3. Allvarliga risker

Halsryggsmanipulation och artärskador

Det finns många rapporter om allvarliga skador efter nackmanipulation utförd av kiropraktorer och andra. Detta förnekas vanligen av kiropraktorerna själva, både i Sverige och andra länder. Här är en lång lista på 182 referenser, de flesta med abstracts. De som är publicerade i riktiga medicinska tidskrifter är de som rapporterar de allvarliga skadorna, som stroke mm. Men de som är publicerade i kiropraktortidskrifter tonar oftast ner riskerna, eller förnekar dem helt. Undantag finns.
Inga garantier att listan är fullständig. Jag har hittat referenserna på PubMed och Medline (Ovid).

Referenser med abstracts

1. Alimi, Y., I. Tonolli, P. Di Mauro, et al. (1996). ”Manipulations des vertebres cervicales et traumatisme de l’artere vertebrale: a propos de deux cas [Manipulations of cervical vertebrae and trauma of the vertebral artery. Report of two cases].” J Mal Vasc 21(5): 320-3.

Vertebrobasilar-distribution stroke is a rare but sometimes severe complication of chiropractic neck manipulation. We report two patients with dissections of the vertebral arteries authenticated two and six days after the cervical manipulation. In the first case, a Wallenberg’s syndrome occurred due to a dissection of the right intracranial vertebral artery; the patient was treated with anticoagulant therapy but little improvement of the disorder was noted. The second patient had transitory neurologic manifestations which led to the discovery of an intimal tear of the ostium of the right vertebral artery with a floating clot. Further embolic complications were avoided by performing a venous bypass between the right common carotid and the vertebral artery at the base of the skull. Therapists should be aware of vertebrobasilar complications after spinal manipulations and should ask for early explorations (brain CT, cerebral angiography) to institute rapidly the most appropriate treatment.

2. Anderson-Peacock, E., J. S. Blouin, R. Bryans, et al. (2005). ”Chiropractic clinical practice guideline: evidence-based treatment of adult neck pain not due to whiplash.” JCCA J Can Chiropr Assoc 49(3): 158-209.

OBJECTIVE: To provide an evidence-based clinical practice guideline for the chiropractic cervical treatment of adults with acute or chronic neck pain not due to whiplash. This is a considerable health concern considered to be a priority by stakeholders, and about which the scientific information was poorly organized. OPTIONS: CERVICAL TREATMENTS: manipulation, mobilization, ischemic pressure, clinic- and home-based exercise, traction, education, low-power laser, massage, transcutaneous electrical nerve stimulation, pillows, pulsed electromagnetic therapy, and ultrasound. OUTCOMES: The primary outcomes considered were improved (reduced and less intrusive) pain and improved (increased and easier) ranges of motion (ROM) of the adult cervical spine. EVIDENCE: An ”extraction” team recorded evidence from articles found by literature search teams using 4 separate literature searches, and rated it using a Table adapted from the Oxford Centre for Evidence-based Medicine. The searches were 1) Treatment; August, 2003, using MEDLINE, CINAHL, AMED, MANTIS, ICL, The Cochrane Library (includes CENTRAL), and EBSCO, identified 182 articles. 2) Risk management (adverse events); October, 2004, identified 230 articles and 2 texts. 3) Risk management (dissection); September, 2003, identified 79 articles. 4) Treatment update; a repeat of the treatment search for articles published between September, 2003 and November, 2004 inclusive identified 121 articles. VALUES: To enable the search of the literature, the authors (Guidelines Development Committee [GDC]) regarded chiropractic treatment as including elements of ”conservative” care in the search strategies, but not in the consideration of the range of chiropractic practice. Also, knowledge based only on clinical experience was considered less valid and reliable than good-caliber evidence, but where the caliber of the relevant evidence was low or it was non-existent, unpublished clinical experience was considered to be equivalent to, or better than the published evidence. REPORTED BENEFITS, HARMS AND COSTS: The expected benefits from the recommendations include more rapid recovery from pain, impairment and disability (improved pain and ROM). The GDC identified evidence-based pain benefits from 10 unimodal treatments and more than 7 multimodal treatments. There were no pain benefits from magnets in necklaces, education or relaxation alone, occipital release alone, or head retraction-extension exercise combinations alone. The specificity of the studied treatments meant few studies could be generalized to more than a minority of patients. Adverse events were not addressed in most studies, but where they were, there were none or they were minor. The theoretic harm of vertebral artery dissection (VAD) was not reported, but an analysis suggested that 1 VAD may occur subsequent to 1 million cervical manipulations. Costs were not analyzed in this guideline, but it is the understanding of the GDC that recommendations limiting ineffective care and promoting a more rapid return of patients to full functional capacity will reduce patient costs, as well as increase patient safety and satisfaction. For simplicity, this version of the guideline includes primarily data synthesized across studies (evidence syntheses), whereas the technical and the interactive versions of this guideline (http://ccachiro.org/cpg) also include relevant data from individual studies (evidence extractions). RECOMMENDATIONS: The GDC developed treatment, risk-management and research recommendations using the available evidence. Treatment recommendations addressing 13 treatment modalities revolved around a decision algorithm comprising diagnosis (or assessment leading to diagnosis), treatment and reassessment. Several specific variations of modalities of treatment were not recommended. For adverse events not associated with a treatment modality, but that occur in the clinical setting, there was evidence to recommend reconsideration of treatment options or referral to the appropriate health services. For adverse events associated with a treatment modality, but not a known or observable risk factor, there was evidence to recommend heightened vigilance when a relevant treatment is planned or administered. For adverse events associated with a treatment modality and predicted by an observable risk factor, there was evidence to recommend absolute contraindications, and requirements for treatment modality modification or caution to minimize harm and maximize benefit. For managing the theoretic risk of dissection, there was evidence to recommend a systematic risk-management approach. For managing the theoretic risk of stroke, there was support to recommend minimal rotation in administering any modality of upper-cervical spine treatment, and to recommend caution in treating a patient with hyperhomocysteinemia, although the evidence was especially ambiguous in both of these areas. Research recommendations addressed the poor caliber of many of the studies; the GDC concluded that the scientific base for chiropractic cervical treatment of neck pain was not of sufficient quality or scope to ”cover” current chiropractic practice comprehensively, although this should not suggest other disciplines are more evidence-based. VALIDATION: This guideline was authored by the 10 members of the GDC (Elizabeth Anderson-Peacock, Jean-Sebastien Blouin, Roland Bryans, Normand Danis, Andrea Furlan, Henri Marcoux, Brock Potter, Rick Ruegg, Janice Gross Stein, Eleanor White) based on the work of 3 literature search teams and an evidence extraction team, and in light of feedback from a commentator (Donald R Murphy), a 5-person review panel (Robert R Burton, Andrea Furlan, Richard Roy, Steven Silk, Roy Till), a 6-person Task Force (Grayden Bridge, H James Duncan, Wanda Lee MacPhee, Bruce Squires, Greg Stewart, Dean Wright), and 2 national profession-wide critiques of complete drafts. Two professional editors with extensive guidelines experience were contracted (Thor Eglington, Bruce P Squires). Key contributors to the guideline included individuals with specialties or expert knowledge in chiropractic, medicine, research processes, literature analysis processes, clinical practice guideline processes, protective association affairs, regulatory affairs, and the public interest. This guideline has been formally peer reviewed.

3. Auer, R. N., J. Krcek and J. C. Butt (1994). ”Delayed symptoms and death after minor head trauma with occult vertebral artery injury.” Journal of Neurology, Neurosurgery & Psychiatry 57(4): 500-2.

Head injury without loss of consciousness is seldom accompanied by grave complications. We report the case of an 18 year old cyclist who was struck by a car in a minor road traffic accident, suffered minor head injury without loss of consciousness, and died unexpectedly seven weeks later with vomiting and coma. Necropsy revealed an expanding cerebellar infarct and vertebral artery thrombosis, superimposed on an old dissecting intramural haematoma of the right vertebral artery in the atlantoaxial region. Vertebrobasilar occlusion after minor head trauma, hyperextending or rotating neck injury, or neck manipulation is commonest in young people. Occult ligamentous injury to the cervical spine after trauma may be a contributing factor to the pathogenesis of vertebral artery damage after injury to the neck.

4. Boyle, E., P. Cote, A. R. Grier, et al. (2008). ”Examining vertebrobasilar artery stroke in two Canadian provinces.” Spine 33(4 Suppl): S170-5.

STUDY DESIGN: Ecological study. OBJECTIVES: To determine the annual incidence of hospitalized vertebrobasilar artery (VBA) stroke and chiropractic utilization in Saskatchewan and Ontario between 1993 and 2004. To determine whether at an ecological level, the incidence of VBA stroke parallels the incidence of chiropractic utilization. SUMMARY OF BACKGROUND DATA: Little is known about the incidence and time trends of VBA stroke diagnoses in the population. Chiropractic manipulation to the neck is believed to be a risk factor for VBA stroke. No study has yet found an association between chiropractic utilization and VBA diagnoses at the population level. METHODS: All hospitalizations with discharge diagnoses of VBA stroke were extracted from administrative databases for Saskatchewan and Ontario. We included incident cases that were diagnosed between January 1993 and December 2004 for Saskatchewan and from April 1993 to March 2002 for Ontario. VBA cases that had previously been hospitalized for any stroke or transient ischemic attack (TIA) were excluded. Chiropractic utilization was measured using billing data from Saskatchewan Health and Ontario Health Insurance Plan. Denominators were derived from Statistics Canada’s annual population estimates. RESULTS: The incidence rate of VBA stroke was 0.855 per 100,000 person-years for Saskatchewan and 0.750 per 100,000 person-years for Ontario. The annual incidence rate spiked dramatically with a 360% increase for Saskatchewan in 2000. There was a 38% increase for the 2000 incidence rate in Ontario. The rate of chiropractic utilization did not increase significantly during the study period. CONCLUSION: In Saskatchewan, we observed a dramatic increase in the incidence rate in 2000 and there was a corresponding relatively small increase in chiropractic utilization. In Ontario, there was a small increase in the incidence rate; however, chiropractic utilization decreased. At the ecological level, the increase in VBA stroke does not seem to be associated with an increase in the rate of chiropractic utilization.

5. Brahee, D. D. and G. M. Guebert (2000). ”Tortuosity of the vertebral artery resulting in vertebral erosion.” Journal of Manipulative & Physiological Therapeutics 23(1): 48-51.

OBJECTIVE: To discuss the case of a patient with unilateral vertebral artery tortuosity and dilatation resulting in vertebral body and transverse foramen erosion. An emphasis is placed on diagnostic imaging. CLINICAL FEATURES: A 45-year-old man had a frozen shoulder and headaches. Previous arm pain, numbness, and a cold extremity were the result of occlusion of the subclavian artery and had been treated with a subclavian-carotid bypass procedure. INTERVENTION AND OUTCOME: As a result of the angiographic detection of the left vertebral artery dilatation and tortuosity and the concomitant hypoplastic right vertebral artery, high-velocity, low-amplitude manipulation of the cervical spine was contraindicated. However, the patient’s symptoms were not related to these findings. Alternatively, low-force manipulation of the cervical spine, shoulder range of motion and muscle techniques were used, and the patient’s symptoms diminished significantly with improved shoulder range of motion. CONCLUSION: Clinicians need to be alert to clinical presentations and appropriate imaging protocols in cases of suggested vertebral artery anomaly.

6. Brand, P. L., R. H. Engelbert, P. J. Helders, et al. (2005). ”Systematisch literatuuronderzoek naar de effecten van behandeling bij zuigelingen met ‘kopgewrichteninvloed bij storingen in de symmetrie’ (‘KISS-syndroom’) [Systematic review of the effects of therapy in infants with the KISS-syndrome (kinetic imbalance due to suboccipital strain)].” Nederlands Tijdschrift voor Geneeskunde 149(13): 703-7.

OBJECTIVE: To establish the effects of manual therapy, chiropractic, or osteopathic treatment of the KISS-syndrome (kinetic imbalance due to suboccipital strain) in infants with positional preference, plagiocephaly, and colic. DESIGN: Systematic review of the literature. METHOD: PubMed, Embase and the Cochrane Library were searched for articles on the effects of manual therapy, chiropractic and osteopathy on the KISS-syndrome. Experts in the field of manual medicine and osteopathy were asked to provide relevant articles. The bibliography in a textbook of manual therapy for children was hand-searched for additional references to the KISS-syndrome. RESULTS: No clinical trials were found that evaluated the effects of manual therapy or osteopathy on either the KISS-syndrome or its symptoms. Pooled analysis of two randomised clinical trials on the effects of chiropractic in infantile colic showed no statistically significant difference between active and control treatments. In addition, we found that 22% of infants showed short episodes of apnoea during manual therapy of the spine, and that one case has been described in which such apnoea resulted in death. CONCLUSION: Given the absence of evidence of beneficial effects of spinal manipulation in infants and in view of its potential risks, manual therapy, chiropractic and osteopathy should not be used in infants with the KISS-syndrome, except within the context of randomised double-blind controlled trials.

7. Braun, I. F., R. S. Pinto, G. J. De Filipp, et al. (1983). ”Brain stem infarction due to chiropractic manipulation of the cervical spine.” South Med J 76(12): 1507-10.

A case of brain stem infarction after chiropractic manipulation of the cervical spine is presented. Proposed mechanisms and sites of possible arterial injury are discussed. A diagnosis of vertebral artery occlusion was made using conventional brachial angiography. Digital intravenous angiography, a relatively new and less invasive vascular imaging technique which was used as an adjunct for evaluating the remainder of the cervicocephalic vessels, documented the vertebral occlusion. Chiropractic manipulation, which is increasing in popularity, may be a cause of potentially devastating neurologic disease.

8. Braune, H. J., M. H. Munk and G. Huffmann (1991). ”Hirninfarkt im Stromgebiet der Arteria cerebri media nach Chirotherapie der Halswirbelsaule [Cerebral infarct in the circulatory area of the arteria cerebri media following chiropractic therapy of the cervical spine].” Dtsch Med Wochenschr 116(27): 1047-50.

Chiropractic manipulation of the neck can occasionally cause severe neurological complications, as demonstrated by this case report. A 59-year-old man who had previously sustained a cardiac infarction and a femoral-popliteal bypass operation, suffered from painful spasms of the cervical muscles for several weeks. After chiropractic manipulation, a left, predominantly brachiofacial, hemiparesis developed during the subsequent 24 hours. Computed tomography demonstrated a recent infarction in the area supplied by the ascending central and parietal branches of the right medial cerebral artery. Doppler sonography revealed occlusion of the right internal carotid artery as the cause. Marked improvement followed hypervolaemic haemodilution daily with 500 ml hydroxyethyl starch and intensive physiotherapy. Blood flow through the internal carotid artery was restored after seven days (demonstrated by Doppler ultrasound). In the presence of arteriosclerotic vessel changes particular care should be exercised in deciding on and execution of chiropractic manipulations.

9. Briganti, F., F. Tortora, A. Elefante, et al. (2004). ”An unusual case of vertebral arteriovenous fistula treated with electrodetachable coil embolization.” Minimally Invasive Neurosurgery 47(6): 386-8.

Vertebral arteriovenous fistulas (VAF) are rare clinical entities. Most are post-traumatic in origin, following direct injury, or iatrogenic. Treatment options include endovascular occlusion or direct surgical closure. We present a rare case of a spontaneous VAF, presenting with cervical and upper limb pain in a patient with previous chiropractic manipulations, successfully treated with electrodetachable coil embolization. While the natural history of the VAFs is still to be settled, endovascular occlusion appears to be a safe and reliable method to deal with such lesions, mainly in symptomatic cases. The use of electrically detachable coils may be considered as an effective alternative for the endovascular occlusion of these fistulas.

10. Brownson, R. J., W. K. Zollinger, T. Madeira, et al. (1986). ”Sudden sensorineural hearing loss following manipulation of the cervical spine.” Laryngoscope 96(2): 166-70.

Review of the otolaryngologic literature reveals no reports of sudden sensorineural hearing loss resulting from manipulation of the cervical spine. Indeed, in previously reported cases of vertebrobasilar artery injury following spinal manipulation, hearing loss has received little attention. Two patients with sudden sensorineural hearing loss following cervical spine manipulation are presented. The audiologic findings and cerebral arteriograms are reviewed and treatment is discussed. A review of the anatomy and pathophysiology is also included, and a possible mechanism of injury to the vertebral artery is proposed.

11. Brynin, R. and C. Yomtob (1999). ”Missed cervical spine fracture: chiropractic implications.” Journal of Manipulative & Physiological Therapeutics 22(9): 610-4.

OBJECTIVE: To discuss the case of a patient with an anterior compression fracture of the cervical spine, which had been overlooked on initial examination. CLINICAL FEATURES: A 36-year-old man was seen at a chiropractic clinic 1 month after diving into the ocean and hitting his head on the ocean floor. He chipped a tooth but denied loss of consciousness. Initial medical examination in the emergency department did not include radiography, but an anti-inflammatory medication was prescribed. Radiographs taken at the chiropractic clinic 1 month later revealed an anterior compression fracture of the C7 vertebra, with migration of the fragment noted on flexion and extension views. INTERVENTION AND OUTCOME: The patient was referred back to his medical doctor for further evaluation and management.He was instructed to wear a Philadelphia collar for 4 weeks. During this time period, he reported ”shooting” pain and tingling from his neck into his arms. The patient reported resolution of his neck and arm symptoms at 2.5 months after injury. Follow-up radiographs at 6 months after injury revealed fusion of the fracture fragment with mild residual deformity. At that time, the patient began a course of chiropractic treatment. CONCLUSION: After head trauma, it is essential to obtain a radiograph of the cervical spine to rule out fracture. Chiropractors should proceed with caution, regardless of any prior medical or ancillary evaluation, before commencing cervical spine manipulation after head and neck trauma.

12. Budgell, B. S. and A. Sato (1997). ”The cervical subluxation and regional cerebral blood flow.[see comment].” Journal of Manipulative & Physiological Therapeutics 20(2): 103-7.

OBJECTIVE: This article specifically addresses the question of whether the manipulable cervical lesion is likely to cause extrinsic compression of the vertebral arteries sufficient to cause such symptoms of reduced regional cerebral blood flow as might be relieved by spinal manipulation. DATA SOURCES: Literature on normal and abnormal cerebral circulation, including vertebrobasilar insufficiency. DATA SYNTHESIS: Signs and symptoms produced by extrinsic compression of the vertebrobasilar system have been compared with those attributed elsewhere to the manipulable cervical lesion (cervical subluxation). RESULTS: Extrinsic compression of the vertebrobasilar system generally does not produce signs and symptoms consistent with those attributed to the manipulable cervical lesion. CONCLUSION: It has been hypothesized elsewhere that the manipulable cervical lesion may induce localized decreases in regional cerebral blood flow, and so signs and symptoms attributable to ”cerebral hibernation.” If a causal relationship does exist between the cervical subluxation and reduced regional cerebral blood flow, it is not likely to be caused by mechanical compression of the vertebral arteries.

13. Cagnie, B., E. Barbaix, E. Vinck, et al. (2005). ”A case of abnormal findings in the course of the vertebral artery associated with an ossified hyoid apparatus. A contraindication for manipulation of the cervical spine?” Journal of Manipulative & Physiological Therapeutics 28(5): 346-51.

OBJECTIVE: To describe a case of a simultaneous occurrence of an ossified stylohyoid ligament in a 56-year-old male cadaver and anomalies of the vertebral artery, and to consider the clinical implications for manipulative therapists. INTERVENTION AND OUTCOME: Dissection showed a simultaneous occurrence of complete developmental ossification of the left hyoid apparatus, variants of the vertebral artery, and a left superior vena cava in a 56-year-old male cadaver. DISCUSSION: Developmental variants, posttraumatic and degenerative changes of the hyoid apparatus may result in variable degrees of ossification or calcification. CONCLUSION: This unusual disorder should be considered in the differential diagnosis of facial and neck pain especially within the scope of manipulation of the upper cervical spine. Cervical spine manipulation may exacerbate existing pathological conditions of the stylohyoid apparatus, thereby irritating neurovascular structures, and induce a fracture. Developmental ossification of this apparatus might be associated with anomalies in the atlantic section of the vertebral artery which make the patient more susceptible to vertebrobasilar insufficiency. We conclude that extreme care should be taken in the presence of such an ossification to avoid trauma to the stylohyoid apparatus and maybe even because of increased vertebrobasilar risk.

14. Cagnie, B., F. Jacobs, E. Barbaix, et al. (2005). ”Changes in cerebellar blood flow after manipulation of the cervical spine using Technetium 99m-ethyl cysteinate dimer.[see comment].” Journal of Manipulative & Physiological Therapeutics 28(2): 103-7.

BACKGROUND: Cervical spine manipulation is one of the many interventions practiced by health professionals to treat musculoskeletal disorders of the cervical spine. Although serious consequences of manipulation have been documented, the incidence is thought to be rare. More frequently, there may be minor transient side effects after manipulation of the cervical spine, such as headache, dizziness, and nausea. One of the hypothesis is that these side effects are caused by ischemia in the areas perfused by the vertebral arteries. OBJECTIVE: The purpose of this study was to investigate whether manipulation of the cervical spine can influence blood flow in the brain. METHODS: Single photon emission computed tomography was used to examine changes in regional cerebral blood flow caused by cervical spine manipulation (CSM) performed by a physiotherapist to 15 volunteers, using a 1-day split-dose Technetium 99m-ethyl cysteinate dimer single photon emission computed tomography activation paradigm. RESULTS: One brain region was identified showing a decreased regional cerebral blood flow after manipulation. This region was situated in the anterior lobe of the left cerebellum (-42, -48, -24). CONCLUSIONS: These findings suggest that cerebellar hypoperfusion may occur after CSM. This could explain why certain people experience headache, dizziness, or nausea after CSM. Further investigation into patient symptoms in the presence of cerebellar hypoperfusion and the possible link of these findings with other adverse reactions are warranted.

15. Cashley, M. (2001). ”Neurological complications of cervical spine manipulation.[comment].” Journal of the Royal Society of Medicine 94(6): 314; author reply 315.

16. Caso, V., M. Paciaroni and J. Bogousslavsky (2005). ”Environmental factors and cervical artery dissection.” Front Neurol Neurosci 20: 44-53.

A history of a minor precipitating event is frequently elicited in patients with a spontaneous dissection of the carotid or vertebral artery. Other precipitating events associated with hyperextension or rotation of the neck include practicing yoga, painting a ceiling, coughing, vomiting, sneezing, the receipt of anesthesia, and the act of resuscitation. Chiropractic manipulation of the neck has been associated with carotid artery dissection and, particularly, vertebral artery dissection. Another risk factor for spontaneous dissections seems to be a recent history of a respiratory tract infection. The possibility of an infectious trigger is supported by the finding of a seasonal variation in the incidence of spontaneous dissections, with a peak incidence in fall. A potential link with common risk factors for vascular disease, such as tobacco use, hypertension, and the use of oral contraceptives, has not been systematically evaluated, but atherosclerosis appears to be distinctly uncommon in patients with a dissection of the carotid or vertebral arteries. In conclusion, although any hypotheses on the pathogenic mechanisms linking environmental factors and dissection remain speculative at present, we believe that these hypotheses may contribute to better define the spectrum of pathogenic conditions predisposing a cervical artery to dissection and provide arguments to better investigate the single or combined effect of such susceptibility factors in future studies.

17. Cassidy, J. D., E. Boyle, P. Cote, et al. (2008). ”Risk of vertebrobasilar stroke and chiropractic care: results of a population-based case-control and case-crossover study.” Spine 33(4 Suppl): S176-83.

STUDY DESIGN: Population-based, case-control and case-crossover study. OBJECTIVE: To investigate associations between chiropractic visits and vertebrobasilar artery (VBA) stroke and to contrast this with primary care physician (PCP) visits and VBA stroke. SUMMARY OF BACKGROUND DATA: Chiropractic care is popular for neck pain and headache, but may increase the risk for VBA dissection and stroke. Neck pain and headache are common symptoms of VBA dissection, which commonly precedes VBA stroke. METHODS: Cases included eligible incident VBA strokes admitted to Ontario hospitals from April 1, 1993 to March 31, 2002. Four controls were age and gender matched to each case. Case and control exposures to chiropractors and PCPs were determined from health billing records in the year before the stroke date. In the case-crossover analysis, cases acted as their own controls. RESULTS: There were 818 VBA strokes hospitalized in a population of more than 100 million person-years. In those aged <45 years, cases were about three times more likely to see a chiropractor or a PCP before their stroke than controls. Results were similar in the case control and case crossover analyses. There was no increased association between chiropractic visits and VBA stroke in those older than 45 years. Positive associations were found between PCP visits and VBA stroke in all age groups. Practitioner visits billed for headache and neck complaints were highly associated with subsequent VBA stroke. 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.

(Jfr. Nelson, C. F., R. D. Metz, T. M. LaBrot, et al. (2005). ”The selection effects of the inclusion of a chiropractic benefit on the patient population of a managed health care organization.” Journal of Manipulative & Physiological Therapeutics 28(3): 164-9.
Ur Abstract. ”At the level of patient self-selection, chiropractic patients are considerably younger and healthier than comparable medical patients.”

18. Cellerier, P. and A. M. Georget (1984). ”Dissection des arteres vertebrales apres manipulation du rachis cervical. A propos d’un cas [Dissection of the vertebral arteries after manipulation of the cervical spine. Apropos of a case].” J Radiol 65(3): 191-6.

