Cervical Manipulative Therapy Research Articles

P.061 Stroke from cerebral artery dissection after cervical spine manipulation therapy in younger patient case report

Background: Cervical and lumber spine manipulation therapy is widely used treatment of spinal degenerative disc disease. Serous side affects can be associated with this treatment especially in cervical spine. Stroke represents an infrequent adverse reaction associated with cervical spine manipulation therapy. Methods: 34 year old lady presented to Emergency Department (ED) referring Hospital 20 minutes after having neck manipulation by a chiropractor, she complained of neck pain after the manipulation with syncope, half hour later developed visual field loss, with few episodes of emesis, and increasing headache. Results: The patient was started on Aspirin and admitted locally for observation. Computers tomography (CT) head , CT-Angiography showed left Vertebral artery (V3 segment) , MRI showed acute infarction within the both cerebellar hemisphere, after 3 days patient transferred to our unit, patient had posterior fossa decompressive craniotomy with external ventricular drainage (EVD), discharged to rehabilitation 2 weeks, 2 months follow-up patient improving. Conclusions: There is inceased evidence that shows increased association between spinal manipulation and adverse effects and dissection of vertebral arteries in younger population. Younger patients (< 45 years) are particulary high risk, they should be informed of the risk of stroke or vascular injury from this procedure. No aggresive manipulation in younger population.

Dry needling and upper cervical spinal manipulation in patients with temporomandibular disorder: A multi-center randomized clinical trial

ABSTRACT Objective To compare the effects of dry needling and upper cervical spinal manipulation with interocclusal splint therapy, diclofenac, and temporomandibular joint (TMJ) mobilization in patients with temporomandibular disorder (TMD). Methods One hundred-twenty patients with TMD were randomized to receive six treatment sessions of dry needling plus upper cervical spinal manipulation (n = 62) or interocclusal splint therapy, diclofenac, and joint mobilization to the TMJ (n = 58). Results Patients receiving dry needling and upper cervical spinal manipulation experienced significantly greater reductions in jaw pain intensity over the last 7 days (VAS: F = 23.696; p < 0.001) and active pain-free mouth opening (F = 29.902; p < 0.001) than those receiving interocclusal splint therapy, diclofenac, and TMJ mobilization at the 3-month follow-up. Conclusion Dry needling and upper cervical spinal manipulation was more effective than interocclusal splint therapy, diclofenac, and TMJ mobilization in patients with TMD.

Beauty Parlor Stroke Syndrome in A 32 Year-Old Female: A Case Report

Purpose To describe a case report of the beauty parlor stroke syndrome in a 32 year old patient Summary: Beauty parlor stroke syndrome, otherwise known as a Hairdresser-related ischemic cerebrovascular event (HICE) or vertebral-basilar ischemia (VBI), is a rare phenomenon caused by either cerebral artery dissection or vertebral artery compression due to neck positioning and manipulation at the hair salon sink bowl. Majority of the cases previously reported occurred in elderly women, rather than younger patients. We describe a case of beauty stroke syndrome in a 32 year-old patient with no prior medical history or risk factors such as atherosclerotic disease, diabetes, hypertension and hyperlipidemia. Conclusion: The 2014 Stroke guidelines issued a warning to healthcare professionals regarding the risk of cervical artery dissections following cervical manipulative therapy in young and middle-aged adults. However, the risk of cervical artery dissection following manipulation at the shampoo bowl was not specifically mentioned. Practitioners must be cognizant of the various symptoms of beauty salon syndrome, and intervene in a timely manner to prevent potential ongoing issues.

Efficacy and safety of Shi-style cervical manipulation therapy for treating acute and subacute neck pain: study protocol for a randomized controlled trial

