Back Clinic Health Team. The level of functional and metabolic efficiency of a living organism. In humans, it is the ability of individuals or communities to adapt and self-manage when facing physical, mental, psychological, and social changes in an environment. Dr.Alex Jimenez D.C., C.C.S.T, a clinical pain doctor who uses cutting-edge therapies and rehabilitation procedures focused on total health, strength training, and complete conditioning. We take a global functional fitness treatment approach to regain complete functional health.
Dr. Jimenez presents articles both from his own experience and from a variety of sources that pertain to a healthy lifestyle or general health issues. I have spent over 30+ years researching and testing methods with thousands of patients and understand what truly works. We strive to create fitness and better the body through researched methods and total health programs.
These programs and methods are natural and use the body’s own ability to achieve improvement goals, rather than introducing harmful chemicals, controversial hormone replacement, surgery, or addictive drugs. As a result, individuals live a fulfilled life with more energy, a positive attitude, better sleep, less pain, proper body weight, and education on maintaining this way of life.
For those millions of Americans with chronic conditions, naturopathic doctors are offering new views and treatment options which are quickly becoming a primary line of care. This popularity has led to license ND’s across the country.
Like chiropractic doctors, naturopathic physicians operate in outpatient, non-emergency centers. Naturopathic doctors work alongside medical doctors.
Combining the wisdom of nature with the rigors of contemporary science, ND’s are highly trained as thorough diagnosticians. Utilizing the body’s inherent ability to restore and maintain health, ND’s treat patients with the least invasive and least toxic treatments. These modalities that are noninvasive and gentle are among the several reasons why naturopathic medicine is safe for you and your family.
Naturopathic Physicians Treat Patients Using Noninvasive & Conservative Modalities
Naturopathic physicians specialize in preventative medication and are specialists in clinical nutrition and dietary interventions. They believe diet and lifestyle is the basis to health.
According to some 2014 National Health Report from the Center for Disease Control and Prevention, seven of the top ten leading causes of death are chronic ailments that could have been prevented or delayed, and quality of life could have been improved through lifestyle changes, including proper diet, physical activity, avoidance of tobacco, and other types of risk reduction. Naturopathic doctors help treat chronic diseases including heart disease and cancer, which account for roughly half of all deaths each year.
Research on naturopathic medicine treatments for the prevention of cardiovascular disease and stress reveal that treatments aren’t only safe but effective. The randomized controlled study regarding naturopathic care for anxiety involved the treatment of 75 participants that received nutritional supplements, deep breathing relaxation techniques, dietary counseling, and herbal medicine. According to the analysis, significant differences between groups were observed in mental health, concentration, fatigue, social functioning, energy, and quality of life. The treatments also resulted in no adverse responses in any group.
In addition to nutrition and lifestyle recommendations, naturopathic medicine utilizes other noninvasive modalities such as hydrotherapy, manipulative therapy, botanical medicine, and homeopathy. Every one of these modalities is gentle, safe, effective, and based on nature’s healing power.
Malpractice Claims In Naturopathic Medicine Are Unusual
Because naturopathic doctors treat their patients via conservative and noninvasive methods, malpractice rates are much lower for naturopathic doctors when compared with conventional doctors. Annual premiums for ND’s are about $3,800 compared to medical doctors with annual premiums of approximately $18,600, based on NCMIC, the largest malpractice insurance coverage for ND’s.
According to 2014 report from the California Naturopathic Doctors Association, because licensure was granted in 2005, nearly 500 practicing naturopathic doctors have a security record that is pristine with no cases of injury. The same report in Washington State says that from 2004-2014, there have only been 25 disciplinary actions against naturopathic doctors in ten years, in comparison to more than 20,000 disciplinary actions for MD’s.
Naturopathic Physicians Are Well Trained
Doctors attend licensed, four-year, on-campus, naturopathic medical colleges in which they study the latest advances in science and natural methods to illness prevention and management. Students gain a comprehensive knowledge of sciences by taking biochemistry, physiology, anatomy, pathology, and pharmacology classes.
Before graduation, students must complete no less than 4,100 hours of course and clinical training, which comprises over 1,200 hours of hands-on, supervised, clinical training. These doctors must also pass board rigorous examinations, to become a licensed practitioner.
ND’s are trained to work in conjunction along with medical physicians. Along with their two years of science coursework students spend 100 hours studying pharmaceuticals . ND’s know how to safely use their treatments integratively with conventional medicine and they understand their limitations.
ND’s Are Trained To Treat A Wide Selection Of Conditions And Populations
ND’s are rigorously trained to practice in a primary care setting in which they experience conditions of all sorts and age groups. A substantial section of an ND’s education is diagnostic training in order that they can treat or refer patients to medical professionals when necessary. This training involves diagnostic tools common in traditional medicine, such as detailed health, disease, prescription medication histories, physical examinations, and lab testing and imaging, according to the American Association of Naturopathic Practitioners.
ND’s consider diet, lifestyle habits and options, exercise history, and also social/emotional factors to evaluate patients’ needs. These approaches often open doors to new and effective treatment choices.
Currently 20 states, the District of Columbia and two U.S. territories license naturopathic physicians with three states gaining licensure approval in the last year: Rhode Island, Massachusetts and Pennsylvania. More legislators have started to acknowledge the value of the naturopathic medicine profession that is growing.
“[Naturopathic medicine] has assisted lots of individuals suffering from chronic diseases get relief without chemicals and pharmaceuticals which may have unintended side effects,” Pennsylvania State Reps. Bryan Cutler and Steve Mentzer said in a statement.
New laws create ND licensing boards in each state, requiring that those who set up practice as an ND hold a graduate degree from an accredited naturopathic medical school.�ND’s must also pass national board examinations, which cover therapeutic and diagnostic subjects, fundamental sciences and clinical sciences.
At the NUHS Whole Health Center at Lombard, Ill, medicine doctors offer you a variety of mild and safe treatments such as hydrotherapy, nutritional counseling, homeopathy, botanical medicine, and more.
Even though the effects of overweight and obesity on diabetes, cardiovascular disease, all-cause mortality, and other health outcomes are widely known, there is less awareness that overweight, obesity, and weight gain are associated with an increased risk of certain cancers. A recent review of more than 1000 studies concluded that sufficient evidence existed to link weight gain, overweight, and obesity with 13 cancers, including adenocarcinoma of the esophagus; cancers of the gastric cardia, colon and rectum, liver, gallbladder, pancreas, corpus uteri, ovary, kidney, and thyroid; postmenopausal female breast cancer; meningioma; and multiple myeloma.1�An 18-year follow-up of almost 93?000 women in the Nurses� Health Study revealed a dose-response association of weight gain and obesity with several cancers.2
Obesity Increase
The prevalence of obesity in the United States has been increasing for almost 50 years. Currently, more than two-thirds of adults and almost one-third of children and adolescents are overweight or obese. Youths who are obese are more likely to be obese as adults, compounding their risk for health consequences such as cardiovascular disease, diabetes, and cancer. Trends in many of the health consequences of overweight and obesity (such as type 2 diabetes and coronary heart disease) also are increasing, coinciding with prior trends in rates of obesity. Furthermore, the sequelae of these diseases are related to the severity of obesity in a dose-response fashion.2�It is therefore not surprising that obesity accounts for a significant portion of health care costs.
Cancers
A report released on October 3, 2017, by the US Centers for Disease Control and Prevention assessed the incidence of the 13 cancers associated with overweight and obesity in 2014 and the trends in these cancers over the 10-year period from 2005 to 2014.3�In 2014, more than 630?000 people were diagnosed as having a cancer associated with overweight and obesity, comprising more than 55% of all cancers diagnosed among women and 24% of cancers among men. Most notable was the finding that cancers related to overweight and obesity were increasingly diagnosed among younger people.
From 2005 to 2014, there was a 1.4% annual increase in cancers related to overweight and obesity among individuals aged 20 to 49 years and a 0.4% increase in these cancers among individuals aged 50 to 64 years. For example, if cancer rates had stayed the same in 2014 as they were in 2005, there would have been 43?000 fewer cases of colorectal cancer but 33?000 more cases of other cancers related to overweight and obesity. Nearly half of all cancers in people younger than 65 years were associated with overweight and obesity. Overweight and obesity among younger people may exact a toll on individuals� health earlier in their lifetimes.2�Given the time lag between exposure to cancer risk factors and cancer diagnosis, the high prevalence of overweight and obesity among adults, children, and adolescents may forecast additional increases in the incidence of cancers related to overweight and obesity.