Dissecting aneurysm of the vertebral arteries following chiropractic manipulation of the spine. A thirty-five years old man had a Wallenberg Syndrome following chiropractic manipulation of the spine. Plain films and hypocycloidal tomography showed a foramen arcuale on both side. Arteriography lead to the diagnosis of dissecting aneurysm of the vertebral arteries. The favourable course point to the value of the posterior communicating arteries and the spinal artery as collateral pathways of the vertebro-basilar circulation.

19. Cerimagic, D. and J. Glavic (2008). ”Cervical spine manipulation: an alternative medical procedure with potentially fatal complications.[comment].” Southern Medical Journal 101(5): 568.

20. Cerimagic, D., J. Glavic, A. Lovrencic-Huzjan, et al. (2007). ”Occlusion of vertebral artery, cerebellar infarction and obstructive hydrocephalus following cervical spine manipulation.” European Neurology 58(4): 248-50.

21. Chen, W. L., C. H. Chern, Y. L. Wu, et al. (2006). ”Vertebral artery dissection and cerebellar infarction following chiropractic manipulation.[see comment].” Emergency Medicine Journal 23(1): e1.

Vertebral artery dissection (VAD) associated with chiropractic cervical manipulation is a rare but potentially disabling condition. In this report, we present a young patient manifesting with repeated vertigo. Owing to the initial misdiagnosis, the patient later developed cerebellar stroke with inability to stand or walk. Vertigo and disequilibrium are the usual presenting symptoms of this condition, which can result from inner ear or vestibular nerve dysfunction, vertebrobasilar insufficiency, and even lethal cerebellar infarction or haemorrhage; these last two, although rarely seen in young adults, can be caused by traumatic or spontaneous arterial injury, including injury secondary to chiropractic cervical manipulation. A number of cases of VAD associated with chiropractic cervical manipulation have been reported, but rarely in the emergency medicine literature. We present a case of this rare occurrence, and discuss the diagnostic pitfalls.

22. Chestnut, J. L. (2004). ”The stroke issue: paucity of valid data, plethora of unsubstantiated conjecture.” J Manipulative Physiol Ther 27(5): 368-72.

23. Cleland, J. A., J. D. Childs, M. McRae, et al. (2005). ”Immediate effects of thoracic manipulation in patients with neck pain: a randomized clinical trial.[see comment].” Manual Therapy 10(2): 127-35.

Mechanical neck pain is a common occurrence in the general population resulting in a considerable economic burden. Often physical therapists will incorporate manual therapies directed at the cervical spine including joint mobilization and manipulation into the management of patients with cervical pain. Although the effectiveness of mobilization and manipulation of the cervical spine has been well documented, the small inherent risks associated with these techniques has led clinicians to frequently utilize manipulation directed at the thoracic spine in this patient population. It is hypothesized that thoracic spine manipulation may elicit similar therapeutic benefits as cervical spine manipulation while minimizing the magnitude of risk associated with the cervical technique. The purpose of this randomized clinical trial was to investigate the immediate effects of thoracic spine manipulation on perceived pain levels in patients presenting with neck pain. The results suggest that thoracic spine manipulation results in immediate analgesic effects in patients with mechanical neck pain. Further studies are needed to determine the effects of thoracic spine manipulation in patients with neck pain on long-term outcomes including function and disability.

24. Combs, S. B. and J. J. Triano (1997). ”Symptoms of neck artery compromise: case presentations of risk estimate for treatment.[see comment].” Journal of Manipulative & Physiological Therapeutics 20(4): 274-8.

OBJECTIVE: To discuss the use of magnetic resonance angiography (MRA) imaging as a definitive means to assess vascular patency and the relative value of various vertebral artery screening maneuvers. CLINICAL FEATURES: Two female patients suffered head and neck trauma with possible vertebral artery insufficiency. Positive vertebral artery screening tests with consistent symptoms were present in both cases. One patient had a congenitally narrowed vertebral artery, whereas the second had no evidence of vascular anomaly. INTERVENTION AND OUTCOME: Conservative chiropractic management using manipulation and rehabilitation led to favorable outcome in both cases. The patient with vascular compromise received a treatment plan avoiding neck manipulation. The second case received manipulation per clinical indications from neck findings. CONCLUSION: MRA imaging may be more important to critical decision making than are the various vertebral artery screening tests in patients with positional vertigo on combined neck extension and rotation.

25. Cote, P., B. G. Kreitz, J. D. Cassidy, et al. (1996). ”The validity of the extension-rotation test as a clinical screening procedure before neck manipulation: a secondary analysis.[see comment].” Journal of Manipulative & Physiological Therapeutics 19(3): 159-64.

OBJECTIVE: To determine the validity of the neck extension-rotation test as a clinical screening procedure to detect decreased vertebrobasilar blood flow that might be associated with dizziness. DESIGN: Secondary analysis of a clinical screening test. METHODS: Twelve subjects with dizziness reproduced by the extension-rotation test and 30 healthy control subjects had Doppler ultrasonography examination of their vertebral arteries with the neck extended and rotated. Vascular impedance to blood flow was measured and the presence of signs and symptoms of vertebrobasilar ischemia was recorded. RESULTS: Cut-off points for validity estimates were derived through the percentile and Gaussian methods using impedance to blood flow as the standard. The sensitivity of the extension-rotation test for increased impedance to blood flow was 0%, regardless of the selected cut-off point. The specificity rates for the left vertebral artery were 71% and 67% for the percentile and Gaussian methods, respectively. The extension-rotation test was more specific on the right side, with a rate varying from 90% with the percentile method to 86% with the Gaussian technique. The positive predictive value of the test was 0% and its negative predictive value ranged from 63% to 97%. CONCLUSION: We were unable to demonstrate that the extension-rotation test is a valid clinical screening procedure to detect decreased blood flow in the vertebral artery. The value of this test for screening patients at risk of stroke after cervical manipulation is questionable.

26. Cox, D. M. (2002). ”Complications of cervical spine manipulation therapy: 5-year retrospective study in a single-group practice.[comment].” Neurosurgical Focus 13(6): 1 p following ecp1.

27. Dahl, A., P. Bjark and I. M. Anke (1982). ”Cerebrovaskulaere komplikasjoner til manipulasjonsbehandling av nakken [Cerebrovascular complications following manipulation of the neck].” Tidsskr Nor Laegeforen 102(3): 155-7.

28. Devereaux, M. W. (2000). ”The neuro-ophthalmologic complications of cervical manipulation.” J Neuroophthalmol 20(4): 236-9.

Cervical manipulation, specifically chiropractic manipulation, is an important cause of vertebrobasilar and occasionally carotid distribution strokes. Neuro-ophthalmologic findings are a common and at times relatively isolated feature of cervical manipulation-induced stroke. A case of chiropractic-induced occipital lobe infarction with homonymous hemianopsia is reported, and the literature regarding neuro-ophthalmologic findings is reviewed.

29. Di Duro, J. O. (2003). ”Stroke in a chiropractic patient population.” Cerebrovasc Dis 15(1-2): 156; author reply 156.

30. Dittrich, R., D. Rohsbach, A. Heidbreder, et al. (2007). ”Mild mechanical traumas are possible risk factors for cervical artery dissection.[see comment].” Cerebrovascular Diseases 23(4): 275-81.

BACKGROUND AND PURPOSE: Cervical artery dissection (CAD) is a common cause of ischemic stroke in younger aged subjects. Retrospective studies suggest cervical manipulative therapy (CMT) and preceding infections as extrinsic risk factors for CAD. In a case-control study, we assessed a questionnaire with 7 mild mechanical traumas as potential trigger factors for CAD, including CMT and recent infections. PATIENTS AND METHODS: Forty-seven consecutive patients with CAD were compared with 47 consecutive patients of similar age with ischemic stroke due to etiologies other than CAD. Patients underwent a standardized face-to-face interview. We assessed head or neck pain and recent infection <7 days before symptom onset, as well as the following mechanical trigger factors <24 h and <7 days prior to symptom onset: (1) heavy lifting, (2) sexual intercourse, (3) mild direct or (4) indirect neck trauma, (5) jerky head movements, (6) sports activity, and (7) CMT. RESULTS:We found no association between any single one of the above risk factors and CAD. CMT (CAD, n = 10; non-CAD, n = 5) and recent infections (CAD, n = 18; non-CAD, n = 10) were more frequent in the CAD group but failed to reach significance. However, the cumulative analysis of all mechanical trigger factors revealed a significant association of mechanical risk factors as a whole in CAD <24 h prior to symptom onset (p = 0.01). CONCLUSION: Mild mechanical stress, including CMT, plays a role as possible trigger factor in the pathogenesis of CAD. CMT and recent infections alone failed to reach significance during the present investigation, presumably due to the relatively small sample size of the study cohort. (c) 2007 S. Karger AG, Basel.

31. Domenicucci, M., A. Ramieri, M. Salvati, et al. (2007). ”Cervicothoracic epidural hematoma after chiropractic spinal manipulation therapy. Case report and review of the literature.” Journal of Neurosurgery Spine 7(5): 571-4.

A spinal epidural hematoma is an extremely rare complication of cervical spine manipulation therapy (CSMT). The authors present the case of an adult woman, otherwise in good health, who developed Brown-Sequard syndrome after CSMT. Decompressive surgery performed within 8 hours after the onset of symptoms allowed for complete recovery of the patient’s preoperative neurological deficit. The unique feature of this case was the magnetic resonance image showing increased signal intensity in the paraspinal musculature consistent with a contusion, which probably formed after SMT. The pertinent literature is also reviewed.

32. Donzis, P. B. and J. S. Factor (1997). ”Visual field loss resulting from cervical chiropractic manipulation.” Am J Ophthalmol 123(6): 851-2.

PURPOSE: To report a complication of chiropractic cervical manipulation. METHOD: Case report. A healthy 39-year-old woman developed sudden left peripheral visual field loss after chiropractic neck manipulation. RESULTS: Visual field testing disclosed a left superior homonymous hemianopsia. A magnetic resonance imaging scan performed the day of the event disclosed acute infarction of the ventromedial aspect of the inferior right occipital lobe. CONCLUSION: Cerebral infarct may occur as a result of chiropractic neck manipulation.

33. Dziewas, R., C. Konrad, B. Drager, et al. (2003). ”Cervical artery dissection–clinical features, risk factors, therapy and outcome in 126 patients.[see comment].” Journal of Neurology 250(10): 1179-84.

The highly variable clinical course of cervical artery dissections still poses a major challenge to the treating physician. This study was conducted (1) to describe the differences in clinical and angiographic presentation of patients with carotid and vertebral artery dissections (CAD, VAD), (2) to define the circumstances that are related to bilateral arterial dissections, and (3) to determine factors that predict a poor outcome. Retrospectively and by standardised interview, we studied 126 patients with cervical artery dissections. Preceding traumata, vascular risk factors, presenting local and ischemic symptoms, and patient-outcome were evaluated. Patients with CAD presented more often with a partial Horner’s syndrome and had a higher prevalence of fibromuscular dysplasia than patients with VAD. Patients with VAD complained more often of neck pain, more frequently reported a preceding chiropractic manipulation and had a higher incidence of bilateral dissections than patients with CAD. Bilateral VAD was significantly related to a preceding chiropractic manipulation. Multivariate analysis showed that the variables stroke and arterial occlusion were the only independent factors associated with a poor outcome. This study emphasises the potential dangers of chiropractic manipulation of the cervical spine. Probably owing to the systematic use of forceful neck-rotation to both sides, this treatment was significantly associated with bilateral VAD. Patients with dissection-related cervical artery occlusion had a significantly increased risk of suffering a disabling stroke.

34. Easton, J. D. and D. G. Sherman (1977). ”Cervical manipulation and stroke.” Stroke 8(5): 594-7.

Three patients are described who experienced vertebro-basilar distribution infarctions associated with neck manipulation. Two of the manipulations were chiropractic. Twenty-two previously reported cases are reviewed. Evidence favoring the use of anticoagulation in these patients is discussed along with the relative risk of such therapy.

35. Ellrodt, A. (2002). ”Assessing the risks of cervical manipulation for neck pain.” Cmaj 166(9): 1134-5.

36. Ernst, E. (2002). ”Manipulation of the cervical spine: a systematic review of case reports of serious adverse events, 1995-2001.[see comment].” Medical Journal of Australia 176(8): 376-80.

OBJECTIVE: To summarise recent evidence from case reports (published January 1995-September 2001) of adverse events after cervical spine manipulation. DATA SOURCES: Five computerised literature searches (MEDLINE-Pubmed; EMBASE, the Cochrane Library, AMED [Allied and Complementary Medicine Database], and CISCOM [Centralised Information Service for Complementary Medicine] were performed. No language restrictions were applied. STUDY SELECTION: All case reports containing original data of adverse events after cervical spine manipulation were included. DATA EXTRACTION: All articles were evaluated and key data extracted according to pre-defined criteria: patient’s age, sex and diagnosis; type of therapist; type of treatment; nature of adverse event; method of diagnosis; and clinical outcome. DATA SYNTHESIS: Thirty-one case reports (42 individual cases) were found. The patients were equally distributed between the sexes (21 male, 20 female, one unknown) and mostly middle-aged (range, 3 months to 87 years). Most were treated by chiropractors. Arterial dissection causing stroke was reported in at least 18 cases. CONCLUSIONS: Serious adverse events after cervical spine manipulation continue to be reported. As the incidence of these events is unknown, large and rigorous prospective studies of cervical spine manipulation are needed to accurately define the risks.

37. Fernandez-de-las-Penas, C., M. Perez-de-Heredia, M. Brea-Rivero, et al. (2007). ”Immediate effects on pressure pain threshold following a single cervical spine manipulation in healthy subjects.” Journal of Orthopaedic & Sports Physical Therapy 37(6): 325-9.

DESIGN: A placebo, control, repeated-measures, single-blinded randomized study. OBJECTIVES: To compare the immediate effects on pressure pain threshold (PPT) tested over the lateral elbow region following a single cervical high-velocity low-amplitude (HVLA) thrust manipulation, a sham-manual application (placebo), or a control condition; and to analyze if a different effect was evident on the side ipsilateral to, compared to the side contralateral to, the intervention. BACKGROUND: Previous studies investigating the effects of spinal manual therapy used passive mobilization procedures. There is a lack of studies exploring the effect of cervical manipulative interventions. METHODS: Fifteen asymptomatic volunteers (7 male, 8 female; aged 19-25 years) participated in this study. Each subject attended 3 experimental sessions on 3 separate days, at least 48 hours apart. At each session, subjects received either the manipulation, placebo, or control intervention provided by an experienced therapist. The manipulative intervention was directed at the posterior joint of the C5-6 vertebral level. PPT over the lateral epicondyle of both elbows was assessed preintervention and 5 minutes postintervention by an examiner blinded to the treatment allocation of the subject. A 3-way analysis of covariance (ANCOVA) with intervention, side, and time as factors, and gender as covariate, was used to evaluate changes in PPT. RESULTS: The analysis of variance detected a significant effect for intervention (F = 31.46, P <.001) and for time (F = 33.81, P <.001), but not for side (F = 0.303, P >.5). A significant interaction between intervention and time (F = 15.74, P <.001) was also found. Gender did not influence the comparative analysis (F = 0.252, P >.6). Post hoc analysis revealed that the application of a HVLA thrust manipulation produced a greater increase of PPT in both elbows, as compared to placebo or control interventions (P <.001). No significant changes in PPT levels were found after the placebo and control interventions (P >.6). Within-group effect sizes were large for PPT levels in both elbows after the manipulative procedure (d > 1.0), but small after placebo or control intervention (d < 0.1). CONCLUSIONS: The application of a manipulative intervention directed at the posterior joint of the C5-6 vertebral level produced an immediate increase in PPT over the lateral epicondyle of both elbows in healthy subjects. Effect sizes for the HVLA thrust manipulation were large, suggesting a strong effect of unknown clinical importance at this stage, whereas effect sizes for both placebo and control procedures were small, suggesting no significant effect.

38. Fernando, C. K. (2002). ”Re: Haldeman, et al. Unpredictability of cerebrovascular ischemia associated with cervical spine manipulation therapy. Spine 2002;1:27.[comment].” Spine 27(17): 1951-3; author reply 1951-3.

39. Frisoni, G. B. and G. P. Anzola (1990). ”Neck manipulation and stroke.” Neurology 40(12): 1910.

40. Frisoni, G. B. and G. P. Anzola (1991). ”Vertebrobasilar ischemia after neck motion.[see comment].” Stroke 22(11): 1452-60.

BACKGROUND. Vertebrobasilar ischemic strokes may occur after chiropractic manipulation of the cervical spine or, less often, after spontaneous and abrupt head movement. SUMMARY OF REVIEW. We describe three such cases of vertebrobasilar ischemic strokes and review 36 other reported cases. CONCLUSIONS. We give evidence that 1) the population at risk cannot be identified a priori in the vast majority of cases; 2) symptoms may develop after many uneventful manipulations; 3) clinical syndromes consist of occipital lobe (5%), cerebellar (8%), locked-in (8%), Wallenberg’s (28%), other brain stem (49%), and unclassifiable (2%); 4) mortality or very severe long-term impairment occurs in 28% of cases; 5) the development of transient neurological symptoms during previous manipulations, the presence of known or suspected ligament laxity, and, if known, the presence of a vertebral artery terminating in posterior inferior cerebellar artery should always contraindicate any chiropractic neck maneuver; and 6) the pathogenetic mechanism involves vertebral artery dissection at the atlantoaxial joint with intimal tear, intramural bleeding, or pseudoaneurysm that can lead to thrombosis or embolism.

41. Frumkin, L. R. and R. W. Baloh (1990). ”Wallenberg’s syndrome following neck manipulation.[see comment].” Neurology 40(4): 611-5.

We describe 4 patients ages 28 to 41 with lateral medullary infarction (Wallenberg’s syndrome) following chiropractic neck manipulation. In 3 patients, angiography documented dissection of the extracranial 3rd segment of the vertebral artery near the atlantoaxial joint. The onset of neurologic symptoms following manipulation varied from immediate to 4 days. All had good recovery with minor residual deficits. Although the association between chiropractic neck manipulation and vertebral-basilar artery distribution infarction is well known, we emphasize its occurrence in young healthy individuals without commonly regarded predisposing factors.

42. Gamer, D., A. Schuster, K. Aicher, et al. (2002). ”Horner-Syndrom bei Karotisdissektion nach chiropraktischer Manipulation [Horner's syndrome in dissection of the carotid artery after chiropractic manipulation].” Klin Monatsbl Augenheilkd 219(9): 673-6.

CASE REPORT: We report on a 37-year old patient with sudden onset of pain of the right scalp and an ipsilateral small pupil, presenting five weeks after chiropractic manipulation of the neck. METHODS/RESULTS: Pharmacologic pupil testing showed a postganglionic Horner’s syndrome on the right side. Magnetic resonance angiography confirmed the diagnosis of a dissection of the right internal carotid artery at a subacute stage. CONCLUSION: There appears to be a causal relationship between carotid artery dissection and the chiropractic manipulation of the cervical spine. Ophthalmological signs played the key role in detecting this complication.

43. Gittinger, J. W., Jr. (1986). ”Occipital infarction following chiropractic cervical manipulation.” J Clin Neuroophthalmol 6(1): 11-3.

A 44-year-old man developed a complete homonymous hemianopia 2 days after undergoing chiropractic cervical manipulation. Thromboembolism from the vertebrobasilar circulation–as the consequence of trauma to the vertebral arteries by adjacent bones, muscles, and ligaments during twisting and extension of the neck–is the probable mechanism for occipital infarction and other strokes in this and previous cases. Other neuroophthalmic manifestations reported include Horner’s syndrome and sixth nerve and gaze palsies.

44. Gouveia, L. O., P. Castanho, J. J. Ferreira, et al. (2007). ”Chiropractic manipulation: reasons for concern?” Clin Neurol Neurosurg 109(10): 922-5.

Chiropractic’s popularity is rising among the general population. Moreover, few studies have been conducted to properly evaluate its safety. We report three cases of serious neurological adverse events in patients treated with chiropractic manipulation. The first case is a 41 years old woman who developed a vertebro-basilar stroke 48 h after cervical manipulation. The second case represents a 68 years old woman who presented a neuropraxic injury of both radial nerves after three sessions of spinal manipulation. The last case is a 34 years old man who developed a cervical epidural haematoma after a chiropractic treatment for neck pain. In all three cases there were criteria to consider a causality relation between the neurological adverse events and the chiropractic manipulation. The described serious adverse events promptly recommend the implementation of a risk alert system.

45. Haavik-Taylor, H. and B. Murphy (2007). ”Cervical spine manipulation alters sensorimotor integration: a somatosensory evoked potential study.” Clinical Neurophysiology 118(2): 391-402.

OBJECTIVE: To study the immediate sensorimotor neurophysiological effects of cervical spine manipulation using somatosensory evoked potentials (SEPs). METHODS: Twelve subjects with a history of reoccurring neck stiffness and/or neck pain, but no acute symptoms at the time of the study were invited to participate in the study. An additional twelve subjects participated in a passive head movement control experiment. Spinal (N11, N13) brainstem (P14) and cortical (N20, N30) SEPs to median nerve stimulation were recorded before and for 30min after a single session of cervical spine manipulation, or passive head movement. RESULTS: There was a significant decrease in the amplitude of parietal N20 and frontal N30 SEP components following the single session of cervical spine manipulation compared to pre-manipulation baseline values. These changes lasted on average 20min following the manipulation intervention. No changes were observed in the passive head movement control condition. CONCLUSIONS: Spinal manipulation of dysfunctional cervical joints can lead to transient cortical plastic changes, as demonstrated by attenuation of cortical somatosensory evoked responses. SIGNIFICANCE: This study suggests that cervical spine manipulation may alter cortical somatosensory processing and sensorimotor integration. These findings may help to elucidate the mechanisms responsible for the effective relief of pain and restoration of functional ability documented following spinal manipulation treatment.

46. Haldeman, S., P. Carey, M. Townsend, et al. (2001). ”Arterial dissections following cervical manipulation: the chiropractic experience.” Cmaj 165(7): 905-6.

47. Haldeman, S., P. Carey, M. Townsend, et al. (2002). ”Clinical perceptions of the risk of vertebral artery dissection after cervical manipulation: the effect of referral bias.” Spine Journal: Official Journal of the North American Spine Society 2(5): 334-42.

BACKGROUND CONTEXT: The growing recognition of cervical manipulation as a treatment of neck pain and cervicogenic headaches has lead to increased interest in potential complications that may result from this treatment approach. Recent surveys have reported that many neurologists will encounter cases of vertebral artery dissection that occur at various times after cervical manipulation, whereas most practitioners of spinal manipulation are of the opinion that these events are extremely rare. We asked the question whether these differences in perception could be explained in part by referral or selection bias. PURPOSE: To assess the effect of referral bias on the differences in perceived incidence of vertebral artery dissection after cervical manipulation between neurologists and chiropractors in Canada. STUDY DESIGN: This study was a retrospective review of cases where neurological symptoms consistent with cerebrovascular ischemia were reported by chiropractors in Canada. METHODS: An analysis of data from a chiropractic malpractice insurance carrier (Canadian Chiropractic Protective Association [CCPA]) and results of a survey of chiropractors was performed to determine the likelihood that a vertebral artery dissection after cervical manipulation would be reported to practicing chiropractors. This was compared with the likelihood that a neurologist would be made aware of such a complication. RESULTS: For the 10-year period 1988 to 1997, there were 23 cases of vertebral artery dissection after cervical manipulation reported to the CCPA that represents 85% of practicing chiropractors in Canada. Based on the survey, an estimated 134,466,765 cervical manipulations were performed during this 10-year period. This gave a calculated rate of vertebral artery dissection after manipulation of 1:5,846,381 cervical manipulations. Based on the number of practicing chiropractors and neurologists during the period of this study, 1 of every 48 chiropractors and one of every two neurologists would have been made aware of a vascular complication from cervical manipulation that was reported to the CCPA during their practice lifetime. CONCLUSIONS: The perceived risk after cervical manipulation by chiropractors and neurologists is related to the probability that a practitioner will be made aware of such an incident. The difference in the number of chiropractors (approximately 3,840 in 1997) and neurologists (approximately 4,000 in 1997) in active practice and the fact that each patient who has a stroke after manipulation will likely be seen by only one chiropractor but by three or more neurologists partly explains the difference in experience and the perception of risk of these two professions. This selection or referral bias is important in shaping the clinical opinions of the various disciplines and distorts discussion on the true incidence of these complications of cervical manipulation. The nature of this study, however, describes the likelihood that a clinician will be made aware of such an event and cannot be interpreted as describing the actual risk of stroke after manipulation.

48. Haldeman, S., F. J. Kohlbeck and M. McGregor (2002). ”Stroke, cerebral artery dissection, and cervical spine manipulation therapy.” Journal of Neurology 249(8): 1098-104.

