Good Night’s: Feeling stressed at work can lead to us reaching for unhealthy snacks and extra portions, but a new study has found that getting enough sleep could help buffer the negative effect of stress on eating habits.
Carried out by a team of researchers from Michigan State University, the University of Illinois, the University of Florida, and Auburn University in the US, along with Sun Yat-sen University in China, the study is one of the first to look at how psychological experiences at work can affect eating behaviors.
The team looked at two studies of 235 total workers in China who experienced regular stress in their jobs.
One study included IT employees who had a high workload and felt there was never enough time in the workday, while the second included call-center workers who experienced stress from dealing with rude and demanding customers.
The researchers found that in both studies employees who had a stressful workday also had a tendency to take these negative feelings home with them, and to the dinner table, leading to them eating more than usual and make unhealthier food choices.
However, the study also showed that sleep could be a way to buffer this effect of stress on unhealthy eating, with the team finding that employees who got a good night’s sleep the night before tended to eat better the next day after a stressful day at work.
Yihao Liu, co-author and assistant professor at the University of Illinois gave two possible explanations for the findings.
“First,�eating is sometimes used as an activity to relieve and regulate one’s negative mood, because individuals instinctually avoid aversive�feelings�and approach desire feelings,” he said.
“Second, unhealthy eating can also be a consequence of diminished self-control. When feeling stressed out by work, individuals usually experience inadequacy�in exerting effective control over their cognitions and behaviors to be aligned�with personal goals and social norms.”
Chu-Hsiang “Daisy” Chang, MSU associate professor of psychology and study co-author, also commented that the findings that sleep has a protective effect against unhealthy food habits shows how the three health behaviours of sleep, stress, and eating are related.
“A good night’s sleep can make workers replenished and feel vigorous again, which may make them better able to deal with stress at work the next day and less vulnerable�to unhealthy eating,” she explained.
The team now believe that companies should take into consideration the importance of sleep and healthy behaviors and think about providing sleep-awareness training and flexible scheduling for employees, as well as rethinking�food-related job perks, which have become very common.
“Food-related�perks may only serve as temporary mood-altering remedies�for stressed employees,” Chang said, “and failure to address the sources of the�work�stress�may have potential long-term detrimental effects on�employee�health.”
The findings were published in the�Journal of Applied Psychology.
Gray hair could be an early warning sign of heart disease. Hiccups that won’t go away may foreshadow cancer. Sometimes your body sends seemingly unrelated signals that something is wrong.
Since the key to treating most health problems is to catch them early, it can pay off big time to spot the tip-offs. And the first thing to check out is your skin.
“Skin is the only organ of the body that you wear on the outside,” says dermatologist Dr. Robert Brodell. “Since it’s connected to internal organs through blood vessels, nerves and other things, it can be like a window to see what’s going on inside.”
Here are 10 symptoms and what they may really mean:
Rash on shins: Formally called necrobiosis lipoidica diabeticorum (NLD), a raised red-brown patch with yellow blotches could mean that you have diabetes or are poised to get it. “Sometimes we see this in patients and know they are diabetic before they know it themselves,” says Brodell, chairman of the dermatology department at the University of Mississippi Medical Center. “In some cases, their blood sugar is normal, but over the next six months to two years, they develop diabetes.”
Splinter hemorrhages: They look like thin red splinters running lengthwise under fingernails and could be caused by endocarditis, a bacterial infection of the heart valves. “You wouldn’t think that someone looking at fingernails could detect what could be a significant heart problem,” Brodell tells Newsmax Health.
Rash on eyelids: This violet-hued rash is a symptom of dermatomyositis, an inflammatory muscle disease that is associated with various forms of cancer, most commonly ovarian. Other symptoms include raised scaly bumps on knuckles and ragged cuticles that separate from the nail.
Skin discoloration: The most common is jaundice, a yellowing of the skin that is a classic symptom of hepatitis and other liver conditions. Less known is a darkening of the skin in creases and old scars that may indicate an adrenal gland problem, such as Addison’s disease.
Tender nodules on shins: A condition called erythema nodosum is marked by red swollen bumps on the front of the legs. Brodell says that while they are sometimes a reaction to medications or oral contraceptives, they could also be a warning of the inflammatory pulmonary disease sarcoidosis.
