What is your scope of practice? ​

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Chiropractic practice is often equated to the act of manipulation, and this has fostered an understanding that this is what we do and solely what we use to treat patients. However, spinal manipulative therapy is widely utilised in various health disciplines including orthopaedic and musculoskeletal specialist clinics. At Peek Practice our focus is on making an accurate diagnosis, from which we can then assess the most appropriate pathway for management.​

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Should a diagnosis fall outside our scope, we will refer, and we will work with you to facilitate the optimum pathway for your patients. We regularly engage and work with musculoskeletal specialists as a complementary discipline to enhance results in more complex cases. 

 

Within our scope of practice, we utilise a range of treatment methods, including soft tissue treatments, joint mobilisation, acupuncture and manipulation (where indicated*). Additionally, we use a range of other approaches advocated for in the literature that include exercise prescription, lifestyle advice and psychologically informed methods to engender self-efficacy. ​​​

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As a member of a collaborative healthcare team we will undertake to provide you and your patient with the following.​

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• Up to date and regular reporting of patient progress.

• Evidence and rationale supporting management strategies.

• Patient choices, preferences and goals as key components to the management plan (including a contemporary approach to informed consent).

• Outcomes-based assessment and reporting and relevant indicators of progress.

• A working case formulation-based diagnosis that accounts for the multidimensional nature of the pain experience.

Do we X-Ray all of our patients?

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No - imaging is utilised in accordance with best practice guidelines and is only requested when there is a need to exclude red flag pathology or provide diagnostic clarity or confirmation. This is based on clinical reasoning on an individual basis. ​​

Is There an Over-Reliance on Passive Management?

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There is a perception that chiropractors overservice patients, whilst there are a small number of patients that utilise our services on an ongoing basis, this is not the norm, nor the approach that we advocate. When considering the best approach to management one needs to consider the needs and clinical picture of each individual.

 

In the end our aim is to harness and encourage the development of patient self-efficacy with emphasis on active coping strategies and patient autonomy.

Is Cervical Manipulation Dangerous?

 

​There is a considerable amount of controversy over the use of cervical manipulation as a means to address mechanical neck pain. 

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It is well established that any therapeutic intervention may pose risk if applied without appropriate clinical discernment. Accordingly, it is incumbent upon the practitioner to determine the suitability of each patient for a proposed treatment. Spinal manipulation is no exception, and its application is governed by clearly delineated absolute and relative contraindications. In recognition of these considerations, our clinical practice adheres to a deliberately conservative approach.

Chiropractic care encompasses a spectrum of manual techniques, of which spinal manipulation constitutes only one modality. The term "manipulation" refers to a broad range of joint mobilisations, each selected and graded according to the biomechanical and physiological integrity of the patient, including potential vascular vulnerabilities.

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The purported association between cervical spinal manipulation and vertebral artery dissection (VAD) has been the subject of longstanding concern. However, the critical distinction between temporal association and causation remains unresolved. Numerous quotidian activities—such as hair washing, yoga, and even reversing a vehicle—have been linked to VAD in individuals with predisposing vascular anomalies. Such associations do not imply inherent danger in these activities, but rather reflect an underlying susceptibility.

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Risk factors for vascular fragility are well documented and include connective tissue disorders such as Ehlers-Danlos and Marfan syndromes, fibromuscular dysplasia, hyperhomocysteinaemia, migraine, and hormonal factors such as oral contraceptive use. VAD often presents initially with nonspecific symptoms such as neck pain or sub-occipital headache, frequently prompting individuals to seek care from manual therapists, thereby complicating attribution of causality.

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Contemporary evidence increasingly suggests that chiropractors are more often implicated as incidental contacts rather than causal agents in such cases. While clinical oversight—such as a failure to recognise a pre-existing dissection or the application of excessive force—remains a theoretical risk, this is distinct from the assertion that spinal manipulation in isolation is capable of inducing VAD in an otherwise healthy individual.

 

If one is to look at the entire scope of the literature with an objective lens highlights a more nuanced understanding of the relationship between cervical arterial dissection (CAD) and manipulation (CSMT)

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As you will see from the below, the cause-and-effect relationship between these two factors is largely determined by the temporal association between pain and treatment rather than mechanically induced cause and effect. 

