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"Death After Chiropractic": Support for the Safety of Cervical Manipulation



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August 4, 2010

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Neck AdjustmentA recent study (July 2010) published in Chiropractic and Osteopathy provides additional support for the safety of cervical manipulation.  The authors evaluated spinal manipulation, spinal mobilization and instrument-assisted manipulation using an Activator instrument.  They concluded that although the sample was small “it appears that all three methods of treating mechanical neck pain had a long-term benefit for subacute neck pain, without moderate or serious adverse events associated with any of the treatment methods”.   It is not the weight of this single study but the totality of published work on the subject that confirms a minimal risk of any serious adverse effect. There are also multiple studies supporting the benefits associated with judicious cervical manipulation including the review of cervicogenic headache found here:  Cervicogenic Headache: Therapy.

The "review" by Ernst last month (please see the last abstract and access to full text below) concludes that "Numerous deaths have occurred after chiropractic manipulations. The risks of this treatment by far outweigh its benefit."  Clearly the real evidence does not support the conclusions of Ernst.

It should be noted that much has been published related to the safety of chiropractic by the chiropractic profession.  Minimizing patient risk is a high priority for the research community as well as those in private practice.

Note:  These mini-reviews are designed as updates and direct the reader to the full text of current research.  The abstracts presented here are no substitute for reading and critically reviewing the full text of the original research.  Where permitted we will direct the reader to that full text.

Relative effectiveness and adverse effects of cervical manipulation, mobilisation and the activator instrument in patients with sub-acute non-specific neck pain: results from a stopped randomised trial.  [FULL TEXT LINK]

Chiropr Osteopat. 2010 Jul 9;18:20.

Gemmell H, Miller P.
Principal Lecturer Chiropractic Sciences, Department of Academic Affairs Anglo-European College of Chiropractic Bournemouth, Dorset, UK. hgemmell@aecc.ac.uk.

BACKGROUND: Neck pain of a mechanical nature is a common complaint seen by practitioners of manual medicine, who use a multitude of methods to treat the condition. It is not known, however, if any of these methods are superior in treatment effectiveness. This trial was stopped due to poor recruitment. The purposes of this report are (1) to describe the trial protocol, (2) to report on the data obtained from subjects who completed the study, (3) to discuss the problems we encountered in conducting this study.

METHODS: A pragmatic randomised clinical trial was undertaken. Patients who met eligibility criteria were randomised into three groups. One group was treated using specific segmental high velocity low amplitude manipulation (diversified), another by specific segmental mobilisation, and a third group by the Activator instrument. All three groups were also treated for any myofascial distortions and given appropriate exercises and advice. Participants were treated six times over a three-week period or until they reported being pain free. The primary outcome measure for the study was Patient Global Impression of Change (PGIC); secondary outcome measures included the Short-Form Health Survey (SF-36v2), the neck Bournemouth Questionnaire, and the numerical rating scale for pain intensity. Participants also kept a diary of any pain medication taken and noted any perceived adverse effects of treatment. Outcomes were measured at four points: end of treatment, and 3, 6, and 12 months thereafter.

RESULTS: Between January 2007 and March 2008, 123 patients were assessed for eligibility, of these 47 were considered eligible, of which 16 were allocated to manipulation, 16 to the Activator instrument and 15 to the mobilisation group. Comparison between the groups on the PGIC adjusted for baseline covariants did not show a significant difference for any of the endpoints. Within group analyses for change from baseline to the 12-month follow up for secondary outcomes were significant for all groups on the Bournemouth Questionnaire and for pain, while the mobilisation group had a significant improvement on the PCS and MCS subscales of the SF-36v2. Finally, there were no moderate, severe, or long-lasting adverse effects reported by any participant in any group.

CONCLUSIONS: Although the small sample size must be taken into consideration, it appears that all three methods of treating mechanical neck pain had a long-term benefit for subacute neck pain, without moderate or serious adverse events associated with any of the treatment methods. There were difficulties in recruiting subjects to this trial. This pragmatic trial should be repeated with a larger sample size.

Adverse events associated with the use of cervical manipulation and mobilization for the treatment of neck pain in adults: A systematic review.  [LINK]

Man Ther. 2010 Mar 11. [Epub ahead of print]

Carlesso LC, Gross AR, Santaguida PL, Burnie S, Voth S, Sadi J.
Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada.