Persistent hiccups: For most of us, this spasm of the diaphragm is an annoying but harmless problem. But when hiccups last two days or more, they could be an early warning sign of deadly esophageal cancer.
Shoplifting: If your elderly mom or dad starts getting sticky fingers, it could be a sign of a certain type of dementia. A study published in the Journal of the American Medical Association’s Neurology details how people with frontotemporal dementia lose their sense of societal conventions and may take items in shops without paying for them.
Color blindness: The inability to distinguish between different hues is a sign of Parkinson’s disease. Other odd symptoms of the neurological disorder are writing smaller and swimming in circles.
Earlobe wrinkle: A diagonal crease in one or both earlobes has long been linked to heart disease. Also called “Frank’s sign” after Dr. Sanders T. Frank, the physician who first made the association, this odd symptom has been supported in several studies, though no one has yet to figure out why.
Gray hair: A touch of gray is another early warning sign of cardiovascular problems, regardless of age and other factors, according to a recent study by Egyptian researchers. Heart disease in general can generate several seemingly unrelated symptoms, including bleeding gums, swollen feet, frequent urination at night, uncontrollable head bobbing, yellow spots on eyelids…and the list goes on.
“The reason that heart disease has so many varied symptoms may be because there are many types of heart disease that will present in different ways,” explains Dr. Richard Greenberg, a cardiologist at Temple University Hospital in Philadelphia, Pa. “Another reason is that the circulatory system is connected to every cell in the body, so it follows that symptoms of heart disease could show up anywhere.”
When it comes to stomach discomfort during exercise, forget that old adage “no pain, no gain.” New research suggests that excessive strenuous exercise may lead to gut damage.
“The stress response of prolonged vigorous exercise shuts down gut function,” said lead author Ricardo Costa.
“The redistribution of blood flow away from the gut and towards working muscles creates gut cell injury that may lead to cell death, leaky gut, and systemic immune responses due to intestinal bacteria entering general circulation,” Costa added. He’s a senior researcher with the department of nutrition, dietetics and food at Monash University in Australia.
Researchers observed that the risk of gut injury and impaired function seems to increase along with the intensity and duration of exercise.
The problem is dubbed “exercise-induced gastrointestinal syndrome.” The researchers reviewed eight previously done studies that looked at this issue.
Two hours appears to be the threshold, the researchers said. After two hours of continuous endurance exercise when 60 percent of an individual’s maximum intensity level is reached, gut damage may occur. Costa said that examples of such exercise are running and cycling.
He said heat stress appears to be an exacerbating factor. People with a predisposition to gut diseases or disorders may be more susceptible to such exercise-related health problems, he added.
Dr. Elena Ivanina is a senior gastroenterology fellow at Lenox Hill Hospital in New York City. She wasn’t involved with this research but reviewed the study. She said that normal blood flow to the gut keeps cells oxygenated and healthy to ensure appropriate metabolism and function.
If the gut loses a significant supply of blood during exercise, it can lead to inflammation that damages the protective gut lining. With a weakened gastrointestinal (GI) immune system, toxins in the gut can leak out into the systemic circulation — the so-called “leaky gut” phenomenon, Ivanina said.
But, she underscored that exercise in moderation has been shown to have many protective benefits to the gut.
“Specifically, through exercise, patients can maintain a healthy weight and avoid the consequences of obesity,” she said. Obesity has been associated with many GI diseases, such as gallbladder disease; fatty liver disease; gastroesophageal reflux disease (GERD); and cancer of the esophagus, stomach, liver and colon. Regular moderate physical activity also lowers the risk of cardiovascular disease, type 2 diabetes and depression.
To prevent exercise-related gut problems, Costa advised maintaining hydration throughout physical activity, and possibly consuming small amounts of carbohydrates and protein before and during exercise.
Ivanina said preventive measures might help keep abdominal troubles in check. These include resting and drinking enough water. She also suggested discussing any symptoms with a doctor to ensure there is no underlying gastrointestinal disorder.
Costa recommended that people exercise within their comfort zone. If you have stomach or abdominal pain, “this is a sign that something is not right,” he said.