Clinical Intervention
Since the release of the landmark 1964 surgeon general�s report on the health consequences of smoking, clinicians have counseled their patients to avoid tobacco and on methods to quit and provided referrals to effective programs to reduce their risk of chronic diseases including cancer. These efforts, coupled with comprehensive public health and policy approaches to reduce tobacco use, have been effective�cigarette smoking is at an all-time low. Similar efforts are warranted to prevent excessive weight gain and treat children, adolescents, and adults who are overweight or obese. Clinician referral to intense, multicomponent behavioral intervention programs to help patients with obesity lose weight can be an important starting point in improving a patient�s health and preventing diseases associatedwith obesity. The benefits of maintaining a healthy weight throughout life include improvements in a wide variety of health outcomes, including cancer. There is emerging but very preliminary data that some of these cancer benefits may be achieved following weight loss among people with overweight or obesity.4
The US Preventive Services Task Force (USPSTF)
The US Preventive Services Task Force (USPSTF) recommends screening for obesity and intensive behavioral interventions delivered over 12 to 16 visits for adults and 26 or more visits for children and adolescents with obesity.5,6�Measuring patients� weight, height, and body mass index (BMI), consistent with USPSTF recommendations, and counseling patients about maintaining a healthy weight can establish a foundation for preventive care in clinical care settings. Scientific data continue to emerge about the negative health effects of weight gain, including an increased risk of cancer.1�Tracking patients� weight over time can identify those who could benefit from counseling and referral early and help them avoid additional weight gain. Yet less than half of primary care physicians regularly assess the BMI of their adult, child, and adolescent patients. Encouraging discussions about weight management in multiple health care settings, including physicians� offices, clinics, emergency departments, and hospitals, can provide multiple opportunities for patients and reinforce messages across contexts and care environments.
Weight Loss Programs
Implementation of clinical interventions, including screening, counseling, and referral, has major challenges. Since 2011, Medicare has covered behavioral counseling sessions for weight loss in primary care settings. However, the benefit has not been widely utilized.7�Whether the lack of utilization is a consequence of lack of clinician or patient knowledge or for other reasons remains uncertain. Few medical schools and residency programs provide adequate training in prevention and management of obesity or in understanding how to make referrals to such services. Obesity is a highly stigmatized condition; many clinicians find it difficult to initiate a conversation about obesity with patients, and some may inadvertently use alienating language when they do. Studies indicate that patients with obesity prefer the use of terms such as�unhealthy weight�or�increased BMI�rather than�overweight�or�obesity�and�improved nutrition and physical activity�rather than�diet and exercise.8�However, it is unknown if switching to these terms will lead to more effective behavioral counseling. Effective clinical decision support tools to measure BMI and guide physicians through referral and counseling interventions can provide clinicians needed support within the patient-clinician encounter. Inclusion of recently developed competencies for prevention and management of obesity into the curricula of health care professionals may improve their ability to deliver effective care. Because few primary care clinicians are trained in behavior change strategies like cognitive behavioral therapy or motivational interviewing, other trained health care professionals, such as nurses, pharmacists, psychologists, and dietitians could assist by providing counseling and appropriate referrals and help people manage their own health.
Achieving sustainable weight loss requires comprehensive strategies that support patients� efforts to make significant lifestyle changes. The availability of clinical and community programs and services to which to refer patients is critically important. Although such programs are available in some communities, there are gaps in availability. Furthermore, even when these programs are available, enhancing linkages between clinical and community care could improve patients� access. Linking community obesity prevention, weight management, and physical activity programs with clinical services can connect people to valuable prevention and intervention resources in the communities where they live, work, and play. Such linkages can give individuals the encouragement they need for the lifestyle changes that maintain or improve their health.
The high prevalence of overweight and obesity in the United States will continue to contribute to increases in health consequences related to obesity, including cancer. Nonetheless, cancer is not inevitable; it is possible that many cancers related to overweight and obesity could be prevented, and physicians have an important responsibility in educating patients and supporting patients� efforts to lead healthy lifestyles. It is important for all health care professionals to emphasize that along with quitting or avoiding tobacco, achieving and maintaining a healthy weight are also important for reducing the risk of cancer.
Corresponding Author:�Greta M. Massetti, PhD, Centers for Disease Control and Prevention, 4770 Buford Hwy NE, Atlanta, GA 30341 (gmassetti@cdc.gov).
Conflict of Interest Disclosures:�All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflict of Interest. Dr Dietz reports receipt of scientific advisory board fees from Weight Watchers and consulting fees from RTI. No other disclosures were reported.
Disclaimer:�The findings and conclusions in this report are those of the authors and not necessarily the official position of the Centers for Disease Control and Prevention.
References
1. Lauby-Secretan B, Scoccianti C, Loomis D, Grosse Y, Bianchini F, Straif K; International Agency for Research on Cancer Handbook Working Group. Body fatness and cancer�viewpoint of the IARC Working Group. N Engl J Med. 2016;375(8):794-798. PubMedArticle
2. Zheng Y, Manson JE, Yuan C, et al. Associations of weight gain from early to middle adulthood with major health outcomes later in life. JAMA. 2017;318(3):255-269. PubMedArticle
4. Byers T, Sedjo RL. Does intentional weight loss reduce cancer risk? Diabetes Obes Metab. 2011;13(12):1063-1072. PubMedArticle
5. Grossman DC, Bibbins-Domingo K, Curry SJ, et al; US Preventive Services Task Force. Screening for obesity in children and adolescents: US Preventive Services Task Force recommendation statement. JAMA. 2017;317(23):2417-2426. PubMedArticle
7. Batsis JA, Bynum JPW. Uptake of the centers for Medicare and Medicaid obesity benefit: 2012-2013. Obesity (Silver Spring). 2016;24(9):1983-1988. PubMedArticle
8. Puhl R, Peterson JL, Luedicke J. Motivating or stigmatizing? public perceptions of weight-related language used by health providers. Int J Obes (Lond). 2013;37(4):612-619. PubMedArticle
Wellness Chiropractor, Dr. Alexander Jimenez takes a look at discussing nutrition with patients in a clinical setting.
How Clinicians Can Do Better
Despite overwhelming evidence that relatively small dietary changes can significantly improve health, clinicians seldom discuss nutrition with their patients. Poor nutritional intake and nutrition-related health conditions, such as cardiovascular disease (CVD), diabetes, obesity, hypertension, and many cancers, are highly prevalent in the United States,1 yet only 12% of office visits include counseling about diet.2 Even among high- risk patients with CVD, diabetes, or hyperlipidemia, only 1 in 5 receive nutrition counseling.2 It is likely that many patients receive most of their nutrition information from other, and often unreliable, sources.
These data may reflect the minimal training, time, and reimbursement allocated to nutrition counseling (and preventive services in general) in clinical practice.3 Most physicians and other health care professionals receive limited education on nutrition in medical school (or other professional schools) or in postgraduate training. Just 25% of medical schools offer a dedicated nutrition course, a decline since the status of nutrition education in US medical schools was first assessed in 1985, and few medical schools achieve the 30 hours of nutrition education recommended by the National Academy of Sciences.4 As a result, physicians report inadequate nutrition knowledge and low self-efficacy for counseling patients about diet.3 In addition, time pressures, especially in primary care, limit opportunities to counsel on nutrition or address preventive issues beyond patients� acute complaints. Lack of time is frequently cited as the greatest barrier to counseling on nutrition and obesity.3
Moreover, nutrition and behavioral counseling have traditionally been non-reimbursed services. Few state Medicaid programs cover nutrition or obesity counseling, and before 2012, Medicare explicitly excluded coverage for obesity counseling; although now a reimbursed service for Medicare beneficiaries, just 1% of eligible Medicare beneficiaries receive this counseling.5 Dietitian counseling is also excluded by Medicare, unless patients have diabetes or renal disease. Although the Affordable Care Act mandates coverage for services graded A or B by the US Preventive Services Task Force, including nutrition counseling for patients with CVD risk factors and obesity counseling for patients with a body mass index of 30 or greater, existing private health insurance benefits are in- consistent, and the covered services are often unclear to both clinicians and patients, thereby limiting use.
Furthermore, health behavior change counseling is often frustrating given the current food environment, in which less nutritious foods tend to be less expensive, larger portioned, more easily accessible, and more heavily marketed than healthier options, making patient adherence 6 to nutrition advice challenging. Conflicting and confusing nutrition messages from popular books, blogs, and other media further complicate patient decision making.
Despite these unfavorable trends, there has been progress in this area. The evidence base supporting the benefits of nutrition intervention and behavioral counseling is expanding. Renewed focus on nutrition education in health care professional training is being driven by both student demand and the health care system. Although time pressures and reimbursement remain impediments, incentives and reimbursement options for nutrition and behavioral counseling are growing, and value-based care and health care team approaches hold promise to better align time demands and incentives for long-term care management. Initiatives to integrate clinical care and community resources offer opportunities to leverage resources that alleviate the clinician�s time commitment. There is evidence of some success; for instance, the amount of sugar-sweetened beverages consumed by individuals in the United States has declined substantially over the past 10 years.7
Clinicians can take the following reasonable steps to include nutrition counseling into the flow of daily practice:
1. Start the conversation. Several short, validated screen- ing questionnaires are available to quickly assess need for nutrition counseling, such as the Starting the Conversation tool8 (Table). This approach can be efficiently used prior to seeing the patient at an appointment, either delivered by medical assistants as part of vital sign assessment or as prescreening paperwork for patients to complete online or in the waiting room.
