The Risk of Stroke After a Chiropractic Adjustment | Podcast Ep. 365

Hello and welcome to the Evidence Based Chiropractor. I AM your host, Dr. Jeff Langmaid. On today's episode we're talking research. This is all around the safety of a spinal adjustment. We're going to take a look at a brand new study that came out titled association between Cervical Artery dissection and Spinal Manipulative Therapy and a Medicare claims analysis. Lot of great data to take home. Brand new study and a lot of interesting points to load up in your mind, in your arsenal to understand truly what are the risk factors, are they real? And what's going on in the real world when we look at claims data for thousands upon thousands of people. Before we get started, I want to say a few words about Patient Pilot by the Smart Chiropractor. Patient Pilot is now launched and we have a 3x ROI guarantee. We want to patch the holes in your bucket. We we've taken the best of the smart chiropractor in 10x down on the automated email campaign. So if you are interested in having more flow of water into the top of your bucket, that's new patients patching the sides, better retention and actually getting a bottom of the bucket. That's reactivation through an automated system with a 3x ROI guarantee, head over to thesmartchiropractor.com, check out patient Pilot. Get started. We'll hook you up with some awesome bonuses as as well as best pricing to get started and ready for 2023. That is patient pilot by the Smart Chiropractor all@thesmartchiropractor.com but as I said at the top of today's episode, we're talking research and this came out in BMC Geriatrics and again the title, I'm gonna drop it down in the episode show notes as well. It is association between cervical artery dissection and spinal manipulative therapy. A Medicare claims analysis. So let's define a few things as we get started. Cervical artery dissection is of course a serious condition and it occurs when there's weakening and disruption of the arterial lining that allows blood to get in between and separate the layers of the arterial wall. I did not know that explicitly. It's interesting. Patients with cervical artery dissection, they often present with symptoms that people normally present to a chiropractic practice with could be neck pain and headache, some may be asymptomatic and often it's thought that strokes in progress can walk into chiropractic practices masquerading as neck pain or headache. The blood that Accumulates within that arterial wall can occlude the artery or cause a blood clot that can then be dislodged, leading to an ischemic stroke. Cervical artery dissection can occur in either the carotid or or the vertebral arteries. So there's two separate types of cervical artery dissection. One occurs in the carotid artery, the other could happen in the vertebral arteries. Now, cervical artery dissection does. It's pretty uncommon. The incidents are reported three cases per 100,000 for carotid, one per 100,000 for vertebral artery dissection. So this isn't happening all the time. It's not super common. But as you can imagine, with the stroke, it can be really devastating. So it's important to really analyze what's going on in literature, understand what's up, what the risk factors are to mitigate them if you can, and then take the appropriate action steps. So when we look at cervical artery dissections, or specifically carotid artery dissections, they're more common than the vertebral artery dissections. And that's about a 3 to 1, right? We said 3 per 100,000 or 1 per 100,000. So it's about a 3 to 1 dominance of carotid over vertebral artery. And that's what we see in the literature. Now, there's been no direct evidence. Let me repeat that. No direct evidence has been found to support that cervical manipulation can cause a vertebral artery dissection. And a retrospective study of 64 medical legal cases of stroke temporarily associated with cervical manipulation found no apparent dose response between cervical manipulation and a cervical artery dissection. Manipulation or spinal adjustments, commonly used, of course, as we know, to treat neck pain. And about 2 million older Medicare beneficiaries received chiropractic care in 2008. And a systematic review found that from those adjustments that it is an effective treatment for chronic, non specific neck pain. As we've talked about all day, every day, each week on this podcast as well, here comes the litany. American College of Physicians, the American Pain Society, the Task Force on Neck Pain and Associated Disorders, the American Geriatric Society, all recommend adjustments for managing neck pain in older adults. So the guidelines have changed. This is not 20 years ago where it's like, does it work? Does it not work? There is no question about it. We see major healthcare organizations stepping in behind what we do with spinal adjustments to say it's great for low back Pain. It's great for neck pain. We've analyzed the emerging research on this podcast about performance. There's just so much to it and it's all good stuff, which is awesome. So let's dive further into this study though, on today's episode and look at the methods. So they analyze the relationship between the adjustment and the cervical artery dissection with three types of controls. One, a case control design consisting of cases with cervical artery dissection and controls from the general population of Medicare beneficiaries matched by sex, age and calendar year of the cervical artery dissection. Number two, a case control design with the same cases and controlled with same cases and controls with ischemic stroke from the population of Medicare beneficiaries. And then thirdly, they looked at another relationship or another method, and that was a case crossover design in which exposures prior to the