Individuals with symptoms of gut disturbances during exercise should see their doctor.
The study authors advised against taking nonsteroidal anti-inflammatory drugs — including ibuprofen (Advil, Motrin) or naproxen sodium (Aleve) — before working out.
Costa said there’s emerging evidence that a special diet — called a low FODMAP diet — leading up to heavy training and competition may reduce gut symptoms. FODMAP stands for fermentable oligosaccharides, disaccharides, monosaccharides, and polyols. FODMAPs are specific types of carbohydrates (sugars) that pull water into the intestinal tract.
The International Foundation for Functional Gastrointestinal Disorders suggests consulting a dietitian familiar with FODMAP diets. Such diets can be difficult to initiate properly on your own, the foundation says.
Costa also said there’s no clear evidence that dietary supplements — such as antioxidants, glutamine, bovine colostrum and/or probiotics — prevent or reduce exercise-associated gut disturbances.
The study results were published online recently in the journal Alimentary Pharmacology & Therapeutics.
Wallpaper may contribute to sick building syndrome, a new study suggests.
Toxins from fungus growing on wallpaper can easily become airborne and pose an indoor health risk, the researchers said.
In laboratory tests, “we demonstrated that mycotoxins could be transferred from a moldy material to air, under conditions that may be encountered in buildings,” said study corresponding author Dr. Jean-Denis Bailly.
“Thus, mycotoxins can be inhaled and should be investigated as parameters of indoor air quality, especially in homes with visible fungal contamination,” added Bailly, a professor of food hygiene at the National Veterinary School of Toulouse, France.
Sick building syndrome is the term used when occupants start feeling ill related to time spent in a particular building. Usually, no specific illnessor cause can be identified, according to the U.S. National Institutes of Health.
For the study, the researchers simulated airflow over a piece of wallpaper contaminated with three species of fungus often found indoors.
“Most of the airborne toxins are likely to be located on fungal spores, but we also demonstrated that part of the toxic load was found on very small particles — dust or tiny fragments of wallpaper, that could be easily inhaled,” said Bailly.
Mycotoxins are better known for their occurrence in food. But “the presence of mycotoxins in indoors should be taken into consideration as an important parameter of air quality,” he said.
The study was published in Applied and Environmental Microbiology, a journal of the American Society for Microbiology.
Creating an increasingly energy-efficient home may aggravate the problem, Bailly and his colleagues said.
Such homes “are strongly isolated from the outside to save energy,” but various water-using appliances such as coffee makers “could lead to favorable conditions for fungal growth,” Bailly explained in a society news release.
Eating fish at least twice a week may significantly reduce the pain and swelling associated with rheumatoid arthritis, a new study says.
Prior studies have shown a beneficial effect of fish oil supplements on rheumatoid arthritis symptoms, but less is known about the value of eating fish containing omega-3, the researchers said.
“We wanted to investigate whether eating fish as a whole food would have a similar kind of effect as the omega 3 fatty acid supplements,” said the study author, Dr. Sara Tedeschi, an associate physician of rheumatology, immunology and allergy at Brigham and Women’s Hospital in Boston.
Generally, the amount of omega 3 fatty acids in fish is lower than the doses that were given in the trials, she said.
Even so, as the 176 study participants increased the amount of fish they ate weekly, their disease activity score lowered, the observational study found.
In rheumatoid arthritis, the body’s immune system mistakenly attacks the joints, creating swelling and pain. It can also affect body systems, such as the cardiovascular or respiratory systems. The Arthritis Foundation estimates that about 1.5 million people in the United States have the disease, women far more often than men.
The new study, which was heavily female, draws attention to the link between diet and arthritic disease, a New York City specialist said.
“While this is not something that is new, per se, and it was a small trial, it does raise an interesting concept of what you eat is as important as the medications you take,” said Dr. Houman Danesh.
“A patient’s diet is something that should be addressed before medication is given,” added Danesh, director of integrative pain management at Mount Sinai Hospital.
When his patients with rheumatoid arthritis ask about diet, he said he often suggests they eat more fish for a few months to see if it will help.
“I encourage them to try it and decide for themselves,” he said, explaining that study results so far have been mixed.
In this case, the majority of study participants were taking medication to reduce inflammation, improve symptoms and prevent long-term joint damage.
