How to reduce stroke concerns by increasing patient confidence with low-force, soft-tissue techniques

The concern over a stroke potentially following chiropractic adjustments of the cervical spine continues to be a subject of ongoing chiropractic research and a focal point of media controversy, periodically propagated by members of the medical profession in the United States and abroad who profess an overtly hostile antichiropractic agenda.

Mainstream media and medical reports usually fail to provide a balanced approach to this issue, frequently overlooking or ignoring the significant amount of research supporting chiropractic’s relative safety in general, and specifically with regard to cervical spinal adjustments.

For example, in an exhaustive systematic literature review, Hurwitz et al stated that the risk of fatal stroke following cervical manipulation has been assessed to be 3 per 10 million manipulations, or about 0.00025%.¹

Haldeman et al placed the potential risk somewhere between 1 in 1.3 million treatment sessions to 1 in 400,000.² According to Myler, the mortality rate from stroke in the general population may actually be higher than that among chiropractic patients.³

Terrett’s research indicates that the actual number of iatrogenic complications specifically ascribed to chiropractic has been significantly overestimated, and that the practitioner actually involved in many cases is not even a chiropractor.⁴

Wenban’s review of the literature concluded that there is no human experimental evidence that chiropractic adjustments are causally related to vertebrobasilar accidents.⁵ Symons et al concluded that the maximum forces on a vertebral artery from chiropractic manipulation are no greater than those recorded during common diagnostic range of motion tests regularly performed by chiropractors, medical doctors, and physical therapists.⁶

Concerns over the possible risk of stroke associated with chiropractic adjustments of the cervical spine seem to focus on, or at least imply, the use of high-velocity, low-amplitude dynamic thrusting techniques, particularly those that use rotational maneuvers, even though the existing body of literature suggests that chiropractic adjustments in all of their variations are relatively and reasonably safe maneuvers.⁷ Moreover, determining what constitutes a chiropractic adjustment (generally implying greater specificity and exactitude of the maneuver to assist in the correction or reduction of vertebral subluxation) versus a generic form, a spinal manipulation (which can mean virtually anything) in the literature is not always clear.

To further confuse the matter, doctors of chiropractic have traditionally relied upon a variety of screening tests to help identify patients who may be at a risk for cerebrovascular compromise, but the current body of research suggests that those tests are unreliable.

Licht et al stated, “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.”⁸

Similarly, Cote et al studied patients who experienced dizziness upon cervical rotation and extension with Doppler ultrasound and concluded: “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.”⁹

In fact, Haldeman et al’s research suggests that no patient can reasonably be seen to be at higher risk from spinal manipulative therapy because of specific predisposing factors or specific types of manipulation, and they consider the risk of vertebrobasilar stroke a rare, random, and unpredictable complication of all neck movements.¹⁰

Where does all of this information leave the practicing chiropractor when confronted with the predictably hostile media, the generally adversarial and skeptical medical profession, and potentially unpredictable, high-risk, or litigious patients?

According to Chapman-Smith, “Much is written about the classic chiropractic adjustment, the precise and fast manipulative techniques that gap the targeted joint and, with spinal joints, produce potent reflex effects in the central peripheral and autonomic branches of the nervous system. However, chiropractic education and practice encompass a wide range of low force and soft tissue techniques. Use of soft tissue manipulation/joint mobilization in combination with joint adjustment/manipulation often means that the latter can be performed with greater ease and effectiveness. There are various classes of patient who will not tolerate or are at added risk with joint manipulation. Perhaps the ultimate goal for some patients is not external force at all.”¹¹

Similarly, Schneider has written that the use of myofascial therapy as a primary chiropractic technique, such as Nimmo or myofascial trigger point therapy, offers doctors the ability to safely and effectively treat frail or elderly patients with osteoporosis; acute, swollen, or inflamed joints; joint or ligament instability from acute whiplash injuries, unstable shoulders or knees; severe or acute disc herniations; prior surgery or joint replacement; those with a history of cerebrovascular disease or transient ischemic attacks; and patients who fear neck manipulation or more forceful techniques.¹²

Moreover, Schneider states, “Many potential patients would prefer a soft tissue or low force technique it if were offered to them,” and he notes that by blending muscular techniques with osseous techniques, the force required to perform a manipulative thrust is dramatically reduced.¹²