2. Structure the encounter.�Using methods such as the �5 A�s� (assess, advise, agree, assist, arrange), which has been adapted from tobacco counseling. Motivational interviewing, which has documented efficacy in numerous behavior change settings, is particularly helpful to engage patients who are not yet committed or are hesitant to consider behavioral change.
3. Focus on small steps. Changing lifelong nutrition behaviors can seem overwhelming, but even exceedingly small shifts can have an effect (Table). For example, increasing fruit intake by just 1 serving per day has the estimated potential to reduce cardiovascular mortality risk by 8%, the equivalent of 60 000 fewer deaths annually in the United States and 1.6 million deaths globally.9 Other examples include reducing intake of sugar-sweetened beverages, fast food meals, processed meats, and sweets, while increasing vegetables, legumes, nuts, and whole grains. Emphasize to patients that every food choice is an opportunity to accrue benefits, and even small ones add up. Small substitutions still allow for �treats,� such as replacing potato chips and cheese dip with tortilla chips and salsa, the latter lowering trans fats and saturated fat and increasing whole grain and vegetable intake (Table).
4. Use available resources. Numerous extracurricular resources are readily available for clinicians. The Nutrition in Medicine program offers online, evidence-based nutrition education and tutorials for clinicians and an online, core nutrition curriculum for medical students. The Dietary Guidelines for Americans offers evidence- based and freely available nutrition guidance, tutorials, and tools for clinicians and patients alike. A companion website, Choose My Plate, offers nutrition and counseling advice for clinicians and handy resources for patients, including recently added videos with useful examples of small substitutions that patients will appreciate.
5. Do not do it all at once. Expecting to create long-term behavioral change during a single episode of care is a recipe for frustration and failure, for both the patient and clinician. Empowering and sup- porting patients is an ongoing process, not a 1-time curative event. Use a few minutes at the close of a patient visit to identify opportunities for future counseling, offer to serve as a resource, and be- gin a discussion and support that can be reinforced over time. Take solace in knowing that small initial steps can quickly improve health; for example, reducing trans fats at a single meal (eg, replacing baked goods with fruit or nuts or fried foods with non-fried alternatives) promptly improves endothelial function.10
6. Do not do it all alone.�The primary care physician need not be the sole clinician who provides nutrition counseling. Proactive use of physician extenders (eg, physician assistants, nurses, medical assistants, and health coaches) and referrals can alleviate much of the burden for the busy clinician. Receptionists can distribute assessment and screening questionnaires for patients to complete in the waiting room; medical assistants can document behavioral change progress while assessing vital signs; administrative staff can identify and con- tact patients who are overdue for interaction. Large practices may benefit from including nutrition or health coaches on staff. Referring to clinical specialists and community-based support programs can significantly extend the clinician�s reach.7 In addition to registered dietitians, numerous clinical and community resources are available and often covered by insurance plans. Board-certified obesity medicine specialists, certified diabetes educators, and physician nutrition specialists are available as referrals in many areas. Diabetes Prevention Program group counseling sessions are now covered by Medicare and available throughout communities, such as in many YMCA sites, and electronically.
Summary
Although there is no conclusive evidence that these steps will improve diet and health outcomes for patients, there is virtually no harm in counseling and the potential gains, especially at the population level, are substantial. Nutrition and health behavior change must become a core competency for virtually all physicians and any other health professionals working with patients who have or are at risk for nutrition-related chronic disease.
A Healthier You
Scott Kahan, MD, MPH Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; and George Washington University School of Medicine, Washington, DC.
JoAnn E. Manson, MD, DrPH Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts; and Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, Massachusetts.
ARTICLE INFORMATION
Published Online: September 7, 2017. doi:10.1001/jama.2017.10434 Conflict of Interest Disclosures: All authors have
completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.
REFERENCES
1. Ward BW, Schiller JS, Goodman RA. Multiple chronic conditions among US adults: a 2012 update. Prev Chronic Dis. 2014;11:E62.
2. Office of Disease Prevention and Health Promotion. Healthy People 2020. www.healthypeople.gov/2020/data-search/Search-the-Data#srch=nutrition. Accessed January 23, 2017.
3. Kolasa KM, Rickett K. Barriers to providing nutrition counseling cited by physicians. Nutr Clin Pract. 2010;25(5):502-509.
4. Adams KM, Kohlmeier M, Zeisel SH. Nutrition education in U.S. medical schools: latest update of a national survey. Acad Med. 2010;85(9):1537-1542.
5. Batsis JA, Bynum JPW. Uptake of the Centers for Medicare and Medicaid obesity benefit: 2012-2013. Obesity (Silver Spring). 2016;24(9):1983-1988.
6. Kahan S, Cheskin LJ. Obesity and eating behaviors and behavior change. In: Kahan S, Gielen AC, Fagan PJ, Green LW, eds. Health Behavior Change in Populations. Baltimore, MD: Johns Hopkins University Press; 2014:chap 13.
7. Rehm CD, Pe�alvo JL, Afshin A, Mozaffarian D. Dietary intake among US adults, 1999-2012.JAMA. 2016;315(23):2542-2553.
8. Paxton AE, Strycker LA, Toobert DJ, Ammerman AS, Glasgow RE. Starting the conversation performance of a brief dietary assessment and intervention tool for health professionals. Am J Prev Med. 2011;40(1):67-71.
9. Mozaffarian D, Capewell S. United Nations� dietary policies to prevent cardiovascular disease. BMJ. 2011;343:d5747.
10. Williams MJA, Sutherland WHF, McCormick MP, de Jong SA, Walker RJ, Wilkins GT. Impaired endothelial function following a meal rich in used cooking fat.J Am Coll Cardiol. 1999;33(4):1050-1055
Editors Note: The information provided here was forwarded to Planet Chiropractic by a chiropractor in Texas. Far too many people (including chiropractors) are not aware of historical events that took place during the 1917 � 1918 Spanish Flu years, which involved chiropractors caring for thousands that suffered influenza infection during those times. With such a firestorm of media coverage and fear surrounding the Swine Flu Pandemic, it would be irresponsible not to attempt seeking knowledge regarding influenza events of the past.
The Official History of Chiropractic in Texas By Walter R. Rhodes, DC
Published by the Texas Chiropractic Association � 1978
CHAPTER VI: THE THREE GREAT SURVIVAL FACTORS [Excerpts by Dan Murphy, DC]
�The 1917 � 1918 influenza epidemic swept silently across the world bringing death and fear to homes in every land. Disease and pestilence, especially the epidemics, are little understood even now and many of the factors that spread them are still mysterious shadows, but in 1917-1918 almost nothing was known about prevention, protection, treatment or cure of influenza. The whole world stood at its mercy, or lack of it.�
�But out of that particular epidemic, the young science of chiropractic grew into a new measure of safety. While many struggles would lie ahead this successful passage of the profession into early maturity assured its immediate survival and made the eventual outcome of chiropractic a matter for optimism. If there had been any lack of enthusiasm among the doctors of chiropractic, or a depleting of the sources of students then the epidemic took care of them too. These chiropractic survivors of the flu epidemic were sure, assured, determined, and ready to fight any battle that came up. The effect of the epidemic becomes evident in interviews made with old-timers practicing in those years. The refrain comes repeatedly,�
�I was about to go out of business when the flu epidemic came � but when it was over, I was firmly established in practice.�
�Why? The answer is reasonably simple. Chiropractors got fantastic results from influenza patients while those under medical care died like flies all around.� �Statistics reflect a most amazing, almost miraculous state of affairs. The medical profession was practically helpless with the flu victims but chiropractors seemed able to do no wrong.�
�In Davenport, Iowa, 50 medical doctors treated 4,953 cases, with 274 deaths. In the same city, 150 chiropractors including students and faculty of the Palmer School of Chiropractic, treated 1,635 cases with only one death.�
�In the state of Iowa, medical doctors treated 93,590 patients, with 6,116 deaths � a loss of one patient out of every 15. In the same state, excluding Davenport, 4,735 patients were treated by chiropractors with a loss of only 6 cases � a loss of one patient out of every 789.�
II.
