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Trager RJ, Troutner AM, Pikus HJ, Daniels CJ, Dusek JA. Symptoms of Patients With Vertebral Artery Dissection Presenting to Chiropractors: A Systematic Review and Meta-Analysis. Cureus 2023; 15:e51297. [PMID: 38283533 PMCID: PMC10822691 DOI: 10.7759/cureus.51297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/28/2023] [Indexed: 01/30/2024] Open
Abstract
Early symptoms of vertebral artery dissection (VAD) may be nonspecific, including neck pain and headache. Neck pain and headache are also common reasons for patients to seek chiropractic care. We hypothesized that neck pain and/or headache would be the most prevalent symptoms among patients with undiagnosed VAD presenting to chiropractors compared to dizziness or other symptoms. We searched PubMed, Ovid, the Index to Chiropractic Literature, Google Scholar, and gray literature through September 2023 for observational studies describing patients aged ≥10 with previously undiagnosed VAD presenting to a chiropractor. Article selection, data extraction, and quality assessment were performed in duplicate. We synthesized the point prevalence of symptoms and other clinical features. We included 10 case reports describing 10 patients (mean age = 37, SD = 7, 60% female). All patients had either neck pain or headache (100%; 95% confidence interval (CI) = 100%-100%). The most prevalent individual symptoms were neck pain (90%; 95% CI = 71%-100%), headache (80%; 95% CI = 55%-100%), visual disturbance (50%; 95% CI = 19%-81%), and dizziness (40%; 95% CI = 10%-70%). The certainty of results was very low due to publication bias. While our findings suggest that neck pain and/or headache are the most prevalent symptoms among patients with undiagnosed VAD visiting a chiropractor, the small sample size and reliance on case reports preclude any definitive conclusions. Further research with larger sample sizes, control groups, and better control of confounders is required to corroborate these results. Chiropractors should be aware of VAD features and refer suspected patients for emergency care.
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Affiliation(s)
- Robert J Trager
- Chiropractic, Connor Whole Health, University Hospitals Cleveland Medical Center, Cleveland, USA
- Department of Family Medicine and Community Health, Case Western Reserve University School of Medicine, Cleveland, USA
- Department of Biostatistics and Bioinformatics Clinical Research Training Program, Duke University School of Medicine, Durham, USA
| | - Alyssa M Troutner
- Department of Clinical Education, Southern California University of Health Sciences, Whittier, USA
| | - Harold J Pikus
- Neurosurgery, Upper Valley Neurology Neurosurgery, Lebanon, USA
| | - Clinton J Daniels
- Rehabilitation Care Services, Veterans Affairs Puget Sound Health Care System, Tacoma, USA
| | - Jeffery A Dusek
- Department of Family Medicine and Community Health, Case Western Reserve University School of Medicine, Cleveland, USA
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2
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Chu ECP, Trager RJ, Lee LYK, Niazi IK. A retrospective analysis of the incidence of severe adverse events among recipients of chiropractic spinal manipulative therapy. Sci Rep 2023; 13:1254. [PMID: 36690712 PMCID: PMC9870863 DOI: 10.1038/s41598-023-28520-4] [Citation(s) in RCA: 29] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 01/19/2023] [Indexed: 01/24/2023] Open
Abstract
This study examined the incidence and severity of adverse events (AEs) of patients receiving chiropractic spinal manipulative therapy (SMT), with the hypothesis that < 1 per 100,000 SMT sessions results in a grade ≥ 3 (severe) AE. A secondary objective was to examine independent predictors of grade ≥ 3 AEs. We identified patients with SMT-related AEs from January 2017 through August 2022 across 30 chiropractic clinics in Hong Kong. AE data were extracted from a complaint log, including solicited patient surveys, complaints, and clinician reports, and corroborated by medical records. AEs were independently graded 1-5 based on severity (1-mild, 2-moderate, 3-severe, 4-life-threatening, 5-death). Among 960,140 SMT sessions for 54,846 patients, 39 AEs were identified, two were grade 3, both of which were rib fractures occurring in women age > 60 with osteoporosis, while none were grade ≥ 4, yielding an incidence of grade ≥ 3 AEs of 0.21 per 100,000 SMT sessions (95% CI 0.00, 0.56 per 100,000). There were no AEs related to stroke or cauda equina syndrome. The sample size was insufficient to identify predictors of grade ≥ 3 AEs using multiple logistic regression. In this study, severe SMT-related AEs were reassuringly very rare.
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Affiliation(s)
- Eric Chun-Pu Chu
- New York Chiropractic and Physiotherapy Centre, EC Healthcare, 41/F Langham Place Office Tower, 8 Argyle Street, Kowloon, Hong Kong
| | - Robert J Trager
- Connor Whole Health, University Hospitals Cleveland Medical Center, 11000 Euclid Ave, Cleveland, OH, 44106, USA.