BackgroundNeck pain is a common clinical disease, which seriously affects people’s mental health and quality of life and results in loss of social productivity. Improving neck pain’s curative effect and reducing its recurrence rate are major medical problems. Shi’s manipulation therapy has unique advantages and technical features that aid in the diagnosis and treatment of neck pain. Compared with first-line non-steroidal anti-inflammatory drug (NSAID) treatment of neck pain, Shi’s cervical manipulation lacks the relevant research basis of therapeutic advantage, safety, and satisfaction for treating acute and subacute neck pain. Herein, we aim to confirm our hypothesis in a clinical trial that the safety and efficacy of Shi’s cervical manipulation will be more effective, safer, and more satisfactory than NSAIDs to treat acute and subacute neck pain.MethodsIn this multicenter, positive-controlled, randomized clinical trial, traditional analgesic drug (NSAID) is used to evaluate and show that Shi’s manipulation is more effective, safe, and satisfactory for treating acute and subacute neck pain. Overall, 240 subjects are randomly divided into the trial and control groups, with both groups treated by the corresponding main intervention method for up to 12 weeks. Clinical data will be collected before the intervention and immediately after the first treatment; at 3 days and 1, 2, 4, 8, and 12 weeks after the intervention; and at 26 and 52 weeks after treatment follow-up of clinical observation index data collection. The clinical observation indices are as follows: (1) cervical pain is the primary observation index, measured by Numerical Rating Scale. The secondary indices include the following: (2) cervical dysfunction index, measured by patient self-evaluation using cervical Neck Disability Index; (3) cervical activity measurement, measured by the cervical vertebra mobility measurement program of Android mobile phone system; (4) overall improvement, measured by patient self-evaluation with SF-36; and (5) satisfactory treatment, determined by patient self-evaluation.DiscussionWe will discuss whether Shi’s cervical manipulation has greater advantages in efficacy, safety, and satisfaction of acute and subacute neck pain than traditional NSAIDs, to provide a scientific basis for the dissemination and application of Shi’s cervical manipulation.Trial registrationChina Registered Clinical Trial Registration Center ChiCTR1900021371. Registered on 17 February 2019

Changes in Vertebral Artery Blood Flow in Different Head Positions and Post–Cervical Manipulative Therapy

ObjectiveThe objective of this study was to investigate the hemodynamics of blood flow through the V3 region of the vertebral artery contralateral to the side manipulated during different rotary head positions and post–cervical spinal manipulation. MethodsThis quasi-experimental study was performed on 25 healthy, asymptomatic participants, both male and female, between 20 and 30 years of age. Each participant presented with a C0/C1 or C1/C2 cervical facet restriction (as determined by motion palpation). Participation was voluntary, and participants had no symptoms of vertebrobasilar artery insufficiency or contraindications to cervical spinal manipulation. Doppler ultrasound was used to measure vertebral artery blood flow (V3 region) hemodynamics, contralateral side of manipulation, as close to C1/C2 region as possible in 4 positions of cervical rotation (neutral, 45°, maximum, and post-manipulation neutral). Doppler ultrasound parameters included peak systolic flow velocity, end diastolic flow velocity, mean flow velocity, vessel diameter, and flow rate. The nonparametric Friedman test was used for analysis across each head and neck position, and post manipulation. ResultsNo clinical or statistically significant results (P > .05) were found for any of the hemodynamic parameters in any of the head positions. ConclusionsHemodynamic measurements of the V3 region of the vertebral artery do not show significant changes in the measured head positions or following manipulation of the upper cervical spine in patients without pre-existing risk factors.

Should we abandon positional testing for vertebrobasilar insufficiency?

Positional testing for vertebrobasilar insufficiency (VBI) is used by physiotherapists as part of pre-manipulative screening protocols. Recently, the validity of the tests have been questioned because a negative test does not infer safety with cervical manipulative therapy but the reasoning surrounding this opinion may be questioned. While the positional tests were developed to test vertebral artery flow contralateral to the direction of head movement and the subsequent effect on cerebral blood supply, as inferred by symptom reproduction, ultrasound studies have shown that vertebral artery flow is inherently variable. Rather, the tests should be considered as testing for adequacy of collateral flow in particular head positions rather than decreased blood flow in a particular artery, with more attention to characteristics of symptom reproduction. We contend that positional testing for VBI remains valuable for testing adequacy of collateral flow, and also has an important place as part of the differential diagnosis of individuals with dizziness or imbalance. The physiotherapist's ability to differentially diagnose dizziness and recognise the presence or not of VBI is not only critical for prompt medical investigation and management because it is a risk factor for transient ischaemic events and stroke, but has important influences over management decisions regarding cervical musculoskeletal treatment including exercise interventions. Importantly, the positional tests should not be considered as tests of arterial integrity and used to assess the risk of damage to the vertebral or internal carotid artery or presence of cervical arterial dissection. Urgent research is needed before we abandon positional testing prematurely.

