Safety: Cerebrovascular

The current scientific evidence indicates that all commonly used treatments for neck pain have limited evidence of effectiveness. All treatments come with fairly common but mild side effects, and some have rare but potentially serious side effects. In general, the physical treatments (including manipulation, mobilization, massage and exercise) have fairly good evidence of effectiveness and are very rarely associated with any serious complications. Pharmaceutical treatments, although commonly used, have limited evidence of effectiveness for treatment of neck pain, and infrequent but potentially serious complications.

The quality of the published literature on the relationship between chiropractic manipulation and CAD is very low. This literature demonstrates a small association between chiropractic neck manipulation and cervical artery dissection. There is good epidemiological evidence that the odds of having a stroke following a visit to a doctor of chiropractic are no greater than the odds of having a stroke following a visit to a primary care doctor. In addition, there is biomechanical evidence that cervical manipulation stretches the vertebral arteries less than routine examination procedures making it unlikely that a cervical manipulation can physically cause an arterial dissection. There is evidence that a manual approach to neck pain including manipulation is at least as effective as a conventional approach using NSAIDs and/or opiates with no greater risk of complications.

Essential Literature

SYSTEMATIC REVIEW AND META-ANALYSIS OF CHIROPRACTIC CARE AND CERVICAL ARTERY DISSECTION: NO EVIDENCE FOR CAUSATION
Church et.al 2016
Conclusion:
The quality of the published literature on the relationship between chiropractic manipulation and CAD is very low. Our analysis shows a small association between chiropractic neck manipulation and cervical artery dissection. This relationship may be explained by the high risk of bias and confounding in the available studies, and in particular by the known association of neck pain with CAD and with chiropractic manipulation. There is no convincing evidence to support a causal link between chiropractic manipulation and CAD.

CERVICAL ARTERIAL DISSECTION: AN OVERVIEW AND IMPLICATIONS FOR MANIPULATIVE THERAPY PRACTICE
Thomas LC 2015
Conclusion:
For those patients presenting with recent onset, moderate to severe unusual headache or neck pain, clinicians should perform a careful history, in particular questioning about recent exposure to head/neck trauma or neck strain. Cardiovascular factors may not be particularly useful indicators of risk of dissection. Clinicians should also be alert to reports of transient neurological dysfunction such as visual disturbance and balance deficits, arm paraesthesia and speech deficits, as these may be subtle. If clinicians suspect arterial dissection is in progress patients should be urgently referred for medical evaluation.

RISK FACTORS AND CLINICAL PRESENTATION OF CERVICAL ARTERIAL DISSECTION
Thomas et. al. 2015
Conclusion:
Recent minor mechanical trauma or strain to the head or neck appears to be associated with cervical arterial dissection. General cardiovascular risk factors, with the exception of migraine, were not important risk factors for dissection in this cohort. Preceding transient neurological symptoms appear to occur commonly and may assist in the identification of this serious pathology.

RISK OF STROKE AFTER CHIROPRACTIC SPINAL MANIPULATION IN MEDICARE B BENEFICIARIES AGED 66 TO 99 YEARS WITH NECK PAIN
Whedon et. al 2015
Conclusion:
With the massive development in the modern medical science, the company buy viagra in australia now has made Kamagra oral jelly, Kamagra soft etc that are enriched with Sildenafil citrate. Bladder purchase cheap levitra cancer is another one of the best herbal supplements to treat weak erection problem in men. Libido sildenafil tablets in india enhancer supplements increases stamina and reduces stimulation problems. Genetics, controllable lifestyle and stress plays important role viagra best for a satisfying sexual activity or I can just live without it? What are the causes for my sluggish gallbladder? Will the gallbladder surgery stop my abdominal pain for good? May I try to rescue of my gallbladder by using something else than surgery? All organs in our body have particular functions, and their works are interrelated. Among Medicare B beneficiaries aged 66 to 99 years with neck pain, incidence of vertebrobasilar stroke was extremely low. Small differences in risk between patients who saw a chiropractor and those who saw a primary care physician are probably not clinically significant.

CHIROPRACTIC CARE AND THE RISK OF VERTEBROBASILAR STROKE
Kosloff et. al. 2015
Conclusion:
We found no significant association between exposure to chiropractic care and the risk of VBA stroke. We conclude that manipulation is an unlikely cause of VBA stroke. The positive association between PCP visits and VBA stroke is most likely due to patient decisions to seek care for the symptoms (headache and neck pain) of arterial dissection. We further conclude that using chiropractic visits as a measure of exposure to manipulation may result in unreliable estimates of the strength of association with the occurrence of VBA stroke.

CERVICAL ARTERIAL DISSECTIONS AND ASSOCIATION WITH CERVICAL MANIPULATIVE THERAPY: A STATEMENT FOR HEALTHCARE PROFESSIONALS FROM THE AMERICAN HEART ASSOCIATION/AMERICAN STROKE ASSOCIATION
Biller et. al. 2014
Conclusion:
Cervical Dissection (CD) is an important cause of ischemic stroke in young and middle-aged patients. CD is most prevalent in the upper cervical spine and can involve the internal carotid artery or vertebral artery. Although current biomechanical evidence is insufficient to establish the claim that CMT causes CD, clinical reports suggest that mechanical forces play a role in a considerable number of CDs and most population controlled studies have found an association between CMT and VAD stroke in young patients. Although the incidence of CMT-associated CD in patients who have previously received CMT is not well established, and probably low, practitioners should strongly consider the possibility of CD as a presenting symptom, and patients should be informed of the statistical association between CD and CMT prior to undergoing manipulation of the cervical spine.

VERTEBRAL ARTERY STRAINS DURING HIGH-SPEED, LOW AMPLITUDE CERVICAL SPINAL MANIPULATION
Herzog et. al. 2012
Conclusion:
Spinal manipulative therapy (SMT) has been recognized as an effective treatment modality for many back, neck and musculoskeletal problems. One of the major issues of the use of SMT is its safety, especially with regards to neck manipulation and the risk of stroke. The vast majority of these accidents involve the vertebro-basilar system, specifically the vertebral artery (VA) between C2/C1. However, the mechanics of this region of the VA during SMT are unexplored. Here, we present first ever data on the mechanics of this region during cervical SMT performed by clinicians. VA strains obtained during SMT are significantly smaller than those obtained during diagnostic and range of motion testing, and are much smaller than failure strains. We conclude from this work that cervical SMT performed by trained clinicians does not appear to place undue strain on VA, and thus does not seem to be a factor in vertebro-basilar injuries.

A POPULATION-BASED CASE-SERIES OF ONTARIO PATIENTS WHO DEVELOP A VERTEBROBASILAR ARTERY STROKE AFTER SEEING A CHIROPRACTOR
Choi et. al. 2011
Conclusion:
Our population-based analysis suggests that VBA stroke patients who consulted a chiropractor the year before their stroke are older than previously documented in clinical case series. We did not find that women were more commonly affected than men. Moreover, we found that most patients had at least one cardio- or cerebrovascular comorbidity. Our analysis suggests that relying on case series or surveys of health care professionals may provide a biased view of who develops a VBA stroke.

RISK OF VERTEBROBASILAR STROKE AND CHIROPRACTIC CARE:RESULTS OF A POPULATION-BASED CASE-CONTROL AND CASE-CROSSOVER STUDY
Cassidy et. al. 2008
Conclusion:
VBA stroke is a very rare event in the population. The increased risks of VBA stroke associated with chiropractic and PCP visits is likely due to patients with headache and neck pain from VBA dissection seeking care before their stroke. We found no evidence of excess risk of VBA stroke associated chiropractic care compared to primary care.