cva final version 2006

8/8/2019 CVA Final Version 2006

1/81

Cervical Spine AdjustingCervical Spine Adjusting

and the Vertebral Arteryand the Vertebral ArteryContemporary perspectives on patientContemporary perspectives on patient

safety and protection, clinical realitysafety and protection, clinical realityand patient managementand patient management


2/81

Why?Why?

Currently the single most important issue relatedCurrently the single most important issue relatedto the practice of chiropractic from ato the practice of chiropractic from a publicpublicsafety issue standpointsafety issue standpoint is associated withis associated with

vertebral artery related matters.vertebral artery related matters.

Similarly, a key issue from aSimilarly, a key issue from a public relationspublic relations

perspectiveperspective is related to the practice ofis related to the practice ofchiropractic as associated with vertebral arterychiropractic as associated with vertebral arteryrelated matters.related matters.


3/81

Why?Why?

The Lewis Inquest in Toronto, Ontario hasThe Lewis Inquest in Toronto, Ontario has

provided a treasure trove of information relatedprovided a treasure trove of information relatedto vertebral artery issues of interest to practicingto vertebral artery issues of interest to practicingchiropractors.chiropractors.

The recent controversy surrounding Vioxx andThe recent controversy surrounding Vioxx andAccutane signals a changing public expectationAccutane signals a changing public expectationwith respect to health care interventions.with respect to health care interventions.


4/81

Outcomes of the presentationOutcomes of the presentation

a. To provide the practicing chiropractor with aa. To provide the practicing chiropractor with areview of the relevant anatomy, physiology andreview of the relevant anatomy, physiology andpathology associated with vertebral arterypathology associated with vertebral arteryinjuries and in particular vertebral arteryinjuries and in particular vertebral arterydissection to assure an understanding of thedissection to assure an understanding of thebasic mechanisms involvedbasic mechanisms involved

b. To offer the practicing chiropractor a reviewb. To offer the practicing chiropractor a reviewof the current demographic and incidence data,of the current demographic and incidence data,

the sources of the data and the strengths andthe sources of the data and the strengths andweaknesses of the data associated withweaknesses of the data associated withvertebral artery injury and cervical spinevertebral artery injury and cervical spineadjustingadjusting


5/81

Outcomes of the presentationOutcomes of the presentation

c. To provide the practicing chiropractor withc. To provide the practicing chiropractor withcurrent thoughts on the appropriate procedurescurrent thoughts on the appropriate proceduresto be used before the initiation of cervical spineto be used before the initiation of cervical spine

adjusting and the recommended procedures inadjusting and the recommended procedures inthe event a patient demonstrates signs of VBAIthe event a patient demonstrates signs of VBAIbefore, during or after a care encounterbefore, during or after a care encounter

d. To provide the practicing chiropractor withd. To provide the practicing chiropractor with

the current perspectives on VAD in progress andthe current perspectives on VAD in progress andthe clinical warning signs of the patient whothe clinical warning signs of the patient whopresents in a potentially compromised state aspresents in a potentially compromised state aswell as the most appropriate response theretowell as the most appropriate response thereto


6/81

Lets Take It from the Top!Lets Take It from the Top!

1. Gross anatomy review1. Gross anatomy review

2. Histology of blood vessels review2. Histology of blood vessels review

3. Review of basic pathology mechanisms:3. Review of basic pathology mechanisms:a. Injury and inflammationa. Injury and inflammation

b. Clotting and thrombus formationb. Clotting and thrombus formation

c. Embolic. Embolid. Ischemiad. Ischemia


7/81

Gross Anatomy ReviewGross Anatomy Review

1. Arterial circulation:1. Arterial circulation:

a. Origin of Vertebral arteriesa. Origin of Vertebral arteries

b. Course of the Vertebral arteriesb. Course of the Vertebral arteriesc. Distal distribution from the Vertebralc. Distal distribution from the Vertebralarteriesarteries

d. Common anomalies of the Vertebrald. Common anomalies of the Vertebral

artery(ies)artery(ies)


8/81

1. Arterial Circulation1. Arterial Circulation

a. Origin of thea. Origin of theVertebral arteries:Vertebral arteries:

i. The left and thei. The left and theright Vertebralright Vertebralarteries arise from thearteries arise from theSubclavian artery.Subclavian artery.

ii. They arise proximalii. They arise proximalto the Thyrocervicalto the Thyrocervicaltrunk and distal to thetrunk and distal to theCommon CarotidCommon Carotid

artery.artery.


