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For Immediate Release: May 21, 2003

Contact: Robin R. Merrifield

1304 Perry Ave., Bremerton WA 98310

Phone: 800-343-0549 or 360-471-7837

Fax: 360-478-0834 E-mail: FCERedit@aol.com

By Anthony L. Rosner, Ph.D.

Norwalk, Iowa—The recent publication by Smith et al. in Neurology addressing vertebral artery dissection¹ represents another episode of regrettable studies which, despite serious flaws which raise substantial questions as to their internal validity, go to great lengths to selectively disparage the advisability of performing cervical manipulations as a means of patient care while obscuring the larger picture.^2-6 By this I refer both to the failure to fully present the well-documented benefits of this procedure as well as the equally well-chronicled risks of alternatives to cervical manipulation—including the use of medications which is so deeply entrenched in our society as to be obviously far more prevalent than any applications of manipulation. The fact that Smith's study has been so extensively and immediately propagated in the printed and televised media (in contrast to the many investigations which have supported cervical manipulations with no reports of substantial side-effects^7-30) represents a major disservice to the American public and threatens their access to the best available options in healthcare.

Specifically, the Smith study uses a nested case-control design to attempt to demonstrate an elevated risk of vertebral artery dissection following spinal manipulative therapy. Unfortunately, the study (i) fails to identify the actual numbers and locations of manipulations administered, (ii) fails to identify the qualifications and backgrounds of the individuals providing manipulations, and (iii) actually excludes more patients due to iatrogenic causes (8) than are actually presumed to bear a relationship to manipulation (7) because their events occurred within 30 days of treatment. The diminutive number of 7 patients thus presented has to raise questions about the robustness of this study, in addition to the implausibly long period of time intervening between dissection and treatment (30 days).

Regarding the studies mentioned above which appear to discredit the wisdom of cervical manipulation,^1-6 there appear to be a number of common fallacies: [i] They fail to disclose that the majority of cerebrovascular accidents (CVA) are spontaneous, cumulative, or caused by factors other than spinal manipulation; [ii] They fail to disclose the potential benefits of the procedure, violating medicine's own ethic of accurately reporting true risk-benefit ratios; [iii] They fail to place the risks of manipulation in the context of those produced by other medical treatments or lifestyle activities; [iv] They fail to indicate the actual frequency of manipulations administered; [v] They fail to account for the possibility that patients undergoing CVAs are reported more than once; [vi] They fail to report the rates of CVAs following manipulation by parties other than licensed chiropractors; and [vii] They incorrectly assume that patients undergoing adverse events following a manipulation might not have reported such instances to either the attending chiropractor or an appropriate authority.

Many signs point to intrinsic aberrations of arterial structure underlying CVAs, many brought on by elevated levels of homocysteine. When applied to cervical manipulation, the body of evidence suggests that the inherent fragility of the arterial wall of the cerebrovascular system rather than any trauma associated with maneuvers by the attending physician is the major culprit regarding arterial dissections. The determination of homocysteine levels as a clinical tool would appear to afford the chiropractic physician a means to bring the actual risks of CVAs to even lower levels than those previously reported. In this regard, homocysteine determinations currently appear to be the most plausible means for assessing patients who are most at risk for experiencing CVAs from routine activities, let alone from cervical manipulations. (With regard to the topics of spontaneous vertebral artery dissections and the possible role of homocysteine as a proposed indicator of patients at risk, I have published more detailed presentations elsewhere.^32,33)

The actual risk of CVA that can be directly attributed to spinal manipulation may be reduced to far less conspicuous levels when compared to everyday lifestyle risks and those brought on by medical treatments widely accepted by the public. Certainly the propagation of risk estimates attributable to visits to the chiropractor's office without adequate justification from data does not perform a useful service to the public; indeed, it does just the opposite. CVAs have been listed as only the fifth most common cause of chiropractic malpractice lawsuits, an unlikely ranking if chiropractors were conclusively found at fault for the majority of CVAs reported. ³¹

A highly methodical and fully-annotated response to Smith's study published in Neurology can be found at FCER's web site at www.fcer.org.

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REFERENCES:

1. Smith WS, Johnston SC, Skalabrin EJ, Weaver M, Azari P, Albers GW, Gress DR. Spinal manipulative therapy is an independent risk factor for vertebral artery dissection. Neurology 2003; 60: 1424-1428.

2. Lee KP, Carlini WG, McCormick GF, Walters GW. Neurologic complications following chiropractic manipulation: A survey of California neurologists. Neurology 1995; 45(6): 1213-1215.

3. Bin Saeed A, Shuaib A, Al-Sulaiti G, Emery D. Vertebral artery dissection: warning symptoms, clinical features and prognosis in 26 patients. The Canadian Journal of Neurological Sciences 2000; 27(4): 292-296.

4. Hufnagel A, Hammers A, Schonle P-W, Bohm K-D, Leonhardt G. Stroke following chiropractic manipulation of the cervical spine. Journal of Neurology 1999; 246(8): 683-688.

5. Norris JW, Beletsky V, Nadareishvilli ZG, Canadian Stroke Consortium. Canadian Medical Association Journal 2000; 163(1): 38-40.

6. Rothwell DM, Bondy SJ, Williams JI. Chiropractic manipulation and stroke: A population-based case-control study. Stroke 2001; 32(5): 1054-1060.

7. McCrory DC, Penzien DB, Hasselblad V, Gray RN. Evidence Report: Behavioral and Physical Treatments for Tension-Type and Cervicogenic Headache. Des Moines, IA: Foundation for Chiropractic Education and Research, 2001.

