In May, some of the popular press brandished a report published in the journal Neurology, claiming that cervical spine manipulation is a significant risk factor for strokes from a dissection of the vertebral artery.
Your patients — or potential patients — may have read those news reports, many of which were lopsided and failed to question the validity of what was obviously a highly flawed study. As a spokesman for the American Chiropractic Association on this issue, I spoke to many reporters from major media outlets, and pointed out that this particular study was fraught with design flaws and that it was needlessly alarming the public about a safe and effective form of treatment for neck pain and headaches.
Unfortunately, retorts are day-old news and typically get little coverage. So, how do you answer your patients’ fears?
In a nutshell: use good, commonsense communication skills. Here is a step-by-step approach:
1 Express genuine concern. Don’t be dismissive or flippant! The patient’s fears are real. Acknowledge the fear or concern in a genuine, caring manner.
2 Find out what your patient knows (or doesn’t know). Ask, “What have you heard about the incidence of stroke and chiropractic adjustment?”
Your goal is to find out how much (or how little) the patient knows and how much of it is grounded on fact. And find out the source of the patient’s information: A patient who relies on television or the newspaper is much less informed than one who has read the actual study.
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If the patient has read the report, you may want to discuss relevant parts of the study — such as the limited number of individuals included in the study and the statistical implication of those limitations.
3 Listen. As the patient tells you what he knows and shares his concerns, don’t interrupt or minimize his feelings or the amount of information he has collected.
4 Reassure. Acknowledge the facts: The probability of experiencing a stroke following a neck adjustment is extraordinarily rare. This type of stroke has also been associated with many other commonplace activities, such as talking on the telephone, swimming, stargazing, doing overhead work and even sleeping. There is no plausible mechanism relating a chiropractic neck treatment to any other type of stroke, including carotid stroke or an intracranial bleed, which are far more common than this type of stroke.
Since these rare types of strokes are associated with commonplace activities (or with no particular activities at all), many researchers now believe that most cases of vertebral artery dissection result from an underlying weakness in the arterial structure, caused by genetic or nutritional factors.
It’s possible that there may be a relationship between vertebral artery dissections and chiropractic neck treatments. However, the scientific evidence implicating a chiropractic adjustment as a true cause of this type of stroke is still preliminary and highly controversial. One recent study measured the forces transmitted to the vertebral artery during cervical adjustments and found that they were no greater than the strains the artery experiences during normal neck movements.
The results of this study suggest that it may be physically impossible for a competently performed neck adjustment to cause a vertebral artery dissection unless the artery already has a significant pre-existing weakness.
Most studies on this subject agree that the odds of suffering a serious complication from a chiropractic neck treatment are about one incident out of every two million treatments! This means that one chiropractor out of 25 might see such an incident in their entire careers — if they are each in practice full-time for 40 years.
Serious complications from a neck adjustment are so rare that, statistically speaking, if a patient drives more than a mile to get to his chiropractic appointment, it’s more likely that he’ll be seriously injured in a car accident than he’ll be seriously injured during his chiropractic visit. In other words — the risk is extremely minimal.
5 Discuss the risk/benefits of neck adjustment and other treatment. Neck adjustment is one form of treatment for neck symptoms or headache. Other common treatments for these symptoms might include surgery, bed rest or non-steroidal anti-inflammatory drugs (NSAIDs)
State the relative risks in terms the patient can understand, by showing the safety of neck adjustments over other alternative treatment methods. For example:
• Cervical spine surgery carries a 3 percent to 4 percent risk of complication and results in 4,000 to 10,000 deaths per million procedures.
• Bed rest to alleviate pain results in more risk, including muscle wasting, cardiopulmonary deconditioning, bone-mineral loss and the risk of thromboembolism.
• The risk of developing a gastric ulcer visible on endoscopic examination after one week’s treatment with naproxen (at 500mg twice daily) is 19 in 100.
6 Add a personal touch. Relate your own personal experiences with cervical adjustments. For example: “I’ve been in practice for over 12 years, and I’ve performed well over 15,000 neck adjustments without a single serious complication that I am aware of. I often perform neck adjust-ments on my friends, family and loved ones, and often receive them myself from colleagues. Based on the available scientific evidence and my past clinical experience, I’m personally convinced that neck adjustments are a very safe and very effective form of treatment.”
7 Answer questions. And then allow the patient to make an informed decision.
As a doctor of chiropractic, you are a member of a highly trained profession who has an excellent track record of providing the public with safe and effective treatments.
Many scientific studies and expert reviews have shown that the chiro-practic approach is safe, effective and appropriate for patients with common forms of neck pain and headache.
Furthermore, many studies have shown that patients are much more satisfied with the chiropractic approach to these conditions than they are with other treatment options.
Remember that, ultimately, it is the continued dedication and passion that thousands of practicing doctors of chiropractic show toward their patients and their profession that will determine our future, not a few negative news stories based on a single flawed and biased study.
Dr. Bill Lauretti practices in Bethes
da and Gaithersburg, Maryland. He is the Maryland Delegate to the American Chiropractic Association, and has written and lectured widely on the topic of chiropractic risk management. His on-line course, “The Risks of Chiropractic Cervical Adjustments: Myths vs. Reality” is available at DCEducation.com. He can be reached at bill-lau@chiro.org.
