Academy of Chiropractic’s Lawyers PI Program

Marketing/Growing Your Practice 14

From the Desk of :
Mark Studin DC, FASBE (C), DAAPM, DAAMLP

"Building MD Specialist Relationships"

The Neurologist/Orthopedist/Neurosurgeon/etc... I referred a patient for a second opinion and the following scenarios occurred:

  1. Sent the patient back for my care with a great report
  2. Never communicated with me afterwards, but the patient came back for care
  3. Sent a report, omitting notes on further conservative care and I never saw the patient again
  4. Told the patient to go to physical therapy and not use a chiropractor
  5. The patient disappeared afterwards and I have no clue what happened

NOTE TO SELF: Many of the paragraphs are going to start with "that asshole" but they are all going to end with my best referral source!!!! Never lose sight of the goal!

Let's take this one item at a time:

    1. Sent the patient back for my care with a great report:

If this happens, keep the referrals flowing to the doctor and ensure that you take this doctor out for breakfast, lunch or dinner on a regular basis to discuss your co-treating patients...and do not forget to take care of the staff; jelly beans, small flower pots, etc... something very nominal but powerful in your thank-you!


2. Never communicated with me afterwards, but the patient came back for care

Call the office and ask for the report. This is a simple, usual and customary request. No office should ever refuse you. Also, if this is a pattern, inform the staff that you will not be referring should this continue. In many cases, the doctor will not be aware of this, so seek to have a direct conversation with the treating doctor and remind the doctor YOU sent the referral!

    1. Told the patient to go to physical therapy and not use a chiropractor
    2. The specialist sent a report, omitting notes on further conservative care and I never saw the patient again
    3. The patient disappeared afterwards and I have no clue what happened

The above 3 are the exact same thing. In scenario #3 the patient was kind enough to share with you (usually based upon your relationship with the patient) and in scenario #4, the patient, for no apparent reason simply vanished. In both scenarios, after an encounter with the specialist that YOU referred the patient, NO MORE PATIENT!!! or at least that was the intent of the specialist.

Before I give you the solution to scenarios 3-5 I would like to make a general comment about medical specialists relationships: first, it is always about the money. You have to realize that their malpractice insurance is upwards of $300,000 per year and without you referrals they cannot support that insurance payment let alone their lifestyle. In addition there is a whole technology in creating relationships with entities that has to do with relationships, paper flow, credentials, knowledge base and all the other aspects for you to be considered "on par" at their level.

Most medical doctors do not even know the doctoral level of training of a chiropractor, nor do they understand or are aware of the evidence to the scientific literature about the positive effects of chiropractic care.

The 2 areas that you need to attack this level of prejudice are at the knowledge base/credentials level and the peer review evidence on the effects of chiropractic care. As for your knowledge base/credentials, it is no different than when dealing with the attorneys. The 4 courses we recommend from the PI Boot Camp to the MRI course to the accident reconstruction course and spinal biomechanical engineering course is more than adequate to not only put you on par with the knowledge base of the medical doctor, it should you significantly above their knowledge base in these particular fields. Once again there is no substitution for being the best of the best.

Procedure:

Contact the medical specialist and request a face-to-face meeting with the doctor to discuss your patient. This is not an unusual request and you may need to be a little persistent. Should the staff not happily schedule you for an appointment, remind them that you have a significant number of future referrals and the one patient you want to discuss is just the beginning of the relationship. This usually works to create the meeting.

At the meeting bring with you your curriculum vitae and a small professional binder to leave with a Doctor and when doing so let the doctor know that credentials are important to you and you wanted to share yours with him/her.

Secondly, research is critical as the medical community is trained to respond to scientific literature. The following are synopsis of research articles taken directly from the US chiropractic directory. If you go to W WW.USChirodirectory.com and click on "research" on the top toolbar there are dozens of peer reviewed research articles for you to choose from to download, print and gather the actual research article (s) reflecting the synopsis. I urge you to bring and the actual article with you. Here are three possibilities to choose from, however read them all as during your conversation, the particular doctor you are with, might have an issue or objection that you can resolve with one of the other articles you have read.