Stroke represents an infrequent adverse reaction associated with cervical spine manipulation therapy. Attempts to identify the patient at risk and the type of manipulation most likely to result in these complications of manipulation have not been successful. A retrospective review of 64 medical legal cases of stroke temporally associated with cervical spine manipulation was performed to evaluate characteristics of the treatment rendered and the presenting complaints in patients reporting these complications. These files included records from the practitioner who administered the manipulation therapy, post stroke testing and treatment records usually by a neurologist, and depositions of the patient and the practitioner of manipulation as well as expert and treating physicians. A retrospective review of the files was carried out by three (two in 11 cases) researchers using the same data abstraction instrument to independently assess each case. These independent reviews were followed by a consensus review in which all reviewers reached agreement on file content. Ninety two percent of cases presented with a history of head and/or neck pain and 16 (25 %) cases presented with sudden onset of new and unusual headache and neck pain often associated with other neurological symptoms that may represent a dissection in progress. The strokes occurred at any point during the course of treatment. Certain patients reporting onset of symptoms immediately after first treatment while in others the dissection occurred after multiple manipulations. There was no apparent dose-response relationship to these complications. These strokes were noted following any form of standard cervical manipulation technique including rotation, extension, lateral flexion and non-force and neutral position manipulations. The results of this study suggest that stroke, particularly vertebrobasilar dissection, should be considered a random and unpredictable complication of any neck movement including cervical manipulation. They may occur at any point in the course of treatment with virtually any method of cervical manipulation. The sudden onset of acute and unusual neck and/or head pain may represent a dissection in progress and be the reason a patient seeks manipulative therapy that then serves as the final insult to the vessel leading to ischemia.

49. Haldeman, S., F. J. Kohlbeck and M. McGregor (2002). ”Unpredictability of cerebrovascular ischemia associated with cervical spine manipulation therapy: a review of sixty-four cases after cervical spine manipulation.[see comment].” Spine 27(1): 49-55.

STUDY DESIGN: A retrospective review of 64 medicolegal records describing cerebrovascular ischemia after cervical spine manipulation was conducted. OBJECTIVES: To describe 64 cases of cerebrovascular accidents temporally associated with cervical spine manipulation therapy in terms of patient characteristics, potential risk factors, nature of complication, and neurologic sequelae. SUMMARY OF BACKGROUND DATA: Approximately 117 cases of postmanipulation cerebrovascular ischemia have been reported in the English language literature. Proposed risk factors include age, gender, migraine headaches, hypertension, diabetes, birth control pills, cervical spondylosis, and smoking. It is often assumed that these complications may be avoided by clinically screening patients and by premanipulation positioning of the head and neck to evaluate the patency of the vertebral arteries. METHODS: Three researchers using a uniform data abstraction instrument performed an independent review of 64 previously unpublished medicolegal records describing cerebrovascular ischemia after cervical spine manipulation. These cases were referred to a single physician for review over a 16-year period from across the United States and Canada. Descriptive statistics were calculated for characteristics of the patients and the complications. Means and standard deviations were computed for continuous variables. Frequencies and proportions were calculated for categorical variables. RESULTS: This study was unable to identify factors from the clinical history and physical examination of the patient that would assist a physician attempting to isolate the patient at risk of cerebral ischemia after cervical manipulation. CONCLUSION: Cerebrovascular accidents after manipulation appear to be unpredictable and should be considered an inherent, idiosyncratic, and rare complication of this treatment approach.

50. Haneline, M. T. and G. Lewkovich (2003). ”Malone D G, Baldwin N G, Tomecek F J, et al: Complications of cervical spine manipulation therapy: 5-year retrospective study in a single-group practice. Neurosurg Focus 13 (6):Clinical Pearl, 2002.[comment].” Neurosurgical Focus 14(3): e10; author reply e10.

51. Haneline, M. T. and G. N. Lewkovich (2005). ”An analysis of the etiology of cervical artery dissections: 1994 to 2003.” Journal of Manipulative & Physiological Therapeutics 28(8): 617-22.

OBJECTIVE: To provide a literature review of the etiologic breakdown of cervical artery dissections. METHODS: A literature search of the MEDLINE database was conducted for English-language articles published from 1994 to 2003 using the search terms cervical artery dissection (CAD), vertebral artery dissection, and internal carotid artery dissection. Articles were selected for inclusion only if they incorporated a minimum of 5 case reports of CAD and contained sufficient information to ascertain a plausible etiology. RESULTS: One thousand fourteen citations were identified; 20 met the selection criteria. There were 606 CAD cases reported in these studies; 321 (54%) were internal carotid artery dissection and 253 (46%) were vertebral artery dissection, not including cases with both. Three hundred seventy-one (61%) were classified as spontaneous, 178 (30%) were associated with trauma/trivial trauma, and 53 (9%) were associated with cervical spinal manipulation. If one apparently biased study is dropped from the data pool, the percentage of CADs related to cervical spinal manipulation drops to approximately 6%. CONCLUSIONS: The case series that were reviewed in this article indicated that most CADs reported in the previous decade were spontaneous but that some were associated with trauma/trivial trauma, and a minority with cervical spine manipulation. This etiologic breakdown of CAD does not differ significantly from what has been portrayed by most other authors.

52. Herzog, J. (1999). ”Use of cervical spine manipulation under anesthesia for management of cervical disk herniation, cervical radiculopathy, and associated cervicogenic headache syndrome.” Journal of Manipulative & Physiological Therapeutics 22(3): 166-70.

OBJECTIVE: To demonstrate the benefits of cervical spine manipulation with the patient under anesthesia as an approach to treating a patient with chronic cervical disk herniation, associated cervical radiculopathy, and cervicogenic headache syndrome. CLINICAL FEATURES: The patient had neck pain with radiating paresthesia into the right upper extremity and incapacitating headaches and had no response to 6 months of conservative therapy. Treatment included spinal manipulative therapy, physical therapy, anti-inflammatory medication, and acupuncture. Magnetic resonance imaging, electromyography, and somatosensory evoked potential examination all revealed positive diagnostic findings. INTERVENTION AND OUTCOME: Treatment included 3 successive days of cervical spine manipulation with the patient under anesthesia. The patient had immediate relief after the first procedure. Her neck and arm pain were reported to be 50% better after the first trial, and her headaches were better by 80% after the third trial. Four months after the last procedure the patient reported a 95% improvement in her overall condition. CONCLUSION: Cervical spine manipulation with the patient under anesthesia has a place in the chiropractic arena. It is a useful tool for treating chronic discopathic disease complicated by cervical radiculopathy and cervicogenic headache syndrome. The beneficial results of this procedure are contingent on careful patient selection and proper training of qualified chiropractic physicians.

53. Hubka, M. J., S. P. Phelan, P. M. Delaney, et al. (1997). ”Rotary manipulation for cervical radiculopathy: observations on the importance of the direction of the thrust.” J Manipulative Physiol Ther 20(9): 622-7.

OBJECTIVE: To describe the clinical presentation of eight patients with cervical spine radiculopathy, the manipulation technique used for each patient and the outcomes of treatment. CLINICAL FEATURES: The cause of radiculopathy in four patients was disc herniation. The other four patients had a combination of spondylosis, disc herniation and sprain injury. INTERVENTION AND OUTCOME: Six of eight patients had a good outcome associated with receiving manipulation performed by contacting the cervical spine at the level of the radiculopathy, laterally flexing toward the side of radiculopathy, rotating the neck away from the side of the radiculopathy and applying a gentle high-velocity, low-amplitude thrust. Two patients had an exacerbation of arm pain and increased neurological deficit associated with manipulation performed with the neck rotated toward the side of radiculopathy. CONCLUSION: There is little compelling evidence supporting or disputing the use of manipulation for patients with cervical spine radiculopathy. In our patients, rotary manipulation was associated with a different outcome depending on the direction of neck rotation. Prospective time-series studies and randomized, blind trials are needed to identify the efficacy and effectiveness of different manipulation techniques for this condition.

54. Hufnagel, A., A. Hammers, P. W. Schonle, et al. (1999). ”Stroke following chiropractic manipulation of the cervical spine.” Journal of Neurology 246(8): 683-8.

We analyzed the clinical course and neuroradiological findings of ten patients aged 27-46 years, with ischemic stroke secondary to vertebral artery dissection (VAD; n = or internal carotid artery dissection (CAD; n = 2), all following chiropractic manipulation of the cervical spine. The following observations were made: (a) All patients had uneventful medical histories, no or only mild vascular risk factors, and no predisposing vascular lesions. (b) VAD was unilateral in five patients and bilateral in three. VAD was located close to the atlantoaxial joint in all eight patients and showed additional involvement of lower sections in six, as well as temporary occlusion of one vertebral artery in three. (c) Nine of ten patients had brain infarction documented by magnetic resonance imaging or computed tomography. (d) Onset of symptoms was immediately after the manipulation (n = 5) or within 2 days (n = 5). (e) Progression of neurological deficits occurred within the following hours to a maximum of 3 weeks. (f) Maximum neurological deficits were severe in nine of ten patients. (g) Outcome after 4 weeks-3 years included no or mild neurological deficits in five patients, marked deficits in three, persistent locked-in syndrome in one, and persistent vegetative state in one. (h) Informed consent was obtained in only one of ten patients. Thus, patients at risk for stroke after chiropractic manipulation may not be identified a priori. Neurological deficits may be severely disabling and are potentially life threatening.

55. Hurley, L., K. Yardley, A. R. Gross, et al. (2002). ”A survey to examine attitudes and patterns of practice of physiotherapists who perform cervical spine manipulation.” Manual Therapy 7(1): 10-8.

As part of the process of developing a Clinical Practice Guideline (CPG) on cervical spine manipulation (CSM), a working group sent out an 82-item postal survey to 150 randomly selected Ontario physiotherapists (PTs) who perform spinal manipulation, to collect information on the socio-demographics, practices, opinions of risk, and attitudes towards CPGs of these PTs (n = 118; response rate = 79%). Of the 118 respondents who performed spinal manipulation, 41 performed CSM. Respondents strongly agreed with three out of six indications listed in the survey for applying CSM: segmental fixation, stiff but stable joint, internal derangement (over 70%). Respondents also strongly agreed (over 88%) that all screening tests listed in the survey should be performed prior to applying CSM: tests for irritability, stability, vascular and neurological systems. Respondents rated patient education, other manual therapy, and exercise as the most common adjuncts to CSM (over 88%). Respondents reported seeing mild complications or side effects only rarely following the application of CSM. Fourteen percent of respondents reported having a written CSM policy or CPG on CSM in their work setting. Feedback from this survey will be used in developing a CSM CPG. A future survey will evaluate changes in clinical practice and in attitudes toward CPGs some time after the dissemination of the CSM CPG. Copyright 2002 Elsevier Science Ltd.

56. Hurwitz, E. L., P. D. Aker, A. H. Adams, et al. (1996). ”Manipulation and mobilization of the cervical spine. A systematic review of the literature.[see comment].” Spine 21(15): 1746-59; discussion 1759-60.

STUDY DESIGN: Cervical spine manipulation and mobilization were reviewed in an analysis of the literature from 1966 to the present. OBJECTIVES: To assess the evidence for the efficacy and complications of cervical spine manipulation and mobilization for the treatment of neck pain and headache. SUMMARY OF BACKGROUND DATA: Although recent research has demonstrated the efficacy of spinal manipulation for some patients with low back pain, little is known about its efficacy for neck pain and headache. METHODS: A structured search of four computerized bibliographic data bases was performed to identify articles on the efficacy and complications of cervical spine manual therapy. Data were summarized, and randomized controlled trials were critically appraised for study quality. The confidence profile method of meta-analysis was used to estimate the effect of spinal manipulation on patients’ pain status. RESULTS: Two of three randomized controlled trials showed a short-term benefit for cervical mobilization for acute neck pain. The combination of three of the randomized controlled trials comparing spinal manipulation with other therapies for patients with subacute or chronic neck pain showed an improvement on a 100-mm visual analogue scale of pain at 3 weeks of 12.6 mm (95% confidence interval, -0.15, 25.5) for manipulation compared with muscle relaxants or usual medical care. The highest quality randomized controlled trial demonstrated that spinal manipulation provided short-term relief for patients with tension-type headache. The complication rate for cervical spine manipulation is estimated to be between 5 and 10 per 10 million manipulations. CONCLUSIONS: Cervical spine manipulation and mobilization probably provide at least short-term benefits for some patients with neck pain and headaches. Although the complication rate of manipulation is small, the potential for adverse outcomes must be considered because of the possibility of permanent impairment or death.

57. Hurwitz, E. L., H. Morgenstern, P. Harber, et al. (2002). ”A randomized trial of chiropractic manipulation and mobilization for patients with neck pain: clinical outcomes from the UCLA neck-pain study.[see comment].” American Journal of Public Health 92(10): 1634-41.

OBJECTIVES: This study compared the relative effectiveness of cervical spine manipulation and mobilization for neck pain. METHODS: Neck-pain patients were randomized to the following conditions: manipulation with or without heat, manipulation with or without electrical muscle stimulation, mobilization with or without heat, and mobilization with or without electrical muscle stimulation. RESULTS: Of 960 eligible patients, 336 enrolled in the study. Mean reductions in pain and disability were similar in the manipulation and mobilization groups through 6 months. CONCLUSIONS: Cervical spine manipulation and mobilization yield comparable clinical outcomes.

58. Hurwitz, E. L., H. Morgenstern, M. Vassilaki, et al. (2004). ”Adverse reactions to chiropractic treatment and their effects on satisfaction and clinical outcomes among patients enrolled in the UCLA Neck Pain Study.[see comment].” Journal of Manipulative & Physiological Therapeutics 27(1): 16-25.

BACKGROUND: Minor side effects associated with chiropractic are common. However, little is known about their predictors or the effects of reactions on satisfaction and clinical outcomes. OBJECTIVE: The objectives of this study are to compare the relative effects of cervical spine manipulation and mobilization on adverse reactions and to estimate the effects of adverse reactions on satisfaction and clinical outcomes among patients with neck pain. METHODS: Neck pain patients were randomized to receive cervical spine manipulation or mobilization. At 2 weeks, subjects were queried about possible treatment-related adverse reactions and followed for 6 months with assessments for pain and disability at 2, 6, 13, and 26 weeks. Numerical rating scales and the Neck Disability Index were used to measure pain and disability. Perceived improvement and satisfaction with care were assessed at 4 weeks. RESULTS: Of 960 eligible patients, 336 enrolled and 280 responded to the adverse event questionnaire. Thirty percent of respondents reported at least 1 adverse symptom, most commonly increased pain and headache. Patients randomized to manipulation were more likely than those randomized to mobilization to report an adverse reaction (adjusted odds ratio = 1.44, 95% confidence interval = 0.85, 2.43). Subjects reporting adverse reactions were less satisfied with care and less likely to have clinically meaningful improvements in pain and disability. CONCLUSIONS: Adverse reactions are more likely to be reported following cervical spine manipulation than mobilization. Chiropractors may reduce iatrogenesis and increase satisfaction and perhaps clinical outcomes by mobilizing rather than manipulating their neck pain patients.

59. Hurwitz, E. L., H. Morgenstern, M. Vassilaki, et al. (2005). ”Frequency and clinical predictors of adverse reactions to chiropractic care in the UCLA neck pain study.[see comment].” Spine 30(13): 1477-84.

STUDY DESIGN: Randomized clinical trial. OBJECTIVES: To document the types and frequencies of adverse reactions associated with the most common chiropractic treatments for neck pain, and to identify possible clinical predictors of adverse reactions to chiropractic treatment. SUMMARY OF BACKGROUND DATA: Chiropractic care is frequently sought by patients for relief from neck pain; however, adverse reactions related to its primary modes of treatment have not been well examined. METHODS: A total of 336 patients with neck pain presenting to 4 southern California health care clinics were randomized in a balanced 2 x 2 x 2 factorial design to manipulation with or without heat, and with or without electrical muscle stimulation (EMS); and mobilization with or without heat and with or without EMS. Discomfort or unpleasant reactions from chiropractic care were self-assessed at 2 weeks after the randomization/baseline visit. RESULTS: Of the 280 participants (83%) who responded, 85 (30.4%) had 212 adverse symptoms as a result of chiropractic care. Increased neck pain or stiffness was the most common symptom, reported by 25% of the participants. Less common were headache and radiating pain. Patients randomized to manipulation were more likely than those randomized to mobilization to have an adverse symptom occurring within 24 hours of treatment (adjusted odds ratio [OR] = 1.44, 95% confidence interval [CI] = 0.83, 2.49). Heat and EMS were only weakly associated with adverse symptoms (heat: OR = 0.94, 95% CI = 0.54, 1.62; EMS: OR = 1.09, 95% CI = 0.63, 1.89). Moderate-to-severe neck disability at baseline was strongly associated with adverse neurologic symptoms (OR = 5.70, 95% CI = 1.49, 21.80). CONCLUSIONS: Our results suggest that adverse reactions to chiropractic care for neck pain are common and that despite somewhat imprecise estimation, adverse reactions appear more likely to follow cervical spine manipulation than mobilization. Given the possible higher risk of adverse reactions and lack of demonstrated effectiveness of manipulation over mobilization, chiropractors should consider a conservative approach for applying manipulation to their patients, especially those with severe neck pain.

60. Inamasu, J. and B. H. Guiot (2005). ”Iatrogenic vertebral artery injury.” Acta Neurol Scand 112(6): 349-57.

Iatrogenic vertebral artery injury (VAI) results from various diagnostic and therapeutic procedures. The objective of this article is to provide an update on the mechanism of injury and management of this potentially devastating complication. A literature search was conducted using PubMed. The iatrogenic VAIs were categorized according to each diagnostic or therapeutic procedure responsible for the injury, i.e., central venous catheterization, cervical spine surgery, chiropractic manipulation, diagnostic cerebral angiography, percutaneous nerve block, and radiation therapy. The incidence, mechanisms of injury, and reparative procedures were discussed for each type of procedure. The type of VAI depends largely on the type of procedure. Laceration was the dominant type of acute injury in central venous catheterization and cervical spine surgery. Arteriovenous fistulae and pseudoaneurysms were the delayed complications. Arterial dissection was the dominant injury type in chiropractic manipulation and diagnostic cerebral angiography. Inadvertent arterial injection caused seizures or stroke in percutaneous nerve block. Radiation therapy was responsible for endothelial injury which in turn resulted in delayed stenosis and occlusion of the vertebral artery (VA). The proximal VA was the most vulnerable portion of the artery. Although iatrogenic VAIs are rare, they may actually be more prevalent than had previously been thought. Diagnosis of iatrogenic VAI may not always be easy because of its rarity and deep location, and a high level of suspicion is necessary for its early detection. A precise knowledge of the surgical anatomy of the VA is essential prior to each procedure to prevent its iatrogenic injury.

61. Izquierdo-Casas, J., L. Soler-Singla, E. Vivas-Diaz, et al. (2004). ”Diseccion vertebral como causa del sindrome de enclaustramiento y opciones terapeuticas con fibrinolisis intraarterial durante la fase aguda [Locked-in syndrome due to a vertebral dissection and therapeutic options with intraarterial fibrinolysis in acute phase].” Revista de Neurologia 38(12): 1139-41.

INTRODUCTION: Dissection of vertebral artery is an unusual pathology but sometimes is the cause of stroke in young patients. Since last years, and with the rise of some chiropractic technics, some authors have related these ones with the dissection of vertebral artery. CASE REPORT: We show a case of a 37 years old woman that after a chiropractic session began symptoms of posterior circulation dysfunction as decrease level of sense, tetraparesis and alteration of cranial nerves. The arteriography confirmed the existence of a vertebral dissection of V2 portion and thrombosis of basilar and contralateral vertebral arteries. Intraarterial fibrinolysis was performed with complete recanalization of the artery. Although this, the patient had parenchimal lesions in pons, cerebellum and territory of posterior cerebral artery that produced a locked-in syndrome. All the complementary exams were normal. DISCUSSION: We discuss the relationship between cervical manipulation as an aetiology of vertebral dissection, locked-in syndrome and therapeutic options in these patients

62. Jacobi, G., T. Riepert, M. Kieslich, et al. (2001). ”Uber einen Todesfall während der Physiotherapie nach Vojta bei einem 3 Monate alten Säugling. Fallbeschreibung und Bemerkungen zur Manualtherapie bei Kindern [Fatal outcome during physiotherapy (Vojta's method) in a 3-month old infant. Case report and comments on manual therapy in children].” Klinische Pädiatrie 213(2): 76-85.

Detailed clinical and neuropathological report on a fatal incident during the first manual therapy according to Vojta conducted in a 3 months old baby: during forced active rotation and head retraction the baby suffered from a bleeding into the adventitia of both her vertebral arteries at the level of C1 prompting ischemia of the caudal brainstem with subarachnoid haemorrhage around. It has to be suggested that similar cases already have occurred but have not been reported yet. There might be a time lag between the performance of physiotherapy and the beginning of neurologic symptoms. The risks of manual therapy in children will be discussed.

63. Jay, W. M., M. I. Shah and M. J. Schneck (2003). ”Bilateral occipital-parietal hemorrhagic infarctions following chiropractic cervical manipulation.” Semin Ophthalmol 18(4): 205-9.

A 26-year-old woman presented with acute headache and hand-motion vision in both eyes. One day prior to presentation she went to her chiropractor for cervical manipulation. The patient had received 20 chiropractic manipulations over the previous two years. CT scan and MRI showed bilateral, symmetric occipital-parietal hemorrhagic infarctions. Angiography revealed severe focal stenosis in the distal vertebral arteries bilaterally at the superior C1 level possibly representing dissections. There was also a pseudoaneurysm of the left vertebral artery at the C1 level. Risk factors included chiropractic manipulation, recent fever, and therapies for polycystic ovarian disease. The patient showed slow, steady improvement in her vision. Twenty days following admission, vision was 20/20 OU. The improvement in her vision most likely reflects the reduction in swelling and absorption of blood at the site of the strokes.

64. Jensen, T. W. (2003). ”Vertebrobasilar ischemia and spinal manipulation.” Journal of Manipulative & Physiological Therapeutics 26(7): 443-7.

OBJECTIVE: To examine cerebral arterial blood flow in 2 patients exhibiting signs of vertebrobasilar arterial ischemia (VBI) before and after spinal manipulative therapy. CLINICAL FEATURES: Two patients had a repetitive/resting tremor, one from a spastic torticollis with the onset immediately after self-manipulation by the patient 6 months earlier, and the second one with a generalized resting tremor, hip clonus, dizziness, and presyncope. The diagnosis of vertebrobasilar ischemia was established by continuous wave Doppler ultrasound and physical examination. INTERVENTION AND OUTCOME: Nonrotary cervical manipulation and diversified technique to the thoracic spine were performed. In the first patient, the spastic tremor improved by 80%. The repeat Doppler performed 13 months later showed an improvement in the arterial flow in the right external carotid artery peak flow from 0.7 kHz to 1.75 kHz. In the second patient, the resting tremor diminished in 4 days, with the right common carotid artery peak systolic flow improving from 1.0 kHz to 1.9 kHz and the left vertebral artery flow improving from 0.175 kHz to 0.5 kHz. The symptoms of VBI and objective Doppler findings improved following spinal manipulation. Both cases had impaired vertebral arterial flow. CONCLUSION: Spinal manipulation may have a normalizing effect on the sympathetic nervous system, allowing for a change in vasospastic cerebral vascular arteries.

65. Jentzen, J. M., J. Amatuzio and G. F. Peterson (1987). ”Complications of cervical manipulation: a case report of fatal brainstem infarct with review of the mechanisms and predisposing factors.” J Forensic Sci 32(4): 1089-94.

Medical and surgical complications of chiropractic manipulation occur infrequently in relation to the number of procedures performed. These complications include intracranial hemorrhage, spinal cord injuries, trauma to the carotid and vertebral arteries, and vertebral-basilar distribution infarction. This is a report of a case of vertebrobasilar infarction following chiropractic manipulation leading to a comatose state within 1 h following the manipulative procedure. This case report should alert the forensic pathologist to the possibility of cervical manipulation as a cause of acute brainstem infarction, and the mechanism and the predisposing factors to injury should be reviewed. The importance of careful autopsy technique and use of postmortem arteriographic techniques are emphasized.

66. Jeret, J. S. and M. Bluth (2002). ”Stroke following chiropractic manipulation. Report of 3 cases and review of the literature.” Cerebrovasc Dis 13(3): 210-3.

We present 3 cases of stroke due to arterial dissection following chiropractic manipulation: (1) a 31-year-old woman with left vertebral dissection developed a large cerebellar infarct, (2) a 64-year-old man developed a left parietal infarct due to left carotid dissection and (3) a 51-year-old man developed right Horner’s syndrome, fluctuating dysarthria, left facial droop, and left arm weakness due to right carotid dissection. Imaging studies and the literature are reviewed.

67. Johnson, D. W., G. Whiting and M. P. Pender (1993). ”Cervical self-manipulation and stroke.” Med J Aust 158(4): 290.

68. Jones, J. (2002). ”Neurologists warn about link between chiropractic, stroke.” Cmaj 166(6): 794.

69. Jones, M. R., R. Waggoner and W. F. Hoyt (1999). ”Cerebral polyopia with extrastriate quadrantanopia: report of a case with magnetic resonance documentation of V2/V3 cortical infarction.” J Neuroophthalmol 19(1): 1-6.

This is a case report of the occurrence of cerebral diplopia with right-side superior homonymous quadrantanopia in a young woman after chiropractic neck manipulation. Magnetic resonance imaging confirmed an infarct in the left inferior V2/V3 (extrastriate) cortex. The characteristics of the diplopia are illustrated with the patient’s drawings, and persisting abnormalities in perception are described in the area of the initial field defect after static (computed) visual field testing yielded normal results.

70. Kapral, M. K. and S. J. Bondy (2001). ”Cervical manipulation and risk of stroke.” Cmaj 165(7): 907-8.

71. Kawchuk, G. N. and W. Herzog (1993). ”Biomechanical characterization (fingerprinting) of five novel methods of cervical spine manipulation.” Journal of Manipulative & Physiological Therapeutics 16(9): 573-7.

