Bør cervikalcolumna manipuleres? Henrik Wulﬀ Christensen Nordic Ins<tute of Chiroprac<c and Clinical Biomechanics (NIKKB) Odense, Danmark JA Hvis der er indika.on Én (ud af mange) sikker og eﬀek.v behandlingsmetode Bivirkninger ved SMT 1.  Godartede (benigne) – normal reaktion!
2.  Alvorlige - komplikationer
Benigne bivirkninger Den normale reaktion hos kiropraktor patienter
• 
Lokal ømhed (19%)
• 
Radikulært ubehag (4%)
• 
Træthed (4%)
• 
Hovedpine (4%)
• 
Svimmelhed (2.5%)
• 
Varme fornemmelse i huden (0.25%)
Senstad et al., Scand J Prim Health Care
(1996) - RETROSPEKTIVT
Benigne bivirkninger Den normale reaktion hos kiropraktor patienter
• 
Lokal ømhed (53%)
• 
Radikulært ubehag (10%)
• 
Træthed (11%)
• 
Hovedpine (12%)
• 
Svimmelhed (<5%)
• 
Varme fornemmelse i huden (<5%)
Senstad et al., Spine (1997) PROSPEKTIVT
Benigne bivirkninger Den ”normale” reaktion hos patienter med nakke smerter
• 
Nakke sm. eller ømhed (27.7%) [22.3%]
• 
Radikulært smerte/ubehag (6.4%) [5.8%]
• 
Træthed (12.1%) [7.9%]
• 
Hovedpine (15.6%) [15.8%]
• 
Svimmelhed (4.3%) [2.2%] *
• 
Opkastning (2.1%) [1.4%] *
• 
Sløret syn (2.8%) [0.7%] *
• 
Susen i ørene (3.5%) [2.2%]
• 
Forvirring/desorientering (1.4%) [2.5%]
Hurwitz et al, JMPT (2004)
Alvorlige bivirkninger ved SMT 1.  Lumbal diskus syndrom inkl. radikulopati
og cauda equina syndrom
2.  Cervical diskus syndrom inkl. radikulopati
og myelopati
3.  Forskellige post manipulative hændelser
4.  Cerebrovasculære hændelser
Lumbal diskus syndrom • 
Nerverodskompression
Hyppighed:
1:174.000 (radikulært udfald)
• 
Cauda equina
Hyppighed:
1:>2.000.000
Cervical diskus syndrom • 
Nerverodskompression
Hyppighed:
Ukendt/ Case reports
• 
Myelopati
Hyppighed:
Ukendt/ Case reports
Post manipula.ve hændelser Comorbiditet
Antikoagulations behandling
(hæmatom)
Spondolytisk stenose (myelopati)
Paget´s sygdom (myelopati)
Tumorer (myelopati)
Post manipula.ve hændelser Traumer
Fractur (eks. costae, kompression?)
Hæmatomer
Cervikal manipulativ behandling
(CMB) : ca. 100.000.000 / år i USA
yderst sparsom forskning !
Spændingshovedpine / smerter i nakken
forekommer meget hyppigt
10.000 nordmænd: 34% indenfor 1 år, 14% > 6 måneder
Bovim G, Schrader H, Sand T
Neck pain in the general population
Spine 1994; 19:1307-1309
RCT: effekt af CMB ?
Cochrane review
27 RCT , 1522 participants
Cervical manipulation and mobilisation produced similar changes. Either
may provide immediate- or short-term change; no long-term data are
available. Optimal techniques and dose are unresolved. Further research is
very likely to have an important impact on our confidence in the estimate of
effect and is likely to change the estimate.
Manipulation or mobilisation for neck pain.Gross A, Miller J, D'Sylva J, Burnie SJ,
Goldsmith CH, Graham N, Haines T, Brønfort G, Hoving JL. Cochrane Database Syst
Rev. 2010 Jan 20; (1):CD004249. Epub 2010 Jan 20.
Effekt af CMB ?
Best synthesis evidence
139 articles
Our best evidence synthesis suggests that therapies
involving manual therapy and exercise are more effective
than usual care for patients with neck pain.
Treatment of neck pain: noninvasive interventions: results of the Bone and
Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders
Spine (Phila Pa 1976). 2008 Feb 15;33(4 Suppl):S123-52. doi: 10.1097/BRS.