9/81


b. Course of theb. Course of theVertebral arteries:Vertebral arteries:

i. The Vertebrali. The Vertebralarteries are dividedarteries are dividedinto four segments asinto four segments asthey ascend thethey ascend thecervical spinecervical spine

I. From theI. From theSubclavian artery to theSubclavian artery to thetransverse foramen oftransverse foramen ofC5/C6C5/C6


10/81


i. The Vertebral arteriesi. The Vertebral arteriesare divided into fourare divided into foursegments as they ascendsegments as they ascendthe cervical spinethe cervical spine

II. Within theII. Within thetransverse foramina fromtransverse foramina fromC5/C6C5/C6--C2C2


11/81


i. The Vertebral arteriesi. The Vertebral arteriesare divided into fourare divided into foursegments as they ascendsegments as they ascendthe cervical spinethe cervical spine

iii. From the superior ofiii. From the superior of

C2 foramen to the duraC2 foramen to the dura


12/81


13/81


c. Distal distribution from the Vertebralc. Distal distribution from the Vertebralarteriesarteries

i. From the Subclavian artery the Vertebrali. From the Subclavian artery the Vertebralarteries continue to unite and form the Basilararteries continue to unite and form the Basilararteryartery

ii. Prior to the junction of the right and leftii. Prior to the junction of the right and leftVertebral arteries forming the Basilar artery theVertebral arteries forming the Basilar artery the

Posterior Inferior Cerebellar artery (PICA) isPosterior Inferior Cerebellar artery (PICA) isgiven off.given off.


14/81


d. Common anomalies of the Vertebrald. Common anomalies of the Vertebralartery(ies)artery(ies)

i. Approximately ten percent of patients havei. Approximately ten percent of patients havesome form of anomaly in their Vertebralsome form of anomaly in their Vertebralartery(ies).artery(ies).

ii. Compression of the Vertebral artery(ies) isii. Compression of the Vertebral artery(ies) is

seen in 5% of the population in a neutralseen in 5% of the population in a neutralposition and the same in rotationposition and the same in rotation..


15/81



iii. Unilateral or bilateral absence of theiii. Unilateral or bilateral absence of theVertebral ArteryVertebral Artery

iiii. Variations in arterial diameter, average 4.3iiii. Variations in arterial diameter, average 4.3mm on the right, 4.7mm on the leftmm on the right, 4.7mm on the left

v. Segment I, tortuous vessel in 39% ofv. Segment I, tortuous vessel in 39% ofspecimensspecimens


16/81



vi. The origin of the Vertebral Artery varies invi. The origin of the Vertebral Artery varies in3.5% of cases3.5% of cases

vii. In 5%vii. In 5%--20% of specimens the Posterior20% of specimens the PosteriorInferior Cerebellar Arteries have an extra duralInferior Cerebellar Arteries have an extra dural

origin approximately 1 cm. proximal to duralorigin approximately 1 cm. proximal to duralpenetration.penetration.


17/81


18/81



viii. 7% of Vertebral arteries cannot be imagedviii. 7% of Vertebral arteries cannot be imageddue to the depth of the tissuedue to the depth of the tissue

ix. Contralateral rotation can cause alterations inix. Contralateral rotation can cause alterations inblood flow at the C1blood flow at the C1--C2 level on MRAC2 level on MRA

x. A change in excess of 56% is needed tox. A change in excess of 56% is needed todetect alterations using Doppler imagingdetect alterations using Doppler imaging


19/81

2. Histology of blood vessels review2. Histology of blood vessels review

a. The Vertebral arteriesa. The Vertebral arteriesare comparable in sizeare comparable in sizeand design to the Renaland design to the Renalarteries or some of thearteries or some of thesmaller Coronary arteries.smaller Coronary arteries.

b. They exhibit the typicalb. They exhibit the typical3 layer pattern from3 layer pattern frominside out of a tunicainside out of a tunica

intima, tunica media andintima, tunica media anda tunica adventitia.a tunica adventitia.

Adventitia

Media

Intima


20/81

3. Review of basic pathology3. Review of basic pathologymechanisms:mechanisms:

a. Injury and inflammationa. Injury and inflammationi. Arteriopathy may arise from heritablei. Arteriopathy may arise from heritable

conditions such as Marfans Disease, Ehlerconditions such as Marfans Disease, EhlerDanlos SyndromeDanlos Syndrome--type IV and VI, autosomaltype IV and VI, autosomaldominant polycystic kidney disease, ordominant polycystic kidney disease, orosteogenesis imperfecta type I (yielding cysticosteogenesis imperfecta type I (yielding cystic

medial degeneration)medial degeneration)ii. Arteriopathy may also arise fromii. Arteriopathy may also arise fromfibromuscular hyperplasiafibromuscular hyperplasia


21/81


b. Clotting and thrombus formationb. Clotting and thrombus formation

i. Arterial damage, particularly involving thei. Arterial damage, particularly involving thetunica intima will yield the start of increasedtunica intima will yield the start of increasedlocalized clotting and thereby thrombuslocalized clotting and thereby thrombusformation.formation.

ii. Arterial flow changes can result fromii. Arterial flow changes can result fromhistological changes as well as from mechanicalhistological changes as well as from mechanicalchanges in the vessel.changes in the vessel.


