Top

Chiropractic & Manual Therapies

Published in:

Open Access 01-12-2016 | Debate

Does case misclassification threaten the validity of studies investigating the relationship between neck manipulation and vertebral artery dissection stroke? Yes

Authors: Jessica K. Paulus, David E. Thaler

Published in: Chiropractic & Manual Therapies | Issue 1/2016

Abstract

Background

For patients and health care providers who are considering spinal manipulative therapy of the neck, it is crucial to establish if it is a trigger for cervical artery dissection and/or stroke, and if it is, the magnitude of the risk.

Discussion

We discuss the biological plausibility of how neck manipulation could cause cervical artery dissection. We also discuss how case misclassification threatens the validity of influential published studies that have investigated the relationship between neck manipulation and dissection. Our position is supported by the fact that the largest epidemiologic studies of neck manipulation safety with respect to neurological outcomes have relied on International Classification of Diseases-9 codes for case identification. However, the application of these codes in prior studies failed to identify dissections (rather than strokes in general) and so conclusions from those studies are invalid.

Conclusion

There are several methodological challenges to understanding the association between neck manipulation and vertebral artery dissection. Addressing these issues is critical because even a modest association between neck manipulation and cervical artery dissection could translate into a significant number of avoidable dissections given the widespread use of neck manipulation by providers from various backgrounds. We believe that valid case classification, accurate measurement of manipulative procedures, and addressing reverse causation bias should be top priorities for future research.

Miley ML, Wellik KE, Wingerchuk DM, Demaerschalk BM. Does cervical manipulative therapy cause vertebral artery dissection and stroke? Neurologist. 2008;14(1):66–73. doi:10.1097/NRL.0b013e318164e53d.CrossRefPubMed

Thomas LC, Rivett DA, Attia JR, Parsons M, Levi C. Risk factors and clinical features of craniocervical arterial dissection. Man Ther. 2011;16(4):351–6. doi:10.1016/j.math.2010.12.008.CrossRefPubMed

Smith WS, Johnston SC, Skalabrin EJ, et al. Spinal manipulative therapy is an independent risk factor for vertebral artery dissection. Neurology. 2003;60(9):1424–8. doi:10.1212/01.WNL.0000063305.61050.E6.CrossRefPubMed

Engelter ST, Grond-Ginsbach C, Metso TM, et al. Cervical artery dissection trauma and other potential mechanical trigger events. Neurology. 2013;80(21):1950–7. doi:10.1212/WNL.0b013e318293e2eb.CrossRefPubMed

Rothwell DM, Bondy SJ, Williams JI. Chiropractic manipulation and stroke: a population-based case–control study. Stroke. 2001;32(5):1054–60. doi:10.1016/j.jemermed.2014.06.025.CrossRefPubMed

Cassidy JD, Boyle E, Cote P, et al. Risk of vertebrobasilar stroke and chiropractic care: results of a population based case control and case-crossover study. Spine. 2008;33:S176–83. doi:10.1097/BRS.0b013e318200478f.CrossRefPubMed

Kosloff TM, Elton D, Tao J, Bannister WM. Chiropractic care and the risk of vertebrobasilar stroke: results of a case–control study in U.S. commercial and Medicare Advantage populations. Chiropr Man Therap. 2015;23(1):19. doi:10.1186/s12998-015-0063-x.CrossRefPubMedPubMedCentral

Schievink WI. Spontaneous dissection of the carotid and vertebral arteries. N Engl J Med. 2001;344(12):898–906. doi:10.1056/NEJM200103223441206.CrossRefPubMed

Mooney SJ, Westreich DJ, El-Sayed AM. Commentary: Epidemiology in the era of big data. Epidemiology. 2015;26(3):390–4. doi:10.1097/EDE.0000000000000274.CrossRefPubMedPubMedCentral

10.

Manuel DG, Rosella LC, Stukel TA. Importance of accurately identifying disease in studies using electronic health records. BMJ. 2010;341:c4226.CrossRefPubMed

11.

Copeland KT, Checkoway H, McMichael AJ, Holbrook RH. Bias due to misclassification in the estimation of relative risk. Am J Epidemiol. 1977;105(5):488–95.PubMed

12.

Herzog W, Leonard TR, Symons B, Tang C, Wuest S. Vertebral artery strains during high-speed, low amplitude cervical spinal manipulation. J Electromyogr Kinesiol. 2012;22(5):740–6. doi:10.1016/j.jelekin.2012.03.005.CrossRefPubMed

13.