OBJECTIVE: To determine the biomechanical characteristics of five clinically common methods of cervical spine manipulation. DESIGN: Descriptive study. SETTING: Human Performance Lab, University of Calgary. PARTICIPANTS: Five volunteer practitioners treating symptomatic patients from their own clinical populations. INTERVENTION: Five commonly used methods of cervical spine manipulation: lateral break (LAT), Gonstead (GON), Activator (ACT), toggle (TOG), rotation (ROT). MAIN OUTCOME MEASURE: Mean thrust duration (msec), normalized mean peak force (N), slope (N/msec), force profile (graphic representation of the above values. RESULTS: Outcome measures for each manipulative technique were as follows: LAT = normalized mean peak force of 102.2 N at 86.7 msec, GON = 109.8 N at 91.9 msec, ACT = 40.9 N at 31.8 msec, TOG = 117.6 N at 47.5 msec, ROT = 40.5 N at 79.1 msec. CONCLUSION: The observed differences and similarities in force profiles between the five techniques studied here may partly be the manifestation of how a particular technique delivers force to the cervical spine. The clinical significance of force profile characterization is not yet known.

72. Kawchuk, G. N., G. S. Jhangri, E. L. Hurwitz, et al. (2008). ”The relation between the spatial distribution of vertebral artery compromise and exposure to cervical manipulation.” Journal of Neurology 255(3): 371-7.

BACKGROUND AND PURPOSE: The vertebral artery is made up of four segments, one of which (V3) is connected to highly mobile cervical vertebrae. This connection underlies the common assumption that persons with pre-event histories of mechanical neck movements, such as cervical spine manipulation (cSMT), should experience increased V3 dissection. METHODS: Two of the largest case series of vertebral artery dissection describing subjects with and without a specific history of cSMT were reassessed to determine which segment(s) of the vertebral artery was most commonly compromised. RESULTS: The V3 segment was the most commonly involved vertebral artery segment in both the +cSMT group (e.g., V3 vs. V1 prevalence ratio (PR) = 8.46) and the -cSMT group (V3 vs. V1 PR = 4.00). However, V3 vulnerability was augmented by the effect of cSMT. The joint effect of V3 location and exposure to cSMT was greater than if each effect were simply combined. In addition,multiple site lesions were significantly more common than single sites in both the +cSMT group (PR = 2.67, p = 0.008) and the -cSMT group (PR = 2.44, p = 0.0008). CONCLUSIONS: In prior studies which identified vertebral artery compromise, those with a history of cSMT were more likely to have involvement of the V3 segment. Although this study does not identify a mechanism which relates vertebral artery dissection and exposure to cSMT, these data are compatible with a greater than additive relation between compromise of an arterial segment thought to be mechanically vulnerable and history of a mechanical event.

73. Kawchuk, G. N., S. Wynd and T. Anderson (2004). ”Defining the effect of cervical manipulation on vertebral artery integrity: establishment of an animal model.” Journal of Manipulative & Physiological Therapeutics 27(9): 539-46.

BACKGROUND: Cervical spine manipulation is most often performed to affect relief of musculoskeletal complaints of the head and neck. Performed typically without complication, this modality is thought to be a potential cause of cerebrovascular injury, although a cause-effect relation has yet to be established. To explore this relation, an experimental platform is needed that is accessible and biologically responsive. OBJECTIVE: To establish an animal model capable of accommodating (1) direct study of its vertebral arteries and (2) creation of controlled interventions simulating arterial injury. STUDY DESIGN: Descriptive. METHODS: Under fluoroscopic guidance, an ultrasonic catheter was inserted into the left vertebral artery of 3 anesthetized dogs. The ultrasonic probe was then drawn proximally through the artery at a specific rate, and cross-sectional images of the vessel were collected. These images were then reconstructed to provide a variety of 2- and 3-dimensional representations of the vessel. This procedure was repeated after the overinflation and/or displacement of an angiographic balloon within the vertebral artery itself. RESULTS: The resulting ultrasonic images were able to delineate the structural layers that constitute the vertebral artery. Analysis of 2- and 3-dimensional reconstructions before and after angiographic intervention revealed the creation of discrete vascular injuries (aneurysm or dissection). CONCLUSIONS: For the first time, an animal model has been established that permits direct interrogation of the internal structures of the vertebral artery. This model can also be manipulated to create ”preexisting” vascular injuries that are thought to be possible prerequisites for cerebrovascular injury associated with manipulation. As a result, an experimental platform has been established that is capable of providing investigators of all backgrounds with the ability to quantify biologic and mechanical outcomes of cervical manipulation.

74. Kewalramani, L. S., D. L. Kewalramani, M. Krebs, et al. (1982). ”Myelopathy following cervical spine manipulation.” American Journal of Physical Medicine 61(4): 165-75.

Manipulation of the spine, a controversial mechanotherapeutic procedure, has been taught and practiced widely. Occlusion of vertebral, basillar, and cerebellar arteries with head and neck manipulation is well documented in the literature. However, there is a paucity of references about myelopathy associated with cervical spine manipulation. Three cases of cervical myelopathy following spinal manipulation are presented. All patients noted increase in cervical pain following manipulation, developed significant sensary/motor deficits within 24 hours and became tetraparetic. Two patients were found to have fracture of C5 and C6 vertebral bodies. On myelography, partial block was noted in all and widening of the spinal cord was noted in two. One patient underwent excision of C5 vertebral body and anterior interbody fusion C4/6. Two patients underwent cervical laminectomy. Hematomyelia was present in one, and in the other patient the spinal cord was reported to be hyperemic and oedematous. Only one patient showed neurological return and became ambulatory, while the other two remained tetraparetic.

75. Kier, A. L. and P. W. McCarthy (2006). ”Cerebrovascular accident without chiropractic manipulation: a case report.” J Manipulative Physiol Ther 29(4): 330-5.

OBJECTIVE: To discuss the case of a patient with chronic headache. Although not in severe pain at time of consultation, signs and symptoms raised concern. The patient later had a cerebrovascular accident. CLINICAL FEATURES: A 49-year-old man with non-traumatic chronic episodic head and neck pain presented for care. Examination and plain film radiographs were unremarkable, suggesting a mechanical origin for the symptoms; however, information in the case history raised concerns. INTERVENTION AND OUTCOME: The patient was examined and not manipulated by the doctor of chiropractic but referred back to his general practitioner for a second opinion. The following week, the patient was admitted to hospital having had a cerebrovascular accident. CONCLUSION: The possible indication of the prodrome to a stroke may lie in the case history rather than the examination findings and provocative testing.

76. Klein, P., C. Broers, V. Feipel, et al. (2003). ”Global 3D head-trunk kinematics during cervical spine manipulation at different levels.” Clinical Biomechanics 18(9): 827-31.

OBJECTIVE: Determination of the three-dimensional kinematics of the head relative to the upper trunk obtained during a manipulation applied on two different cervical levels and on both sides. DESIGN: Descriptive study performed on 14 asymptomatic volunteers. The range of motion was measured by a 3D electrogoniometer during manipulation executed by the same practitioner. BACKGROUND: Spinal manipulative therapy is a common treatment approach in patients suffering from some spinal disorders. Complications exist; they are thought to be related to the force applied by the practitioner and the range of spinal motion obtained during the manipulation. Yet, little is known about cervical spine motion during manipulation. METHODS: Three dimensional electrogoniometry using a 6 degree-of-freedom spatial linkage fixed between the head and the upper trunk was used to record the pattern of motion and the amplitudes obtained during a manipulation on two cervical levels (C3 and C5) and on left and right sides. On single practitioner applied the same technique to all subjects in a seated position. RESULTS: The side and the spinal level manipulated did not influence 3D ranges of motion. The mean ranges of motion obtained were 30 degrees axial rotation, 46 degrees lateral bending and 2 degrees flexion. A significant difference of the flexion-extension range existed between manipulations with and without audible release. Axial rotation and lateral bending ranges were correlated. Except for lateral bending which was close to active range, the motion ranges obtained during manipulation were well below active range of motion reported in literature. CONCLUSIONS: The results of this study suggest that for the kind of manipulation applied, maximal amplitude between head and trunk does not exceed physiological active range of motion. The amplitude for rotation, which is generally assumed to involve greatest risks for negative side effects, is significantly lower than during active motion. As the study was performed with one practitioner, this result may only be generalized with care. RELEVANCE: In spinal manipulative therapy, extreme range of motion as the result of the forces applied is generally believed to represent a major risk for negative side effects, especially with regard to the cervical spine. With a multiple component technique, amplitudes between head and upper trunk were shown not to differ significantly with regard to the side nor to the spinal level. Recorded ranges of motion did not exceed those reported for active motion in literature.

77. Koch, L. E., H. Biedermann and K. S. Saternus (1998). ”High cervical stress and apnoea.” Forensic Science International 97(1): 1-9.

The aim of this study was to investigate vegetative reactions in infants after mechanical irritation of the suboccipital region. The investigation is based on 199 infants who were observed while being treated with a suboccipital impulse (manual therapy). The results revealed vegetative reactions in more than half of all cases (52.8%, n = 105). The frequency of such vegetative reactions observed was at follows: flush 48.7% (n = 97), apnoea 22.1% (n = 44), hyperextension 13% (n = 26), and sweating 7.5% (n = 15). It is pointed out that approximately 25% of all the infants examined reacted by apnoea due to a mechanical irritation of the suboccipital region. This symptom was part of an extensive vegetative reaction. This method of inducing an apnoea has not yet been described; from this it follows that there are close relations to sudden infant death.

78. Koch, L. E., H. Koch, S. Graumann-Brunt, et al. (2002). ”Heart rate changes in response to mild mechanical irritation of the high cervical spinal cord region in infants.” Forensic Science International 128(3): 168-76.

Alterations in the heart rate were monitored before, during and after the application of a unilateral mechanical impulse to the high cervical spinal cord region which was administered strictly in connection with the so called manual therapy (diagnosis= KISS). The investigation is based on a survey of 695 infants between the ages of 1 and 12 months. A notable change in the heart rate was evident in 47.2% of all examined infants (n= 695). In 40.1% of these infants, the change in heart rate was characterized by heart rate decrease of 15-83% compared to control conditions. Infants in their first 3 months of life responded more often with a severe bradycardia (50-83% decrease), older infants (7-12 months) more often with a mild bradycardia (15-49.9% decrease). This comparison revealed a significantly increased occurrence of severe bradycardia in the younger age group compared to the group of children >3 months (significance 0.0017). In 12.1% (n= 84) of the infants, the bradycardia was accompanied by an apnea. We discuss the hypothesis that mechanical irritation of the high-cervical region serves as a trigger that may be involved in sudden infant death (SID).

79. Kponkton, A., C. Hamonet, A. Montagne, et al. (1992). ”Complications de la manipulation cervicale. Une observation de ”locked-in syndrome” [Complications of cervical spine manipulation. A case of "locked-in syndrome"].” Presse Medicale 21(42): 2050-2.

The current craze for cervical spine manipulation is due to its rapid and even dramatic results and to the ineffectiveness of many treatments prescribed by physicians. Complications of thoracic or lumbar spine manipulation are very rarely reported, but this is not the case with the cervical spine. We present the case of a woman who suffered a severely disabling complication caused by an ”osteopathic” manoeuvre. This technique should be rejected as it is dangerous and as harmless methods can be used with good results in common cervicalgia, even if it is very severe.

80. Kraft, C. N., R. Conrad, M. Vahlensieck, et al. (2001). ”Nicht-zerebrovaskuläre Komplikationen der chirotherapeutischen HWS-Manipulation [Non-cerebrovascular complication in chirotherapy manipulation of the cervical vertebrae].” Zeitschrift fur Orthopadie und Ihre Grenzgebiete 139(1): 8-11.

PURPOSE: Chirotherapy is a popular and successful management option for reversible functional disorders of the cervical spine. Though rarely observed, complications do occur, mainly involving the cerebrovascular system. By means of the here described case and a literature survey, we aim to highlight non-cerebrovascular complications of chirotherapeutic cervical spine manipulation. RESULTS: A 43-year-old male initially consulted an ENT specialist, suffering from tinnitus aurium and loss of hearing ability. His hearing significantly increased after intravenous drug therapy, but the tinnitus remained. During chiropractic manipulation of the cervical spine by an orthopaedic surgeon for the tinnitus, the patient described severe neck pain following a clearly audible clicking sound. Scans of the cervical spine prior to and after manipulation showed an intracapsular/intraosseus oedema of the facet joints C2/C3 with lesion of the nerve root C3, most probably induced by chirotherapy. CONCLUSION: Although complications after chiropractic manipulation are extremely rare, treatment of the spine, especially the cervical spine, is not wholly harmless. An adequate history taking followed by clinical and radiographic patient evaluation is necessary to keep the risk of iatrogenic trauma at a minimum. Above all, the chiropractic manipulation of the cervical spine belongs in the hands of a qualified and experienced medical practitioner.

81. Krakauer, J. (2001). ”Literature alert.” Curr Neurol Neurosci Rep 1(5): 408-9.

(Inget abstract, men bland Keywords: ”Chiropractic/*adverse effects, Stroke/*etiology”)

82. Krespi, Y., M. E. Gurol, O. Coban, et al. (2002). ”Vertebral artery dissection presenting with isolated neck pain.” Journal of Neuroimaging 12(2): 179-82.

Unilateral pain in the cervical region and limitation of neck movements are nonspecific symptoms frequently encountered in daily medical practice. Vertebral artery dissection is rarely considered as a diagnostic possibility unless brainstem or cerebellar ischemia follows the acute pain. Three cases of vertebral artery dissection (VAD) having the sole complaint of pain of acute onset in the posterior neck region are presented. None of the patients had ever reported a similar pain, and the neurological examination was unremarkable in all of them. Doppler ultrasonography suggested VAD in 2 cases, and the diagnosis was confirmed with T1 fat-suppressed magnetic resonance imaging technique in all patients. Severe neck pain and/or occipital headache frequently accompanies ischemic symptoms in cases with VAD. The cases in this report emphasize that spontaneous and often unilateral posterior cervical pain of acute onset can be the only manifestation of a VAD. A high degree of suspicion especially in young patients with no past history of a similar pain can help to establish the diagnosis, thereby preventing erroneous and potentially hazardous therapeutic interventions such as physiotherapy or neck manipulation.

83. Krieger, D., M. Leibold and H. Bruckmann (1990). ”Dissektionen der Arteria vertebralis nach zervikalen chiropraktischen Manipulationen [Dissections of the vertebral artery following cervical chiropractic manipulations].” Deutsche Medizinische Wochenschrift 115(15): 580-3.

In a 37-year-old female patient complaining of increasing pain in the neck and occiput, chiropractic manipulations at the cervical vertebral column were associated with ischaemias of the brain stem presenting as vertigo, transient ”locked-in” syndrome followed by vomiting, and sensorimotor hemiparesis. Digital subtraction angiography (DSA) revealed complete obstruction of the right and slight dissection of the left vertebral artery. The symptoms receded within a few days after heparinisation with 1000 IU/h intravenously. A 39-year-old female patient developed vertigo, nystagmus, tetraparesis and dysarthria two days after chiropractic intervention because of refractory pain in the neck and occiput. DSA showed embolism of the basilar artery and extensive dissections of the vertebral arteries. The basilar artery was completely recanalized after local intraarterial fibrinolysis with 50,000 IU urokinase. During the further course of treatment the symptoms receded under heparin and phenprocoumon over a period of 8 months, except for hemiparesis on the left side especially affecting the arm. Trivial traumas can result in dissections of the vertebral arteries. Severe neck pain is a frequent, typical early symptom. Hence, patients with cervical vertebral column syndromes should receive chiropractic treatment only after careful diagnosis.

84. Krueger, B. R. and H. Okazaki (1980). ”Vertebral-basilar distribution infarction following chiropractic cervical manipulation.” Mayo Clinic Proceedings 55(5): 322-32.

Previous case reports of vertebral-basilar system infarction following chiropractic cervical manipulation have emphasized the role of predisposing factors such as cervical spondylosis, atherosclerosis, and congenital asymmetry of the posterior circulation. Ten patients without prior neurologic symptoms had vertebral-basilar system infarction promptly after chiropractic maneuvers. One patient, who was free of clinical and radiographic evidence of predisposing factors, subsequently died. Autopsy studies revealed massive nonhemorrhagic brainstem infarction due to bilateral vertebral artery thrombosis. Nine patients survived with residual neurologic deficits due to lesions in various locations of the posterior circulation. No patient received anticoagulants. Previous case reports are summarized and the kinetic anatomy of the vertebral arteries is reviewed to clarify the potential mechanisms involved in the pathogenesis of this entity. Although a causal relationship may be difficult to establish in individual cases, cervical manipulation seems to be the major identifiable factor in the pathogenesis of stroke in some patients.

85. Kukurin, G. W. (2004). ”The amelioration of symptoms in cervical spinal stenosis with spinal cord deformation through specific chiropractic manipulation: a case report with long-term follow-up.” J Manipulative Physiol Ther 27(5): e7.

OBJECTIVE: To describe the chiropractic management of a patient with paresthesia on the entire left side of her body and magnetic resonance imaging (MRI)-documented cervical spinal cord deformation secondary to cervical spinal stenosis. CLINICAL FEATURES: A 70-year-old special education teacher had neck pain, headaches, and burning paresthesia on the entire left side of her body. These symptoms developed within hours of being injured in a side-impact motor vehicle accident. Prior to her visit, she had been misdiagnosed with a cerebrovascular accident. INTERVENTION AND OUTCOMES: Additional diagnostic studies revealed that the patient was suffering from cervical spinal stenosis with spinal cord deformation. Two manipulative technique systems (Advanced Biostructural Therapy and Atlas Coccygeal Technique) unique to the chiropractic profession and based on the theory of relief of adverse mechanical neural tension were administered to the patient. This intervention provided complete relief of the patient’s complaints. The patient remained symptom-free at long-term follow-up, 1 year postaccident. CONCLUSION: There is a paucity of published reports describing the treatment of cervical spinal stenosis through manipulative methods. Existing reports of the manipulative management of cervical spondylosis suggest that traditional manual therapy is ineffective or even contraindicated. This case reports the excellent short-term and long-term response of a 70-year-old patient with MRI-documented cervical spinal stenosis and spinal cord deformation to less traditional, uniquely chiropractic manipulative techniques. This appears to be the first case (reported in the indexed literature) that describes the successful amelioration of the symptoms of cervical spinal stenosis through chiropractic manipulation. More research into the less traditional chiropractic systems of spinal manipulation should be undertaken.

86. Leaver, A. M., K. M. Refshauge, C. G. Maher, et al. (2007). ”Efficacy of manipulation for non-specific neck pain of recent onset: design of a randomised controlled trial.” BMC Musculoskelet Disord 8: 18.

BACKGROUND: Manipulation is a common treatment for non-specific neck pain. Neck manipulation, unlike gentler forms of manual therapy such as mobilisation, is associated with a small risk of serious neurovascular injury and can result in stroke or death. It is thought however, that neck manipulation provides better results than mobilisation where clinically indicated. There is long standing and vigorous debate both within and between the professions that use neck manipulation as well as the wider scientific community as to whether neck manipulation potentially does more harm than good. The primary aim of this study is to determine whether neck manipulation provides more rapid resolution of an episode of neck pain than mobilisation. METHODS/DESIGN: 182 participants with acute and sub-acute neck pain will be recruited from physiotherapy, chiropractic and osteopathy practices in Sydney, Australia. Participants will be randomly allocated to treatment with either manipulation or mobilisation. Randomisation will occur after the treating practitioner decides that manipulation is an appropriate treatment for the individual participant. Both groups will receive at least 4 treatments over 2 weeks. The primary outcome is number of days taken to recover from the episode of neck pain. Cox regression will be used to compare survival curves for time to recovery for the manipulation and mobilisation treatment groups. DISCUSSION: This paper presents the rationale and design of a randomised controlled trial to compare the effectiveness of neck manipulation and neck mobilisation for acute and subacute neck pain.

87. Lee, K. P., W. G. Carlini, G. F. McCormick, et al. (1995). ”Neurologic complications following chiropractic manipulation: a survey of California neurologists.” Neurology 45(6): 1213-5.

To obtain an estimate of how often practicing neurologists in California encounter unexpected strokes, myelopathies, or radiculopathies following chiropractic manipulation, we surveyed each member of the American Academy of Neurology in California and inquired about the number of patients evaluated over the preceding 2 years who suffered a neurologic complication within 24 hours of chiropractic manipulation. Four hundred eighty-six neurologists were surveyed, 177 responded; 55 strokes, 16 myelopathies, and 30 radiculopathies were reported. Patients were between the ages of 21 and 60, and the majority experienced complications following cervical manipulation. Most of the patients continued to have persistent neurologic deficits 3 months after the onset, and about one-half had marked or severe deficits. Nearly all of the strokes involved the posterior circulation and almost one-half were angiographically proven. Patients, physicians, and chiropractors should be aware of the risk of neurologic complications associated with chiropractic manipulation.

88. Lemmens, B., L. Kouyoumdjian, P. Cotty, et al. (1992). ”Paralyse phrenique apres manipulation vertebrale cervicale [Phrenic nerve paralysis after cervical spine manipulation].” Presse Medicale 21(35): 1685-6.

89. Leon-Sanchez, A., A. Cuetter and G. Ferrer (2007). ”Cervical spine manipulation: an alternative medical procedure with potentially fatal complications.[see comment].” Southern Medical Journal 100(2): 201-3.

There are multiple reports in the literature of serious and at times fatal complications after cervical spine manipulation therapy (CSMT), even though CSMT is considered by some health providers to be an effective and safe therapeutic procedure for head and neck pain syndromes. We report a case of a young female with cervicalgia and headache with fatal posterior circulation cerebrovascular accident after CSMT. Serious complications are infrequent, with a reported incidence between one per 100,000 to one in 2 million manipulations. The most frequent injuries involve artery dissection or spasm. Stroke as a complication of cervical manipulation and dissection of the vertebral arteries (VAD) is a rare but well recognized problem. Neck pain, headache, vertigo, vomiting and ataxia are typical symptoms of VAD, but this vascular injury also can be asymptomatic. The most common risk factors are migraine, hypertension, oral contraceptive pills and smoking. Stroke following CSMT is more common than the literature reports. The best values derive from retrospective surveys. The lack of identifiable risk factors place those who undergo CSMT at risk of neurologic damage. Accurate patient information and early recognition of the symptoms are important to avoid catastrophic consequences.

90. Lersa, L. B., C. M. Stinear and R. A. Lersa (2005). ”The relationship between spinal dysfunction and reaction time measures.” Journal of Manipulative & Physiological Therapeutics 28(7): 502-7.

OBJECTIVE: The objective of this study was to investigate the relationship between the number of sites of spinal dysfunction and a range of measures of cognitive processing. METHODS: This double-blind, randomized, observational pilot study was performed at a chiropractic college clinical training facility. Thirty volunteers with clinical evidence of cervical spinal joint dysfunction participated. Subjects were classified into 2 groups depending on whether they exhibited signs of cervical spinal joint dysfunction at one or more sites. A range of computer-based tasks was used to determine simple reaction time (RT), choice RT, probe RT, and inhibition of a preplanned response. RESULTS: Multiple sites of cervical spinal joint dysfunction were related to impaired cortical processing as revealed by significantly higher loads on central capacity, significantly less accurate response selection, and a trend toward more variable performance of an anticipated response. Multiple sites of cervical spinal joint dysfunction do not appear to be related to the speed of response selection or the ability to inhibit a preplanned response. CONCLUSION: This pilot study provides a context for the improvements in cortical processing observed after cervical spine adjustment. It shows that probe RT may be a useful tool in further studies examining the effects of cervical spine manipulation of joint dysfunction and the associated effect on cognitive function.

91. Lewkovich, G. N. and M. T. Haneline (2005). ”Patient recall of the mechanics of cervical spine manipulation.” Journal of Manipulative & Physiological Therapeutics 28(9): 708-12.

OBJECTIVE: To determine how accurately patients with neck pain and/or headache can recall the mechanics of their cervical spine manipulative therapy immediately after its administration. METHODS: A survey analysis of immediate patient recall after cervical spine manipulative therapy was performed in a private clinic. The group consisted of 94 sequentially presenting neck pain and/or headache patients with 54 (57%) females and 40 (43%) males. The mean age of the patients was 41.9 years (SD = 13.8; range, 17-96 years). Patients received diversified cervical spine manipulative therapy using a standardized set-up of lateral flexion coupled with flexion. Immediately after the cervical spine manipulative therapy, each patient completed a one-page questionnaire regarding the mechanics of the procedure. Patient responses were analyzed to determine the accuracy of their recall of head positioning. RESULTS: Among the patients, 78.7% reported that they experienced a component of rotation and/or extension, although the technique used involved a premanipulative set-up of lateral bending coupled with flexion. CONCLUSION: Patients with primary complaints of neck pain and/or headache, when asked to recall the mechanics of their recently applied cervical spine manipulative therapy, displayed a low rate of accuracy. Rotation and/or extension of the cervical spine were the most frequently given incorrect responses.

92. Licht, P. B., H. W. Christensen and P. F. Hoilund-Carlsen (1999). ”Vertebral artery volume flow in human beings.” Journal of Manipulative & Physiological Therapeutics 22(6): 363-7.