Chronic Low Back Pain: Chiropractic vs. Medicine

Research Results: Chiropractic is 457% more effective

By Mark Studin DC, FASBE (C), DAAPM, DAAMLP


As reported in 2003 by the National Institute of Neurological Disorders and Stroke, "If you have lower back pain, you are not alone. Nearly everyone at some point has back pain that interferes with work, routine daily activities, or recreation. Americans spend at least $50 billion each year on low back pain, the most common cause of job-related disability and a leading contributor to missed work. Back pain is the second most common neurological ailment in the United States — only headache is more common"(http://www.ninds.nih.gov/disorders/backpain/detail_backpain.htm))

They went on to report many of the causes of low back pain. " As people age, bone strength and muscle elasticity and tone tend to decrease. The discs begin to lose fluid and flexibility, which decreases their ability to cushion the vertebrae" (National Institute of Neurological Disorders and Stroke, 2003,http://www.ninds.nih.gov/disorders/backpain/detail_backpain.htm).

"Pain can occur when, for example, someone lifts something too heavy or overstretches, causing a sprain, strain, or spasm in one of the muscles or ligaments in the back. If the spine becomes overly strained or compressed, a disc may rupture or bulge outward. This rupture may put pressure on one of the more than 50 nerves rooted to the spinal cord that control body movements and transmit signals from the body to the brain. When these nerve roots become compressed or irritated, back pain results" (National Institute of Neurological Disorders and Stroke, 2003, http://www.ninds.nih.gov/disorders/backpain/detail_backpain.htm).

"Low back pain may reflect nerve or muscle irritation or bone lesions. Most low back pain follows injury or trauma to the back, but pain may also be caused by degenerative conditions such as arthritis or disc disease, osteoporosis or other bone diseases, viral infections, irritation to joints and discs, or congenital abnormalities in the spine. Obesity, smoking, weight gain during pregnancy, stress, poor physical condition, posture inappropriate for the activity being performed, and poor sleeping position also may contribute to low back pain. Additionally, scar tissue created when the injured back heals itself does not have the strength or flexibility of normal tissue. Buildup of scar tissue from repeated injuries eventually weakens the back and can lead to more serious injury" (National Institute of Neurological Disorders and Stroke, 2003, http://www.ninds.nih.gov/disorders/backpain/detail_backpain.htm).

Chronic low back pain is where the symptoms have persisted for longer than 3 months, as reported by Bogduk in 2004, although recent studies have classified chronic low back pain as pain persisting for only 4 weeks. The duration is important from a diagnosis and prognosis perspective, where it is critical for the doctor to develop an accurate plan of care. The most important component is not the label, but a complete history being performed, including examination and subsequent testing, when indicated, to develop the right treatment plan.

Wilkey, Gregory, Byfield, & McCarthy reported in 2008 that the proportion of the population that suffers from persistent or chronic low back pain is between 8% and 33%. 13% accounts for those whose pain never goes away and the remainder fluctuate in and out of pain. They also reported that the low back pain was generally recurring, indicating that doing nothing is a poor choice.

While there are a limitless number of treatments, the National Institute of Health in the United States and the National Health Service in the United Kingdom have listed accepted treatment modalities for this very prevalent condition. While there are choices for the public, the question is what is the best treatment choice for each individual back pain sufferer? The answer has to be based on real evidence and outcome based studies offer the answer.

As mentioned ealier, Wilkey, Gregory, Byfield, & McCarthy (2008) studied randomized clinical trials comparing chiropractic care to medical care in a pain clinic. "The treatment regimens employed by the pain clinic in this study consisted of standard pharmaceutical therapy (nonsteroidal anti-inflammatory drugs, analgesics, and gabapentin), facet joint injection, and soft-tissue injection. Transcutaneous electrical nerve stimulation (TENS) machines were also employed. These modalities were used in isolation or in combination with any of the other treatments. Chiropractic group subjects followed an equally unrestricted and normal clinical treatment regimens for the treatment of [chronic low back pain] were followed. All techniques that were employed are recognized within the chiropractic profession as methods used for the treatment of [low back pain]. Many of the methods used are common to other manual therapy professions" (p. 466-467).