- College of Chiropractic, Logan University, Chesterfield, MO, 63017, USA.
| | - Linda Yin-King Lee
- School of Nursing and Health Studies, Hong Kong Metropolitan University, Kowloon, Hong Kong
| | - Imran Khan Niazi
- Centre for Chiropractic Research, New Zealand College of Chiropractic, Auckland, 1060, New Zealand
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3
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Russell BS, Keller M, Wynd SE, Hosek RS, Owens EF, Hoiriis KT. Angular Kinematics of Chiropractic Supine Cervical Spine Manipulation: Rotational Measures and Comparisons to Doctor and Recipient Perceptions. J Manipulative Physiol Ther 2022; 45:497-507. [PMID: 36922054 DOI: 10.1016/j.jmpt.2022.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2021] [Revised: 10/20/2022] [Accepted: 12/01/2022] [Indexed: 03/17/2023]
Abstract
OBJECTIVES The primary purposes of this study were to measure axial rotation during supine cervical spinal manipulative therapy (cSMT) and to record recipients' and doctors' perceptions of rotational magnitudes. METHODS Experienced doctors of chiropractic (DCs) provided supine cSMT and acted as recipients of cSMT. Participants who received SMT wore inertial measurement units attached to the forehead and sternum for motion capture. Afterward, recipients and DCs completed questionnaires asking about their perceptions of motion. Data were analyzed for magnitudes of axial rotation at peak thrust and correlations with patient and doctor perceptions. Secondary analyses included angular velocity, angular acceleration, and other kinematic variables. RESULTS We recorded 23 SMT events with 14 DCs. Rotation at thrust peaks averaged 32.4° (17.4°). Doctors' and recipients' perceptions of rotation were higher than measured values 45% and 50% of the time, respectively. Maximum angular velocity and acceleration averaged 221.9°/s (124.9) and 4786.5°/s2 (2456.6), respectively. We found no correlation between perceptions and velocity or acceleration; doctors' perceptions had an inverse correlation with measurements. CONCLUSION On average, we found rotation during supine cSMT to be 32°. Both DCs and SMT recipients overestimated rotation compared with actual measurements. These factors should be considered in discussions of rotation and SMT.
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Affiliation(s)
- Brent S Russell
- Life University Center for Chiropractic Research, Atlanta, Georgia.
| | - Mackenzie Keller
- Life University Center for Chiropractic Research, Atlanta, Georgia
| | - Shari E Wynd
- Department of Foundational Sciences, Texas Chiropractic College, Pasadena, Texas
| | - Ronald S Hosek
- Life University Center for Chiropractic Research, Atlanta, Georgia
| | - Edward F Owens
- Life University Center for Chiropractic Research, Atlanta, Georgia
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Perle SM, Jung H, Ham J, Choi H. Letter to the Editor: A Case of Posterior Inferior Cerebellar Artery Infarction after Cervical Chiropractic Manipulation ( Korean J Neurotrauma 2018;14:159-163). Korean J Neurotrauma 2019; 15:72-73. [PMID: 31098354 PMCID: PMC6495580 DOI: 10.13004/kjnt.2019.15.e5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Accepted: 04/01/2019] [Indexed: 11/15/2022] Open
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Chaibi A, Russell MB. A risk-benefit assessment strategy to exclude cervical artery dissection in spinal manual-therapy: a comprehensive review. Ann Med 2019; 51:118-127. [PMID: 30889367 PMCID: PMC7857472 DOI: 10.1080/07853890.2019.1590627] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Cervical artery dissection refers to a tear in the internal carotid or the vertebral artery that results in an intramural haematoma and/or an aneurysmal dilatation. Although cervical artery dissection is thought to occur spontaneously, physical trauma to the neck, especially hyperextension and rotation, has been reported as a trigger. Headache and/or neck pain is the most common initial symptom of cervical artery dissection. Other symptoms include Horner's syndrome and lower cranial nerve palsy. Both headache and/or neck pain are common symptoms and leading causes of disability, while cervical artery dissection is rare. Patients often consult their general practitioner for headache and/or neck pain, and because manual-therapy interventions can alleviate headache and/or neck pain, many patients seek manual therapists, such as chiropractors and physiotherapists. Cervical mobilization and manipulation are two interventions that manual therapists use. Both interventions have been suspected of being able to trigger cervical artery dissection as an adverse event. The aim of this review is to provide an updated step-by-step risk-benefit assessment strategy regarding manual therapy and to provide tools for clinicians to exclude cervical artery dissection. Key messages Cervical mobilization and/or manipulation have been suspected to be able to trigger cervical artery dissection (CAD). However, these assumptions are based on case studies which are unable to established direct causality. The concern relates to the chicken and the egg discussion, i.e. whether the CAD symptoms lead the patient to seek cervical manual-therapy or whether the cervical manual-therapy provoked CAD along with the non-CAD presenting complaint. Thus, instead of proving a nearly impossible causality hypothesis, this study provide clinicians with an updated step-by-step risk-benefit assessment strategy tool to (a) facilitate clinicians understanding of CAD, (b) appraise the risk and applicability of cervical manual-therapy, and (c) provide clinicians with adequate tools to better detect and exclude CAD in clinical settings.
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Affiliation(s)
- Aleksander Chaibi
- a Head and Neck Research Group, Research Centre, Akershus University Hospital , Oslo , Norway.,b Institute of Clinical Medicine, Akershus University Hospital, University of Oslo , Nordbyhagen , Norway
| | - Michael Bjørn Russell
- a Head and Neck Research Group, Research Centre, Akershus University Hospital , Oslo , Norway.,b Institute of Clinical Medicine, Akershus University Hospital, University of Oslo , Nordbyhagen , Norway
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Boucher P, Robidoux S, Chahine S. Cervical artery dissections: Factors that influence causation determination in litigated cases. J Forensic Leg Med 2018; 58:169-178. [PMID: 30005337 DOI: 10.1016/j.jflm.2018.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2018] [Revised: 04/17/2018] [Accepted: 06/27/2018] [Indexed: 11/16/2022]
Abstract
In litigated cases, the suspected causes of cervical artery dissections (CADs) are a source of considerable debate among experts. In this study, we sought to examine the factors influencing court decisions and discover how Canadian tribunals analyzed and arbitrated conflicting expert opinions in CAD cases. Cases for this review were identified through searches of the Canadian CANLII database. First, the results of this study show that there is no standardized methodology to assist health care personnel in the processing and interpretation of data in individual cases of CAD. This leads to wide ranges of personal interpretations and opinions which may confuse tribunals. Of concern is the implication of treating physicians who may not have the objectivity to act as expert witnesses when one of their patients is engaged in a legal proceeding.