�National figures show that 1,142 chiropractors treated 46,394 patients for influenza during 1918, with a loss of 54 patients � one out of every 886.�
�Reports show that in New York City, during the influenza epidemic of 1918, out of every 10,000 cases medically treated, 950 died; and in every 10,000 pneumonia cases medically treated 6,400 died. These figures are exact, for in that city these are reportable diseases.�
�In the same epidemic, under drugless methods, only 25 patients died of influenza out of every 10,000 cases; and only 100 patients died of pneumonia out of every 10,000 cases. This comparison is made more striking by the following table:�
Influenza Cases Deaths � Under medical methods � Under drugless methods �In the same epidemic reports show that chiropractors in Oklahoma treated 3,490 cases of influenza with only 7 deaths. But the best part of this is, in Oklahoma there is a clear record showing that chiropractors were called in 233 cases where medical doctors had cared for the patients, and finally gave them up as lost. The chiropractors saved all these lost cases but 25.�
�Statistics alone, however, don�t put in that little human element needed to spark the material properly. Dr. S. T. McMurrain [DC] had a makeshift table installed in the influenza ward in Base Hospital No. 84 unit stationed in Perigau, in Southwestern France, about 85 kilometers from Bordeaux [during WWI]. The medical officer in charge sent all influenza patients in for chiropractic adjustments from Dr. McMurrain [DC] for the several months the epidemic raged in that area. Lt. Col. McNaughton, the detachment commander, was so impressed he requested to have Dr. McMurrain [DC] commissioned in the Sanitary Corps.�
III.
�Dr. Paul Myers [DC] of Wichita Falls was pressed into service by the County Health Officer and authorized to write prescriptions for the duration of the epidemic there � but Dr. Myers [DC] said he never wrote any, getting better results without medication.�
Dr. Helen B. Mason [DC], whose �son, when only a year old, became very ill with bronchitis. My husband and I took him to several medical specialists without any worthwhile results. We called a chiropractor, as a last resort, and were amazed at the rapidity of his recovery. We discussed this amazing cure at length and came to the decision that if chiropractic could do as much for the health of other individuals as it had done for our son we wanted to become chiropractors.�
Dr. M. L. Stanphill [DC] recounts his experiences: �I had quite a bit of practice in 1918 when the flu broke out. I stayed (in Van Alstyne) until the flu was over and had the greatest success, taking many cases that had been given up and restoring them back to health. During the flu we didn�t have the automobile. I went horseback and drove a buggy day and night. I stayed overnight when the patients were real bad. When the rain and snow came I just stayed it out. There wasn�t a member of my family that had the flu.�
When he came to Denison he said: �I had a lot of trouble with pneumonia when I first came. Once again took all the cases that had been given up. C. R. Crabetree, who lived about 18 miles west of Denison, had double pneumonia and I went and stayed all night with him and until he came to the next morning. He is still living today. That gave me a boost on the west side of town.�
�And when interviews of the old timers are made it is evident that each still vividly remembers the 1917-1918 influenza epidemic. We now know about 20 million persons [recent estimates are as high as 100 million deaths] around the world died of the flu with about 500,000 Americans among that number. But most chiropractors and their patients were miraculously spared and we repeatedly hear about those decisions to become a chiropractor after a remarkable recovery or when a close family member given up for dead suddenly came back to vibrant health.�
�Some of these men and women were to become the major characters thrust upon the profession�s stage in the 20�s and 30�s and they had the courage, the background and the conviction to withstand all that would shortly be thrown against them� [including being thrown in jail for practicing medicine without a license].
�The publicity and reputation of such effectiveness in handling flu cases also brought new patients and much acclaim from people who knew nothing of chiropractic before 1918.�
IV.
�The first survival factor for chiropractic: they were the legal and legislative salvation. But the fabulous success of chiropractic in combating the 1917-1918 influenza outbreak was the public relations breakthrough that can certainly be called the second great survival factor. Better acceptance by the public followed and more patients meant financial safety for practicing chiropractors. Dedicated chiropractors came into the profession in increasing numbers and they had a sure sense of certainty, heady conviction, and a great willingness to fight for the cause.�
Other Texas Chiropractic History (view more at chirotexas.com)
1916 � Texas State Chiropractic Association Formed
1916 � First TSCA annual convention held at the St. Anthony Hotel in San Antonio
1917 � First chiropractic bill introduced into Texas Legislature
1923 � Second chiropractic bill introduced into Texas Legislature
In the last few decades, important puzzles of mainstream science have generated a re-evaluation of the nature of the world which goes far beyond anything we could have imagined. A more precise comprehension of the planet requires that we believe it is biologically centered.
It’s a very simple but wonderful notion that Biocentrism tries to clarify. Knowing this fully yields answers. This new version, blending physics and biology rather than keeping them separate, and placing observers to the equation, is called biocentrism. Its requirement is driven in part by the attempts to make a theory of everything, an overarching view.
What’s Biocentrism?
Biocentrism, in an ecological and political sense, as well as literally, is a moral standpoint that extends value that is inherent to all things. It’s an understanding of how the earth works as it relates to biodiversity. It stands in contrast to anthropocentrism, which centers only on humans value. The biocentrism extends value to the whole of nature.
The term biocentrism encompasses all environmental ethics that expand the standing of moral object from human beings to all living things in character. Ethics calls for a rethinking of the relationship between people and nature. It states that character does not exist only to be consumed or used by people, but that people are only one species among many, and that because we are a part of an ecosystem, any activities which negatively influence the living systems of which we’re a part adversely affect us as well, whether or not we maintain that a biocentric worldview.
Biocentrism and Human Health
Biocentrists endorse species’ equality. But is endorsing the equality of species compatible with maintaining the health of individuals, or should at least sometimes the health of humans be forfeited for the sake of other species? In the following guide, the compatibility of individual and biocentrism health is discussed in detail. It is asserted that maintaining the prestige of species is in no way in conflict. In fact, It can be additionally argued that there’s a relationship between the prerequisites for human well-being and the requirements of biocentrism.
Biocentrists are well known for their devotion to the equality of species. Yet if this dedication is to be defensible, it may be argued that it has to be understood by analogy with humans’ equality. Accordingly, just as we claim that people are equivalent, yet justifiably treat them otherwise, we ought to also have the ability to claim that all species are equal, yet justifiably treat them as such. In human ethics, there are interpretations which we give. Everybody is equally at liberty to pursue her or his own interests, but this allows us to always prefer ourselves to others, who are understood to be like competitions in a competitive match.
In fact, this belief �and how it could relate to human health and wellness can be closely correlated with the study of microbiology and it’s institution. Microbiology is a modern discipline intended to objectively study microorganisms, including pathogens and nonpathogens. Also, it can be argued that an exclusively biocentric microbiology is crucial for enhancing our understanding not only of the microbial world outside, but also that of our own guts, and our own species.
Since its birth, microbiology associated with biocentrism has been associated with human health and individual pursuits (e.g., cheese, yogurt, beer, wine, pickles, and recently fuel). Biology is largely microscopic; large plants, other animals that are macroscopic, and individuals are the exception. The simple fact that human eyes have a limited range shouldn’t stop individuals from embracing a realistic view of nature. Nevertheless, research institutions and funding agencies give priority to the analysis of microbes which interact with human health, the ones that make energy, or the ones that improve the taste and yield of individual foods, largely ignoring the vast majority of projected bacterial and archaeal cells on Earth.
The area of metagenomics has crossed the medical barrier, and it is becoming common to see that the gut and mouth microbiomes, by way of example, are being examined and explained similarly to those in other environments.
Biocentric microbiology helps us better understand pathogenesis. Classifying microbes into friends and foes, often preventing us from recognizing the main goal of each microbe, which will be not any different from the most important objective of every organism: survival. Biocentric microbiology will especially benefit genomics, phylogenomics evolutionary biology.
It may be argued that microbiology will progress fields associated with human health, including diagnostics, immunoprophylaxis, and therapeutics. The classical illustration of how diagnostics have profited from environmental microbiology is that the development of polymerase chain reaction (PCR)-based microbial analysis tools. PCR is essential in identifying and quantifying human pathogens, and is the only reliable method.
As with a variety of treatments and alternative care methods, biocentrism in the medical field can ultimately help health care professionals improve the well-being of humans simply from the understanding that the biology around us, by keeping it safe, can substantially help improve the overall health and wellness of human beings.
The scope of our information is limited to chiropractic and spinal injuries and conditions. To discuss options on the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .�
By Dr. Alex Jimenez
Additional Topics: Wellness
Overall health and wellness are essential towards maintaining the proper mental and physical balance in the body. From eating a balanced nutrition as well as exercising and participating in physical activities, to sleeping a healthy amount of time on a regular basis, following the best health and wellness tips can ultimately help maintain overall well-being. Eating plenty of fruits and vegetables can go a long way towards helping people become healthy.
Disclosures can be found in Additional Information at the end of the article
Background
Case reports and case control studies have suggested an association between chiropractic neck manipulation and cervical artery dissection (CAD), but a causal relationship has not been established. We evaluated the evidence related to this topic by performing a systematic review and meta-analysis of published data on chiropractic manipulation and CAD.
Methods
Search terms were entered into standard search engines in a systematic fashion. The articles were reviewed by study authors, graded independently for class of evidence, and combined in a meta-analysis. The total body of evidence was evaluated according to GRADE criteria.