cervical artery dissection are compared to exposures in the time period six months earlier in the same patient. So lot, a lot that they analyzed. Study subjects were fee for service Medicare beneficiaries. The primary outcome was they were looking was there a cervical artery dissection and then they subdivided that again to vertebral artery or carotid artery. They created a three level exposure for each time frame, seven days, 14 days, and 30 days prior to the event. So they were parsing through and looking at a ton of data. This data actually became the largest study of the association between cervical spinal manipulation and cervical artery dissection ever. So in this study, the sample size was nine times larger than the previous at nearly 10,000 people, which provided a statistical advantage for studying this condition. And here is the drum roll section here. The various analyses consistently failed to show any increased risk associated with a spinal adjustment. We have seen this time and time again, yet it keeps coming back up in the literature. And I think it's great that it comes up in the literature because it continues to show the safety of what we do. I'll go off on a little bit of a tangent here before we get to the actual conclusions in this study, but I think it's important to set some context now that we know what this study was about. Couple things that come to mind for me, and one is when I look at the safety of what we do, there's. I haven't seen a single study that really shows causation. And quite often it's like the same as if you get like an exam from a primary care doctor. It's like the same as if you go to a chiropractor and have a stroke. So there's like no causation. There's almost no correlation between the two at all. Yet because we work with the neck, it's a good question and it's a valid question to say, is there a challenge? Now, let's frame that a little bit because I've seen tons of previous literature, or at least a few studies, let me put it that way, that has showcased within the paraphysiological space, you really can't do damage. Now, can somebody walk into your practice with a stroke in progress? Yes. Is it pretty hard to pick up on? Yes, it is. You can do a great physical exam and ask the right questions. And sometimes it just doesn't present in a way that's super obvious. And there's just a lot of nuance there that does happen in reality. But we know that when we're delivering a chiropractic adjustment, we're getting into that paraphysiological space. Practically, by definition, you're picking up slack on those arteries. It's not to the point of the breaking point, so to speak. It's not to the point of challenge. Now, can somebody again, be coming in with a stroke in progress? Yes. Could somebody come in with a bunch of challenges in their vertebral arteries and carotid arteries that are quite frankly, impossible for any doctor to pick up on on an orthopedic physical exam? Yes, absolutely correct. However, the care that you deliver, the care that we deliver through a chiropractic adjustment, literally, by definition in the paraphysiological space, is picking up the slack associated with those arteries. It's not extending to a terminal point. It's not extending to a break point. That is why, in my opinion, say this probably overly simply from a research sense, but that's why when we look at studies, there's no causation and there's very little correlation. Because by definition, what we do doesn't get to that breaking point. That's important to remember the second component. And I'm going to highlight a study, hope to get to it next week. But. But if we wanna really look at safety, let's talk about surgical intervention. Let's talk about injections. Again, valid questions to analyze with what we do as a chiropractor. But man, sometimes I feel like chiropractors feel like they're on their back feet on this. And you shouldn't be at all. You should not be on your back foot. We are exceptionally safe when we're gonna look at if you have a lumbar fusion. One person every two days dies after having a lumbar fusion. About 200 people die per year post lumbar fusion, like within a couple days. That's meaningful data. There's like we literally know the number currently is around zero for a chiropractic adjustment as direct causation. So there are, there's safety questions need to come up in healthcare, they should continue to come up in healthcare. But man, I love studies like this that we're highlighting today because it continues to show we're just about the safest thing out there. Movement based care for neuromusculoskeletal conditions is the best way to go about it. But bar none, what we do segmentally, regionally and whole body as chiropractors is in my opinion basically untouched by any other profession. And when we look at what people are doing with medications, we look at what I'm going to call the traditional medical approach which is happening in your community today. People are being prescribed medications, they're getting injections and they're having surgical intervention elective all for neuromusculoskeletal conditions that quite frankly can and should be resolving with your help in your practice. So the question then remains, how do you get the word out there? Well I'm going to encourage you obviously to check out patient pilot and also if you're looking to build relationships with other healthcare providers, the evidence based chiropractor. But people are getting a lot of bad advice each and every day in their community. It's not because their doctors don't like them, there are other doctors. It's because literally their skill set is that low. And I don't mean to overestimate it or pity another healthcare profession or put it on so to speak. But I really think it's important to understand what we do is incredibly powerful. What others do is not only guideline discordant, in many cases it may not be FDA approved, it has super high risks, it structurally changes biomechanics forever that lead to further advanced intervention and and it's just quite frankly bad medical advice most of the time. And it's not because people don't like their patients, it's because they literally don't know any better. It's on us to get out there and tell that story. Let me highlight a few conclusions in this study. So their study characterized by advanced statistical methods to control for potential confounding different groups ischemic stroke controls, population controls and those case crossover analysis. They also analyze multiple different time points. 