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Affiliation(s)
- Pierre Boucher
- Département de chiropratique, Université du Québec à Trois-Rivières, 3351, boul. des Forges, C.P. 500, Trois-Rivières, Québec, G9A 5H7, Canada.
| | - Sébastien Robidoux
- Département de chiropratique, Université du Québec à Trois-Rivières, 3351, boul. des Forges, C.P. 500, Trois-Rivières, Québec, G9A 5H7, Canada.
| | - Sarah Chahine
- Stikeman Elliott Law Firm, 1155, Boul. René-Lévesque Ouest, 41(e) étage, Montréal, QC, H3B 3V2, Canada.
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Turner RC, Lucke-Wold BP, Boo S, Rosen CL, Sedney CL. The potential dangers of neck manipulation & risk for dissection and devastating stroke: An illustrative case & review of the literature. BIOMEDICAL RESEARCH AND REVIEWS 2018; 2:10.15761/BRR.1000110. [PMID: 29951644 PMCID: PMC6016850 DOI: 10.15761/brr.1000110] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Chiropractic cervical manipulation is a common practice utilized around the world. Most patients are never cleared medically for manipulation, which can be devastating for those few who are at increased risk for dissections. The high velocity thrust used in cervical manipulation can produce significant strain on carotid and vertebral vessels. Once a dissection has occurred, the risk of thrombus formation, ischemic stroke, paralysis, and even death is drastically increased. In this case report, we highlight a case of a 32-year-old woman who underwent chiropractic manipulation and had vertebral artery dissection with subsequent brainstem infarct. She quickly deteriorated and passed away shortly after arrival to the hospital. Although rare, one in 48 chiropractors have experienced such an event. We utilize this case to highlight the risk associated with cervical manipulation and urge open dialogue between chiropractors and physicians. Receiving medical clearance prior to cervical manipulation in potential at risk patients would drastically reduce morbidity and mortality.
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Affiliation(s)
- Ryan C Turner
- Department of Neurosurgery, West Virginia University School of Medicine, Morgantown, West Virginia
- Center for Neuroscience, West Virginia University School of Medicine, Morgantown, West Virginia
- West Virginia Clinical & Translational Science Institute, West Virginia University School of Medicine, Morgantown, West Virginia
| | - Brandon P Lucke-Wold
- Department of Neurosurgery, West Virginia University School of Medicine, Morgantown, West Virginia
- Center for Neuroscience, West Virginia University School of Medicine, Morgantown, West Virginia
- West Virginia Clinical & Translational Science Institute, West Virginia University School of Medicine, Morgantown, West Virginia
| | - Sohyun Boo
- Department of Radiology, West Virginia University School of Medicine, Morgantown, West Virginia
| | - Charles L Rosen
- Department of Neurosurgery, West Virginia University School of Medicine, Morgantown, West Virginia
- Center for Neuroscience, West Virginia University School of Medicine, Morgantown, West Virginia
- West Virginia Clinical & Translational Science Institute, West Virginia University School of Medicine, Morgantown, West Virginia
| | - Cara L Sedney
- Department of Neurosurgery, West Virginia University School of Medicine, Morgantown, West Virginia
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Swait G, Finch R. What are the risks of manual treatment of the spine? A scoping review for clinicians. Chiropr Man Therap 2017; 25:37. [PMID: 29234493 PMCID: PMC5719861 DOI: 10.1186/s12998-017-0168-5] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Accepted: 11/08/2017] [Indexed: 12/20/2022] Open
Abstract
Background Communicating to patients the risks of manual treatment to the spine is an important, but challenging element of informed consent. This scoping review aimed to characterise and summarise the available literature on risks and to describe implications for clinical practice and research. Method A methodological framework for scoping reviews was followed. Systematic searches were conducted during June 2017. The quantity, nature and sources of literature were described. Findings of included studies were narratively summarised, highlighting key clinical points. Results Two hundred and fifty articles were included. Cases of serious adverse events were reported. Observational studies, randomised studies and systematic reviews were also identified, reporting both benign and serious adverse events.Benign adverse events were reported to occur commonly in adults and children. Predictive factors for risk are unclear, but for neck pain patients might include higher levels of neck disability or cervical manipulation. In neck pain patients benign adverse events may result in poorer short term, but not long term outcomes.Serious adverse event incidence estimates ranged from 1 per 2 million manipulations to 13 per 10,000 patients. Cases are reported in adults and children, including spinal or neurological problems as well as cervical arterial strokes. Case-control studies indicate some association, in the under 45 years age group, between manual interventions and cervical arterial stroke, however it is unclear whether this is causal. Elderly patients have no greater risk of traumatic injury compared with visiting a medical practitioner for neuro-musculoskeletal problems, however some underlying conditions may increase risk. Conclusion Existing literature indicates that benign adverse events following manual treatments to the spine are common, while serious adverse events are rare. The incidence and causal relationships with serious adverse events are challenging to establish, with gaps in the literature and inherent methodological limitations of studies. Clinicians should ensure that patients are informed of risks during the consent process. Since serious adverse events could result from pre-existing pathologies, assessment for signs or symptoms of these is important. Clinicians may also contribute to furthering understanding by utilising patient safety incident reporting and learning systems where adverse events have occurred.
