Newsletter 4-6 Chiropractic Equity Offices Phone 321-868-5690
The following article is the address given by Dr Adrian Upton to the Hamilton Medical Society. I think it is
timely and represents a rational position at this time of irrational attacks on Chiropractic. Read and enjoy.
Thanks to Dr. Roger Mayall and Dr. Dan Stevenson for seeing that this became available.
CHIROPRACTIC:- A PHYSICIAN'S PERSPECTIVE - A CHIROPRACTOR'S PERSPECTIVE
Dr. Adrian R.M. Upton, M.A., M.B., B.Chir., FRCP(C), FRCP(E)
February 6, 2002
~INTRODUCTION~
Physicians and chiropractors have different views of the mechanism of therapeutic benefit of chiropractic
manipulation. Putting aside the views of some physicians and neurologists who believe that there are no
benefits from chiropractic treatments, there is some scientific support for the view that relief of muscle
spasm in paraspinal muscles and freeing up of the facet joints can relieve acute back or neck pain. When
there is injury to a facet, the surrounding muscles usually go into spasm to protect the injured area in the
same way that abdominal muscles are in spasm over an infected appendix. Nerve branches that supply
the facet joints (e.g. -the recurrent branch of Luschka) can trigger somatic or sclerotomal pain which can
be felt in the local area and in the distribution of the anterior primary divisions of the nerve roots at the
same and nearby levels or even down the limb or up into the head. Stretching of the muscles may allow
relief of muscle spasm und unlocking of the facet. Physicians may inject local anaesthetic into the
affected areas with results that overlap with those of manipulation. Many who have experienced almost
immediate relief of severe back or neck pain after manipulation will have no problem accepting the
potential benefits of manipulation.
HEALING ART~
Another form of healing involves laying on of hands and personal contact with the patient. Many
chiropractors seem to be adept at both measures, whereas some physicians choose to avoid much
contact with the patient by relying on the results of "objective" tests and laboratory results. Hence, there
may be a better bond between the patient and a chiropractor in comparison with treating physicians or
surgeons. Very short clinic visits and overbooked clinics may provide "efficiency" and better financial
results at the expense of the patient. Some physicians seem to believe that talking to the patient and
clinical skills are a thing of the past when we have statistical studies, imaging techniques such as MRI
and CT scans, echos, EKG, EEG, bone scans and lab tests to provide a "scientific" basis for medicine.
Personal contact, intelligent use of the placebo effect and a good bond between the patient and treating
professional seem to be better understood by many chiropractors. Patients often discuss their
chiropractor using first name terms, but this is rare in discussing a physician.
ATTACKS ON CHIROPRACTORS BY THE MEDICAL PROFESSION
A particular attack on the chiropractic profession has involved a body of physicians and neurologists who
have emphasized the potential dangers of manipulation, particularly in association with manipulation of
the neck. Since almost every medical and surgical procedure is associated with some risk to the patients,
and since the risks of chiropractic treatments must be very low when the number of procedures is
considered, it is unreasonable to criticise chiropractors for potential adverse effects of manipulation
unless it can be shown that chiropractic treatments are of no proven value. The chiropractic profession
has been criticised for the lack of ongoing scientific studies (double blind cross over studies)
demonstrating efficacy of manipulation, but this does not demonstrate that manipulation is of no value.
The arguments against chiropractic manipulation of the neck are:
a) They are unnecessary.
b) They are of no proven benefit.
c) They are dangerous.
d) They can produce damage to the vertebral arteries in the portion outside the skull (the extracranial
area).
c) Damage to the vertebral arteries can cause tearing of the inner lining of the vertebral arteries
(dissection).
f) Dissection of the vertebral arteries can cause blood clots inside the artery and in the artery wall.
Reduction of the inner tube of the artery can then lead to further clots. Furthermore, the blood clots can
spread up the vessel to the brainstem blood supply and blood heparin or coumadin) after the onset of
symptoms.
