dr. robert fulford, DO

[facetguy]

Perhaps he's referring to the very rare basilar strokes that follow a high cervical manipulation.

So are you ever going to pursue a MD/DO degree, or do you just really enjoy taking over any chiropractic post on this site? I tried to search your history, and the only real theme is that you like to defend DC's with anyone that has an issue with the field.

Very rare being the key descriptor. I'm just trying to remind surag and others not to lose sight of just how rare these events are, as well as to bear in mind that the understanding of these events is changing from one of direct causation to indirect.

Fahimaz, I sent you a PM earlier in response to your earlier question. Did you get it?

---

Members don't see this ad.

 

[fahimaz7]

Very rare being the key descriptor. I'm just trying to remind surag and others not to lose sight of just how rare these events are, as well as to bear in mind that the understanding of these events is changing from one of direct causation to indirect.

Fahimaz, I sent you a PM earlier in response to your earlier question. Did you get it?

I just did. Mailbox was full. Why are you hesitant to answer that inquiry in the public forum?

 

[JaggerPlate]

Very rare being the key descriptor. I'm just trying to remind surag and others not to lose sight of just how rare these events are, as well as to bear in mind that the understanding of these events is changing from one of direct causation to indirect.

Fahimaz, I sent you a PM earlier in response to your earlier question. Did you get it?

Do you know how frequently these seizures from cervical manipulation occur and what the circumstances are? Is it the practitioners fault, or is there some sort of underlying condition that makes people more susceptible?

 

[facetguy]

First off all, you bring in the uncertainity in my comment when it does not exist. The Wiki article clearly states that it is referring to chiro subluxation. It seems you're ubfuscating my argument to create a sheen of doubt. Unnecesseary my friend. Just unnecessary. The article even clearly says that its referencing the second not "vertebral subluxation".

So lets only focus on chiro subluxation. You get the chiro sense it is continually evolving? How about the general consensus there is absolutely no evidence of chiro subs value in any form? How about the inherent unscientific aspect of it? Going back to a previous poster-just because it says there is no proof for its validity does not mean we can continue with it. You cannot prove to me aliens have never abducted you...should I go on saying that you were because of that?

Finally, chiro subluxation is a joke and there is no "evolving" science for it. You imply, disingenuously, that somehow in the future chiro subluxation may be proven to be scientifically valid even though the current science strongly suggests otherwise.

Did you know currently there is no evidence that Cold Fusion does NOT work? Did you also know if we do discover how to harness Cold Fusion effectively all of our energy ills will be all but eliminated? Does this justify continued funding for cold fusion? This is a very dangerous ethical and logical fallacy that, if used for all other controversies in science, will only lead to waste in time, people, and funding. Please stop.

That's a lot of huffing and puffing over nothing. Vertebral sublux, chiro sublux, same thing.

 

[facetguy]

Do you know how frequently these seizures from cervical manipulation occur and what the circumstances are? Is it the practitioners fault, or is there some sort of underlying condition that makes people more susceptible?

Stroke is the key issue. How frequently they occur has proven difficult to study. You'll see all kinds of ranges in the literature. The articles suggesting the highest frequency tend to be small, case-report type studies, often from neurologists. An interesting article a few years ago addressed this, and pointed out that each stroke is likely to been seen by several neurologists, thus helping form the impression on the part of neurologists that these things happen more frequently (one of the authors is a neurologist; if interested, I'll try to dig it up). The larger studies put the risk at at least 1:1 million. But when you get that rare, exact numbers are elusive. A recent study looking at 109 million person-years over 9 years was still not sensitive enough to pick up the risk of stroke from manipulation; that's rare!

Susceptibility is also difficult to determine. Studies tell us that there are no reliable exam/screening procedures. There are various 'vertebrobasilar artery insufficiency' positioning manuevers out there, along with auscultating for bruits, but unfortunately none are reliable. Should you still do them? Yes, at least for med-legal reasons.

As far as practitioner fault, it's hard to say. It is thought that combining rotation with extension puts the vessel at greatest tension, but not all biomechanical studies agree. So, I guess you could say that cranking someone way into rotation/extension increases risk, but it's not completely clear. Using HVLA on a 90 year old might also be seen as practitioner 'fault' in terms of patient selection. But strokes from manipulation are more associated with younger paitents.