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Affiliation(s)
- Gabrielle Swait
- The Royal College of Chiropractors, Chiltern Chambers, St. Peters Avenue, Reading, RG4 7DH UK
| | - Rob Finch
- The Royal College of Chiropractors, Chiltern Chambers, St. Peters Avenue, Reading, RG4 7DH UK
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9
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Letter to the editor - Adverse events associated with the use of cervical spine manipulation or mobilization and patient characteristics. Musculoskelet Sci Pract 2017; 30:e93-e94. [PMID: 28579368 DOI: 10.1016/j.msksp.2017.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Accepted: 05/17/2017] [Indexed: 11/23/2022]
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10
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Haas M, Brønfort G, Evans RL, Leininger B, Schmitt J, Levin M, Westrom K, Goldsmith CH. Spinal rehabilitative exercise or manual treatment for the prevention of cervicogenic headache in adults. Hippokratia 2017. [DOI: 10.1002/14651858.cd012205.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Mitchell Haas
- University of Western States; 2900 NE 132nd Avenue Portland OR USA 97230
| | - Gert Brønfort
- University of Minnesota; Integrative Health & Wellbeing Research Program, Center for Spirituality & Healing; 420 Delaware Street SE, MMC505 Minneapolis MN USA 55455
| | - Roni L Evans
- University of Minnesota; Integrative Health & Wellbeing Research Program, Center for Spirituality & Healing; 420 Delaware Street SE, MMC505 Minneapolis MN USA 55455
| | - Brent Leininger
- University of Minnesota; Integrative Health & Wellbeing Research Program, Center for Spirituality & Healing; 420 Delaware Street SE, MMC505 Minneapolis MN USA 55455
| | - John Schmitt
- St Catherine University; 601 25th Avenue S. Minneapolis MN USA 55454
| | - Morris Levin
- UCSF School of Medicine; Neurology; 2330 Post Street San Francisco California USA 94115
| | | | - Charles H Goldsmith
- Simon Fraser University; Faculty of Health Sciences; Blossom Hall, Room 9510 8888 University Drive Burnaby BC Canada V5A 1S6
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11
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Kranenburg HA, Lakke SE, Schmitt MA, Van der Schans CP. Adverse events following cervical manipulative therapy: consensus on classification among Dutch medical specialists, manual therapists, and patients. J Man Manip Ther 2017; 25:279-287. [PMID: 29449770 DOI: 10.1080/10669817.2017.1332556] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Objectives To obtain consensus-based agreement on a classification system of adverse events (AE) following cervical spinal manipulation. The classification system should be comprised of clear definitions, include patients' and clinicians' perspectives, and have an acceptable number of categories. Methods Design: A three-round Delphi study. Participants: Thirty Dutch participants (medical specialists, manual therapists, and patients) participated in an online survey. Procedure: Participants inventoried AE and were asked about their preferences for either a three- or a four-category classification system. The identified AE were classified by two analysts following the International Classification of Functioning, Disability and Health (ICF), and the International Classification of Diseases and Related Health Problems (ICD-10). Participants were asked to classify the severity for all AE in relation to the time duration. Results Consensus occurred in a three-category classification system. There was strong consensus for 16 AE in all severities (no, minor, and major AE) and all three time durations [hours, days, weeks]. The 16 AE included anxiety, flushing, skin rash, fainting, dizziness, coma, altered sensation, muscle tenderness, pain, increased pain during movement, radiating pain, dislocation, fracture, transient ischemic attack, stroke, and death. Mild to strong consensus was reached for 13 AE. Discussion A consensus-based classification system of AE is established which includes patients' and clinicians' perspectives and has three categories. The classification comprises a precise description of potential AE in accordance with internationally accepted classifications. After international validation, clinicians and researchers may use this AE classification system to report AE in clinical practice and research.