.CAUSES OF VERTEBRAL ARTERY INJURY
The main problem with these arguments is that vertebral artery (and carotid artery) damage or thrombosis
can occur:
a) Spontaneously -without apparent cause.
b) In patients with blood clotting problems: -Polycythemia. -Arteritis. -Deficiency of antithrombin 3, protein
C and protein S.
c) In association with hypertension, smoking, high cholesterol, use of the birth control pill and in
association with arterial disorders including anomalies of the vertebral arteries.
d) In patients with heart problems such as recent myocardial infarction, arrhythmia, patent foramen ovale,
valve disease, cardiomyopathy and infection.
e) Any trauma to the vertebral or carotid arteries in pregnancy. (Ref. 1.11).
f) There are numerous anecdotal reports in the literature of patients who have had vertebral (or carotid)
artery blood clots or dissection from: -Roller coasters. -Lying at an angle in bed. -Turning the head in
tennis matches or other sports. -Coughing. -Playing golf or practising golf shots. -Most sports (baseball,
football, squash, tennis, basketball, judo). -Trivial trauma. -Pressure of the neck from collars or straps. Riding horses. -Blows to the neck or head. -Kick boxing. -Motor vehicle accidents. -In-line skating. Atherosclerosis. -Blood disorders. -Blood vessel wall damage. -Infection. -Chiropractic manipulation. (Ref.
lZ-30C)
Hence, chiropractic manipulation is only one of many potential causes of vertebral artery injury or
dissection. However, some physicians have claimed that vertebral artery damage is mostly due to
chiropractic treatment even up to years before. If the patients were questioned about the rest of the list of
potential causes it is probable that many would report other potential causes of traumatic damage to the
vertebral or carotid arteries. Unfortunately, some physicians have adopted a belief system that is not
consistent with current scientific standards. This does not help relations between "medicine" and
"chiropractic" professions and does not serve the interests of patients or the public.
EVIDENCE
There have been attempts to find scientific evidence for the hypothesis that chiropractic manipulation is
the major cause of vertebral artery dissection or damage. In a population based study in Toronto from
1993~ 1998, 582 cases of stroke were analysed and showed that stroke patients were 5 times more likely
than controls to have visited a chiropractor within a week of the stroke, but there were potential sources of
bias. All the other potential sources of stroke were not sought. (31) Epidemiological studies have not
demonstrated a clear association, but there is little dispute that chiropractic manipulation is one potential
cause of vertebral artery dissection.
Collecting every patient who may have had vertebral artery problems and then seeking evidence that they
have had recent or remote chiropractic manipulation is not a satisfactory method of trying to answer
questions about the potential risks of neck manipulation which is such a commonly performed procedure.
Such studies involve numerous selection and reporting biases. Other potential causes may not receive
sufficient attention. Unfortunately, most of the evidence is based on anecdotal, case report or small case
series papers.
At one time I had thought that pathology reports in patients who die after vertebral dissection or
thrombosis were an objective and reliable measure of the cause of death. I have since discovered
examples where there are many and conflicting reports on the same pathological specimens. Hence,
clinicopathological correlations, the very cornerstone of the scientific basis of medicine, may not be the
objective benchmark that they are supposed to be. Some of the interpretations appeared to be affected
by preconceived notions. This makes it even more difficult to quantify any risks of chiropractic
manipulation. Fortunately, death is an unusual outcome after vertebral artery injuries.
SYMPTOMS OF VERTEBRAL ARTERY PROBLEMS
Symptoms of vertebral artery damage may be absent or may involve a range from headache and
dizziness to paralysis, double vision and in fact asymptomatic vertebral artery injury occurs in up to 19%
of people who have suffered trauma to the lower cervical spine. (32). Others may have tinnitus (ringing in
the ears)(33). Patients may have headache, neck pain" focal same sided cerebral ischemic signs and a
Horner's syndrome (small pupil, drooped eyelid)(34). There may be a lateral medullary (brainstem)
syndrome. (35) Unilateral headache around the eye on the same side seems to be common.(36.) Since
headache and neck pain may be the main symptoms(37) the patient may be receiving neck manipulation
for a pre-existing dissection or vertebral injury.
Eye signs may be (38)
- 45% double vision. -14% blurred vision. -8% transient visual dimming. -4% oscillopsia (jumping of the
eyes). -4% photophobia. -2% upside down vision. -2% positional transient visual obscuration. -2%
unilateral dry eye.
