Stroke

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I found one of the articles I base my last E-mail on. I will continue to search. The Chiropractic Report by Chapman July 1999 Vol13 No.4 published an excellent review of cervical adjusting. Haldeman's article published in Spine was included. I highly recommend it. Some of the key conclusions were and I quote ...

" Cerebrovascular accidents from vertebrobasilar artery dissection (CVAs) can be an unexpected and devastating case of stroke. However they are on 1.3 in 1000 cases of stroke." ... "43% of the 367 reported cases follow no known precipitating event and are thus labeled 'spontaneous. Of those with identifiable trauma 16% are trivial, involving normal sporting activities, walking, household chores, turning the head while driving, coughing, ect. "..."accordingly 6 in 10 (59%) of CVAs have a trivial cause. The other 41% of the cases have been attributed to cervical manipulation (31%) and major trauma (10%) motor vehicle accidents, significant sports injuries, lifting injuries, ect. The facts of various individual cases make it plain that manipulation can be the proximate case of CVA. Haldeman et al suggests that it may not be the underlying cause, or even the cause, in many cases where it is assumed to be. Patients may have had a spontaneous dissection from a minor trauma, and consulted a practitioner with the resulting symptoms of neck pain or headaches. Spinal manipulation is then " administered to patients who already had spontaneous dissection in progress".

This conclusion is supported by a compelling argument. If the primary case of CVA was cervical manipulation, or indeed any specific head position or movement or trauma, "considerably more cases would be anticipated". There are about 250 million office visits to chiropractors in the US each year and millions of whiplash injuries, falls and other activities causing violent movements to the head and neck, but few CVA's. This suggests that there may be "some unique factor that causes certain people to be at risk."

"All of this amounts to good and bad news. They good news is that in chiropractic practice you can use any cervical adjustment technique you deem appropriate, since the best evidence is that no position or technique carries additional risk. Additional studies from North America and Europe report that pre-manipulation test of vertebral artery function are invalid and unnecessary.

The bad news is that rare patients are CVA's waiting to happen. No one knows why. They cannot be screened in advance, competent and skillful practice will not protect you, and a CVA can happen in your office tomorrow. Fortunately the is risk is remote. Most persons turning to reverse their car out of a driveway will not have a CVA, and most chiropractors will never experience one in a lifetime of practice.

What should you be doing about this? The answer, in terms of patients rights, law and ethics, is be disciplined and responsible about getting informed consent. In the words of the current US national guidelines for chiropractic practice:

"Patient consent to treatment is always necessary, it is often implied rather than expressed. However, where there is risk of significant harm from the treatment proposed, this risk must be disclosed, understood and accepted by the patient. Such informed consent is required for ethical and legal reasons. The best record of consent is one that is objectively documented (e.g. a witnessed written consent or videotape)."...

"If a patient of yours were to suffer serious consequences from a CVA caused by cervical adjustment, wouldn't you sleep more soundly at night knowing you had disclosed this very rare but foreseeable risk of your treatment?"

The article can be condensed into the sub title: ROTATION IS FINE, PRETESTING IS OUT, BUT GET CONSENT"