8. Boline P, Kassak K, Bronfort G, Nelson C, Anderson AV. Spinal manipulation vs. amiltriptyline for the treatment of chronic tension-type headaches: A randomized clinical trial. Journal of Manipulative and Physiological Therapeutics 1995; 18(3): 148-154.

9. Hoyt WH, Shaffer F, Bard DA, Benesler JS, Blankenhorn GD, Gray JH, Hartman WT, Hughes LC. Osteopathic manipulation in the treatment of muscle contraction headache. Journal of the American Osteopathic Association 1979; 78: 322-325.

10. Nilsson N. A randomized controlled trial of the effect of spinal manipulation in the treatment of cervicogenic headache. Journal of Manipulative and Physiological Therapeutics 1995; 18(7): 435-440.

11. Nilsson N, Christensen HW, Hartvigsen J. The effect of spinal manipulation in the treatment of cervicogenic headaches. J Manipulative Physiol Ther 1997; 20(5): 326-330.

12. Parker G, Tupling H, Pryor D. A controlled trial of cervical manipulation for migraine. Australian and New Zealand Journal of Medicine 1978; 8: 589-593.

13. Jensen IK, Nielsen FF, Vosmar L. An open study comparing manual therapy with the use of cold packs in the treatment of post-traumatic headache. Cephalalgia 1990; 10: 243-250.

14. Nelson C, Bronfort G, Evans R, Boline P, Goldsmith C, Anderson AV. The efficacy of spinal manipulation, amitriptyline, and the combination of both therapies for the prophylaxis of migraine headache. Journal of Manipulative and Physiological Therapeutics 1998; 21(8): 511-519.

15. Whittingham W, Ellis WB, Molyneux TP. The effect of manipulation [toggle recoil] for headaches with upper cervical joint dysfunction: a pilot study. Journal of Manipulative and Physiological Therapeutics 1994; 17(6): 369-375.

16. Mootz RD, Dhami MSI, Hess JA, Cook RD, Schorr DB. Chiropractic treatment of chronic episodic tension type headache in male subjects: a case series analysis. Journal of the Canadian Chiropractic Association 1994; 38(3): 152-159.

17. Droz JM, Crot F. Occipital headaches: statistical results in the treatment of vertebrogenic headache. Annals of the Swiss Chiropractic Association 1985; 8: 127-136.

18. Vernon HT. Spinal manipulation and headaches of cervical origin. Journal of Manipulative and Physiological Therapeutics 1982; 5(3): 109-112.

19. Wight JS. Migraine: A statistical analysis of chiropractic treatment. Chiropractic Journal 1978; 12: 363-367.

20. Stodolny J, Chmielewski H. Manual therapy in the treatment of patients with cervical migraine. Manual Medicine 1989; 4: 49-51.

21. Turk Z, Ratkolb O. Mobilization of the cervical spine in chronic headaches. Manual Medicine 1987; 3: 15-17.

22. Bove G, Nilsson N. Spinal manipulation in the treatment of episodic tension-type headache. Journal of the American Medical Association 1998; 280(18): 1576-1579.

23. Davis PT, Hulbert JR, Kassak KM, Meyer JJ. Comparative efficacy of conservative medical and chiropractic treatments for carpal tunnel syndrome: A randomized clinical trial. Journal of Manipulative and Physiological Therapeutics 1998; 21(5): 317-326.

24. Froehle RM. Ear infection: A retrospective study examining improvement from chiropractic care and analyzing for influencing factors. Journal of Manipulative and Physiological Therapeutics 1996; 19(3): 169-177.

25. Fallon J. The role of chiropractic adjustment in the care and treatment of 332 children with otitis media. Journal of Clinical Chiropractic Pediatrics 1997; 2(2): 167-183.

26. Degenhardt BF, Kuchera ML. Efficacy of osteopathic evaluation and manipulative treatment in reducing the morbidity of otitis media in children. Journal of the American Osteopathic Association 1994; 94(8): 673.

27. Klougart N, Nilsson N, Jacobsen J. Infantile colic treated by chiropractors: a prospective study of 316 cases. Journal of Manipulative and Physiological Therapeutics 1989; 12(4): 281-288.

28. Wiberg JMM, Nordsteen J, Nilsson N. The short-term effect of spinal manipulation in the treatment of infantile colic: A randomized controlled trial with a blinded observer. Journal of Manipulative and Physiological Therapeutics 1999; 22(8): 517-522.

29. Reed WR, Beavers S, Reddy SK, Kern G. Chiropractic management of primary nocturnal enuresis. Journal of Manipulative and Physiological Therapeutics 1994; 17(9): 596-600.

30. Yates RG, Lamping DL, Abram NL, Wright C. Effects of chiropractic treatment on blood pressure and anxiety: a randomized, controlled trial. Journal of Manipulative and Physiological Therapeutics 1989; 11(6): 484-488.

31. Type of loss study: Malpractice only for loss year 1995. Des Moines, IA: National Chiropractic Mutual Insurance Company as reported in Jagbandhansingh, MP. Most common causes of chiropractic malpractice lawsuits. Journal of Manipulative and Physiological Therapeutics 1997; 20(1): 60-64.

32. Rosner A. Spontaneous cervical artery dissections: Another perspective. Journal of Manipulative and Physiologial Therapeutics 2003; 26: In press.

33. Rosner A. CVA risks in perspective. Manuelle Medizin 2003; In press.

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