Canadian Neurologists Lobbying to Ban ‘Chiropractic’ Neck Manipulation

The results of an ongoing study presented at the American Stroke Association’s 27th International Stroke Conference, are prompting Canadian neurologists to campaign against neck manipulation by chiropractors.

According to the results of a study conducted by Dr. John W. Norris of the University of Toronto and colleagues, cervical artery dissections (CADs) appear to be the leading cause of stroke among younger people, and neck manipulation is a precipitating event. However, the level of risk to patients remains unclear.

The study is taking place in Canada against the backdrop of lawsuits contending that chiropractic adjustments caused the deaths of 2 women. To investigate the link between CADs and manipulation, the researchers analysed 156 cases of cervical artery dissection. Trauma was the cause of CAD in 98(63%), of the 156 cases they analysed. In 38 cases of trauma(39%), the initiating event appeared to be chiropractic neck manipulation. Classification of traumatic events also included everyday trauma such as turning the head while reversing the car, golfing and painting the ceiling. Sixteen percent of the patients were found to have malformations in their cervical arteries, which may have made them more vulnerable to dissection.

Of the 38 chiropractic patients who experienced stroke, vertebral artery dissection occurred in 30 and carotid artery dissection occurred in 8. Two deaths occurred in the patients who experienced artery damage after neck manipulation. Based on their statistical data, Norris and colleagues estimate that 100 Canadian patients younger than 45 suffer strokes each year as a result of chiropractic neck manipulation.

The researchers claim that ‘there is serious under-reporting’ of strokes associated with neck manipulation, and speculate that this may have something to do with fear of litigation. Norris is quoted by WebMD Health (1) as stating that ‘Quite a number of strokes are associated with chiropractic manipulations. It’s not generally known by patients or doctors or chiropractors how common it is.’ He then goes on to say, that ‘God did not mean for you to twist the neck like that. The artery is stretched beyond its capacity. We think 100 patients per year in Canada alone have chiropractic-associated cervical dissections, and there must be 1,000 a year in the U.S.’.

Not so, says neurologist and chiropractor Scott Haldeman. Haldeman has analysed the Norris team’s data and says that the researchers have jumped to their conclusion.

‘Where the incorrect jump is made is that if someone has a chiropractic manipulation and then has a stroke, they say that the manipulation caused the stroke.’ Haldeman told WebMD Health. ‘They don’t ask what the patient was like before he went to the chiropractor’s office. A substantial number of them probably went to the chiropractor because their stroke was already evolving. This type of stroke starts off as neck pain and headaches - a main reason people go to a chiropractor.’ Haldeman says the best estimates available put the risk at a little more than 1 stroke per 100,000 chiropractic patients. ‘Even that estimate,’ he says, ‘doesn’t account for people whose stroke was caused by a trauma that happened before seeing the chiropractor. I think putting emphasis on this problem is reasonable, but it has reached hysteria among neurologists,’.

What Haldeman and Norris do agree on is no treatment is risk-free. They both say that chiropractors (and osteopaths) should warn people that there is a risk of stroke from neck manipulation.

The researchers claim that ‘there is serious under-reporting’ of strokes associated with neck manipulation

Haldeman and colleagues have conducted their own research into this area, the results of which were recently published in the journal Spine (2). This study was a retrospective review of 64 medicolegal records describing cerebrovascular ischaemia after cervical spine manipulation. All of these cases were previously unpublished in the medical literature, considerably increasing the total number of cases published, which previously stood at approximately 117.

The study by Haldeman and colleagues was unable to identify factors from the clinical history and physical examination of the patient that would assist a physician attempting to isolate the patient at risk of cerebral ischaemia after cervical manipulation. They therefore concluded that ‘cerebrovascular accidents after manipulation appear to be unpredictable and should be considered an inherent, idiosyncratic, and rare complication of this treatment approach.’

Haldeman and colleagues.... concluded that ‘cerebrovascular accidents after manipulation appear to be unpredictable and should be considered an inherent, idiosyncratic, and rare complication of this treatment approach.’

The increasing focus by medical researchers, and subsequently the public, on stroke after cervical manipulation is forcing chiropractors, osteopaths and others who perform manipulation to assess the true risk of this procedure. Further research is urgently required to determine the risk to a patient who undergoes cervical manipulation. The practitioner who believes that it will not happen to them may be naive, or may be vindicated by the results of such a study. Currently we do not know the true risk. Only a large, prospective, multicentre study can determine it. It is an ideal opportunity for the professions to take control of this issue and not be bullied by others who are increasingly producing this type of research.

Bound inexplicitly with this is the medicolegal issue. In an increasingly litigious society, each practitioner must obtain informed consent from patients undergoing this procedure, and also consider utilising alternative procedures to cervical manipulation.

The COCA Executive has recently produced a Risk Management Program, consisting of a Seminar series and a Risk Management Module which attempts to approach these difficult issues, and other issues in practice. Please refer to advertising elsewhere in this edition of COCA News.

Simon French

References:

1. DeNoon DJ. Strokes linked to chiropractic treatment. WebMD Health. Feb 8, 2002. http://cbshealthwatch.medscape.com/cx/viewarticle/424319
2. Haldeman S, Kohlbeck FJ, McGregor M. Unpredictability of cerebrovascular ischemia associated with cervical spine manipulation therapy. A review of sixty-four cases after cervical spine manipulation. Spine 2002;27:49-55.