Adverse events (AE) are a concern for practitioners utilizing cervical manipulation or mobilization. While efficacious, these techniques are associated with rare but serious adverse events. Five bibliographic databases (PubMed, CINAHL, PEDro, AMED, EMBASE) and the gray literature were searched from 1998 to 2009 for any AE associated with cervical manipulation or mobilization for neck pain. Randomized controlled trials (RCTs), prospective or cross-sectional observational studies were included. Two independent reviewers conducted study selection, method quality assessment and data abstraction. Pooled relative risks (RR) were calculated. Study quality was assessed using the Cochrane system, a modified Critical Appraisal Skills Program form and the McHarm scale to assess the reporting of harms. Seventeen of 76 identified citations resulted in no major AE. Two pooled estimates for minor AE found transient neurological symptoms [RR 1.96 (95% CI: 1.09-3.54) p<0.05]; and increased neck pain [RR 1.23 (95% CI: 0.85-1.77) p>.05]. Forty-four studies (58%) were excluded for not reporting AE. No definitive conclusions can be made due to a small number of studies, weak association, moderate study quality, and notable ascertainment bias. Improved reporting of AE in manual therapy trials as recommended by the CONSORT statement extension on harms reporting is warranted. Copyright © 2010 Elsevier Ltd. All rights reserved

Risk of vertebrobasilar stroke and chiropractic care: results of a population-based case-control and case-crossover study.  [LINK]

J Manipulative Physiol Ther. 2009 Feb;32(2 Suppl):S201-8.

Cassidy JD, Boyle E, Côté P, He Y, Hogg-Johnson S, Silver FL, Bondy SJ.
Centre of Research Expertise for Improved Disability Outcomes, University Health Network Rehabilitation Solutions, Toronto Western Hospital, Toronto, ON, Canada. dcassidy@uhnresearch.ca

STUDY DESIGN: Population-based, case-control and case-crossover study.

OBJECTIVE: To investigate associations between chiropractic visits and vertebrobasilar artery (VBA) stroke and to contrast this with primary care physician (PCP) visits and VBA stroke.

SUMMARY OF BACKGROUND DATA: Chiropractic care is popular for neck pain and headache, but may increase the risk for VBA dissection and stroke. Neck pain and headache are common symptoms of VBA dissection, which commonly precedes VBA stroke.

METHODS: Cases included eligible incident VBA strokes admitted to Ontario hospitals from April 1, 1993 to March 31, 2002. Four controls were age and gender matched to each case. Case and control exposures to chiropractors and PCPs were determined from health billing records in the year before the stroke date. In the case-crossover analysis, cases acted as their own controls.

RESULTS: There were 818 VBA strokes hospitalized in a population of more than 100 million person-years. In those aged <45 years, cases were about three times more likely to see a chiropractor or a PCP before their stroke than controls. Results were similar in the case control and case crossover analyses. There was no increased association between chiropractic visits and VBA stroke in those older than 45 years. Positive associations were found between PCP visits and VBA stroke in all age groups. Practitioner visits billed for headache and neck complaints were highly associated with subsequent VBA stroke.

CONCLUSION: VBA stroke is a very rare event in the population. The increased risks of VBA stroke associated with chiropractic and PCP 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.

Safety of Chiropractic Manual Therapy for Children: How Are We Doing?

JOURNAL OF CLINICAL CHIROPRACTIC PEDIATRICS. 2009 DEC Vol. 10(2) pp. 655 - 660

MillerJ.E.M.

Objectives:
To assess the risk of adverse effects of chiropractic spinal manipulation in the pediatric population and to promote a culture of safety along with full reporting of adverse events in the chiropractic profession

Methods: Narrative review of all published reports of adverse effects of chiropractic pediatric spinal manipulation

Results: Adverse effects from chiropractic spinal manipulation are rare with 2 moderate and 4 severe events reported during a 59 year period with up to 30 million treatments estimated per year. Current reports show a very low rate (<1% in 8,290 treatments) of mild transient side effects lasting less than 24 hours.

Conclusion: Based on the published literature, chiropractic spinal manipulation, when performed by skilled chiropractors, provides very low risk of adverse effect to the pediatric patient. Vigilance to detect occult pathology as well as other steps to maintain safe practice are of utmost importance.

Adverse effects of spinal manipulative therapy in children younger than 3 years: a retrospective study in a chiropractic teaching clinic.  [LINK]

MillerJ.E.BenfieldK.

JOURNAL OF MANIPULATIVE AND PHYSIOLOGICAL THERAPEUTICS. 2008 JUL-AUG Vol. 31(6) pp. 419 - 23

OBJECTIVE:
The purpose of this study is to identify any adverse effects to chiropractic care occurring in the pediatric patient and to evaluate the risk of complications arising in the pediatric patient resulting from chiropractic care.

