Chiropractic manipulation

By Marcello Cherchi, MD PhD

For patients

Some patients visit a chiropractor for neck and back problems. Chiropractic treatment may not be helpful for illnesses that cause disequilibrium.

For clinicians

Overview

Evidence for efficacy of chiropractic manipulation in the treatment of specific otoneurological conditions is lacking. Chiropractic manipulation also poses the risk of complications such as cervical arterial dissection and stroke.

Introduction

In the United States, chiropractic manipulation is a popular treatment modality among complementary and alternative medicine. It is estimated that from 6% (Davis et al. 2012) to 7.5% (Barnes et al. 2004) of adults consult a chiropractor each year in the US, and expenditures on chiropractic care are growing (Davis et al. 2010).

Application

Patients often express interest in chiropractic manipulation for disequilibrium. One study commented that:

“The National Health Interview Survey data indicate that, although seeking chiropractic care for balance and dizziness is not highly prevalent, a higher proportion of those who do report that it has helped their condition, compared to all other health professions in the analysis. Those who were older and who reported the cause of their balance problem to be head or neck trauma or neuromusculoskeletal were most likely to report being helped by chiropractic” (Ndetan et al. 2016).

In this paper, Ndetan and colleagues (Ndetan et al. 2016) used broad diagnostic categories including (“head or neck trauma,” “inner ear infection,” “neurological or muscular conditions,” “side effects of medicines and drugs,” “other health problems”) which makes it difficult to interpret their conclusions. A category such as “neurological or muscular conditions” is vague, and thus difficult to assess. The picture is further clouded by claims such as chiropractic manipulation being effective in treating Ménière’s disease (Emary 2010); we find it difficult to postulate a physiologically plausible mechanism for such efficacy.

Adverse effects

Millions of people undergo chiropractic manipulation without suffering any medical complications. When complications do occur, they can include catastrophic problems such as cervical arterial dissection (Albuquerque et al. 2011; Chen et al. 2006; Hillier and Gross 1998; Vibert et al. 1993) and stroke (Chen et al. 2006; Jeong and Hwang 2018; Miller and Burton 1974) — conditions for which a neurologist is usually consulted — and because of this sampling bias, neurologists often develop an unfavorable view of chiropractic manipulation. Cai and colleagues (Cai et al. 2014) comment that estimates of occurrence of cervical arterial dissection following chiropractic manipulation are wildly divergent, ranging from 1 in 958 manipulations (Thomas et al. 2011) to 1 in 5.85 million manipulations (Haldeman et al. 2001) — in other words, a difference of 3 orders of magnitude.

Relevance in otoneurology

Given the limited evidence of efficacy of chiropractic manipulation for specific otoneurological conditions, and the potential for significant medical complications, we do not currently see a role for this treatment modality in otoneurology.

References

Albuquerque FC, Hu YC, Dashti SR, Abla AA, Clark JC, Alkire B, Theodore N, McDougall CG (2011) Craniocervical arterial dissections as sequelae of chiropractic manipulation: patterns of injury and management. J Neurosurg 115: 1197-205. doi: 10.3171/2011.8.JNS111212

Barnes PM, Powell-Griner E, McFann K, Nahin RL (2004) Complementary and alternative medicine use among adults: United States, 2002. Advance Data 343: 1-19.

Chen WL, Chern CH, Wu YL, Lee CH (2006) Vertebral artery dissection and cerebellar infarction following chiropractic manipulation. Emerg Med J 23: e1. doi: 10.1136/emj.2004.015636

Davis MA, Onega T, Weeks WB, Lurie JD (2012) Where the United States spends its spine dollars: expenditures on different ambulatory services for the management of back and neck conditions. Spine (Phila Pa 1976) 37: 1693-701. doi: 10.1097/BRS.0b013e3182541f45

Davis MA, Sirovich BE, Weeks WB (2010) Utilization and expenditures on chiropractic care in the United States from 1997 to 2006. Health Serv Res 45: 748-61. doi: 10.1111/j.1475-6773.2009.01067.x

Emary PC (2010) Chiropractic management of a 40-year-old female patient with Meniere disease. J Chiropr Med 9: 22-7. doi: 10.1016/j.jcm.2009.12.007

Hillier CE, Gross ML (1998) Sudden onset vomiting and vertigo following chiropractic neck manipulation. Postgrad Med J 74: 567-8. doi: 10.1136/pgmj.74.875.567

Jeong DK, Hwang SK (2018) A Case of Posterior Inferior Cerebellar Artery Infarction after Cervical Chiropractic Manipulation. Korean J Neurotrauma 14: 159-163. doi: 10.13004/kjnt.2018.14.2.159

Miller RG, Burton R (1974) Stroke following chiropractic manipulation of the spine. JAMA 229: 189-90.

Ndetan H, Hawk C, Sekhon VK, Chiusano M (2016) The Role of Chiropractic Care in the Treatment of Dizziness or Balance Disorders: Analysis of National Health Interview Survey Data. J Evid Based Complementary Altern Med 21: 138-42. doi: 10.1177/2156587215604974

Vibert D, Rohr-Le Floch J, Gauthier G (1993) Vertigo as manifestation of vertebral artery dissection after chiropractic neck manipulations. ORL J Otorhinolaryngol Relat Spec 55: 140-2. doi: 10.1159/000276405