After 8 weeks of treatment, the 95% confidence intervals based on the raw scores showed improvement was1.99 for medicine and 9.03 for the chiropractic group. This research indicates that chiropractic is 457% more effective than medicine for chronic low back pain. To say that the medical approach doesn't have a place in healthcare would be inaccurate and irresponsible, but based upon evidenced based outcome studies, research concludes that for chronic low back pain, the path is chiropractic first and drugs 457% second. Chiropractic doctors are trained to determine the cause of the injury and are expert at formulating an accurate and effective diagnosis, prognosis and treatment plan. The cornerstone of that plan is the chiropractic adjustment.

These studies along with many others conclude that a drug-free approach of chiropractic care is the best solutions for patients with chronic low back pain. To find a qualified doctor of chiropractic near you go to the US Chiropractic Directory at www.USChiroDirectory.com and search your state.

References

  1. National Institute of Neurological Disorders and Stroke. (2003, July). Low Back Pain Fact Sheet. Retrieved from http://www.ninds.nih.gov/disorders/backpain/detail_backpain.htm
  2. Bogduk, N. (2004). Management of chronic low back pain. The Medical Journal of Australia, 180(2), 79-83. Retrieved from http://www.mja.com.au/public/issues/180_02_190104/bog10461_fm.html
  3. Wilkey, A., Gregory M., Byfield, D., & McCarthy, P. W. (2008). A comparison between chiropractic management and pain clinic management for chronic low-back pain in a national health service outpatient clinic. The Journal of Alternative and Complementary Medicine, 14(5), 465-473.

Low Back Pain: Chiropractic Adjustments vs. Muscle Relaxants

by Mark Studin DC, FASBE(C), DAAPM, DAAMLP

Chiropractic outperforms muscle relaxants by 24%

Low back pain is one of the most common maladies among the general population and the incidence of occurrence was reported by Ghaffari, Alipour,Farshad, Yensen, and Vingard (2006) to be between 15% and 45% yearly. Hoiriiset al. (2004) reported it to be between 75% and 85% over an adult lifetime in the United States. Chou (2010) writes that, "Back pain is also the fifth most common reason for office visits in the US, and the second most common symptomatic reason..." (p. 388). Historically and based upon this authors 3+ decades of treating low back pain with treatment options that range from heating pads, ice packs, over-the-counter drugs, prescription drugs, surgery, acupuncture and beyond, the most important questions are, "What works? What's proven and what has the best results with the least side effects allowing the patient to regain a normal lifestyle as quickly as possible."

Muscle relaxers are a common drug that has been prescribed by medical doctors for years for nonspecific low back pain. According to Chou (2010), " The term ‘skeletal muscle relaxants’ refers to a diverse collection of pharmacologically unrelated medications, grouped together because they are approved by regulatory agencies for treatment of spasticity or for musculoskeletal conditions such as tension headache or back pain." They are drugs that has been long studied and the effects and side effects have been well documented. Van Tudlar, Touray,Furlan, Solway, and Bouter (2003) concluded that, "Muscle relaxants are effective in the management of nonspecific low back pain, but the adverse effects require that they be used with caution"(p. 1978).

Chou (2010) also stated that, "Skeletal muscle relaxants are an option for acute nonspecific low back pain, although not recommended as first-line therapy because of a high prevalence of adverse effects" (p. 397). He reported that muscle relaxants had a moderate success rate defined by a 1-2 decrease in pain scales rated out of 10. Simply put, if a patient had a pain scale of 9, one could expect the muscle relaxers prescribed to bring the pain to an 8 or 7 at best and include all of the side effects. According to Drugs.com, side effects of muscle relaxants include:

More common

Blurred or double vision or any change in vision; dizziness or lightheadedness; drowsiness

