|VICUS.COM (7 Sept. 2000) -- Conventional
medical wisdom says that chiropractic spinal
manipulation has a very limited role, if any, to play in mainstream
health care. Yet, the American public sees it differently.
Chiropractors now make up
the third largest group of health-care providers in the United States,
after physicians and dentists (Pelletier, 2000). There are more than
50,000 chiropractors in the United States who treat about 50 million
How can these facts be
explained? This is a reasonable question, considering how far
chiropractic has come in a little more than a century.
From its beginnings in
the late 1800s, chiropractic has had a stormy relationship with
In the 1960s, the
American Medical Association (AMA) declared that its members could not
ethically consult with any members of the "cult of
chiropractic" (Pelletier, 2000). However, after legal actions
against the AMA and other medical organizations in the 1970s and
1980s, the profession began to gain increasing acceptance among
Chiropractic is now
widely accepted as a legitimate therapy for musculoskeletal pain in
selected patients, particularly back pain.
Is it effective?
An increasing number of
studies support the benefits of chiropractic over alternative
treatments for back and neck pain in selected patient groups.
A 1996 RAND report (Hurwitz, et
al.; Pelletier, 2000) concluded that, based on the results of a
systematic literature review and me4ta-analysis of
67 studies, spinal manipulation was more effective than alternative
treatments for patients with acute or sub-acute low-back pain that was
uncomplicated by sciatica.
manipulation was analyzed, it was concluded that manipulation was
effective for neck pain and for muscle-tension-related headache
In a 1995 study reported
in the British Medical Journal (Meade, et al.),
741 patients with low-back pain received either chiropractic
manipulation or outpatient hospital
management. At three years follow-up, according to Oswestry back pain
scores, the chiropractic-treated patients' scores were about 29%
better than those receiving hospital treatment
In a 1995 retrospective
study (Dabbs and Lauretti), it was concluded that cervical
manipulation for neck pain is much safer than the use of non-steroidal
anti-inflammatory drugs (NSAIDs), by as much as a factor of several
is it safe?
Manipulation of the
cervical spine has been questioned more frequently than any other
chiropractic procedure, and reports of complications appear
intermittently in the medical literature.
is the most serious complication resulting from cervical manipulation.
1999 article in the Journal
of Neurology (Hufnagel, et
al.) described 10 patients who suffered ischemic stroke secondary
to vertebral artery dissection or internal carotid artery dissection,
all following chiropractic manipulation of the cervical spine. All of
the patients had no or mild risk factors and no predisposing factors.
Nine cases were documented by magnetic resonance imaging (MRI) or
computerized tomography (CT), with an onset of symptoms immediately or
within two days of the manipulation. All of these patients had
residual effects ranging from mild neurological deficits to a
persistent vegetative state, according to the study.
researchers concluded that patients at risk for stroke after
chiropractic manipulation couldn't be identified before treatment.
Moreover, neurological deficits may be permanent, severely disabling
risk is small
One main blood supply to
the brain comes from the vertebral artery, which follows a tortuous
course through the cervical vertebrae into the brain. According to
William Lauretti, D.C., a doctor of chiropractic in Maryland, it is
possible that by vigorously rotating the neck, the vertebral artery
can become traumatized. A tear can occur, or the injured area can
become the site of a blood clot and subsequently a stroke (although
the risk of this event is rare).
help put this risk into perspective, Lauretti noted that similar
events can result from the administration of anesthesia during surgery
or during neck extension for radiography.
risk for death following cervical spinal manipulation is about
equivalent to the risk for death during a 20-mile round-trip drive to
a chiropractic office, according to Lauretti. For cervical
manipulation, the estimated risk for serious complications is 6.39 per
10 million manipulations (see also Hurwitz, et
lumbar manipulation, the estimate is one serious complication per 100
data compare the risk of serious complications per manipulation with
one surgical procedure or one course of treatment with an NSAID.
Repeated manipulations increase the risk.
high-risk patients (such as those with predisposing factors for
vertebral or carotid artery dissection) before treatment can further
reduce adverse events, although one study cited above noted the
difficulty in identifying that patient subgroup prior to therapy.
Russo Jr., PharmD, is senior vice president of
medical communications at Vicus.com. He is a pharmacist and medical
writer with more than 20 years of experience in medical education.
story was updated on 7 Sept. 2000.