0b013e3181644b1d, Hurwitz et al,
The task force concluded:
Manipulation as one of several firstline treatments
for neck pain, whiplash, and related headaches
(RCT + adverse effects) (Hurwitz Spine 2008)
Decision analysis model examining drugs,
exercise, mobilisation, and manipulation for neck
pain incl benefits and harms and incorporating
patient preferences – NO CLEAR WINNER when
the objective was to maximise quality adjusted life
(Hurwitz Spine 2008)
»cervical manipulation arouses far more
concern about safety than the use of
lumbar manipulation«
Shekelle PG. What role for chiropractic in health care?
N Engl J Med 1998;339:1074-5
»discourage the use of cervical
manipulation ….
because of an unacceptably high risk/
benefit ratio«
Powell FC et al. A risk/benefit analysis of spinal manipulation therapy
for relief of lumbar or cervical pain.
Neurosurgery 1993;33(1):73-8
Frygt for
vertebrobasilar arterie (VBA)
hjerneblødning (stroke)
Hvor ofte sker VBA efter CMB ?
1:20.000 - 1:3.000.000
Vickers A, Zollman C. The manipulative therapies; osteopaty and chiropractic. BMJ 1999; 319:1176-9
Carey PF: A report on the occurence of cerebral vascular accidents in chiropractic practice.
J Can Chiropract Assoc 1993;37:104-106
Dvorak J et al.: How dangerous is manipulation of the cervical spine ? Man Med 1985;2:1-4
Dabbs V et al.: A risk assessment of cervical manipulation vs. NSAIDs for the treatment of neck pain.
J Manipulative Physiol Ther 1995;18:530-536
Terrett AGJ: Vascular accidents from cervical spine manipulation: Report on 107 cases.
J Aust Chiro Assoc 1987;17:15-24
Haynes MJ: Stroke following cervical manipulation in Perth. Chiro J Aust 1994;24:42-46
Gutmann G: Verletzungen der Arteria vertebralis durch manuelle Therapie. Manuelle Medizin 1983;21:2-14
Dvorak J et al.: Frequency of complications of manipulation of the spine.
A survey among the Swiss Medical Society of Manual Medicine. Eur Spine J 1993;2:136-139
Klougart N et al.: Safety in chiropractic practice, Part I; The occurrence of cerebrovascular accidents after
manipulation to the neck in Denmark from 1978-1988. J Manipulative Physiol Ther 1996;19:371-377
Hosek RS et al.: Cervical manipulation. JAMA 1981;245:922-922
DK VBA i kiropraktorpraksis
Patientforsikringen: 10 tilfælde 2004-2010
Antagelse
550 kiropraktorer i DK.
320.000 patienter / år
7 behandlinger / pt
2/5 cervikale behandlinger
1/560.000
Patient karakteristik?
Age distribution
Tidsfaktor mellem SMT og CVA
69 %
3%
9%
8%
5%
6%
umiddelbart under SMT
minutter efter SMT
< 1 time efter SMT
1 - 6 timer efter SMT
7 - 24 timer efter SMT
> 24 timer efter SMT
Terrett, 1996
183 ptt
Terrett AGJ.
Vertebrobasilar Stroke following Manipulation.
National Chiropractic Mutual Insurance Company, 1996
115 ptt
Haldeman S et al.
Risk factors and precipitating neck movements causing vertebrobasilar
artery dissection after cervical trauma and spinal manipulation.
Spine 1999; 24:785-794
196 ptt
Smedegaard Andersen B & Thim HM
CVAs and cervical manipulation – a diploma study.
Odense University 2001
# cases publiceret i 5-års intervaller
Cerebrovaskulære katastrofer efter SMT
er meget sjældne:
ca. 400-500 i litteraturen
Måske hyppigere ?
Lee KP, Carlini WG, McCormick GF, Albers GW.
Neurologic complications following chiropractic manipulation: a
survey of California neurologists.
Neurology 1995; 45:1213-1215
Robertson JT. Authors rebuttal to »Neck manipulation as a cause
of stroke«.
Stroke 1982; 13:260-261
Rivett DA, Milburn PD. Complications arising from spinal
manipulative therapy in New Zealand.