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Affiliation(s)
- Hendrikus A Kranenburg
- Research Group Healthy Ageing, Allied Health Care and Nursing, Hanze University of Applied Sciences, Groningen, The Netherlands.,Department of Rehabilitation, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Sandra E Lakke
- Research Group Healthy Ageing, Allied Health Care and Nursing, Hanze University of Applied Sciences, Groningen, The Netherlands
| | - Maarten A Schmitt
- Research Centre Innovations in Care, Rotterdam University of Applied Sciences, Rotterdam, The Netherlands
| | - Cees P Van der Schans
- Research Group Healthy Ageing, Allied Health Care and Nursing, Hanze University of Applied Sciences, Groningen, The Netherlands.,Department of Rehabilitation, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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Tuchin P. Postural Headaches Due to Cerebrospinal Fluid Leakage Through Subarachnoid-Pleural Fistula: A Case Report. Headache 2017; 57:665-666. [DOI: 10.1111/head.13049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2016] [Accepted: 12/10/2016] [Indexed: 11/28/2022]
Affiliation(s)
- Peter Tuchin
- Chiropractic; Macquarie University; North Ryde Sydney Australia
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13
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Nielsen SM, Tarp S, Christensen R, Bliddal H, Klokker L, Henriksen M. The risk associated with spinal manipulation: an overview of reviews. Syst Rev 2017; 6:64. [PMID: 28340595 PMCID: PMC5366149 DOI: 10.1186/s13643-017-0458-y] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Accepted: 03/15/2017] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Spinal manipulative therapy (SMT) is a widely used manual treatment, but many reviews exist with conflicting conclusions about the safety of SMT. We performed an overview of reviews to elucidate and quantify the risk of serious adverse events (SAEs) associated with SMT. METHODS We searched five electronic databases from inception to December 8, 2015. We included reviews on any type of studies, patients, and SMT technique. Our primary outcome was SAEs. Quality of the included reviews was assessed using a measurement tool to assess systematic reviews (AMSTAR). Since there were insufficient data for calculating incidence rates of SAEs, we used an alternative approach; the conclusions regarding safety of SMT were extracted for each review, and the communicated opinion were judged by two reviewers independently as safe, harmful, or neutral/unclear. Risk ratios (RRs) of a review communicating that SMT is safe and meeting the requirements for each AMSTAR item, were calculated. RESULTS We identified 283 eligible reviews, but only 118 provided data for synthesis. The most frequently described adverse events (AEs) were stroke, headache, and vertebral artery dissection. Fifty-four reviews (46%) expressed that SMT is safe, 15 (13%) expressed that SMT is harmful, and 49 reviews (42%) were neutral or unclear. Thirteen reviews reported incidence estimates for SAEs, roughly ranging from 1 in 20,000 to 1 in 250,000,000 manipulations. Low methodological quality was present, with a median of 4 of 11 AMSTAR items met (interquartile range, 3 to 6). Reviews meeting the requirements for each of the AMSTAR items (i.e. good internal validity) had a higher chance of expressing that SMT is safe. CONCLUSIONS It is currently not possible to provide an overall conclusion about the safety of SMT; however, the types of SAEs reported can indeed be significant, sustaining that some risk is present. High quality research and consistent reporting of AEs and SAEs are needed. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42015030068 .
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Affiliation(s)
- Sabrina Mai Nielsen
- The Parker Institute, Copenhagen University Hospital, Frederiksberg & Bispebjerg, Frederiksberg, 2000, Denmark
| | - Simon Tarp
- The Parker Institute, Copenhagen University Hospital, Frederiksberg & Bispebjerg, Frederiksberg, 2000, Denmark
| | - Robin Christensen
- The Parker Institute, Copenhagen University Hospital, Frederiksberg & Bispebjerg, Frederiksberg, 2000, Denmark
| | - Henning Bliddal
- Clinical Research Unit, The Parker Institute, Copenhagen University Hospital, Frederiksberg & Bispebjerg, Frederiksberg, 2000, Denmark
| | - Louise Klokker
- The Parker Institute, Copenhagen University Hospital, Frederiksberg & Bispebjerg, Frederiksberg, 2000, Denmark
| | - Marius Henriksen
- Physiotherapy and Biomechanics Research Unit, The Parker Institute, Copenhagen University Hospital, Frederiksberg & Bispebjerg, Frederiksberg, 2000, Denmark.
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14
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Bronson MA, Perle SM, Tuchin P. Issues with vertebral artery dissections. Interv Neuroradiol 2017; 23:154-155. [PMID: 28304208 DOI: 10.1177/1591019916680111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
| | | | - Peter Tuchin
- 3 Department of Chiropractic, Macquarie University, Australia
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15
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Gelfand AA, Johnson H, Lenaerts ME, Litwin JR, De Mesa C, Bogduk N, Goadsby PJ. Neck-Tongue syndrome: A systematic review. Cephalalgia 2017; 38:374-382. [PMID: 28100071 DOI: 10.1177/0333102416681570] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective Neck-Tongue syndrome (NTS) is characterized by brief attacks of neck or occipital pain, or both, brought out by abrupt head turning and accompanied by ipsilateral tongue symptoms. As the disorder is rare, we undertook a systematic review of the literature to identify all reported cases in order to phenotype clinically the disorder and subsequently inform clinical diagnostic criteria. Methods Two electronic databases were searched using the search term "neck tongue syndrome". All English language references were reviewed in full. Cases were abstracted using a standardized abstraction form and the references of the retrieved articles were reviewed by hand to identify additional references and cases. Conference proceedings from recent headache meetings were searched. We also report six new cases from our centers. Results There were 39 primary cases, 56% of which were female. Mean age (SD) at onset was 16 (12) years. Twenty (53%) experienced neck pain, seven (18%) occipital pain, and 11 (29%) both. Pain was most often sharp or stabbing and severe, lasting several seconds to several minutes. Eleven experienced numbness and/or tingling in the neck/occiput following the pain. Thirty-six had an accompanying tongue sensory disturbance and three a motor/posture disturbance; five had both. Thirteen had other headaches, and four a family history of Neck-Tongue syndrome. Conclusions Neck-Tongue syndrome typically has pediatric or adolescent onset, suggesting that ligamentous laxity during growth and development may facilitate transient subluxation of the lateral atlantoaxial joint with sudden head turning. Familial cases suggest a genetic predisposition in some individuals. Neck-Tongue syndrome should be re-instated in the International Classification of Headache Disorders.