Results
Our search yielded 253 articles. We identified two class II and four class III studies. There were no discrepancies among article ratings (i.e., kappa=1). The meta-analysis revealed a small association between chiropractic care and dissection (OR 1.74, 95% CI 1.26-2.41). The quality of the body of evidence according to GRADE criteria was “very low.”
Conclusions
The quality of the published literature on the relationship between chiropractic manipulation and CAD is very low. Our analysis shows a small association between chiropractic neck manipulation and cervical artery dissection. This relationship may be explained by the high risk of bias and confounding in the available studies, and in particular by the known association of neck pain with CAD and with chiropractic manipulation. There is no convincing evidence to support a causal link between chiropractic manipulation and CAD. Belief in a causal link may have significant negative consequences such as numerous episodes of litigation.
� Copyright 2016
Church et al. This is an open access article distributed under the terms of the Creative Commons Attribution License CC-BY 3.0., which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
How to cite this article
Church E W, Sieg E P, Zalatimo O, et al. (February 16, 2016) Systematic Review and Meta-analysis of Chiropractic Care and Cervical Artery Dissection: No Evidence for Causation. Cureus 8(2): e498. DOI 10.7759/cureus.498
Neck pain is a common complaint in physicians� and chiropractors� offices. Data from the Centers for Disease Control and from national surveys document 10.2 million ambulatory care visits for a neck problem in 2001 and 2002. By comparison, there were 11 million office-based visits for ischemic heart disease [1]. Many patients with neck pain seek chiropractic care and undergo cervical manipulation. As many as 12% of North Americans receive chiropractic care every year, and a majority of these are treated with spinal manipulation [2].
In contrast to the frequency of neck pain and chiropractic treatments, spontaneous cervical artery dissection (CAD) is rare. The annual incidence of internal carotid artery dissection has been estimated at 2.5�3 per 100,000 patients and that of vertebral artery dissection at 1�1.5 per 100,000 [3]. Stroke occurs in a small proportion of those with CAD, and its true incidence is difficult to estimate. Overall, dissection accounts for two percent of all ischemic strokes [4].
Case reports and case series of cervical dissection following manipulation have been published. Despite their rarity, these cases are frequently publicized for several reasons. Patients are often young and otherwise in good health. Dissection accounts for 10�25% of ischemic strokes in young and middle aged patients [4]. If dissection is caused by cervical manipulation it is potentially a preventable condition. Recent reports, including case control studies, have suggested an association between chiropractic neck manipulation and cervical dissection [5- 10]. Notably, a recent study from the American Heart Association evaluated the available evidence and concluded such an association exists [11]. This report did not include a meta- analysis, nor did it seek to classify studies and grade the body of evidence. We sought to examine the strength of evidence related to this question by performing a systematic review, meta-analysis, and evaluation of the body of evidence as a whole.
Materials & Methods
Search terms �chiropract*,� �spinal manipulation,� �carotid artery dissection,� �vertebral artery dissection,� and �stroke� were included in the search. We used the Medline and Cochrane databases. We additionally reviewed references of key articles for completeness. A librarian with expertise in systematic review was consulted throughout the search process.
Two study authors independently reviewed all articles (EC, ES). They selected any applicable studies for evaluation based on pre-specified inclusion and exclusion criteria. We included only human trials examining patients with carotid or vertebrobasilar artery dissection and recent chiropractic neck manipulation. We excluded non-English language studies. The articles were independently graded using the classification of evidence scheme adopted by the American Academy of Neurology [12-14]. A third author (MG) arbitrated any discrepancies in the class- of-evidence ratings for the included studies.
Data from all class II and III studies were included in a meta-analysis. A second meta-analysis excluding class III studies was also performed. The inverse variance method and a fixed effects model were employed. Additionally, we report results using a variable effects model. The analyses were performed using RevMan 5.3 software from the Cochrane Informatics and Knowledge Management Department. We did not compose a protocol for our review, although PRISMA and MOOSE methodologies were used throughout [15-16].
We evaluated the total body of evidence for quality using the GRADE system [17-20]. A final GRADE designation was achieved by consensus after discussions involving all study authors as recommended by GRADE guidelines. This system is designed to assess the total body of evidence rather than individual studies. The criteria include study design, risk of bias, inconsistency, indirectness, imprecision, publication bias, effect size, dose response, and all plausible residual confounding. Four possible final designations are specified: high, moderate,�low, and very low quality.
Results
Results of the systematic review
Our search strategy yielded 253 articles. Seventy-seven were judged by all reviewers to be non- relevant. Four articles were judged to be class III studies, and two were rated class II. There were no discrepancies between the independent ratings (i.e., kappa=1). Studies rated class III or higher are listed in Table 1. Figure 1 outlines our process of selecting studies for inclusion in the meta-analysis.
Meta-Analysis
Combined data from class II and III studies suggests an association between dissection and chiropractic care, OR 1.74, 95% CI 1.26-2.41 (Figure 2). The result was similar using a random effects model, OR 4.05, 95% CI 1.27-12.91. We did not include the study by Rothwell et al. because it describes a subset of patients in the study by Cassidy et al. [5,8]. There was considerable heterogeneity among the studies (I2=84%).
We repeated the meta-analysis excluding class III studies. The combined effect size was again indicative of a small association between dissection and chiropractic care, OR 3.17, 95% CI 1.30-7.74). The result was identical when using a random effects model.
Class II Studies
Smith et al. used a retrospective case control design, combining databases from two academic stroke centers to identify cases of arterial dissection [9]. They found 51 cases and 100 controls. Exposure to spinal manipulative therapy (SMT) was assessed by mail survey. The authors reported an association between SMT and VBA (P = .032). In multivariate analysis, chiropractor care within 30 days was associated with VBA, even when adjusting for neck pain or headache (OR 6.6, 95% CI 1.4-30). While this study controlled for possible confounders such as neck pain, there were several limitations. Head and neck pain as well as chiropractor visit were assessed in a retrospective fashion by mail survey, very possibly introducing both recall and survivor bias. The reason for reporting to the chiropractor (e.g., trauma) was not assessed. Further, there was significant variability among diagnostic procedures, which may reflect increased motivation by physicians to rule out dissection in patients with a history of SMT. Such motivation could result in interviewer bias.
Dittrich et al. compared 47 patients with CAD to a control group with stroke due to etiologies other than dissection [6]. They assessed for risk factors using a face-to-face interview with blinding. These authors found no association between any individual risk factor and CAD, including cervical manipulative therapy. They blame the small sample size for the negative result, and they point out that cumulative analysis of all mechanical risk factors <24 hours prior to symptom onset showed an association (P = .01). This study is subject to recall bias.
Class III Studies
Rothwell et al. used a retrospective case control design to test for an association between chiropractic manipulation and vertebrobasilar accidents (VBA) [8]. They reviewed Ontario hospital records for admissions for VBA from 1993�1998. There were 582 cases and 2328 matching controls. The authors report an association between VBA and visit to a chiropractor within one week (OR 5.03, 95% CI 1.32-43.87), but this was only true for young patients (<45 years). This study represented the first attempt to delineate the association between chiropractic manipulation and extremely rare VBA with controls. Limitations included requisite use of ICD-9 codes to identify cases and associated classification bias, as well as potential unmeasured confounders (e.g., neck pain).
In 2008, Cassidy et al. set out to address the problem of neck pain possibly confounding the association between chiropractic care and VBA [5]. Again using a retrospective case control design, they included all residents of Ontario over a period of 9 years (1993�2002, 109,020,875 person years of observation). They identified 818 VBA strokes resulting in hospitalization and randomly selected age and sex matched controls. Next, they examined ambulatory encounters with chiropractors and primary care physicians (PCPs) in the one year preceding the stroke, limited to cervical manipulation, neck pain, and headache. Associations between chiropractor visit and VBA versus PCP visits and VBA were compared. Indeed, there were associations between both chiropractor visit and VBA (<45yrs OR 1.37, 95% CI 1.04-1.91), and PCP visit and VBA (<45 yrs OR 1.34, 95% CI .94-1.87; >45 yrs and OR 1.53, 95% CI 1.36-1.67). The association for chiropractor visit was not greater than for PCP visit. This data was interpreted as evidence that a confounder such as neck pain may account for the association between chiropractor visit and VBA. This study was subject to many of the same limitations as previous efforts. Canadian health records would not reveal whether a patient with cervical complaints underwent cervical manipulation, and the researchers could not review each chart for imaging confirming dissection. Additionally, the incidence of comorbidities (e.g., hypertension, heart disease,�diabetes) was significantly higher among cases as compared to controls, and we are concerned that these differences were non-random.