Physiotherapy 1997; 83:626-632
Klinik •  Risikopa.enten? –  alder –  køn –  diabetes/rygestatus/hormonel behandling m.m. –  symptomer –  forandringer i col. cerv. –  vaskulære forandringer (e.g. Ehlors-‐Danlos) –  comorbiditet Rubinstein, Thesis 2008
Sidney Cervical arterie dissec.on •  Gene.sk predisposi.on –  a1 (ingen associa.on), bindevævssygdomme (mulig associa.on), gene muta.oner (ingen associa.on), homocystein (stærk associa.on), karabnormaliteter (stærk associa.on), migræne (stærk associa.on) METODEPROBLEMER; selek.on bias, lille studie, manglende mul.variat analyse, mangelen blinding af undersøger, mulig confounder Rubinstein 2008
Cervical arterie dissec.on •  Miljøfaktorer –  infek.oner (svag associa.on), p-‐piller (posi.v associa.on) METODEPROBLEMER: selek.onsbias, manglende blinding, manglende stra.ﬁcering. Rubinstein 2008
Cervical arterie dissec.on •  Traume –  manipula.on (stærk associa.on) METODEPROBLEMER: små studier (n=7), selek.ons og informa.ons bias. Rubinstein 2008
Cervical arterie dissec.on •  Risikofaktorer for arteriosklerose –  vaskulære risikofaktorer (hypertension, DM, rygning, p-‐piller, kolesterol) nega.v associa.on sammenlignet med andre ”strokes” -‐  alder < 45 år højere frekvens METODEPROBLEMER: ingen rapporteret. Rubinstein 2008
”Predictors of adverse events” •  Prospek.vt, mul.center kohorte studie •  579 pa.enter •  60 uabængige variable undersøgt –  4 faktorer var prædik.ve for ”adverse event” i .lfælde af kiroprak.sk behandling for nakkesmerter en af disse beskycende eﬀekt Rubinstein 2008
”Predictors of adverse events” •  Rapporteret brug af rota.onsteknik ved behandling i nakken •  Erhvervsstatus (fuld.d, del.d, arbejdsløs >< sygemeldt/understøcelse) •  Langvarige nakkesmerter indenfor det sidste år (>60 dg) •  Beskycende eﬀekt: besøg hos e.l. inden besøg hos kiropraktor Rubinstein 2008
Klinik •  Manipula.onen –  behandlingsstyrken –  behandlingsfrekvensen –  behandlingsniveauet –  selve teknikken Anbefalinger ved SMT i cervical kolumna •  Størstedelen af .lfælde drejer sig om skader på AV i øvre del af nakken. •  Rota.on af col. cerv. i særlig grad kompromicerer AV i den øvre del af nakken. •  Med rimelighed kan antages, at især rota.onsbehandling har været anvendt på de skadeslidte pa.enter. Symptomer ved muligt CVI • 
• 
• 
• 
• 
• 
• 
• 
• 
Svimmelhed Bevistløshed Dobbeltsyn Dysarthria Dysphagia Ataxi Opkastninger Følelsesløshed Nystagmus ... er manipulationsbehandling
farlig ?
Er behandling av cervikalcolumna farlig Henrik Wulﬀ Christensen Nordic Ins<tute of Chiroprac<c and Clinical Biomechanics Odense, Danmark NEJ Vertebrobasilar Artery (VBA) Stroke
and Chiropractic Care
•  One concern about manipulation is the risk of
stroke
•  Multiple case reports of VBA dissection and
stroke – lowest level of evidence
•  Other activitites like rotation and extension af the
neck, yoga, looking up and hair washing at a
salon have been reported as cases
J. David Cassidy, DC, PhD, DrMedSc
Prævalens, incidens, prognose, risiko Cohort Case-‐control Designed studies Cross-‐sec<onal Case-‐series Case-‐reports Clinical observa<on Learning Objectives
•  Consider epidemiology of vertebral artery
dissection and subsequent stroke.
•  Understand strengths and weakness of the
evidence on this issue.
•  Consider causal mechanisms for stroke in
younger persons seeking chiropractic care.
47
Presentation
•  Stroke and Chiropractic
•  Past Studies
•  Study Methods
•  Study Results
•  Discussion
48
Cervical Artery Dissections
Internal Carotid
Vertebral
49
Cervical Artery Dissections
•  Arise from intimal tear
–  Possible risk factors: genetic (connective tissue disorder), migraine,
minor trauma, spontaneous (idiopathic)
•  Prognosis depends on severity (stenosis, collateral circulation and
thromboembolic complications)
–  Most strokes due to dissection are thromboembolic
–  Most recover (< 5% deaths)
•  Annual incidence of dissection-related strokes (from Olmstead
County, MN: Lee et al., Neurology 2006: 67:1809-12):
–  Carotid: 1.72 per 100,000 per year in population (95% CI: 1.13-2.32)
–  Vertebral: 0.97 per 100,000 per year in population (95% CI: 0.52-1.40)
•  80% presented with head or neck pain
50
Chiropractic Stroke?
