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Stroke and chiropractic Taylorsville UT

At Camp4 Human Performance we highly prioritize educating our patients and the public at large about what we do, before we do it. This is a topic which is in need of much attention, especially given the lack of quality evidence that is available to the public. In order to best serve the community as physicians we need to stay as current as possible with literature. In order for us to do that we need to discuss stroke and chiropractic Taylorsville UT.

Once again, we need to begin this discussion by familiarizing you with some terminology:

The term CVA (cerebrovascular accident) is the medical term stating that there is a lack of blood (vascular) flow to the brain (cerbrum), and is known more commonly as stroke. When someone has a stroke, it simply means the the blood supply to the brain has been a compromised by either ischemia (restriction of blood flow), or hemorrhage (escape of blood from a blood vessel). Both of which result in some form of altered consciousness. VADS, as is used in the following page, stands for vertebral artery dissection and CMT will be short hand for chiropractic manipulative therapy, or manipulation Taylorsville UT.

VADS and CMT have been linked in the past with the first reported case being all the way back in 1934. The primary controversy has centered around neurologists and other medical practitioners who have perceived VADS to be a frequent complication of CMT, and chiropractors who perceive it as infrequent

Now lets talk about what causes a stroke

1- Atherosclerosis – this is a disease in which plaque buildup in your arteries can restrict oxygen rich blood from reaching your heart, organs, muscles, and other tissues. Plaque buildup comes from  fat, cholesterol, calcium, and other substances found in excess within the blood. Over time, plaque hardens and narrows your arteries restricting blood flow to the brain and this is called ischemia.

2 – Aneurysm – an aneurysm is a ballon-like bulge in an artery. The anatomy of arteries consist of thick muscular walls and are very strong and resilient to stretch. Under normal conditions your arteries are able to withstand normal blood pressure changes, even if it spikes temporarily during exercise. However, certain medical problems such as genetic conditions and trauma can damage or injure artery walls. The force of blood pushing against the weakened or injured walls can cause an aneurysm. An aneurysm can grow large and rupture or dissect causing dangerous bleeding inside the body.

3 – Arteriovenous malformation – this is a genetic variant where there is an abnormal connection of a vein with an artery causing a back flow of deoxygenated blood to where oxygenated blood flow should be. This can also cause ischemia by shunting blood away from its normal path, or cause hypoxia which is a decrease in oxygenation to your tissues.  

4 – Dissection – as mentioned above, this is when there is a tear in one or more layers of the vessel walls allowing blood to enter and split the layers producing a cavity or thrombus (clot) within the wall. Subsequently a dissection can result in stenosis (narrowing of the vessel), occlusion (closure of the vessel’s opening), aneurysmal dilation, thrombus formation, and extravascular hemorrhage (outside the blood vessel into other tissues).

Stroke and chiropractic Taylorsville UTSpontaneous cerebrovascular dissections are a significant cause of stroke, accounting for 14% to 20% of ischemic strokes in patients younger than 50 years of age and 0.63% to 2% of ischemic strokes overall.8

Spontaneous arterial dissections occur in the absence of blunt or penetrating trauma. Provoked spontaneous dissections occur following some form of precipitating trivial event which is present in 12 – 34% of patients with “spontaneous” dissections. These events are similar to everyday movements such as neck rotation, coughing, and vomiting. In these cases, dissection probably results from a combination of factors that put the vessel at risk of dissection, coupled with movement or minor trauma.

Intrinsic structural defects in the arterial wall are believed to make the vessel more vulnerable to injury during normal neck movement or minor trauma.

The most important anatomic feature of most dissections is the presence and extent of intimal wall disruption. The vessel wall disruption exposes circulating blood to intrinsic clotting factors leading to acute thrombosis (clotting) and increases the risk of intracranial obstruction. By far the greatest risk of undergoing an ischemic stroke is in the acute phase after a dissection.

So which arteries are believed to be at risk? 