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Affiliation(s)
- Amy A Gelfand
- 1 UCSF Pediatric Headache, University of California, San Francisco, CA, USA.,2 UCSF Child Neurology, University of California, San Francisco, CA, USA
| | | | - Marc Ep Lenaerts
- 4 University of California, Davis, Department of Neurology, Davis, CA, USA
| | - Jessica R Litwin
- 2 UCSF Child Neurology, University of California, San Francisco, CA, USA
| | - Charles De Mesa
- 5 Univsersity of California, Davis, Pain Management Department, Davis, CA, USA
| | - Nikolai Bogduk
- 6 Faculty of Health and Medicine, University of Newcastle, Newcastle, New South Wales, Australia
| | - Peter J Goadsby
- 1 UCSF Pediatric Headache, University of California, San Francisco, CA, USA.,7 NIHR-Wellcome Trust King's Clinical Research Facility, King's College London, London, UK
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Paulus JK, Thaler DE. Does case misclassification threaten the validity of studies investigating the relationship between neck manipulation and vertebral artery dissection stroke? Yes. Chiropr Man Therap 2016; 24:42. [PMID: 27822362 PMCID: PMC5097396 DOI: 10.1186/s12998-016-0123-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Accepted: 09/21/2016] [Indexed: 01/16/2023] Open
Abstract
Background For patients and health care providers who are considering spinal manipulative therapy of the neck, it is crucial to establish if it is a trigger for cervical artery dissection and/or stroke, and if it is, the magnitude of the risk. Discussion We discuss the biological plausibility of how neck manipulation could cause cervical artery dissection. We also discuss how case misclassification threatens the validity of influential published studies that have investigated the relationship between neck manipulation and dissection. Our position is supported by the fact that the largest epidemiologic studies of neck manipulation safety with respect to neurological outcomes have relied on International Classification of Diseases-9 codes for case identification. However, the application of these codes in prior studies failed to identify dissections (rather than strokes in general) and so conclusions from those studies are invalid. Conclusion There are several methodological challenges to understanding the association between neck manipulation and vertebral artery dissection. Addressing these issues is critical because even a modest association between neck manipulation and cervical artery dissection could translate into a significant number of avoidable dissections given the widespread use of neck manipulation by providers from various backgrounds. We believe that valid case classification, accurate measurement of manipulative procedures, and addressing reverse causation bias should be top priorities for future research.
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Affiliation(s)
- Jessica K Paulus
- Predictive Analytics and Comparative Effectiveness (PACE) Center, Institute for Clinical Research and Health Policy Studies (ICRHPS), Tufts Medical Center/Tufts University School of Medicine, Boston, MA USA
| | - David E Thaler
- Predictive Analytics and Comparative Effectiveness (PACE) Center, Institute for Clinical Research and Health Policy Studies (ICRHPS), Tufts Medical Center/Tufts University School of Medicine, Boston, MA USA ; Department of Neurology, Tufts Medical Center/Tufts University School of Medicine, 800 Washington St, Box 314, Boston, MA 02111 USA
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17
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Haas M, Brønfort G, Evans RL, Leininger B, Schmitt J, Levin M, Westrom K, Goldsmith CH. Spinal rehabilitative exercise or manual treatment for the prevention of cervicogenic headache in adults. Cochrane Database Syst Rev 2016; 2016:CD012205. [PMID: 28090192 PMCID: PMC5226451 DOI: 10.1002/14651858.cd012205] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
This is the protocol for a review and there is no abstract. The objectives are as follows: To quantify and compare the short- and long-term effects of manual treatment and spinal rehabilitative exercise for cervicogenic headache, classified according to the International Headache Society's (IHS) diagnostic criteria, with an active or placebo/sham comparison or wait-list control.
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Affiliation(s)
| | - Gert Brønfort
- Integrative Health & Wellbeing Research Program, Center for Spirituality & Healing, University of Minnesota, Minneapolis, MN, USA
| | - Roni L Evans
- Integrative Health & Wellbeing Research Program, Center for Spirituality & Healing, University of Minnesota, Minneapolis, MN, USA
| | - Brent Leininger
- Integrative Health & Wellbeing Research Program, Center for Spirituality & Healing, University of Minnesota, Minneapolis, MN, USA
| | | | - Morris Levin
- Neurology, UCSF School of Medicine, San Francisco, California, USA
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18
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Mikkelsen R, Dalby RB, Hjort N, Simonsen CZ, Karabegovic S. Endovascular Treatment of Basilar Artery Thrombosis Secondary to Bilateral Vertebral Artery Dissection with Symptom Onset Following Cervical Spine Manipulation Therapy. AMERICAN JOURNAL OF CASE REPORTS 2015; 16:868-71. [PMID: 26647210 PMCID: PMC4678923 DOI: 10.12659/ajcr.895273] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Patient: Female, 37 Final Diagnosis: Vertebral artery dissection Symptoms: Neck pain and focal neurological deficits Medication: No previous Clinical Procedure: Endovascular thrombectomy Specialty: Neurology
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Affiliation(s)
- Ronni Mikkelsen
- Department of Neuroradiology, Aarhus University Hospital, Aarhus, Denmark
| | - Rikke Beese Dalby
- Department of Neuroradiology, Aarhus University Hospital, Aarhus, Denmark
| | - Niels Hjort
- Danish Stroke Center, Aarhus University Hospital, Aarhus, Denmark
| | | | - Sanja Karabegovic
- Department of Neuroradiology, Aarhus University Hospital, Aarhus, Denmark
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Tarola G, Phillips RB. Chiropractic Response to a Spontaneous Vertebral Artery Dissection. J Chiropr Med 2015; 14:183-90. [PMID: 26778932 DOI: 10.1016/j.jcm.2015.10.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2015] [Revised: 10/13/2015] [Accepted: 10/13/2015] [Indexed: 01/11/2023] Open
Abstract
OBJECTIVE The purpose of this case report is to describe a case in which early detection and proper follow-up of spontaneous vertebral artery dissection led to satisfactory outcomes. CLINICAL FEATURES A 34-year old white woman reported to a chiropractic clinic with a constant burning pain at the right side of her neck and shoulder with a limited ability to turn her head from side to side, periods of blurred vision, and muffled hearing. Dizziness, visual and auditory disturbances, and balance difficulty abated within 1 hour of onset and were not present at the time of evaluation. A pain drawing indicated burning pain in the suboccipital area, neck, and upper shoulder on the right and a pins and needles sensation on the dorsal surface of both forearms. Turning her head from side-to-side aggravated the pain, and the application of heat brought temporary relief. The Neck Disability Index score of 44 placed the patient's pain in the most severe category. INTERVENTION AND OUTCOME The patient was not treated on the initial visit but was advised of the possibility of a vertebral artery or carotid artery dissection and was recommended to the emergency department for immediate evaluation. The patient declined but later was convinced by her chiropractor to present to the emergency department. A magnetic resonance angiogram of the neck and carotid arteries was performed showing that the left vertebral artery was hypoplastic and appeared to terminate at the left posterior inferior cerebellar artery. There was an abrupt moderately long segment of narrowing involving the right vertebral artery beginning near the junction of the V1 and V2 segments. The radiologist noted a concern regarding right vertebral artery dissection. Symptoms resolved and the patient was cleared of any medications but advised that if symptoms reoccurred she was to go for emergency care immediately. CONCLUSION Recognition and rapid response by the chiropractic physician provided the optimum outcome for this particular patient.
