Dr Hal Brown, Naturopathic Physician
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The History of Manipulation


Spinal Manipulation
Dr. Brown instructing a class in spinal manipulation at BINM (Spring 2004)

Spinal Manipulation is Safe in the hands of Naturopathic Physicians
As a graduate of an accredited chiropractic college and having been a practicing chiropractor from 1977 until 1991, I have used spinal adjustment extensively in 30 years of practice.  As well, I am the chair of physical medicine and instructor in manipulation therapies at the Boucher Institute of Naturopathic Medicine, an accredited naturopathic school in New Westminster, BC.

Since 1921 when naturopathic physicians were first licensed in B.C., there have been no cases of any serious complications following cervical or other spinal manipulations.  In British Columbia, naturopathic physicians are required to maintain continuing education in staying current with scientific research in this field.  

There are many factors that can affect spinal health.  Because naturopathic therapy is holistic and treats the entire body, there are many other therapeutic options available to address your health concerns, which will reduce the need for the frequent use of manipulation.  The risks related to manipulation are also greatly reduced by incorporating many non-manipulative spinal techniques, avoiding the use of specific adjustments associated with increased risk and reducing factors related to stroke.  To promote and maintain correction of your neck and back problems, there are many natural therapies to select from to address underlying physical, structural, nutritional, energetic and stress causes.


Other therapies that would be alternatives to or complement the effectiveness of manipulation therapy include:

With this naturopathic approach and a broad range of therapies to choose from, the need for frequent use of manipulation will be reduced and the combined benefit of a constellation of treatments will enhance the effectiveness of your recovery program.


A toggle adjustment gently re-aligns
the atlas without force and without
any neck rotation or "clicking" sounds



The Activator instrument is another effective and safe method of adjusting
the spine, using a minimum of force.


A study of over 2,000 low back pain patients, published in the Journal of the American Medical Association (JAMA) was recently reported in the New York Times. The study clearly demonstrated that patients with lower back pain that had surgery, may have had a short term improvement in pain, but after 3-6 months they were no better off than those that did nothing but wait. As well the study demonstrated that waiting for surgery did not put a patient at risk for further aggravation of the condition.

This study does not address the issue of what I and many physical medicine doctors observe clinically, which is the re-occurence of lower back pain years after surgery in many patients.  It also does not address the benefit from manipulation, acupuncture prolotherapy and other naturopathic treatments in the long term improvement of those cases, whether they had surgery or just waited.



The method of adjustment is geared towards the patient's needs.

Spinal Adjustment
The treatment involves locating,
diagnosing and correcting.

Spinal Adjustments and Naturopathy

Naturopathic Physicians as well as chiropractors, are licensed in British Columbia to use spinal manipulations (adjustments) within their scope of practice.  This treatment involves locating, diagnosing and correcting joint and associated muscular dysfunction.  These joint disturbances are called subluxations or fixations, which indicates locking, or misalignment of spinal or extremity joints. Subluxations can result in abnormal joint movement and be a cause of pain.  The treatment involves the gentle re-setting of the joint restriction by adjustment.  The adjustment may cause a clicking sound, or may be a gentle low force maneuver, which is barely felt.  There are a great variety of techniques available to best address your needs.

Neck Manipulation
Spinal Adjustment
Benefits of Spinal Adjustments

The effect of the adjustment is to improve mobility and nerve function throughout the entire body. Consequently, you not only feel better, but also the improved autonomic nervous system effect will regulate circulation to all muscles and tissues as well as directly improve organ function, resulting in an overall health benefit.

The benefits of cervical spinal adjustments upon neck pain, whiplash, and headache have been extensively outlined in the Annals of Internal Medicine [1].  A systematic review of 20 randomized clinical trials has addressed this issue, with the majority indicating positive, and the remainder yielding equivocal results.  Neither negative results, nor significant adverse events to these cervical manipulations were shown [2,3].

Forty-three randomized trials of spinal manipulation for treatment of acute, subacute, and chronic low-back pain have been published.  Thirty favored manipulation over the comparison treatments in at least a subgroup of patients, and the other 13 found no significant differences [4].

