Cervical Manipulation Revisited This section is compiled by Frank M. Painter, D.C.
Send all comments or additions to: Frankp@chiro.org
FROM: Chiropractic Report ~ September 2014
David Chapman-Smith, LL.B. (Hons) FICC (Hon)
“Current biomechanical evidence is insufficient to establish the claim that spinal manipulation causes cervical artery dissection (CD).”
— American Heart Association [1]
— Also endorsed by the American Association of Neurological Surgeons
A. Introduction
This report has previously reviewed in depth the scientific and professional issues arising from the extremely rare but now well-researched association between cervical manipulative therapy (CMT) and stroke, most recently last January, and did not anticipate returning to the subject soon.
However we now do because a landmark new paper represents an historic turning point in this field. It was published on August 7 in the American Heart Association’s journal Stroke and is endorsed by the American Association of Neurological Surgeons.
Until now, and despite accumulating evidence to the contrary, many individual neurologists, other critics and their professional organizations have felt free to claim that cervical manipulation may cause cervical artery dissection (CD) and stroke, has little or no proven benefit, is therefore unacceptable, and that the public should be warned of these things.
The new “Scientific Statement for Healthcare Professionals” from Biller, Sacco et al. on behalf of the American Heart Association, its Stroke Council and the American Stroke Association, changes all that. It exposes such critics as unscientific and irresponsible and strips away the professional solidarity they have relied upon. This clearly has major significance for the chiropractic profession and patients – as we say, represents an historic change.
In a comprehensive review titled Cervical Arterial Dissections and Association with Cervical Manipulative Therapy [1] Biller, Sacco et al., a writing group of 13 experts appointed by the AHA Stroke Council’s Scientific Statements Oversight Committee, report:
Definition. Spinal manipulation is defined as “a therapeutic intervention in which a high- or low-velocity, low-amplitude thrust is applied to the spine.” It is performed in North America and internationally not only by chiropractors but also “members of the allopathic, osteopathic and physical therapy/physiotherapy professions.” Cervical Manipulative Therapy (CMT) “is a broad term that encompasses cervical spine manipulation by any healthcare professional.”
Effectiveness. A number of controlled trials provide evidence that CMT is effective for patients with neck pain, and more effective than non-steroidal anti-inflammatory drugs (NSAIDs), acetaminophen, muscle relaxants, and narcotics. A recent multi-center, randomized, controlled trial by Dunning, Cleland et al. [2] suggests that manipulation is superior to mobilization. It “compared cervical and thoracic thrust manipulation with cervical and thoracic non-thrust mobilization for patients with neck pain and found an improvement in the manipulation (vs mobilization) group at 48 hours.”
Causation. “Current biomechanical evidence is insufficient to establish the claim that spinal manipulation causes CD.” In other words no one can make an evidence-based claim that CMT generally, including spinal manipulation specifically, may cause CD – the injury to the vertebral arteries or internal carotid artery that may lead to stroke.
Association. There is a statistical association in time between CD and CMT in that the percentage of those consulting a health professional for CMT during the week or month before ischemic stroke from vertebral artery dissection (VAD) is slightly higher than for matched control patients with stroke who did not receive CMT. However the only study that evaluated association not only with CMT but also primary medical care not involving CMT, found the same increase and association in patients receiving medical care. This was the Bone and Joint Decade Neck Pain Task Force study by Cassidy, Boyle, Côté et al. [3] These authors, as Biller, Sacco et al. note, concluded that CMT (in that study chiropractic care) “does not appear to pose an excess risk of VA stroke” and that headache and/or neck pain from already existing VAD causes people to seek care from a chiropractor or physician. That explains the increased association.
