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Thanks for your interest in our case report and the literature review on CeAD and spinal manipulation, which is the most important element of patient care.
All clinicians would like to have a positive outcome for their patients using evidence-based practice.
Unfortunately, the patient in this case had a near fatal outcome by a chiropractor practising in a major metropolitan region of China. The chiropractor is a graduate of a traditional Chinese medical university. The patient could only recall heavy massage and possibly using an equipment (activator? we did not put in the paper because of the uncertainty).
The side effect with this mode of chiropractor treatment is extremely rare as what we have reviewed. This mode of treatment can certainly be the risk factors for the outcome (we ruled out most of the other risk factors presented in our case). We are sharing this case purely for education purpose without the intention of criticising any individual and the chiropractor profession. We did not want to see any more similar cases with an almost fatal outcome. We do appreciate that the whole profession of chiropractors constantly reviews their practice to ensure the delivery of evidence-based practice for treatment effectiveness of various aches and pain (shoulder girdle and neck pain in our case), which all health professionals should practice routinely.
Hope the response helps to clarify the queries.
Dr Daniel Xu
MBBS, PhD, FRACGP
Academic Coordinators, General Practice Research & International Health
Curtin Medical School
The First Affiliated Hospital, Sun Yat-Sen University
Senior Research Fellow
CCRE, School of Public Health
Faculty of Health Sciences
Location Building 408, Level 3, Room 3516
Postal Address |GPO Box U1987, Perth, Western Australia, 6845 | AUSTRALIA
Tel | +61 (0)8 9266 1740
Mobile | +61 (0)415288896
We read with interest the case report by Yap et al regarding “A near-fatal consequence of chiropractor massage: massive stroke from carotid arterial dissection and vertebral arterial oedema,”(1) which describes a 35-year-old man with a massive stroke purportedly caused by massage. Cerebrovascular disease is an invested topic for manual therapists, considering such providers are responsible for recognizing emergent signs/symptoms of a cervical artery dissection (CeAD) and referring accordingly,(2) however, we are concerned about appropriate and accurate reporting of details of the case including several inconsistencies and evident biases.
We believe this case report likely misclassifies the treating provider as a chiropractor. The report does not specify the credentials of the person providing massage during the business trip. As pointed out by the authors, there is limited regulation and licensing of chiropractic in China.(3) Furthermore, spinal manipulation is by far the most common treatment intervention provided by chiropractors(4) but the authors did not mention its use in the case presentation.
We request the authors clarify the credentials of the massage provider, and elaborate on treatment interventions, specifically if cervical spinal manipulation was performed. Previous case reports have misrepresented the treating provider as a chiropractor when describing potential adverse events.(5) This practice is spurious and adds to over-reporting of adverse...
We request the authors clarify the credentials of the massage provider, and elaborate on treatment interventions, specifically if cervical spinal manipulation was performed. Previous case reports have misrepresented the treating provider as a chiropractor when describing potential adverse events.(5) This practice is spurious and adds to over-reporting of adverse events incorrectly linked to the chiropractic profession.(5)
The authors also conflate “massage” with “chiropractic manipulation” which are two distinct forms of treatment. Spinal manipulation performed by a chiropractor typically involves a thrust or impulse directed to the spine, while massage does not.(6) While the case presentation states massage was the treatment rendered, the title, the discussion, and learning points all highlight chiropractic cervical spine manipulation—which by definition, is not massage. The authors’ literature review included the search term “chiropractic manipulation” which is inappropriate to introduce, as their case pertains to massage.
The authors’ discussion references case reports only, missing seminal studies relevant to manipulation and CeAD, and their conclusions regarding “chiropractic massage” being a “fatal practice” is not supported by the literature. A systematic review of several large observational studies including more than 100 million person-years of data did not identify evidence of a causal association between chiropractic spinal manipulation and CeAD.(7) This is supported by a systematic review of 47 prospective trials that did not identify any incidents of CeAD in recipients of spinal manipulation.(8) Further, to our knowledge there is no epidemiologic evidence linking massage and stroke, and only one case report describing a potential relationship.(9)
Protopathic bias, or confounding by indication, have been proposed as explanations for rare instances in which a stroke is preceded by chiropractic spinal manipulation. In both models, neck pain or headache, common prodromal symptoms of CeAD, prompt a patient to seek care from a chiropractor when the dissection is already in progress.(7, 10-14) This hypothesis is supported by case reports describing such patients presenting to chiropractors with evolving CeAD and referring appropriately.(15-18)
The current case is potentially another example of a dissection-in-progress considering the patient sought massage for neck, shoulder girdle, and upper back pain. The details of initial presentation and physical examination (if performed) for this “chiropractor massage” are not reported, which may have led to a different outcome if the case was managed by a qualified/licensed chiropractor.
The authors’ report of symptom onset coinciding solely with this “chiropractor massage” is not supported in the literature. We propose alternative explanations to the authors regarding the mechanism and resulting conclusions for the case report. Cervical artery dissections are often spontaneous without a known cause.(19) However, there are hypothesized triggers of CeAD which the authors did not mention and could have played a role in the current case such as airplane travel20 and/or viral infection such as mild case of COVID-19 given the timing of this report.(21,22)
In summary, the authors’ conclusions regarding a correlation between chiropractic spinal manipulation and carotid artery dissection and are superseded by higher levels of epidemiologic evidence that has not identified such a causal link. Additionally, the postulated causal relationship between carotid artery dissection and massage exceeds the available data. The patient’s stroke could have been precipitated by a spontaneous CeAD and was treated with massage therapy rather than emergency care. This case should not deter health care providers from referring to, or patients from seeking care from, qualified chiropractors.