Vertebral
Dissection
VBA
Stroke
C1-2 Rotation
Over 80% of patients with vertebral artery dissection present with
neck and/or headache (Lee et al., Neurology, 2006).
51
Chiropractic Stroke?
52
Chiropractic Stroke?
53
Past Studies
•  Multiple case reports and opinion
papers.
–  Occurs in previously healthy young
people
•  Only 3 analytic (i.e., controlled)
studies:
–  Rothwell et al., Stroke 2001 (Ontario)
–  Smith et al., Neurology 2003 (California)
–  Cassidy et al., Spine 2008 (Ontario)
54
Past Case-Control Study
Past Chiropractic Service within one week?
yes
582
stroke
cases
no
Time
yes
no
< 45 years old:
Ontario
1993-1998
(pop.~11 M)
2,328 different
control subjects
OR=5.03 (95% CI=1.32-43.87)
* Rothwell et al., Stroke 2001
Past Case-Control Study
Past Chiropractic Service within 30 Days?
yes
no
Time
yes
no
26 CAD
51 VAD
N=100
Other
Strokes
N=100
OR not significant for all and CAD
OR= 6.6 (95% CI=1.4-30) for VAD
UCSF &
Stanford Stroke
Registries
1995-2000
N=1,107
< 60 years old
Smith et al., Neurology 2003
56
Presentation
•  Stroke and Chiropractic
•  Past Studies
•  Study Methods
•  Study Results
•  Discussion
57
Study Population
•  Ontario population (pop.~12 million)
•  Excluding institutionalized, Military
Universal health care databases:
•  94% of population covered
•  CIHI hospitalizations capture VBA stroke
•  OHIP ambulatory care captures chiropractic
and physician visits (exposures)
Methods
•  Cases
–  All incident VBA stroke cases hospitalized
over 9 years in Ontario
•  ICD-9 433.0 and 433.2 (occlusion and stenosis
of vertebral and basilar artery)
–  No previous hospital admission for stroke
•  Controls (4 per case)
–  Matched on sex and age
–  No previous hospital admission for stroke
Study Exposures
1.  Chiropractic (DC)
– 
Diagnostic billing codes used to identify services
– 
Excludes radiographic services
– 
Identified headache and neck pain services
2.  General Practitioners (GP)
– 
Diagnostic billing codes used to identify services
– 
Excludes services without individual patient care
– 
Identified headache and neck pain services
Designs
1.  Matched Pair Case Control
–  Control is different person matched on age
and sex to case on index date
2.  Matched Pair Case Crossover
–  Control is same person matched to
themselves at previous times.
–  Better control of confounding factors.
Case-Control Design
Past DC or GP Service within x days?
yes
818
stroke
cases
no
Time
yes
no
Ontario
1993-2002
(pop.~12 M)
3,164 different
control subjects
Cassidy et al, Spine 2008
Stratified by < 45 years and >= 45 years old
Case-Crossover Design
Past DC or GP Service within x days?
yes
818
stroke
cases
no
Time
yes
no
Ontario
1993-2002
(pop.~12 M)
Multiple past
control times
Stratified by < 45 years and >= 45 years old
Case-Crossover Design
week
1 year
2 weeks
week
2 week washout
time prior to stroke
Stroke (index) date:
Exposure window:
Washout period:
Control periods:
0-7 days
0
Presentation
•  Stroke and Chiropractic
•  Past Studies
•  Study Methods
•  Study Results
•  Discussion
Results VBA
•  818 VBA strokes from 1993-2002