22/81

Intimal dissection with blood flow beneath the intimaand associated thrombus formation


23/81


c. Embolic. Emboli

i. Emboli present in three primary formsi. Emboli present in three primary forms--liquid,liquid,solid or gaseous. The thrombus at the site ofsolid or gaseous. The thrombus at the site ofarterial damage is invariably the source ofarterial damage is invariably the source ofemboli yielding ischemic stroke from theemboli yielding ischemic stroke from the

Vertebral artery.Vertebral artery.


24/81


d. Ischemiad. Ischemia

i. The degree of ischemia resultant from ani. The degree of ischemia resultant from anembolism is the consequence of the size of theembolism is the consequence of the size of theembolism, the location of the embolism and theembolism, the location of the embolism and thepresence/absence of collateral circulation to thepresence/absence of collateral circulation to the

affected area.affected area.


25/81

From the Basics to the AdvancedFrom the Basics to the Advanced

1. Mechanisms (origins) of Vertebral1. Mechanisms (origins) of Vertebralartery dissectionartery dissection

2. Types of Vertebral artery dissections2. Types of Vertebral artery dissections3. Pathophysiology of various dissections3. Pathophysiology of various dissectionsto the Vertebral arteryto the Vertebral artery

4. Sequellae of dissections the Vertebral4. Sequellae of dissections the Vertebralarteryartery


26/81

1. Mechanisms (origins) of1. Mechanisms (origins) ofVertebral Artery DissectionVertebral Artery Dissection

a. The literature indicates that VAD arisesa. The literature indicates that VAD arisesspontaneously, from trivial movement, minorspontaneously, from trivial movement, minortrauma or major trauma.trauma or major trauma.

b. The following have been cited in the literatureb. The following have been cited in the literatureas preceding a VADas preceding a VAD-- Judo, yoga, ceilingJudo, yoga, ceilingpainting, nose blowing, hypertension, oralpainting, nose blowing, hypertension, oralcontraceptive use, sexual activity, receivingcontraceptive use, sexual activity, receiving

anesthesia, use of resuscitation activities,anesthesia, use of resuscitation activities,receiving a shampoo, vomiting, sneezing,receiving a shampoo, vomiting, sneezing,chiropractic care.chiropractic care.


27/81

2. Types of Vertebral Artery2. Types of Vertebral ArteryDissectionsDissections

a. Dissections arise from an intimal tear.a. Dissections arise from an intimal tear.Yielding an intramural hematoma and theyYielding an intramural hematoma and theyhave been identified as subintimal orhave been identified as subintimal orsubadventital.subadventital.

i. Subintimal dissections tend to result ini. Subintimal dissections tend to result instenosis of the arterystenosis of the artery

ii. Subadventital dissections tend to resultii. Subadventital dissections tend to resultin aneurysm formation.in aneurysm formation.


28/81


29/81


30/81

3. Pathophysiology of Dissections3. Pathophysiology of Dissectionsof the Vertebral arteryof the Vertebral artery

b. The consequences of the evolution ofb. The consequences of the evolution ofthe hematoma include the following:the hematoma include the following:i. It seals off, remains small and is largelyi. It seals off, remains small and is largelyasymptomaticasymptomaticii. An expanding hematoma of a subintimalii. An expanding hematoma of a subintimalnature occludes the vessel yielding ischemia andnature occludes the vessel yielding ischemia anda subsequent infarctiona subsequent infarction

iii. A lesion of a subadventitial nature yields aniii. A lesion of a subadventitial nature yields ananeurysm that is prone to rupture through theaneurysm that is prone to rupture through theadventitia yielding a subdural hematomaadventitia yielding a subdural hematoma


31/81

Subintimal v. SubadventitialSubintimal v. Subadventitial

Vessel lumen

Aneurysm


32/81

. a op ys o ogy o ssec ons. a op ys o ogy o ssec onsof the Vertebral arteryof the Vertebral artery

b. The consequences of the evolution ofb. The consequences of the evolution ofthe hematoma include the following:the hematoma include the following:

iv. The intimal disruption results in aniv. The intimal disruption results in analteration of normal hemodynamics, thealteration of normal hemodynamics, thecreation of a thrombogenic environment,creation of a thrombogenic environment,the formation of a thrombus and thethe formation of a thrombus and the

potential generation of emboli.potential generation of emboli.


33/81


34/81

4. Sequellae of various forms of4. Sequellae of various forms ofinjury to the Vertebral arteryinjury to the Vertebral artery

a. The effects of altered arterial flowa. The effects of altered arterial flowthrough the Vertebral artery as a result ofthrough the Vertebral artery as a result ofa dissection can yield few or minimala dissection can yield few or minimalsymptoms, transient ischemic attacks duesymptoms, transient ischemic attacks dueto the altered circulation, development ofto the altered circulation, development of

thrombi and emboli potentially yieldingthrombi and emboli potentially yieldingischemia and/or infarction.ischemia and/or infarction.