During the last generation the American neurologists Dr Walter Carlini et al., the Canadian neurologist Dr John Norris, the UK-based critic of complementary medicine Dr Edzard Ernst and many others have relied upon retrospective opinion surveys, case reports and other invalid and anecdotal evidence to claim that CMT, including specifically chiropractic adjustment, causes VAD and stroke, is unacceptably dangerous and should be banned. Just last year there was a concerted effort by medical specialists in the Netherlands to have upper cervical manipulation banned. The world being what it is critics will remain. But this comprehensive new scientific statement from the heart of American neurology will render them exposed and toothless at last. That is the historic significance of this new scientific statement.
2. This is a moment when everyone in the chiropractic profession should pause to acknowledge and give profound thanks to the researchers inside and outside the profession, and those who have funded their work, who have brought about this change. It is the research of the current generation of researchers that has fashioned the new scientific statement, evidence that appears in its 236 references. Prominent chiropractic research scientists with significant papers referenced include:
Scott Haldeman DC, MD, PhD, consulting neurologist and chiropractor of Los Angeles and David Cassidy DC, PhD, DrMedSci, epidemiologist and chiropractor of Toronto, the profession’s foremost leaders in this field.
Greg Kawchuk DC, PhD and Walter Hertzog PhD, biomechanics experts and their research teams in Alberta, Canada – studies on exact forces reaching the vertebral arteries during manipulation.
Eric Hurwitz DC, PhD of Hawaii, Pierre Côté DC, PhD of Toronto, epidemiologists, and other members of the Bone and Joint Decade Neck Pain Task Force – studies on safety and effectiveness.
Gert Bronfort DC, PhD, Roni Evans DC, PhD, clinical science researchers from Minnesota – evidence on effectiveness.
Alan Breen DC, PhD, and Haymo Thiel DC, PhD of the UK – studies on safety and effectiveness.
As to funding, Dr Louis Sportelli, President, NCMIC Group in the USA, and Dr Paul Carey, now Past-President, Canadian Chiropractic Protective Association in Canada.
3. Having emphasized the overall positive impact of the AHA ’s Scientific Statement, it must be said that there are still substantial concerns. These are reflected by the fact that, even though the American Chiropractic Association accepted the offer to participate in development of the paper – clearly a wise decision given its importance to the profession, its representative elected not to be named as an author.
Significant concerns include:
The singular focus on CMT, only one of many factors associated with CD. Why was this not a statement on CAD and Association with Trivial Trauma, or even more appropriately CAD and Association with Minor Movements and Forces?
Failure to emphasize how very rare CD and ischemic stroke from all causes are, how extremely rare the association between CMT, CD and stroke is, and how the issue of stroke following CMT is not a significant public health issue. The AHA must have known that this paper for health professionals would lead to media articles and warnings against CMT, discouraging patient from seeking a treatment option as appropriate as any other for many patients. It has led to such media articles – see more on this below.
From the evidence of a mechanical cause of CD from major trauma (e.g. high-impact vehicle accidents or sports), assuming there is likely a mechanical cause from trivial or minor trauma (e.g. sneezing, coughing, various sports, turning to back the car, CMT).
A pervasive medical bias throughout, quite revealing given the efforts by the AHA and these neurologists to be purely scientific. This is seen for example in describing the evidence of effectiveness of CMT as “sparse and questionable” when according to standard evidence ratings in systematic reviews and clinical guidelines it is either “positive” or “moderate” – and stronger than the evidence supporting the medical interventions after stroke that Biller, Sacco et al. review and recommend. [4, 5]
As another example it is also seen in calling potentially severe complications including stroke from a medical diagnostic procedure for imaging the arteries, digital subtraction angiography, “rare” at “up to 1%”, but the much more rare association between CMT and CD as “probably low”.
4. This report now discusses in more detail the content of the AHA paper, the above and other concerns, the paper’s public impact, and how chirpractors and others employing CMT should respond, if at all, to media comment. The World Federation of Chiropractic (WFC) has already distributed talking points which may be found at www.wfc.org under News, as have some larger national associations.
