procedure, including cervical manipulation, and as I stated previously, the astutue clinician weighs the risks and benefits of procedure in consideration of the patient's clinical scenario. That said, the controversy surrounding the issue of serious (i.e., life-threatening or life-damaging) complications resulting from chiropractic cervical manipulation are, it seems of the existing evidence, quite exaggerated.
I hope that this adequately addresses your concerns, and I again recommend that you voice your concerns to your chiropractor as well.
AnswerMark,
As I pointed out in my prior responses, chiropractic training and practice encompass a variety of non-forceful, soft-tissue manipulation and joint mobilization techniques which provide a safe and effective alternative to dynamic thrusting manipulative techniques for individuals that may not be appropriate candidates for thrusting manipulations/adjustments, or for those individuals who simply prefer a soft tissue approach to treatment.
In my practice, individuals with a history of stroke or transient ischemic attack, those taking anti-coagulant medications, females taking oral contraceptives, those with abnormal neurological signs and symptoms, those with severe neck pain or severe disc-related pain, those with bone spurs causing occlusion of the neural-foramina, osteoporotic patients, or those with other medical pathologies of the cervical spine or neuro-vascular structures do not receive thrusting manipulations of the cervical spine, and generally fare quite well with soft tissue manipulation and/or joint mobilization.
My previous responses were based on the best available peer-reviewed evidence, rather than my personal opinion. The links that you referenced generally expressed opinion, not objective data, regarding the safety of chiropractic cervical manipulation, which seems to be the issue with which you are most concerned. As I am unaware of your clinical condition and scenario, I cannot determine if you are in fact an appropriate candidate for chiropractic care.
You should discuss alternative treatment options with your chiropractor if you feel uncomfortable with the present treatment approach.
