Re: Vertebral Artery Stroke

[Guest guest]

This is an issue that I have long quietly felt was questionable. While I

agree it is a time when rotary torque may not be appropriate, it seems to me

that using other methods (i.e. cervical stairstep, releasing cranial/dural

torque) could be promotional of improving cerebral flow. Sunny

Sunny Kierstyn, RN DC

Fibromyalgia Care Center of Oregon

59 Santa Clara St.,

Eugene, Oregon, 97404

541-689-0935

>From: tlf-3@...

>

>Subject: Vertebral Artery Stroke

>Date: Thu, 4 Nov 2004 08:03:21 -0800

>

>

>I'm forwarding this dialogue from another group because I think many of

>you might find this interesting.

>Ted

>

>Ted Forcum, DC, DACBSP, FICC, CSCS

>Medical Director, 2005 Portland US Figure Skating Championships

>Back In Motion Sports Injuries Clinic, LLC

>11385 SW Scholls Ferry Road

>Beaverton, Oregon 97008

>

>

>Actually, I agree with the idea that there is likely a protective effect

>from SMT.... data from a vast study done about 15 years ago in Moscow,

>showed that a significant majority of patients with partial vertebral

>arterial occlusions, who had SMT, had improved cerebral blood flow after

>the

>SMT... conclusion: that for people with + george's test, etc., SMT may be

>INDICATED rather than contraindicated.... This seems to correlate with

>the

>literature review and analysis that Haldemann did for the 1997

>Tokyo

>Congress...

>

>Dr. J. PRESS

>DC, PhD(Cand.), CCSP, FACSM, FICC

>Chief Physician, Olympic Team of the USSR

> XVIth Winter Olympic Games, Albertville, 1992

>Chairman, IAOCO (www.iaoco.org)

>President, Russian Chiropractic Association (

>www.sport-dc.com/RCA/index.html )

>

>Founder, 1st Pres, FICS (www.fics-online.org)

>Past Pres., FIRS' Medical Comm (www.rollersports.org)

>Past VP, Founder, FIDE Medical Commission (www.fide.com)

>Fellow, Amer. College of Sports Medicine (www.acsm.org)

>Author: " Passion, Profession and Politics " , Autobiography of the

>American

>Chiropractor who became Chief Physician of the Olympic Team of the USSR "

>-

>2004, Infinity Publishing, AVAILABLE, and online....

>And; " Chiropractic Patient's Q & A " , 2004, AVAILABLE, and online - in BOTH

>English and Russian editions

>

>

>

>

> > 1) the estimated risk (1:400K to 1:3.8M) is based on limited study.

>The

> > most recent reference is 1990. There has been a TON published in the

> > last few years on this topic and the estimates for stroke range as low

> > as 1:5,000 (not that that's accurate).

> >

> > Schievink WI. Spontaneous dissection of the carotid and vertebral

> > arteries. N Engl J Med. 2001 Mar 22;344(12):898-906. (1:20,000)

> >

> > 2) Their comment, " However, the risk of vertebrobasilar artery stroke

> > from manipulation is less than the risk of a spontaneous

>vertebrobasilar

> > artery stroke. " is nonsensical. This implies a protective effect from

> > SMT. They have not taken into account a susceptible population.

> >

> > 3) Their " most common risk factors for vertebrobasilar artery stroke "

>is

> > not consistent with the literature on the topic. Oral contraceptives

> > are related to embolic stroke and not dissections.

> >

> > Terret was mentioned earlier for this.

> >

> > Terrett AGJ. Current concepts in vertebrobasilar complications

> > following spinal manipulation. West Des Moines, IA: NCMIC Group Inc.;

> > 2001.

> >

> > 4) They have completely ignored the population based study out of

> > Ontario that identifies a potentially susceptible population.

> >

> > Rothwell DM, Bondy SJ, JI. Chiropractic manipulation and

> > stroke: A population-based case-control study. Stroke 2001;

> > 32:1054-1060.

> >

> > 5) They are comparing apples to oranges yet again - " safer than

>NSAIDs " .