Biller J, Sacco RL, Albuquerque FC, et al. Cervical arterial dissections and association with cervical manipulative therapy: A statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2014. doi:10.1161/STR.0000000000000016.

14.

Weintraub MI. Beauty Parlor Stroke Syndrome: Report of Five Cases. JAMA. 1993;269:2085–6. doi:10.1001/jama.1993.03500160051022.CrossRefPubMed

15.

Puhl AA, Reinhart CJ, Injeyan HS. Diagnostic and treatment methods used by chiropractors: A random sample survey of Canada’s English-speaking provinces. J Can Chiropr Assoc. 2015;59(3):279–87.PubMedPubMedCentral

16.

Rupert RL. A survey of practice patterns and the health promotion and prevention attitudes of US chiropractors. Maintenance care: part I. J Manipulative Physiol Ther. 2000;23(1):1–9.CrossRefPubMed

17.

Hurwitz EL, Coulter ID, Adams AH, Genovese BJ, Shekelle PG. Use of chiropractic services from 1985 through 1991 in the United States and Canada. Am J Public Health. 1998;88(5):771–6.CrossRefPubMedPubMedCentral

18.

Cherkin DC, Mootz RD. Chiropractic in the United States: training, practice, and research. AHCPR Publication No. 98-N002. 1997.

19.

Ladeira CE, Samuel Cheng M, Hill CJ. Physical therapists’ treatment choices for non-specific low back pain in Florida: an electronic survey. J Man Manip Ther. 2015;23(2):109–18. doi:10.1179/2042618613Y.0000000065.CrossRefPubMedPubMedCentral

20.

Flynn TW, Wainner RS, Fritz JM. Spinal manipulation in physical therapist professional degree education: A model for teaching and integration into clinical practice. J Orthop Sports Phys Ther. 2006;36(8):577–87. doi:10.2519/jospt.2006.2159.CrossRefPubMed

21.

Cook CE. Orthopedic Manual Therapy: An Evidence-Based Approach. Upper Saddle River: Pearson Education Inc.; 2007.

22.

Thigpen JL, Dillon C, Forster KB, et al. Validity of international classification of disease codes to identify ischemic stroke and intracranial hemorrhage among individuals with associated diagnosis of atrial fibrillation. Circ Cardiovasc Qual Outcomes. 2015;8(1):8–14. doi:10.1161/CIRCOUTCOMES.113.000371.CrossRefPubMedPubMedCentral

23.

Heckbert SR, Kooperberg C, Safford MM, et al. Comparison of self-report, hospital discharge codes, and adjudication of cardiovascular events in the Women’s Health Initiative. Am J Epidemiol. 2004;160(12):1152–8. doi:10.1093/aje/.CrossRefPubMed

24.

Psaty BM, Delaney JA, Arnold AM, et al. Study of Cardiovascular Health Outcomes in the Era of Claims Data: The Cardiovascular Health Study. Circulation. 2016;133(2):156–64. doi:10.1161/CIRCULATIONAHA.115.018610.CrossRefPubMed

25.

Woodfield R, Grant I, UK Biobank Stroke Outcomes Group, UK Biobank Follow-Up and Outcomes Working Group, Sudlow CLM. Accuracy of Electronic Health Record Data for Identifying Stroke Cases in Large-Scale Epidemiological Studies: A Systematic Review from the UK Biobank Stroke Outcomes Group. PLoS One. 2015;10(10), e0140533. doi:10.1371/journal.pone.0140533.CrossRefPubMedPubMedCentral

26.

McCormick N, Bhole V, Lacaille D, Avina-Zubieta JA. Validity of Diagnostic Codes for Acute Stroke in Administrative Databases: A Systematic Review. PLoS One. 2015;10(8), e0135834. doi:10.1371/journal.pone.0135834.CrossRefPubMedPubMedCentral

27.

Goldstein LB. Accuracy of ICD-9-CM Coding for the Identification of Patients With Acute Ischemic Stroke : Effect of Modifier Codes. Stroke. 1998;29(8):1602–4. doi:10.1161/01.STR.29.8.1602.CrossRefPubMed

28.

Andrade SE, Harrold LR, Tjia J, et al. A systematic review of validated methods for identifying cerebrovascular accident or transient ischemic attack using administrative data. Pharmacoepidemiol Drug Saf. 2012;21 Suppl 1:100–28. doi:10.1002/pds.2312.CrossRefPubMedPubMedCentral

29.

