I have attempted to understand the current
situation, which draws an association between
cerebrovascular arterial (CVA) events and
cervical
spine manipulation. I am clearly not an
expert in this field but have attempted to
search databases, read various research
studies, and attend multiple chiropractic
research conferences that have discussed
cervical manipulation and risk of stroke.
So far what has clearly been shown is that
the risk is so small that any possible study
to properly study the phenomena would take
about 25 million subjects. The reason is that
the incident appears to be so rare, that it
is hard to differentiate between causal and
coincidental factors. The coincidence factor
is rare also; to the degree that research is
showing in some cases seeing a visit to a
chiropractor might reduce the incidence of
stroke as compared to common incidental or
trivial causes.
So what are we at this time as chiropractors are
left with? Apparently as healthcare
practitioners we are responsible to
differentiate when a patient presents in our
office whether or not they might be having a
stroke in progress and making sure they are
referred both immediately and appropriately.
Part of the difficulty is that many factors
associated with stroke in progress are
reasons why patients seek our care.
What are some factors that we can use to
differentiate patient care and the need for
referrals?
Be cautious to watch for patient dizziness,
drop attacks, blurred vision, difficulty
speaking, swallowing, or walking, along with
nausea, numbness, and nystagmus. Since a
subset of patients treated by chiropractic
care can receive relief from the above
symptoms what is important in this
differential diagnosis is a mix of ALL of
these symptoms in one patient.
We need to be concerned when a patient tells
us "I have a pain in my neck and/or head
unlike anything I have ever had before." Also
we will need to increase any investigation if
the patient has posterior head pain that is
throbbing, steady or sharp, called a
"thunderclap headache."
In an effort to keep SOT chiropractors
advised of the most current events that may
affect our practices this newsletter will
feature:
1. A recent article in Dynamic
Chiropractic entitled, "Chiropractic and
Stroke Risk: Setting the Record Straight."
2. An abstract of an article and comment
published in the October 1, 200t issue of
Spine entitled, "Safety of Chiropractic
Manipulation of the Cervical Spine: A
Prospective National Survey"
3. "Migraine With Aura Increases Risk for
Ischemic Stroke" discussed in a prior SOT
Research Update.
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Chiropractic and Stroke Risk: Setting the Record Straight
Dynamic Chiropractic, September 24, 2007, Volume 25, Issue 20
A groundbreaking study on vertebral artery
dissection (VAD) and stroke following
chiropractic office visits is pending
publication in Spine and the European Spine
Journal. The study, conducted as part of the
Bone and Joint Decade 2000-2010 Task Force on
Neck Pain and Its Associated Disorders,
looked at the association between
chiropractic office visits and the incidence
of vertebral artery strokes.
"Current research suggests that dissections
are probably multifactorial in origin," said
Task Force President Scott Haldeman, DC, MD,
PhD. "They appear to occur in a person with a
genetic predisposition to arterial
dissection. They also appear to require a
second factor such as viral infection or
possibly estrogen. They can then be triggered
by a minor head movement, including
activities of daily living, an adjustment or
an examination of the neck."
Chiropractic and Stroke Risk: Setting the Record Straight · click here
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Safety of Chiropractic Manipulation of the Cervical Spine: A Prospective National Survey
Thiel HW, Bolton JE, Docherty S, Portlock JC. Spine. 32(21):2375-2378, October 1, 2007.
Objective. To estimate the risk of serious
and relatively minor adverse events following
chiropractic manipulation of the cervical
spine by a sample of U.K. chiropractors.
Summary of Background Data. The risk of a
serious adverse event following chiropractic
manipulation of the cervical spine is largely
unknown. Estimates range from 1 in 200,000 to
1 in several million cervical spine
manipulations.
Methods. We studied treatment outcomes
obtained from 19,722 patients. Manipulation
was defined as the application of a
high-velocity/low-amplitude or mechanically
assisted thrust to the cervical spine.
Serious adverse events, defined as "referred
to hospital A&E and/or severe onset/worsening
of symptoms immediately after treatment
and/or resulted in persistent or significant
disability/incapacity," and minor adverse
events reported by patients as a worsening of
presenting symptoms or onset of new symptoms,
were recorded immediately, and up to 7 days,
after treatment.