Less common

Fainting; fast heartbeat; fever; hive-like swellings (large) on face, eyelids, mouth, lips, and/or tongue; mental depression; shortness of breath, troubled breathing, tightness in chest, and/or wheezing; skin rash, hives, itching, or redness; slow heartbeat (methocarbamol injection only); stinging or burning of eyes; stuffy nose and red or bloodshot eyes

Less common or rare

Abdominal or stomach cramps or pain; clumsiness or unsteadiness; confusion; constipation; diarrhea; excitement, nervousness, restlessness, or irritability; flushing or redness of face; headache; heartburn; hiccups; muscle weakness; nausea or vomiting; pain or peeling of skin at place of injection (methocarbamol only); trembling; trouble in sleeping; uncontrolled movements of eyes (methocarbamol injection only)

Rare

Blood in urine; bloody or black, tarry stools; convulsions (seizures) (methocarbamol injection only); cough or hoarseness; fast or irregular breathing; lower back or side pain; muscle cramps or pain (not present before treatment or more painful than before treatment); painful or difficult urination; pain, tenderness, heat, redness, or swelling over a blood vessel (vein) in arm or leg (methocarbamolinjection only); pinpoint red spots on skin; puffiness or swelling of the eyelids or around the eyes; sores, ulcers, or white spots on lips or in mouth; sore throat and fever with or without chills; swollen and/or painful glands; unusual bruising or bleeding; unusual tiredness or weakness; vomiting of blood or material that looks like coffee grounds; yellow eyes or skin (http://www.drugs.com/cons/skeletal-muscle-relaxants.html).

When comparing chiropractic spinal adjustments to muscle relaxants for low back pain, it first must be clarified that we are not discussing physical therapy or osteopathic manipulation. While different specialists render tremendous benefits to patients specific to various diagnoses, this research review is limited to a chiropractic spinal adjustment.

Wilkey, Gregory, Byfield, & McCarthy (2008) studied randomized clinical trials comparing chiropractic care to medical care in a pain clinic. "The treatment regimens employed by the pain clinic in this study consisted of standard pharmaceutical therapy (nonsteroidal anti-inflammatory drugs, analgesics, andgabapentin), facet joint injection, and soft-tissue injection. Transcutaneouselectrical nerve stimulation (TENS) machines were also employed. These modalities were used in isolation or in combination with any of the other treatments. Chiropractic group subjects followed an equally unrestricted and normal clinical treatment regimens for the treatment of [chronic low back pain] were followed. All techniques that were employed are recognized within the chiropractic profession as methods used for the treatment of [low back pain]. Many of the methods used are common to other manual therapy professions" (p. 466-467).

After 8 weeks of treatment, the 95% confidence intervals based on the raw scores showed improvement was 1.99 for medicine and 9.03 for the chiropractic group. This research indicates that chiropractic is 457% more effective than medicine for chronic low back pain.

Within that group of 457% falls patients cared for by muscle relaxants.

Hoiriis et al. (2004) reported in their raw data that the chiropractic groups responded 24% better in reducing pain and concluded that, "Statistically, the chiropractic group responded significantly better than the control group with respect to a decrease in pain scores" (p. 396). This was done in "blinded, randomized clinical trials [which] are considered the gold standard of experimental design" (Hoiriis et al., 2004, p. 396).

REFERENCES

    1. Ghaffari, M., Alipour, A., Farshad, A. A., Yensen, I., & Vingard, E.(2006).Incidence and recurrence of disabling low back pain and neck-shoulder pain. Spine, 31(21), 2500-2506.
    2. Hoiriis, K. T., Pfleger, B., McDuffie, F. C., Cotsonis, G., Elsangak, O., Hinson, R., & Verzosa, G. T. (2004). A randomized clinical trial comparing chiropractic adjustments to muscle relaxants for subacute low back pain. Journal of Manipulative and Physiological Therapeutics, 27(6), 388-398.
    3. Chou, R. (2010). Pharmacological management of low back pain. Drugs, 70(4) 387-402.
    4. van Tudlar, M. W., Touray, T., Furlan, A. D., Solway, S., & Bouter, L. M. (2003). Muscle relaxants for nonspecific low back pain: A systematic review within the framework of the cochrane collaboration. Spine, 28(17), 1978-1992.
    5. Drugs.com, (2004). Skeletal muscle relaxants (systemic). Retrieved fromhttp://www.drugs.com/cons/skeletal-muscle-relaxants.html
    6. Wilkey, A., Gregory M., Byfield, D., & McCarthy, P. W. (2008). A comparison between chiropractic management and pain clinic management for chronic low-back pain in a national health service outpatient clinic. The Journal of Alternative and Complementary Medicine, 14(5), 465-473.

