No announcement yet.

Re: CVAs resulting from cervi... (fwd)

This topic is closed.
  • Filter
  • Time
  • Show
Clear All
new posts

  • Re: CVAs resulting from cervi... (fwd)

    To the Biomechanics List

    I am forwarding a response to the following request from Darren A Rivett.

    Stephen Perle, D.C.
    Assistant Professor of Clinical Sciences
    University of Bridgeport College of Chiropractic
    Bridgeport, CT 06601

    On 2/16/95 Darren A Rivett wrote:
    > >> I am interested in determining the incidence of cerebrovascular
    > >> complications caused by cervical manual therapy/manipulation. This
    > >> includes
    > >> all professions using such techniques eg physios, osteopaths,
    > >> chiropractors etc.
    > >> I understand that the Swiss Association of Manual Medicine
    > >> retrospectively found the risk factor to be 1 in 400,000
    > >> manipulations.
    > >> Is anyone aware of any other studies or estimates of the incidence
    > >> of strokes related to manual therapy (current or completed)?
    > > Darren A Rivett
    > > Dunedin, New Zealand

    Forwarded message:
    > Studies Estimating the Risk of Stroke from Cervical Manipulation:
    > Every published which has estimated the incidence of stroke from cervical
    > manipulation has agreed that the risk is 1 to 3 incidents per million
    > treatments. Dvorak, (1) in a survey of 203 practitioners of manual medicine
    > in Switzerland, found a rate of one serious complication per 400,000 cervical
    > manipulations, without any reported deaths, among an estimated 1.5 million
    > cervical manipulations. Jaskoviak (2) reported approximately 5 million
    > cervical manipulations from 1965 to 1980 at The National College of
    > Chiropractic Clinic in Chicago, without a single case of vertebral artery
    > stroke or serious injury.
    > Henderson and Cassidy (3) reported a survey done at the Canadian Memorial
    > Chiropractic College outpatient clinic where more than a half-million
    > treatments were given over a nine-year period, again without serious
    > incident. Eder (4) offered a report of 168,000 cervical manipulations over a
    > 28 year period, without a single significant complication. After an extensive
    > literature review performed to formulate practice guidelines (5), the
    > authors concurred that the risk of serious neurological complications from
    > cervical manipulation] is extremely low, and is approximately one or two per
    > million cervical manipulations.
    > In another survey, based on a computerized registration system in Holland,
    > Patjin (6) found an overall rate of one complication in 518,886
    > manipulations. A survey of California neurologists (7), which inquired
    > about the number of patients they had treated who had suffered a stroke
    > within 24 hours of cervical manipulation, estimated the rate of stroke to be
    > about one in 500,000 manipulations. Other experts on manipulation (8) have
    > published opinions that the risk of stroke from cervical manipulation is two
    > or three more-or-less serious incidents per million treatments.
    > In addition to these published studies, data from the National Chiropractic
    > Mutual Insurance Company (NCMIC), which insures over 50 percent of US
    > chiropractors, is also useful for estimating the risk of cervial
    > manipulation. Since chiropractors deliver over 80 percent of the spinal
    > manipulation performed in the US, and this company insures about one-half of
    > the profession in the US, this malpractice insurer is a good source of
    > statistics on this subject. They reported that strokes accounted for about 5
    > percent of the 700 claims settled against their 24,000 members in 1993.
    > Using this figure, we calculate there are about 35 strokes per year among
    > the chiropractors insured by NCMIC.
    > However, we have learned that these published statistics are based upon the
    > total amount of money paid for claims. Since claims for strokes tend to be
    > more costly, the figures are skewed. According to a member of NCMIC Board
    > of Directors (personal communication with Louis Sportelli, DC, Dec. 21,
    > 1994), in the three years of 1991-92-93, NCMIC closed a total of 96 claims
    > for CVA; of this total 61 were closed with payment, and 35 were closed
    > without payment. If one concludes that there was little or no merit to the
    > 35 claims which were closed without payment, this would represent an average
    > of 20 CVA claims per year. If these NCMIC chiropractors are similar to the
    > national average, they see approximately 120 patient visits per week (9).
    > Curtis and Bove (10) report that rotary adjustments of the cervical spine
    > comprise about 30% of the visits made to chiropractors. Therefore,
    > chiropractors insured by NCMIC each performed some 1800 cervical
    > manipulations in each of those three years. Considering these numbers, we
    > calculate that NCMIC's 24,000 DCs perform some 43,000,000 cervical
    > manipulations per year. If this leads to 20 strokes, that's a rate of less
    > than one stroke per 2 million cervical manipulations.
    > Based upon these studies, the most reasonable estimate of the risk of stroke
    > from cervical manipulation is one-half to two incidents per million
    > manipulations performed. Only a minority of these cases are fatal. About
    > one-third of the cases of stroke following cervical manipulation reported in
    > Terrett's review of 107 cases (11) resolved with mild or no residuals. In a
    > later review, Terrett (12) found a total of 126 cases of vertebrobasilar
    > accidents following manipulation reported in the international literature
    > from 1934-1987, of which 29 cases resulted in death. This yields a mortality
    > rate of 23% among the incidences reported in the literature. While it has
    > been argued that the rate of strokes may be significantly under-reported in
    > the literature, it is probable that the rate of deaths are proportionally
    > over-reported, since it is likely the more serious and impressive cases would
    > be described in the literature.
    > SUMMARY:
    > * A reasonable estimate of the risks of stroke following cervical
    > manipulation is 1/2 to 2 incidents per one million treatments.
    > * About one-third resolve with mild or no residuals (probably more due to
    > reporting bias).
    > * About one-fourth prove fatal (probably less due to reporting bias).
    > * Therefore, there are about 40-50 manipulation-caused strokes in the US per
    > year, and perhaps a dozen deaths, out of some 80-90 million neck
    > manipulations.
    > Compare this risk to the 3-4% rate of complication for cervical spine
    > surgery, and the 4,000-10,000 DEATHS per million neck surgeries (13) Or,
    > compare it to the risk from the most conservative treatment of neck pain,
    > prescription of Non-Steroidal Anti-Inflammatory Drugs (NSAIDs). One author
    > (14) estimates 32,000 hospitalizations due GI hemorrhage from NSAID use for
    > musculoskeletal complaints and osteoarthritis per year in the US (a rate of
    > 0.4%). He estimates 3,200 deaths from GI hemorrhage due to NSAID use for
    > musculoskeletal complaints annually.
    > Bill Lauretti, DC
    > Bethesda, Maryland
    > BillLaur@AOL.COM
    > 1. Dvorak J, Orelli F. How dangerous is manipulation to the cervical spine?
    > Manual Medicine 1985; 2: 1-4.

