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WFC Talking Points on AHA Scientific Statement on CMT and Cervical Artery Dissection. August 2014

August 2014

A Scientific Statement titled Cervical Artery Dissections and Association with Cervical Manipulative Therapy for neurologists and other health professionals, written by Biller, Sacco et al. on behalf of the American Heart Association Stroke Council, was published online in the AHA’s journal Stroke on August 7 and may be found here.  There are a number of concerns with the statement, including the overall concern that it focuses on cervical manipulative therapy (CMT) when this is only one of many trivial movements/activities that have been associated with cervical artery dissection (CD).  

It has already been misinterpreted by some in the media and may be referred to in your country in the weeks and months ahead.  The WFC therefore provides these talking points.  It is recommended that any comment should be left to appropriately qualified spokespersons in the profession, who should focus on the positive aspects of the Statement which include:

1.    This statement is about cervical manipulative therapy (CMT) not chiropractic treatment.  Although it mentions accurately that spinal manipulations are most commonly performed in North America by chiropractors it notes “however they are also done by members of the allopathic, osteopathic and physical therapy/physiotherapy professions.” (Page 2, col 2, para 3.)

2.    There is no suggestion that CMT is inappropriate.  (On current research evidence it is a first line option for many patients on the grounds of safety, effectiveness and patient preference/satisfaction - for example those with common forms of neck pain and headache1).

3.    It is acknowledged that there is no clear evidence that cervical artery injury and stroke are caused by CMT, as opposed to being associated in time with it. (14/2/Conclusion.)  On this the AHA explains:

a.    Study of the forces reaching the cervical arteries during manipulation/CMT shows that these are insufficient to strain the arteries and are less than “during passive range of motion” (5/2/3).  In other words less than during normal medical examination procedures.

b.    The only study comparing the frequency of stroke after visiting either a chiropractor or a primary care medical doctor, reports no difference.  In the AHA’s words:  “Because patients with VAD (vertebral artery dissection) commonly present with neck pain, it is possible that they seek therapy for this symptom from providers, including CMT practitioners, and that the VAD occurs spontaneously, implying that the association between CMT and VAD/vertebrobasilar artery stroke is not causal.” (5/1/3.)

4.    It is acknowledged that the association between stroke and CMT is rare.  It is fair to say that the AHA statement does not make this sufficiently clear.  On this:

a.    The authors, in the conclusion say that “the incidence of CD (cervical artery dissection) in CMT patients is probably low” (14/2/Conclusion).

b.    In fact it is generally described by researchers as extremely low or rare with an incidence of about 1 in one million treatments2.  This can be better understood by most people if described as one incident in a group of 25 CMT practitioners all of whom have been in practice for 40 years.

c.    This form of ischaemic stroke is found following many apparently mild activities, such as turning to back the car, overhead painting, sports activities, yoga, prayer, etc.  Again, it is very rare.  No-one knows whether it is more common after CMT or any of the activities mentioned.

d.    CMT/neck manipulation is far safer than other common medical treatments for neck pain.  By comparison nonsteroidal anti-inflammatory drugs (NSAIDS) cause 153 stroke deaths per one million people3 and spinal surgery of the neck causes 500 stroke deaths per one million people4.

5.    The AHA’s conclusion is that health care professionals performing CMT should be aware of the possible association between CMT and CD, in rare patients with both severe neck pain or headache and with other factors associated with stroke that can be discovered from the patient history and exam.  There should be informed consent where appropriate.  The chiropractic profession has done much of the research in this field, is aware of the issues, and agrees.

1.    Haldeman S, Carroll LJ, Cassidy JD et al. (2008) A Best Evidence Synthesis on Neck Pain: Findings From the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders.  Spine 33(4S):S1-S220.
2.    Haldeman S, Kohlbeck FJ, McGregor M (2001) Unpredictability of Cerebrovascular Ischemia Associated with Cervical Spine Manipulation Therapy: A Review of Sixty-Four Cases After Cervical Spine Manipulation.  Spine 27(1):49-55.
3.    (2005) Lanas A et al. A Nationwide Study of Mortality Associated with Hospital Admission due to Severe Gastrointestinal Events and Those Associated with Nonsteroidal Anti-inflammatory Drug Use. Am J Gastroenterology 100(8):1685-93.
4.    (2014) Marquez-Lara A, Nandyala SV et al.  Sentinel Events in Cervical Spine Surgery.  Spine Jan 29 [Epub ahead of print], http://www.ncbi.nlm.nih.gov/pubmed/24480955.

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