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Affiliation(s)
- Gary Tarola
- Private Practice, Lehigh Valley Medical Network, Allentown, PA
| | - Reed B Phillips
- Adjunct Faculty, Southern California University of Health Sciences, Whittier, CA
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Wynd S, Estaway M, Vohra S, Kawchuk G. Correction: The Quality of Reports on Cervical Arterial Dissection following Cervical Spinal Manipulation. PLoS One 2015; 10:e0130221. [PMID: 26061539 PMCID: PMC4465339 DOI: 10.1371/journal.pone.0130221] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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21
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von Heymann W. Aktuelle Datenlage zu Zwischenfällen bei manuellen Wirbelsäulenmanipulationen. MANUELLE MEDIZIN 2015. [DOI: 10.1007/s00337-015-1251-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Bien JY, Morel J, Demasles S, Abboud K, Molliex S. [Postoperative dissection of the vertebral artery in two steps]. ACTA ACUST UNITED AC 2014; 33:696-9. [PMID: 25447780 DOI: 10.1016/j.annfar.2014.07.750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2014] [Accepted: 07/22/2014] [Indexed: 10/24/2022]
Abstract
The diagnosis of perioperative vertebral artery dissection can be difficult because of non-specific clinical signs. We report a case revealed by a tegmento-thalamic stroke after an abdominal second surgical look. The interest of this observation is related to a particular evolution in two steps separated by a 2-month-interval and an intercurrent cervical manipulation. After the second anesthesia, neck pain associated with a third cranial nerve palsy and a supranuclear ophtalmoplegia revealed a tegmento-thalamic ischemic stroke due to vertebral artery dissection. We discuss here the different factors possibly involved in the pathophysiology of postoperative vertebral artery dissection: positioning, cervical manipulation, subclavian central venous access and cisplatin toxicity. Vertebral artery dissection should be discussed in case of postoperative neck pain, especially with non-typical symptomatology.
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Affiliation(s)
- J-Y Bien
- Service d'anesthésie réanimation, hôpital Nord, CHU de Saint-Étienne, avenue Albert-Raymond, 42270 Saint-Priest-en-Jarez, France.
| | - J Morel
- Service d'anesthésie réanimation, hôpital Nord, CHU de Saint-Étienne, avenue Albert-Raymond, 42270 Saint-Priest-en-Jarez, France
| | - S Demasles
- Service de neurologie, hôpital Nord, CHU de Saint-Étienne, avenue Albert-Raymond, 42270 Saint-Priest-en-Jarez, France
| | - K Abboud
- Service de chirurgie digestive et cancérologique, hôpital Nord, CHU de Saint-Étienne, avenue Albert-Raymond, 42270 Saint-Priest-en-Jarez, France
| | - S Molliex
- Service d'anesthésie réanimation, hôpital Nord, CHU de Saint-Étienne, avenue Albert-Raymond, 42270 Saint-Priest-en-Jarez, France
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Piper SL, Howarth SJ, Triano J, Herzog W. Quantifying strain in the vertebral artery with simultaneous motion analysis of the head and neck: a preliminary investigation. Clin Biomech (Bristol, Avon) 2014; 29:1099-107. [PMID: 25457973 DOI: 10.1016/j.clinbiomech.2014.10.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2013] [Revised: 10/03/2014] [Accepted: 10/06/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND Spontaneous vertebral artery dissection has significant mortality and morbidity among young adults. Unfortunately, causal mechanisms remain unclear. The purpose of this study was to quantify mechanical strain in the vertebral artery while simultaneously capturing motion analysis data during passive movements of the head and neck relative to the trunk during spinal manipulation and cardinal planes of motion. METHODS Eight piezoelectric crystals (four per vertebral artery) were sutured into the lumen of the left and right vertebral arteries of 3 cadaveric specimens. Strain was then calculated as changes in length between neighboring crystals from a neutral head/neck reference position using ultrasound pulses. Simultaneously, passive motion of the head and neck on the trunk was captured using eight infrared cameras. The instantaneous strain arising in the vertebral artery was correlated with the relative changes in head position. FINDINGS Strain in the contralateral vertebral artery during passive flexion-rotation compared to that of extension-rotation is variable ([df=32]: -0.61<r<0.55). Peak strain does not coincide with peak angular displacement during spinal manipulation and cardinal planes of motion. Axial rotation displayed the greatest amount of strain. The greatest amount of strain achieved during spinal manipulation was comparably lower than strains achieved during passive end range motions and previously reported failure limits. INTERPRETATION The results of this study suggest that vertebral artery strains during head movements including spinal manipulation, do not exceed published failure strains. This study provides new evidence that peak strain in the vertebral artery may not occur at the end range of motion, but rather at some intermediate point during the head and neck motion.
