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10-24-2016

It has been reported by respected entities that low back pain is the number one cause of pain in the world with neck pain being fourth. Chiropractic spinal manipulation has been proven as one of the safest and effective forms of pain relief for those affected by these types of spinal related disorders. This fact cannot reasonably be argued when utilizing research available up to this date.

Over many years there has been and continues to be misunderstanding regarding chiropractic spinal manipulation. In my opinion this is due to poor public education from the chiropractic profession as well as uninformed and/or disingenuous organizations and individuals who knowingly or unknowingly trying to limit competition (perform a search for the Wilk case). While any type of injury or adverse result is extremely unfortunate, those of us in healthcare must look at the risk to benefit ratio of a treatment or therapy and to uphold our promise to do no harm. Staying informed of current research is helpful to accomplish this. Once again in terms of safety, chiropractic manipulation of the spine has been irrefutably shown to be much safer than commonly used pharmaceuticals for pain relief such as non-steroidal anti-inflammatories and pain medication.

In my over 25 years of private practice, I have found there is another important point to address in an attempt to reduce concerns about chiropractic joint manipulation. That is the sound made by some, not all, methods of joint manipulation. At times a popping type of sound is heard which has now been shown to be a collision of gas bubbles within the joint space and is not needed to have positive effects. Ultimately chiropractic joint manipulation is a quick stretch of soft tissues attached to bones such as ligaments, joint capsules, tendons and muscle. Bones are levers to apply the stretch. This treatment’s mechanism of effect for symptom reduction most commonly includes one or more of the following; improved structure and/or function of tissues stretched, decreasing compressed nerve tissue and utilizing nerve receptors in the tissues stretched to enhance peripheral and central nervous system function.

Much of the public and private sector are unaware that chiropractors are primary portal of entry physicians/doctors. This means based on education and law we must take the necessary steps to diagnose and suggest treatment dependent on scope of practice laws in each state.  In addition, the knowledge to know when a treatment should be suggested and/or referral to appropriate entities should be made.

Due to information available today, in my opinion, a health care provider advising a patient not to acquire chiropractic spinal manipulation for spinal related disorders, when red and yellow flags are not present, borders on medical malpractice.

A goal of mine has always been to assist patients and health care professionals with the best known options regarding therapeutics available today. The following are my compilations of references and synopses from peer reviewed medical journals that document the safety of chiropractic spinal manipulation, especially with regard to vertebral arteries.

I hope the reader finds this helpful and thank you.

Craig Steingraber, D.C.

  • Ephraim Church, Emily Sieg, Omar Zalatimo, Manath Hussain, Michael Glantz, Robert Harbaugh. Cureus, 2016 Feb; 8(2); e498. Systematic Review and Meta-analysis of Chiropractic Care and Cervical Artery Dissection: No Evidence of Causation. This review was done by a team of neurosurgeons in the Department of Neurosurgery Penn State Hershey Medical Center.  When evaluating current research they found no convincing evidence to support a causal link between chiropractic manipulation and CAD. 
  • Kosloff T, et al. Chiropractic Care and the risk of Vertebrobasilar Stroke: Results of a Case Control Study in U.S. Commercial and Medicare Advantage Populations. Chiropractic and Manual Therapies; 2015; 23:19. Study using 39 million people in the US reports no causal relationship between cervical spinal manipulation and vertebrobasilar artery stroke and concludes that neck spinal manipulation may be associated in time with stroke but does not cause it.
  • Whedon JM, DC, MS, et al. Risk of Traumatic injury associated with chiropractic spinal manipulation in Medicare Part B beneficiaries aged 66-99. Spine 2015. 15, 40(4): 264-70. This retrospective study was based on Medicare data of patients aged 66-99 with an office visit in 2007 for a neuromusculoskeletal (NMS) complaint to evaluate risk of injury to the head, neck or trunk within 7 days. The study compared treatment of spinal manipulation versus treatment by primary care physicians. Injuries were categorized as dislocation/soft tissue injury, fracture, brain or spinal cord injury or injury to blood vessels. Study involved over 23 million Medicare patients. CONCLUSIONS: There was a 76% lower risk of injury with a chiropractic office visit versus patient who had a primary care physician visit.
  • Harvard Health Publications. (2015). Chiropractic Care for Pain Relief. http://health.harvard.edu/pain/chiropractic-care-for-pain-relief. Along with additional explanations for the public regarding chiropractic care, it is pointed out by the author that there have been some reports of serious complications, including stroke, but this has been shown to be extremely rare and some studies suggests this may not be directly caused by the treatment provided by the chiropractor.
  • Biller J, Sacco RL et al. On behalf of the American Heart Association Stroke Council; Cervical Arterial Dissections and Association with Cervical Manipulative Therapy. Stroke 2014. 45: xxx-xxx doi:10.1161/STR.0000000000000016. Current biomechanical evidence is insufficient to establish the claim that spinal manipulation causes cervical arterial dissection.” The studies have demonstrated that spinal manipulation produces less force on the vertebral arteries than passive range of motion testing, and insufficient force to strain the arteries to the level of potential injury. Herzog W, Leonard TR, Symons B et al. (2012) Vertebral Artery Strains During High-Speed, Low amplitude Cervical Spinal Manipulation. J Electromyogr Kinesiol.  22:740-746. Symons BP, Leonard T, Herzog W. et al. (2002) Internal Forces Sustained by the Vertebral Artery during Spinal Manipulative Therapy. J Manipulative Physiol Ther. 25:504-510. Wuest S, Symons B, Leonard T et al. (2010) Preliminary Report: Biomechanics of Vertebral Artery Segments C1-C6 during Cervical Spinal Manipulation. J Manipulative Physiol Ther. 33:273-278.  The new “Scientific Statement for Healthcare Professionals “on behalf of the American Heart Association, its Stroke Council and the American Stroke Association, and endorsed by the American Association of Neurological Surgeons will hopefully change statements referring that cervical  manipulative therapy (CMT) causes cervical arterial dissection (CD). The AHA statement can be relied upon to explain that leading neurologists, other medical experts and their organizations including the Stroke Council of the American Heart Association agree that there is no evidence to support the claim that CMT causes CD or stroke.