We will discuss the two arteries of the head and neck which have been purported as having a association with spinal manipulative therapy. Cervical (neck) artery dissections happen at the most mobile portions of the arteries rather than at other more fixed locations.
Cervical ICA (internal carotid artery) dissections commonly occur 2 to 3 cm distal to the carotid bulb (carotid bulb is the point where the ICA and ECA split as seen in the picture) and in 17% of cases the dissection extends into the intracranial segment of the ICA.

Stroke and chiropractic Taylorsville UT

Vertebral artery (VA) dissections are usually located in the V2 (susceptible to longitudinal stretching within foramen) segment where the artery travels within the transverse foramen and the v3 segment (rotation and torsion put stress here) where it runs around the lateral mass of C1 and C2.

Classic triad of symptoms (rarely do patients have all three symptoms)

1- neck or head pain

2- drooping of the eye lid, dryness of the eyes, constricted pupil

3- Cerebral ischemia (confusion, lethargy, trouble speaking and comprehending)

The most common presenting symptom of cervical artery dissections is pain (occurs in 26% of ICA and 46% of VA dissections). Second MC symptom is headache.
   ICA headache symptoms are typically one sided with a gradual and pulsating quality. VA is less typical, which makes it much harder to diagnose. Sharp and severe headache present in 80% VA dissections.

What does the literature say about a relationship between stroke and chiropractic Taylorsville UT?

After the initial paper in 1934, case reports describing a temporal relationship  between CMT and VADs started surfacing. Some of the early studies erroneously described the practitioner delivering the therapy as a chiropractor. Some surveys of practitioners which came later surprisingly included both chiropractors and neurologists as having this relationship to stroke.

Scott Haldeman D.C. retrospectively reviewed 23 cases of VADS from a Canadian malpractice carrier and found considerable selection bias in the literature.

-1 in 48 chiropractors had been directly involved in VADS post manipulation case, and 1 in 2 neurologists had been directly involved.

– He also reviewed 67 cases looking for any factors in the history and examination that would identify an individual at risk for VADS and found that CVA post manipulation appear to be unpredictable and should be considered an inherent, idiosyncratic, and rare complication of the CMT.

There are some limitations in the literature.

None of the study designs discussed to this point have been adequate to assess risk and effectively investigate a causal relationship between CMT and VADS. There needs to be more randomized controlled trials, cohort, and case-controlled studies done to assess any relationship or prior activity engagement to create causality.

Cassidy et al. 2008 provided the most rigorous and large study performed yet on the topic. They found an increased association between visits to a chiropractor within 30 days and VADS in individuals under 45 but not over.

ico-style1Interestingly they found a similar association between visits to primary care provider physicians and VADs also in patients              under 45.

ico-style1Cassidy found that the odds of stroke occurring within 24 hours of a visit to a primary care physician was virtually the same as        stroke occurring within 24 hours after a visit to a chiropractor.

ico_infoSo let’s review what we know today from the current literature.

1- To date, there is no strong foundation for a causal relationship between CMT and VADS.

2- The most plausible explanation is that those experiencing symptoms of VADS seek chiropractic care for relief of their      neck pain and headache that results from the dissection.

3- Sometime after the visit the dissection becomes complete and the causality is created in the emergency room.

 Does this mean there is no concern in respect to getting your neck adjusted?qmark

– Not exactly, there is always the chance that CMT could produce or hasten a VADS event, but it is very small. The important thing is to be aware of the possibility and take any precautionary measures as possible to help our patients. 

– The issue for all practitioners now is one of an accurate differential diagnosis.

– Our responsibility is not to attempt to identify patients who are at risk, which would not be cost effective, of “post-manipulative stroke” but to attempt to identify the patient who is having a dissection in progress so an appropriate referral can be made.

This is where our neurological training and a careful examination comes into play so we can best serve our patients needs and make a proper diagnosis. In some cases watchful waiting is, and should be considered prior to CMT. If a VADS is suspected an emergency referral should be considered and additional imaging is mandatory.

Additional neurological deficits we watch out for in patients which could be undergoing this particular condition are as follows.

* Note that there are other causes for these symptoms and only a medical professional can properly diagnose a patient undergoing a stroke.

Double vision, dizziness, drop attacks, trouble speaking or understanding speech, difficulty swallowing, uncoordinated body movements, nausea, numbness in the hands or feet, rapid involuntary eye movements. 