35/81

Vertebral Artery DissectionVertebral Artery Dissection

1. Mechanisms of origin1. Mechanisms of origin

2. Incidence of VAD2. Incidence of VAD

3. Morbidity and mortality associated with3. Morbidity and mortality associated withVADVAD

4. Predisposing factors4. Predisposing factors

5. Theorized predisposing factors5. Theorized predisposing factors6. Predictors of VAD6. Predictors of VAD


36/81


1. Mechanism of origin1. Mechanism of origin

i. According to Haldeman et al. Spine 1999 Apri. According to Haldeman et al. Spine 1999 Apr15;24(8):78515;24(8):785--9494

I. 43% of are spontaneous in natureI. 43% of are spontaneous in nature

II. 31% were associated with cervical spineII. 31% were associated with cervical spinemanipulationmanipulation

III. 16% from trivial traumaIII. 16% from trivial traumaIIII. 10% from major traumaIIII. 10% from major trauma


37/81


1. Mechanism of origin1. Mechanism of origin

ii.ii. According to Beaudry and Spence (The CanadianAccording to Beaudry and Spence (The Canadian

Journal of Neurological Sciences, V. 30, No. 4, NovemberJournal of Neurological Sciences, V. 30, No. 4, November2003, pp. 3202003, pp. 320--304)304)

I. The most common cause of traumatic VertebrobasilarI. The most common cause of traumatic Vertebrobasilar

ischemia is motor vehicle accidents.ischemia is motor vehicle accidents.

II. Of 80 cases that presented over 20 years to a singleII. Of 80 cases that presented over 20 years to a single

neurovascular practice, 70 were related to MVAs, 5 to industrialneurovascular practice, 70 were related to MVAs, 5 to industrialinjuries, 5 associated with chiropractic. Consideration was offeredinjuries, 5 associated with chiropractic. Consideration was offeredthat some of the cases that were related to chiropractors were alsothat some of the cases that were related to chiropractors were alsoinvolved in MVAs further confounding the matter.involved in MVAs further confounding the matter.


38/81


2. Incidence of VAD2. Incidence of VAD (Schievink, NEJM(Schievink, NEJM3/22/01)3/22/01)

a. For every 100,000 strokes of any origina. For every 100,000 strokes of any originthere will be one stroke associated with athere will be one stroke associated with a

Vertebral artery dissectionVertebral artery dissection

b. Dissections account for 10%b. Dissections account for 10%--25% of all25% of all

ischemic strokes in young or middle agedischemic strokes in young or middle agedpersonspersons

c. Less than 5% result in death and aboutc. Less than 5% result in death and about75% have a good recovery75% have a good recovery


39/81



dd. VAD and CAD account for 2.6 per 100,000. VAD and CAD account for 2.6 per 100,000

e. Cervical dissections are the underlyinge. Cervical dissections are the underlyingetiology in 20% of ischemic strokes in patientetiology in 20% of ischemic strokes in patient3030--45 years of age.45 years of age.

f. Female to male ratio: 3:1 (disputed)f. Female to male ratio: 3:1 (disputed)

g. Average age: VADg. Average age: VAD--40, CAD40, CAD--47 (disputed)47 (disputed)


40/81



hh. From the literature:. From the literature:

i. 1 in 5,000 adjustments cause ai. 1 in 5,000 adjustments cause a stroke (Norris,stroke (Norris,SPONTADS,SPONTADS, unpublished)unpublished)

ii. 1 in 20,000 adjustments cause a stroke (Vickers,ii. 1 in 20,000 adjustments cause a stroke (Vickers,BMJ, 1999)BMJ, 1999)

iii. 1.3 in 100,000 patients (Rothwell, Stroke, 2001)iii. 1.3 in 100,000 patients (Rothwell, Stroke, 2001)


41/81



hh. From the literature:. From the literature:

iv. 1 in 1 million adjustments (Hosek et al, JAMA,iv. 1 in 1 million adjustments (Hosek et al, JAMA,1981)1981)

v. 1 in 2 million adjustments (Klougart et al, JMPT,v. 1 in 2 million adjustments (Klougart et al, JMPT,1996)1996)

vi. 1 in 5.85 million cervical spinevi. 1 in 5.85 million cervical spine adjustmentsadjustments(Carey et al, CMAJ, 2001)(Carey et al, CMAJ, 2001)