  • Haldeman S, Carroll LJ, Cassidy JD, and the Scientific Secretariat, Bone and Joint Decade 2000-2010 Task Force on Neck Pain and its Associated Disorders (2008) a Best Evidence Synthesis on Neck Pain: Findings from the BJD Task Force on Neck Pain and its Associated Disorders Spine 33(4S):S1-S206. McCrory DC, Penzien DB et al. (2001) Evidence Report: Behavioral and Physical Treatment for Tension-Type and Cervicogenic Headache Des Moines, Iowa, Foundation for Chiropractic Education and Research Product No. 2085.  Coulter ID, Hurwitz EL et al (1996) The Appropriateness of Manipulation and Mobilization of the Cervical Spine Santa Monica, California: RAN D, Document No. MR-781-CR. Over years of study many expert panels, including those from the RAN D Corporation (1996), the Evidence-Based Practice Center at Duke University (2001) and the Bone and Joint Decade Neck Pain Task Force (2008) have recommended neck manipulation as appropriate for patients with neck pain and/or headaches after assessing the evidence on risks and benefits.
  • Cassidy JD, Boyle E et al. Risk of Vertebrobasilar Stroke and Chiropractic Care: Results of a Population-Based Case-Control and Case Crossover Stud. Spine 2008.  33(4S:S5-S7). One of the, if not the most thorough study investigating the association between chiropractic manipulation and stroke. Using a large government database in Canada that captured all strokes in Ontario over 8 years to March 2002, representing 109 million person years, they found: Only 818 VBA strokes from all causes – 7.5 cases per million person years. In other words this is a very rare form of stroke from any cause. The increased risk of stroke amongst those who had seen a chiropractor in the past 7 days was exactly the same as for those who had seen a family physician in that time. This suggests that strokes are “associated with” chiropractic or medical visits in time rather than “caused by” such visits. Cassidy, Boyle et al. explain that an estimated 80% of VBA stroke patients have neck pain from artery dissection during the days before their stroke. From that point any neck movement can precipitate the stroke. Where there has already been damage to a vertebral artery and formation of a blood clot “a chiropractic manipulation or even simple range of motion examination by any practitioner could result in a thromboembolic event in a patient with pre-existing vertebral dissection”– in other words release of an embolus and stroke.
  • Thiel, Haymo W. DC, PhD *; Bolton, Jennifer E. PhD *; Docherty, Sharon PhD *; Portlock, Jane C. PhD.  Safety of Chiropractic Manipulation of the Cervical Spine: A Prospective National Survey. Health Services Research. Spine. 2007.32(21):2375-2378. 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. This study involved 19,722 patients. Results. Data were obtained from 28,807 treatment consultations and 50,276 cervical spine manipulations. There were no reports of serious adverse events. Conclusion. The risk of a serious adverse event, immediately or up to 7 days after treatment, was low to very low.
  • Rubenstein SM, Haldeman S, Van Tulder MW. An Etiologic Model to Help Explain the Pathogenesis of Cervical Artery Dissection: Implications for Cervical Manipulation. J Manipulative Physiol Therapeutics. 2006. 29:336-338. Manual treatments of the cervical spine, though maligned by some, are much safer than commonly used medical and surgical treatments for neck and head pain. The incidence of cervical artery dissection and stroke associated with manipulation/mobilization is generally accepted as one incident in 1 million treatments.
  • Haldeman S, Kohlbeck FJ, McGregor M. Unpredictability of cerebrovascular ischemia associated with cervical spine manipulation therapy.  Spine 2002: 27(1), pp. 49-55.  The growing acceptance of cervical manipulation as an effective treatment for head and neck conditions has necessitated the determination of possible side effects of this treatment and ways to avoid them.  Conclusions were cerebrovascular accident following manipulation seems to be unpredictable and there are few warning signs to identify patients at higher risk. 