 

Stroke Risks While Under Chiropractic Care
Debunking the Myth that Chiropractic Causes Stroke

By Gerard Clum DC, President, Life Chiropractic College West
Mark Studin DC, FASBE (C), DAAPM, DAAMLP

According to the American Heart Association (2010), a stroke "...is a disease that affects the arteries leading to and within the brain. It is the No. 3 cause of death in the United States, behind diseases of the heart and cancer. A stroke occurs when a blood vessel that carries oxygen and nutrients to the brain is either blocked by a clot or bursts. When that happens, part of the brain cannot get the blood (and oxygen) it needs, so it starts to die...Stroke can be caused either by a clot obstructing the flow of blood to the brain (called an ischemic stroke) or by a blood vessel rupturing and preventing blood flow to the brain (called a hemorrhagic stroke)...The brain is an extremely complex organ that controls various body functions. If a stroke occurs and blood flow can't reach the region that controls a particular body function, a stroke will ensue, then that part of the body won't work as it should" (http://www.strokeassociation.org/STROKEORG/AboutStroke/About-stroke_UCM_308529_SubHomePage.jsp).

The AHA (2010) also posts signs and symptoms of an impending stroke. These include numbness or weakness of one side of the face, sudden confusion, difficulty speaking or understanding, problems seeing out of one or both eyes, sudden trouble walking, dizziness, loss of balance or coordination, and severe and sudden headaches with no known cause.

The blood supply to the brain is provided through the vertebral arteries and the carotid arteries. Problems in any of these arteries can result in the development of a thrombus (clot) or an embolism. If the thrombus is large enough it can occlude the normal blood flow. If an embolism occurs, it can move through the circulation into the brain and occlude blood flow. Either way, a stroke can be the result of these situations. One of the unique characteristics of strokes of this nature is that they can involve neck pain and headache.

Many patients will seek chiropractor care for neck pain and headaches. In the great majority of cases, the pain involved is not related to a stroke. However, on occasion, it may be. When the pain is related to a stroke, some of these patients developed a full range of stroke symptoms. Over the years, reports in the popular press and the scientific literature have suggested or stated outright that in patients who experience a stroke following chiropractic care, the stroke was caused by the chiropractor! We now know that this is very unlikely to be the case. What is far more likely is that the patient developed a thrombus or embolism in their vertebral arteries, producing neck pain and headache. This person sought health care for the pain. Whether they saw a chiropractor or their medical provider, they would progress on to a stroke at virtually the same rate. While the argument that the chiropractor caused the problem is convenient, the science indicates that it is in all likelihood a mistake to draw such a conclusion.

In 2008, Cassidy, Boyle, Côté, He, Hogg-Johnson, Silver, and Bondy studied the occurrence of this problem in the province of Ontario over a nine year period with a database representing almost 110 million person-years (12.2 million people, studied over 9 years equals 110 million person-years). The purpose of this study was to investigate if an association between chiropractic care and vertebral basilar artery stroke exceeded the association between medical primary care providers and vertebral basilar artery stroke. The premise was that if there was a greater association between chiropractic care and this stroke then one could logically say there was a cause and effect relationship between chiropractic care and this problem. There was no greater likelihood of a patient experiencing a stroke following a visit to his/her chiropractor than there was after a visit to his/her primary care physician. The results were conclusive; there was no greater association between manipulation (chiropractic adjustments) and ischemic stroke or TIA's (transient ischemic attacks).

