The worst of treatments..... the best of treatments....

It was the worst of treatment sessions. It was the best of treatment sessions

Marion was a lovely lady, the mother of my best pal at school. She was a regular patient of mine. She was an avid reader of ‘The Times’, and one day came in brandishing her copy, telling me that ‘...apparently neck manipulation is dangerous, it can cause strokes. It says here in the newspaper’

I knew of the article. They come out from time to time, suggesting that chiropractic manipulation can cause a stroke. I was feeling pretty defensive. Marion could be a bit scary…… ‘Well, these articles often refer to treatment given by untrained personnel, but the newspapers say that they are chiropractors. People do have strokes, of course, but it seems that patients who have strokes are probably going to have them anyway. The neck manipulation may not be the cause of the stroke in any one case. Anyway, we do checks and tests to try and screen out the patients who we feel are at risk of a stroke. That way, patients who are at risk of stroke risks can be identified’ and directed back to their GP for assessment and preventative treatment’.....

‘What checks and tests do you do, then?’...... Marion asked me, directly.

I had to think pretty quickly: ‘Well, we ask whether there is a family history of strokes, we ask about what medication you are on. We take your blood pressure to make sure that it's not high…..and ….. err….. we feel your pulse to make sure that it’s regular…… umm…. We check that the blood flow up the vertebral arteries is OK…… and the carotid arteries too’!

Marion raised an eyebrow: ‘when did you last do those tests on me’?

My heart sank. I could not fudge the issue. I knew that I had not done these tests. This was the worst treatment session ever. I made a show of looking through her records. She knew. I knew. ‘I can’t see any record of me doing these tests on you Marion. I’m sorry. Shall we do the tests now’?

‘That sounds like a very good idea, Andrew’. So we did.

Checks:

• Any familial history of strokes?

• Any clotting disorders or history of DVT?

• On any anticoagulant medication?

• Any speech or swallowing issues?

• Any balance issues?

Tests:

• Blood pressure within guidelines?

• Heart sounds normal?

• Pulse regular?

• Sustained rotational test (VBAI): any dizziness or double vision or dysphasia? or feeling unwell? Any nystagmus? ‘Drop attack’ without losing consciousness?

• Listen to the carotid arteries (low specificity/sensitivity) +/or ultrasound them if qualified to do so….

‘Everything seems fine, Marion’ I told her afterwards. ‘I don’t think that you are at any significant risk of having a stroke’. I felt a sense of confidence as I told her this. It felt like a very positive assessment to have done’.

‘That’s very reassuring, Andrew.’ said Marion. ‘Perhaps we should do this every year’? What had been the worst of interactions was transforming into the best of interactions.

I did these checks and tests on Marion every year after that, and every year on all of my maintenance patients after that. These tests became part of their annual review. I must have done thousands of annual reassessments

‘Did it help’? I hear you ask.

Yes, it made a huge difference. The most common issue that I detected was an irregular heartbeat (atrial fibrillation, AF). AF significantly increases stroke risk. These patients need to be on an anticoagulant, like Apixaban. There was probably a similar incidence of untreated, high blood pressure. This is another cardiovascular risk. That can be detected and treated. I found very few problems with the vertebral and the carotid arteries. Occasionally I would hear a murmur in a carotid artery. Sometimes this would prove to be turbulent blood flow in the artery due to artherosclerosis. Sometimes the murmur could also be heard in the heart, suggesting a cardiac issue.

I like to think that doing these assessments and then referring those patients with positive findings back to their GP prevented a few strokes, but I’ll never know what would have happened without those assessments.

Marion passed away from cancer quite a few years ago. Thanks Marion. You made me up my game and do my job properly.

Useful links and reading:

Australian Physiotherapy Guidelines on neck manipulation.

Brown, Steven P. “Plausible Mechanisms of Causation of Immediate Stroke by Cervical Spine Manipulation: A Narrative Review.” Cureus, Mar. 2024, https://doi.org/10.7759/cureus.56565.

Chen, Yimin, et al. “Carotid Artery Dissection and Ischemic Stroke Following Cervical Chiropractic Manipulation: Two Case Reports.” Vascular and Endovascular Surgery, vol. 56, no. 3, 2022, pp. 303–07, https://doi.org/10.1177/15385744211072660.

Gottesman, Rebecca F., et al. “Clinical Characteristics of Symptomatic Vertebral Artery Dissection: A Systematic Review.” The Neurologist, vol. 18, no. 5, 2012, pp. 245–54, https://doi.org/10.1097/NRL.0b013e31826754e1.

Jeret, Joseph S., and Mark Bluth. “Stroke Following Chiropractic Manipulation.” Cerebrovascular Diseases, vol. 13, no. 3, 2002, pp. 210–13, https://doi.org/10.1159/000047778.

Trager, Robert J., et al. “Symptoms of Patients With Vertebral Artery Dissection Presenting to Chiropractors: A Systematic Review and Meta-Analysis.” Cureus, Dec. 2023, https://doi.org/10.7759/cureus.51297.

I am a chiropractor and sonographer. I also mentor colleagues to help them become the clinicians that they want to become. Find out more here.