1. Yap T, Feng L, Xu D, Zhang J. A near-fatal consequence of chiropractor massage: massive stroke from carotid arterial dissection and bilateral vertebral arterial oedema. BMJ Case Rep. 2021 Aug 6;14(8):e243976. doi: 10.1136/bcr-2021-243976. PMID: 34362754; PMCID: PMC8351484.
2. Chaibi A, Russell MB. A risk-benefit assessment strategy to exclude cervical artery dissection in spinal manual-therapy: a comprehensive review. Ann Med. 2019 Mar;51(2):118-127. doi: 10.1080/07853890.2019.1590627. Epub 2019 Apr 6. PMID: 30889367; PMCID: PMC7857472.
3. World Federation of Chiropractic: Legal Status of Chiropractic by Country. (Accessed August 23, 2021) https://www.wfc.org/website/index.php?option=com_content&view=article&id...
4. Beliveau PJH, Wong JJ, Sutton DA, Simon NB, Bussières AE, Mior SA, French SD. The chiropractic profession: a scoping review of utilization rates, reasons for seeking care, patient profiles, and care provided. Chiropr Man Therap. 2017 Nov 22;25:35. doi: 10.1186/s12998-017-0165-8. PMID: 29201346; PMCID: PMC5698931.
5. Wenban AB. Inappropriate use of the title 'chiropractor' and term 'chiropractic manipulation' in the peer-reviewed biomedical literature. Chiropr Osteopat. 2006 Aug 22;14:16. doi: 10.1186/1746-1340-14-16. PMID: 16925822; PMCID: PMC1570468.
6. Hurwitz EL. Epidemiology: Spinal manipulation utilization. J Electromyogr Kinesiol. 2012;22(5):648-654. doi:10.1016/j.jelekin.2012.01.006
7. Church EW, Sieg EP, Zalatimo O, Hussain NS, Glantz M, Harbaugh RE. (2016). Systematic Review and Meta-analysis of Chiropractic Care and Cervical Artery Dissection: No Evidence for Causation. Cureus. 2016;8(2):e498.
8. Coulter ID, Crawford C, Vernon H, Hurtwitz L, Khorsan R, et al. Manipulation and mobilization for treating chronic nonspecific neck pain: a systematic review and meta-analysis for an appropriateness panel. Pain Physician 2019;22(2):E55-E70.
9. Birkett W, Pouryahya P, Meyer ADM. Bilateral vertebral artery dissection and cerebellar stroke: a rare complication of massage. N Z Med J. 2020 Apr 3;133(1512):88-92. PMID: 32242183.
10. Cassidy JD, Bronfort G, Hartvigsen J. Should we abandon cervical spine manipulation for mechanical neck pain? No. BMJ. 2012;344:e3680. doi:10.1136/bmj.e3680
11. Hutting N, Kerry R, Coppieters MW, Scholten-Peeters GG. Considerations to improve the safety of cervical spine manual therapy. Musculoskelet Sci Pract. 2018;33:41-45.
12. Perle SM, Jung H, Ham J, Choi H. Letter to the Editor: A Case of Posterior Inferior Cerebellar Artery Infarction after Cervical Chiropractic Manipulation (Korean J Neurotrauma 2018; 14: 159–163). Korean J Neurotrauma. 2019;15(1):72-73.
13. Murphy DR, Schneider MJ, Perle SM, Bise CG, Timko M, Haas M. Does case misclassification threaten the validity of studies investigating the relationship between neck manipulation and vertebral artery dissection stroke? No. Chiropr Man Ther. 2016;24(1):43. doi:10.1186/s12998-016-0124-9
14. Bronson MA, Perle SM, Tuchin P. Issues with vertebral artery dissections. Interv Neuroradiol. 2017;23(2):154-155. doi:10.1177/1591019916680111
15. Michaud TC. Uneventful upper cervical manipulation in the presence of a damaged vertebral artery. Journal of Manipulative and Physiological Therapeutics. 2002;25(7):472-483.
16. Tarola G, Phillips RB. Chiropractic response to a spontaneous vertebral artery dissection. Journal of Chiropractic Medicine 2015;14(3):183-190.
17. Futch D, et al. Vertebral artery dissection in evolution found during chiropractic examination. BMJ Case Reports. 2015: bcr2015212568.
18. Mosby JS, Duray SM. Vertebral artery dissection in a patient practicing self-manipulation of the neck. Journal of Chiropractic Medicine. 2011;10(4):283-287.
19. Schievink WI. Spontaneous dissection of the carotid and vertebral arteries. N Engl J Med. 2001 Mar 22;344(12):898-906. doi: 10.1056/NEJM200103223441206. PMID: 11259724.
20. Humaidan H, et al. Airplane stroke syndrome. Journal of Clinical Neuroscience. 2016;29:77-80.
21. Morassi M, et al. Bilateral carotid artery dissection in a SARS-CoV-2 infected patient: causality or coincidence? Journal of Neurology. 2020.;267(10):2812-2814.
22. Gencler OS, Meltem RE, Aydın A. Unilateral common carotid artery dissection in a patient with recent COVID-19: An association or a coincidence? Journal of Clinical Neuroscience. 2021;87: 26-28.