The research did conclude that overall, 4% of stroke victims had visited a chiropractor within 30 days of their strokes, while 53% of the stroke cases had visited their medical primary care providers within the same time frame. The authors offer the perspective that because neck pain is associated with some stroke, patients visit their doctors prior to the development of a full-blown stroke scenario. Cassidy et al. (2008) noted, "Because the association between chiropractic visits and [vertebral basilar artery] stroke is not greater than the association between PCP [medical primary care providers] visits and [vertebral basilar] stroke, there is no excess risk of [vertebral basilar] stroke from chiropractic care" (p. S180). In fact, the incident of chiropractic vs. medical care was substantially lower in certain situations based upon the data.

In 2010, Murphy considered the argument that a chiropractic manipulation could cause stroke and concluded, "...if this is a possibility, it would have to be considered so rare that a case-control and case crossover study covering over 109,000,000 person-years failed to detect it" (http://www.chiroandosteo.com/content/18/1/22). He also reports that "... in 20% of cases of [vertebral artery dissection and stroke] the individual does not have neck pain or headache and in a very small percentage of vertebral artery dissections can occur in a person who has no symptoms of any kind. Thus, in cases in which an asymptomatic individual experiences [vertebral artery dissection and stroke] after [chiropractic manipulation] it is not clear whether manipulation was a cause or contributing factor to the dissection or whether the patient had an asymptomatic arterial dissection prior to the chiropractic visit" (Murphy, 2010, http://www.chiroandosteo.com/content/18/1/22). He concluded his report with the following, "...current evidence indicates that [vertebral artery dissection and stroke] is not a 'complication to [chiropractic manipulation]' per se. That is, the weight of the evidence suggests that [chiropractic manipulation] is not a cause of [vertebral artery dissection and stroke]..." (Murphy, 2010, http://www.chiroandosteo.com/content/18/1/22).

The real issue is not whether chiropractic or medical primary care causes stroke, as the research conclusively refutes this, but rather it is an issue of public awareness and perception. The argument must shift to the real issue of protecting the public and making people aware of the importance of recognizing risk factors and of gettiing immediate care to avoid long term disability or death.

Murphy (2010) offers the following advice, "...engage in a public health campaign to educate the public about the warning signs and symptoms of this uncommon but potentially devastating disorder...public education materials regarding stroke in general are available from organizations such as the American Stroke Association (http://www.strokeassociation.org/presenter.jhtml?identifier=3030387 accessed 1 April 2010) the National Stroke Association (http://www.stroke.org/site/PageServer?pagename=HOME accessed 1 April 2010) the British Stroke Association (http://www.stroke.org.uk/information/index.html accessed 22 May 2010), the Heart and Stroke Association of Canada (http:/ / www.heartandstroke.com/ site/ c.ikIQLcMWJtE/ b.2796497/ k.BF8B/ Home.htm?src=home accessed 22 May 2010) and the National Stroke Foundation - Australia (http://www.strokefoundation.com.au/ accessed 22 May 2010)..."(http://www.chiroandosteo.com/content/18/1/22).

References:

      1. American Heart Association, Inc. (2010). About stroke. Retrieved from http://www.strokeassociation.org/STROKEORG/AboutStroke/About-stroke_UCM_308529_SubHomePage.jsp
      2. American Heart Association, Inc. (2010). Warning signs. Retrieved fromhttp://www.strokeassociation.org/STROKEORG/WarningSigns/Warning-Signs_UCM_308528_SubHomePage.jsp
      3. American Heart Association, Inc. (2010). Ischemic (clots). Retrieved fromhttp://www.strokeassociation.org/STROKEORG/AboutStroke/TypesofStroke/IschemicClots/Ischemic-Clots_UCM_310939_Article.jsp
      4. Cassidy, J. D., Boyle, E., Côté, P., He, Y., Hogg-Johnson, S., Silver, F. L., & Bondy, S. J. (2008). Risk of vertebrobasilar stroke and chiropractic care: Results of a population-based case-control and case-crossover study. Spine, 33(45), S176-S183.
      5. Murphy, D. R. (2010). Current understanding of the relationship between cervical manipulation and stroke: What does it mean for the chiropractic profession? Chiorpractic & Osteopathy, 18(22), http://www.chiroandosteo.com/content/18/1/22


