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Chiropractic Research Review

Stroke: Specific Link to Manipulation Elusive

Previous efforts to isolate possible types of manipulation and/or patients associated with the highest risk for stroke or cerebral artery dissection have proved inconclusive.

The authors of this study reviewed 64 medical legal cases involving cerebrovascular ischemic events occurring after cervical spine manipulation, to determine characteristics of treatment rendered and symptoms reported by patients experiencing these complications.

Files included practitioner records before, during and after the cerebrovascular event; neurologist records (post-stroke); and practitioner and patient depositions. Three researchers assessed each case independently using a standardized process and reached agreement by consensus on case content.

Twenty-five percent of cases presented to the chiropractor with sudden onset of "new and unusual" head and neck pain, which may have been associated with other neurological symptoms of a cerebral artery dissection in progress. This type of pain was often very severe. Head and/or neck pain was reported in 92% of the cases.

The investigators also attempted to identify the type of manipulation used in each case and found that rotation manipulation was associated with dissection most frequently (51% of cases). The authors point out that it is unknown if rotation is more associated with stroke, or if it is simply the most common procedure employed. Other manipulation procedures reported were lateral break; seated; traction; toggle; instrument; drop-table; and nonforce. One case of alleged post-manipulation stroke occurred when no manipulation was actually performed.

The authors found that the C1-C2 vertebral levels were the most common sites of arterial occlusion, based upon review of angio-grams taken after the stroke. The authors found no significant pattern relating stroke to the number of manipulations performed on each patient, stating, "They appear to occur randomly during the process of manipulation with an almost equal number of cases occurring after the first manipulation, the first five manipulations, 16-35 manipulations, and over 35 manipulations, all performed by the same practitioner."

Conclusion: Vertebrobasilar dissection and stroke "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."

Haldeman S, Kohlbeck FJ, McGregor M. Original communication: Stroke, cerebral artery dissection, and cervical spine manipulation therapy. Journal of Neurology 2002:249(8), pp. 1098-1104. Reprints: www.infotrieve.com

Chiropractic Research Review

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