    > 2. Jaskoviak P. Complications arising from manipulation of the cervical
    > spine. J Manip Physiol Ther 1980; 3: 213-19.

    > 3. Henderson DJ, Cassidy JD. Vertebral Artery syndrome. In: Vernon H. Upper
    > cervical syndrome: chiropractic diagnosis and treatment. Baltimore: Williams
    > and Wilkins, 1988: 195-222.

    > 4. Eder M, Tilscher H. Chiropractic therapy: diagnosis and treatment
    > (English translation). Rockville, Md: Aspen Publishers, 1990: 61.

    > 5. Haldeman S, Chapman-Smith D, Petersen DM. Guidelines for chiropractic
    > quality assurance and practice parameters. Gaithersburg, Md: Aspen Publishers
    > 1993: 170-2.

    > 6. Patijn J. Complications in Manual Medicine: A Review of the Literature.
    > J Manual Medicine 1991; 6: 89-92.

    > 7. Carlini W, Lee P, et al. Incidence of stroke following chiropractic
    > manipulation. In press. Based on abstract and press release presented at
    > American Heart Association's 19th International Conference on Stroke and
    > Cerebral Circulation, San Diego, February 19, 1994.

    > 8. Guttman G: Injuries to the vertebral artery caused by manual therapy
    > (English abstract), Manuelle Medizin 1983; 21: 2-14.

    > 9. Plamandon RL. Summary of 1992 ACA annual statistical survey. ACA J
    > Chiropractic 1993; 30 (Feb): 36-42.

    > 10. Curtis P, Bove G. Family physicians, chiropractors, and back pain. J
    > Family Practice 1992; 35 (5): 551-5.

    > 11. Terrett AG. Vascular accidents from cervical spine manipulation: Report
    > of 107 cases. J Aust Chiro Assoc 1987; 17: 15-24.

    > 12. Terret AG, Kleynhans AM. Cerebrovascular complications of manipulation.
    > In: Haldeman S., ed. Principals and Practice of Chiropractic. Norwalk,CT:
    > Appleton & Lang, 1992: 579-98.

    > 13. The cervical spine research society editorial committee. The Cervical
    > Spine, Second edition. Philadelphia: J.B. Lippincott Company 1990: 834.

    > 14. Fries, JF. Assessing and understanding patient risk. Scand J Rheumatol
    > 1992; Suppl. 92: 21-4.