The introduction is also posted on Spotify as a podcast by “Gerry at The Health Equation”

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https://podcasters.spotify.com/pod/show/gerrygaj

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Gerry Gajadharsingh writes:

“All medical interventions carry some risk. I have lectured on the subject of Osteopathic Manual Treatment (OMT), especially high velocity low amplitude thrust techniques (HVT) for over 37 years at both undergraduate and postgraduate level, as well as obviously providing OMT, including cervical manipulation (HVT) to many thousands of my patients. I mostly use and teach minimal leverage, multiple component HVT, considered to be gentler and safer than classical combined leverage HVT (it’s technical).

HVT is the joint manipulation that often results in a “click” when the joint is momentarily gapped or separated.

Understanding the various contraindications for the types of treatment that clinicians provide, including the full spectrum of OMT, not just HVT, is a pre-requisite for all regulated medical professionals including Osteopaths. I was part of a small group of Osteopaths who developed the contraindications in our profession, prior to the formation of The General Osteopathic Council in the early 1990’s.

Osteopaths in the UK have an enviable safety record, but inevitably accidents can happen which is why it’s requirement for all regulated medical professions to carry medical malpractice/professional indemnity insurance. The actuaries in the insurance industry are obviously very well placed to understand the claims made against medical professionals and set insurance premiums accordingly and its good to know that Osteopaths pay some of the lowest annual premiums compared to most medical professionals.

Typical premiums for UK clinicians per annum are, Neurosurgeons £50,000, Obstetricians/Gynaecologists (OB/GYN) £40,000, Orthopaedic Surgeons £20,000, Radiologists £10,000, General Practitioners (GPs) £7,500, Psychiatrists £5,000, Dentists £2,500, Nurse Practitioners, £1,500

and Osteopaths ………… £500.

The research discussed recently on Medscape focused on the risk of stroke after cervical manipulation.

Epidemiologically, internal carotid artery dissection leading to stroke is a relatively rare event with an estimated annual incidence of 1.72 per 100,000 individuals (0.00172%). The study compared post-medical consultation and post-chiropractic consultation outcomes, knowing that as a first line for complaints of neck pain or headache, patients often turn to one of these two types of primary care clinicians.

Data analysis shows, among subjects aged under 45 years, positive associations for both different consultations in cases of subsequent carotid stroke (but no association for those aged over 45 years). These associations tended to increase when analyses were limited to visits for diagnoses of neck pain and headaches. Nevertheless, there was no significant difference between risk estimates after chiropractic (presumably using HVT to the cervical spine) or general medical consultation (presumably NOT using HVT to the cervical spine.

For comparison, for short-term users of Ibuprofen (another treatment for neck pain and headache) at standard doses, the risk of GI bleeding is very low, likely less than 0.1%. However, this risk increases with dose and duration. The risk of a heart attack or stroke with long-term use at high doses is estimated to increase by about 30-50%, but the absolute risk remains small. For example, an increase from 1% to 1.3%-1.5% over a year.

Based on these figures the risk of a stroke after cervical manipulation is much lower than taking Ibuprofen long term and lower than a GI bleed after taking Ibuprofen short term.

Whilst the statistical risk of a stroke after cervical manipulation is an extremely rare event, inevitably any clinician nor their patient would want to be part of the statistics. The benefits of using HVT (applied cautiously by a clinician who is highly trained in the procedure) continues to carry minimal risk. But as the article concludes, there is insufficient data for example in relation to other vascular structures in the neck such as the vertebral artery, and so difficult to quantify the total risk at the moment.

The risk of adverse events following lumbar spinal manipulation is generally considered low, but it varies depending on the type and severity of the adverse event. Serious adverse events are much rarer. These could include conditions like cauda equina syndrome, fractures, or serious neurological damage. The risk of such serious complications is estimated to be between 1 in 1 million (0.000001%) to 1 in 2 million (0.000002%) manipulations. Some studies estimate even lower rates.

In individuals without osteoporosis, the risk of fracture due to spinal manipulation is extremely low, estimated at less than 1 in 1 million manipulations (0.000001%).

The risk increases in individuals with osteoporosis but remains low. The exact percentage risk is challenging to quantify due to the rarity of reported cases and variability in individual bone density, but it’s generally acknowledged to be higher than in the general population.

So, I expect my professional colleagues to continue to approach any proposed treatment/intervention with a patient after a careful and considered understanding of any risk and benefits to their patients. Patients need to consent to any treatment that is proposed and Osteopaths cannot carry out any treatment until a patient consents.