Studies of the naturopathic approach to treating low back pain have demonstrated statistically significant benefits.

This study concluded that Naturopathic treatment was shown to have significant (95% CI) benefit in decreasing disability and pain due to chronic low back pain. Pain medication use was significantly reduced, and quality of life measures dramatically improved. The most significant changes occur within the first 4 weeks of Naturopathic treatment. In this industrialized setting, it appears that not only were Naturopathic treatments effective, but an individualized approach to back pain resulted in greater benefits compared with a physiotherapy equivalent previously shown to be effective.[27]

Risks of Manipulation Therapy
As with any therapeutic procedure there are possible side effects and risks involved.  Complications are rare and may include strain or sprain of spinal joints and muscles, fractures, or injury to discs or nerve roots.

Non-Serious Effects of Spinal Manipulation
"50% of spinal manipulations will result in mild and short term effects". A 2001 independent literature review of the most valid studies to identify the safety of spinal manipulation, suggests that about half of all patients will experience adverse events after spinal manipulation.  These events, although frequent, are usually mild and transient.  [26]

A 1997 study, reported in Spine, questioned 1058 new patients after 4712 treatments by 102 Norwegian chiropractors.  The results showed that at least one reaction was reported by 55% of the patients.  The most common were:
  • Local discomfort (53%)
  • Headache (12%)
  • Tiredness (11%)
  • Radiating discomfort (10%).
  • Reactions were mild or moderate in 85% of patients.
  • Sixty-four percent of reactions appeared within 4 hours of treatment
  • 74% had disappeared within 24 hours.
  • There were no reports of serious complications in this study.[25]

Serious Risks to Spinal Manipulation
The most serious, but rare risk, is that of a vertebral or coratid artery dissection or stroke following cervical manipulation.  A recent research article in the Canadian Medical Association Journal determined the risk of such a stroke to occur in 1 out 5.85 million cervical manipulations [5].  Another study determined that there was a risk of 1.3 strokes per 100,000 manipulations one week after a manipulation [6].  These authors state the bias in their study regarding the cause and effect nature of their analysis. That is there is no way to determine whether a manipulation one week before a stroke had any relationship to the onset.  As a comparison the rate of spontaneous vertebral artery dissection without manipulation is estimated to be about 1- 3 per 100,000 persons [7,8,9], about the same rate attributed to spinal manipulation.  Many persons suffer spontaneous stroke from everyday activities such as turning the head, looking at the sky, shoulder checking while driving, holding a telephone against the shoulder, getting a hair shampoo at the beauty parlour, doing yoga and many more common activities.  Other studies rank the risk of stroke from cervical manipulation to be 1 per 500,000 [10]; 0.65 per million [11]; 1per 3 million [12]; 0 in 5 million [13,14].

The research is not clear as to whether neck manipulations may be a cause of stroke or a triggering factor in already vulnerable arteries.

Recent biomechanical research has studied the strain, if any, that cervical adjustment may place on the vertebral arteries.  The preliminary findings indicate that the movement of joints during cervical adjustment is done well within the normal range of motion and that cervical adjustment is " very unlikely to mechanically disrupt the vertebral artery" [15].

It is not possible to predict who specifically would be at risk for a stroke from cervical manipulation, but it is possible to recognize possible risk factors in your case history and examination and advise you appropriately.  These may include a history of stroke, transient ischemic attacks (TIA), severe hypertension, and vascular disease.

Although spinal manipulation is associated with a very small but serious risk of complication, some patients occasionally choose to forgo high velocity low amplitude manipulation even with the precautions described in the side bar.  In these cases, there are many other options for correcting spinal fixations/subluxations and relieving pain and discomfort without the use of conventional manipulation techniques, Often utilizing what are referred to as "low force techniques". These might include using Muscle release techniques, Activator Methods, Toggle adjustments, or other methods.