  • Symons BP, Leonard T, Herzog W. Internal Forces Sustained by the Vertebral Artery during Spinal Manipulative Therapy. J Manipulative Physiol Ther 2002 (25)8:504-510. The forces actually reaching the vertebral artery (VA) during neck manipulation have now been measured in sophisticated biomechanical research at the University of Calgary in Canada. They found that the maximum forces on a vertebral artery from chiropractic manipulation are no greater than those recorded during common diagnostic range of motion tests regularly performed by many health professionals, and provide only “approximately one ninth of the strain” required to produce first mechanical failure in the tissues of the VA.
  • Terrett AGJ (2001) Current Concepts in Vertebrobasilar Complications Following Spinal Manipulation NC MIC Group Ind. West Des Moines, Iowa. Haldeman S, Kohlbeck FJ, McGregor M (1999) Risk Factors and Precipitating Neck Movements Causing Vertebrobasilar Artery Dissection After Cervical Trauma and Spinal Manipulation Spine 24(8):785-594. Key points and evidence are: The only area of concern is potential vertebral artery injury leading to vertebrobasilar stroke. This complication associated with neck manipulation is extremely rare, with an accepted risk rate of approximately 1 in 1 million treatments
  • 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): 785-794.  This study suggests that those rare patients suffering significant harm from manipulation may have a connective tissue disease that weakens the vertebral arteries. This may be why many other common neck movements also lead to vertebral artery injury- kneeling at prayer, yoga, washing walls and ceilings, turning the head while driving or sneezing.
  • Senstad, D.C., Leboef-Yde, D.C., MPH, Ph.D., Borchgrevink, M.D.  Spine 1997; 22(4): 435-440.  Unpleasant Side Effects after Spinal Manipulation.  Based on data from 4712 treatments of 1058 new patients by 102 Norwegian D.C.’s. Most common side effect is minor soreness, suggesting that the SPINAL MANIPULATION itself is rarely painful.  Reactions are short, with symptoms usually disappearing on the day of their appearance.  89% of the patients did not curtail their activities of daily living.
  • Wiesel, M.D.  Survey by the National Council on Aging.  NSAIDS Use and Risk in Senior Citizens. 1997; 12(8): 87.   “The serious side effects NSAIDS result in 200,000 hospitalizations and 20,000 deaths annually,” says Thomas Schnitzer, MD, rheumatologist and geriatrician at Northwestern University.  Over 20% of seniors age 60 and older regularly take medication for chronic pain.
  • Coulter, Ph.D.  et al.  RAND Corporation 1996: Table 6, page 36.  The Appropriateness of Manipulation and Mobilization of the Cervical Spine.  This was a comparative study, which shows the extreme safety of spinal manipulation in the hands of trained individuals.  1) Non-steroidal anti-inflammatories (NSAIDS): Serious gastrointestinal complications were 3,200/million for those greater than 65 and 390/million for those less than 65, 1000/million for all ages.  2) Cervical Spinal Surgery: Neurologic Complications, 15,600/million, deaths, 6,900/million.  3) Spinal Manipulation:  Cerebral Vascular Accident and other complications, 1.46/million, major Impairment, 6.3/10 million, death, 2.6/10 million. 
  • Dabbs, D.C. and Lauretti, D.C.  Journal of Manipulative and Physiological Therapeutics 1995; 18(8): 530-535.  Risk of cervical Spinal Manipulation vs. Non-steroidal anti-inflammatories (NSAIDS). The most reasonable estimate of risk of stroke from cervical spinal manipulation is 0.5 to 2 per million.  Risk of gastric ulcer is 10-20%, 5-10 times the rate of non-users.  Based on the literature, the risk of serious complications or deaths is 100 to 400 times greater for the use of NSAIDS than for cervical spinal manipulation in the treatment of similar conditions.

  • Heigh, M.D.  Postgraduate Medicine 1994; 96(6): 63-6.  The prevalence of ulcers in patients taking NSAIDS ranges from 10% to 30%.  In the Aspirin for Myocardial Infarction Trial, risk of hospital admission for duodenal ulcer was 10.7 times greater in aspirin vs. Placebo patients.  Gastric ulcers develop in 26% of patients who take aspirin regularly.  Patients who take NSAIDS for a total of 30 or fewer days had the highest risk. 
  • Terrett AG. J. “Vascular Accidents from Cervical Spine Manipulation:  Report of 107 Cases.”  Journal of the Australian Chiropractors Association, Volume 17, Number 1, March 1987, Pages 15-23.  Fifty-year review of chiropractic treatment shows low risk of injury.  This study shows when chiropractors perform adjustment/manipulation, it is very rare that injury happens and there are few side effects.