Triple and quadruple cervical artery dissections: a systematic review of individual patient data

Background and purposeSimultaneous dissection of three or four cervical arteries rarely occurs. As a result, limited information is available on clinical characteristics, underlying causes, treatment, and outcome of these patients.MethodsWe performed a systematic review of individual patient data on triple and quadruple cervical artery dissection (CeAD). We included all cases for whom, at minimum, data on age, sex and affected cervical arteries were available.ResultsOut of 1396 publications identified in the initial search, 52 were included, with data available on 96 patients. Mean age was 42 years and 66% were women. 63% had triple CeAD. The most common manifestations were headache (69%), neck pain (44%), motor deficit (36%), and Horner syndrome (34%). 57% had an ischemic stroke, in the majority of these patients the stroke was confined to the vascular territory of a single artery. 83% were managed medically (antiplatelets or anticoagulants) and 11% underwent endovascular treatment. An underlying disease or triggering event was identified in 71%, most commonly trauma (35%, cervical manipulative therapy in 13%), infection (18%), fibromuscular dysplasia (16%), and hereditary connective tissue disorder (8%). In-hospital mortality was 1%. 80% of patients had a good functional outcome (mRS 0–1) at follow-up. Two recurrences (3%) were reported.ConclusionsTriple or quadruple CeAD mostly affected young women, and underlying disease or triggering event could be identified in more than two-thirds of patients. Less than two-thirds of triple or quadruple CeAD patients suffered ischemic stroke. Most patients were managed medically and the majority had a favorable outcome.

Adverse events following cervical manipulative therapy: consensus on classification among Dutch medical specialists, manual therapists, and patients

Objectives: To obtain consensus-based agreement on a classification system of adverse events (AE) following cervical spinal manipulation. The classification system should be comprised of clear definitions, include patients’ and clinicians’ perspectives, and have an acceptable number of categories.Methods: Design: A three-round Delphi study. Participants: Thirty Dutch participants (medical specialists, manual therapists, and patients) participated in an online survey. Procedure: Participants inventoried AE and were asked about their preferences for either a three- or a four-category classification system. The identified AE were classified by two analysts following the International Classification of Functioning, Disability and Health (ICF), and the International Classification of Diseases and Related Health Problems (ICD-10). Participants were asked to classify the severity for all AE in relation to the time duration.Results: Consensus occurred in a three-category classification system. There was strong consensus for 16 AE in all severities (no, minor, and major AE) and all three time durations [hours, days, weeks]. The 16 AE included anxiety, flushing, skin rash, fainting, dizziness, coma, altered sensation, muscle tenderness, pain, increased pain during movement, radiating pain, dislocation, fracture, transient ischemic attack, stroke, and death. Mild to strong consensus was reached for 13 AE.Discussion: A consensus-based classification system of AE is established which includes patients’ and clinicians’ perspectives and has three categories. The classification comprises a precise description of potential AE in accordance with internationally accepted classifications. After international validation, clinicians and researchers may use this AE classification system to report AE in clinical practice and research.

Does case misclassification threaten the validity of studies investigating the relationship between neck manipulation and vertebral artery dissection stroke? No.

