179- Manipulation and Stroke: Is there a link?

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Hello and welcome to the Evidence Based Chiropractor. I AM your host, Dr. Jeff Langme. This week we are back at it with the research. We are talking about the safety of a chiropractic adjustment. This is brand new research just published through the Annals of Internal Medicine. This is one you do not want to miss. Before we get started, I'll say a few words about Rock Tape. Rock Tape is proud to be a sponsor of the Evidence Based Chiropractor and if you have not checked out Rock Blade's Mohawk, please do so. So it is a soft tissue tool that I have touched on on my YouTube channel I've utilized myself. It's a fantastic tool. You can pick it up for 175 bucks. See all the educational courses and more at rocktape.com mohawk Additionally, we are in the final countdown to adjust 2019, my live immersion event where we are going to go through every aspect of marketing your practice, create a strategy for you, have a ton of fun in the process, check out the evidencebasedchiropractor.com and if you have any questions about that, shoot me an email. Jeffevidencebasedchiropractor.com I'd be happy to hop on the phone and make sure it's a perfect fit for you. So as I said at the top, we are talking about safety and chiropractic adjustments today and the title of the research paper this was just released in 2019 is titled a Risk Benefit Assessment Strategy to Exclude Cervical Artery Dissection in Spinal Manual Therapy. A Comprehensive Review. So these researchers really looked back at all of the literature and determined or put together a really, really cool assessment strategy that all of us would be able to utilize in our practice to reduce the risk of any cervical artery dissection, but also be able to preemptively identify those individuals who may be at a high risk. And this is a really important point because quite often we see the old did that chiropractic adjustment cause a stroke? There's never been any literature to support causation. There's hardly any that even delve into correlation. But what does occur quite often is that people present to a chiropractor with a potential stroke in progress or a cervical artery dissection in progress. That's where the trouble starts. So let's take it from the top. We know cervical artery dissection occurs when a tear in the internal carotid or vertebral artery results in an intradural hematoma or an aneurysmal dilation. That's kind of the technical aspects of it. So if we take that one step further, we see the incidence of this cervical artery dissection. It's extremely, extremely low. It's actually less than 3 in 100,000 people per year. But in the correlation has really not been well understood. Now, we've never seen any causation, we've really never seen any correl, but there have consistently been question marks. I think all of us have probably been asked about this by patients or by other healthcare providers. Hey, is an adjustment, is a high velocity adjustment of the cervical spine. Does that increase the risk? Does it not? And there's been a massive over reporting from really overzealous neurologists that publish one case study that quite frankly doesn't even tie back to the chiropractor. And it gains. It's sensationalism. Right, we know that, but let's keep it on the literature here. So this new comprehensive review, again it was published by the Annals of Internal Medicine, provides a thorough background on the pathophysiology of cervical artery dissection. And additionally, of course, they outline that step by step assessment strategy to help clinicians, whether it's us as chiropractors or primary care physicians, identify patients that might have a high risk. Incidentally, there's also been literature that shows somebody, you know, you take a population of individuals, 100,000 people, if you send 50,000 of those to see chiropractors, 50,000 to see primary care doctors, there's absolutely no difference in the rate of stroke in those populations. So it should be a moot point. But it's not yet, which is why it's important to keep showcasing literature like this. So the researchers involved in this study concurred with previous research which showed the risk of cervical artery dissection is again, it's no higher for patients visiting a primary care physician than those who visit a chiropractor. And there's really, as such, there's no established causation between a cervical spine manipulation and an increased risk of a cervical artery dissection. So I believe, I hope you do as well, that the assessment strategy provided is a fantastic tool for really all healthcare providers to better identify individuals and to really hopefully eliminate this conversation for once and for all. So we're gonna Go through some of the assessment strategy. But if you wanna check it out for yourself, I will hyperlink the paper which includes of course, the assessment strategy in the show notes. So you can feel free to click down below and head over and kinda check that out. But let's take a few key facts that the researchers found. First, researchers found, quote, the World Health Organization regards manual mobilization and or spinal manipulative treatment conducted by chiropractors to be a safe and effective treatment with few mild transient effects. So this is cool because they obviously highlight in this case, spinal manipulative therapy and chiropractors specifically, which I think is important. Next, the researchers found, quote, several extensive cohort studies and meta analyses have found no excess risk of CAD resulting in secondary ischemic stroke for chiropractic SMT compared to primary care follow up, no difference whatsoever. And finally, they found, quote, history taking, especially regarding the time of symptom onset, is the single most important factor for detecting subtle symptoms of cad. So this is really cool because they were looking at the previous literature and they're showcasing, hey, this history taking is where it's at. I know we all learn these orthopedic tests in school and even I remember when we were learning them, it was like, well, this isn't really valid. It's never really been proven to be valid, but it's probably a good thing to know. Never hesitate to do an orthopedic test. If