B. AHA Statement — Contents
5. The full text of this statement, approved by the AHA Science Advisory and Coordinating Committee on November 29, 2013, is available free online at www.myamericanheart.org/statements under the By Publication Date link.
Chair and Co-Chair respectively of the writing group of 13 authors are José Biller MD, Professor of Neurology and Neurological Surgery at the Stritch School of Medicine, Loyola University, Chicago, and Ralph Sacco MS, MD, Professor and Chairman of Neurology at the Miller School of Medicine, University of Miami, and formerly of Columbia University and a recent AHA President (2010-2011). As mentioned the Statement is written specifically for health professionals, and it therefore includes:a) Sections relative to cervical manipulative therapy (CMT):
Definition, utilization, effectiveness.
Association of CD and CMT.
Cervical spine biomechanics and CMT.
Postulated mechanisms of vessel (artery) injury.
Locations of arterial injury – for each of the internal carotid artery (ICA) and the vertebral artery (VA ).
b) Extensive sections relative to all cervical artery dissection (CD):
Clinical presentation.
Pathology.
Diagnosis and investigations – including initial and followup duplux ultra-sonography, CT and CTA, MRI/MRA , and digital subtraction angiography (DSA).
Treatment – including acute management (e.g. endovascular treatment to re-establish blood flow; thrombolysis to reduce local thrombus formation and secondary embolism) and prevention of recurrences.
Outcomes and prognosis – including clinical outcomes and risk of recurrence of CD or stroke.
6. Much of this is familiar information to chiropractors, given their specialized field of education and practice, but there is valuable reference to recent research findings in many areas. The paper, available free online, should be read directly and in full. Points of clinical interest include:
a) Causation of CD. The cause of most CD is “unknown”. The exception is severe trauma, as in a high-speed motor vehicle crash, where the cause is mechanical force. However even with “blunt cervical trauma” the prevalence of CD is only 1-2% of patients. In all other circumstances, and for the great majority of patients with CD, the cause and etiology are unclear. Biller, Sacco et al. list 25 factors identified in research and propose a model consistent with the multi-factorial model of CD and stroke that has been advanced by Rubinstein, Haldeman, and van Tulder [6]
Four necessary elements found in these rare but troubling stroke patients are:
Genetic predisposition – e.g. connective tissue disorders (“ultra-structural aberrations of dermal collagen fibrils and elastic fibres, hereditary hemochromatosis”)
Environmental exposure – e.g. increased CD in autumn/winter “believed to be a result of increased occurrence of infection or weather-related changes in blood pressure”; and also current use of oral contraceptives.
Common risk factors associated with atherosclerosis, e.g. hypertension, diabetes mellitus, smoking.
Trivial trauma characterized by hyperextension, rotation or lateroversion of the neck – e.g. CMT and “coughing, sneezing or countless sporting activities such as heavy lifting, golf, tennis and yoga”.
Biller, Sacco et al. acknowledge “confusion” about the distinction that has been made between spontaneous CD, where the patient and health professional cannot identify any precipitating trivial trauma, and CD following trivial trauma – identified in an estimated 12-34% of patients. They say that “the relationship, if any, of CD to any of these minor cervical traumas is often difficult to discern in an individual patient.” (Emphasis added.) On this issue of whether CMT or other everyday movements that have been called “trivial trauma” can ever cause CD or stroke Biller, Sacco et al. review much important new evidence including:
The line of research by Hertzog and others demonstrating 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. [7-9]
The research by Kawchuk, Wynd and Anderson using a canine model and showing “no significant change in VA lesions before and after cervical manipulation”. [10, 11]
Case control studies investigating the association between VAD and CMT, including that by Cassidy, Boyle, Côté et al. [3] As already mentioned, this was the first and is currently the only one to look at increased risk of stroke after both chiropractic and medical primary care visits, and it reports that the slightly increased incidence of stroke for those who had visited a chiropractor in the past 7 or 30 days compared with those in the general population, was exactly the same for those who had visited a primary care physician during the past 7 or 30 days.