In another case control study, Thomas et al. compared the records of 47 patients with confirmed or suspected vertebral or internal carotid artery dissection with 43 controls [10]. They limited their analysis to young patients defined as <55 years. These authors report a significant association between dissection and recent head or neck trauma (OR 23.51, 95% CI 5.71-96.89) as well as neck manual therapy (OR 1.67, 95% CI 1.43-112.0). An inconsistent standard for case ascertainment (a significant number of patients lacked radiographic confirmation of dissection) and lack of blinding weaken this study.
Engelter et al. evaluated data from the Cervical Artery Dissection and Ischemic Stroke Patients (CADISP) consortium, identifying 966 patients with CAD, 651 with stroke attributable to another cause, and 280 healthy controls [7]. The CADISP study involved both prospectively and retrospectively collected data at multiple centers in several countries. They assessed for prior cervical trauma within one month using questionnaires administered during clinic visits. Cervical manipulation therapy was more common for CAD versus stroke from another cause (OR 12.1, CI 4.37-33.2). The report notes that an association between any trauma and CAD was present even when restricting the analysis to prospectively recruited patients. However, in patients to whom the questionnaire was administered after dissection, recall bias may have been at work whether or not the patient was enrolled prospectively. Indeed, the frequency of prior cervical trauma in this study was substantially higher than previous reports (40% versus 12-34%). Additional weaknesses include a highly heterogeneous standard for case definition and no clear masking procedures.
Body Of Evidence Quality (GRADE Rating)
Having performed a systematic review and rated articles according to their individual strengths and weaknesses, we graded the overall body of evidence using the system proposed by Guyatt et al. [17-20]. The GRADE approach to rating quality of evidence proposes four categories that are applied to a body of evidence: high, moderate, low, and very low. In the setting of systematic review, a particular rating reflects the extent of confidence that the estimates of effect are correct. The GRADE approach begins with study design and sequentially examines features with the potential to enhance or diminish confidence in the meta-analytic estimate of effect size.
Our final assessment of the quality of the body of evidence using these criteria was very low. The initial rating based on study design was low (observational studies). Given the controversial nature of this topic and the legal ramifications of results, there is certainly potential for bias (-1 serious). However, blinding in the Class II studies mitigated this risk to some extent. Inconsistency and imprecision did not lower our rating. Because the body of evidence is derived from measures of association, the rating was lowered for indirectness (-1 serious). Publication bias is less likely because of the impact of a negative result in this case. The funnel plot from our meta-analysis was inconclusive with regard to possible publication bias because of the small number of studies included but suggested a deficit in the publication of small negative trials. There was not a large effect size, and currently there is no evidence for a dose response gradient. Moreover, the most worrisome potential confounder (neck pain) would increase rather than reduce the hypothesized effect.
Discussion
The results of our systematic review and meta-analysis suggest a small association between chiropractic care and CAD. There are no class I studies addressing this issue, and this conclusion is based on five class II and III studies. Scrutiny of the quality of the body of data�using the GRADE criteria revealed that it fell within the �very low� category. We found no evidence for a causal link between chiropractic care and CAD. This is a significant finding because belief in a causal link is not uncommon, and such a belief may have significant adverse effects such as numerous episodes of litigation.
The studies included in our meta-analysis share several common weaknesses. Two of the five studies used health administrative databases, and since conclusions depend on accurate ICD coding, this technique for case ascertainment may introduce misclassification bias. It is not possible to account for the type of spinal manipulation that may have been used. Retrospective collection of data is also a potential weakness and may introduce recall bias when a survey or interview was used. Moreover, patients arriving at a hospital complaining of neck pain and describing a recent visit to a chiropractor may be subject to a more rigorous evaluation for CAD (interviewer bias). Another potential source of interviewer bias was lack of blinding in the class III studies. Further, we noted substantial variability among diagnostic procedures performed. All of these weaknesses affect the reliability of the available evidence and are not �corrected� by performing a meta-analysis.
Perhaps the greatest threat to the reliability of any conclusions drawn from these data is that together they describe a correlation but not a causal relationship, and any unmeasured variable is a potential confounder. The most likely potential confounder in this case is neck pain. Patients with neck pain are more likely to have CAD (80% of patients with CAD report neck pain or headache) [21], and they are more likely to visit a chiropractor than patients without neck pain (Figure 3). Several of the studies identified in our systematic review provide suggestive evidence that neck pain is a confounder of the apparent association between chiropractic neck manipulation and CAD. For example, in Engelter et al. patients with CAD and prior cervical trauma (e.g., cervical manipulation therapy) were more likely to present with neck pain but less often with stroke than those with CAD and no prior cervical trauma (58% vs. 43% for trauma and 61% vs. 69% for stroke) [7]. If patients with CAD without neurological symptoms came to medical attention, it was probably because of pain. Patients with neck pain would also be more likely to visit a chiropractor than those without neck pain.
Cassidy et al. hypothesized that, although an association between chiropractor visits and vertebrobasilar artery stroke is present, it may be fully explained by neck pain and headache [5]. These authors reviewed 818 patients with vertebrobasilar artery strokes hospitalized in a population of 100 million person-years. They compared chiropractor and PCP visits in this population and reported no significant difference between these associations. For patients under 45 years of age, each chiropractor visit in the previous month increased the risk of stroke (OR 1.37, 95% CI 1.04-1.91), but each PCP visit in the previous month increased the risk in a nearly identical manner (<45 yrs OR 1.34, 95% CI .94-1.87; >45 yrs and OR 1.53, 95% CI 1.36- 1.67). The authors conclude that, since patients with vertebrobasilar stroke were as likely to visit a PCP as they were to visit a chiropractor, these visits were likely due to pain from an existing dissection.
Cervical artery dissection is a rare event, creating a significant challenge for those who wish to understand it. A prospective, randomized study design is best suited to control for confounders, but given the infrequency of dissection, performing such a study would be logistically and also ethically challenging. Sir Austin Bradford Hill famously addressed the problem of assigning causation to an association with the application of nine tests [22]. These criteria include strength, consistency, specificity, temporality, biological gradient, plausibility, coherence, experimental evidence, and analogy. The specific tests and our assessment for the association between cervical manipulation and CAD are summarized in Table 2. In our appraisal, this association clearly passes only one test, it fails four, and the remaining four are equivocal due to absence of relevant data [23]. Further, a 2013 assessment of the quality of reports of cervical arterial dissection following cervical spinal manipulation similarly found lacking data to support a causal relationship [24].
In spite of the very weak data supporting an association between chiropractic neck manipulation and CAD, and even more modest data supporting a causal association, such a relationship is assumed by many clinicians. In fact, this idea seems to enjoy the status of medical dogma. Excellent peer reviewed publications frequently contain statements asserting a causal relationship between cervical manipulation and CAD [4,25,26]. We suggest that physicians should exercise caution in ascribing causation to associations in the absence of adequate and reliable data. Medical history offers many examples of relationships that were initially falsely assumed to be causal [27], and the relationship between CAD and chiropractic neck manipulation may need to be added to this list.
Conclusions
Our systematic review revealed that the quality of the published literature on the relationship between chiropractic manipulation and CAD is very low. A meta-analysis of available data shows a small association between chiropractic neck manipulation and CAD. We uncovered evidence for considerable risk of bias and confounding in the available studies. In particular, the known association of neck pain both with cervical artery dissection and with chiropractic manipulation may explain the relationship between manipulation and CAD. There is no convincing evidence to support a causal link, and unfounded belief in causation may have dire consequences.
Additional Information
Disclosures
Conflicts of interest: The authors have declared that no conflicts of interest exist.
Acknowledgements
The authors wish to thank Elaine Dean, MLS, of the Penn State Hershey Medical Center George T. Harrell Health Sciences Library, for her assistance with the systematic review.