METHODS: A 3-year retrospective study of pediatric case files from the Anglo-European College of Chiropractic (AECC) (Bournemouth, England) teaching clinic practice in Bournemouth, England. All files (n = 781) of pediatric patients younger than 3 years of age were selected manually in sequential order from current files stored in the AECC clinic presenting to the AECC clinic during a specific period. Most (73.5%) patients presenting were 12 weeks of age or younger (n = 574).

RESULTS: Six hundred ninety-seven children received a total of 5242 chiropractic treatments, with 85% of parents reporting an improvement. Seven parents reported an adverse effect. There was a reaction rate of approximately 1 child in 100, or one reaction reported for every 749 treatments. There were no serious complications resulting from chiropractic treatment (reactions lasting >24 hours or severe enough to require hospital care).

CONCLUSION: This study shows that for the population studied, chiropractic manipulation produced very few adverse effects and was a safe form of therapy in the treatment of patients in this age group.

Safety of chiropractic manipulation of the cervical spine: a prospective national survey.  [LINK]

Spine (Phila Pa 1976)
. 2007 Oct 1;32(21):2375-8; discussion 2379.

Thiel HW, Bolton JE, Docherty S, Portlock JC.
Department of Research and Professional Development, Anglo-European College of Chiropractic, Bournemouth, United Kingdom. hthiel@aecc.ac.uk

STUDY DESIGN: Prospective national survey.

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 approximately 1 per 10,000 treatment consultations immediately after cervical spine manipulation, approximately 2 per 10,000 treatment consultations up to 7 days after treatment and approximately 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 approximately 16 per 1000 treatment consultations. Up to 7 days after treatment, these risks were headache in, at worse approximately 4 per 100, numbness/tingling in upper limbs in, at worse approximately 15 per 1000 and fainting/dizziness/light-headedness in, at worse approximately 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.

Effect of cervical spine manipulation on a pre-existing vascular lesion within the canine vertebral artery.  [LINK]

Cerebrovasc Dis. 2008;26(3):304-9. Epub 2008 Jul 31.

Wynd S, Anderson T, Kawchuk G.
University of Calgary, Calgary, Alta., Canada.

BACKGROUND: Serious adverse events such as cervical artery dissection (CAD) have been reported to occur following cervical spine manipulation therapy (cSMT). To investigate the relation between these events, we utilized an animal model to determine if vertebral arteries with a suspected susceptibility factor (wall lesion) could be injured further by cSMT.

METHODS: Lesions to the vertebral artery wall were created by angioplasty in 10 anesthetized canines. Resulting injury dimensions were quantified using intravascular ultrasound before and after cSMT. Student's t were performed to assess the significance of changes in arterial dimension.

RESULTS: Statistical analysis demonstrated that the pre-cSMT and post-cSMT lesions did not differ significantly in their length, area or volume (p > 0.05).

CONCLUSIONS: In this animal model, cSMT did not alter the dimensions of pre-existing vertebral artery lesions. Copyright 2008 S. Karger AG, Basel.

Deaths after chiropractic: a review of published cases.  [FULL TEXT LINK]

Int J Clin Pract. 2010 Jul;64(8):1162-5.

Ernst E.
Complementary Medicine, Peninsula Medical School, University of Exeter, Exeter, UK. Edzard.Ernst@pms.ac.uk

OBJECTIVE: The aim of this study was to summarise all cases in which chiropractic spinal manipulation was followed by death.

DESIGN: This study is a systematic review of case reports.

METHODS: Literature searches in four electronic databases with no restrictions of time or language.

MAIN OUTCOME MEASURE: Death.

RESULTS: Twenty six fatalities were published in the medical literature and many more might have remained unpublished. The alleged pathology usually was a vascular accident involving the dissection of a vertebral artery.

CONCLUSION: Numerous deaths have occurred after chiropractic manipulations. The risks of this treatment by far outweigh its benefit.
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"Death After Chiropractic": Support for the Safety of Cervical Manipulation

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Re:"Death After Chiropractic": Support for the Safety of Cervical Manipulation


by Ronaldchiro   (8/11/2010 4:39:44 AM)
Hi,
          It's true that Chiropractic treatments support the safety of cervical manipulation. Alternative therapies, such as Active Release Technique, can also be used to relieve tension and stress on the neck.cervical manipulation can cause stroke by injuring vertebrobasilar arteries. Many chiropractors routinely manipulate the neck as part of a treatment regimen designed to improve health by adjusting “vertebral subluxations.”