Biller, Sacco et al. present these conclusions:
i. There is no evidence to support the claim that CMT causes CD.
ii. There is evidence of association. “Because patients with VA D commonly present with neck-pain, it is possible that they seek therapy for this symptom from providers, including CMT practitioners, and that the VA D occurs spontaneously, implying that the association between CMT and VA D/vertebrobasilar artery stroke is not causal.”
iii. It is “plausible CMT could exacerbate the symptoms or the VA D and possibly increase the risk of stroke.” In this sense CMT, as with many other usual neck movements, may represent a “mechanical trigger event.”
iv. This association suggests that there should be “increased education of providers, including CMT providers, in diagnosing CD.”
v. “Patients with neck pain and without neurological symptoms after any trauma should be informed about the potential risks and benefits of receiving CMT, and practitioners should carefully consider CD prior to performing CMT.” In practice and for legal reasons, which are rather different than scientific ones, chiropractors in many jurisdictions do advise patients of the remote risk of CMT as they obtain informed consent for treatment. However this final recommendation from Biller, Sacco et al. is scientifically controversial. To be consistent all health professionals would need to advise patients of risk of stroke from passive cervical range of motion tests, which is never done. Primary care medical doctors would need to give similar advice before prescribing nonsteroidal anti-inflammatory drugs (NSAIDs) – again, never done.
Here are the comparisons. Patient groups are not exactly equivalent but this gives meaningful context:
The generally accepted risk rate of association of stroke with CMT is about 1 in 1 million treatments.12 Fortunately, as Biller, Sacco et al. note, 70 – 92% or the great majority of these and all patients with stroke following CD have good outcomes with minimal or no permanent disability.
Use of NSAIDs cause 153 stroke deaths per million patients. [13]
Cervical spine surgery causes 500 stroke deaths per million patients. [14]
b) Clinical Presentation. To assist primary care professionals in early recognition of CD and prevention of stroke, Biller, Sacco et al. give detailed advice on symptoms of internal carotid artery dissection (ICAD) and vertebral artery dissection (VAD).
Typical presentations by patients with ICAD are:
The “classic triad” of pain on one side of the head, face or neck, accompanied by a partial Horner’s Syndrome and followed hours or days later by cerebral or retinal ischemia. However only about a third of ICAD patients have this.
Wherever the extracranial pain, “usually there is an ipsilateral headache … most commonly in the frontotemporal area.” This is usually of gradual onset but may be sudden. It is “most commonly described as a constant steady aching” but may be “throbbing or steady and sharp.”
“Most patients consider the headache or facial pain to be unlike any other pain”.
“After the onset of pain the median time to appearance of neural symptoms is an average 9 days (range 1-90 days)”.
Unilateral Horner’s Syndrome “should be considered to be caused by an ICAD until proven otherwise.”
Typical presentations by patients with VAD are:
“Pain in the back of the neck or head followed by posterior circulation ischemia,” but first manifestations are less distinct than for ICAD “and usually interpreted as musculoskeletal in nature.”
Pain develops in the back of the neck in half of patients, and a headache occurs in two thirds of patients.
The pain can be unilateral or bilateral, but when unilateral is always ipsilateral to the dissected VA.
Headache may be throbbing or steady and sharp.
Only half of the patients consider the neck pain or headache “to be unlike any other”, but it is rarely mistaken for migraine by those with a history of migraine.
The median interval between the onset of neck pain and the appearance of other symptoms is two weeks.