Participants were enrolled in a study investigating risk factors for heart disease in rheumatoid arthritis patients. The researchers conducted a secondary study from that data, analyzing results of a food frequency questionnaire that assessed patients’ diet over the past year.
Consumption of fish was counted if it was cooked — broiled, steamed, or baked — or raw, including sashimi and sushi. Fried fish, shellfish and fish in mixed dishes, such as stir-fries, were not included.
Frequency of consumption was categorized as: never or less than once a month; once a month to less than once a week; once a week; and two or more times a week.
Almost 20 percent of participants ate fish less than once a month or never, while close to 18 percent consumed fish more than twice a week.
The most frequent fish eaters reported less pain and swelling compared to those who ate fish less than once a month, the study found.
Researchers can’t prove that the fish was responsible for the improvements. And they theorized that those who regularly consumed fish could have a healthier lifestyle overall, contributing to their lower disease activity score.
While they were unable to get specific data on information such as patients’ exercise, its benefits are proven, Tedeschi said.
She acknowledged that fish tends to be an expensive food to purchase. For those unable to afford fish several times a week, Danesh cited other options.
“In general, patients should eat whole, unprocessed foods,” he said. “If you can’t for whatever reason, an omega 3 pill is a second option.”
Because the study was not randomized, researchers were unable to make definite conclusions, but they were pleased with what they learned.
One finding that impressed Tedeschi “was that the absolute difference in the disease activity scores between the group that ate fish the most frequently and least frequently was the same percentage as what has been observed in trials of methotrexate, which is the standard of care medication for rheumatoid arthritis,” she said.
The findings were reported June 21 in Arthritis Care & Research.
Abstract objective: �To examine the diagnosis and care of a patient suffering from chronic low back pain with associated right leg pain and numbness. ���Diagnostic studies include standing plain film radiographs, lumbar MRI without contrast, chiropractic analysis, range of motion, orthopedic and neurological examination. ���Treatments include both manual and instrument assisted chiropractic adjustments, ice, heat, cold laser, Pettibon wobble chair and repetitive neck traction exercises and non-surgical spinal decompression. ��The patient’s� outcome was very good with significant reduction in pain frequency, pain intensity and abatement of numbness in foot.
Introduction: �A 58 year old, 6�0�, 270 pound male was seen for a chief complaint of lower back pain with radiation into the right leg with right foot numbness. �The pain had started 9 months prior with an insidious onset. ��The patient had first injured his back in high school lifting weights with several episodes of pain over the ensuing years. ��The patient had been treating with Advil and had tried physical therapy, acupuncture, chiropractic and ice with no relief of pain and numbness. ��Walking and standing tend to worsen the problem and lying down did provide some relief. ���A number of activities of daily living were affected at a severe level including standing, walking, bending over, climbing stairs, looking over shoulder, caring for family, grocery shopping, household chores, lifting objects staying asleep and exercising. ��The patient remarked that he �Feels like 100 years old.� �Social history includes three to four beers per week, three diet cokes per day.
The patient�s health history included high blood pressure, several significant shoulder injuries, knee injuries, apnea, hearing loss, weight gain, anxiety and low libido. ���Family history includes Alzheimer�s disease, heart disease, colon cancer and obesity.
Clinical Findings
Posture analysis revealed a high left shoulder and hip with 2 inches of anterior head projection. Bilateral weight scales revealed a +24 pound differential on the left. ��Weight bearing dysfunction and imbalance suggest that neurological compromise, ligamentous instability and or spinal distortion may be present. �Range of motion in the lumbar spine revealed a 10 degree decrease in both flexion and extension. There was a 5 degree decrease in both right and left lateral bending with sharp pain with right lateral bending.
Cervical range of motion revealed a 30 degree decrease in extension, a 42 and 40 degree decrease in right and left rotation respectively and a 25 degree decrease in both right and left lateral flexion. ��Stability analysis to assess and identify the presence of dynamic instability of the cervical and lumbar spine showed positive in the cervical and lumbar spine and negative for sacroiliac dysfunction. ��Palpatory findings include spinal restrictions at occiput, C5, T5, T10, L4,5 and the sacrum. ��Muscle palpation findings include +2 spasm in the psoas, traps, and all gluteus muscles.
