stroke caused by manipulation?

[tlh908]

I saw this news storys today, although I wish I had more information:

What about OMM that DO's perform? Could there be similiar risks? I am a premed student who wants to be a DO and would like others take on the above article.

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[Medic171]

What above article?

 

[pags]

Yes, this absolutely can happen, although not frequently. If you start tugging on a vertebral artery with a ripe plaque about to break off, you definitely can cause a CNS infarct. Most of the high velocity techniques practiced by chiroparctors and osteopaths are very similar.

 

[UHS2002]

It is not just a matter of causing a stroke by dislodging plaque. There have been very well documented cases of carotid artery dissections as a result of cervical manipulation done by chiropractors. I have not seen any numbers for the same when DOs are involved, but I bet it happens as cervical HVLA techniques are similar, although I heard that some chiropractic techniques use more overextension than the standard for osteopathic cervical HVLA.

One of my attendings told me that he saw 2 such cases during his IM residency and they were both post-chiropractic manipulation.

I think carotid artery dissections are underdocumented for a series of reasons: they can occur up to a week post manipulation, which makes it hard to connect cause/effect. Some can actually be pratically silent, as they are usually not complete disections.

Also, a word to the wise: although everyone seems to have a healthy respect regarding HVLA in the older population, particular cervical, due to the fear of dislodging plaque or dealing with individuals with often severe degenerative changes, carotid artery dissections have been documented mostly on a younger population 20s-30s age range, which most DC/DO students or practitioners who not think twice about manipulating.

Additionally, there have been some studies which have shown that excessive repetitive cervical manip can "loosen things a bit too much" so to speak, and cause some cervical instability.

I would be interested to hear Freeeeedom (whatever many "e"s are there) on this matter, since he has lots of experience with manipulative treatments.

 

[drusso]

Stroke (vertebral artery dissection) following manipulation to the cervical spine is a rare but catastrophic complication of high velocity manipulation. Just like any intervention in medicine, physicians must weigh the risks and benefits, be skilled and knowledgable in their field, and most importantly, use prudent patient selection. Some have speculated that DO's have a lower complication rate compared to chiropractors because DO's are trained in a broader range of manipulative modalities while chiropractors tend to emphasive high velocity modalities.

--------------------------------------

: J Am Osteopath Assoc 1996 Feb;96(2):113-5 Related Articles, Books, LinkOut

The safety of manipulative treatment: review of the literature from 1925 to 1993.

Vick DA, McKay C, Zengerle CR.

Department of Osteopathic Manipulative Medicine, University of North Texas Health Science Center at Fort Worth-Texas College of Osteopathic Medicine 76107-2699, USA.

Many osteopathic medical students and physicians have an inherent fear of injuring patients when they perform osteopathic manipulative treatment (OMT). Based on the estimated several hundred million treatments performed each year in the United States as well as a review of the literature over the past six decades, only 185 reports of injury were found. However, besides good training in these techniques, the key to the safety of OMT is the taking of a thorough patient history and performing a thorough physical examination before the application of any manipulative procedure.

Publication Types:
Multicenter Study
Review
Review Literature

 

[Neurogirl]

UHS2002,

Don't you mean VERTEBRAL ARTERY DISSECTION (VAD)? You'd really have to twist someone's head off to injure the carotids! I believe the incidence of VAD is in the neighborhood of 1/100,000 patients (not individual manipulations). Even though it's fairly rare, it's something I've always feared...I won't do cervical HVLA. For that region I'll only do muscle energy or counterstrain.

 

[drcrafey]

Neurogirl is right. The Carotids would be hard to damage. Being a Chiropractor, I would guess the incidence for this to happen is greater because there is a greater number of HVLA manips done, thus increasing the odds it will happen to a Chiropractor. While the main Adjusting technique in my school, Logan College of Chiropractic, was HVLA, a majority of elective techniques were alternative low velocity muscle energy techniques.

Just my two cents worth

 

[tlh908]

Thanks for your input so far. I am not sure what happened to the original story, but it was there when I posted. I did see soon afterwards.....