Other therapies that would be alternative methods of spinal correction or complement the effectiveness of manipulation therapy include:

Activator adjustment, toggle adjustment, acupuncture, Muscle Release Techniquesart, applied kinesiology, life style counselling, therapeutic exercises, prolotherapy. trigger point injection, neural therapy, scar therapy, hyaluronic acid injection, NET.

Risks of Remaining Untreated
Delay of treatment allows formation of adhesions, scar tissue and other degenerative changes.  These changes can reduce skeletal mobility and induce and maintain a chronic pain condition.  Delay of appropriate treatment may complicate a condition, impede future recovery and prevent healing of the underlying injury.  Impaired mobility will restrict activity and limit exercise that will consequently have a serious negative impact on your health and well being.  As one of my teachers used to say: "use it or lose it".

Comparative Risks
The risk of spinal manipulation needs to be put into perspective compared to no treatment at all and to the risks of other treatments available.

As explained earlier the risk of stroke from vertebral artery dissection following cervical manipulation is similar to the risk of spontaneous dissection.  An editorial in the Canadian Journal of Neurological Science indicates that no clear cause and effect relationship has been established [18].  Clearly more study is required to determine whether there is a risk relationship between cervical manipulation and stroke, what that risk might be and what screening methods are most reliable.  

 Many people with untreated neck pain and headaches take NSAIDS (non-steroid anti-inflammatory drugs).  These include Aspirin, Ibutrophen, and Advil etc.  The New England Journal of Medicine claims that in the U.S. 16,500 people die each year from the use of these medications [19].  That is about 1 death for every 20,000 Americans per year (not all Americans are using NSAIDS). Recently the New York Times [20] reported that the FDA announced that 450 Americans die each year from the use of acetaminophen (Tylenol).  There are 1 billion pills sold annually, calculations show us that there is one death per 2.22 million acetaminophen pills sold. Note that these statistics question the safety of using medication as opposed to cervical manipulation.  In fact there is a greater risk of death from power boating, pregnancy, taking birth control pills, driving a car and other normal activities than from receiving a neck adjustment [21].  Less conservative treatments such as neck surgery are also used for conditions very similar to the conditions treated with spinal manipulation.  There is a 3-4% rate of complication for cervical spine surgery, and 4,000-10,000 deaths per million neck surgeries [22].

If you are considering lumbar spinal surgery, realize that there is a risk of death of 7 persons per 10,000 surgeries [23].  

In risk management practices, 1 per million risks are considered acceptable, where as 1 per 100,000 risks are generally considered unacceptably high [24].  

Let's put the concept of risk into perspective. This 2007 article in the Vancouver Sun looks at many risks that we are prone to on a daily basis without serious consideration.  For example, a Canadian has a one in 226,165 chance of dying in a lawnmower accident, or a 1 in 255 chance of dying from poisoning.  Consider that you are 65 times more likely to be killed in an automobile crash than an airplane crash.


REFERENCES

[1] Meeker WC, Haldeman S. Chiropractic: A Profession at the Crossroads of Mainstream and Alternative Medicine; Annals of Internal Medicine 2002; 136: 216-227;

[2] Meeker WC, Mootz RO, Haldeman S. Back To Basics... The State of Chiropractic Research
Topics in Clinical Chiropractic 2002; 9 (1): 1-13

[3] Haynes MJ, Lesley AC, Melsom A, Mastaglia FL, Minle N, McGeachies JK. Vertebral Arteries and Cervical Rotation: Modeling and Magnetic Resonance Angiography Studies; J Manipulative Physiol Ther 2002; 25 (6): 370-383

[4] Meeker WC, Haldeman S. Chiropractic: A Profession at the Crossroads of Mainstream and Alternative Medicine; Annals of Internal Medicine 2002; 136: 216-227

[5] Haldeman et al; Arterial dissections following cervical manipulation: the chiropractic experience; CMAJ; Oct. 2, 2001; 165 (7)

[6] Rothwell et al; Chiropractic Manipulation and Stroke; Stroke. 2001;32:1054

[7] Shievink WT, Mokri B, Whisnant JP. Internal Carotid Artery Dissection in a Community: Rochester, Minnesota, 1987-1992; Stroke 1993; 24 (11): 1678-1680