Cervical radiographs reveal significant degenerative changes throughout the cervical spine. This represents phase II of spinal degeneration according the Kirkaldy-Wills degeneration classification. ���Cervical curve is 8 degrees which represents an 83% loss from normal. ��Flexion and extension stress x-rays reveal decreased flexion at occiput through C4 and decreased extension at C2, C4-C7.
Lumbar radiographs reveal significant degenerative changes throughout representing phase II of spinal degeneration according to the Kirkaldy-Willis spinal degeneration classification. ���There is a 9 degree lumbar lordosis which represents a 74% loss from normal. ��There is a 2 mm short right leg and a grade II spondylolisthesis at the L5-S1 level.
Lumbar MRI without contrast was ordered immediately with a 4 mm slice thickness and 1 mm gap in between slices on a Hitachi Oasis 1.2 Telsa machine for optimal visualization of pathology due to the clinical presentation of right L5 nerve root compression.
Lumbar MRI Imaging Results
Significant degenerative changes throughout the lumbar spine including multi-level degenerative disc changes at all levels.
Transverse Annular Fissures at L1-2 (17.3 mm), L2-3 (29.5 mm), L4-5 (14.3 mm) and L5-S1 (30.8 mm) and broad based disc bulging at all levels except L5-S1. ���The fissures at L2-3 and L5-S1 both have radial components extends through to the vertebral endplate.
Facet osteoarthritic changes and facet effusions at all levels.
Grade II spondylitic spondylolisthesis is confirmed at L5-S1 with severe narrowing of the right neural foramen compressing the right exiting L5 nerve root.
Degenerative retrolisthesis at L1-2.
Modic Type II changes at L2 inferior endplate, L3 superior endplate, L4 inferior endplate and L5 inferior endplate.2
There is a 18.9 mm wide Schmorl�s node at the superior endplate of L3.
There is a 5.7 mm wide focal protrusion type disc herniation at L4-5 which impinges on the thecal sac.
T2 sagittal Lumbar Spine MRI:� Note the Modic Type II changes and the L2-3 Schmorls node.
T1 Sagittal Annular fissures at multiple levels and spondylolisthesis at L5S1
T2 Axial L4-5:� Focal Disc Protrusion Type Herniation
Definition �Bulging Disc: A disc in which the contour of the outer annulus extends, or appears to extend, in the horizontal (axial) plane beyond the edges of the disc space, over greater than 50% (180 degrees) of the circumference of the disc and usually less than 3mm beyond the edges of the vertebral body apophyses.3
Definition: Herniation is defined as a localized or focal displacement of disc material beyond the limits of the intervertebral disc space.3
Protrusion Type Herniation: is present if the greatest distance between the edges of the disc material presenting outside the disc space is less than the distance between the edges of the base of that disc material extending outside the disc space.3
Definition: Extrusion Type Herniation: �is present when, in at least one plane, any one distance between the edges of the disc material beyond the disc space is greater than the distance between the edges of the base of the disc material beyond the disc space or when no continuity exists between the disc material beyond the disc space and that within the disc space. 3
Definition: �Annular Fissures: �separations between the annular fibers of separations of the annual fibers from their attachments to the vertebral bone. 4
Definition � Radiculopathy: Sometimes referred to as a pinched nerve, it refers to compression of the nerve root – the part of a nerve between vertebrae. This compression causes pain to be perceived in areas to which the nerve leads.
The patient underwent multimodal treatment regime consisting of 4 months of active chiropractic adjustments, non-surgical spinal decompression with pretreatment spinal warm-up exercises on the Pettibon wobble chair and neck traction and heat. Post spinal decompression with ice and cold laser. ��The patient reported long periods of symptom free activities of daily living with occasional short flare-ups of pain. ��Exacerbations are usually of short duration and much lower frequency. �The only activity of daily living noted as affected severely at the end of care is exercising.
Post care lumbar radiographs revealed a 26 degree lumbar curve a 15 degree (38%) increase
Post care cervical x-rays revealed a 10 mm decrease in anterior head projection and a 2 degree improvement in the cervical lordosis.