So what is the prognosis of patients with VADS who undergo a stroke.

– Persistent neurological deficits are present in 58% of carotid and 42% VA dissections but overall outcome is good or excellent in 70-80% of cases.

– Mortality rates are 3-7 %

– Rate of subsequent stroke is between .3 and 3.4 % per year.

– The greatest risk to the patient is in the first month after diagnosis.

– Most healing occurs within first 3 to 6 months after injury and vertebral artery dissections are more likely to resolve  than carotid artery ones.

– Recurrent (happening more than once) dissections are uncommon.

What is our duty now in respect to stroke and chiropractic Taylorsville UT?

Public eduction !!

– it is a benefit to the public to provide information regarding a potentially serious disorder that can initially be mistaken for a common benign condition. Such information is not readily available from other sources, even leading stroke societies. 

– The chiropractic profession has traditionally taken a defensive approach to the issue. Understandable to some degree, however the current understanding of the issue allows the profession to move away from the defensiveness toward a positive, proactive, patient oriented approach. A public campaign would allow the profession to do this.

– Unfortunately our profession does not have a solid history of involvement in public health.

It is our goal to properly educate our patients about these types of concerns and to be respectful to the patients needs while knowing when to co-manage care

So, let’s do a mini Camp4 health campaign

– VADS is a rare but potentially serious disorder

– Some initial symptoms can mimic more common and relatively benign neck and headache problems.

Diagnosis can be difficult and because of this some individuals and health care providers are not aware that they are experiencing VADS.

– There can be subtle signs and symptoms that may alert the patient and practitioner of something more serious is going on.

For more information please ask a question here, or come in to get a proper evaluation to see how we can better serve your needs with manipulation Taylorsville UT. 

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Page citations

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Thornton FV: Malpractice: death resulting from chiropractic treatment of headache (medicolegal abstract). JAMA 1934, 103:1260.

Lee KP, Carlini WG, McCormick GF, Albers GW: Neurologic complications following chiropractic manipulation: a survey of California neurologists. Neurology 1995, 45(6):1213-5.

Norris JW, Beletsky V, Nadareishvili ZG: Sudden neck movement and cervical artery dissection. CMAJ 2000, 163(1):38-40.

Dabbs V, Lauretti WJ: A risk assessment of cervical manipulation vs NSAIDs for the treatment of neck pain. J Manipulative Physiol Ther 1995, 18(8):530-6.

Haneline MT, Lewkovich G: Ongoing stroke dialogue: A response to the Smith, et al study on the association of spinal manipulation and vertebral artery dissection. JACA 2003, 40(10):24-7.

Haneline MT, Lewkovich G: Critique of the Canadian Stroke Consortium’s spontaneous vs. traumatic arterial dissection. JACA 2004, 41(5):18-22.

Murphy DR: Current understanding of the relationship between cervical manipulation and stroke: what does it mean for the chiropractic profession? Chiropractic & Osteopathy 2010, 18:22.

Fusco MR, Harrigan MR. Cerebrovascular dissections–a review part I: Spontaneous dissections. Neurosurgery. 2011 Jan;68(1):242-57.

Pelkonen O, Tikkakoski T, Leinonen S, Pyhtinen J, Lepojarvi M, Sotaniemi K. Extracranial internal carotid and vertebral artery dissections: angiographic spectrum, course and prognosis. Neuroradiology. 2003;45(2):71-77.

Silbert PL, Mokri B, Schievink WI. Headache and neck pain in spontaneous internal carotid and vertebral artery dissections. Neurology. 1995;45(8): 1517-1522.

Redekop GJ. Extracranial carotid and vertebral artery dissection: a review. Can J Neurol Sci. 2008;35:146-152.

Saeed AB, Shuaib A, Al-Sulaiti G, Emery D. Vertebral artery dissection: warning symptoms, clinical features and prognosis in 26 patients. Can J Neurol Sci. 2000;27(4):292-296.

Haldeman S, Carey P, Townsend M, Papadopoulos C: Clinical perceptions of the risk of vertebral artery dissection after cervical manipulation: the effect of

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