[8] Giroud M, Fayolle H, Andre N, Dumas R, Becker F, Martin D, Baudoin N, Krause D. Incidence of Internal Carotid Artery Dissection in the Community of Dijon [Letter] J Neurol Neurosurg Psychiatry 1994; 57(11): 1443

[9] Shievink WT, Mokri, B, O'Falion WM. Recurrent Spontaneous Cervical-artery Dissection New England Journal of Medicine 1994; 330 (6): 393-397

[10] Lee KP, Carlini WG, McCormick GF, Walters GW; Neurologic Complications Following Chiropractic Manipulation: A Survey of California Neurologists; Neurology 1995; 45 (6): 1213-1215

[11] Eric L. Hurwitz, DC, PhD; Peter D. Aker, DC; Alan H. Adams, DC; William C. Meeker, DC, MPH; Paul G. Shekelle, MD, PhD, Manipulation and Mobilization of the Cervical Spine. A Systematic Review of the Literature; Spine 1996 (Aug 1);  21 (15):  1746-1760

[12] Carey PF. A Report on the Occurrence of Cerebral Vascular Accidents in Chiropractic Practice; Journal of the Canadian Chiropractic Association 1993; 57 (2): 104-106

[13] Jaskoviak PA. Complications Arising from Manipulation of the Cervical Spine; J Manipulative Physiol Ther 1980; 3: 213-219

[14] Henderson OJ, Cassidy JO. Vertebral artery syndrome : In: Vernon H, ed. Upper Cervical Syndrome: Chiropractic Diagnosis and Treatment. Baltimore: Williams & Wilkins, 1988. 195-222

[15] Herzog, Symons,  Leonard; Internal forces sustained by the vertebral artery during spinal manipulative therapy. Journal of Manipulative Physiologics and Therapeutics; October 25, 2002 (8); 504-10

[16] Lang, Eddy; Dissection, Vertebral Artery ; e-medicine website; February 12, 2004; http://www.emedicine.com/emerg/topic832.htm

[17] Guillon B, Levy C, Bousser MG; Internal carotid artery dissection: an update; J Neurol Sci. 1998 Jan 8;153(2):146-58.

[18] Hill, Michael; Cervical Artery Dissection,imaging,Ttrauma and Causal Inference; Can. J. Neurol. Sci 2003; 30: 302-303

[19] Wolfe M. M., Lichtenstein D. R., Singh G; Medical Progress: Gastrointestinal Toxicity of Nonsteroidal Antiinflammatory Drugs; N Engl J Med 1999; 340:1888-1899, Jun 17, 1999. Review Articles ; related article

[20] New York Times; Here's Something for That Headache; William Lee; March 17, 2004

[21] Dinman, B.D.; The Reality and Acceptance of Risk; Journal of the American Medical Association , Vol. 244 (11): 1126-1128, 1980

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

[23] RA Deyo, DC Cherkin, JD Loeser, SJ Bigos and MA Ciol   Morbidity and Mortality in Association with Operations on the Lumbar Spine. The Influence of Age, Diagnosis, and Procedure
Journal of Bone and Joint Surgery 1992 (Apr 1);  74 (4):  536-543

[24] e-mail communication with Kenneth Green, risk advisor for the Fraser Institute, Vancouver, BC.

[25] Senstad O., Leboeuf-Yde, C., Borchgrevink, C., 1997, Feb 15, Frequency and Characteristics of Side Effects of Spinal Manipulative Therapy. Spine 22(4):435-440

[26] Ernst, E., March 2001, Prospective Investigations into the Safety of Spinal Manipulation Journal of Pain and Symptom Management, Volume 21, Issue 3 Pages 238-242

[27] Cooley PK, Szczurko O, Bernhardt B, Busse J, Seely D, Mills E; Low Back Pain: A Randomized Controlled Blinded Parallel-group Study; The Effects of Naturopathic Medicine on Health Outcomes in Low Back Pain: A Randomized Controlled Blinded Parallel-group Study, Canadian College of Naturopathic Medicine Trial