you think it provides value and you can glean information from it, go for it. But these researchers found by looking at, again, it's a comprehensive review, Annals of Internal Medicine. So you know, they're not messing around with this. They found history taking as really the primary component. And I'll start this assessment strategy. There's a lot to it. It's not overly complex. There's just a lot of ifs and ors. So I'm going to start it. But again, please hit the show notes and check this out on your own. So they identify at the level, they basically classify environmental risks and inherited risks. So an environmental risk would be a recent acute infection, for example, a vitamin deficiency, low body mass index, low cholesterol, smoking. Those are environmental risks. They also then talk about inherited risk, which could be medical history of arterial anomalies, fibromuscular dysplasia, connective tissue disorders, and of course a history of cervical artery dissection. So they say, okay, these are some risk factors. Then if there's two or more distinct symptoms of this list, then you want to think about really making that Referral for potential emergency recent head, neck or thoracic trauma. Now a lot of people do come into our practices with that. Again, that's why it's two or more symptoms, not just one. Other would be new ipsilateral, periorbital, frontal, upper neck or suboccipital neck pain. So new with recent trauma. Right. Those are two things together, distinct new or continued headache. So headache with recent trauma. You know, new pain. That's frontal with a headache, partial Horner syndrome. So obviously if there's, you know, challenges there or if there's retinal cerebral brainstem or cerebellar ischemic symptoms. So if you, obviously, if the person is having difficulty with balance, let's say, or you know, those, those sort of symptoms, if you have two or more of those, those listed in that distinct list, that's a good indication, especially if they have one of the environmental or inher risk factors that you want to definitely refer for a potential medical emergency. So to me, this document is really cool because it's not about us as chiropractors having to practice in fear or practice scared. They're setting the bar and saying, hey, there is absolutely no, you know, no causation that we see whatsoever. However, you know, here is a guide, a step by step process, an assessment strategy to hopefully identify people even earlier on. Which is just part of being patient centric, being the best doc you can. So I love it. Again, it's a little bit long, so I don't want to go through every single nuance of it. You're better off to read it, download it, keep it on your desk. You can check that out in the show notes again, but I loved this paper. I think it's important to continue to share this information. This is actually what we highlighted for all members of the Evidence based chiropractor as their research brief in April of 2019, just last month. Because I think it's really important. There's a lot of friction to potential referrals. There's a lot of reasons for that potential friction. One of them is safety. People don't know if, if a primary care doctor feels as though there might be a risk of sending to a chiropractor, which is a real thing, even though it's foolish, when we really break down the science of it, that friction is gonna prevent somebody from making the referral. So how do you overcome that? Education and outreach. That's why I'd encourage you, if you're not to be a member of the Evidence based Chiropractor that's specifically what we focus on in bridging the gap and building those referral relationships. And a key component of that is the education process. And I want everybody to think of this, I use this example consistently, but it's very real. If that primary care physician says, sees somebody who is 65, it doesn't matter what age really, let's just say 70 years old, their neck is killing them, they have no range of motion, they can barely move, and they're in such exquisite pain that doctor, if they're associating your office with only a high velocity manipulation, they cannot imagine you performing it on that individual who can barely move due to pain. Right. So that referral probably isn't gonna happen, especially not as a first referral. But that is why, you know, you may choose or not choose to do a high velocity adjustment, but you have to think about it as if you are not a chiropractor. As the primary care physician, they're going to be very hesitant, especially if that was going to be the potentially first patient they referred. I got news for you. They're probably not going to make that referral. That is why an educational process is so, so important. The education and the marketing is one. When you're talking about B2B referrals, when you're talking about bridging the gap with other physicians, education and marketing go hand in hand. That's why again, highlighting papers like this are awesome. They help open the eyes of physicians, they showcase the latest literature. They of course, further position your practice as the local leader. And that is really where you should be at. All of us should be through the doors with people just on back pain alone. Chiropractic can do a heck of a lot more than only take care of people's aches and pains. But with that being said, we know 90, 95% of individuals are gonna have aches and pains. Only 1% are gonna have red flags. We should all be seeing a heck of a lot more people in our practices to do so. You should keep on marketing externally, whether that's through social media, whether that email, hopefully using the smart chiropractor or chiro emails. But if you want to pick up and do the part that many doctors are not, many chiropractors are not doing B2B physician to physician marketing. Check us out at the evidencebasedchiropractor.com if you have any questions about my event adjust. It's happening in a couple weeks. I'd love to see you down here. I have a couple tickets left, and I'm probably going to be willing to wheel and deal on them a little bit. So give me. Hit me up. Jeffevidencebasedchiropractor.com and I hope you have a great week of practice and I will talk to you soon.

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Sam.