Results. Data were obtained from 28,807
treatment consultations and 50,276 cervical
spine manipulations. There were no reports of
serious adverse events. This translates to an
estimated risk of a serious adverse event of,
at worse [almost equal to]1 per 10,000
treatment consultations immediately after
cervical spine manipulation, [almost equal
to]2 per 10,000 treatment consultations up to
7 days after treatment and [almost equal to]6
per 100,000 cervical spine manipulations.
Minor side effects with a possible neurologic
involvement were more common. The highest
risk immediately after treatment was
fainting/dizziness/light-headedness in, at
worse [almost equal to]16 per 1000 treatment
consultations. Up to 7 days after treatment,
these risks were headache in, at worse
[almost equal to]4 per 100, numbness/tingling
in upper limbs in, at worse [almost equal
to]15 per 1000 and
fainting/dizziness/light-headedness in, at
worse [almost equal to]13 per 1000 treatment
consultations.
Conclusion. Although minor side effects
following cervical spine manipulation were
relatively common, the risk of a serious
adverse event, immediately or up to 7 days
after treatment, was low to very low.
Safety of Chiropractic Manipulation of the Cervical Spine: A Prospective National Survey. · click here
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Safety of Chiropractic Manipulation of the Cervical Spine: A Prospective National Survey.
Comment: Paul Shekelle, MD, PhD, RAND Corporation
This paper is a good first step at trying to
build the evidence base for one of the most
vexing concerns about cervical spine
manipulation, the possibility of serious
adverse events. Data from 377 chiropractors
in Britain gathered reports from treating
19,722 patients who received more than 50,000
cervical spine manipulations. No serious
adverse events were reported. This is
reassuring.
However, it is concerning that only about a
third of chiropractors in Britain
participated in the data collection;
therefore, the safety of cervical spine
manipulations performed by the other two
thirds of British chiropractors is unknown.
Also, for the chiropractors who did
participate, no follow-up data were available
for 413 treatment consultations. Even though
this a small percentage of the total number
of treatment consultations, a serious adverse
event in a small number of these, even one
serious adverse event, would be cause for a
major revision of the conclusion.
What's needed now is for possible adverse
events of cervical spine manipulation to be
gathered the same way it is for adverse
events of surgery: on every patient and every
clinician. Then we'll really start to
understand just how low the risk might be.
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Migraine with Aura Increases Risk for Ischemic Stroke
Medscape Medical News 2007
August 14, 2007 - New research suggests that
women who have recent onset of migraine with
visual aura have an almost 7-fold increased
risk for ischemic stroke. Results from the
Stroke Prevention in Young Women Study found
the risk for first-ever ischemic stroke was
highest among women who reported new onset
(within the past year) of probable migraine
with visual aura (PMVA).
Key points to take from the article:
1. "...risk for first-ever ischemic stroke
was highest among women who reported new
onset (within the past year) of probable
migraine with visual aura... "
2. "Women who had probable migraine with
visual symptoms who also smoked and used oral
contraceptives (OCs) had seven times the risk
of stroke than women who had probable
migraine with visual symptoms alone,"
3. In this study the group that had
probable migraine with visual aura (PMVA) who
smoked and used OCs had a 10-fold increased
risk for stroke compared with women with no
history of migraine, who did not smoke or use
OCs.
Main point: The doctor should be cautious
with HVLA (typical diversified type) cervical
adjustment with women with PMVA who smoke and
take OCs, possibly even exercise caution with
cervical stairstep adjustments and consider
investigating co-treatment with a
neurologist, if clinically indicated.
To access following link you will need to
open an account with Medscape, which is free
and only takes minutes.
Migraine with Aura Increases Risk for Ischemic Stroke
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The important point of this newsletter is
that while it is unlikely that chiropractic
cervical spine manipulation may cause a CVA
we must be aware of patients that present
with a stroke in progress or with significant
findings warranting a referral for a
neurological consultation or to the local
emergency room.
Sacro Occipital Technique Organization - USA
is a
non-profit,
professional organization formed to promote the
awareness,
understanding and utilization of the Sacro
Occipital
Technique
method of chiropractic as founded and
developed by
Dr.
Major Bertrand DeJarnette.
The SOTO-USA family all looks forward to
seeing you
in
Nashville for October 25-29th,
2007 Clinical
Symposium. It will be a great opportunity
learn the
essence of SOT or advance your SOT training
with
integrative classes in SOT, CMRT, and Cranial.
For those interested in working with the dental
profession
treating TMD then this symposium will be
leading the
way.
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Thank you for your dedication and interest
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