References
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25. Albuquerque FC, Hu YC, Dashti SR, et al.: Craniocervical arterial dissections as sequelae of chiropractic manipulation: patterns of injury and management. J Neurosurg. 2011, 115:1197�1205. 10.3171/2011.8.JNS111212
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Ephraim W. Church 1 , Emily P. Sieg 1 , Omar Zalatimo 1 , Namath S. Hussain 1 , Michael Glantz 1 , Robert E. Harbaugh 1
1. Department of Neurosurgery, Penn State Hershey Medical Center
Corresponding author: Ephraim W. Church, echurch@hmc.psu.edu
Results Of A Population-Based Case-Control & Case-Crossover Study
J. David Cassidy, DC, PhD, DrMedSc,*�� Eleanor Boyle, PhD,* Pierre Co�te ?, DC, PhD,*��� Yaohua He, MD, PhD,* Sheilah Hogg-Johnson, PhD,�� Frank L. Silver, MD, FRCPC, and Susan J. Bondy, PhD�
SPINE Volume 33, Number 4S, pp S176 �S183 �2008, Lippincott Williams & Wilkins
Neck pain is a common problem associated with consid- erable comorbidity, disability, and cost to society.1�5 In North America, the clinical management of back pain is provided mainly by medical physicians, physi- cal therapists and chiropractors.6 Approximately 12% of American and Canadian adults seek chiropractic care annually and 80% of these visits result in spinal manipulation.7,8 When compared to those seeking medical care for back pain, Canadian chiropractic pa- tients tend to be younger and have higher socioeco- nomic status and fewer health problems.6,8 In On- tario, the average number of chiropractic visits per episode of care was 10 (median 6) in 1985 through 1991.7 Several systematic reviews and our best- evidence synthesis suggest that manual therapy can benefit neck pain, but the trials are too small to eval- uate the risk of rare complications.9 �13
Two deaths in Canada from vertebral artery dissection and stroke following chiropractic care in the 1990s attracted much media attention and a call by some neurologists to avoid neck manipulation for acute neck pain.14 There have been many published case reports linking neck manipulation to vertebral artery dissection15�and stroke.�The prevailing theory is that extension�and/or rotation of the neck can damage the vertebral artery, particularly within the foramen transversarium at the C1�C2 level. Activities leading to sudden or sustained rotation and extension of the neck have been implicated, included motor vehicle collision, shoulder checking while driving, sports, lifting, working over- head, falls, sneezing, and coughing.16 However, most cases of extracranial vertebral arterial dissection are thought to occur spontaneously, and other factors such as connective tissue disorders, migraine, hyper- tension, infection, levels of plasma homocysteine, vessel abnormalities, atherosclerosis, central venous�catherization, cervical spine surgery, cervical percutaneous nerve blocks, radiation therapy and diagnostic cerebral angiography have been identified as possible risk factors.17�21
The true incidence of vertebrobasilar dissection is un- known, since many cases are probably asymptomatic, or the dissection produces mild symptoms.22 Confirming the diagnosis requires a high index of suspicion and good vascular imaging. The cases that are most likely to be diagnosed are those that result in stroke.19,22 Ischemic stroke occurs when a thrombus develops intraluminally and embolizes to more distal arteries, or less commonly, when the dissection extends distally into the intracranial vertebral artery, obliterating branching vessels.22 The best incidence estimate comes from Olmstead county, where vertebral artery dissection causing stroke affected 0.97 residents per 100,000 population between 1987 and 2003.23
To date there have been two case-control studies of stroke following neck manipulation. Rothwell et al used Ontario health data to compare 582 cases of VBA stroke to 2328 age and sex-matched controls.24 For those aged 45 years, cases were five times more likely than con- trols to have visited a chiropractor within 1 week of VBA stroke. Smith et al studied 51 patients with cervical ar- tery dissection and ischemic stroke or transient ischemic attack (TIA) and compared them to 100 control patients suffering from other strokes not caused by dissections.25 Cases and controls came from two academic stroke cen- ters in the United States and were matched on age and sex. They found no significant association between neck manipulation and ischemic stroke or TIA. However, a subgroup analysis showed that the 25 cases with verte- bral artery dissection were six times more likely to have consulted a chiropractor within 30 days before their stroke than the controls.
Finally, because patients with vertebrobasilar artery dissection commonly present with headache and neck pain,23 it is possible that patients seek chiropractic care for these symptoms and that the subsequent VBA stroke occurs spontaneously, implying that the associ- ation between chiropractic care and VBA stroke is not causal.23,26 Since patients also seek medical care for headache and neck pain, any association between pri- mary care physician (PCP) visits and VBA stroke could be attributed to seeking care for the symptoms of verte- bral artery dissection.
The purpose of this study is to investigate the association between chiropractic care and VBA stroke and compare it to the association between recent PCP care and VBA stroke using two epidemiological designs. Evidence that chiropractic care increases the risk of VBA stroke would be present if the measured association between chiropractic visits and VBA stroke exceeds the association between PCP visits and VBA strokes.
Study Design
We undertook population-based case-control and case- crossover studies. Both designs use the same cases. In the case- control design, we sampled independent control subjects from the same source population as the cases. In the case-crossover design, cases served as their own controls, by sampling control periods before the study exposures.27 This design is most appropriate when a brief exposure (e.g., chiropractic care) causes a transient change in risk (i.e., hazard period) of a rare-onset disease (e.g., VBA stroke). It is well suited to our research questions, since within person comparisons control for unmeasured risk factors by design, rather than by statistical modeling.28 �30 Thus the advantage over the case control design is better control of confounding.
Source Population
The source population included all residents of Ontario (109,020,875 person-years of observation over 9 years) covered by the publicly funded Ontario Health Insurance Plan (OHIP). Available utilization data included hospitalizations with diagnostic coding, and practitioner (physician and chiropractic) utilization as documented by fee-for-service billings accompanied by diagnostic coding. We used two data sources: (1) the Discharge Abstract Database (DAD) from the Canadian Institute for Health Information, which captures hospital separations and ICD codes, and (2) the OHIP Databases for services provided by physicians and chiropractors. These data- bases can be linked from April 1992 onward.
Cases
We included all incident vertebrobasilar occlusion and stenosis strokes (ICD-9433.0 and 433.2) resulting in an acute care hospital admission from April 1, 1993 to March 31, 2002. Codes were chosen in consultation with stroke experts and an epidemiologist who participated in a similar past study (SB).24 Cases that had an acute care hospital admission for any type of stroke (ICD-9433.0, 433.2, 434, 436, 433.1, 433.3, 433.8, 433.9, 430, 431, 432, and 437.1), transient cerebral ischemia (ICD- 9435) or late effects of cerebrovascular diseases (ICD-9438) before their VBA stroke admission or since April 1, 1991 were excluded. Cases residing in long-term care facilities were also excluded. The index date was defined as the hospital admission date for the VBA stroke.
Controls
For the case-control study, four age and sex-matched controls were randomly selected from the Registered Persons Database, which contains a listing of all health card numbers for Ontario. Controls were excluded if they previously had a stroke or were residing in a long-term care facility.
For the case crossover study, four control periods were randomly chosen from the year before the VBA stroke date, using a time-stratified approach.31 The year was divided into disjoint strata with 2 week periods between the strata. For the 1 month hazard period, the disjoint strata were separated by 1 month periods and the five remaining control periods were used in the analyses. We randomly sampled disjoint strata because chiropractic care is often delivered in episodes, and this strategy eliminates overlap bias and bias associated with time trends in the exposure.32
Exposures
All reimbursed ambulatory encounters with chiropractors and PCPs were extracted for the one-year period before the index date from the OHIP database. Neck-related chiropractic visits were identified using diagnostic codes: C01�C06, cervical and cervicothoracic subluxation; C13�C15, multiple site subluxation; C30, cervical sprain/strain; C40, cervical neuritis/ neuralgia; C44, arm neuritis/neuralgia; C50, brachial radiculitis; C51, cervical radiculitis; and C60, headache. For PCP visits, we included community medicine physicians if they submitted ambulatory fee codes to OHIP. Fee codes for group therapy and signing forms were excluded. Headache or neck pain- related PCP visits were identified using the diagnostic codes: ICD-9307, tension headaches; 346, migraine headaches; 722, intervertebral disc disorders; 780, headache, except tension headache and migraine; 729, fibrositis, myositis and muscular rheumatism; and 847, whiplash, sprain/strain and other traumas associated with neck (These codes include other diagnoses, and we list only those relevant to neck pain or headache). There is no limit on the number of reimbursed PCP visits per year. However, there are limits chiropractors, but less than 15% of patients surpass them.24
Statistical Analysis
Conditional logistic regression was used to estimate the asso- ciation between VBA stroke after chiropractor and PCP visits. Separate models were built using different a priori specified hazard periods, stratified by age ( 45 years and 45 years) and by visits with or without head and neck pain related diag- nostic codes. For the chiropractic analysis, the index date was included in the hazard period, since chiropractic treatment might cause immediate stroke and patients would not normally consult a chiropractor after having a stroke. However, the in- dex day was excluded from the PCP analysis, since patients might consult these physicians after experiencing a stroke. We tested different hazard periods, including 1 day, 3 days, 1 week, 2 weeks, and 1 month before the index date. Exposure occurred if any chiropractic or PCP visits were recorded during the des- ignated hazard periods.
We also measured the effect of cumulative numbers of chiropractic and PCP visits in the month before the index date by computing the odds ratio for each incremental visit. These estimates were similarly stratified by age and by diagnostic codes related to headache and/or neck pain. Finally, we conducted analyses to determine if our results were sensitive to chiropractic and PCP visits related to neck complaints and headaches. We report our results as odds ratios (OR) and 95% confidence intervals. Confidence intervals were estimated by accelerated bias corrected bootstraps with 2000 replications using the variance co-variance method.33 All statistical analyses were per- formed using STATA/SE version 9.2.34
Results
A total of 818 VBA strokes met our inclusion/exclusion criteria over the 9 year inception period. Of the 3272 matched control subjects, 31 were excluded because of prior stroke, one had died before the index date and 76 were receiving long-term care. Thus, 3164 control subjects were matched to the cases. The mean age of cases and controls was 63 years at the index date and 63% were male. Cases had a higher proportion of comorbid conditions (Table 1). Of the 818 stroke cases, 337�(41.2%) were coded as basilar occlusion and stenosis, 443 (54.2%) as vertebral occlusion and stenosis and 38 (4.7%) had both codes.