Recently, the thought on causality has begun to shift. It had always been assumed that there was direct causality: manipulation is done, damages artery, leading to dissection/stroke. Now we're seeing a shift in thought to a more indirect association: patient is experiencing a dissection, which creates symptoms, which causes patient to seek care for neck pain or headache. Interestingly, according to a recent study in Spine, it didn't matter whether the patient decided to see a DC or their MD; the incidence of stroke was the same, suggesting something was already happening before they even presented for care.

 

[fahimaz7]

So what you're basically trying to say there is that the 18 y/o with a basilar stroke actually had a dissection before they visited the DC for a C1/2 manipulation? Really? I just don't believe that you see a walking, talking, mostly health patient, with a week long history of neck stiffness, that has actually had a dissection for a week.

Neurologists see the patient that presets to the ER with visual field changes, balance changes, or pontine-nuclie infarcts, after they were taken to the ER by their parents. These patients are not strolling into a DC looking for a manipulation, they are trying to simply walk or see at all.

 

[facetguy]

So what you're basically trying to say there is that the 18 y/o with a basilar stroke actually had a dissection before they visited the DC for a C1/2 manipulation? Really? I just don't believe that you see a walking, talking, mostly health patient, with a week long history of neck stiffness, that has actually had a dissection for a week.

Neurologists see the patient that presets to the ER with visual field changes, balance changes, or pontine-nuclie infarcts, after they were taken to the ER by their parents. These patients are not strolling into a DC looking for a manipulation, they are trying to simply walk or see at all.

A few quick things. First, of course there are sudden onset strokes that occur, as you describe above. Second, no doubt at least some of these sudden strokes have occurred post-manipulation (with various 'manipulators', not just chiros), but again they are super rare and difficult to quantify. But third, the most common initial symptoms for vertebral artery dissection are neck pain and headache. Others such as dizziness, nausea, etc may be there are well, but not always. But the evolution isn't always sudden and may take a period of time before reaching the stage you describe above. This evolution may then be hastened by manipulation, but it's unclear. That's the current thinking, and it's not just a chiro thing.

 

[NYEMMED]

Chiros are not necessary in the US medical system at all. DOs are trained in everything a chiro can do and much more. They are also licensed medical physicians and go to medical school. We only need to use DOs, Chiros are not needed

 

[fahimaz7]

A few quick things. First, of course there are sudden onset strokes that occur, as you describe above. Second, no doubt at least some of these sudden strokes have occurred post-manipulation (with various 'manipulators', not just chiros), but again they are super rare and difficult to quantify. But third, the most common initial symptoms for vertebral artery dissection are neck pain and headache. Others such as dizziness, nausea, etc may be there are well, but not always. But the evolution isn't always sudden and may take a period of time before reaching the stage you describe above. This evolution may then be hastened by manipulation, but it's unclear. That's the current thinking, and it's not just a chiro thing.

Here's the difference though. If this guy presented to the ER with the same complaint (neck pain, terrible headache, changes in vision) he would go right to imaging, well before anyone tried to do a manipulation on this patient. How often do you really think that MD's are manipulating patients (high cervical) with these symptoms in a young adult? Transient diplopia? And he still continued?

Either way, here's a good example

http://www.ajnr.org/cgi/reprint/16/4/952.pdf

"A 26-year-old woman had had neck stiffness for ap- proximately 1 month. During this time she had had a number of chiropractic neck manipulations with no im- provement. On one occasion she had experienced a tran- sient episode of diplopia shortly after the manipulation, but this rapidly resolved.

On the day of presentation she had received an injec- tion of lidocaine and betamethosone into the right side of her neck at the level of the third cervical vertebra. Her neck was then forcibly rotated to both right and left sides. During this maneuver she had a rapid onset of symptoms includ- ing diplopia, tinnitus, weakness of the left side of her face, and paresthesia of both upper and lower limbs, particularly on the right. On admission, neurologic examination re- vealed some cranial nerve signs including absence of eye abduction bilaterally, nystagmus, and left facial weakness in addition to long-tract signs with weakness of all four limbs, right-sided clonus, and a left extensor plantar response."