Similarly, Roth and D’Ambrogio have stated that appropriately applied low force, soft tissue techniques, such as Positional Release Therapy (PRT) readily offer normalization of muscle hypertonicity and fascial tension, reduction of joint hypomobility, increased circulation and reduced swelling, decreased pain, and increased muscular strength to a variety of patient types, including those with spinal-related and neuromusculoskeletal disorders, disc herniations or degenerative disc disease, arthritis, scoliosis, fracture, postsurgical laminectomy, postsurgical discectomy, Harrington rods, pediatric patients, geriatric patients, sports injury patients, amputees, motor vehicle accident patients, respiratory patients, and neurologic patients.¹³

Low force, soft tissue techniques readily address components of the chiropractic model of vertebral subluxation complex, which generally includes kinesiology, neurology, myology, connective tissue physiology, angiology, inflammatory response, anatomy, physiology, and biochemistry.¹⁴

Soft tissue techniques make perfect sense to patients. Raymond Nimmo, DC, pioneer of the Receptor-Tonus Technique, expressed the concept perfectly when in 1957 he wrote, “The trouble is not bones but the things that control them. Muscles and ligaments control bones, but the nervous system controls these. And that control is not lost through nerve pressure. It is a nerve condition, and its correction is our rightful field.”¹⁵

By incorporating low force, soft tissue techniques into my practice as my primary adjusting techniques (namely, Nimmo, PRT, SOT blocking, and mechanical flexion-distraction), I have built a practice that eliminates patient anxiety, yields predictably quick, favorable, and consistent clinical results, inspires immediate patient confidence, and remains consistent with the done-by-the-hands philosophy of chiropractic to remove interference to the normal function of the nervous system.

Gerald A. Anzalone, DC, of Hudson Valley Neck and Back Care, Peekskill, NY, has been in practice for 8 years. He is a writer and lecturer of health care issues and CE classes. Anazalone can be reached via email: janzalonedc@hotmail.com.

References
1. Hurwitz EL, Aker PD, Adams AH, Meeker WC, Shekelle PG. Manipulation and mobilization of the cervical spine: A systematic review of the literature. Spine. 1996;21(15):1746–1760.
2. Haldeman S, Kohlbeck FJ, McGregor M. Risk factors and precipitating neck movements causing vertebrobasilar artery dissection after cervical trauma and spinal manipulation. Spine. 1999;24(8):785–794.
3. Myler L. A risk assessment of cervical manipulation vs. NSAIDs for the treatment of neck pain. J Manipulative Physiol Ther. 1996;19(5):357.
4. Terrett AG. Misuse of the literature by medical authors in discussing spinal manipulative therapy. J Manipulative Physiol Ther. 1995;18(4):203–210.
5. Wenban A. Critical appraisal of an article about harm: Chiropractic adjustment and stroke. J Verterbal Sublux Res. 2001;4(3):68–74.
6. Symons B, Leonard T, Herzog W. Internal forces sustained by the vertebral artery during spinal manipulative therapy. J Manipulative Physiol Ther. 2002;25 (8):504–510.
7. Chapman-Smith D. ed. Cervical adjustment. Chiropractic Report. 1999;13(4).
8. Licht PB, Christensen HW, Hoilund-Carlsen PF. Is there a role for premanipulative testing before cervical manipulation? J Manipulative Physiol Ther. 2000;23 (3):175–179.
9. Cote P, Kreitz B, Cassidy J, Theil H. The validity of extension-rotation test as a clinical screening procedure before neck manipulation: secondary analysis. J Manipulative Physiol Ther. 1996;19:159.
10. Haldeman S, Kohlbeck FJ, McGregor M. Unpredictability of cerebrovascular ischemia associated with cervical spine manipulation therapy: a review of sixty-four cases after cervical spine manipulation. Spine. 2002;27(1):49–55.
11. Chapman-Smith, D. ed. Low-force and soft-tissue techniques. Chiropractic Report. 1998;12(4).
12. Schneider M. Principles of Manual Myofascial Therapy. Pittsburgh, Pa; 1999:61–62.
13. D’Ambrogio K, Roth G D’Ambrogio J. Positional Release Therapy: Assessment and Treatment Musculoskeletal Dysfunction. Mosby: St Louis, Mo; 1997:20–24.
14. Lantz CA. The subluxation complex. In: Gatterman MI. ed. Foundations of Chiropractic Subluxation. Mosby: St. Louis, Mo; 1995.
15. Nimmo R. In: Schneider M, Cohen J, Laws S. The Collected Writings of Nimmo and Vannerson: Pioneers of Chiropractic Trigger Point Therapy. Pittsburgh, Pa; 2001:3.