The outlier is of course unregulated practitioners, who have learnt some of these techniques via short weekend courses. I saw a patient recently who had been inadvertently manipulated by her Yoga teacher! The yoga teacher in her wisdom decided to apply a HVT to the patient’s neck, the patient ended up in hospital. Luckily there was no series damage to vascular structure, but the pain was left in agony for over one month with both neck and arm pain.

I have seen some YouTube and TikTok videos with so-called practitioners applying extremely forceful HVT to patients’ joints. This is completely unnecessary in order to gap a joint and comes with significant risk. Do not go anywhere near these sorts of practitioners!

The moral of the story is that if you’re going to receive treatment especially HVT, make sure the person you are seeing is highly trained and from a recognised and regulated medical profession.”

Medscape

Céline Rigaud

Cervical manipulations have been associated with vascular complications. While the incidence of carotid dissections does not seem to have increased, the question remains open for vertebral artery injuries.

Resorting to joint manipulation for neck pain is not unusual. Currently, cervical manipulation remains a popular first-line treatment for cervicodynia or headaches. Although evidence exists showing that specific joint mobilization can improve this type of symptomatology, there is a possibility that it may risk damaging the cervical arteries and causing ischaemic stroke through arterial dissection.

Epidemiologically, internal carotid artery dissection is a relatively rare event with an estimated annual incidence of 1.72 per 100,000 individuals (those most likely to be diagnosed being obviously those leading to hospitalization for stroke) but represents one of the most common causes of stroke in young and middle-aged adults. Faced with case reports that may raise concerns and hypotheses about an associated risk, two studies have sought to delve into the issue.

No Increased Carotid Risk Identified

Earlier research first published in 2016 in the Journal of Stroke and Cardiovascular Diseases, identified all incident cases of ischemic stroke in the territory of the internal carotid artery admitted to the hospital over a 9-year period using administrative healthcare data, the cases being used as their own control by sampling control periods before the date of the index stroke. Thus, 15,523 cases were compared with 62,092 control periods using exposure windows of 1, 3, 7, and 14 days before the stroke. The study also compared post-medical consultation and post-chiropractic consultation outcomes, knowing that as a first line for complaints of neck pain or headache, patients often turn to one of these two types of primary care clinicians.

However, data analysis shows, among subjects aged under 45 years, positive associations for both different consultations in cases of subsequent carotid stroke (but no association for those aged over 45 years). These associations tended to increase when analyses were limited to visits for diagnoses of neck pain and headaches. Nevertheless, there was no significant difference between risk estimates after chiropractic or general medical consultation.

A notable limitation of this work is that it did not focus on strokes due to vertebral artery dissections that run through the transverse foramina of the cervical vertebrae.

A Screening Test Lacking Precision

More recently, the International Federation of Orthopaedic Manual Physical Therapists has looked into the subject to refine the assessment of the risk for vascular complications in patients seeking physiotherapy/osteopathy care for neck pain and/or headaches. Through a cross-sectional study of 150 patients in the October 2023 issue of the Journal of Physiotherapy, it tested a vascular complication risk index (from high to low grade, based on history taking and clinical examination), developed to estimate the risk for the presence of vascular rather than musculoskeletal pathology, to determine whether or not there is a contraindication to cervical manipulation.

However, the developed index had only low sensitivity (0.50; 95% CI, 0.39-0.61) and moderate specificity (0.63; 95% CI, 0.51-0.75), knowing that the reference test was a consensus medical decision made by a vascular neurologist, an interventional neurologist, and a neuroradiologist (based on clinical data and cervical MRI). Similarly, positive and negative likelihood ratios were low at 1.36 (95% CI, 0.93-1.99) and 0.79 (95% CI, 0.60-1.05), respectively.

In conclusion, the data from the case-cross study did not seem to demonstrate an excess risk for stroke in the territory of the internal carotid artery after cervical joint manipulations. Associations between cervical manipulation sessions or medical consultations and carotid strokes appear similar and could have been due to the fact that patients with early symptoms related to arterial dissection seek care before developing their stroke.

However, it is regrettable that the study did not focus on vertebral artery dissections, which are anatomically more exposed to cervical chiropractic sessions. Nevertheless, because indices defined from joint tests and medical history are insufficient to identify patients “at risk or in the process of arterial dissection,” and because stroke can result in severe disability, practitioners managing patients with neck pain cannot take this type of complication lightly.