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• Case reports provide us with valuable information; however, they are considered low level of evidence, thus causation cannot be inferred by case reports alone (1). The abundance of case reports and retrospective case series or surveys from neurologists lack methodological quality to establish causality. They also likely contribute to over reporting of serious catastrophic adverse events (2, 12-14).

• The highest level of evidence one can reasonably use to determine causation is a case-control study (1, 3, 4).

• CAD’s are considered rare events approx. 3 per 100 000 (5, 6). Carotid artery dissections are more common (3-5 times more frequent) than vertebral artery dissections (VAD) (7).

• The most common primary symptom of CAD is head and or neck pain (approximately 80%) of individuals (3, 5).

• Head and or neck pain are common non-specific symptoms that may present independently of and prior to the development of neurological deficit, this can in some cases make screening for CAD complex and of little utility.

• Prodromal symptoms of CAD (headache and neck pain) can be prolonged from a few minutes to several weeks (8).

• Temporality, i.e. patients seeking care for symptoms of head and neck pain are likely to seek care from a provider that offers relief for such symptoms (GPs, chiropractors, physiotherapists, osteopaths etc) (2) This association is demonstrated in the literature and provides the mainstay of evidence refuting the causation hypothesis (3, 4, 9).

• Protopathic bias – the erroneous conclusion that CSMT initiated for pain (undiagnosed CAD) leads to CAD. i.e. stroke in progress (neck and head pain) are the reason for seeking healthcare.

• Studies show that there is a small association between CSMT and CAD, a similar association is noted between general practitioner visits and CAD (3, 4, 9).

• Case studies further provide some confirmation of this temporality (10, 11).

• Mechanistic studies have illustrated that “vertebral artery strain during CSMT are significantly smaller than those obtained during diagnostic and range of motion testing, and are much smaller than failure strains”

• Haemodynamic studies of the VA further refute a mechanistic model (15, 16) Moser et al. (2019) concluded.

 

“Our work is the first to show that cervical manipulation does not result in brain perfusion changes compared with a neutral neck position or maximal neck rotation. The changes observed were found to not be clinically meaningful and suggests that cervical manipulation may not increase the risk of cerebrovascular events through a haemodynamic mechanism”

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• There are a number of reported mechanistic explanations involving neck motion that are implicated in CAD including major trauma and minor traumas, however, according to Cassidy et al. (2008); 

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“Most cases of CAD are thought to occur spontaneously, other factors including connective tissue disorders, migraine, hypertension, infection, levels of plasma homocysteine, vessel abnormalities, atherosclerosis, cervical spine surgery, cervical percutaneous nerve blocks, radiation therapy and diagnostic cerebral angiography have been identified as possible risk factors” (3).

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• Pathophysiological mechanisms appear to predominate as primary aetiological considerations in the development of CAD, and particularly with VAD, connective tissue disorders (vascular Ehlers-Danlos syndrome) and migraine appear to be associated with spontaneous VAD. This is illustrated in the relatively higher proportion of younger individuals <45 being predisposed to VAD. This suggests a complex multifactorial disease is likely the primary predisposing risk factor (7).​

 

• A recent systematic review conducted by Church et al. (2016) concluded; 

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“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” (17)

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• As you will see from the literature, there is a balance of researchers and clinicians involved in this body of literature, for example the Church et al. (2016) study was conducted by a team of neurosurgeons.

• Current best practice guidelines place emphasis on the neck and head pain work up, subtle signs and symptoms can be pivotal in recognising a patient that doesn’t fit the mechanical picture; however, it must also be considered that there are many “non-pathognomonic symptoms” that may accompany this disease presentation.

• CSMT is no longer confined to chiropractic practice, it is increasingly utilised by a number of professional disciplines including physiotherapy and osteopathy. The literature also highlights that there is an assumption that a chiropractor performed manipulation (in relation to adverse events) (18) despite its use in several disciplines both qualified (regulated) and unqualified (unregulated for example Thai massage).