> >

> > If I go here, I'll get apoplectic. :-)

> >

> > Mike

> >

> > --------------------------------------------------

> > Carstensen, BASc, DC

> > MUN MD Class of 2008

> > St. 's, Newfoundland

> > docmike@...

> > --------------------------------------------------

>

>

>

>

>OregonDCs rules:

>1. Keep correspondence professional; the purpose of the listserve is to

>foster communication and collegiality. No personal attacks on listserve

>members will be tolerated.

>2. Always sign your e-mails with your first and last name.

>3. The listserve is not secure; your e-mail could end up anywhere. However,

>it is against the rules of the listserve to copy, print, forward, or

>otherwise distribute correspondence written by another member without his

>or her consent, unless all personal identifiers have been removed.

>

[Guest guest]

Ted,

I am constantly involved with malpractice actions on both sides for VBA and carotid strokes that are typically temporally associated with a chiropractic manipulation. I have reviewed quite a bit of literature on the subject, and got a great leg up on this from Vern's excellent review that he did a few years back. Sometimes the effects of the strokes are devastating and sometimes they are negligible or temporary. Sometimes they are caused by the manipulation quite obviously and sometimes it is equally obvious that they are not. But, the one thing that is clear is that to claim that there is a protective effect of manipulation on known cases of a dissection in process or some other occlusive process is just reckless. The doc who proposes this theory bases it on some Russian data and a literature review (BTW, I notice that both docs are in transition - one is a PhD candidate and the other apparently just started in medical school. The PhD candidate, Dr. Press, has as part of his signature that he was "chief physician" of the Soviet Olympic team for the Winter Olympics 12 years ago. This seems odd to me, like he is trapped in time or something.).

Anyone who would treat patients based on this theory and caused an injury better carry about $5 billion in malpractice insurance.

Freeman Vertebral Artery Stroke I'm forwarding this dialogue from another group because I think many ofyou might find this interesting.TedTed Forcum, DC, DACBSP, FICC, CSCSMedical Director, 2005 Portland US Figure Skating ChampionshipsBack In Motion Sports Injuries Clinic, LLC11385 SW Scholls Ferry RoadBeaverton, Oregon 97008Actually, I agree with the idea that there is likely a protective effectfrom SMT.... data from a vast study done about 15 years ago in Moscow,showed that a significant majority of patients with partial vertebralarterial occlusions, who had SMT, had improved cerebral blood flow aftertheSMT... conclusion: that for people with + george's test, etc., SMT may beINDICATED rather than contraindicated.... This seems to correlate withtheliterature review and analysis that Haldemann did for the 1997TokyoCongress...Dr. J. PRESSDC, PhD(Cand.), CCSP, FACSM, FICCChief Physician, Olympic Team of the USSR XVIth Winter Olympic Games, Albertville, 1992Chairman, IAOCO (www.iaoco.org)President, Russian Chiropractic Association (www.sport-dc.com/RCA/index.html ) Founder, 1st Pres, FICS (www.fics-online.org)Past Pres., FIRS' Medical Comm (www.rollersports.org)Past VP, Founder, FIDE Medical Commission (www.fide.com)Fellow, Amer. College of Sports Medicine (www.acsm.org)Author: "Passion, Profession and Politics", Autobiography of theAmericanChiropractor who became Chief Physician of the Olympic Team of the USSR"-2004, Infinity Publishing, AVAILABLE, and online....And; "Chiropractic Patient's Q & A", 2004, AVAILABLE, and online - in BOTHEnglish and Russian editions> 1) the estimated risk (1:400K to 1:3.8M) is based on limited study. The> most recent reference is 1990. There has been a TON published in the> last few years on this topic and the estimates for stroke range as low> as 1:5,000 (not that that's accurate).>> Schievink WI. Spontaneous dissection of the carotid and vertebral> arteries. N Engl J Med. 2001 Mar 22;344(12):898-906. (1:20,000)>> 2) Their comment, "However, the risk of vertebrobasilar artery stroke> from manipulation is less than the risk of a spontaneousvertebrobasilar> artery stroke." is nonsensical. This implies a protective effect from> SMT. They have not taken into account a susceptible population.>> 3) Their "most common risk factors for vertebrobasilar artery stroke"is> not consistent with the literature on the topic. Oral contraceptives> are related to embolic stroke and not dissections.>> Terret was mentioned earlier for this.>> Terrett AGJ. Current concepts in vertebrobasilar complications> following spinal manipulation. West Des Moines, IA: NCMIC Group Inc.;> 2001.>> 4) They have completely ignored the population based study out of> Ontario that identifies a potentially susceptible population.>> Rothwell DM, Bondy SJ, JI. Chiropractic manipulation and> stroke: A population-based case-control study. Stroke 2001;> 32:1054-1060.>> 5) They are comparing apples to oranges yet again - "safer thanNSAIDs".>> If I go here, I'll get apoplectic. :-)>> Mike>> --------------------------------------------------> Carstensen, BASc, DC> MUN MD Class of 2008> St. 's, Newfoundland> docmike@...> --------------------------------------------------OregonDCs rules:1. Keep correspondence professional; the purpose of the listserve is to foster communication and collegiality. No personal attacks on listserve members will be tolerated.2. Always sign your e-mails with your first and last name.3. The listserve is not secure; your e-mail could end up anywhere. However, it is against the rules of the listserve to copy, print, forward, or otherwise distribute correspondence written by another member without his or her consent, unless all personal identifiers have been removed.