This final fact demonstrates the challenge for all in recognizing these rare patients with VA D, presenting with neck/head pain and likely to progress to stroke unless preventive steps are taken. It also explains why any minor neck movement including CMT in this two week period may trigger release of an embolus and stroke. Here is a chiropractic case report illustrating the time sequence: [15]
a) The patient was a 49-year-old farmer with chronic, episodic head and neck pain since the age of 19, not in severe pain, with unremarkable imaging and many things suggesting a mechanical origin for his problem and suitability for chiropractic adjustment.
b) However a careful examination revealed various risk factors and signs suggesting potential for cardiovascular disease – elevated blood pressure, family history of cardiovascular disease including stroke, bilateral tinnitus and nausea during severe attacks of pain, reduced cervical range of motion in all directions during severe attack, and inability of the chiropractor to reproduce the patient’s head pain during examination.
c) He was referred to his general practitioner for further assessment prior to commencement of any chiropractic are, and the following week had a stroke leaving him hemiplegic and with speech impairment.
As this case indicates there may be cases where, based upon presenting symptoms, predisposing factors for stroke in the patient’s history and examination findings, it is appropriate to delay CMT until more than two weeks have passed since pain symptoms began. (It also illustrates why there is slightly increased incidence of stroke after a patient consults either a primary care medical practitioner or chiropractor, but why that stroke is not caused by either. It also illustrates why case reports cannot prove causation, and why those criticizing CMT based on case reports have been scientifically naïve or irresponsible.)
d) Treatment of CDs. See the paper for review of the strengths and limitations of the current imaging modalities being used for better detection of the site and exact nature of CD in individual patients. All treatments for CD, however caused, are based on case reports or series or clinical experience since none is yet supported by a randomized controlled trial. They include:
Acute Management. This is focused on re-establishment of blood flow to brain tissue at risk. Thrombolysis with tissue type plasminogen activator is a primary option, but worsens the dissection in rare cases. Other endovascular treatments involve stenting of the artery, and are used to re-establish blood flow in patients with severe occlusion/stenosis at the site of CD.
Prevention of Re-Occurrences – Anti-Thrombotic Therapy. Anticoagulants and antiplatelet agents are widely used to prevent both early and late stroke recurrence. They are used to prevent local thrombus formation at the site of the CD and secondary embolism. Preliminary observational studies show that neither of these two alternative approaches is superior to the other in terms of subsequent rates of stroke. The best choice of anticoagulant (e.g. intravenous or oral warfarin) or antiplatelet agent (aspirin being the most common in antiplatelet-naïve patients), and the optimal duration of treatment are not known. If anticoagulant therapy is used it is generally discontinued after 3-6 months “since arterial remodeling, if it is to occur, is generally complete by 6 months”. Long-term antiplatelet therapy is thought to be less warranted for most patients.
Other risk factors (e.g. hypertension, use of oral contraceptives or hormone replacement therapy) should be managed. e) Clinical Outcomes. As already mentioned 70-92% of patients with strokes following CD from any cause have a good final outcome/result, defined as 0-2 (no or slight residual disability) on the modified Rankin Scale (mRS). “Generally neurobiological outcome depends upon lesion location and the presence of adequate collaterals”. Estimates of overall recovery of arterial patency range from 55-78%. “Factors associated with increased chances of recanalization include spontaneous (versus traumatic) dissections, stenotic vessels (versus occluded vessels), dissections in women, and VA Ds versus ICADs.”
C. Further Concerns with the AHA Statement
8. As previously commented the singular focus on CMT in this article, without making it clear that the association with stroke is extremely rare and that CMT is overall a safe and appropriate treatment, seems irresponsible. Furthermore, maintaining the concept that CMT involves trauma seems illegitimate. Surely Biller, Sacco et al. should have at least questioned that concept given the evidence they reviewed, which includes:
Basic science research showing that direct forces on the vertebral arteries from CMT are far less than those generated during normal range of motion testing and are similar to those from many activities of daily living – none of which are described as “traumatic”.
Compelling new evidence showing that stroke is equally associated with healthcare visits to primary care medical doctors who do not use CMT.