Range of Motion
pre
post
increase
Lumbar
flexion
60
60
0
extension
40
40
0
r. lateral flexion
20
25
5
l. lateral flexion
20
25
5
cervical
pre
Post
increase
flexion
50
50
0
extension
30
40
10
r. lateral flexion
20
35
15
l. lateral flexion
20
20
0
r. rotation
38
70
42
l. rotation
40
80
40
Discussion of Results
It is appropriate to immediately order MRI imaging with radicular pain and numbness. ��Previous health providers who did not order advanced imaging with these long term radicular symptoms are at risk of missing important clinical findings that could adversely affect the patient�s health. ��The increasing managed care induced trend to forego taking plain film radiographs is also a risk factor for patients with these problems.
This case is a typical presentation of long standing spinal injuries that over many years have gone through periods of high and low symptoms but continue to get worse functionally and eventually result in a breakdown of spinal tissues leading to neurological compromise and injury.
Chiropractic treatment resulted in a very favorable outcome aided by an accurate diagnosis. �This is also the case where the different treatment modalities all contributed to the success of the protocol. ��The different modalities all focus on different areas of pathology contributing to the patients� disabled condition.
Modality
Therapeutic Goals
Chiropractic adjustment
Manual and instrument assisted forces introduced to the osseous structures that focuses on improving motor segment mobility
Cold laser
Increases speed of tissue repair and decreases inflammation.4
Pettibon
wobble chair
Loading and unloading cycles applied to injured soft tissues and
Pettibon
neck traction
speeds up & improves remodeling of injured tissue as well as rehydrates dehydrated vertebral discs.5
Non-surgical
spinal decompression
Computer assisted, slow and controlled stretching of spine, creating vacuum effect on spinal disc, bringing it back into its proper place in the spine.6,7
Ice
Decrease inflammation through vasoconstriction
Heat
Warm up tissues for mechanical therapy through increasing blood flow.
Posture Correction Hat
Weighted hat that activates righting reflex resetting head posture.8
A major factor in the success of the care plan in this case was an integrative approach to the spine. �John Bland, M.D. in the text Disorders of the Cervical Spine writes
�We tend to divide the examination of the spine into regions: cervical, thoracic and the lumbar spine clinical studies.� This is a mistake.� The three units are closely interrelated structurally and functionally- a whole person with a whole spine.� The cervical spine may be symptomatic because of a thoracic or lumbar spine abnormality, and vice versa!� Sometimes treating a lumbar spine will relieve a cervical spine syndrome, or proper management of cervical spine will relieve low backache.�9
When addressing the spine as an integrative system, and not regionally it has a very strong benefit to the total care results. ��The focus on the restoration of the cervical spine function as well as lumbar spine function is a hallmark of a holistic spine approach that has been a tradition in the chiropractic profession.
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 .�
References:
Kirkaldy-Willis, W.H, Wedge JH, Young-Hing K.J.R. Pathology and pathogenesis of lumbar spondylosis and stenosis. �Spine 1978; 3: 319-328
David F. Fardon, MD, Alan L. Williams, MD, Edward J. Dohring, MD. Lumbar disc nomenclature: version 2.0 Recommendations of the combined task forces of the North American Spine Society, the American Society of Spine Radiology and the American Society of Neuroradiology. The Spine Journal 14 (2014) 2525�2545
Shealy CM, Decompression, Reduction and Stabilization of the Lumbar Spine: A cost effective treatment for lumbosacral pain.�� Pain management 1955, pg 263-265
Shealy, CM, New Concepts of Back Pain Management, Decompression, Reduction and Stabilization.�� Pain Management, a Practical guide for Clinicians.� Boca Raton, St. Lucie Press: 1993 pg 239-251
Bland, John MD, Disorders of the Cervical Spine WB Saunders Company, 1987 pg 84
Additional Topics: Preventing Spinal Degeneration
Spinal degeneration can occur naturally over time as a result of age and the constant wear-and-tear of the vertebrae and other complex structures of the spine, generally developing in people over the ages of 40. On occasion, spinal degeneration can also occur due to spinal damage or injury, which may result in further complications if left untreated. Chiropractic care can help strengthen the structures of the spine, helping to prevent spinal degeneration.
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.
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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, [email protected]
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