[Guest guest]

,

I certainly do not have your background expertise in the subject matter, but I totally agree. Although Dr. Press is brilliant in some subject matters, I found this to be stretching claim. Hence the interest in the groups thoughts.

On your later comment. It does make me think of the Rocky Horror Picture Show song Time Warp!

Ted

Ted Forcum, DC, DACBSP, FICC, CSCSMedical Director, 2005 Portland US Figure Skating ChampionshipsBack In Motion Sports Injuries Clinic, LLC11385 SW Scholls Ferry RoadBeaverton, Oregon 97008

On Thu, 4 Nov 2004 09:28:43 -0800 (GMT-08:00) "Dr. Freeman" <drmfreeman@...> writes:

Ted,

I am constantly involved with malpractice actions on both sides for VBA and carotid strokes that are typically temporally associated with a chiropractic manipulation. I have reviewed quite a bit of literature on the subject, and got a great leg up on this from Vern's excellent review that he did a few years back. Sometimes the effects of the strokes are devastating and sometimes they are negligible or temporary. Sometimes they are caused by the manipulation quite obviously and sometimes it is equally obvious that they are not. But, the one thing that is clear is that to claim that there is a protective effect of manipulation on known cases of a dissection in process or some other occlusive process is just reckless. The doc who proposes this theory bases it on some Russian data and a literature review (BTW, I notice that both docs are in transition - one is a PhD candidate and the other apparently just started in medical school. The PhD candidate, Dr. Press, has as part of his signature that he was "chief physician" of the Soviet Olympic team for the Winter Olympics 12 years ago. This seems odd to me, like he is trapped in time or something.).

Anyone who would treat patients based on this theory and caused an injury better carry about $5 billion in malpractice insurance.