BACKGROUND: A number of studies have investigated vertebral artery flow velocity. Because perfusion relates to the volume of blood flowing through the vessel, this parameter is of great importance when vertebral artery hemodynamics are investigated. We could not find any such Doppler studies in the literature, possibly because of known errors with previous techniques. New advanced color-coded duplex sonography has since been validated and may be used with confidence for volume flow investigations. OBJECTIVE: To use advanced color-coded duplex sonography to investigate volume flow through the vertebral arteries during cervical rotation, as well as before and after spinal manipulation therapy. DESIGN AND SETTING: A randomized controlled study at a university hospital vascular laboratory. PARTICIPANTS: Twenty university students. RESULTS: Volume blood flow through the vertebral arteries does not change with cervical rotation or after spinal manipulation therapy. CONCLUSION: This appears to be the first in vivo Doppler study on human vertebral artery volume blood flow. Our results indicate that in symptom-free subjects there is no change in vertebral artery perfusion during rotation in spite of significant changes in flow velocity. This finding, as well as the observed changes in flow velocity reported by others, may be explained by a positional change in the vertebral artery diameter. In addition, we have investigated volume blood flow in the vertebral arteries before or after spinal manipulation therapy but found no significant changes.

93. Licht, P. B., H. W. Christensen and P. F. Hoilund-Carlsen (2000). ”Is there a role for premanipulative testing before cervical manipulation?” Journal of Manipulative & Physiological Therapeutics 23(3): 175-9.

BACKGROUND: Spinal manipulative therapy is used millions of times every year to relieve symptoms from biomechanic dysfunction of the cervical spine. Concern about cerebrovascular accidents after cervical manipulative therapy is common but rarely reported. Premanipulative tests of the vertebral artery are presumed to identify patients at risk but controversy exists about their usefulness. OBJECTIVE: The aim of this study was to examine vertebral artery blood flow in patients with a positive premanipulative test for contraindication to spinal manipulative therapy and to investigate if chiropractors would reconsider treating such patients if dynamic vascular Doppler examination was normal. DESIGN AND SETTING: A prospective study at a university hospital vascular laboratory. METHODS: Chiropractors in private practice from 3 Danish counties referred patients with a positive premanipulative test for an examination of vertebral artery blood flow. Premanipulative testing was performed by an experienced chiropractor. Flow velocities were measured in both vertebral arteries by color duplex sonography. In addition, chiropractors were asked if they would treat their patient despite a positive premanipulative test if the vascular ultrasound examination was normal. RESULTS: A total of 20 consecutive patients with a positive premanipulative test were referred. Five were excluded because symptoms could not be reproduced during the vascular examination. In the remaining patients, no significant difference in peak flow velocity or time-averaged mean flow velocity with different head positions was found. Nineteen of 21 chiropractors would treat a patient with a positive premanipulative test if the vascular examination was normal. Eight of the patients with a positive manipulative test were treated without complications. Six are now symptom-free, and 2 have improved symptoms. The remaining 8 patients refused manipulation and continue to have the same symptoms. CONCLUSION: It appears that a positive premanipulative test is not an absolute contraindication to manipulation of the cervical spine. If the test is able to identify patients at risk for cerebrovascular accidents, we suggest patients with a reproducible positive test should be referred for a duplex examination of the vertebral artery flow. If duplex flow is normal, the patient should be eligible for cervical manipulation despite the positive premanipulative test.

94. Licht, P. B., H. W. Christensen and P. F. Hoilund-Carlsen (2002). ”Carotid artery blood flow during premanipulative testing.” Journal of Manipulative & Physiological Therapeutics 25(9): 568-72.

BACKGROUND: Cervical manipulation is used millions of times every year. Concern about cerebrovascular accidents (CVAs) is common, but actual cases are rarely reported. Premanipulative tests are presumed to identify patients at risk of CVA. In an earlier study we found no significant changes in the vertebral artery blood flow of patients with a positive premanipulative test with different head positions. Consequently, we questioned whether there is a role for premanipulative testing to identify patients at risk of CVAs. OBJECTIVE: The aim of this study was to examine whether instead, blood flow velocity in the internal carotid arteries changes with head position in patients with a positive premanipulative test, potentially giving contraindication to cervical manipulation. METHODS: In a prospective study private practicing chiropractors from 3 Danish counties referred patients with a positive premanipulative test for an examination of cervical artery blood flow. Premanipulative testing was performed by an experienced chiropractor, and flow velocities were measured in both vertebral and internal carotid arteries by color duplex sonography at a university hospital vascular laboratory. RESULTS: A total of 11 consecutive patients with a positive premanipulative test were referred. Two of these were excluded because we could not reproduce any symptoms at repeat premanipulative testing before the vascular examination. In the remaining 9 patients we found no significant difference with different head positions in peak flow velocity or time-averaged mean flow velocity in the internal carotid arteries. Blood flow did not cease in 1 single patient despite a positive premanipulative test in all. CONCLUSION: It appears that a positive premanipulative test is not associated with a change in peak flow velocity or time-averaged mean flow velocity in either the carotid or the vertebral arteries. If premanipulative testing is used solely for the detection of vascular insufficiency as a potential substrate for CVAs after cervical manipulation, we believe that premanipulative testing is of little clinical value.

95. Licht, P. B., H. W. Christensen and P. F. Hoilund-Carlsen (2003). ”Is cervical spinal manipulation dangerous?” Journal of Manipulative & Physiological Therapeutics 26(1): 48-52.

OBJECTIVE: Concern about cerebrovascular accidents after cervical manipulation is common. We report a case of cerebrovascular infarction without sequelae. CLINICAL FEATURES: A 39-year-old man with nonspecific neck pain was treated by his general practitioner with cervical manipulation. INTERVENTION AND OUTCOME: This immediately elicited severe headache and neurologic symptoms that disappeared completely within 3 months despite permanent signs of a complete left-sided cerebellar infarction on computed tomography and magnetic resonance imaging. At 7-year follow-up the patient was fully employed, and repeated magnetic resonance imaging still showed infarction of the left cerebellar hemisphere. However, the patient remained completely free of neurologic symptoms, and color duplex ultrasonography showed normal cervical vessels, including patent vertebral arteries. CONCLUSION: It appears that the risk of cerebrovascular accidents after cervical manipulation is low, considering the enormous number of treatments given each year, and very much lower than the risk of serious complications associated with generally accepted surgery. Provided there is a solid indication for cervical manipulation, we believe that the risk involved is acceptably low and that the fear of serious complications is greatly exaggerated.

96. Licht, P. B., H. W. Christensen, P. Svendensen, et al. (1999). ”Vertebral artery flow and cervical manipulation: an experimental study.” Journal of Manipulative & Physiological Therapeutics 22(7): 431-5.

BACKGROUND: Spinal manipulation therapy is used by millions of patients each year to relieve symptoms caused by biomechanical dysfunction of the spine. Cerebrovascular accidents in the posterior cerebral circulation are a feared complication, but little research has been done on vertebral artery hemodynamics during cervical manipulation. OBJECTIVE: The purpose of this study was to develop an experimental model for investigations of volume blood flow changes in the vertebral arteries during premanipulative testing of these vessels and during spinal manipulation therapy of the cervical spine. DESIGN AND SETTING: An experimental study in a university biomedical laboratory. MATERIAL AND METHODS: The vertebral arteries were exposed in 8 adult pigs after extensive mediastinal dissection. Volume blood flow was measured on both sides simultaneously by advanced transit-time flowmetry. RESULTS: After cervical manipulation, the vertebral artery volume blood flow increased significantly for 40 seconds before returning to baseline values in less than 3 minutes. We found no significant changes in volume flow during premanipulative testing of the vertebral arteries (DeKleyn’s test). CONCLUSION: We present an experimental model for investigations of vertebral artery hemodynamics during biomechanical interventions. We found a modest and transient effect of cervical manipulation on vertebral artery volume flow. The model may have further applications in future biomechanical research, for example, to determine whether any of several spinal manipulative techniques imposes less strain on the vertebral artery, thereby reducing possible future cerebrovascular accidents after such treatment.

97. Lipper, M. H., J. H. Goldstein and H. M. Do (1998). ”Brown-Sequard syndrome of the cervical spinal cord after chiropractic manipulation.” AJNR Am J Neuroradiol 19(7): 1349-52.

We report a case of increased signal in the left hemicord at the C4 level on T2-weighted MR images after chiropractic manipulation, consistent with contusion. The patient displayed clinical features of Brown-Sequard syndrome, which stabilized with immobilization and steroids. Follow-up imaging showed decreased cord swelling with persistent increased signal. After physical therapy, the patient regained strength on the left side, with residual decreased sensation to pain involving the right arm.

98. Liu, D. (2007). ”Cervical manipulation leading to dissection was not performed by a chiropractor.” Emerg Med J 24(2): 146.

99. Malone, D. G., N. G. Baldwin, F. J. Tomecek, et al. (2002). ”Complications of cervical spine manipulation therapy: 5-year retrospective study in a single-group practice.[see comment].” Neurosurgical Focus 13(6): ecp1.

OBJECT: The authors report a series of 22 patients in whom major complications developed after cervical spinal manipulation therapy (CSMT). A second objective was to estimate the regional incidence of these complications and to compare it with the very low incidences reported in the literature. METHODS: During a 5-year period, practioners at a single group neurosurgical practice in Tulsa, Oklahoma, treated 22 patients, who were markedly worse during, or immediately after, CSMT. The details of these cases are reported. The 1995 US Government National Census was used to define the regional referral population for Tulsa. The published data regarding the incidence of serious CSMT-related complications and the rate of CSMTs undertaken nationally were used to estimate the expected number of CSMT-related complications in the authors’ region. The number (22 cases) reported in this series was used to estimate the actual regional incidence. Complications in the series included radiculopathy (21 cases), myelopathy (11 cases), Brown-Sequard syndrome (two cases), and vertebral artery (VA) occlusion (one case). Twenty-one patients underwent surgery. Poor outcomes were observed in three, outcome was unchanged in one, and 17 improved. The number of patients in this series exceeded the expected number for the region. CONCLUSIONS: Cervical spinal manipulation therapy may worsen preexisting cervical disc herniation or cause disc herniation resulting in radiculopathy, myelopathy, or VA compression. In cases of cervical spondylosis, CSMT may also worsen preexisting myelopathy or radiculopathy. Manipulation of the cervical spine may also be associated with higher complication rates than previously reported.

100. Mann, T. and K. M. Refshauge (2001). ”Causes of complications from cervical spine manipulation.[see comment].” Australian Journal of Physiotherapy 47(4): 255-66.

Cervical manipulation occasionally causes serious vertebrobasilar complications. The usual cause is vertebral artery dissection, however in some cases there has been no obvious arterial injury. The present paper reviews the mechanisms by which complications occur, particularly when the applied force is trivial or there is no injury to the vertebral arteries, and the factors that increase risk of complications. In addition, implications are drawn for use of the recently revised Australian Physiotherapy Association (APA) guidelines. In the absence of vertebral artery rupture, complications are proposed to arise from vasospasm, haemostasis, endothelial injury or turbulent flow. These mechanisms have a sound scientific basis but have yet to be demonstrated as specifically causing vertebrobasilar complications. The most important risk factors for vertebrobasilar complications appear to be prior trauma to the vertebral arteries and symptoms of vertebrobasilar ischaemia from previous manipulation. There is weak evidence that hypoplasia of the vertebral arteries also increases the risk of complications. Neither general vascular factors nor pre-existing degenerative conditions of the cervical spine increase risk of vertebrobasilar complications. The procedures described in the APA guidelines test adequacy of total cerebral perfusion during cervical movements rather than patency of the vertebral arteries or their susceptibility to injury. The guidelines may therefore indicate potential for surviving a complication from manipulation. They may also identify patients at risk of complications from minor trauma. It is recommended that the procedures described in the APA guidelines be applied prior to every manipulation, and that manipulation be avoided in the presence of any signs of vertebrobasilar insufficiency.

101. Mas, J. L., M. G. Bousser, D. Hasboun, et al. (1987). ”Extracranial vertebral artery dissections: a review of 13 cases.” Stroke 18(6): 1037-47.

Clinical and radiologic findings in 13 patients (11 women, 2 men) with extracranial vertebral artery dissection are reported. Dissection was spontaneous in 8 patients, occurred after neck manipulation in 2 and after a potential minor injury to the neck in 3. Six had a history of common migraine, 4 were using oral contraceptives at the time of dissection, and 3 had fibromuscular dysplasia. Dissection was bilateral in 8 patients and associated with carotid dissection in 3. It usually presented with neck or occipital pain preceding basilar ischemic symptoms by a few minutes to 1 month. In 3 patients, transient ischemic attacks were the only manifestation of basilar ischemia, and in 1 patient there was no symptom of basilar ischemia despite bilateral vertebral dissection. In 19 of the 21 dissected vertebral arteries, the angiographic appearance was that of an irregular stenosis, which was associated in 6 arteries with pseudoaneurysmal formation. In 2 patients, 1 vertebral artery was occluded but the contralateral artery showed the typical irregular stenosis. The dissection involved only the third segment in 33%, only the second segment in 24%, and 2 or more segments in 38%. Eleven patients were treated with anticoagulants and 2 with aspirin; 11 recovered without sequelae and 2 had residual deficit. No recurrence was observed (mean follow-up 34 months). At control angiography (n = 12) or ultrasonic study (n = 1), 63% of dissected vertebral arteries had returned to normal, 26% showed marked improvement, and 11% were occluded. Our patient characteristics are compared with those of previously published cases. The validity of the distinction between spontaneous dissection and dissection associated with minor trauma is discussed.

102. Mas, J. L., D. Henin, M. G. Bousser, et al. (1989). ”Dissecting aneurysm of the vertebral artery and cervical manipulation: a case report with autopsy.” Neurology 39(4): 512-5.

A 35-year-old woman with 3 weeks of cervical pain developed ischemia in the basilar artery territory following cervical manipulation. At autopsy, there was a dissecting aneurysm within the third segment of the right vertebral artery. The pathologic changes in the lower and the upper part of the dissecting aneurysm were different, indicating recurring bleeding. Cervical manipulation could have accounted for one recent dissection, but not for another, which was a few weeks old. This suggests that cervical pain, which prompted the manipulation, may have been the first symptom of the dissection, and manipulation of the neck precipitated the stroke by inducing bleeding within the dissecting aneurysm.

103. Mascalchi, M., M. C. Bianchi, S. Mangiafico, et al. (1997). ”MRI and MR angiography of vertebral artery dissection.” Neuroradiology 39(5): 329-40.

A review of 4,500 angiograms yielded 11 patients with dissection of the vertebral arteries who had MRI and (in 4 patients) MR angiography (MRA) in the acute phase of stroke. One patient with incidental discovery at arteriography of asymptomatic vertebral artery dissection and two patients with acute strokes with MRI and MRA findings consistent with vertebral artery dissection were included. Dissection occurred after neck trauma or chiropractic manipulation in 4 patients and was spontaneous in 10. Dissection involved the extracranial vertebral artery in 9 patients, the extra-intracranial junction in 1, and the intracranial artery in 4. MRI demonstrated infarcts in the brain stem, cerebellum, thalamus or temporo-occipital regions in 7 patients with extra- or extra-intracranial dissections and a solitary lateral medullary infarct in 4 patients (3 with intracranial and 1 with extra-intracranial dissection). In 2 patients no brain abnormality related to vertebral artery dissection was found and in one MRI did not show subarachnoid haemorrhage revealed by CT. Intramural dissecting haematoma appeared as crescentic or rounded high signal on T1-weighted images in 10 patients examined 3-20 days after the onset of symptoms. The abnormal vessel stood out in the low signal cerebrospinal fluid in intracranial dissections, whereas it was more difficult to detect in extracranial dissections because of the intermediate-to-high signal of the normal perivascular structures and slow flow proximal and distal to the dissection. In two patients examined within 36 h of the onset, mural thickening was of intermediate signal intensity on T1-weighted images and high signal on spin-density and T2-weighted images. MRA showed abrupt stenosis in 2 patients and disappearance of flow signal at and distal to the dissection in 5. Follow-up arteriography, MRI or MRA showed findings consistent with occlusion of the dissected vessel in 6 of 8 patients.

104. Melin, T. and A. Soderstrom (2007). ”Inget påvisbart samband mellan kiropraktisk nackjustering och stroke.” Lakartidningen 104(22): 1713; discussion 1713-4.

105. Menendez-Gonzalez, M., C. Garcia, E. Suarez, et al. (2003). ”Sindrome de Wallemberg secundario a diseccion de la arteria vertebral por manipulacion quiropractica [Wallenberg's syndrome secondary to dissection of the vertebral artery caused by chiropractic manipulation].” Revista de Neurologia 37(9): 837-9.

INTRODUCTION: Chiropractic manipulations of the cervical region are techniques that are used more and more frequently to treat a number of osteomuscular pathologies, but can give rise to important complications, such as the dissection of the cervical arteries. Dissection of the vertebral artery generally presents as alternating syndromes, of which Wallenberg s syndrome, either complete or incomplete, is the most frequent. In this paper we review the literature published to date on the pathogenesis, risk factors, clinical features, chronopathology, diagnosis, treatment and prognosis of this complication. CASE REPORT: We describe the case of a young patient who suffered from incomplete Wallenberg s syndrome a few hours after a single session of cervical chiropractic manipulation, and we also show the resonance images that were used to support the diagnosis. CONCLUSIONS: The appearance of a pain in the neck and neurological symptoms in a patient who has undergone chiropractic manipulation in the last few hours or days must lead us to consider a possible dissection of the cervical arteries. Dissection of the vertebral artery usually gives rise to alternating syndromes, the most frequent of which is lateral bulbomedullary infarction or Wallenberg s syndrome due to proximal occlusion of the posteroinferior cerebellar artery. Magnetic resonance angiography of the supra aortic trunks and cranial magnetic resonance scanning are valid techniques for demonstrating the dissection of the artery and the associated ischemic lesion.

106. Michaud, T. C. (2002). ”Uneventful upper cervical manipulation in the presence of a damaged vertebral artery.” Journal of Manipulative & Physiological Therapeutics 25(7): 472-83.

OBJECTIVE: To discuss a case in which a patient with a previously injured vertebral artery underwent manipulation in the upper cervical spine without alteration of her symptom pattern. The literature concerning the relative safety of specific upper cervical manipulative techniques is reviewed. CLINICAL FEATURES: A 42-year-old woman had a 3-week history of unilateral suboccipital pain that she related to a sudden twisting of her head and neck that occurred while she was putting sheets of drywall on top of her car. Subsequent examination by a neurologist 2 weeks later was unremarkable, and a tension-type headache was diagnosed. Approximately 10 days later (3 weeks after injury), a single high-velocity upper-cervical manipulation (incorporating slight rotation and full lateral flexion) was performed with no change in her symptom pattern. Two weeks after that, the patient had development of a lateral medullary syndrome (also known as Wallenberg syndrome) after she briefly extended and rotated her upper cervical spine while painting a ceiling. INTERVENTION AND OUTCOME: The patient was treated with anticoagulant therapy, and the lateral medullary infarct healed without incident. The spinocerebellar and subtle motor symptoms also resolved, but the ipsilateral suboccipital headache and the loss of temperature sensation associated with the spinothalamic tract lesion were still present 9 months later. CONCLUSION: This case report demonstrates that vigorous manipulation of the upper cervical spine is possible without injuring an already damaged vertebral artery. It is suggested that the line of drive used during the single manipulation, almost pure lateral flexion with slight rotation, was responsible for the apparent innocuous response. Guidelines for the evaluation and management of vertebral artery dissection are reviewed. Because it is currently impossible to identify patients at risk of having a dissected vertebral artery with standard in-office examination procedures, rotational manipulation of the upper cervical spine should be abandoned by all practitioners, and schools should remove such techniques from their curriculums.

107. Miller, R. G. and R. Burton (1974). ”Stroke following chiropractic manipulation of the spine.” Jama 229(2): 189-90.

108. Misra, U. K., J. Kalita and D. Khandelwal (2001). ”Consequences of neck manipulation performed by a non-professional.” Spinal Cord 39(2): 112-3.

Case report.Documentation of complication of neck manipulation by an untrained person.Tertiary care referral teaching hospital at Lucknow, India.Clinical evaluation, plain radiography of cervical spine, spinal MRI.A 30-year-old man who fainted after neck manipulation by a barber and developed spinal cord and brainstem dysfunction. His MRI revealed an extramedullary, intradural dumbbell shaped mass on the right side at C1 and C2 level compressing the spinal cord.Public awareness should be increased about the danger of neck manipulation by an untrained person especially in the communities where it is commonly practiced.

109. Mitchell, J. (2007). ”Doppler insonation of vertebral artery blood flow changes associated with cervical spine rotation: Implications for manual therapists.” Physiotherapy Theory & Practice 23(6): 303-13.

The controversy related to changes in vertebral artery (VA) blood flow associated with rotation of the cervical spine and the implications for professional practice is still of concern to manual therapists. The aim of this review of the literature is, first, to assess current evidence of altered VA blood flow following cervical spine rotation in persons with and without signs and symptoms of vertebrobasilar ischemia/insufficiency (VBI). Second, any reported, related alterations in blood flow that may have consequences for the individual will be discussed to assist manual therapists in pretreatment risk assessment of patients. The most commonly used noninvasive, in vivo technique for measuring blood flow is Doppler ultrasonography. Of the 88 relevant papers retrieved by a systematic literature search covering the past 50 years, 20 studies reported measurement of VA blood flow related to cervical spine rotation. A critical analysis of these reports revealed that there is no standardization of methods used (heterogeneous samples, small sample sizes, various measurement positions and instruments, and different parts of the VA measured); no consensus of findings (no change, and a significant reduction in contralateral VA blood flow, with or without VBI); and no correlations found between rotation, blood flow, and VBI. Nevertheless, this review is of value in increasing our knowledge of the possible mechanisms and consequences of repeated minor arterial trauma and of blood flow changes related to rotational movements used in cervical manual therapy. It highlights, too, the need for caution in the interpretation of pretreatment risk assessment outcome measures.

110. Mitchell, J., D. Keene, C. Dyson, et al. (2004). ”Is cervical spine rotation, as used in the standard vertebrobasilar insufficiency test, associated with a measureable change in intracranial vertebral artery blood flow?[see comment].” Manual Therapy 9(4): 220-7.

Cervical spine rotation is used by manual therapists as a premanipulative vertebrobasilar insufficiency (VBI) test to identify patients at risk of developing VBI post-manipulation. Investigations of the effect of rotation on vertebral artery blood flow have yielded conflicting results, the validity of the test being debated. It was the aim of this study, therefore, to investigate the effects of cervical spine rotation on vertebral artery blood flow. Transcranial Doppler sonography was used to measure intracranial vertebral artery blood flow in 30 young, healthy, female subjects, with the cervical spine in the neutral position and with sustained, end-of-range rotation. Statistically significant decreases in blood flow were demonstrated with contralateral rotation particularly, in the left (45.9+/-8.5 to 41.8+/-11.6 cm/s) and right (27.8+/-6.9 to 25.2+/-8.2 cm/s) vertebral arteries. Despite this change in blood flow, signs and symptoms of VBI were not demonstrated in these subjects. Nevertheless, these findings are of clinical importance, especially in patients who may have underlying vascular pathology. Thus, this study supports the use of the VBI test, in the absence of a more specific, sensitive and valid test, to assess the adequacy of hindbrain blood supply to identify those patients who may be at risk of serious complications post-manipulation.

111. Mitchell, J. and A. McKay (1995). ”Comparison of left and right vertebral artery intracranial diameters.” Anatomical Record 242(3): 350-4.

BACKGROUND: The vertebral artery is vulnerable to mechanical injury, especially in the region of the first and second cervical vertebrae, with resultant thrombus and/or emboli formation, often found at the vertebro-basilar junction. Such vascular injuries and associated neurological insults have been documented repeatedly in the literature as following cervical spine manipulation, when movements of the head and neck can cause compression and/or stretching of the vertebral artery and alterations in its blood flow. This has particular clinical relevance if a patient has a hypoplastic vertebral artery. Such persons may be considered at risk as regards vascular accidents following manipulation of the cervical spine. The aim of this study was to measure and compare the intracranial diameters of the left and right vertebral arteries in groups of black and white male and female South African subjects. METHODS: Cadaver material from 58 specimens was processed for light microscopy, and measurements of inner (lumen only) and outer (lumen, tunica intima, and tunica media) diameters taken and compared, using the t-test. RESULTS: Data analysis revealed a significant difference between the left and right vertebral artery intracranial diameters in the white female group only (N = 8). CONCLUSIONS: Such a statistically significant difference implies a difference of biological importance and it is suggested that this particular group of subjects may be a high-risk group as regards vascular accidents following cervical spine manipulation.

112. Morelli, N., S. Gallerini, S. Gori, et al. (2006). ”Intracranial hypotension syndrome following chiropractic manipulation of the cervical spine.” Journal of Headache & Pain 7(4): 211-3.

Cervical spine manipulation has been associated with several disorders such as cervical arteries dissection, but rarely has a relationship with intracranial hypotension been reported. We describe a patient showing intracranial hypotension syndrome following chiropractic cervical spine treatment. Magnetic resonance showed the presence of dural leakage at cervical level, suggesting the pathogenesis of the syndrome. We state that cervical spine manipulation should be considered a treatment with risk of neurological complications, including the occurrence of intracranial hypotension.

113. Moser, U. (2000). ”Mit Kopf- und Nackenschmerzen besser nicht zum Chiropraktiker? [With head and neck pain rather not consult a chiropractic?].” MMW Fortschr Med 142(11): 14.

(Inget abstract, men keywords: ”Manipulation, Spinal/*adverse effects, Neck Pain/*therapy, Stroke/*etiology, Vertebral Artery Dissection/*etiology”)

114. Murphy, B. A. and N. J. Dawson (1995). ”The assessment of intramuscular discrimination using signal detection theory: its potential contribution to chiropractic.” Journal of Manipulative & Physiological Therapeutics 18(9): 572-6.