BackgroundThe purported relationship between cervical manipulative therapy (CMT) and stroke related to vertebral artery dissection (VAD) has been debated for several decades. A large number of publications, from case reports to case–control studies, have investigated this relationship. A recent article suggested that case misclassification in the case–control studies on this topic resulted in biased odds ratios in those studies.DiscussionGiven its rarity, the best epidemiologic research design for investigating the relationship between CMT and VAD is the case–control study. The addition of a case-crossover aspect further strengthens the scientific rigor of such studies by reducing bias. The most recent studies investigating the relationship between CMT and VAD indicate that the relationship is not causal. In fact, a comparable relationship between vertebral artery-related stroke and visits to a primary care physician has been observed. The statistical association between visits to chiropractors and VAD can best be explained as resulting from a patient with early manifestation of VAD (neck pain with or without headache) seeking the services of a chiropractor for relief of this pain. Sometime after the visit the patient experiences VAD-related stroke that would have occurred regardless of the care received.This explanation has been challenged by a recent article putting forth the argument that case misclassification is likely to have biased the odds ratios of the case–control studies that have investigated the association between CMT and vertebral artery related stroke. The challenge particularly focused on one of the case–control studies, which had concluded that the association between CMT and vertebral artery related stroke was not causal.It was suggested by the authors of the recent article that misclassification led to an underestimation of risk. We argue that the information presented in that article does not support the authors’ claim for a variety of reasons, including the fact that the assumptions upon which their analysis is based lack substantiation and the fact that any possible misclassification would not have changed the conclusion of the study in question.ConclusionCurrent evidence does not support the notion that misclassification threatens the validity of recent case–control studies investigating the relationship between CMT and VAD. Hence, the recent re-analysis cannot refute the conclusion from previous studies that CMT is not a cause of VAD.

Abstract WP197: Spinal Manipulation Therapy and Risk of Cerebrovascular Events: Evidence Map and Meta-analysis

Introduction: Cervical spinal manipulation therapy (SMT) has been associated with cerebrovascular events, including arterial dissection and stroke. We constructed an evidence map of the published literature and systematically reviewed epidemiological studies on the association between SMT and cerebrovascular events. Methods: We searched MEDLINE, EMBASE, Cochrane, the ISI database, and reference lists through 7/14 to identify studies with data, evidence, or opinions on stroke or dissection occurring after SMT. Descriptive statistics were used to summarize the study design and publication date of studies. Summary ORs with 95% confidence intervals (CI) were estimated using random effects inverse variance analyses. Results: Among 311 studies meeting eligibility criteria, most were case reports (105, 34%), editorials/letters (n=81, 26%) and case series (n=51, 16%). Six eligible analytic epidemiologic studies (in 5 publications) were found: 5 case control studies included a median of 53 cases (range 47-818; total 1546) and 100 controls (range 43-3164; total 5671) and one case-crossover study used 818 cases from one of the case control studies. SMT exposure within 30 days of the index date was not statistically significantly associated with stroke/dissection risk (OR = 1.79, 95% CI 0.88-3.64, p=0.11; I2 = 63%, p for heterogeneity = 0.03). Three studies used more reliable case definitions (imaging-confirmed dissection), and found that SMT was associated with a significantly increased risk (OR=4.31, 95% CI 1.32-14.07, p=0.015). Conclusion: Most studies published on the relation between SMT and cerebrovascular events cannot provide robust information on causal inference, but the few available epidemiologic studies indicate possible harm associated with SMT. More well-powered studies with better case ascertainment are needed to guide inference about SMT safety.

Cervical arterial dissection: An overview and implications for manipulative therapy practice

IntroductionCervical arterial dissection (CAD) is a common cause of stroke in young people under 55 years. It can occur spontaneously or subsequent to minor trauma or infection. The incidence is difficult to determine accurately as not all CAD progress to stroke. CAD is the most catastrophic adverse event associated with cervical manipulative therapy but it is rare. Early features of CAD can mimic a painful musculoskeletal presentation and a patient may present for treatment of neck pain and headache with a dissection in progress. Whether the manipulative technique is responsible for dissection or whether the diagnosis of CAD has been missed is unclear. Identification of individuals at risk, or early recognition of CAD could help expedite medical intervention and avoid inappropriate treatment. PurposeThe aims of this masterclass are to outline current research into the pathophysiology, aetiology and clinical presentation of CAD, to place the risk in context in a manipulative therapy setting and to discuss its possible clinical recognition. ImplicationsFor those patients presenting with recent onset, moderate to severe unusual headache or neck pain, clinicians should perform a careful history, in particular questioning about recent exposure to head/neck trauma or neck strain. Cardiovascular factors may not be particularly useful indicators of risk of dissection. Clinicians should also be alert to reports of transient neurological dysfunction such as visual disturbance and balance deficits, arm paraesthesia and speech deficits, as these may be subtle. If clinicians suspect arterial dissection is in progress patients should be urgently referred for medical evaluation.