Freeman Vertebral Artery Stroke I'm forwarding this dialogue from another group because I think many ofyou might find this interesting.TedTed Forcum, DC, DACBSP, FICC, CSCSMedical Director, 2005 Portland US Figure Skating ChampionshipsBack In Motion Sports Injuries Clinic, LLC11385 SW Scholls Ferry RoadBeaverton, Oregon 97008Actually, I agree with the idea that there is likely a protective effectfrom SMT.... data from a vast study done about 15 years ago in Moscow,showed that a significant majority of patients with partial vertebralarterial occlusions, who had SMT, had improved cerebral blood flow aftertheSMT... conclusion: that for people with + george's test, etc., SMT may beINDICATED rather than contraindicated.... This seems to correlate withtheliterature review and analysis that Haldemann did for the 1997TokyoCongress...Dr. J. PRESSDC, PhD(Cand.), CCSP, FACSM, FICCChief Physician, Olympic Team of the USSR XVIth Winter Olympic Games, Albertville, 1992Chairman, IAOCO (www.iaoco.org)President, Russian Chiropractic Association (www.sport-dc.com/RCA/index.html ) Founder, 1st Pres, FICS (www.fics-online.org)Past Pres., FIRS' Medical Comm (www.rollersports.org)Past VP, Founder, FIDE Medical Commission (www.fide.com)Fellow, Amer. College of Sports Medicine (www.acsm.org)Author: "Passion, Profession and Politics", Autobiography of theAmericanChiropractor who became Chief Physician of the Olympic Team of the USSR"-2004, Infinity Publishing, AVAILABLE, and online....And; "Chiropractic Patient's Q & A", 2004, AVAILABLE, and online - in BOTHEnglish and Russian editions> 1) the estimated risk (1:400K to 1:3.8M) is based on limited study. The> most recent reference is 1990. There has been a TON published in the> last few years on this topic and the estimates for stroke range as low> as 1:5,000 (not that that's accurate).>> Schievink WI. Spontaneous dissection of the carotid and vertebral> arteries. N Engl J Med. 2001 Mar 22;344(12):898-906. (1:20,000)>> 2) Their comment, "However, the risk of vertebrobasilar artery stroke> from manipulation is less than the risk of a spontaneousvertebrobasilar> artery stroke." is nonsensical. This implies a protective effect from> SMT. They have not taken into account a susceptible population.>> 3) Their "most common risk factors for vertebrobasilar artery stroke"is> not consistent with the literature on the topic. Oral contraceptives> are related to embolic stroke and not dissections.>> Terret was mentioned earlier for this.>> Terrett AGJ. Current concepts in vertebrobasilar complications> following spinal manipulation. West Des Moines, IA: NCMIC Group Inc.;> 2001.>> 4) They have completely ignored the population based study out of> Ontario that identifies a potentially susceptible population.>> Rothwell DM, Bondy SJ, JI. Chiropractic manipulation and> stroke: A population-based case-control study. Stroke 2001;> 32:1054-1060.>> 5) They are comparing apples to oranges yet again - "safer thanNSAIDs".>> If I go here, I'll get apoplectic. :-)>> Mike>> --------------------------------------------------> Carstensen, BASc, DC> MUN MD Class of 2008> St. 's, Newfoundland> docmike@...> --------------------------------------------------OregonDCs rules:1. Keep correspondence professional; the purpose of the listserve is to foster communication and collegiality. No personal attacks on listserve members will be tolerated.2. Always sign your e-mails with your first and last name.3. The listserve is not secure; your e-mail could end up anywhere. However, it is against the rules of the listserve to copy, print, forward, or otherwise distribute correspondence written by another member without his or her consent, unless all personal identifiers have been removed.

[Guest guest]

Oh, REEEALLLY!

...."Sometimes they are caused by the manipulation quite obviously and sometimes it is equally obvious that they are not." ...

Dr. Freeman:

I am very curious. What was the mechanism of injury in those cases? I do not see how dissection can occur when an adjustment is appropriately performed. The effects of coupled motion (flexion, lateral flexion, rotation) about the joint reduces motion so that the cervical spine doesn't come anywhere near producing any neurovascular traction of the sort necessary to even wiggle those elements...