The other ophthalmic signs were:
-37% nystagmus. -33% ocular misaligment. -27% Horner's syndrome. -22% decreased sensation of the
cornea. -16% ptosis. -10% visual field detect. -6% abnormal eye movements (pursuits and saccades). 4% ocular bobbing.
-4% internuclear ophthalmoplegia (damage to the medial longitudinal fasciculus between the sixth and
third nerve nuclei). -4% anisocoria (unequal pupils). -2% pinpoint pupils.
This series was based on 51 vertebral artery dissections from 1976 to 1992 at the Mayo Clinic. However,
there have been anecdotal reports of headache and pulsatile tinnitus alone.(39) The carotid artery may
also be involved and may be bilatera1. (4O) Unfortunately, no controlled study has ever demonstrated
benefit from the use of heparin or coumadin once the dissection of the vertebral or carotid arteries has
begun (e.g. -stroke or evolution). Thc definitive investigations have been MRA (MRl angiography),
arteriography and Doppler Studies. (40,41.42)
DISC LESIONS RESULTING FROM CHIROPRACTIC MANIPULATION
There is no scientific evidence that chiropractic manipulation causes disc lesions. Unfornately, MRI scans
on 98 healthy, normal people has demonstrated disc bulging or protrusion in 64% of the subjects, and the
results were similar in men and woman. (43) Therefore, it can be very difficult to demonstrate that a disc
lesion arose as a result of trauma of any kind unless there was a pre-accident or pre-treatment MRI. The
forces required to damage a disc are considerable and it is improbable that most forms of manipulation
would cause such injuries to the lower back or the neck.
LEGAL ASPECTS
As physicians, we are fortunate that we are not sued over every negative effect or complication of our
therapies particularly if:
a) There is a signed consent process which is approved by ethical and scientific committees.
b) If the risks of the procedures are clearly explained to the patient and there is good reason to believe
that the patient understands the risk.
c) There are no significant language impairments which affect comprehension of the risks by the patient.
d) If methods of explanation include easily understood documents and/or videotape,
c) If reasonable measures have been taken to minimise any risk factors (e,g. - exclusion of hypertension,
previous neck injury, clotting factors. arterial disease,
migraine, smoking etc.).
In the past there were successful legal cases over:
a) Trauma and MS. Subsequent studies failed to demonstrate that trauma affects the course of MS.
b) Immunisation and brain damage: Subsequent studies failed to demonstrate a statistically significant
risk.
c) Parkinson's being caused by motor vehicle accidents.
The use of anecdotal evidence in any particular case may seem to be valid if there is a close temporal
relationship between an event and the clinical problem. However, this was the very basis of the examples
I cited in MS. Parkinson's disease and immunization cases. In the case of chiropractic manipulation, there
are potential risks that chiropractic manipulation could cause vertebral artery damage. However, it would
be difficult to eliminate coincidence as a potential explanation for the clinical problems in individual cases
unless all other potential factors are excluded. The patient may not remember other trivial trauma.
Furthermore, the patients usually have symptoms (e.g. -headache, neck pain) before any manipulation.
A major problem is that children and young adults can have vertebral artery dissections without any
known risk factors so that it is unreasonable to expect the chiropractor to be able to eliminate any risk.
Furthermore, the patient may have headache or neck pain because they already had an injury to blood
vessels in the neck so there is a potential for the dissection to have preceded any manipulation. Whatever
the risk of chiropractic manipulation, it must be very low if the probable number of manipulations is taken
into account. At this time there is tendency to seek a compensable cause for any clinical problem. At this
time I urge the medical and chiropractic professions to seek more evidence before there are any
conclusions about the level of risk of vertebral damage associated with chiropractic manipulation of the
neck. I do not see anecdotal reports or case series reports of thousands of chiropractic manipulations
without any vertebral artery damage. Furthermore, as relatively asymptomatic investigations such as
vascular MRI become available it may be possible to undertake prospective randomised studies which
will answer some of the issues discussed in this paper including investigation of asymptomatic patients
who may have subclinical vertebral artery damage. Meanwhile, there should be every effort to exclude
patients who have known risk factors (e.g. -hypertension, smoking, high cholesterol, previous vascular
problems, blood disorders) wherever possible and patients should sign easily understood consent forms
which lay out potential risks of neck movement or manipulation.
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