Here's some of the sources for that paper if you're into that kind of thing.

2. Sherman DG, Hart RG, Easton JD. Abrupt change in head position and cerebral infarction. Stroke 1981;12:2–6
3. Schellhas KP, Latchaw RE, Wendling LR, Gold LH. Vertebro-basi- lar injuries following cervical manipulation. JAMA 1980;244: 1450 –1453
4. Pratt-Thomas HR, Berger KE. Cerebellar and spinal injuries after chiropractic manipulation. JAMA 1947;133:600 – 603

 

[vanbamm]

I don't have a enough time to create a formal reply at the moment- but I feel I must interject to set some people straight on the current ideas of the subluxation and stroke within chiropractic colleges- as I am a 3rd year right now and in the middle of the transitions that are occuring-

1. Subluxation- A term that is ill defined in scientific terms- and so the ACA is going to be dropping the use of this term in describing the ailments that chiropractors fix- this is huge- but serves the profession well in a number of ways despite some moans and groans of old school D.C.'s-

a. insurance companies (such as those in NY) are hard up to reimburse for the subluxation because it is so vague of a term. In an effort to create a more scientific evidence-based approach, the subluxation is being dropped this coming year.

b. respect from other medical professionals- namely the MD.DO, who DC's come into the most contact with, and find the description null and void...on that front, the subluxation is a universal term but without universal definition- chiropractors have been inadequate in describing it-it is simple: a partial loss of contact between articulating surfaces, whereas full loss of contact is a dislocation.

2. Stroke; read http://www.chiroandosteo.com/content/18/1/22
It is pounded into the chiropractic students at our school from day one: signs of stroke: Ataxia, Nausea, Nystagmus, Numbness, Dizziness, Dysarthria, Dysphagia, Drop-Attack, Diplopia...as a baseline of symptoms to look for....

The cervical manipulation should not be done without a very thorough history and only after vascular integrity remains to be seen to be compromised and recognition of the signs of stroke, either current, or in the past....Deklines and Hallpikes are not the best fit, but are tell tale, as well as some other basic maneuvers such as Barre-Lieu, Underburg's, Hautant's, Vertebrobasilar Functional Manuever, Compression Test's with rotation and or flextion (which will stress the vertebral and carotid on the contralateral side)....

In short it comes down to recognition of the signs and symptoms and making the correct clinical decision.

 

[fahimaz7]

I don't have a enough time to create a formal reply at the moment- but I feel I must interject to set some people straight on the current ideas of the subluxation and stroke within chiropractic colleges- as I am a 3rd year right now and in the middle of the transitions that are occuring-

1. Subluxation- A term that is ill defined in scientific terms- and so the ACA is going to be dropping the use of this term in describing the ailments that chiropractors fix- this is huge- but serves the profession well in a number of ways despite some moans and groans of old school D.C.'s-

a. insurance companies (such as those in NY) are hard up to reimburse for the subluxation because it is so vague of a term. In an effort to create a more scientific evidence-based approach, the subluxation is being dropped this coming year.

b. respect from other medical professionals- namely the MD.DO, who DC's come into the most contact with, and find the description null and void...on that front, the subluxation is a universal term but without universal definition- chiropractors have been inadequate in describing it-it is simple: a partial loss of contact between articulating surfaces, whereas full loss of contact is a dislocation.

2. Stroke; read http://www.chiroandosteo.com/content/18/1/22
It is pounded into the chiropractic students at our school from day one: signs of stroke: Ataxia, Nausea, Nystagmus, Numbness, Dizziness, Dysarthria, Dysphagia, Drop-Attack, Diplopia...as a baseline of symptoms to look for....

The cervical manipulation should not be done without a very thorough history and only after vascular integrity remains to be seen to be compromised and recognition of the signs of stroke, either current, or in the past....Deklines and Hallpikes are not the best fit, but are tell tale, as well as some other basic maneuvers such as Barre-Lieu, Underburg's, Hautant's, Vertebrobasilar Functional Manuever, Compression Test's with rotation and or flextion (which will stress the vertebral and carotid on the contralateral side)....