Glenn Gumaer

Vertebral Artery Stroke I'm forwarding this dialogue from another group because I think many ofyou might find this interesting.TedTed Forcum, DC, DACBSP, FICC, CSCSMedical Director, 2005 Portland US Figure Skating ChampionshipsBack In Motion Sports Injuries Clinic, LLC11385 SW Scholls Ferry RoadBeaverton, Oregon 97008Actually, I agree with the idea that there is likely a protective effectfrom SMT.... data from a vast study done about 15 years ago in Moscow,showed that a significant majority of patients with partial vertebralarterial occlusions, who had SMT, had improved cerebral blood flow aftertheSMT... conclusion: that for people with + george's test, etc., SMT may beINDICATED rather than contraindicated.... This seems to correlate withtheliterature review and analysis that Haldemann did for the 1997TokyoCongress...Dr. J. PRESSDC, PhD(Cand.), CCSP, FACSM, FICCChief Physician, Olympic Team of the USSR XVIth Winter Olympic Games, Albertville, 1992Chairman, IAOCO (www.iaoco.org)President, Russian Chiropractic Association (www.sport-dc.com/RCA/index.html ) Founder, 1st Pres, FICS (www.fics-online.org)Past Pres., FIRS' Medical Comm (www.rollersports.org)Past VP, Founder, FIDE Medical Commission (www.fide.com)Fellow, Amer. College of Sports Medicine (www.acsm.org)Author: "Passion, Profession and Politics", Autobiography of theAmericanChiropractor who became Chief Physician of the Olympic Team of the USSR"-2004, Infinity Publishing, AVAILABLE, and online....And; "Chiropractic Patient's Q & A", 2004, AVAILABLE, and online - in BOTHEnglish and Russian editions> 1) the estimated risk (1:400K to 1:3.8M) is based on limited study. The> most recent reference is 1990. There has been a TON published in the> last few years on this topic and the estimates for stroke range as low> as 1:5,000 (not that that's accurate).>> Schievink WI. Spontaneous dissection of the carotid and vertebral> arteries. N Engl J Med. 2001 Mar 22;344(12):898-906. (1:20,000)>> 2) Their comment, "However, the risk of vertebrobasilar artery stroke> from manipulation is less than the risk of a spontaneousvertebrobasilar> artery stroke." is nonsensical. This implies a protective effect from> SMT. They have not taken into account a susceptible population.>> 3) Their "most common risk factors for vertebrobasilar artery stroke"is> not consistent with the literature on the topic. Oral contraceptives> are related to embolic stroke and not dissections.>> Terret was mentioned earlier for this.>> Terrett AGJ. Current concepts in vertebrobasilar complications> following spinal manipulation. West Des Moines, IA: NCMIC Group Inc.;> 2001.>> 4) They have completely ignored the population based study out of> Ontario that identifies a potentially susceptible population.>> Rothwell DM, Bondy SJ, JI. Chiropractic manipulation and> stroke: A population-based case-control study. Stroke 2001;> 32:1054-1060.>> 5) They are comparing apples to oranges yet again - "safer thanNSAIDs".>> If I go here, I'll get apoplectic. :-)>> Mike>> --------------------------------------------------> Carstensen, BASc, DC> MUN MD Class of 2008> St. 's, Newfoundland> docmike@...> --------------------------------------------------OregonDCs rules:1. Keep correspondence professional; the purpose of the listserve is to foster communication and collegiality. No personal attacks on listserve members will be tolerated.2. Always sign your e-mails with your first and last name.3. The listserve is not secure; your e-mail could end up anywhere. However, it is against the rules of the listserve to copy, print, forward, or otherwise distribute correspondence written by another member without his or her consent, unless all personal identifiers have been removed.

[Guest guest]

Glenn,

My standard for causation is pretty straight forward; if a patient with risk factors presents to a doc (severe headache for a week with no prior history, dizziness, etc.) and the doc does virtually no exam, manipulates the patient manually using what is typically a diversified maneuver, and the patient strokes shortly after the manipulation, then there is a causal relationship. Now I am not saying that the doc caused the stroke in a healthy person; the dissection was likely in progress. But the manipulation undoubtedly worsened or accelerated the dissection and the doc failed to recognize that the manipulation was contraindicated. I agree that there is no properly performed chiropractic manipulation that can cause a dissection in a healthy VBA or carotid, as if this was the case patients would be stroking right and left. The risk of dissection [worsening] following manipulation is extremely remote, but this does not mean that it doesn't happen.

D Freeman PhD DC MPH Forensic Trauma Consultants Mailing address: 205 Liberty Street NE, Suite B Salem, OR 97301 503 586-0127 fax 503 586-0192 cell 503 871-0715 drmfreeman@...

-----Original Message-----From: Dr. Glenn F. Gumaer [mailto:gfgdc@...]Sent: Thursday, November 04, 2004 12:54 PMDr. FreemanCc: Oregondcs Subject: Re: Vertebral Artery Stroke

Oh, REEEALLLY!

...."Sometimes they are caused by the manipulation quite obviously and sometimes it is equally obvious that they are not." ...

