Headache & Pain
Migraine: pathogenesis and pathophysiology
Nov. 18, 2022
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Chiropractic healthcare is of interest to neurologists because it is used as a treatment for several neurologic conditions. More importantly, severe neurologic complications can result from chiropractic manipulation. No scientific basis can be found for the treatment of neurologic disorders by the technique of cervical manipulation by chiropractors. Although success has been claimed in the relief of backache, rigorously controlled studies have failed to prove the role of chiropractic manipulations in this benefit. Of concern are the serious neurologic complications resulting from cervical manipulation, of which the most important is stroke. Various recommendations are made to prevent these complications.
• Chiropractic, a nonscientific method of healthcare, is used for treatment of several neurologic disorders.
• Cervical spine manipulations are carried out for spinal problems and are claimed to benefit many other diseases as well.
• Neurologic complications can result from cervical spinal manipulation, such as compression or dissection injury of the vertebral artery, causing stroke.
"Chiropractic" is derived from the Greek word chiros, meaning "hand." It is a system of healthcare based on the relationship between the vertebral column and musculoskeletal system and on the function of various systems of the body, particularly the nervous system. The main therapeutic method is manipulation of the spine, which is not unique to chiropractic, but has been used since 400 BC and has been accepted and rejected several times over the centuries. Currently, chiropractors are the most prominent among practitioners of spinal manipulation, which include osteopaths, manual therapists, and even some physicians.
Chiropractic healthcare is of interest to neurologists because it is used as a treatment for several neurologic conditions. More importantly, severe neurologic complications can result from chiropractic manipulation.
Daniel David Palmer, a fish peddler and grocer who practiced magnetic healing, founded chiropractic in the United States in 1895. The establishment of chiropractic is related to Palmer's examination of a patient who had lost his hearing 17 years earlier when he exerted himself in a cramped and stooped position. Palmer located a painful prominent vertebra that appeared out of place. Using the reasoning that if he repositioned the vertebra the hearing might be restored, he applied a sharp thrust to the spinous process of the vertebra, and the patient's hearing improved (13). It was not explained how the acoustic nerve (contained within the cranial cavity with no connection to the spinal nerves) could be affected by spinal manipulation.
The original hypothesis of Palmer was that human disease is caused by misalignment or subluxations of bony vertebrae and adjacent structures, and that by "proper adjustment to release the pressure on the nerves caused thereby, the cause of disease is removed and the body rendered capable of natural restoration to good health." This hypothesis has remained unchanged over the past 125 years and forms the basis of modern chiropractic. Chiropractic differs from traditional medicine in that it avoids the use of pharmaceutical agents and surgery, instead relying on the body's ability to heal itself. As such, it is not a complete system of medicine but an alternative to western traditional medicine.
Neurologic complications of chiropractic manipulation have probably been occurring since the beginning of this technique, but the first report did not appear until 1925, when a patient suffered dislocation of the atlas (05). Cauda equina syndrome due to traumatic herniation of nucleus pulposus was described in 1943 (22). Stroke was first described in 1947 (66). Vascular complications were not well documented until stroke due to occlusion of the neck arteries was recognized and documented by angiography, which had become an established diagnostic procedure. Some of the cases cited in this article occurred more than 2 decades ago, but they are retained as the pattern of complications has not changed in more recent cases. This may be due to lack of any change in chiropractic technique.
Chiropractors undergo 4 years of schooling after graduation from secondary school. They learn the anatomy of the spine and detailed techniques of spinal manipulation.
Spinal examination and x-ray of the spine are frequently carried out during a patient’s initial investigation. Although imaging techniques such as CT scan and MRI can be ordered by chiropractors, they do not usually use these early in the course of management of spinal problems. In the case of backache, imaging studies are considered if the patient does not improve after a series of manipulations. Neurologic examination involves testing of cranial nerves, reflexes, and muscles, but the integration of information from this examination in the diagnosis of the patient is vague because of lack of any training in neurology.
There are about 60,000 practitioners of chiropractic healthcare in the United States but few in Europe. They are licensed as health practitioners. The United States government recognizes chiropractors as practitioners of medicine, and they can be commissioned in the United States Army. Insurance companies reimburse for some of the services performed by chiropractors. Chiropractic is now an established part of the American healthcare system, and some physicians work with chiropractors. A community-based study demonstrated a chiropractic visit rate of 41 per 100 persons and that 7.5% of the community used a chiropractor's service during a 3 to 5 year period (73). Approximately 12 million Americans undergo spinal manipulation therapy every year.
Some young chiropractors in Canada want to dissociate themselves from their colleagues. These chiropractors want to oppose the claim that their colleagues can treat numerous medical conditions by spinal manipulation. This new generation of chiropractors wants to apply modern medical research methods to spinal manipulation, hoping that will improve their standing within the healthcare community.
According to an attempted overview of reviews to elucidate and quantify the risk of serious adverse events associated with spinal manipulative therapy, it is not possible to provide an overall conclusion about the safety of this procedure; however, the types of serious adverse events that are reported is significant, indicating the presence of some risk (55). High-quality research and consistent reporting of adverse events are needed.
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