Paulus JK, Thaler DE. Case misclassification renders this study uninformative for the manipulation/dissection debate. Chiropr Man Ther. 2015. http://chiromt.biomedcentral.com/articles/10.1186/s12998-015-0063-x/comments.

30.

Kokotailo RA, Hill MD. Coding of stroke and stroke risk factors using international classification of diseases, revisions 9 and 10. Stroke. 2005;36(8):1776–81. doi:10.1161/01.STR.0000174293.17959.a1.CrossRefPubMed

31.

Cai X, Razmara A, Paulus JK, et al. Case Misclassification in Studies of Spinal Manipulation and Arterial Dissection. J Stroke Cerebrovasc Dis. 2014;23(8):2031–5. doi:10.1016/j.jstrokecerebrovasdis.2014.03.007.CrossRefPubMedPubMedCentral

32.

Dittrich R, Rohsbach D, Heidbreder A, et al. Mild mechanical traumas are possible risk factors for cervical artery dissection. Cerebrovasc Dis. 2007;23(4):275–81. doi:10.1159/000098327.CrossRefPubMed

33.

Church EW, Sieg EP, Zalatimo O, Hussain NS, Glantz M, Harbaugh RE. Systematic Review and Meta-analysis of Chiropractic Care and Cervical Artery Dissection: No Evidence for Causation. Cureus. 2016;8(2):e498. doi:10.7759/cureus.498.PubMedPubMedCentral

34.

Paulus JK, Redden LM, Murashka K, Dahabreh IJ, Thaler DE. Abstract WP197: Spinal Manipulation Therapy and Risk of Cerebrovascular Events: Evidence Map and Meta-analysis. Stroke. 2016;47 Suppl 1:AWP197.

35.

Haldeman S, Kohlbeck FJ, McGregor M. Unpredictability of cerebrovascular ischemia associated with cervical spine manipulation therapy: a review of sixty-four cases after cervical spine manipulation. Spine. 2002;27(1):49–55.CrossRefPubMed

36.

Puentedura EJ, March J, Anders J, et al. Safety of cervical spine manipulation: are adverse events preventable and are manipulations being performed appropriately? A review of 134 case reports. J Man Manip Ther. 2012;20(2):66–74. doi:10.1179/2042618611Y.0000000022.CrossRefPubMedPubMedCentral

37.

Reggars JW, French SD, Walker BF, et al. RISK MANAGEMENT FOR CHIROPRACTORS AND OSTEOPATHS: Neck Manipulation & Vertebrobasilar Stroke. Australas Chiropr Osteopathy. 2003;11(1):9–15.PubMedPubMedCentral

38.

Clarke TC, Black LI, Stussman BJ, Barnes PM, Nahin RL. Trends in the use of complementary health approaches among adults: United States, 2002–2012. Natl Health Stat Report. 2015;79:1–16.PubMed

39.

Wynd S, Westaway M, Vohra S, Kawchuk G. The quality of reports on cervical arterial dissection following cervical spinal manipulation. PLoS One. 2013;8(3), e59170. doi:10.1371/journal.pone.0059170.CrossRefPubMedPubMedCentral

40.

American Chiropractic Association. Safety of Neck Manipulation: Key Messages. http://www.acatoday.org/Portals/60/Docs/Stroke/Safety_TalkingPoints_Feb2016.pdf. Accessed 6 June 2016.

Title: Does case misclassification threaten the validity of studies investigating the relationship between neck manipulation and vertebral artery dissection stroke? Yes
Authors: Jessica K. Paulus
David E. Thaler
Publication date: 01-12-2016
Publisher: BioMed Central
Published in: Chiropractic & Manual Therapies / Issue 1/2016
Electronic ISSN: 2045-709X
DOI: https://doi.org/10.1186/s12998-016-0123-x

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Does case misclassification threaten the validity of studies investigating the relationship between neck manipulation and vertebral artery dissection stroke? Yes

Abstract

Background

Discussion

Conclusion

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Background

Discussion

Conclusion

Please log in to get access to this content

Other articles of this Issue 1/2016

Absence of low back pain to demarcate an episode: a prospective multicentre study in primary care

An anatomical study of arcuate foramen and its clinical implications: a case report

Understanding clinical reasoning in osteopathy: a qualitative research approach

The immediate effect of multiple mechanical impulses on electromyography and pressure pain threshold of lumbar latent trigger points: an experimental study

Outcomes of a pilot study in chiropractic practices in Western Australia

The effect of obesity on treatment outcomes for low back pain