Dr. Freeman:

I am very curious. What was the mechanism of injury in those cases? I do not see how dissection can occur when an adjustment is appropriately performed. The effects of coupled motion (flexion, lateral flexion, rotation) about the joint reduces motion so that the cervical spine doesn't come anywhere near producing any neurovascular traction of the sort necessary to even wiggle those elements...

Glenn Gumaer

Vertebral Artery Stroke I'm forwarding this dialogue from another group because I think many ofyou might find this interesting.TedTed Forcum, DC, DACBSP, FICC, CSCSMedical Director, 2005 Portland US Figure Skating ChampionshipsBack In Motion Sports Injuries Clinic, LLC11385 SW Scholls Ferry RoadBeaverton, Oregon 97008Actually, I agree with the idea that there is likely a protective effectfrom SMT.... data from a vast study done about 15 years ago in Moscow,showed that a significant majority of patients with partial vertebralarterial occlusions, who had SMT, had improved cerebral blood flow aftertheSMT... conclusion: that for people with + george's test, etc., SMT may beINDICATED rather than contraindicated.... This seems to correlate withtheliterature review and analysis that Haldemann did for the 1997TokyoCongress...Dr. J. PRESSDC, PhD(Cand.), CCSP, FACSM, FICCChief Physician, Olympic Team of the USSR XVIth Winter Olympic Games, Albertville, 1992Chairman, IAOCO (www.iaoco.org)President, Russian Chiropractic Association (www.sport-dc.com/RCA/index.html ) Founder, 1st Pres, FICS (www.fics-online.org)Past Pres., FIRS' Medical Comm (www.rollersports.org)Past VP, Founder, FIDE Medical Commission (www.fide.com)Fellow, Amer. College of Sports Medicine (www.acsm.org)Author: "Passion, Profession and Politics", Autobiography of theAmericanChiropractor who became Chief Physician of the Olympic Team of the USSR"-2004, Infinity Publishing, AVAILABLE, and online....And; "Chiropractic Patient's Q & A", 2004, AVAILABLE, and online - in BOTHEnglish and Russian editions> 1) the estimated risk (1:400K to 1:3.8M) is based on limited study. The> most recent reference is 1990. There has been a TON published in the> last few years on this topic and the estimates for stroke range as low> as 1:5,000 (not that that's accurate).>> Schievink WI. Spontaneous dissection of the carotid and vertebral> arteries. N Engl J Med. 2001 Mar 22;344(12):898-906. (1:20,000)>> 2) Their comment, "However, the risk of vertebrobasilar artery stroke> from manipulation is less than the risk of a spontaneousvertebrobasilar> artery stroke." is nonsensical. This implies a protective effect from> SMT. They have not taken into account a susceptible population.>> 3) Their "most common risk factors for vertebrobasilar artery stroke"is> not consistent with the literature on the topic. Oral contraceptives> are related to embolic stroke and not dissections.>> Terret was mentioned earlier for this.>> Terrett AGJ. Current concepts in vertebrobasilar complications> following spinal manipulation. West Des Moines, IA: NCMIC Group Inc.;> 2001.>> 4) They have completely ignored the population based study out of> Ontario that identifies a potentially susceptible population.>> Rothwell DM, Bondy SJ, JI. Chiropractic manipulation and> stroke: A population-based case-control study. Stroke 2001;> 32:1054-1060.>> 5) They are comparing apples to oranges yet again - "safer thanNSAIDs".>> If I go here, I'll get apoplectic. :-)>> Mike>> --------------------------------------------------> Carstensen, BASc, DC> MUN MD Class of 2008> St. 's, Newfoundland> docmike@...> --------------------------------------------------OregonDCs rules:1. Keep correspondence professional; the purpose of the listserve is to foster communication and collegiality. No personal attacks on listserve members will be tolerated.2. Always sign your e-mails with your first and last name.3. The listserve is not secure; your e-mail could end up anywhere. However, it is against the rules of the listserve to copy, print, forward, or otherwise distribute correspondence written by another member without his or her consent, unless all personal identifiers have been removed.