• There is a significant body of current research that highlights the complexity of CAD as a “disease”, whilst mechanistic factors should by no means be excluded (major trauma) there is a growing and convincing base of information that challenges the premise that range of motion changes are implicatory in CAD. Purely from an evolutionary model of understanding it seems to be of no value for these arteries to be so fragile, and this is supported by a disease-based hypothesis (spontaneous).​

 

References

1. Perle SM, Jung H, Ham J, Choi H. Letter to the Editor: A Case of Posterior Inferior Cerebellar Artery Infarction after Cervical Chiropractic Manipulation (Korean J Neurotrauma 2018;14:159–163). Korean J Neurotrauma. 2019;15(1):72-3.
2. Chaibi A, Russell MB. A risk-benefit assessment strategy to exclude cervical artery dissection in spinal manual-therapy: A comprehensive review. Ann Med. 2019:1-27.
3. Cassidy D, Boyle LE, Côté JP, He JY, Hogg-Johnson JS, Silver JF, et al. Risk of Vertebrobasilar Stroke and Chiropractic Care: Results of a Population-Based Case-Control and Case-Crossover Study. Spine. 2008;33(4S Suppl):S176-S83.
4. Cassidy D, Boyle E, Cote P, Hogg-Johnson S, Bondy SJ, Haldeman S. Risk of Carotid Stroke after Chiropractic Care: A Population-Based Case-Crossover Study. J Stroke Cerebrovasc Dis. 2017;26(4):842-50.
5. Lee VH, Brown RD, Jr., Mandrekar JN, Mokri B. Incidence and outcome of cervical artery dissection: a population-based study. Neurology. 2006;67(10):1809-12.
6. Bejot Y, Daubail B, Debette S, Durier J, Giroud M. Incidence and outcome of cerebrovascular events related to cervical artery dissection: the Dijon Stroke Registry. Int J Stroke. 2014;9(7):879-82.
7. Debette S, Leys D. Cervical-artery dissections: predisposing factors, diagnosis, and outcome. Lancet Neurol. 2009;8(7):668-78.
8. Cadena R, Kim J. Cervical artery dissection: early recognition and stroke prevention [digest]. Emerg Med Pract. 2016;18(7 Suppl Points & Pearls):S1-s2.
9. Kosloff TM, Elton D, Tao J, Bannister WM. Chiropractic care and the risk of vertebrobasilar stroke: results of a case-control study in U.S. commercial and Medicare Advantage populations.(Report)(Case study). Chiropractic & Manual Therapies. 2015;23(1).
10. Futch D, Schneider MJ, Murphy D, Grayev A. Vertebral artery dissection in evolution found during chiropractic examination. BMJ Case Reports. 2015;2015(nov12 1).
11. Mattox R, Smith LW, Kettner NW. Recognition of Spontaneous Vertebral Artery Dissection Preempting Spinal Manipulative Therapy: A Patient Presenting With Neck Pain and Headache for Chiropractic Care. Journal of Chiropractic Medicine. 2014;13(2):90-5.
12. Herzog W, Leonard TR, Symons B, Tang C, Wuest S. Vertebral artery strains during high-speed, low amplitude cervical spinal manipulation. Journal of Electromyography and Kinesiology. 2012;22(5):740-6.
13. Piper SL, Howarth SJ, Triano J, Herzog W. Quantifying strain in the vertebral artery with simultaneous motion analysis of the head and neck: A preliminary investigation. Clinical Biomechanics. 2014;29(10):1099-107.
14. Symons BP, Leonard T, Herzog W. Internal forces sustained by the vertebral artery during spinal manipulative therapy. Journal of Manipulative and Physiological Therapeutics. 2002;25(8):504-10.
15. Yelverton C, Wood JJ, Petersen DL, Peterson C. Changes in Vertebral Artery Blood Flow in Different Head Positions and Post-Cervical Manipulative Therapy. Journal of manipulative and physiological therapeutics. 2020.
16. Moser N, Mior S, Noseworthy M, Cote P, Wells G, Behr M, et al. Effect of cervical manipulation on vertebral artery and cerebral haemodynamics in patients with chronic neck pain: a crossover randomised controlled trial. BMJ Open. 2019;9(5):e025219.
17. Church EW, Sieg EP, Zalatimo O, Hussain NS, Glantz M, Harbaugh RE. Systematic Review and Meta-analysis of Chiropractic Care and Cervical Artery Dissection: No Evidence for Causation. Cureus. 2016;8(2):e498.
18. Wenban AB. Inappropriate use of the title 'chiropractor' and term 'chiropractic manipulation' in the peer-reviewed biomedical literature. Chiropractic & Osteopathy. 2006;14(1):16.