42/81


ii. Discussion of range of incidence data from the. Discussion of range of incidence data from theliterature:literature:

i. The Rothwell data involves all patients whoi. The Rothwell data involves all patients whoexperienced a stroke within 7 days of a chiropracticexperienced a stroke within 7 days of a chiropracticoffice visitoffice visit

ii. The Carey data reflects claims filed for a strokeii. The Carey data reflects claims filed for a stroke

following chiropractic carefollowing chiropractic careiii. It is likely that among the Rothwell data thereiii. It is likely that among the Rothwell data therewere unrelated strokes and among the Carey datawere unrelated strokes and among the Carey datathere were unreported claimsthere were unreported claims--therefore 1therefore 1--2/per2/permillionmillion


43/81


3. Morbidity and mortality associated with3. Morbidity and mortality associated withVADVAD

a. The reported death rate from dissections ofa. The reported death rate from dissections ofthe carotid and vertebral arteries is less than 5the carotid and vertebral arteries is less than 5percent. Schievink, NEJM, 2001percent. Schievink, NEJM, 2001

b. VAD has been associated with a 10%b. VAD has been associated with a 10%

mortality rate in the acute phase. E. Lang, M.D.mortality rate in the acute phase. E. Lang, M.D.Department of Family Medicine, McGillDepartment of Family Medicine, McGillUniversity;University;


44/81


4. Predisposing factors4. Predisposing factors

a. Please see the heritable conditions noteda. Please see the heritable conditions notedpreviously.previously.

b. approximately 5 percent of patients withb. approximately 5 percent of patients withspontaneous dissection of the carotid orspontaneous dissection of the carotid orvertebral artery have at least one familyvertebral artery have at least one family

member who has had a spontaneous dissectionmember who has had a spontaneous dissectionof the aorta or its main branches. (Schievink,of the aorta or its main branches. (Schievink,NEJM 2001)NEJM 2001)


45/81


5. Theorized predisposing factors:5. Theorized predisposing factors:

a. One casea. One case--control study in 1989 suggestedcontrol study in 1989 suggestedmigraine was a risk factor for cervical arterymigraine was a risk factor for cervical artery

dissection (DAnglejan, Headache, 1989)dissection (DAnglejan, Headache, 1989)

b. Hyperhomocysteinemia as reported byb. Hyperhomocysteinemia as reported byPezzini, J Neurology, 2002Pezzini, J Neurology, 2002

c. Previous respiratory infection together withc. Previous respiratory infection together withother neurological symptomsother neurological symptoms


46/81


6. Predictors of VAD6. Predictors of VAD

a. Thus, given the current state of thea. Thus, given the current state of theliterature, it is impossible to advise patients orliterature, it is impossible to advise patients orphysicians about how to avoid vertebrobasilarphysicians about how to avoid vertebrobasilarartery dissection when considering cervicalartery dissection when considering cervicalmanipulation or about specific sports ormanipulation or about specific sports orexercises that result in neck movement orexercises that result in neck movement ortrauma. (Haldeman et al, Spine 1999)trauma. (Haldeman et al, Spine 1999)


47/81

Clinical Pearl Number OneClinical Pearl Number One

Current thinking holds that theCurrent thinking holds that the

majority of patients who developmajority of patients who developfrank symptoms of a vertebralfrank symptoms of a vertebralartery dissection followingartery dissection following

chiropractic care were in thechiropractic care were in theprocess of dissection when theyprocess of dissection when theypresented for care.presented for care.


48/81

In Support of this IdeaIn Support of this Idea

Did the SMT Practitioner Cause the ArterialDid the SMT Practitioner Cause the ArterialInjury?Injury?Terrett, Chiropractic Journal of Australia, Vol. 32,Terrett, Chiropractic Journal of Australia, Vol. 32,No. 3, 9/2003, pp. 99No. 3, 9/2003, pp. 99--110110Manipulation of the Neck and Stroke: time forManipulation of the Neck and Stroke: time formore rigorous evidencemore rigorous evidenceBreene, Medical Journal of Australia, Vol. 176,Breene, Medical Journal of Australia, Vol. 176,15 Apr 2002, pp.36415 Apr 2002, pp.364--365365

Spinal manipulative therapy is an independentSpinal manipulative therapy is an independentrisk factor for vertebral artery dissectionrisk factor for vertebral artery dissectionSmith, Neurology, Vol. 60, pp. 1424Smith, Neurology, Vol. 60, pp. 1424--14281428


49/81

The Other Side of the QuestionThe Other Side of the Question

Spinal Manipulative Therapy is an IndependentSpinal Manipulative Therapy is an IndependentRisk Factor for Vertebral Artery DissectionRisk Factor for Vertebral Artery Dissection

Smith, Neurology, 2003, Vol. 60, pp.Smith, Neurology, 2003, Vol. 60, pp.

14241424--14281428


50/81

PrePre--adjustment screening testsadjustment screening tests

We were all taught Georges Test,We were all taught Georges Test,DeKlynes Test and other tests forDeKlynes Test and other tests forVertebral artery competency.Vertebral artery competency.