Stroke Risks While Under Chiropractic Care
Debunking the Myth that Chiropractic Causes Stroke

By Gerard Clum DC, President, Life Chiropractic College West
Mark Studin DC, FASBE (C), DAAPM, DAAMLP

According to the American Heart Association (2010), a stroke "...is a disease that affects the arteries leading to and within the brain. It is the No. 3 cause of death in the United States, behind diseases of the heart and cancer. A stroke occurs when a blood vessel that carries oxygen and nutrients to the brain is either blocked by a clot or bursts. When that happens, part of the brain cannot get the blood (and oxygen) it needs, so it starts to die...Stroke can be caused either by a clot obstructing the flow of blood to the brain (called an ischemic stroke) or by a blood vessel rupturing and preventing blood flow to the brain (called a hemorrhagic stroke)...The brain is an extremely complex organ that controls various body functions. If a stroke occurs and blood flow can't reach the region that controls a particular body function, a stroke will ensue, then that part of the body won't work as it should" (http://www.strokeassociation.org/STROKEORG/AboutStroke/About-stroke_UCM_308529_SubHomePage.jsp).

The AHA (2010) also posts signs and symptoms of an impending stroke. These include numbness or weakness of one side of the face, sudden confusion, difficulty speaking or understanding, problems seeing out of one or both eyes, sudden trouble walking, dizziness, loss of balance or coordination, and severe and sudden headaches with no known cause.

The blood supply to the brain is provided through the vertebral arteries and the carotid arteries. Problems in any of these arteries can result in the development of a thrombus (clot) or an embolism. If the thrombus is large enough it can occlude the normal blood flow. If an embolism occurs, it can move through the circulation into the brain and occlude blood flow. Either way, a stroke can be the result of these situations. One of the unique characteristics of strokes of this nature is that they can involve neck pain and headache.

Many patients will seek chiropractor care for neck pain and headaches. In the great majority of cases, the pain involved is not related to a stroke. However, on occasion, it may be. When the pain is related to a stroke, some of these patients developed a full range of stroke symptoms. Over the years, reports in the popular press and the scientific literature have suggested or stated outright that in patients who experience a stroke following chiropractic care, the stroke was caused by the chiropractor! We now know that this is very unlikely to be the case. What is far more likely is that the patient developed a thrombus or embolism in their vertebral arteries, producing neck pain and headache. This person sought health care for the pain. Whether they saw a chiropractor or their medical provider, they would progress on to a stroke at virtually the same rate. While the argument that the chiropractor caused the problem is convenient, the science indicates that it is in all likelihood a mistake to draw such a conclusion.

In 2008, Cassidy, Boyle, Côté, He, Hogg-Johnson, Silver, and Bondy studied the occurrence of this problem in the province of Ontario over a nine year period with a database representing almost 110 million person-years (12.2 million people, studied over 9 years equals 110 million person-years). The purpose of this study was to investigate if an association between chiropractic care and vertebral basilar artery stroke exceeded the association between medical primary care providers and vertebral basilar artery stroke. The premise was that if there was a greater association between chiropractic care and this stroke then one could logically say there was a cause and effect relationship between chiropractic care and this problem. There was no greater likelihood of a patient experiencing a stroke following a visit to his/her chiropractor than there was after a visit to his/her primary care physician. The results were conclusive; there was no greater association between manipulation (chiropractic adjustments) and ischemic stroke or TIA's (transient ischemic attacks).