Risk Factors and Clinical Presentation of Cervical Arterial Dissection: Preliminary Results of a Prospective Case-Control Study.

Cross-sectional case-control study. To identify risk factors and clinical presentation of individuals with cervical arterial dissection. Cervical arterial dissection is a common cause of stroke in young people and has in rare cases been associated with cervical manipulative therapy. The mechanism is considered to involve pre-existing arterial susceptibility and a precipitating event, such as minor trauma. Identification of individuals at risk or early recognition of a dissection in progress could help expedite medical intervention and avoid inappropriate treatment. Participants were individuals 55 years of age or younger from the Hunter region of New South Wales, Australia with radiologically confirmed vertebral or internal carotid artery dissection and an age- and sex-matched comparison group. Participants were interviewed about risk factors, preceding events, and clinical features of their stroke. Physical examination of joint mobility and soft tissue compliance was undertaken. Twenty-four participants with cervical arterial dissection and 21 matched comparisons with ischemic stroke but not dissection were included in the study. Seventeen (71%) of the 24 participants with dissection reported a recent history of minor mechanical neck trauma or strain, with 4 of these 17 reporting recent neck manipulative therapy treatment. Cardiovascular risk factors were uncommon, with the exception of diagnosed migraine. Among the participants with dissection, 67% reported transient ischemic features in the month prior to their admission for dissection. Recent minor mechanical trauma or strain to the head or neck appears to be associated with cervical arterial dissection. General cardiovascular risk factors, with the exception of migraine, were not important risk factors for dissection in this cohort. Preceding transient neurological symptoms appear to occur commonly and may assist in the identification of this serious pathology. Prognosis, level 4.

The addition of upper cervical manipulative therapy in the treatment of patients with fibromyalgia: a randomized controlled trial.

The aim of this study was to investigate the immediate and long-term effects of a one-year multimodal program, with the addition of upper cervical manipulative therapy, on fibromyalgia management outcomes in addition to three-dimensional (3D) postural measures. This randomized clinical trial with one-year follow-up was completed at the research laboratory of our university. A total of 120 (52 female) patients with fibromyalgia syndrome (FMS) and definite C1-2 joint dysfunction were randomly assigned to the control or an experimental group. Both groups received a multimodal program; additionally, the experimental group received upper cervical manipulative therapy. Primary outcomes were the Fibromyalgia Impact Questionnaire (FIQ), whereas secondary outcomes included Pain Catastrophizing Scale (PCS), algometric score, Pittsburgh Sleep Quality Index (PSQI), Beck Anxiety Inventory (BAI), Beck Depression Inventory (BDI), and 3D postural measures. Measures were assessed at three time intervals: baseline, 12weeks, and 1year after the 12-week follow-up. The general linear model with repeated measures indicated a significant group×time effect in favor of the experimental group on the measures of 3D postural parameters (P<.0005), FIQ (P<.0005), PCS (P<.0005), algometric score (F=P<.0005), PSQI (P<.0005), BAI (P<.0005), and BDI (P<.0005). The addition of the upper cervical manipulative therapy to a multimodal program is beneficial in treating patients with FMS.

Acute effects of single and multiple level thoracic manipulations on chronic mechanical neck pain: a randomized controlled trial.

BackgroundThoracic spine manipulation has become a popular alternative to local cervical manipulative therapy for mechanical neck pain. This study investigated the acute effects of single-level and multiple-level thoracic manipulations on chronic mechanical neck pain (CMNP).MethodsForty-eight patients with CMNP were randomly allocated to single-level thoracic manipulation (STM) at T6–T7 or multiple-level thoracic manipulation (MTM), or to a control group (prone lying). Cervical range of motion (CROM), visual analog scale (VAS), and the Thai version of the Neck Disability Index (NDI-TH) scores were measured at baseline, and at 24-hour and at 1-week follow-up.ResultsAt 24-hour and 1-week follow-up, neck disability and pain levels were significantly (P<0.05) improved in the STM and MTM groups compared with the control group. CROM in flexion and left lateral flexion were increased significantly (P<0.05) in the STM group when compared with the control group at 1-week follow-up. The CROM in right rotation was increased significantly after MTM compared to the control group (P<0.05) at 24-hour follow-up. There were no statistically significant differences in neck disability, pain level at rest, and CROM between the STM and MTM groups.ConclusionThese results suggest that both single-level and multiple-level thoracic manipulation improve neck disability, pain levels, and CROM at 24-hour and 1-week follow-up in patients with CMNP.