In defense Biller, Sacco et al. and the AHA may assert that they didn’t need to put CMT in context and review the established concept of ‘trivial trauma’ because this statement was written for health professionals rather than the public. But they must have known that this new AHA Scientific Statement would lead to media misinterpretation, and comment warning the public that CMT was dangerous. The Statement was published on Thursday, August 7. We can illustrate the above concerns with an article in Europe on Monday, August 11. This followed an interview with and quoted Dr José Biller, the AHA ’s primary author.
9. On August 11 the Times of Malta, the national paper in that country, published a prominent article titled Experts Warn over Neck Treatment Risks: Techniques to ease pain, including extending and rotating the neck can cause serious injury. This is reproduced in full as Figure 1. Points to note are:
Already in the title the distinction between association and cause is lost.
The article begins with a “new warning”, later refers to other medical warnings about “unnecessary and inadvisable” treatments that are “provided by chiropractors and osteopaths”, and ends with Biller’s advice concerning the “red flag” of “neck trauma or neck manipulation”.
Unsurprisingly Dr Nicolo Orlando, President of the Malta Chiropractic Association, reports that he and other MCA members were approached by existing patients with serious concerns. The wider concern is that many people with neck pain and headache and other conditions for which skilled CMT is an appropriate treatment will be deterred from receiving it.
D. Conclusion
10. Publication of the AHA Scientific Statement represents the end of the era in which individual neurologists can claim that CMT causes CD and stroke, present case reports as evidence, and rely on their colleagues for professional and scientific support. The AHA Statement, notwithstanding the concerns mentioned, is therefore a truly important milestone in the ongoing documentation of the appropriateness and value of CMT for many patients.
How should health professionals practicing CMT, specifically including chiropractors, respond to future media reports of patients allegedly suffering CD/stroke as a result of CMT? There must be an expression of sympathy for any patient suffering a stroke whatever the cause, but the AHA statement, with its evidence and conclusions, 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.
How should chiropractors and their associations respond if asked about the AHA statement itself? There should be a focus on its positive features, including those summarized at the beginning of this article. That is consistent with the advice of the World Federation of Chiropractic and its Talking Points published under News at www.wfc.org
Plainly, any possible association between CD and CMT is an important professional issue, warranting careful understanding, diagnosis and all reasonable steps to prevent harm to patients. On the other hand any such association is extremely rare and is not a significant public health issue. It doesn’t warrant more attention and debate than many other everyday neck movements or than medical interventions for similar patients that have less benefit and far higher risk of serious harm. The AHA Statement should be read and received in this context.
For relevant past issues of The Chiropractic Report, available online at www.chiropracticreport.com, see March 2008 (BJD Neck Pain Task Force); March 2012 (Best Treatments for Neck Pain); July 2012 (BMJ Debate on CMT) and January 2014 (CMT – Safety and Effectiveness – embargoed until January 2015).
References:
Biller J, Sacco RL, Albuquerque FC, et al.:
Cervical Arterial Dissections and Association With Cervical
Manipulative Therapy A Statement for Healthcare Professionals
From the American Heart Association/ American Stroke Association
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Upper Cervical and Upper Thoracic Thrust Manipulation versus Nonthrust Mobilization in Patients
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Effectiveness of Manual Therapies: The UK Evidence Report
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Defining the Effect of Cervical Manipulation on Vertebral Artery Integrity:
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J Manipulative Physiol Ther 2004 (Nov); 27 (9): 539–546Wynd S, Anderson T, Kawchuk G
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Spine (Phila Pa 1976) 2002 (Jan 1); 27 (1): 49–55Lanas A et al.
A Nationwide Study of Mortality Associated with Hospital Admission due to Severe Gastrointestinal Events and Those Associated with Nonsteroidal Anti-inflammatory Drug Use
Am J Gastroenterol. 2005 (Aug); 100 (8): 1685-93Marquez-Lara A, Nandyala SV et al.
Sentinel Events in Cervical Spine Surgery
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Cerebrovascular Accident Without Chiropractic Manipulation: A Case Report
J Manipulative Physiol Ther 2006 (May); 29 (4): 330–335
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