CVAs and manipulation-response to Drs. Good and Lauretti
I was shocked to see a full, three-page rebuttal to Dr. Holsworth’s and my article in your journal. While I do feel scholarly debate is appropriate, and admirable, I felt it was inappropriate to publish such an article without the courtesy of notifying us.
The purpose of our paper was to point out that in cases of vascular disease and accidents, there is overwhelming evidence of chemical and histological damages. We wished to focus the clinician’s and science’s attention on this: If these factors are a major cause of vascular accidents and disease outside of manipulation, why not when associated with manipulation as well?
Of course, both authors had useful and valuable contributions in pointing out certain weaknesses inherent not only in our paper, but in the body of knowledge on the subject. I take exception, however, to two main points. First, I believe that Dr. Good’s assertion that rotation and force do play a major role in decreasing the patency of the vertebral arteries (or carotid) is false. Our paper clearly documented numerous papers from the peer-reviewed literature that did not agree with this assertion. Some papers do support this hypothesis, but we refuted one of them in our paper. Due to lack of space, however, we did not refute every single one. Our paper was not a meta-analysis on the validity of provocative testing, although we felt this was an important issue to expound upon because it laid the foundation for the hypothesis that chemical and nutritional factors are playing a major role in weakening and damaging of the vertebral arteries, and spinal manipulative therapy is only a causal factor, not a cause.
Unfortunately, evidence/research for or against provocative testing’s validity supports both sides; however, we felt that we clearly quoted the preponderance of research data, even though some papers have found contradictory findings. Perhaps we were negligent in pointing this out, and we do appreciate Dr. Good adding some balance to the argument.
Dr. Good mentions the work of Allan Terrett as the Holy Grail for research on CVAs and manipulation adding that Dr. Terrett’s findings contradict our findings. We disagree. We extensively studied Dr. Terrett’s published work, and do agree it is the broadest and most comprehensive analysis published to date on the subject. However, Dr. Terrett himself questions the validity of provocative testing. He actually quotes work supporting both sides and agrees that the issue is far from resolved.
Dr. Good tries to make sense of an apparent contradiction in Dr. Holsworth’s and my paper, saying that if mechanical forces alone were responsible for CVA due to manipulation, one would not expect to see them outside of Spinal Manipulative Therapy. Perhaps we were unclear on communicating our intended point, so let me state it now: if force alone were responsible, we would not expect to see CVAs occurring with very low-force or no-force activities, yet we cited numerous articles pointing out that CVAs and vertebral artery dissection happen m yoga, childbirth, lifting the hands over the head, etc. In other words, it is our opinion, which we feel has support in research, that mechanical factors alone cannot explain the phenomena of CVAs and it must be underlying causes, such as weakening by chemical or other factors, that set the stage for their occurrence as they have been reported to occur in very low-force activities-even spontaneously. Our belief is that if the vascular tissue is histologically sound, the force of an adjustment would be unlikely to cause such accidents, except in extreme cases of genetic defects or abnormalities. Dr. Lauretti, however, rightly points out that many cases of reported CVAs due to manipulation are wrongfully associated with doctors of chiropractic-when the majority of these cases were associated with adjustments performed by “unskilled,” non-chiropractic providers. I believe we clearly demonstrated in our paper, however, the dependency or the integrity of the vascular histology on nutritional factors, and the susceptibility of the vascular histology to damage from toxic substances, such as oxidants, free radicals, and homocysteine (ammo acid metabolites)-all of which are amenable to nutritional intervention.
It is important to understand that while no published paper directly supports our views, our paper drew on an enormous amount of research from a variety of disciplines, including chiropractic, nutrition, biomechanics, radiology, histology, cardiology, free-radical pathology, etc. With supporting knowledge, we intertwined those articles into a new, working hypothesis for the basis of CVAs associated with manipulation.
What I found most distressing about Dr. Good’s review is its accusatory tone and that he openly questions our motives, calling our arguments misleading and unfounded. To set the record straight, I worked for more than four years on the paper and Dr. Holsworth and I submitted the hypothesis after reviewing more than 5,000 pages of literature (we cited close to 135 references). Our motive was to raise awareness of three things, in the doctor of chiropractic’s mind: 1) Provocative testing does not provide the ultimate in understanding whether someone is a candidate for adjustment of the cervical spine-especially when rotation and extension are involved. 2) It is possible that chemical and histological changes are occurring to predispose certain high-risk groups to complications associated with manipulation. These chemical factors are influenced and amenable to non-surgical, non-medical means, such as chiropractic and nutrition. 3) Most important, we feel, is the fact that regardless of the cause of CVAs associated with manipulation, it is imperative the clinician be aware of this possibility-beware of the signs and symptoms and NOT re-adjust! We are glad Dr. Lauretti reiterated the emphasis not to re-adjust in his paper, as it cannot be stated frequently enough.
We strongly appreciated the expansion on our research given by Dr. Lauretti, especially in pointing out in detail and with specifics, the other predisposing factors to arterial weakness and damage that may set the stage for vertebral artery dissection. This was an excellent review, and certainly valuable information to the clinician. We also appreciated Dr. Lauretti’s emphasis, and better expansion, on the proper history, red flags, symptoms, etc., that should create a high index of suspicion by the clinician either to forgo certain adjustive procedures or to be aware that a patient is having a reaction to such procedures.
On a final note, we would like to praise both Dr. Good and Dr. Lauretti for taking the time to respond to our article. We need more doctors in our profession who will take the time to intelligently evaluate the literature, and to share their opinions, research findings, and experience with the rest of us. Although we take exception to some of their points, we are honored by their passion and diligence and regard them with the highest esteem.
Copyright American Chiropractic Association May 2003
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