Cervical arterial dissections and association with cervical manipulative therapy: a statement for healthcare professionals from the american heart association/american stroke association.

Cervical artery dissections (CDs) are among the most common causes of stroke in young and middle-aged adults. The aim of this scientific statement is to review the current state of evidence on the diagnosis and management of CDs and their statistical association with cervical manipulative therapy (CMT). In some forms of CMT, a high or low amplitude thrust is applied to the cervical spine by a healthcare professional. Members of the writing group were appointed by the American Heart Association Stroke Council's Scientific Statements Oversight Committee and the American Heart Association's Manuscript Oversight Committee. Members were assigned topics relevant to their areas of expertise and reviewed appropriate literature, references to published clinical and epidemiology studies, morbidity and mortality reports, clinical and public health guidelines, authoritative statements, personal files, and expert opinion to summarize existing evidence and to indicate gaps in current knowledge. Patients with CD may present with unilateral headaches, posterior cervical pain, or cerebral or retinal ischemia (transient ischemic or strokes) attributable mainly to artery-artery embolism, CD cranial nerve palsies, oculosympathetic palsy, or pulsatile tinnitus. Diagnosis of CD depends on a thorough history, physical examination, and targeted ancillary investigations. Although the role of trivial trauma is debatable, mechanical forces can lead to intimal injuries of the vertebral arteries and internal carotid arteries and result in CD. Disability levels vary among CD patients with many having good outcomes, but serious neurological sequelae can occur. No evidence-based guidelines are currently available to endorse best management strategies for CDs. Antiplatelet and anticoagulant treatments are both used for prevention of local thrombus and secondary embolism. Case-control and other articles have suggested an epidemiologic association between CD, particularly vertebral artery dissection, and CMT. It is unclear whether this is due to lack of recognition of preexisting CD in these patients or due to trauma caused by CMT. Ultrasonography, computed tomographic angiography, and magnetic resonance imaging with magnetic resonance angiography are useful in the diagnosis of CD. Follow-up neuroimaging is preferentially done with noninvasive modalities, but we suggest that no single test should be seen as the gold standard. CD is an important cause of ischemic stroke in young and middle-aged patients. CD is most prevalent in the upper cervical spine and can involve the internal carotid artery or vertebral artery. Although current biomechanical evidence is insufficient to establish the claim that CMT causes CD, clinical reports suggest that mechanical forces play a role in a considerable number of CDs and most population controlled studies have found an association between CMT and VAD stroke in young patients. Although the incidence of CMT-associated CD in patients who have previously received CMT is not well established, and probably low, practitioners should strongly consider the possibility of CD as a presenting symptom, and patients should be informed of the statistical association between CD and CMT prior to undergoing manipulation of the cervical spine.

The quality of reports on cervical arterial dissection following cervical spinal manipulation.

BackgroundCervical artery dissection (CAD) and stroke are serious harms that are sometimes associated with cervical spinal manipulation therapy (cSMT). Because of the relative rarity of these adverse events, studying them prospectively is challenging. As a result, systematic review of reports describing these events offers an important opportunity to better understand the relation between adverse events and cSMT. Of note, the quality of the case report literature in this area has not yet been assessed.Purpose1) To systematically collect and synthesize available reports of CAD that have been associated with cSMT in the literature and 2) assess the quality of these reports.MethodsA systematic review of the literature was conducted using several databases. All clinical study designs involving CADs associated with cSMT were eligible for inclusion. Included studies were screened by two independent reviewers for the presence/absence of 11 factors considered to be important in understanding the relation between CAD and cSMT.ResultsOverall, 43 articles reported 901 cases of CAD and 707 incidents of stroke reported to be associated with cSMT. The most common type of stroke reported was ischemic stroke (92%). Time-to-onset of symptoms was reported most frequently (95%). No single case included all 11 factors.ConclusionsThis study has demonstrated that the literature infrequently reports useful data toward understanding the association between cSMT, CADs and stroke. Improving the quality, completeness, and consistency of reporting adverse events may improve our understanding of this important relation.