 

[bry]

Good conversation. I may be a little late in adding this post, but here's my two cents worth anyway: (by the way, I'm a chiropractic student at Northwestern - and I love MDs/DOs so don't jump all over me thinking I'm anti-medicine)

First of all, as soon-to-be doctors (regardless of the field), we are all responsible for making sure that the information we provide to other people is accurate, because people are going to be making decisions based on the information we give them. I just say that because of the post by UHS2002. First off, have you actually read these studies about excessive repetitive cervical manipulation causing instability? I'm not challenging you, I'm actually just really interested. I do a lot of journal research/reading on manipulation and spine/extremity adjusting and have never seen any study like this. I'd be interested to know where it was. If it's just something you heard, careful how factual you make it in your statements. That's a hefty claim that would really cause people to shy away from a treatment that could help them relieve pain. The reason I kind of wondered about the validity of your statement is because you also say that you heard that chiropractic techniques use more overextension than standard osteopathic cervical HVLA techniques. I can't speak for any chiropractic education except the one I've received at Northwestern, but the first thing that is drilled into our heads about cervical adjusting is that you always bring the neck into partial flexion. We're taught never to let it become extended while adjusting. I just thought you should be aware of that. I dearly hope that other schools are teaching that!

I just wanted to add (to neurogirl) that I am also nervous about cervical adjusting, but quite honestly, people who would have complications from an adjustment are likely to have a stroke or VBAI while doing something else (like looking over their shoulder to back up their car). It's kind of scary to think about. I know two people who have suffered strokes while getting their hair shampooed in a salon. So maybe these people would be "lucky" to have the problem while they're in a doctor's office as opposed to driving down the freeway. I know it's never a "lucky" thing, but it's just something to think about.

Sorry for rambling guys. Just wanted you to see some other points of view.

 

[prefontaine]

ROM exams are more stressful to vertebral arteries than HVLA...as is looking over your shoulder when backing up.

IMO, properly performed manipulation is one of our safer practices.

 

[UHS2002]

•••quote:•••Originally posted by bry:
•Good conversation. I may be a little late in adding this post, but here's my two cents worth anyway: (by the way, I'm a chiropractic student at Northwestern - and I love MDs/DOs so don't jump all over me thinking I'm anti-medicine)

First of all, as soon-to-be doctors (regardless of the field), we are all responsible for making sure that the information we provide to other people is accurate, because people are going to be making decisions based on the information we give them. I just say that because of the post by UHS2002.•••••Before you are too quick to criticize, please read:

<a href="http://www.cma.ca/cmaj/vol-163/issue-1/0038.htm" target="_blank">http://www.cma.ca/cmaj/vol-163/issue-1/0038.htm</a>

 

[UHS2002]

•••quote:•••Originally posted by Neurogirl:
•UHS2002,

Don't you mean VERTEBRAL ARTERY DISSECTION (VAD)? You'd really have to twist someone's head off to injure the carotids! I believe the incidence of VAD is in the neighborhood of 1/100,000 patients (not individual manipulations). Even though it's fairly rare, it's something I've always feared...I won't do cervical HVLA. For that region I'll only do muscle energy or counterstrain.•••••Neurogirl, although I am somewhat sleep deprived of late (long hours in the hospital these days...)I meant what I said. I know that vertebral artery dissection is more common, but saying that would be stating the obvious in response to the first posts. I just wanted to point out another risk of HVLA of the cervicals. Refer to the following:

<a href="http://www.cma.ca/cmaj/vol-163/issue-1/0038.htm" target="_blank">http://www.cma.ca/cmaj/vol-163/issue-1/0038.htm</a>

Since it is more up "your alley" than mine, I think you might find it interesting, including description of etiology/presentation. Who knows, you might come across it some day.

There are a few more articles on the subject. It was sort of an interest of mine during the pre-clinical years (twisted interest, if you will, sorry for the pun).

 

[climber]

The key is not not doing the treatments, some people need those treatments. To reiterate, do an adequate patient history and then treat if you feel confident in your abilities. If we get in this mode where we won't treat people because we are afraid of the possible outcome, then we are useless. What about pushing thrombolytics? You can do a CT and be fairly confident, but there is always the risk that the patient will bleed out. So, do we stop using thrombolytics? My father-in-law, is active and alive today because of them. I can tell you that the young doc who suggested it to us was ready to pee his pants but he did what he knew could help, even with the associated risks. So don't start freaking out and digressing back to the days where DO's were not allowed to practice manipulation just because 1/100,000 people could have complications associated with the treatment. I can safely say most medical stats are not even that favorable.