You have been told by many people fromYou have been told by many people fromyour teachers, to your colleagues, to youryour teachers, to your colleagues, to your

professional liability carrier, to your riskprofessional liability carrier, to your riskmanagement consultants to use thesemanagement consultants to use theseprovocative testsprovocative testsDontDont..


51/81


Georges Test or DeKlynes Test yield anGeorges Test or DeKlynes Test yield anunacceptable percentage of false positivesunacceptable percentage of false positivesand of false negatives. It tells you nothingand of false negatives. It tells you nothingreliable.reliable.

For the patient who is a VADFor the patient who is a VAD--inin--progressprogress

the testing may be enough to make a badthe testing may be enough to make a badsituation worse.situation worse.


52/81


In March 2004 all of the clinic directors ofIn March 2004 all of the clinic directors ofall of the U.S. chiropractic colleges andall of the U.S. chiropractic colleges andprograms agreed to abandon the teachingprograms agreed to abandon the teaching

of and use ofof and use of provocativeprovocative testing of thistesting of thisnature.nature.

At the same meeting the presidents/deansAt the same meeting the presidents/deansaccepted the recommendation of the clinicaccepted the recommendation of the clinicdirectors.directors.


53/81


Bottomline: There are no reliable or safeBottomline: There are no reliable or safetests that will rule out a VADtests that will rule out a VAD--inin--progress.progress.There are no tests that will identify aThere are no tests that will identify apatient at risk for VAD.patient at risk for VAD.

Your best evaluative tools are: Your earsYour best evaluative tools are: Your ears

and your gut.and your gut.


54/81

What is a Person to Do?What is a Person to Do?

If there are no clearIf there are no clear--cut predisposingcut predisposingfactors suggesting VAD, andfactors suggesting VAD, and

If there are no testing procedures helpfulIf there are no testing procedures helpfulin ruling out potential VAD patients, andin ruling out potential VAD patients, and

If the great majority of VADIf the great majority of VAD--inin--progressprogresspatients present with musculoskeletalpatients present with musculoskeletal

complaints, then,complaints, then,

What is a person to do?What is a person to do?


55/81

What is a Person to Do?What is a Person to Do?

Look, listen, ask and thinkLook, listen, ask and think


56/81

Look for What?Look for What?

Five DsFive Ds

DizzinessDizziness

Drop attacksDrop attacksDiplopiaDiplopia

DysarthriaDysarthria

DysphagiaDysphagia

AndAnd

AtaxiaAtaxia

Three NsThree NsNauseaNausea

NumbnessNumbness

NystagmusNystagmus


57/81

Perspective on the 5 Ds, 3 Ns and the A!Perspective on the 5 Ds, 3 Ns and the A!

Many patients present to chiropractors exhibitingMany patients present to chiropractors exhibitingone or more of these symptoms, many patientsone or more of these symptoms, many patientsseek care for these symptoms, the presence ofseek care for these symptoms, the presence of

these symptoms, in and of themselvesthese symptoms, in and of themselves--may ormay orMAY NOT be an indication of a possible VADMAY NOT be an indication of a possible VAD--inin--progress, rather it is the constellation ofprogress, rather it is the constellation ofsymptoms (dizziness, nausea and diplopia forsymptoms (dizziness, nausea and diplopia forexample), the uniqueness of the symptom (dropexample), the uniqueness of the symptom (dropattacks for example) and the degree/severity ofattacks for example) and the degree/severity ofthe symptoms that should draw the cliniciansthe symptoms that should draw the cliniciansattentionattention


58/81


59/81

Clinical Pearl Number TwoClinical Pearl Number Two

The phraseThe phrase::

I have a pain in myI have a pain in myneck and (or) headneck and (or) head

unlike anything I haveunlike anything I haveever had beforeever had before..


60/81

Clinical Pearl Number ThreeClinical Pearl Number Three

For those patients who experienced aFor those patients who experienced aVAD, on followVAD, on follow--up 50% had a recentup 50% had a recent

appearance of a new chief complaintappearance of a new chief complaintof upper quadrant neck pain (occipitalof upper quadrant neck pain (occipitalarea) and/or the hemicranium. Thearea) and/or the hemicranium. The

pain was described as throbbing,pain was described as throbbing,steady or sharp, the thunderclapsteady or sharp, the thunderclapheadache.headache.


61/81

Pain referral common to Vertebral Pain referral common to Internal Carotid


62/81

Ask What?Ask What?

DC: Tell me some more about this pain.DC: Tell me some more about this pain.

DC: Were you doing anything before youDC: Were you doing anything before youexperienced the pain, or did it come out ofexperienced the pain, or did it come out ofthe blue?the blue?