In short it comes down to recognition of the signs and symptoms and making the correct clinical decision.

Now lets see if you guys stick to what you're being taught as a 3rd year DC student.

 

[facetguy]

Jaggs, the paper Vanbamm cited ( http://www.chiroandosteo.com/content/18/1/22 ) is a nice summary and will bring you up to current understanding better than my previous answer to your question.

Fahimaz, a case study like the one you cited demonstrates a couple things. One, if a patient of mine ever experienced transient diplopia after cervical manipulation, she would never, ever be manipulated with HVLA again. Two, it shows that neck movements other than HVLA can create dissection/stroke-related complications. Along that same line, there are reports in the literature of strokes caused by sitting at a hairdressors sink, star-gazing, turning the head while driving, etc. These things can happen spontaneously. (There's a study by Terrett that went back and looked at all the cases in the literature that had been attributed specifically to chiropractic manipulation and found a good number of them had nothing to do with chiropractors at all; I'll dig it up as time permits). Third, and most important, is the need to identify these people before applying HVLA. The article cited above mentions this. Unfortunately, most if not all of the provocative maneuvers out there are not reliable across the board.

When I get some time, I'll try to pull up some of what I consider to be good articles on this topic; busy w/ patients today.

 

[facetguy]

Chiros are not necessary in the US medical system at all. DOs are trained in everything a chiro can do and much more. They are also licensed medical physicians and go to medical school. We only need to use DOs, Chiros are not needed

Millions of happy chiropractic patients disagree with you.

 

[fahimaz7]

Fahimaz, a case study like the one you cited demonstrates a couple things. One, if a patient of mine ever experienced transient diplopia after cervical manipulation, she would never, ever be manipulated with HVLA again. Two, it shows that neck movements other than HVLA can create dissection/stroke-related complications. Along that same line, there are reports in the literature of strokes caused by sitting at a hairdressors sink, star-gazing, turning the head while driving, etc. These things can happen spontaneously. (There's a study by Terrett that went back and looked at all the cases in the literature that had been attributed specifically to chiropractic manipulation and found a good number of them had nothing to do with chiropractors at all; I'll dig it up as time permits). Third, and most important, is the need to identify these people before applying HVLA. The article cited above mentions this. Unfortunately, most if not all of the provocative maneuvers out there are not reliable across the board.

So you are comparing the repetitive manipulations with a patient who demonstrates signs and symptoms of a vertebral artery dissection, to star-gazing, driving a care, and hairdresser appointments? The difference here is that your intervention is what caused the ultimate stroke, and not her ADL's.

This chiropractor is a good example of practitioners NOT doing what you are talking about. 1 month of manipulations without any relief, several of which precipitated TIA type symptoms, but yet he still continued to do the same crap? Why can't you just admit that there are some quack chiropractors that have very questionable practices, and fail to abide by the standards that are set forth by your own governing associations? These are peoples lives that are being ruined by some of these manipulations, when there were clear, red-flag symptoms to support immediate medical intervention (MD/DO). I bet his over-exposed x-rays really did a good job of protecting the patient prior to the interventions.

 

[vanbamm]

ADL can trigger the TIA symptoms before presenting to the chiropractor, who would be responsible for recognizing the symptoms and coorelating them with the history of the patient (taking into consideration ADL's, age, gender, current conditions, medication, family history) so as to rule out the possibility that cervical manipulation may further enhance the TIA...cervical manipulation is not routine and employed carefully and skillfully- even more so now bc of the evidence and documentation required by insurance companies to support why it was being done. As far as ruining lives- that is not consistent and can be said for anything; medications, surgery

 

[JHInt]

Chiros are not necessary in the US medical system at all. DOs are trained in everything a chiro can do and much more. They are also licensed medical physicians and go to medical school. We only need to use DOs, Chiros are not needed

I agree 100% chiros are not necessary nor needed as long as their are DOs. DOs are actual doctors who know all of the chiro techniques and a whole lot more. I always refer my patients to PM&R DOs and family practice DOs.