INTRODUCTION: Most studies on sensory changes after manual therapies have focused on pain sensitivity. This ignores the wider range of sensory alternations that may be important in assessing patient functioning and neglects the issue of bias, which is inherent in most methods of pain assessment employing threshold methodology. Signal detection theory (SDT) addresses the issue of bias and provides a measurement of intramuscular discrimination–the ability to discriminate between two stimuli–which can be assessed over the full range of sensation. This paper will discuss the strengths and limitations of SDT and report on the effects of trigger point therapy and manipulation on intramuscular discrimination to illustrate the potential contribution of this methodology to chiropractic. METHODS: Intramuscular needle electrodes were used to provide a pair of electrical stimuli to the forearm extensor muscles. Subjects were asked to assess the differences between stimuli before and after treatment. The treatments consisted of manual trigger point therapy applied to the forearm extensors, cervical spine manipulation and a control treatment. RESULTS: After the trigger point therapy, there was a significant improvement in the ability of the subjects to discriminate between intramuscular signals to treated muscle. Some individual subjects showed alterations in ability to discriminate after cervical spine manipulation but the effect was not significant in the group as a whole. CONCLUSIONS: The methodology of signal detection theory provides a promising, bias-free method of assessing changes in intramuscular sensation after various treatments. In these experiments, trigger point therapy was found to enhance intramuscular discrimination, suggesting that a peripheral reflex may be involved.

115. Nadgir, R. N., L. A. Loevner, T. Ahmed, et al. (2003). ”Simultaneous bilateral internal carotid and vertebral artery dissection following chiropractic manipulation: case report and review of the literature.” Neuroradiology 45(5): 311-4.

Single-vessel cervical arterial dissections typically occur in young adults and are a common cause of cerebral ischemia and stroke. Although the pathogenesis of multivessel dissection is unclear, it is thought to be a consequence of underlying collagen vascular disease. We present a 34-year-old previously healthy man who developed bilateral internal carotid and vertebral artery dissection following chiropractic manipulation.

116. Neck911. (2008). ”An international volunteer group of individuals who provide consultations on complications due to neck manipulation.” Retrieved nov 30, 2008, from http://www.neck911.com/about.html.

117. Norris, J. W. and V. Beletsky (2001). ”Update from the Canadian Stroke Consortium.” Cmaj 165(7): 887.

(Inget abstract, men bland keywords: ”*Chiropractic, Craniocerebral Trauma/*complications, Neck Injuries/*complications, Stroke/*complications/diagnosis”)

118. Norris, J. W., V. Beletsky and Z. Nadareishvili (2002). ””Spontaneous” cervical arterial dissection.” Stroke 33(8): 1945-6; author reply 1945-6.

(Inget abstract, men bland keywords: ”Carotid Artery Injuries, Manipulation, Chiropractic/adverse effects, Stroke/*etiology/prevention & control, Vertebral Artery/injuries, Vertebral Artery Dissection/*complications/*diagnosis/etiology, Wounds and Injuries/complications”)

119. Nyberg, J., T. Olsson and J. Malm (2007). ”Karotis- och vertebralisdissektion vanlig orsak till stroke hos yngre. Lindrigt trauma utlösande faktor hos mer an hälften, visar retrospektiv studie.” Lakartidningen 104(1-2): 24-8.

120. Oehler, J., J. Gandjour, J. Fiebach, et al. (2003). ”Beidseitge A.-vertebralis-Dissektion nach chiropraktischer Behandlungn [Bilateral vertebral artery dissection after chiropractic treatment].” Orthopäde 32(10): 911-3; discussion 914-5.

A 31-year-old woman suffered a brainstem infarction secondary to chiropractic neck manipulation. A dissection of both vertebral arteries could be demonstrated by MR tomography. This case report should alert therapists to be aware of vertebrobasilar complications after spinal manipulations.

121. Padua, L., R. Padua, M. LoMonaco, et al. (1996). ”Radiculomedullary complications of cervical spinal manipulation.” Spinal Cord 34(8): 488-92.

Spinal manipulation is commonly used by some therapists for the treatment of cervical pain. Flexion-extension of the cervical spine produces sliding movements of one vertebra over the one below it, which leads to physiological reduction in the antero-posterior diameter of the spinal canal. Spinal manipulation provokes movements that exceed the physiological limits of these articulations and thereby lead to a more significant reduction of the canal diameter. In patients with pre-existing stenosis of the canal or those with vertebral instability, these movements may cause (or aggravate) myelopathy. For this reason, a thorough neurological examination and cervical spine films should be considered mandatory in patients being considered for spinal manipulation. This report describes four patients with cervical myelopathy and/or radiculopathy caused or aggravated by spinal manipulation. In one patient, magnetic resonance scans before and after chiropractic treatment strongly suggests that the disc prolapse syndrome experienced by the patient was provoked by the spinal manipulation.

122. Parenti, G., G. Orlandi, M. Bianchi, et al. (1999). ”Vertebral and carotid artery dissection following chiropractic cervical manipulation.” Neurosurg Rev 22(2-3): 127-9.

A 50-year-old woman presented a sudden left occipital headache and a posterior circulation stroke after cervical manipulation for neck pain. Magnetic resonance imaging documented a left intracranial vertebral artery occlusive dissection associated with an ipsilateral internal carotid artery dissection with vessel stenosis in its prepetrous tract. This is the first reported case showing an associate vertebral and carotid artery dissection following cervical manipulation. Carotid dissection was asymptomatic and, therefore, its incidence may be underestimated. We emphasize that cervical manipulation should be performed only in patients without predisposing factors for artery dissection and after an appropriate diagnosis of neck pain.

123. Parkin, P. J., W. E. Wallis and J. L. Wilson (1978). ”Vertebral artery occlusion following manipulation of the neck.” N Z Med J 88(625): 441-3.

A 23-year-old woman developed brainstem infarction following cervical manipulation. Vertebral angiography showed total occlusion of the left vertebral artery with a thrombus extending into the basilar artery. The literature dealing with this rare but serious complication of cervical manipulation is reviewed.

124. Patel, A., R. Lee, W. Fritz, et al. (2008). ”Vertebral artery dissection from cervical spine manipulation: case reports and analysis.” South Dakota Medicine: The Journal of the South Dakota State Medical Association 61(3): 95.

125. Paterson, J. K. (2001). ”Neurological complications of cervical spine manipulation.[comment].” Journal of the Royal Society of Medicine 94(6): 314-5.

126. Peters, M., J. Bohl, F. Thomke, et al. (1995). ”Dissection of the internal carotid artery after chiropractic manipulation of the neck.” Neurology 45(12): 2284-6.

A 29-year-old woman died from a right hemispheric infarction caused by dissection and subsequent thrombosis of the internal carotid artery after chiropractic manipulations of the neck. Pathologic study of several arteries of muscular and elastic type revealed a mediolytic arteriopathy with widespread mucoid degeneration and cystic transformation of the vessel wall caused by segmental degeneration of smooth muscle cells of the tunica media. We hypothesize that mediolytic arteriopathy was a predisposing factor for the dissection of the internal carotid artery after chiropractic manipulations in our patient.

127. Phillips, S. J., W. J. Maloney and J. Gray (1989). ”Pure motor stroke due to vertebral artery dissection.” Can J Neurol Sci 16(3): 348-51.

A 39-year-old man presented with a pure motor stroke 9 days after cervical chiropractic manipulation. Computerised tomographic scanning showed a pontine infarct. Cerebral angiography showed changes consistent with the diagnosis of bilateral vertebral artery dissection. It is postulated that the infarct resulted from artery-to-artery embolism.

128. Prasad, S., G. El-Haddad, H. Zhuang, et al. (2006). ”Intracranial hypotension following chiropractic spinal manipulation.” Headache 46(9): 1456-8.

We report a case of intracranial hypotension caused by chiropractic manipulation which, in contrast to previously reported cases, documents the location of the cerebrospinal fluid leak by radionuclide cisternography. Cervical spinal manipulation produced a remote lumbar dural tear in our patient. Spinal magnetic resonance imaging may falsely localize the dural tear in this condition. Although conservative management is often sufficient, precise localization is required for more invasive therapies.

129. Raskind, R. and C. M. North (1990). ”Vertebral artery injuries following chiropractic cervical spine manipulation–case reports.” Angiology 41(6): 445-52.

Four patients undergoing cervical spinal manipulations for nonneurologic diseases and with no previous neurologic signs or symptoms all developed significant neurologic deficits, one fatal, following manipulations of the cervical spine. Both the literature and the authors’ series show that a number of patients have a prodrome prior to the onset of neurologic changes. There is no established therapy for the syndrome. Perhaps prevention is the best means of reducing neurologic injury.

130. Refshauge, K. M., S. Parry, D. Shirley, et al. (2002). ”Professional responsibility in relation to cervical spine manipulation.[see comment].” Australian Journal of Physiotherapy 48(3): 171-9; discussion 180-5.

Manipulation of the cervical spine is one of the few potentially life-threatening procedures performed by physiotherapists. Is it worth the risk? A comparison of risks versus benefits indicates that at present, the risks of cervical manipulation outweigh the benefits: manipulation has yet to be shown to be more effective for neck pain and headache than other interventions such as mobilisation, whereas the risks, although infrequent, are serious. This analysis is of particular concern because the conditions for which manipulation is indicated are benign and usually self-limiting. Because physiotherapists have legal and ethical obligations to the community to avoid foreseeable harm and provide optimum care, it may be prudent to determine who in our profession should perform cervical manipulation. That is, the profession could restrict the practice of cervical spine manipulation. Although all registered physiotherapists in Australia are entitled to perform cervical manipulation, few choose to use this intervention. Therefore, it might be feasible to encourage those practitioners who wish to use cervical manipulation to undertake formal education programs. Such a requirement could be embodied in a code of practice that discourages those without formal training from performing cervical manipulation. By taking such measures, we could ensure that our profession exercises wisdom in its monitoring and use of cervical manipulation.

131. Reuter, U., M. Hamling, I. Kavuk, et al. (2006). ”Vertebral artery dissections after chiropractic neck manipulation in Germany over three years.” Journal of Neurology 253(6): 724-30.

Vertebral artery dissection (VAD) has been observed in association with chirotherapy of the neck. However, most publications describe only single case reports or a small number of cases. We analyzed data from neurological departments at university hospitals in Germany over a three year period of time of subjects with vertebral artery dissections associated with chiropractic neck manipulation. We conducted a country-wide survey at neurological departments of all medical schools to identify patients with VAD after chirotherapy followed by a standardized questionnaire for each patient. 36 patients (mean age 40 + 11 years) with VAD were identified in 13 neurological departments. Clinical symptoms consistent with VAD started in 55% of patients within 12 hours after neck manipulation. Diagnosis of VAD was established in most cases using digital subtraction angiography (DSA), magnetic resonance angiography (MRA) or duplex sonography. 90% of patients admitted to hospital showed focal neurological deficits and among these 11 % had a reduced level of consciousness. 50% of subjects were discharged after 20 +/- 14 hospital days with focal neurological deficits, 1 patient died and 1 was in a persistent vegetative state. Risk factors associated with artery dissections (e. g. fibromuscular dysplasia) were present in only 25% of subjects.In summary, we describe the clinical pattern of 36 patients with vertebral artery dissections and prior chiropractic neck manipulation.

132. Rivett, D. A., K. J. Sharples and P. D. Milburn (1999). ”Effect of premanipulative tests on vertebral artery and internal carotid artery blood flow: a pilot study.” Journal of Manipulative & Physiological Therapeutics 22(6): 368-75.

BACKGROUND: Neck manipulation occasionally causes stroke after trauma to the vertebral or internal carotid artery. Premanipulativ e tests involving cervical spine rotation or extension have been recommended to detect patients at risk of neurovascular ischemia. However, the effect of these procedures on extracranial blood flow is not well established, and their validity is thus controversial. OBJECTIVE: To determine the effect of premanipulative tests involving cervical spine rotation or extension on vertebral artery and internal carotid artery blood flow parameters. DESIGN: Two-group experimental study. SUBJECTS: Twenty subjects consisting of 16 patients treated with physiotherapy and four volunteers. METHODS: Subjects were tested with a recommended premanipulative protocol by both an independent physiotherapist and an investigator. One group consisted of 10 subjects with signs or symptoms indicative of neurovascular ischemia on premanipulative testing, with 10 subjects with no signs or symptoms indicative of neurovascular ischemia on premanipulative testing comprising the second group. Hemodynamic measurements for both vertebral and both internal carotid arteries were taken by use of duplex Doppler ultrasonography with color-flow imaging with the subjects in the following positions: neutral, end-range extension, 45 degrees contralateral rotation, end-range contralateral rotation, and combined end-range contralateral rotation/extension. RESULTS: The reliability of premanipulative testing was supported. Significant changes in flow velocity of the vertebral artery (and to a lesser extent of the internal carotid artery) were shown in end-range positions involving rotation and extension. No meaningful significant differences were found between the two groups. CONCLUSIONS: Screening procedures that use rotation and extension may be useful tests of the adequacy of collateral circulation. A larger study is needed to determine whether subjects testing positive significantly differ from those testing negative.

133. Rosner, A. L. (2001). ”Chiropractic manipulation and stroke.” Stroke 32(9): 2207-8.

134. Rothwell, D. M., S. J. Bondy and J. I. Williams (2001). ”Chiropractic manipulation and stroke: a population-based case-control study.” Stroke 32(5): 1054-60.

BACKGROUND AND PURPOSE: Several reports have linked chiropractic manipulation of the neck to dissection or occlusion of the vertebral artery. However, previous studies linking such strokes to neck manipulation consist primarily of uncontrolled case series. We designed a population-based nested case-control study to test the association. METHODS: Hospitalization records were used to identify vertebrobasilar accidents (VBAs) in Ontario, Canada, during 1993-1998. Each of 582 cases was age and sex matched to 4 controls from the Ontario population with no history of stroke at the event date. Public health insurance billing records were used to document use of chiropractic services before the event date. RESULTS: Results for those aged <45 years showed VBA cases to be 5 times more likely than controls to have visited a chiropractor within 1 week of the VBA (95% CI from bootstrapping, 1.32 to 43.87). Additionally, in the younger age group, cases were 5 times as likely to have had >/=3 visits with a cervical diagnosis in the month before the case’s VBA date (95% CI from bootstrapping, 1.34 to 18.57). No significant associations were found for those aged >/=45 years. CONCLUSIONS:While our analysis is consistent with a positive association in young adults, potential sources of bias are also discussed. The rarity of VBAs makes this association difficult to study despite high volumes of chiropractic treatment. Because of the popularity of spinal manipulation, high-quality research on both its risks and benefits is recommended.

135. Rubinstein, S. M. (2008). ”Adverse events following chiropractic care for subjects with neck or low-back pain: do the benefits outweigh the risks?” J Manipulative Physiol Ther 31(6): 461-4.

This synopsis provides an overview of the benign and serious risks associated with chiropractic care for subjects with neck or low-back pain. Most adverse events associated with spinal manipulation are benign and self-limiting. The incidence of severe complications following chiropractic care and manipulation is extremely low. The best evidence suggests that chiropractic care is a useful therapy for subjects with neck or low-back pain for which the risks of serious adverse events should be considered negligible.

136. Rubinstein, S. M., C. Leboeuf-Yde, D. L. Knol, et al. (2007). ”The benefits outweigh the risks for patients undergoing chiropractic care for neck pain: a prospective, multicenter, cohort study.” J Manipulative Physiol Ther 30(6): 408-18.

OBJECTIVE: This study describes both positive clinical outcomes and adverse events in patients treated for neck pain by a chiropractor. METHODS: This study was a prospective, multicenter, observational cohort study. Patients with neck pain of any duration who fulfilled the inclusion criteria were recruited in a practice-based study. Data were collected on the patients and from the chiropractors at baseline, the first 3 visits, and at 3 and 12 months. Clinical outcome measures included (1) neck pain in the 24 hours preceding the visit, (2) neck disability, (3) treatment satisfaction, (4) global assessment, and (5) adverse events. Recovery was defined as ”completely improved” or ”much better” using the global assessment scale. An adverse event was defined as either a new related complaint or a worsening of the presenting or existing complaint by >30% based upon an 11-point numerical rating scale. RESULTS: In all, 79 chiropractors participated, recruiting 529 subjects, representing 4891 treatment consultations. Follow-up was possible for 90% and 92%, respectively, at 3 and 12 months. Most patients had chronic, recurrent complaints; mild to moderate disability of the neck; and a mild amount of pain at baseline; and two thirds had sought previous care for the presenting complaint in the preceding 6 months. Adverse events after any of the first 3 treatments were reported by 56%, and 13% of the study population reported these events to be severe in intensity. The most common adverse events affected the musculoskeletal system or were pain related, whereas symptoms such as tiredness, dizziness, nausea, or ringing in the ears were uncommon (<8%). Only 5 subjects (1%) reported to be much worse at 12 months. No serious adverse events were recorded during the study period. Of the patients who returned for a fourth visit, approximately half reported to be recovered, whereas approximately two thirds of the cohort were recovered at 3 and 12 months. CONCLUSION: Adverse events may be common, but are rarely severe in intensity. Most of the patients report recovery, particularly in the long term. Therefore, the benefits of chiropractic care for neck pain seem to outweigh the potential risks.

137. Ruiz-Saez, M., C. Fernandez-de-las-Penas, C. R. Blanco, et al. (2007). ”Changes in pressure pain sensitivity in latent myofascial trigger points in the upper trapezius muscle after a cervical spine manipulation in pain-free subjects.[see comment].” Journal of Manipulative & Physiological Therapeutics 30(8): 578-83.

OBJECTIVE: This study analyzed the immediate effects on pressure pain threshold (PPT) in latent myofascial trigger points (MTrPs) in the upper trapezius muscle of a single cervical spine manipulation directed at the C3 through C4 level. METHODS: Seventy-two volunteers (27 men and 46 women; mean age, 31 years; SD, 10 years) participated in this study. Subjects underwent a screening process to establish both the presence of MTrPs in the upper trapezius muscle as described by Simons et al (Myofascial pain and dysfunction: the trigger point manual, vol 2. 3rd ed. Baltimore: Williams & Wilkins, 1999. p. 23-34) and the presence of intervertebral joint dysfunction at the C3 through C4 level by the lateral gliding test for the cervical spine. Subjects were divided randomly into 2 groups: manipulative group, which received a cervical spine manipulation directed at the C3 through C4 level, and a placebo group, which received a sham manual procedure. The outcome measure was the PPT on the MTrP in the upper trapezius muscle ipsilateral to the side of the joint dysfunction, which was assessed pretreatment and 1, 5, and 10 minutes posttreatment by an assessor blinded to the treatment allocation of the subject. RESULTS: The analysis of variance showed a significant effect for time (F = 5.157; P =.02) but not for side (F = 0.234; P =.63). Furthermore, an interaction between group and time was also found (F = 37.240; P <.001). The experimental group showed a trend toward an increase in PPT levels after the manipulative procedure, whereas the control group showed a trend toward a decrease in PPT. Positive within-group effect sizes ranging from medium to small were found in the manipulative group (0.1 <d < 0.5), whereas negative within-group effect sizes ranging from large to medium were found in the placebo group (0.3 <d < 1). CONCLUSIONS: Our results suggest that a cervical spine manipulation directed at the C3 through C4 segment induced changes in pressure pain sensitivity in latent MTrPs in the upper trapezius muscle. Different therapeutic mechanisms, either segmental or central, may be involved at the same time.

138. Rydell, N. and L. Raf (1999). ”Spinal manipulation–behandling med stor komplikationsrisk.” Lakartidningen 96(34): 3536-40.

The article consists in a review of injuries for which claims were submitted to one or another of three insurance companies during a two-year period, and which had arisen in conjunction with manipulation of the cervical spine (n = 21), thoracic spine (n = 6), lumbar spine (n = 13), or the sacro-iliac joint (n = 14). Cervical spine manipulation had caused injury of the vertebral artery with resulting paralysis in three cases, and cervical disc herniation in three cases. Lumbar spine manipulation had caused disc herniation in six patients, of whom three had severe persistent problems. Of the 14 patients who had undergone manipulation of the sacroiliac joint, six had disc herniation which was operated with varying outcome. One patient with a compression fracture of an osteoporotic L3 vertebra developed paraparesis.

139. Saeed, A. B., A. Shuaib, G. Al-Sulaiti, et al. (2000). ”Vertebral artery dissection: warning symptoms, clinical features and prognosis in 26 patients.” Canadian Journal of Neurological Sciences 27(4): 292-6.

BACKGROUND AND OBJECTIVES: Internal carotid artery dissection has been extensively studied and well-described. Although there has been a recent increase in the number of reported cases of vertebral artery (VA) dissection, the clinical variety of presentation and the early warning symptoms have not been well-described before. Our objectives in this study include: (1) To determine the early symptoms and warning signs which may help the clinician in the early identification and treatment of patients with VA dissection. (2) To explore the variety of clinical presentation of VA dissection and its relation to prognosis. DESIGN AND SETTING: Retrospective analysis of hospital records in a tertiary academic centre for the period 1989-1999. RESULTS: Twenty-six patients were identified (13 men and 13 women). The mean age was 48. Possible precipitating factors were identified in 14 patients (53%). Sporting activity and chiropractic manipulations were the most common (15% and 11% respectively). Headache and/or neck pain was the prominent feature in 88% of patients and was a warning sign in 53%, preceding onset of stroke by up to 14 days. The most common clinical features included vertigo (57%), unilateral facial paresthesia (46%), cerebellar signs (33%), lateral medullary signs (26%) and visual field defects (15%). Bilateral VA dissection presented in six patients (24%). The most common region of dissection was the C1-C2 level (16 arteries, 51%). Intracranial VA dissection was found in eight arteries (25%). The majority of patients (83%) had favorable outcome. Poor prognosis was associated with (1) bilateral dissection; (2) intracranial VA dissection accompanied by subarachnoid hemorrhage. Only two patients reported stroke recurrence. CONCLUSIONS: Our findings show that VA dissection affects mainly middle age persons and involves both sexes equally. Headache and/or neck pain followed by vertigo or unilateral facial paresthesia is an important warning sign that may precede onset of stroke by several days. Although the majority of patients will have excellent prognosis, this was less likely in patients presenting with subarachnoid hemorrhage or bilateral VA dissection. Recurrence rate was low.

140. Saghafi, D. and D. D. Curl (1995). ”Chiropractic manipulation of anteriorly displaced temporomandibular disc with adhesion.” Journal of Manipulative & Physiological Therapeutics 18(2): 98-104.

OBJECTIVE: This AB, single-subject case study was conducted to investigate the capability of chiropractic manipulation of the temporomandibular joint (TMJ) in treating unilateral anterior displacement of the articular disc with adhesion to the articular eminence. A specific joint manipulation was designed to reduce the anteriorly displaced and adhered TMJ disc. CLINICAL FEATURES: A 21-yr-old woman suffered from a four year history of right-sided temporomandibular joint pain and clicking, with limitation of mandibular opening. The patient reported previous unsuccessful treatments for her condition. An exhaustive history, a complete review of systems and a physical examination (including, but not limited to, eyes, ears, nose, throat and motor, sensory and reflex neurological tests) were obtained. Relevant or contributory findings are extracted for this article. A clinical diagnosis of left-sided anteriorly displaced TMJ disc with adhesion to the articular eminence was made. INTERVENTION AND OUTCOME: Patient’s pain level, presence of joint clicking upon mandibular opening and the amount of mandibular opening were used as outcome measures for capability of treatments. An AB, single-subject study was used where A was the baseline period and B the therapeutic intervention period. The patient was treated twice a week for a total of 19 visits. During the baseline period no treatment was given to the TMJ (3 visits) where the patient received cervical manipulation alone. During the experimental period the patient received both cervical spine manipulation and a specific manipulation to the left mandible. There were no physical therapeutic modalities applied to the jaw. The specific TMJ manipulation used requires a very low-amplitude high velocity thrust parallel to the slope of the articular eminence. The results of this study show mandibular opening distance was returned to normal in addition to the abolition of the patient’s TMJ pain and clicking. During the three baseline visits mandibular opening showed no significant change, with an average of 25.3 mm (range 25-26 mm). There was also no change in the patient’s TMJ pain or clicking during this baseline period. The patient’s TMJ clicking was absent following the third treatment and the patient reported significant subjective pain relief as well. Temporomandibular pain was again reported during the fifth, sixth and seventh post-treatment visits due to exacerbations caused by daily activities. There was no pain reported from the beginning of the eighth post-treatment visit to the end of the study. CONCLUSION: The findings of this study show this specific manipulation of the TMJ may be appropriate for the conservative treatment of adhered anteriorly dislocated disc.

141. Saxler, G. and B. Barden (2004). ”Das ausgedehnte spinale epidurale Hämatom–Eine seltene Komplikation nach chirotherapeutischer Manipulationsbehandlung der Halswirbelsäule [Extensive spinal epidural hematoma--an uncommon entity following cervical chiropractic manipulation].” Z Orthop Ihre Grenzgeb 142(1): 79-82.