DC: How do you feel otherwise? LightDC: How do you feel otherwise? Lightheaded? A little dizzy? Etc.headed? A little dizzy? Etc.


63/81

Think AboutWhat?Think AboutWhat?

Stopping cold in your tracks when youStopping cold in your tracks when youhave heardhave heard TheThe phrase.phrase.

Taking a step back, slowing down andTaking a step back, slowing down andpaying close attention to everything aboutpaying close attention to everything aboutthis patient.this patient.

Moving cautiously, discretion is the betterMoving cautiously, discretion is the betterpart of valor.part of valor.


64/81

Think AboutWhat?Think AboutWhat?

In the presence of a patient whoIn the presence of a patient whoexpresses nonexpresses non--traumatic or posttraumatic or post--whiplashwhiplash

neck pain as a new chief complaint, whoneck pain as a new chief complaint, whorefers to the pain as unlike anything theyrefers to the pain as unlike anything theyhave ever had before, who is exhibitinghave ever had before, who is exhibitingother neurological symptoms referral forother neurological symptoms referral forevaluation of possible VAD beforeevaluation of possible VAD beforeadjusting is strongly recommended.adjusting is strongly recommended.


65/81

When a Patient Shows Signs ofWhen a Patient Shows Signs of

Possible VAD following anPossible VAD following anAdjustmentAdjustment

Your management of the situation andYour management of the situation and

your documentation of the situation areyour documentation of the situation arethe most important issues in reducingthe most important issues in reducingmorbidity and mortality as well as inmorbidity and mortality as well as in

limiting or reducing liability.limiting or reducing liability.


66/81

When a Patient Shows Signs ofWhen a Patient Shows Signs ofPossible VAD following anPossible VAD following an

AdjustmentAdjustment

Your recognition of the postYour recognition of the post--adjustmentadjustment

symptomatic picture is critical. You cannotsymptomatic picture is critical. You cannotassume because a VAD is extremely rare itassume because a VAD is extremely rare itwont or didnt happen.wont or didnt happen.

Keep your antenna up!Keep your antenna up!


67/81



If the patient shows any of the 5 Ds, an AIf the patient shows any of the 5 Ds, an A

or any of the 3 Ns pay attentionor any of the 3 Ns pay attentionimmediately.immediately.

If the symptoms are mild monitor themIf the symptoms are mild monitor themfor their decrease or their resolution, iffor their decrease or their resolution, ifsevere consider emergency servicessevere consider emergency servicesimmediatelyimmediately


68/81

What symptoms should beWhat symptoms should bemonitored?monitored?

Each situation will require a differentEach situation will require a differentresponse, but in general the clinicianresponse, but in general the clinicianshould be monitoring the patients vitalshould be monitoring the patients vital

signs as well as the specific neurologicalsigns as well as the specific neurologicalresponse that has drawn attention.response that has drawn attention.

The availability of baseline vitals will causeThe availability of baseline vitals will causethis data to be more meaningful.this data to be more meaningful.

Wh P ti t Sh Si fWh P ti t Sh Si f


69/81



If the symptoms are very transient, limitedIf the symptoms are very transient, limited

and resolve quickly take a position ofand resolve quickly take a position ofwatchful waiting.watchful waiting.

Consider the area adjusted, the type ofConsider the area adjusted, the type of

adjustment given and if an alternateadjustment given and if an alternateapproach would be in order.approach would be in order.

Do not readjust the patient at that timeDo not readjust the patient at that time

Wh P ti t Sh Si fWh P ti t Sh Si f


70/81

When a Patient Shows Signs ofWhen a Patient Shows Signs ofPossible VAD following andPossible VAD following and


If the symptoms do NOT resolve monitorIf the symptoms do NOT resolve monitor

the patient, stay with the patientthe patient, stay with the patientnonomatter how stacked up the waiting roommatter how stacked up the waiting roomis.is.

Watch for the development of additionalWatch for the development of additionalsymptoms, note the mental status, degreesymptoms, note the mental status, degreeof confusion if any, etc.of confusion if any, etc.

Do not readjust the patient at that timeDo not readjust the patient at that time

When a Patient Shows Signs ofWhen a Patient Shows Signs of


71/81



If the symptoms persist, or if theIf the symptoms persist, or if the

symptoms worsen seek emergencysymptoms worsen seek emergencyservices support. Monitor the patient whileservices support. Monitor the patient whilewaiting for support services.waiting for support services.

Do not readjust the patient at that time.Do not readjust the patient at that time.


72/81

Why Not Readjust?Why Not Readjust?

IF the patient is experiencing a VAD thereIF the patient is experiencing a VAD thereis no form of adjustment that willis no form of adjustment that willminimize the consequences of theminimize the consequences of the

dissection and the introduction of anotherdissection and the introduction of anotherforce may serve to create emboli andforce may serve to create emboli andincrease the likelihood of an ischemicincrease the likelihood of an ischemic

event.event.