•  > 109 million person-years at risk
•  36.7% female
•  Mean age 63; Median age 63
•  102 case < 45 years
Comorbid Conditions
Variable*
Cases (n=818) Controls (n=3,164)
Hypertension
276 (33.7%)
738 (23.3%)
Heart Disease
275 (33.6%)
506 (16.0%)
Diabetes
155 (19.0%)
247 (7.8%)
62 (7.6%)
200 (6.3%)
515 (63.0%)
1,294 (40.9%)
High Cholesterol
At least one risk factor
* Ambulatory diagnoses from data during the one-year period
preceding the index date
Case Control: DC
Case Control
Exposure
window
Age < 45 years
Age ≥ 45 years
Odds Ratio
(95% CI)
Bootstrap
95% CI
Odds Ratio
(95% CI)
Bootstrap
95% CI
Odds Ratio
(95% CI)
Bootstrap
95% CI
0-1 days
1.1
(0.4-2.6)
0.4-2.6
12.0
(1.2-115.4)
*
0.6
(0.2-1.9)
0.1-1.9
0-3 days
0.9
(0.4-1.8)
0.4-1.8
3.3
(1.0-10.9)
0.8-14.0
0.4
(0.2-1.3)
0.1-1.3
0-7 days
1.00
(0.5-1.8)
0.5-1.8
2.4
(1.0-6.0)
0.8-6.3
0.6
(0.2-1.3)
0.2-1.2
0-14 days
1.2
(0.8-1.9)
0.8-1.9
3.1
(1.4-6.7)
1.3-7.3
0.8
(0.5-1.5)
0.5-1.5
0-30 days
1.1
(0.8-1.7)
0.8-1.6
3.1
(1.5-6.6)
1.3-7.2
0.8
(0.5-1.3)
0.5-1.3
* Unable to estimate
Case Control: GP
Case Control
Exposure
window
Age < 45 years
Age ≥ 45 years
Odds Ratio
(95% CI)
Bootstrap
95% CI
Odds Ratio
(95% CI)
Bootstrap
95% CI
Odds Ratio
(95% CI)
Bootstrap
95% CI
1-1 days
7.2
(4.7-11.1)
4.6-11.2
11.2
(3.6-35.0)
2.7-52.0
6.7
(4.2-10.6)
4.2-10.7
1-3 days
3.6
(2.8-4.7)
2.7-4.8
9.5
(4.0-23.0)
3.5-28.0
3.2
(2.4-4.3)
2.4-4.3
1-7 days
3.3
(2.7-4.0)
2.7-4.0
4.8
(2.6-9.0)
2.4-8.7
3.1
(2.5-3.9)
2.5-3.9
1-14 days
3.1
(2.6-3.7)
2.6-3.7
4.7
(2.8-7.8)
2.7-7.9
3.0
(2.5-3.5)
2.5-3.5
1-30 days
2.8
(2.4-3.2)
2.4-3.3
3.6
(2.2-5.9)
2.1-6.2
2.7
(2.3-3.2)
2.3-3.2
Case Crossover: DC
Case Crossover
Exposure
window
Age < 45 years
Age ≥ 45 years
Odds Ratio
(95% CI)
Bootstrap
95% CI
Odds Ratio
(95% CI)
Bootstrap
95% CI
Odds Ratio
(95% CI)
Bootstrap
95% CI
0-1 days
1.8
(0.7-4.8)
0.5-5.6
5.0
(0.8-31.0)
*
1.1
(0.3-4.0)
0.0-4.8
0-3 days
1.1
(0.5-2.5)
0.5-2.8
3.4
(1.0-12.3)
*
0.6
(0.2-1.8)
0.2-2.1
0-7 days
0.8
(0.4-1.6)
0.4-1.9
12.2
(2.5-59.0)
*
0.3
(0.1-0.8)
*
0-14 days
1.5
(0.9-2.5)
0.8-2.7
4.9
(1.6-12.6)
*
1.0
(0.5-1.9)
0.5-2.0
0-30 days
1.3
(0.8-2.1)
0.7-2.1
3.6
(1.4-9.4)
1.5-10.8
0.9
(0.5-1.6)
0.5-1.6
* Unable to estimate
Case Crossover: GP
Case Crossover
Exposure
window
Age < 45 years
Age ≥ 45 years
Odds Ratio
(95% CI)
Bootstrap
95% CI
Odds Ratio
(95% CI)
Bootstrap
95% CI
Odds Ratio
(95% CI)
Bootstrap
95% CI
1-1 days
4.4
(3.0-6.3)
3.1-6.5
15.2
(4.3-54.2)
3.7-68.0
3.7
(2.5-5.5)
2.5-5.6
1-3 days
2.9
(2.3-3.8)
2.2-3.7
5.6
(2.6-12.4)
2.1-14.6
2.7
(2.0-3.5)
2.0-3.5
1-7 days
2.4
(1.9-2.9)
1.9-3.0
2.9
(1.6-5.1)
1.6-5.1
2.3
(1.9-2.9)
1.9-2.9
1-14 days
2.4
(2.0-2.9)
2.0-2.9
3.5
(2.1-6.0)
2.0-6.5
2.3
(1.9-2.7)
1.9-2.8
1-30 days
2.4
(2.0-2.9)
2.0-3.0
3.0
(1.8-5.0)
1.7-5.1
2.3
(1.9-2.9)
1.9-3.0
Number of Services
All cases
Services month
before index date
Age < 45 years
Age ≥ 45 years
Odds Ratio
(95% CI)
Bootstrap
95% CI
Odds Ratio
(95% CI)
Bootstrap
95% CI
Odds Ratio
(95% CI)
Bootstrap
95% CI
1.1
(1.0-1.2)
1.0-1.2
1.4
(1.1-1.7)
1.0-1.9
1.0
(0.8-1.1)
0.8-1.2
1.5
(1.4-1.6)
1.3-1.7
1.3
(1.1-1.7)
0.9-1.9
1.5
(1.4-1.7)
1.4-1.7
Headache or cervical