INTRODUCTION: Spinal epidural hematoma is a rare complication after chiropractic manipulation. In the literature, only three cases have been reported, which all necessitated surgical treatment. CASE: A 27-year-old woman was treated with cervical chiropractic manipulation (C5/6) and facet joint infiltration. 10 minutes later the patient presented signs of intracranial pressure with nausea, vertigo, headache and vomiting. The magnetic resonance imaging of the spine demonstrated an epidural hematoma extending from the cervical to the sacral spine. As the patient had no sensible or motor deficits and recovered quickly, surgical treatment was not necessary. A few days later the patient had a complete persisting remission of symptoms. CONCLUSION: If neurological deficits occur after chiropractic manipulation, a spinal epidural hematoma should be considered to provide adequate therapy without delay. The current case report shows an unusual expansion of the hematoma which has not described so far after chiropractic manipulation. But, in contrast to the three cases reported before, a surgical intervention was not necessary.

142. Saxler, G., E. Schopphoff, H. Quitmann, et al. (2005). ”Chirotherapie der Halswirbelsäule und Gefässdissektionen [Spinal manipulative therapy and cervical artery dissections].” HNO 53(6): 563-7.

Severe complications after cervical spine manipulation are rare. As experts for medical treatment errors, we received between July 2002 and February 2004 cases with serious complications in the central nervous system after manipulation. 5 vertebral artery dissections with subsequent brain infarction were registered. In all cases, the patients showed complete persisting remission of symptoms. In addition, a kinematic estimation model was developed to study the possible causes of vertebral artery damage. We were able to demonstrate that material extension is dependent on cervical rotation and the ”free length” of the vertebral artery in the upper cervical spine.

143. van Schalkwyk, R. and G. F. Parkin-Smith (2000). ”A clinical trial investigating the possible effect of the supine cervical rotatory manipulation and the supine lateral break manipulation in the treatment of mechanical neck pain: a pilot study.” J Manipulative Physiol Ther 23(5): 324-31.

OBJECTIVE: To evaluate the possible effect of the supine cervical rotary manipulation and the supine lateral break manipulation in the treatment of mechanical neck pain, according to subjective and objective clinical findings. BACKGROUND: Delivering a supine lateral break manipulation to the ipsilateral side of an inflamed facet joint(s) that exhibits a lateral flexion fixation may result in pain and/or discomfort to the patient. Thus the proposed alternative is a supine cervical rotary manipulation delivered on the ipsilateral side or a supine lateral break manipulation delivered on the contralateral side of the relevant joint(s). DESIGN: Randomized, comparative clinical trial. SUBJECTS: Two groups of 15 subjects diagnosed with mechanical neck pain. INTERVENTION: The diagnosis of mechanical neck pain and the identification of lateral flexion fixations in the cervical spine were made with conventional clinical evaluation, including motion palpation. Group A received a cervical rotary manipulation(s) on the ipsilateral side of the lateral flexion fixation(s), while group B received a supine lateral break manipulation(s) on the contralateral side of the lateral flexion fixation(s). Subjects received a maximum of 10 treatments over a 4-week treatment period. Outcome Measures: Both treatment groups were assessed with subjective (Numerical Pain Rating Scale 101, McGill Short-Form Pain Questionnaire and the Canadian Memorial Chiropractic College Neck Disability Index) and objective (cervical range of motion goniometer and algometer) measurement parameters at the initial consultation (before any treatment), the final consultation, and at a 1-month follow-up consultation. Statistical analysis was conducted at a 95% confidence level (alpha =.05) with the non-parametric 2-tailed Wilcoxon signed ranks test, the Mann-Whitney U test, and descriptive statistics. Two-tailed power analysis was conducted after the fact, where a confidence level of 80% (beta =.20) was considered satisfactory. RESULTS: Intragroup analysis indicated a significant difference between the initial consultation data and the final consultation data for the subjective data, indicating an effect. Analysis of the objective data did not reveal any significant difference. Intergroup analysis did not reveal any significant difference between the 2 groups when comparing the data of the initial consultation and the final consultation, indicating that both treatments had a similar or equal effect. Power analysis was not satisfactory for most data, indicating the possibility of many Type II errors. CONCLUSION AND RECOMMENDATIONS: Statistically, the results suggested that both treatments had an effect but that neither group showed a benefit over the other. However, because of the unsatisfactory power of the study, conclusions are to be drawn with caution. Clinical significance supported the statistical outcomes where it was suggested that both treatments had an effect and that neither treatment had a greater effect. A larger sample size and the inclusion of a placebo group is recommended to reveal true treatment outcomes and trends.

144. Schellhas, K. P., R. E. Latchaw, L. R. Wendling, et al. (1980). ”Vertebrobasilar injuries following cervical manipulation.” Jama 244(13): 1450-3.

Four cases of brainstem stroke syndromes followed mechanical cervical manipulation; vascular injury was confirmed angiographically. A comprehensive review of the literature on vertebrobasilar injuries disclosed the various mechanisms of injury and pathogenesis of subsequent vascular complications following cervical manipulation. Emphasis is given to the potentially devastating neurological complications, particularly in view of the increasing utilization of chiropractic therapy.

145. Schmitt, H. P. (1976). ”Rupturen und Thrombosen der Arteria vertebralis nach gedeckten mechanischen Insulten [Ruptures and thromboses of the vertebral artery following closed mechanical injuries].” Schweizer Archiv fur Neurologie, Neurochirurgie und Psychiatrie 119(2): 363-79.

Five cases of occlusion of the vertebral artery in context with mechanical stress – from endogene reasons in one case – and lesions of the vessel walls (in three cases) are recorded. The inferior posterior cerebellar artery was involved in all cases. Variable ischemic lesions resulted in the medulla oblongata and in the cerebellum, which were survived up to four weeks in one case. In the others death occurred within few hours or suddenly and unexpectedly. Related neurological symptoms were absent in one case only. A chiropractic manipulation of the neck was the reason for the arterial insult in two cases.

146. Schmitz, A., G. Lutterbey, L. von Engelhardt, et al. (2005). ”Pathological cervical fracture after spinal manipulation in a pregnant patient.” J Manipulative Physiol Ther 28(8): 633-6.

OBJECTIVE: To present the rare case of a displaced odontoid fracture after manipulative treatment. CLINICAL FEATURES: A 37-year-old, 15-week pregnant patient was referred with acute neck pain and a diffuse paravertebral swelling that started after cervical manipulation performed by her general medical practitioner 5 days before. Because of pregnancy, a cervical spine radiographic series was not obtained before treatment. Magnetic resonance imaging revealed a displaced odontoid fracture associated with a pathological process in the vertebral body of C2 and a paravertebral hematoma on the left side from C2 to C4. INTERVENTION AND OUTCOME: After initial halo vest immobilization, an anterior-posterior fusion of C1-C2 was performed. The histological analysis showed features of an aneurysmal bone cyst. The patient was discharged and had an undisturbed pregnancy and was without any neurological complications. CONCLUSIONS: Because of the weakening lesion in C2, the spinal manipulation most likely caused the displaced odontoid fracture. Special imaging should be performed, preferably with magnetic resonance imaging, when a patient experiences significant new symptoms after cervical manipulation.

147. Schneider, M. (2008). ”Changes in pressure pain sensitivity in latent myofascial trigger points in the upper trapezius muscle after a cervical spine manipulation in pain-free subjects.[comment].” Journal of Manipulative & Physiological Therapeutics 31(3): 251; author reply 251-2.

148. Scoville, W. B. and D. B. Bettis (1979). ”Motor tics of the head and neck: surgical approaches and their complications.” Acta Neurochir (Wien) 48(1-2): 47-66.

Motor tics of the head and neck, especially hemifacial spasm and spastic torticollis, are the substance of this paper. Forty-six cases are presented, and surgical techniques are described. In hemifacial spasm the intracranial neurovascular lysis of Jannetta is a valid operation with the best results to date but has a 7 1/2% risk of unilateral deafness. The extracranial submastoid partial section of Scoville is completely safe and gives excellent results, but there is a probability of mild to moderate return of the spasm in one to two year’s time. In spastic torticollis the accepted radical operation consists of bilateral anterior rhizotomy of the upper three roots plus bilateral spinal accessory nerve section in the neck. A tragic complication of this operation has recently been observed by ourselves, Sweet, and Hamlin. This complication is bilateral infarction of the medulla (bilateral Wallenberg’s syndrome). This has also been reported as occurring following chiropractic manipulations. For this reason the writer does limited unilateral sectioning of the spinal accessory nerve in the neck and resection of the upper third of the sternomastoid muscle, as a first stage procedure, in those cases in which rotation of the neck is the principal symptom, before doing the radical operation. Safeguards to prevent this complication include preoperative vertebral arteriography and preservation of both motor and sensory radicular arteries under magnification and maintenance of adequate neck support during the early postoperative days.

149. Sedat, J., M. Dib, M. H. Mahagne, et al. (2002). ”Stroke after chiropractic manipulation as a result of extracranial postero-inferior cerebellar artery dissection.” J Manipulative Physiol Ther 25(9): 588-90.

OBJECTIVE: To describe a case of dissection of the postero-inferior cerebellar artery (PICA) after cervical manipulation. Clinical Features: After cervical manipulation, a 42-year-old woman had a cerebellar syndrome related to an infarct in the area supplied by the PICA, confirmed by computed tomography of the brain. Cerebral angiography showed a normal appearance of the vertebral artery, a cervical extradural origin of PICA, and a dissection of the latter at the C1-C2 level. Intervention and Outcome: Anticoagulant treatment with heparin was implemented. A positive outcome was achieved after 3 weeks. CONCLUSION: Anatomical variations of the vertebral arteries and their branches are not infrequent and may constitute a predisposing factor to complications after neck manipulation.

150. Shafrir, Y. and B. A. Kaufman (1992). ”Quadriplegia after chiropractic manipulation in an infant with congenital torticollis caused by a spinal cord astrocytoma.” Journal of Pediatrics 120(2 Pt 1): 266-9.

An infant with congenital torticollis underwent chiropractic manipulation, and within a few hours had respiratory insufficiency, seizures, and quadriplegia. A holocord astrocytoma, with extensive acute necrosis believed to be a result of the neck manipulation, was found and resected. We believe that every child with torticollis, regardless of age, should undergo neurologic and radiologic evaluation before any form of physical treatment is instituted.

151. Shambaugh, P. (1987). ”Changes in electrical activity in muscles resulting from chiropractic adjustment: a pilot study.” J Manipulative Physiol Ther 10(6): 300-4.

This study examines the effects of chiropractic adjustment on the muscles of the back. Vertebrae that are hypomobile may be held in that state by the erector spinae muscle group; adjusting such vertebrae should result in less muscle tension. By measuring the change in electrical activity, such relaxation can be observed. Hypomobile vertebrae were found by motion palpation. The patient was then placed prone and surface electrodes were placed over the upper trapezius, upper erector spinae (T3-T5), and lumbar erector spinae (L1-L3) muscle groups on both sides of the body. The patient was adjusted using full spine toggle recoil thrusts, and postadjustment readings were taken. Results from this study show that significant changes in muscle electrical activity occur as a consequence of adjusting. On average, a 25% reduction in muscle activity was observed across the 20 subjects tested, while no significant reductions were observed with the control group of 14 subjects. Significant reductions in side-to-side imbalances were also observed.

152. Shekelle, P. G. and I. Coulter (1997). ”Cervical spine manipulation: summary report of a systematic review of the literature and a multidisciplinary expert panel.” Journal of Spinal Disorders 10(3): 223-8.

(Inget abstract. Ur keywords: ”Cervical Vertebrae, Chiropractic/mt [Methods], Manipulation, Orthopedic/ae [Adverse Effects], Manipulation, Orthopedic/ct [Contraindications]”)

153. Sherman, D. G., R. G. Hart and J. D. Easton (1981). ”Abrupt change in head position and cerebral infarction.” Stroke 12(1): 2-6.

Eight patients are described who developed infarctions in the vertebral-basilar artery distribution following chiropractic neck manipulation or spontaneous head turning. The angiographic and autopsy findings indicate that injury to the intima of the vertebral artery at the atlantoaxial joint forms a nidus for thrombus formation which may propogate or embolize to involve other vessels in the vertebral-basilar system and result in progressive brainstem infarction. The role of anticoagulation in these patients is discussed.

154. Sherman, M. R., J. E. Smialek and W. E. Zane (1987). ”Pathogenesis of vertebral artery occlusion following cervical spine manipulation.” Archives of Pathology & Laboratory Medicine 111(9): 851-3.

Sporadic cases of vertebral artery occlusion following neck manipulation have been reported since 1947. The pathogenesis of occlusion, however, has remained largely speculative. Autopsy examination of the intracranial and extracranial portions of the vertebral arteries in the case presented here clearly demonstrates that intramural hematoma arising within granulation tissue in the tunica media was the acute, occlusive event. Furthermore, prior neck manipulation may have caused asymptomatic development of granulation tissue within the tunica media, thereby predisposing the patient to acute intramural hematoma during subsequent neck manipulation.

155. Silber, J. S. (2002). ”Re: Haldeman S, Kohlbeck FJ, McGregor M. Unpredictability of cerebrovascular ischemia associated with cervical spine manipulation therapy. Spine 2002;27:49-55.[comment].” Spine 27(20): 2300.

156. Smith, W. S., S. C. Johnston, E. J. Skalabrin, et al. (2003). ”Spinal manipulative therapy is an independent risk factor for vertebral artery dissection.” Neurology 60(9): 1424-8.

OBJECTIVE: To determine whether spinal manipulative therapy (SMT) is an independent risk factor for cervical artery dissection. METHODS: Using a nested case-control design, the authors reviewed all patients under age 60 with cervical arterial dissection (n = 151) and ischemic stroke or TIA from between 1995 and 2000 at two academic stroke centers. Controls (n = 306) were selected to match cases by sex and within age strata. Cases and controls were solicited by mail, and respondents were interviewed using a structured questionnaire. The medical records of interviewed patients were reviewed by two blinded neurologists to confirm that the patient had stroke or TIA and to determine whether there was evidence of arterial dissection. RESULTS: After interview and blinded chart review, 51 patients with dissection (mean age 41 +/- 10 years; 59% female) and 100 control patients (44 +/- 9 years; 58% female) were studied. In univariate analysis, patients with dissection were more likely to have had SMT within 30 days (14% vs 3%, p = 0.032), to have had neck or head pain preceding stroke or TIA (76% vs 40%, p < 0.001), and to be current consumers of alcohol (76% vs 57%, p = 0.021). In multivariate analysis, vertebral artery dissections were independently associated with SMT within 30 days (OR 6.62, 95% CI 1.4 to 30) and pain before stroke/TIA (OR 3.76, 95% CI 1.3 to 11). CONCLUSIONS: This case-controlled study of the influence of SMT and cervical arterial dissection shows that SMT is independently associated with vertebral arterial dissection, even after controlling for neck pain. Patients undergoing SMT should be consented for risk of stroke or vascular injury from the procedure. A significant increase in neck pain following spinal manipulative therapy warrants immediate medical evaluation.

157. Stevinson, C., W. Honan, B. Cooke, et al. (2001). ”Neurological complications of cervical spine manipulation.[see comment].” Journal of the Royal Society of Medicine 94(3): 107-10.

To obtain preliminary data on neurological complications of spinal manipulation in the UK all members of the Association of British Neurologists were asked to report cases referred to them of neurological complications occurring within 24 hours of cervical spine manipulation over a 12-month period. The response rate was 74%. 24 respondents reported at least one case each, contributing to a total of about 35 cases. These included 7 cases of stroke in brainstem territory (4 with confirmation of vertebral artery dissection), 2 cases of stroke in carotid territory and 1 case of acute subdural haematoma. There were 3 cases of myelopathy and 3 of cervical radiculopathy. Concern about neurological complications following cervical spine manipulation appears to be justified. A large long-term prospective study is required to determine the scale of the hazard.

158. Sturzenegger, M. (1993). ”Dissektion der Arteria vertebralis nach Manipulation der Halswirbelsaule [Vertebral artery dissection following manipulation of the cervical vertebrae].[see comment][comment].” Schweizerische Medizinische Wochenschrift. Journal Suisse de Medecine 123(27-28): 1389-99.

We report on two patients who developed symptoms and signs of infarction of dorsolateral medulla oblongata (Wallenberg’s syndrome) and the cerebellum respectively, following cervical manipulation for slight neck pain. Subsequent vertebral artery angiography and MRI showed the typical signs of vertebral artery dissection of the atlantoaxial and intracranial segment in one patient, and of the intertransverse segment in the second. The pathogenesis of vertebral artery injury following cervical manipulation is discussed and the literature is reviewed. The practical implications of this rare complication are discussed.

159. Suh, S. I., S. B. Koh, E. J. Choi, et al. (2005). ”Intracranial hypotension induced by cervical spine chiropractic manipulation.” Spine 30(12): E340-2.

STUDY DESIGN: Case report. OBJECTIVES: We report a case of intracranial hypotension ensuing after a spinal chiropractic manipulation leading to cerebrospinal fluid (CSF) isodense effusion in the upper cervical and thoracic spine. SUMMARY OF BACKGROUND DATA: The etiology of intracranial hypotension is not fully understood, but CSF leakage from spinal meningeal diverticula or dural tears may be involved. METHODS: A 36-year-old woman presented with neck and both shoulder pain 4 days earlier. She undertook a spinal chiropractic manipulation. After this maneuver, she complained of a throbbing headache with nausea and vomiting. Her headache worsened, and lying down gave the only measure of limited relief. In CSF study, it showed dry tapping. Brain MRI showed pachymeningeal gadolinum enhancement. Thoracic spine MRI showed CSF leakage. After admission to the hospital, she was treated by hydration and pain control over several days. However, her headache did not improve. RESULTS: She was treated by epidural blood patch. Afterwards, her headache was improved. This is the first case of spontaneous intracranial hypotension in which spinal chiropractic manipulation coincided with the development of symptoms and in which a CSF collection in the upper cervical and thoracic spine was demonstrated radiographically in Korea. CONCLUSIONS: From this case, we can understand the etiology of intracranial hypotension and consider the complication of chiropractic manipulation.

160. Suter, E. and G. McMorland (2002). ”Decrease in elbow flexor inhibition after cervical spine manipulation in patients with chronic neck pain.” Clinical Biomechanics 17(7): 541-4.

OBJECTIVE: This study measured functional capacity and subjective pain in patients with chronic neck pain before and after manipulation of the cervical spine. DESIGN: Outcomes study on 16 patients with chronic neck pain. BACKGROUND: Muscle inhibition, i.e., the inability to fully activate a muscle, has been observed following joint pathologies and in low back pain conditions. Although chronic neck pain has been associated with changes in muscle recruitment and coordination in the shoulder and arms, the possibility of muscle inhibition has not been explored. METHODS: Biceps activation during a maximal voluntary elbow flexor contraction was assessed using the interpolated twitch technique and electromyography. Cervical range of motion and pressure pain thresholds were measured using a goniometer and an algometer. Manipulation of the cervical spine was applied at the level of C5/6/7, and functional assessments were repeated. RESULTS: Patients showed significant inhibition in their biceps muscles. Cervical range of motion was restricted laterally, and increased pressure pain sensitivity was evident. After cervical spine manipulation, a significant reduction in biceps inhibition and an increase in biceps force occurred. Cervical range of motion and pressure pain thresholds increased significantly. CONCLUSIONS: Significant dysfunction in biceps activation was evident in patients with chronic neck pain, indicating that this muscle group cannot be used to the full extent. Spinal manipulation decreased muscle inhibition and increased elbow flexor strength at least in the short term. RELEVANCE: Muscle inhibition in the biceps has not been previously documented in patients with chronic neck pain. Further research is needed to establish whether muscle inhibition is related to clinical symptoms and functional outcome. Spinal manipulation improved muscle function, cervical range of motion and pain sensitivity, and might therefore be beneficial for treating patients with chronic neck pain. Copyright 2002 Elsevier Science Ireland Ltd.

161. Tait, C. P., E. Grigg and C. J. Quirk (1998). ”Brachioradial pruritus and cervical spine manipulation.” Australasian Journal of Dermatology 39(3): 168-70.

Brachioradial pruritus (BRP) causes significant morbidity in the majority of patients for whom no effective treatment is found. Chronic ultraviolet radiation exposure has usually been cited as the cause, but nerve damage from cervical spine disease has also been implicated. We report on a small retrospective exploratory study, conducted by questionnaire, of a group of patients who were treated with a specific cervical spine manipulation. Ten of 14 patients reported resolution of symptoms following manipulative treatment. All six patients who had had previous cervical spine disease responded to manipulation, as did half the remaining eight patients who had no previous history of neck symptoms. Although patients with BRP, by definition, share similar symptoms, the aetiology is almost certainly multifactorial. Prospective studies looking for cervical spine disease, as well as assessment of this particular method of cervical spine manipulation as a treatment modality for BRP, should be considered.

162. Taylor, H. H. and B. Murphy (2008). ”Altered sensorimotor integration with cervical spine manipulation.” Journal of Manipulative & Physiological Therapeutics 31(2): 115-26.

OBJECTIVE: This study investigates changes in the intrinsic inhibitory and facilitatory interactions within the sensorimotor cortex subsequent to a single session of cervical spine manipulation using single- and paired-pulse transcranial magnetic stimulation protocols. METHOD: Twelve subjects with a history of reoccurring neck pain participated in this study. Short interval intracortical inhibition, short interval intracortical facilitation (SICF), motor evoked potentials, and cortical silent periods (CSPs) were recorded from the abductor pollicis brevis and the extensor indices proprios muscles of the dominant limb after single- and paired-pulse transcranial magnetic stimulation of the contralateral motor cortex. The experimental measures were recorded before and after spinal manipulation of dysfunctional cervical joints, and on a different day after passive head movement. To assess spinal excitability, F wave persistence and amplitudes were recorded after median nerve stimulation at the wrist. RESULTS: After cervical manipulations, there was an increase in SICF, a decrease in short interval intracortical inhibition, and a shortening of the CSP in abductor pollicis brevis. The opposite effect was observed in extensor indices proprios, with a decrease in SICF and a lengthening of the CSP. No motor evoked potentials or F wave response alterations were observed, and no changes were observed after the control condition. CONCLUSION: Spinal manipulation of dysfunctional cervical joints may alter specific central corticomotor facilitatory and inhibitory neural processing and cortical motor control of 2 upper limb muscles in a muscle-specific manner. This suggests that spinal manipulation may alter sensorimotor integration. These findings may help elucidate mechanisms responsible for the effective relief of pain and restoration of functional ability documented after spinal manipulation.

163. Terrett, A. G. (1995). ”Misuse of the literature by medical authors in discussing spinal manipulative therapy injury.[see comment].” Journal of Manipulative & Physiological Therapeutics 18(4): 203-10.

OBJECTIVE: This study was conducted to determine how the words chiropractic and chiropractor have been used in publications in relation to the reporting of complications from cervical spinal manipulation therapy (SMT). STUDY DESIGN: The study method was to collect recent publications relating to spinal manipulation iatrogenesis which mentioned the words chiropractic and/or chiropractor and then determine the actual professional training of the practitioner involved. METHOD: The training of the practitioner in each report was determined by one of three means: surveying previous publications, surveying subsequent publications and/or by writing to the author(s) of ten recent publications which had used the words chiropractic and/or chiropractor. RESULTS: This study reveals that the words chiropractic and chiropractor commonly appear in the literature to describe SMT, or practitioner of SMT, in association with iatrogenic complications, regardless of the presence or absence of professional training of the practitioner involved. CONCLUSION: The words chiropractic and chiropractor have been incorrectly used in numerous publications dealing with SMT injury by medical authors, respected medical journals and medical organizations. In many cases, this is not accidental; the authors had access to original reports that identified the practitioner involved as a nonchiropractor. The true incidence of such reporting cannot be determined. Such reporting adversely affects the reader’s opinion of chiropractic and chiropractors.

164. Thiel, H. and G. Rix (2005). ”Is it time to stop functional pre-manipulation testing of the cervical spine?” Manual Therapy 10(2): 154-8.

The combined extended and rotated cervical spine position has been postulated to affect vertebral artery blood flow by primarily causing a narrowing of the vessel lumen, usually within the artery contralateral to the side of head rotation. The production of brainstem symptoms during the manoeuvre has generally been considered to be a positive test result. As a consequence, functional pre-manipulation testing of the cervical spine has been part of clinical screening undertaken by chiropractors and other manual practitioners to rule out the risk of possible injury to the vertebral artery. To date, these testing procedures are taught to students and carried out in daily clinical practice, despite the considerable controversy that exists about their validity. This paper considers and discusses the usefulness of functional pre-manipulation testing for clinical scenarios, involving dissection, spasm or stenosis of the vertebral artery, and makes the following recommendations: (1) Practitioners must assess the patient thoroughly, through careful history taking and physical examination, for the possibility of vertebral artery dissection. It is important to note that vertebral artery dissection (VAD) may present as pain only, and may not be associated with symptoms and signs of brainstem ischaemia. (2) If there is a strong likelihood of VAD, provocative pre-manipulation tests should not be performed, and the patient must be referred appropriately. (3) In the patient presenting with symptoms of brainstem ischaemia due to non-dissection stenotic vertebral artery pathologies, provocative testing is very unlikely to provide any useful additional diagnostic information. (4) In the patient with unapparent vertebral artery pathology, where spinal manipulative therapy (SMT) is considered as the treatment of choice, provocative testing is very unlikely to provide any useful information in assessing the probability of manipulation induced vertebral artery injury.

165. Thiel, H. W. (1991). ”Gross morphology and pathoanatomy of the vertebral arteries.” Journal of Manipulative & Physiological Therapeutics 14(2): 133-41.

Cerebrovascular accidents are an uncommon, but well documented, complication of cervical spine manipulation. This paper reviews vertebral artery gross morphology and pathoanatomy as they relate to possible mechanisms of injury to this vessel. Certain positions of the head and neck can lead to vertebral artery compromise and may ultimately lead to a cerebrovascular accident. The results obtained from a cadaver study on vertebral artery diameter at the site of the posterior arch of atlas are also presented.