73/81


74/81

Why Cant I Wait and See WhatWhy Cant I Wait and See What

Happens?Happens?If the patient has experienced a VAD, andIf the patient has experienced a VAD, andif the VAD has resulted in a thrombusif the VAD has resulted in a thrombus

being formed and emboli being thrown itbeing formed and emboli being thrown itwill result in cerebellar or brainstemwill result in cerebellar or brainstemischemia. Emergency pharmaceuticalischemia. Emergency pharmaceuticalintervention, i.e. tPA, is most effective inintervention, i.e. tPA, is most effective in

the first 90 minutes, moderately effectivethe first 90 minutes, moderately effectivefor three hours and possible effective forfor three hours and possible effective forup to six hoursup to six hours--time is of the essence.time is of the essence.


75/81

Professional Liability ComplicationsProfessional Liability Complications

1. Your failure to recognize what is going on, to1. Your failure to recognize what is going on, towrite it off as a normal or typical reaction towrite it off as a normal or typical reaction toan adjustment.an adjustment.

2. Your failure to monitor and document the2. Your failure to monitor and document theprogress of the patient following the onset ofprogress of the patient following the onset ofthe problem, as well as to document yourthe problem, as well as to document yourthought processes regarding the situation.thought processes regarding the situation.

3. Your failure to manage the situation properly3. Your failure to manage the situation properlyand in a timely manner.and in a timely manner.


76/81

Professional Liability ComplicationsProfessional Liability Complications

4. Readjusting the patient4. Readjusting the patient

5. Sending the patient home if in an5. Sending the patient home if in anunstable or fragile stateunstable or fragile state

6. Taking a casual approach to seeing6. Taking a casual approach to seeinganother provideranother provider-- you might want toyou might want to

7. Failing to document what went on,7. Failing to document what went on,what you were thinking, what you did,what you were thinking, what you did,being less than honest and explicit in thebeing less than honest and explicit in therecord.record.


77/81

Tomorrow MorningTomorrow Morning

1. There is no need to be fearful of1. There is no need to be fearful ofdelivering a competent cervical spinedelivering a competent cervical spineadjustmentadjustment

2. Pay close attention to the responses of2. Pay close attention to the responses ofpatients following cervical spinepatients following cervical spineadjustmentsadjustments

3. Do NOT assume it couldnt happen in3. Do NOT assume it couldnt happen inmy officemy office


78/81


4. Have a plan for what you would do if,4. Have a plan for what you would do if,keep emergency numbers handy, discusskeep emergency numbers handy, discussthe possible scenario with your staff, planthe possible scenario with your staff, plan

and respond to the plan dont react to aand respond to the plan dont react to aproblemproblem

5. Document, document, document5. Document, document, document

6. Understand the mechanisms involved6. Understand the mechanisms involvedand respond accordinglyand respond accordingly


79/81


7. Evaluate your procedures in general, are you7. Evaluate your procedures in general, are youasking the questions you should be asking, areasking the questions you should be asking, areyou and your staff attuned to catching subtleyou and your staff attuned to catching subtle

changes in your patients, does your staff havechanges in your patients, does your staff havemechanisms to let you know about things theymechanisms to let you know about things theysee in patients?see in patients?

8. Act in the best interests of the patient, always8. Act in the best interests of the patient, always

in all waysin all ways--this is ultimately in your best interestthis is ultimately in your best interestas wellas well


80/81

This lecture has been developed as anThis lecture has been developed as aninstructional guide. The information containedinstructional guide. The information containedherein is based on sources believed to beherein is based on sources believed to begenerally correct, however, because of variancesgenerally correct, however, because of variances

in state statutes, educational philosophy,in state statutes, educational philosophy,professional assiduity, and court opinions theprofessional assiduity, and court opinions theAssociation of Chiropractic Colleges assumes noAssociation of Chiropractic Colleges assumes noresponsibility as to the accuracy or scope of theresponsibility as to the accuracy or scope of thesuggestions offered in a particular circumstance.suggestions offered in a particular circumstance.

Legal counsel should be consulted for optimalLegal counsel should be consulted for optimalguidance. The opinions expressed in this lectureguidance. The opinions expressed in this lectureare exclusively those of the author.are exclusively those of the author.


81/81

Copies of this presentation in PowerPointCopies of this presentation in PowerPointare available, as are any of the articlesare available, as are any of the articlesreferenced in this presentation. If youreferenced in this presentation. If you

desire to receive any of this informationdesire to receive any of this informationcontact Dr. Clum at:contact Dr. Clum at:

[email protected]@lifewest.edu

Let us know the article(s) you wish, yourLet us know the article(s) you wish, yourpostal address and telephone number!postal address and telephone number!

cva final version 2006

Documents