The research did conclude that overall, 4% of stroke victims had visited a chiropractor within 30 days of their strokes, while 53% of the stroke cases had visited their medical primary care providers within the same time frame. The authors offer the perspective that because neck pain is associated with some stroke, patients visit their doctors prior to the development of a full-blown stroke scenario. Cassidy et al. (2008) noted, "Because the association between chiropractic visits and [vertebral basilar artery] stroke is not greater than the association between PCP [medical primary care providers] visits and [vertebral basilar] stroke, there is no excess risk of [vertebral basilar] stroke from chiropractic care" (p. S180). In fact, the incident of chiropractic vs. medical care was substantially lower in certain situations based upon the data.

In 2010, Murphy considered the argument that a chiropractic manipulation could cause stroke and concluded, "...if this is a possibility, it would have to be considered so rare that a case-control and case crossover study covering over 109,000,000 person-years failed to detect it" (http://www.chiroandosteo.com/content/18/1/22). He also reports that "... in 20% of cases of [vertebral artery dissection and stroke] the individual does not have neck pain or headache and in a very small percentage of vertebral artery dissections can occur in a person who has no symptoms of any kind. Thus, in cases in which an asymptomatic individual experiences [vertebral artery dissection and stroke] after [chiropractic manipulation] it is not clear whether manipulation was a cause or contributing factor to the dissection or whether the patient had an asymptomatic arterial dissection prior to the chiropractic visit" (Murphy, 2010, http://www.chiroandosteo.com/content/18/1/22). He concluded his report with the following, "...current evidence indicates that [vertebral artery dissection and stroke] is not a 'complication to [chiropractic manipulation]' per se. That is, the weight of the evidence suggests that [chiropractic manipulation] is not a cause of [vertebral artery dissection and stroke]..." (Murphy, 2010, http://www.chiroandosteo.com/content/18/1/22).

The real issue is not whether chiropractic or medical primary care causes stroke, as the research conclusively refutes this, but rather it is an issue of public awareness and perception. The argument must shift to the real issue of protecting the public and making people aware of the importance of recognizing risk factors and of gettiing immediate care to avoid long term disability or death.

Murphy (2010) offers the following advice, "...engage in a public health campaign to educate the public about the warning signs and symptoms of this uncommon but potentially devastating disorder...public education materials regarding stroke in general are available from organizations such as the American Stroke Association (http://www.strokeassociation.org/presenter.jhtml?identifier=3030387 accessed 1 April 2010) the National Stroke Association (http://www.stroke.org/site/PageServer?pagename=HOME accessed 1 April 2010) the British Stroke Association (http://www.stroke.org.uk/information/index.html accessed 22 May 2010), the Heart and Stroke Association of Canada (http:/ / www.heartandstroke.com/ site/ c.ikIQLcMWJtE/ b.2796497/ k.BF8B/ Home.htm?src=home accessed 22 May 2010) and the National Stroke Foundation - Australia (http://www.strokefoundation.com.au/ accessed 22 May 2010)..."(http://www.chiroandosteo.com/content/18/1/22).

References:

    1. American Heart Association, Inc. (2010). About stroke. Retrieved from http://www.strokeassociation.org/STROKEORG/AboutStroke/About-stroke_UCM_308529_SubHomePage.jsp
    2. American Heart Association, Inc. (2010). Warning signs. Retrieved fromhttp://www.strokeassociation.org/STROKEORG/WarningSigns/Warning-Signs_UCM_308528_SubHomePage.jsp
    3. American Heart Association, Inc. (2010). Ischemic (clots). Retrieved fromhttp://www.strokeassociation.org/STROKEORG/AboutStroke/TypesofStroke/IschemicClots/Ischemic-Clots_UCM_310939_Article.jsp
    4. Cassidy, J. D., Boyle, E., Côté, P., He, Y., Hogg-Johnson, S., Silver, F. L., & Bondy, S. J. (2008). Risk of vertebrobasilar stroke and chiropractic care: Results of a population-based case-control and case-crossover study. Spine, 33(45), S176-S183.
    5. Murphy, D. R. (2010). Current understanding of the relationship between cervical manipulation and stroke: What does it mean for the chiropractic profession? Chiorpractic & Osteopathy, 18(22), http://www.chiroandosteo.com/content/18/1/22