Overall, 4% of cases and controls had visited a chiropractor within 30 days of the index date, while 53% of cases and 30% of controls had visited a PCP within that time (Table 2). For those under 45 years of age, 8 cases (7.8%) had consulted a chiropractor within 7 days of the index date, compared to 14 (3.4%) of controls. For PCPs, 25 cases (24.5%) under 45 years of age had a consultation within 7 days of the index date, com- pared to 27 (6.6%) of controls. With respect to the number of visits within 1 month of the index date, 7.8% of cases under the age of 45 years had three or more chiropractic visits, whereas 5.9% had three or more PCP visits (Table 2).
The case control and case crossover analyses gave similar results. (Tables 3�7) Age modified the effect of chiropractic visits on the risk of VBA stroke. For those under 45 years of age, there was an increased association between chiropractic visits and VBA stroke regardless of the hazard period. For those 45 years of age and older, there was no association. Each chiropractic visit in the month before the index date was associated with an in- creased risk of VBA stroke in those under 45 years of age (OR 1.37; 95% CI 1.04�1.91 from the case crossover analysis) (Table 7). We were not able to estimate boot- strap confidence intervals in some cases because of sparse data.
Similarly, we found that visiting a PCP in the month before the index date was associated with an increased risk of VBA stroke regardless of the hazard period, or the age of the subject. Each PCP visit in the month before the stroke was associated with an increased risk of VBA stroke both in those under 45 years of age (OR 1.34; 95% CI 0.94 �1.87 from the case crossover analysis) and 45 years and older (OR 1.52; 95% CI 1.36�1.67 from the case crossover analysis) (Table 7).
Our results were sensitive to chiropractic and PCP visits related to neck complaints and headaches, and we observed sharp increases in the associations when restricting the analyses to these visits (Tables 3�7). Overall,�these associations were more pronounced in the PCP analyses. However, the data are sparse, and we were unable to compute bootstrap confidence intervals in many cases.
Discussion
Our study advances knowledge about the association between chiropractic care and VBA stroke in two respects. First, our case control results agree with past case control studies that found an association between chiropractic care and vertebral artery dissection and VBA stroke.24,25 Second, our case crossover results confirm these findings using a stronger research design with better control of confounding variables. The case-crossover design controls for time independent confounding factors, both known and unknown, which could affect the risk of VBA stroke. This is important since smoking, obesity, undiagnosed hypertension, some connective tis- sue disorders and other important risk factors for dissection and VBA stroke are unlikely to be recorded in ad- ministrative databases.
We also found strong associations between PCP visits and subsequent VBA stroke. A plausible explanation for this is that patients with head and neck pain due to vertebral artery dissection seek care for these symptoms, which precede more than 80% of VBA strokes.23 Since it�is unlikely that PCPs cause stroke while caring for these patients, we can assume that the observed association between recent PCP care and VBA stroke represents the background risk associated with patients seeking care for dissection-related symptoms leading to VBA stroke. Be- cause the association between chiropractic visits and VBA stroke is not greater than the association between PCP visits and VBA stroke, there is no excess risk of VBA stroke from chiropractic care.
Our study has several strengths and limitations. The study base includes an entire population over a 9-year period representing 109,020,875 person-years of observation. Despite this, we found only 818 VBA strokes, which limited our ability to compute some estimates and bootstrap confidence intervals. In particular, our age stratified analyses are based on small numbers of ex- posed cases and controls (Table 2). Further stratification by diagnostic codes for headache and neck pain related visits imposed even greater difficulty with these estimates. However, there are few databases that can link�incident VBA strokes with chiropractic and PCP visits in a large enough population to undertake a study of such a rare event.
A major limitation of using health administrative data are misclassification bias, and the possibility of bias in assignment of VBA-related diagnoses, which has previously been raised in this context.24 Liu et al have shown that ICD-9 hospital discharge codes for stroke have a poor positive predictive value when compared to chart review.35 Furthermore, not all VBA strokes are secondary to vertebral artery dissection and administrative databases do not provide the clinical detail to determine the specific cause. To investigate this bias, we did a sensitivity analysis using different positive predictive values for stroke diagnosis (ranging from 0.2 to 0.8). Assuming non differential misclassification of chiropractic and PCP cases, our analysis showed attenuation of the estimates towards the null with lower positive predictive values, but the conclusions did not change (i.e., associations remained positive and significant�data not shown). The�reliability and validity of the codes to classify headache and cervical visits to chiropractors and PCPs is not known.
It is also possible that patients presenting to hospital with neurologic symptoms who have recently seen a chiropractor might be subjected to a more vigorous diagnostic workup focused on VBA stroke (i.e., differential misclassification).36 In this case, the predictive values of the stroke codes would be greater for cases that had seen a chiropractor and our results would underestimate the association between PCP care and VBA stroke.
A major strength of our study is that exposures were measured independently of case definition and handled identically across cases and controls. However, there was some overlap between chiropractic care and PCP care. In the month before their stroke, only 16 (2.0%) of our cases had seen only a chiropractor, while 20 (2.4%) had seen both a chiropractor and PCP, and 417 (51.0%) had�just seen only a PCP. We were not able to run a subgroup analysis on the small number of cases that just saw a chiropractor. However, subgroup analysis on the PCP cases (n 782) that did not visit a chiropractors during the 1 month before their stroke did not change the conclusions (data not shown).
Our results should be interpreted cautiously and placed into clinical perspective. We have not ruled out neck manipulation as a potential cause of some VBA strokes. On the other hand, it is unlikely to be a major cause of these rare events. Our results suggest that the association between chiropractic care and VBA stroke found in previous studies is likely explained by present- ing symptoms attributable to vertebral artery dissection. It might also be possible that chiropractic manipulation, or even simple range of motion examination by any practitioner, could result in a thromboembolic event in a patient with a pre-existing vertebral dissection. Unfortunately, there is no acceptable screening procedure to identify patients with neck pain at risk of VBA stroke.37 These events are so rare and difficult to diagnose that future studies would need to be multi-centered and have unbiased ascertainment of all potential exposures. Given our current state of knowledge, the decision of how to treat patients with neck pain and/or headache should be driven by effectiveness and patient preference.38
Conclusion
Our population-based case-control and case-crossover study shows an association between chiropractic visits and VBA strokes. However, we found a similar association between primary care physician visits and VBA stroke. This suggests that patients with undiagnosed vertebral artery dissection are seeking clinical care for head- ache and neck pain before having a VBA stroke.
Acknowledgments
The authors acknowledge the members of the Decade of the Bone and Joint 2000 �2010 Task Force on Neck Pain and its Associate Disorders for advice about de- signing this study. In particular, they acknowledge the help of Drs. Hal Morgenstern, Eric Hurwitz, Scott Haldeman, Linda Carroll, Gabrielle van der Velde, Lena Holm, Paul Peloso, Margareta Nordin, Jaime Guzman, Eugene Carragee, Rachid Salmi, Alexander Grier, and Mr. Jon Schubert.
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From the *Centre of Research Expertise for Improved Disability Outcomes (CREIDO), University Health Network Rehabilitation Solutions, Toronto Western Hospital, and the Division of Heath Care and Outcomes Research, Toronto Western Research Institute, Toronto, ON, Canada; �Department of Public Health Sciences, Management and Evaluation, University of Toronto, Toronto, ON, Canada; �Department of Health Policy, Management and Evalua- tion, University of Toronto, Toronto, ON, Canada; �Institute for Work & Health, Toronto, ON, Canada; �University Health Net- work Stroke Program, Toronto Western Hospital, Toronto, ON, Canada; and Division of Neurology, Department of Medicine, Fac- ulty of Medicine, University of Toronto, Toronto, ON, Canada. Supported by Ontario Ministry of Health and Long-term Care. P.C. is supported by the Canadian Institute of Health Research through a New Investigator Award. S.H.-J. is supported by the Institute for Work & Health and the Workplace Safety and Insurance Board of Ontario. The opinions, results, and conclusions are those of the authors and no endorsement by the Ministry is intended or should be inferred.
The manuscript submitted does not contain information about medical device(s)/drug(s).
University Health Network Research Ethics Board Approval number 05-0533-AE.
Address correspondence and reprint requests to J. David Cassidy, DC, PhD, DrMedSc, Toronto Western Hospital, Fell 4-114, 399 Bathurst Street, Toronto, ON, Canada M5T 2S8; E-mail: dcassidy@uhnresearch.ca
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