The Weekend Sun | A touchy issue...

Dr David Wellington
Greerton Chiropractic
greertonchiropractic

The topic of stroke (as a result of vertebral artery dissection) and chiropractic manipulation is always delicate if not inflammatory. There are two opposing opinions. First is, the risk is almost negligible ie one in 5,000,000 cervical manipulations to one per 20,000. Or, with two recent epidemiological studies results indicating no casual association versus a casual association.

Two recent epidemiological studies.

1) Chiropractic manipulation and stroke a population-based case-control study

Deanna M. Rothwell et al 2001

Results – Results for those aged <45 years showed VBAcases to be 5 times more likely than controls to have visiteda chiropractor within 1 week of the VBA (95% CI from bootstrapping,1.32 to 43.87). Additionally, in the younger age group, caseswere 5 times as likely to have had 3 visits with a cervicaldiagnosis in the month before the case's VBA date (95%CI from bootstrapping, 1.34 to 18.57). No significant associationswere found for those aged 45 years.

Conclusions – While our analysis is consistent with a positiveassociation in young adults, potential sources of bias are alsodiscussed. The rarity of VBAs makes this association difficultto study despite high volumes of chiropractic treatment. Becauseof the popularity of spinal manipulation, high-quality researchon both its risks and benefits is recommended

2) Risk of vertebrobasilar stroke and chiropractic care: results of a population-based case-control and case-crossover Study

J. David Cassidy, et al 2009

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 (Primary Care Practitioner) 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.

So What?

Cassidy study: Essentially the above articles outline frequency of Vertebral Artery Dissections within a population, that if a VAD is in progress you are more likely to see either a Chiropractor or GP to seek treatment for what you believe is a headache / neck pain at a similar rate.

Rothwell study: Or if a VAD occurred they were 5 times more likely to have visited a Chiropractor within 1 week. VAD occur in this population at 1.3 per 100,000 individuals under the age of 45.

( This would be equivalent to 1 practitioner seeing all of the under 45 population in Tauranga and surrounding areas and 1.3 strokes occurring within one week of that visit. )

However, if there is a screening process, modality and exercises that further decrease the risk, then surely the onus lies with the practitioner to utilise those modalities.

Gislason et.al 'Use of some nonsteroidal anti-inflammatory drugs (NSAIDs) is associated with increased cardiovascular risk in several patient groups, but whether this excess risk exists in apparently healthy individuals has not been clarified.”

Therefore, the obligation is to minimise risk at all times, as NSAIDs may increase the risk for some groups. Hence, if you are able to use a less demanding intervention for an at risk group, why not use it at all times.

Being aware of a patient presenting with several or more; Signs and Symptoms: Nystagmus, Nausea, Numbness, Ataxia, Dysphagia, Dysathria, Diplopia and Dysequilibrium accompanied with a thunderclap headache or sudden onset of severe neck pain without known cause, can lead to appropriate medical help, as it is crucial for the best outcomes anticoagulation treatment is delivered within four hours of onset.