Risks Related to Manipulation of the Cervical Spine: Consequences for Evidence Based Practice
Consequences for Evidence Based Practice
1. Cervical manipulation, especially with rotation (the most commonly used method by chiropractors), should be considered a contraindicated technique.
2. Manipulation of the upper cervical spine - otherwise known as the "cervicocranium" (the occipito-atlanto-axial region) - should be considered absolutely contraindicated. (This is also the area of the neck most commonly manipulated by many chiropractors, most likely as a hangover from BJ Palmer's "Hole-In-One" theory.)
3. In principle these guidelines and cautions apply to all involved professions, since it is primarily the technique that is the problem, even though chiropractors are by far responsible for the greatest number of injuries, strokes, and deaths.
This is a logical consequence of their exaggerated and unwarranted self-confidence and erroneous education, combined with their historically and educationally conditioned overrating of the value of spinal manipulation as a whole.
4. All healthcare professions, including Emergency Room staff, must be alert to the possibility of injuries caused by spinal manipulative therapy (SMT). The patient's medical history should include questions about possible spinal manipulation within the last 30 days, at the very least.
Symptoms and injuries can include: headache, dizziness, vertigo, nausea, pain, strains, sprains, whiplash type injuries, Horner's syndrome, Wallenberg's syndrome, permanent or transient paralysis, blackouts, fainting, blod clots to the brain, and death.
Few of these consequences, especially deaths, are ever identified as results of previous SMT, since autopsies are rarely performed in these cases. Since strokes can occur up to a month - and even later - after manipulation of the cervical spine, a suspicion of any connection is rarely awakened.
5. When dealing with stroke cases, all MDs - be they general practitioners, specialists, pathologists, or coroners - should routinely examine the patient's (or deceased's) medical history (including interviews with relatives) for any cases of SMT within the previous 2-3 months, including number of times, since each repetition increases the risk.
If this isn't done, the real extent of SMT induced strokes and deaths will not be exposed, and it will be impossible to institute preventive measures in harmony with quality control principles.
6. Physical Therapists should encourage patients with such injuries to report them to their own doctors. (I can't be the only PT who has encountered patients with fractured spines, spinal stenosis, herniated discs, paralysis, stable fractures made unstable, severe sprains and strains, torn muscles, and unremitting headaches for years, all as a direct result of a specific chiropractic "adjustment". I have seen all of these injuries, but those who have died haven't come to me or their chiro, for obvious reasons.)
7. Whiplash patients should never receive cervical manipulation, especially in the acute phase. Hairline fractures are easily overseen on x-rays at this point in time. This may create a false sense of security, resulting in treatment which can destabilize otherwise stable fractures. Such fractures become visible after a short time, often within a few weeks *if* the x-ray is taken from precisely the right angle, which isn't necessarily one of the standard angles.
No more underreporting
The massive underreporting (nearly 100%) that is currently occurring must stop. Neurologists and Physical Therapists encounter these cases regularly, but may not be recognizing them. Awareness of the problem will help to bring far more cases to light. They should then be reported to centrally established centers in all lands.
In Canada the Canadian Stroke Consortium is attempting to uncover the real frequency of these injuries and deaths, since they are much more common than are indicated by chiropractic sources, where there is a vested interest to deny, ignore, and even cover-up, the problem.
No excuse for manipulation of the cervical spine (MCS)
There is no excuse (with rare exception) for the manipulation of the cervical spine (MCS), especially in light of several facts:
1. The majority of such manipulations are not indicated, especially when the problem is located elsewhere in the body. MCS in such cases constitutes gross malpractice and reckless endangerment.
2. The real problems in the neck, head, and upper extremities, for which treatment of the neck is properly indicated, can be treated
(a) without the use of MCS,
(b) using other methods,
(c) with longer lasting results, and
(d) with much less risk than is involved with MCS.
I hope that these precautionary guidelines will become widely disseminated, properly adapted, and then formally adopted by all medical professions which deal with the locomotor system.
For much more on this subject:
MUST SEE!: Dangers of chiropractic therapy