7 days, 14 days and 30 days, as well as controlling for care seeking behavior. By comparing the risk of cervical artery dissection in patients receiving manipulation to patients receiving a similar evaluation and management visit, or neither, our findings strongly suggest that cervical artery dissection patients are likely to seek out care for neck pain and related symptoms from either a provider that provides cervical adjustments, a medical provider, or both, leading up to the diagnosis, rather than having a specific risk for artery dissection imparted by recipients of the adjustments themselves. So, long story short, what does that equate to? It says among Medicare beneficiaries age 65 years and older who received cervical spine manipulation, the association with cervical artery dissection is no greater than that among control groups, and cervical manipulation does not appear to be a significant risk factor for cervical artery dissection in this population group. So this study just adds to that depth of knowledge with our understanding of the fact that there is very little if any association, there is very little if any additional risk from receiving that adjustment. Now, again, tying back to what we said earlier, I think it's important for us as medical providers do no harm job number one. So make sure that you're asking great questions, make sure you're doing a great functional exam to do your best to identify if there is a patient walking into your practice with a stroke in progress, but do not feel as though the care that you're delivering with the cervical manipulation has abject risk that's just never been shown in the literature. If we want to look at risk, we should be looking at surgery, we should be looking at injections, we should be looking at medications, of which medications we're looking at 130 people each day dying injections. I'm not sure on the death rate, but I certainly know that it's not FDA approved, meaning ESIs in the spine and and then the third component is related to lumbar fusions, of which many, many, many, way too many are done each and every year that leads to further surgery and results in a few death every couple days. To me, those are the areas where we need to be focusing on risk because the risk reward ratio there is way out of whack. And the Hippocratic oath of do no harm, quite frankly, needs to be reevaluated by many other healthcare professionals. But us as movement based healthcare professionals need to stay firm, need to continue to get our message out there so people understand who we are and what we do so that they can choose the best care to find relief from those neuromusculoskeletal conditions. So hopefully today's episode had some key takeaways for you. Hopefully it had some nice information for you to be able to use if patients ask you questions about this, if other providers ask you questions about it, or just building your confidence to better treat the patients in your practice. Now before we wrap, I want to say a few words about Power Step. It's getting towards the end of the year. Now is the time to get your complimentary pair of Power Step orthotics. It's what I use. It's what my dad uses. I could not recommend these orthotics enough. They're going to hook you up. They support this podcast. Go support them. Hit the Episode notes pro powerstep.com sample pro.powerstep.com sample use the code EBC evidence based chiropractor EBC. They will send you a free sample pair. Check it out yourself. See if it's something that would be beneficial for your patients through experiencing the Power step Advantage yourself. Pro.powerstep.com sample Also, before we wrap up, one more word about Patient Pilot Patient Pilot makes everything in your practice work better. If you are spending money on a website, if you are spending money on paid advertising, if you are spending money on any sort of marketing in your practice, you you need to have the foundation of automated email campaigns. It can help convert more patients from your website. That's what we do with our new patient popup. It can improve retention through awesome onboarding and welcome campaign and our weekly email newsletters provide consistent reactivations. Our average doc gets about five reactivations each and every week. Patient Pilot by the Smart Chiropractor we are going to hook you up with a 3x ROI guarantee and some special bonuses and best pricing. But you gotta get started now. We are an open enrollment period until the end of the year. Thesmartchiropractor.com will drop that link below. Check out Patient Pilot get started today. We want to hook you up with that 3x ROI guarantee. We want to help you be as successful as possible in 2023. Thanks for being a chiropractor. Thanks for listening to this podcast. Have a great week in practice and I will talk to you soon.

Thank you for joining us on this episode of the Evidence Based Chiropractor. If you want to grow your practice, come back for next week's episode. If you want to grow faster, visit the evidencebasedchiropractor.com and join our MD Marketing membership today.