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Affiliation(s)
- Steven L Piper
- Canadian Memorial Chiropractic College, Toronto, Ontario M2H 3J1, Canada
| | - Samuel J Howarth
- Canadian Memorial Chiropractic College, Toronto, Ontario M2H 3J1, Canada
| | - John Triano
- Canadian Memorial Chiropractic College, Toronto, Ontario M2H 3J1, Canada
| | - Walter Herzog
- University of Calgary, Calgary, Alberta T2N 1N4, Canada,.
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Jevne J, Hartvigsen J, Christensen HW. Compensation claims for chiropractic in Denmark and Norway 2004-2012. Chiropr Man Therap 2014; 22:37. [PMID: 25389462 PMCID: PMC4226888 DOI: 10.1186/s12998-014-0037-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2014] [Accepted: 10/21/2014] [Indexed: 01/30/2023] Open
Abstract
Background Adverse events are commonly observed in all parts of health care and have been reported extensively following manual therapy, including chiropractic. The majority of reported adverse events following chiropractic care are mild, transitory and self-limiting. However, little is known about patient filed compensation claims related to the chiropractic consultation process. The aim of this study was to describe claims reported to the Danish Patient Compensation Association and the Norwegian System of Compensation to Patients related to chiropractic from 2004 to 2012. Methods All finalized compensation claims involving chiropractors reported to one of the two associations between 2004 and 2012 were assessed for age, gender, type of complaint, decisions and appeals. Descriptive statistics were used to describe the study population. Results 338 claims were registered in Denmark and Norway between 2004 and 2012 of which 300 were included in the analysis. 41 (13.7%) were approved for financial compensation. The most frequent complaints were worsening of symptoms following treatment (n = 91, 30.3%), alleged disk herniations (n = 57, 19%) and cases with delayed referral (n = 46, 15.3%). A total financial payment of €2,305,757 (median payment €7,730) were distributed among the forty-one cases with complaints relating to a few cases of cervical artery dissection (n = 11, 5.7%) accounting for 88.7% of the total amount. Conclusion Chiropractors in Denmark and Norway received approximately one compensation claim per 100.000 consultations. The approval rate was low across the majority of complaint categories and lower than the approval rates for general practioners and physiotherapists. Many claims can probably be prevented if chiropractors would prioritize informing patients about the normal course of their complaint and normal benign reactions to treatment.
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Affiliation(s)
- Jørgen Jevne
- Hønefoss Kiropraktikk og Rehabilitering, Torvgata 2, 3513 Hønefoss, Norway
| | - Jan Hartvigsen
- Department of Sports Science and Clinical Biomechanics, Faculty of Health Sciences, University of Southern Denmark, Campusvej 55, DK-5230 Odense M, Denmark ; Nordic Institute of Chiropractic and Clinical Biomechanics, Campusvej 55, DK-5230 Odense M, Denmark
| | - Henrik Wulff Christensen
- Nordic Institute of Chiropractic and Clinical Biomechanics, Campusvej 55, DK-5230 Odense M, Denmark
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Liebich JM, Reinke TS. Presentation of an 85-year-old woman with musculoskeletal pain to a chiropractic clinic: a case of ischemic stroke. J Chiropr Med 2014; 13:49-54. [PMID: 24711785 PMCID: PMC3976496 DOI: 10.1016/j.jcm.2014.01.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
OBJECTIVE The purpose of this case is to describe a patient who had a stroke preceding a chiropractic appointment and was unaware that the cerebrovascular event had occurred. CLINICAL FEATURES An 85-year-old established patient presented for chiropractic treatment of pain in the left side of the neck, hip, and low back associated with known advanced degenerative spinal disease and lumbar stenosis. On the day of presentation, the patient reported morning nausea, double vision, and right-sided vision loss; she related that she had collided into a car while driving to the appointment. Review of her medical history divulged residual neurological deficits related to a previous subdural hematoma, resulting in craniotomy. Examination revealed a right inferior quadrantanopia in the right eye and right nasal hemianopia in the left eye. Nystagmus was present in the left eye with saccadic intrusion on pursuit right to left. INTERVENTION AND OUTCOME The patient was transported immediately to an emergency room,where diagnosis of an Acute infarct in the left cerebrum at the junction of the left occipital, parietal and temporal lobes in the watershed area was confirmed. CONCLUSION Patients with signs and symptoms of stroke in progress may occasionally present for chiropractic care. It is imperative to complete a thorough history and examination prior to care.
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Affiliation(s)
- Julia M. Liebich
- Chiropractic Physician and Doctor of Naturopathic Medicine, Chief Clinician, Naturopathic Medicine, Department of Clinical Practice; Instructor, Clinical Sciences, National University of Health Sciences, Lombard, IL
| | - Tari S. Reinke
- Chiropractic Physician, Attending Clinician, Department of Clinical Practice, National University of Health Sciences, Lombard, IL
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