166. Thiel, H. W. and J. E. Bolton (2008). ”Predictors for immediate and global responses to chiropractic manipulation of the cervical spine.” Journal of Manipulative & Physiological Therapeutics 31(3): 172-83.

OBJECTIVE: Patients with nonspecific musculoskeletal disorders may vary in their response to treatment. This study set out to identify the predictors for either improvement or worsening in symptoms for which cervical spine manipulation is indicated. METHOD: A large prospective study recorded details on patients, their presenting symptoms, and type of treatment. At the end of the consultation, any immediate improvement or worsening in presenting symptoms was noted. At the follow-up visit, information was collected on the patients’ self-reported improvement. RESULTS: Data were collected from 28,807 treatment consultations (in 19,722 patients) and 13,873 follow-up treatments. The presenting symptoms of ”neck pain,” ”shoulder, arm pain,” ”reduced neck, shoulder, arm movement, stiffness,” ”headache,” ”upper, mid back pain,” and ”none or one presenting symptom” emerged in the final model as significant predictors for an immediate improvement. The presence of any 4 of these predictors raised the probability for an immediate improvement in presenting symptoms after treatment from 70% to approximately 95%. With regard to immediate worsening, ”neck pain,” ”shoulder, arm pain, ”headache,” ”numbness, tingling upper limbs,” ”upper, mid back pain,” and ”fainting, dizziness, light-headedness” emerged as predictors; and the presence of any 4 of these raised the probability for immediate worsening from 4.4% to approximately 12%. For global improvement, only 2 predictors were identified; but these did not enhance the postprediction probability. CONCLUSIONS: This study is the first attempt to identify variables that can predict immediate outcomes in terms of improvement and worsening of presenting symptoms, and global improvement, after cervical spine manipulation. The predictor variables were strongest for immediate improvement.

167. Thiel, H. W., J. E. Bolton, S. Docherty, et al. (2007). ”Safety of chiropractic manipulation of the cervical spine: a prospective national survey.[see comment].” Spine 32(21): 2375-8; discussion 2379.

STUDY DESIGN: Prospective national survey. OBJECTIVE: To estimate the risk of serious and relatively minor adverse events following chiropractic manipulation of the cervical spine by a sample of U.K. chiropractors. SUMMARY OF BACKGROUND DATA: The risk of a serious adverse event following chiropractic manipulation of the cervical spine is largely unknown. Estimates range from 1 in 200,000 to 1 in several million cervical spine manipulations. METHODS: We studied treatment outcomes obtained from 19,722 patients. Manipulation was defined as the application of a high-velocity/low-amplitude or mechanically assisted thrust to the cervical spine. Serious adverse events, defined as ”referred to hospital A&E and/or severe onset/worsening of symptoms immediately after treatment and/or resulted in persistent or significant disability/incapacity,” and minor adverse events reported by patients as a worsening of presenting symptoms or onset of new symptoms, were recorded immediately, and up to 7 days, after treatment. RESULTS: Data were obtained from 28,807 treatment consultations and 50,276 cervical spine manipulations. There were no reports of serious adverse events. This translates to an estimated risk of a serious adverse event of, at worse approximately 1 per 10,000 treatment consultations immediately after cervical spine manipulation, approximately 2 per 10,000 treatment consultations up to 7 days after treatment and approximately 6 per 100,000 cervical spine manipulations. Minor side effects with a possible neurologic involvement were more common. The highest risk immediately after treatment was fainting/dizziness/light-headedness in, at worse approximately 16 per 1000 treatment consultations. Up to 7 days after treatment, these risks were headache in, at worse approximately 4 per 100, numbness/tingling in upper limbs in, at worse approximately 15 per 1000 and fainting/dizziness/light-headedness in, at worse approximately 13 per 1000 treatment consultations. CONCLUSION: Although minor side effects following cervical spine manipulation were relatively common, the risk of a serious adverse event, immediately or up to 7 days after treatment, was low to very low.

168. Tinel, D., E. Bliznakova, C. Juhel, et al. (2008). ”Vertebrobasilar ischemia after cervical spine manipulation: a case report.” Annales de Readaptation et de Medecine Physique 51(5): 403-14.

INTRODUCTION: The most serious accidents after cervical spine manipulation are vertebrobasilar ischemia. Their incidence is underestimated. Their risk of apparition is lower if the contraindications are respected and if they are realised according to suitable practice. CASE REPORT: Mrs B, 39 years old, was an active smoker and had migraine for 10 years ago. One day, she presented an unusual headache associated with neck pain that was treated by a cervical spine manipulation. Seven hours after, she developed an alternate syndrome with a right sensory motor defect, a cerebellar syndrome, a pyramidal syndrome and a left defect of cranial nerves. The arteriography showed a thrombosis of the basilar trunk and a dissection of the left vertebral artery. A thrombolysis ”in situ” was realized six hours and a half after the onset of the neurological defects. After eight months of rehabilitation, there were still a paralysis of the right upper limb, of the cranial nerves and a cerebellar syndrome but the patient was able to walk with two crutches and can eat by herself. DISCUSSION: Several risk factors were present in this case and there was also a major contraindication to manipulations: unusual acute occipital headache. Given the long period between the onset of neurological symptoms and the confirmation of the diagnosis, intravenous thrombolysis could not be done. Unfortunately, after eight months, important neurological sequels persisted. In order to avoid this type of accident after cervical manipulations, it is necessary to realize a strict medical examination and to implement the recommendations from the French society of manual and orthopaedic osteopathic medicine (Societe francaise de medecine manuelle orthopedique et osteopathique [SOFMMOO]).

169. Tseng, S. H., S. M. Lin, Y. Chen, et al. (2002). ”Ruptured cervical disc after spinal manipulation therapy: report of two cases.” Spine 27(3): E80-2.

STUDY DESIGN: Case reports of ruptured cervical disc after spinal manipulation therapy. OBJECTIVES: To present the rare cases of ruptured cervical disc temporally related to spinal manipulation therapy. SUMMARY OF BACKGROUND DATA: The complication of ruptured cervical disc was rare in the literature. METHODS: Two patients developed cervical myelopathy or radiculopathy after spinal manipulation therapy, and magnetic resonance imaging showed herniated cervical discs at C4-C5 and C6-C7, respectively. RESULTS: Anterior cervical discectomy was performed, and ruptured disc fragments were removed in these two patients. Both patients had good neurologic recovery after operation, and no neurologic deficits were noted after 15 and 6 months of follow-up, respectively. CONCLUSIONS: The experience of these two patients reminds us that cervical disc rupture can occur during a course of cervical spinal manipulation. Full neurologic recovery is achievable if accurate diagnosis and prompt surgical treatment are done.

170. Turgut, M. (2002). ”Ischemic stroke secondary to vertebral and cartid artery dissection following chiropractic manipulation of the cervical spine.” Neurosurg Rev 25(4): 267.

171. Urakawa, M., Y. Ueda, H. Yasuda, et al. (2003). ”[Vertebral artery occlusion following neck trauma: report of two cases] 外傷性椎骨動脈閉塞の2症例.” No to Shinkei – Brain & Nerve (脳と神経) 55(2): 141-5.

We are reporting two cases of vertebral artery occlusion resulting from cervical spine trauma. A 41-year-old man experienced vertigo and nausea 6 hrs after chiropractic manipulation. On admission, he was alert and demonstrated nystagmus, hypalgia of left leg, and right Horner sign. A MR image revealed infarction in the right cerebellar hemisphere. A MR angiogram did not show the proximal part of the right vertebral artery. A right vertebral angiogram revealed right vertebral artery occlusion at the level of C 1. He underwent anticoagulation and wore a cervical collar. He was discharged with hypalgia of left leg. A 53-year-old man was admitted to our hospital after an automobile accident. A CT scan revealed a subarachnoid hemorrhage and an intraventricular hemorrhage. A cervical CT scan revealed fractures of the C 5 facet joint and C 6 vertebral body. A MR angiogram did not show the proximal part of the left vertebral artery. A subsequent left vertebral angiogram revealed left vertebral artery occlusion at the level of C 6. He underwent anticoagulation and wore a cervical collar. In addition, he underwent coil embolization of the left vertebral artery. He was discharged with no neurological deficits. It is said that traumatic vertebral artery injuries cause cerebral infarction with time lags. The therapeutic point is to prevent propagation of the thrombus and distal embolism; therefore wearing a collar, anticoagulation, and endovascular interventional therapy is recommended.

172. Watanabe, M., T. Murayama, K. Mano, et al. (1996). ”[Medial medullary infarction following neck manipulation].” Rinsho Shinkeigaku – Clinical Neurology (臨床神経) 36(1): 43-6.

Reported is a case of a 39-year-old man with medial medullary infarction following chiropractic neck manipulation. Neurologically, he showed right hemiparesis sparing the face, right deep sensory impairment and tongue deviation to the left in five hours after neck manipulation. A cranial MRI revealed an ischemic lesion in the left medial portion of the medulla oblongata. Cerebral angiography demonstrated no apparent organic lesion of the right vertebral artery (VA), but showed hypoplasia of the left VA. We suspect that the left medial medullary infarction occurred because of the reduced VA blood flow following the contralateral VA compression, in addition to the ipsilateral VA hypoplasia. This case is the first one reported in which medial medullary infarction was possibly induced by neck manipulation.

173. Vautravers, P. and J. Y. Maigne (2000). ”Cervical spine manipulation and the precautionary principle.” Joint, Bone, Spine: Revue du Rhumatisme 67(4): 272-6.

Cervical manipulations can cause severe neurologic complications, which are both exceedingly rare and generally unpredictable. To meet the requirements of the principles of prevention and precaution, we believe the number of cervical manipulations should be reduced. To this end, we suggest that five recommendations developed by consensus be followed: unwanted effects, however minor, of previous manipulation should be looked for routinely and taken as absolute contraindications to further manipulation; a thorough physical examination, including a neurological evaluation, should be performed prior to manipulation; all known contraindications and indications should be followed; manipulation should be performed only by physicians experienced in this technique; and special caution should be exercised when performing first-line cervical manipulation.

174. Vautravers, P. and J. Y. Maigne (2003). ”Manipulations du rachis cervical: risques–benefices–precautions [Cervical spine manipulation: risks--benefit--assessment].” Revue Neurologique 159(11): 1064-6.

Cervical manipulation is a widely used method indicated in non-specific mechanical neck pain and cervicogenic headache. Cervical manipulation can cause severe neurologic complications which are both rare and generally unpredictable, which can be compared with the accidents occurring with other treatments (nonsteroidal anti-inflammatory drugs.). To decrease this risk, we propose five recommendations developed by consensus: –unwanted effects, however minor (e.g. nausea or vertigo), of prior manipulation should be searched for routinely and taken as contraindications for future spinal manipulations; –a thorough physical examination, including a neurological evaluation should be performed prior to manipulation; –all know indications and contraindications should be followed; — manipulations should be performed only by physicians experienced in this technique; –special caution should be exercised when performing first-line cervical manipulation and simple, honest and easily understandable information about these risks should be included when informed consent is obtained.

175. Weinstein, S. M. and R. C. Cantu (1991). ”Cerebral stroke in a semi-pro football player: a case report.[see comment].” Medicine & Science in Sports & Exercise 23(10): 1119-21.

Cervical spine trauma can clearly result in neurologic injury. An unusual traumatic event is a vascular insult of the vertebral arteries, potentially leading to stroke. The vertebral arteries are vulnerable to compression at several sites in the cervical spine. The high degree of physiologic rotation at the atlanto-axial joint places the vertebral artery at risk through normal daily activities as well as following forceful trauma, including manipulative treatment. Cerebrovascular insufficiency is an uncommon but serious complication of cervical spinal manipulation, which can lead to posterior circulatory impairment. Comprehensive diagnostic studies may be required to differentiate primary intracranial pathology from cerebral symptoms secondary to vascular compromise.

176. WHO (2005). WHO guidelines on basic training and safety in chiropractic. Geneva, World Health Organization.

Written mainly by chiropractors. Exerpt:
”Objectives
In order to facilitate qualified and safe practice of chiropractic as well as to protect the public and patients, the objectives of these guidelines are:
• to provide minimum requirements for chiropractic education
• to serve as a reference for national authorities in establishing an examination and licensing system for the qualified practice of chiropractic
• to review contraindications in order to minimize the risk of accidents and to advise on the management of complications occurring during treatment and to promote the safe practice of chiropractic.”

”5.4 Vascular accidents
Understandably, vascular accidents are responsible for the major criticism of spinal manipulative therapy. However, it has been pointed out that ”critics of manipulative therapy emphasize the possibility of serious injury, especially at the brain stem, due to arterial trauma after cervical manipulation. It has required only the very rare reporting of these accidents to malign a therapeutic procedure that, in experienced hands, gives beneficial results with few adverse side effects” (43).
In very rare instances, the manipulative adjustment to the cervical spine of a vulnerable patient becomes the final intrusive act which, almost by chance, results in a very serious consequence (54, 55, 56, 57).

5.4.1 Mechanism
Vertebrobasilar artery insufficiency is the result of transient, partial or complete obstruction of one or both of the vertebral arteries or its branches. The signs and symptoms of vertebral artery syndrome arising from that compression include vertigo, dizziness, light]headedness, giddiness, disequilibria, ataxia, walking difficulties, nausea and/or vomiting, dysphasia, numbness to one side of the face and/or body, sudden and severe neck/head pain after spinal manipulative therapy (43:579). Most cases of arterial thrombosis and infarction generally occur in the elderly and are spontaneous and unrelated to trauma.

5.4.2 Incidence
Vertebral artery syndrome attributed to cervical manipulation occurs in younger patients. The average age is under 40, and it occurs more often in women than men. In 1980, Jaskoviak estimated that five million treatments had been given at National College of Chiropractic clinics over a 15]year period, without a single case of vertebral artery syndrome associated with manipulation (58).
While it is understood that the actual incidence of cerebral vascular injury could be higher than the number of reported incidents, estimates from recognized authorities in research in this area have varied from as little as one fatality in several tens of millions of manipulations (59), one in 10 million (60) and one in one million (61) to the slightly more significant ”one important complication in 400 000 cervical manipulations” (62).”

177. Williams, L. S. and J. Biller (2003). ”Vertebrobasilar dissection and cervical spine manipulation A complex pain in the neck.[comment].” Neurology 60(9): 1408-9.

(Inget abstract. Ur keywords: ”*Aneurysm, Dissecting/et [Etiology], *Intracranial Aneurysm/et [Etiology], *Manipulation, Chiropractic/ae [Adverse Effects], Manipulation, Chiropractic/sn [Statistics & Numerical Data], *Neck Pain/th [Therapy], Risk, Stroke/ep [Epidemiology], *Stroke/et [Etiology], *Vertebral Artery Dissection/et [Etiology]”)

178. Wright, G. T. (2002). ”Assessing the risks of cervical manipulation for neck pain.” Cmaj 166(9): 1134.

Inget abstract. Ur keywords: ”Cervical Vertebrae/pathology, Manipulation, Chiropractic/*adverse effects, Risk Factors, Stroke/*etiology”)

179. Yokota, J., Y. Amakusa, Y. Tomita, et al. (2003). ”[The medial medullary infarction (Dejerine syndrome) following chiropractic neck manipulation] 頸部整体中に延髄内側症候群（Dejerine症候群）を発症した椎骨動脈解離の1例.” No to Shinkei – Brain & Nerve (脳と神経) 55(2): 121-5.

A-38-year-old man suddenly developed nausea, vomiting and vertigo during chiropractic neck manipulation. This was followed by right hemiplegia, right deep sensory disturbance and left hypoglossal nerve palsy, consistent with the medial medullary infarction (Dejerine syndrome). The MRI revealed infarction at left medial part of the medulla. The vertebral angiogram and MRA showed marked narrowing of the left vertebral artery. X-rays of the cervical spine showed no spondylosis, dislocation nor osteolysis of the odontoid process. The serological studies, including lupus anticoagulant, protein C, and protein S gave normal results. Although vascular accidents involving the brain stem after chiropractic neck manipulation have been reported since Pratt-Thomas and Berger, previous reports are still rare. In them lateral medullary infarction (Wallenberg syndrome) is probably the most common case. On the other hand, medial medullary syndrome (Dejerine syndrome) is absolutely rare. To our knowledge, the only one report has been made by Watanabe and his colleagues before our present case. The mechanism was suggested that rotation and tilting of the neck stretches and compresses the vertebral artery at the cervical joint causing injury to the vessel, with an intimal tearing, dissection, and pseudoaneurysm formation. Consequently, the present case may be caused by injury to the left vertebral artery with an intimal tearing during neck manipulation sufficient to cause disection and subsequent infarction of the brain stem.

180. Yoshida, S., K. Nakazawa and Y. Oda (2000). ”Spontaneous vertebral arteriovenous fistula–case report.” Neurologia Medico-Chirurgica 40(4): 211-5.

A 57-year-old male presented with a rare case of spontaneous vertebral arteriovenous fistula manifesting as radiculopathy of the right arm, subsequently associated with pulsating tinnitus and vascular bruit in the nape. He had a past history of chiropractic-induced vertebrobasilar infarction. Angiography showed a simple and direct fistula between the third segment of the right vertebral artery and the epidural veins at the C-1 level, where the artery runs backward above the arch of the C-1 just proximal to the penetration of the dura. The fistula was successfully obliterated by coil embolization, resulting in rapid improvement of the signs and symptoms. Mechanical compression to the nerve roots by the engorged epidural veins with arterial pressure was considered to be the major cause of radiculopathy. Vertebral artery dissection induced by chiropractic manipulation is most likely responsible for the development of the fistula.

181. Yoshida, T., J. Jinnouchi, K. Toyoda, et al. (2008). ”[Cerebellar infarction in a young adult due to traumatic vertebral artery dissection after lateral mass fracture at the sixth cervical vertebrae].” Brain & Nerve / Shinkei Kenkyu no Shinpo 60(5): 567-70.

A 23-years-old man fell off stairs and got a blow on the left head and right shoulder. He felt dysesthesia at the right thumb on the following day, and received chiropractic therapy from the forth day after injury. On the sixth day after injury, he developed dizziness and nausea, and was urgently hospitalized in our cerebrovascular center. On admission, he had horizontal nystagmus and truncal ataxia. Diffusion-weighted magnetic resonance imaging showed high intensity lesions in right cerebellum hemisphere of posterior inferior cerebellar artery territory, indicating fresh infarcts. On angiogram, right vertebral artery showed tapering occlusion at C6 level, indicating dissection. Computed tomogram showed fracture of the right lateral mass at C6 which extended into the transverse foramen. Under diagnosis of the traumatic vertebral artery dissection due to cervical fracture, we started anticoagulation therapy, which was followed by oral antiplatelet therapy in the chronic stage. Extracranial vertebral artery dissection due to cervical fracture is an important cause of brain infarction in a young adult. Radiological examinations are necessary to rule out traumatic vertebral artery dissection for patients with prolonged dizziness after head injury.

182. Zak, S. M. and R. F. Carmody (1984). ”Cerebellar infarction from chiropractic neck manipulation: case report and review of the literature.” Ariz Med 41(5): 333-7.

2. Varför inte låta dem tro om de vill?

En mycket vanlig och utbredd uppfattning är, att om människor upplever sig bli hjälpta av alternativa behandlingar så är det väl bra, låt dem hållas. Vad man då glömmer bort är att väldigt många, eller de flesta, faktiskt inte blir hjälpta. En del prövar den ena behandlingen efter den andra i sina desperata försök att hitta en bot för sin sjukdom, och somliga ruinerar sig på kuppen. Varje ny behandling ger förnyat hopp som följs av en allvarlig besvikelse när det inte fungerar som utlovat.

Vi ser flera viktiga orsaker till att bekämpa och informera om de alternativa behandlingsmetoderna. Då definierar vi alternativmedicin som behandlingar som saknar evidens (bevis), behandlingar som är motbevisade och behandlingar som endast har marginell effekt.

1. De säljer falska förhoppningar.
2. De är inte bra för vår hälsa.
3. De tar resurser från viktig och relevant forskning.
4. De hotar vår intellektuella kultur, fördummar och gör narr av oss. Vetenskapen har ägnat mer än hundra år åt att bekämpa vidskepelse och villfarelser. Är det rätt att ersätta vättar, troll och andra oknytt med Qi, meridianer och slaggprodukter?
5. De slösar bort människors pengar, i vissa fall även skattepengar.
6. De underminerar och förtalar några av våra mest värdefulla och viktiga institutioner. De som förespråkar alternativmedicinen, och den fantasivetenskap som ofta är intimt förknippad med den, är ett hot mot mänsklighetens utveckling och framtid.

1. Hälsning och introduktion

Vi heter Olle och Ragnvi Kjellin, vanliga människor i Småland. Olle är läkare och språkvetare, Ragnvi är veterinär och skogsbrukare. Vi är både naturvetare och humanister. Olle är disputerad, forskarutbildad, och storkonsument av forskningslitteratur. Som läkare är Olle skyldig att även tänka och arbeta förebyggande. Med de kunskaper vi har känns det oetiskt att stillatigande se på när mörka krafter försöker rasera vad vetenskapen har byggt upp under de senaste 100-150 åren, och framför allt de senaste 50-60 åren, bl.a. tack vare utvecklingen av statistiska testmetoder. Man kan inte ljuga med statistik! Men man kan av okunnighet (eller illvilja) använda den fel och därmed lura både sig själv och andra. Därför är forskning svår att utföra, och svår att förstå för lekmän.

Detta är vår första blogg: Varför vill någon utsätta sig för diverse risker genom att låta sig behandlas av s.k. alternativmedicinare? Det ska denna bloggplats handla om. Med sporadiska inlägg och fritt fram för kommentarer.

Vi är bekymrade över all den vidskepelse i form av olika ”alternativa, komplementära och integrativa” behandlingsformer som sprider sig i samhället och som motarbetar vetenskapens utveckling. Tron på detta är ångestskapande för massor av användare, levebröd för många godtrogna utövare, och väldigt vinstskapande för dem som ligger bakom mytbildningarna. Människans hjärna gillar magi och ceremonier. Vår intuition räcker inte för att se sanningen. Rigorös vetenskap kan hjälpa oss att hitta sanningen. Okunnig, slarvig eller falsk vetenskap ger aldrig sanningen. Det finns ingen alternativ sanning, ingen alternativ vetenskap, ingen alternativ medicin!

Kanske arbetar utövarna i god tro i brist på djupare kunskap, men vi är övertygade om att tillverkare av t.ex. diverse bluffmanicker typ ”Vegatest”, ”millimetervågsapparat”, ”aurakamera” mm gör detta med iskall beräkning i rent profitsyfte. De vet att tillräckligt många människor vill gå på blufferna för att det ska löna sig, även om de åker på böter mm för kvacksalveri. Likaså de som tillverkar ”naturmedel” med allehanda mer eller mindre farliga tillsatser, som inte deklareras. Vidare också de som har stora fabriker för att tillverka utspätt vatten och hundraprocentiga sockerpiller under det klatschiga namnet ”homeopatmediciner”. För att inte tala om s.k. ”kosttillskott”! De troende är alltid troende, och de gillar martyrer. Vi vill upplysa de ännu icke troende, de som står och vacklar och undrar inför det överflöd av information och fagra löften som bombarderar dem. Vi vill tillhandahålla sanningen, inga löften. Vi vill tillhandahålla kunskap, inga fantasipåhitt.

Risker med alternativmedicin

Risker? Javisst! Alternativmedicinare är fantasimedicinare. De har ingen eller otillräcklig medicinsk utbildning, men (många) hävdar ändå att de kan ställa diagnoser och bota sjukdomar. De ställer typiskt nog diagnoser ”som inte ens de riktiga läkarna kunde hitta”, och behandlar dem framgångsrikt. Dvs, de fanns nog inte från början!

Exempel på risker:

1. Kiropraktik – stroke, förlamning, död pga halskärlsskador som leder till blodpropp i hjärnan! Detta måste anses vara den allra farligaste alternativmedicinska behandlingen. Visserligen sällsynt biverkan, men den finns. Illamående är vanligt efter kiropraktikbehandling. Vad beror det på? Kiropraktorerna säger själva att det är normalt med illamående efter behandling, ”visar att behandlingen varit effektiv”. Den logiska slutsatsen för oss är snarare att också det beror på halskärlspåverkan men med lyckligtvis mindre allvarligt slut. Det finns ingen som helst anledning annars att må illa av hårdhänt massage. (Yrsel, illamående och/eller huvudvärk är ofta de första symptomen vid stroke.)

Hundratals fall av stroke efter nackmanipulation är dokumenterade, men förnekas av kiropraktorerna själva. Men ett enda fall av stroke är för mycket för en behandling som har ingen eller knappt någon effekt, och som är baserad på medicinska omöjligheter. Väldigt dyrt i både hälsa och pengar!

2. Homeopati – bevisat verkningslös behandling, och ev. gå miste om rätt diagnos och behandling. Dyrt!

3. Kosttillskott och ”slaggrensning” – livsångest inför något onödigt, ”tänk om jag inte får i mig rätt näringsämnen!” ”Tänk om jag samlar på mig en massa slaggprodukter och blir sjuk!” Dyrt!

Vi vill lära oss varför det kan finnas människor som hellre vill tro på fantasimedicin än på vetenskapligt grundade behandlingsprinciper. Det är viktigt att förstå det, så att vi kan rätta till det som fattas i den moderna, vetenskapliga vården.