chiropractic services
1.2
(1.0-1.4)
1.0-1.5
2.8
(1.4-5.5)
*
1.0
(0.8-1.2)
0.7-1.3
Headache or cervical
general practitioner
services
4.0
(2.9-5.5)
2.7-5.8
10.6
(3.5-32.8)
3.5-43.6
3.5
(2.5-5.0)
2.4-5.3
Chiropractic services
General practitioner
services
* Unable to estimate
Presentation
•  Stroke and Chiropractic
•  Past Studies
•  Study Methods
•  Study Results
•  Discussion
Discussion
1.  102 VBA strokes in persons under
age 45 years over 9 years in Ontario
2.  Risks are same for DC and GP
3.  Risks are greater for neck/head pain
related visits to GP and DC
Causal Pathways?
1. Chiropractic causes dissection
Vertebrobasilar Dissection
Neck Pain
Headache
Chiropractic
Manipulation
Stroke
Causal Pathways?
2a. Chiropractic causes thrombus
Dissection
Thrombus
Neck Pain
Headache
Chiropractic
Manipulation
Stroke
Causal Pathways?
2b. DC or GP causes thrombus
Dissection
Thrombus
Neck Pain
Headache
DC/GP visit
Stroke
Causal Pathways?
3. DC or GP visit not causal
Dissection
Thrombus
Neck Pain
Headache
DC/GP visit
Protopathic Bias
Stroke
Strengths - Limitations
1.  Large source population (more than 109
million person-years)
2.  Accurate and independent measures of
GP and DC visits (exposures)
3.  Selection bias controlled by design
4.  Confounding controlled by design
5.  Misclassification of stroke diagnoses
Take Home Messages
1.  VBA stroke is rare.
2.  Risk is the same for DC and GP
care.
3.  Dissection presenting as neck pain
and/or headache likely explains
these associations.
4.  More studies needed.
... er det farligt at komme på hospital ?
Review af 30.121 journaler fra 51 NY hospitaler i
1984
•  3,7 % »disabling iatrogenic injuries«
•  13,6% af disse fatale
Brennan TA et al. Incidence of adverse events and negligence in hospitalized patients
Results of the Harvard Medical Practice Study I. N Engl J Med 1991;324:370-376
Leape LL et al. The nature of adverse events in hospitalized patients
Results of the Harvard Medical Practice Study II. N Engl J Med 1991;324:377-384
Generel anæstesi
mortalitet 1- 4 /10.000
Fedtsugning
15 døde ved 112.756 operationer
CABG
3,7 % - 11,0 %
3,4 % - 5,7 %
Hofte alloplastik
4,0 % - 20,9%
1,1 % - 1,9 %
TUR-P
Hemorrhoidectomy 11 %
1,1 %
(27.000 ptt)
(16.000 ptt)
(85.000 ptt)
(+70 årige)
Sammenlignet med mange andre
smertelindrende procedurer (kirurgi) synes
SMT ikke at være specielt farligt
Den udbredte frygt blandt sundhedspersonale
for SMT
er måske mere et fagpolitisk holdning
end et egentligt klinisk problem ?
More Information?
•  Email:
[email protected]
[email protected]
[email protected]
•  Web sites:
www.uhnresearch.ca
www.nikkb.dk
•  Acknowledgements:
• 
David Cassidy – for providing most of the slides
Internal caro.d artery strains during HVLA – manipula.on of the neck •  SMT been postulated to damage internal structure at the treatment site •  Licle informa.on •  Examined (n=12) sonomicrometry – strains on caro.d artery during ROM and SMT •  Concluded: Maximal ICA strains imparted by cervical SMT were well within the normal ROM (thus does not seem to be a factor of ICA injuries) Herzog et al, JMPT, 2012