Cerebral Embolus Following Chiropractic Manipulation in a Patient with a Calcified Carotid Artery

Dissection of the cervicocranial vessels is the principal cause of ischemic brain injury following cervical spinal manipulation. Cervical spinal manipulation leading to cerebral embolus in the absence of dissection is not described in the literature. Current case documents cerebral embolism originating from extensively calcified internal carotid artery immediately following cervical spinal manipulation in the absence of dissection. We describe a case and imaging findings of a 63-year-old male who underwent cervical spinal manipulation and developed sudden onset of left-arm numbness and weakness. Computed tomography angiography demonstrated extensively calcified right internal carotid artery at the site of redone carotid endarterectomy as well as calcified embolus in the right inferior middle cerebral artery. Calcified carotid artery may be at risk for embolization following cervical spinal manipulation. Our recommendation is that, patients with extensively calcified carotid arteries should refrain from aggressive neck maneuvers and cervical spine manipulation therapy to avoid liberation of cerebral embolus.

Migraine-like presentation of vertebral artery dissection after cervical manipulative therapy

Headache is the common symptom in patients with cervical artery dissection. However, it rarely occurs in isolation, without focal neurological signs, and even more rarely mimics migraine. We present a clinical case of young woman with new severe throbbing unilateral headache which started one week after cervical manipulative therapy. No history of migraine was present. Vertebral artery dissection was diagnosed after duplex ultrasound and CT angiography. Local symptoms and signs were absent, and diffusion-weighted MRI did not show any acute brain ischemic lesions. Throbbing headache gradually resolved in 10 days. Follow-up 5 months later showed near-complete normalization of lumen and flow of dissected vertebral artery. The possibility of extracranial dissection should be considered in patients with first attack of migraine-like hemicrania, especially if cervical manipulations or trauma occurred recently.

Effect of Cervical Spine Manipulative Therapy on Judo Athletes' Grip Strength

Objective The objective of this study was to perform an investigation evaluating if cervical spinal manipulative therapy (SMT) can increase grip strength on judo athletes in a top 10 national-ranked team. Methods A single-blinded, prospective, comparative, pilot, randomized, clinical trial was performed with 18 athletes of both sexes from a judo team currently competing on a national level. The athletes were randomly assigned to 2 groups: chiropractic SMT and sham. Three interventions were performed on each of the athletes at different time points. Force measurements were obtained by a hydraulic dynamometer immediately before and after each intervention at the same period before training up to 3 weeks with at least 36 hours between interventions. Results Analysis of grip strength data revealed a statistically significant increase in strength within the treatment group after the first intervention (6.95% right, 12.61% left) as compared with the second (11.53% right, 17.02% left) and the third interventions (10.53% right, 16.81% left). No statistically significant differences were found in grip strength comparison within the sham group. Overall differences in strength were consistently significant between the study groups ( P = .0025). Conclusion The present study suggests that the grip strength of national level judo athletes receiving chiropractic SMT improved compared to those receiving sham.

Upper Cervical Manipulation Combined with Mobilization for the Treatment of Atlantoaxial Osteoarthritis: A Report of 10 Cases

Objective This study presents the outcomes of patients with idiopathic degenerative and posttraumatic atlantoaxial osteoarthritis who were treated with upper cervical manipulation in combination with mobilization device therapy. Clinical Features A retrospective case review of 10 patients who were diagnosed with either degenerative or posttraumatic atlantoaxial arthritis based on histories, clinical symptoms, physical examination, and radiographic presentations was conducted at a multidisciplinary integrated clinic that used both chiropractic and orthopedic services. All 10 patients selected for this series were treated with a combination of upper cervical manipulation and mechanical mobilization device therapy. Outcome measures were collected at baseline and at the end of the treatment period. Assessments were measured using patients' self-report of pain using a numeric pain scale (NPS), physical examination, and radiologic changes. Average premanipulative NPS was 8.6 (range, 7-10), which was improved to a mean NPS of 2.6 (range, 0-7) at posttreatment follow-up. Mean rotation of C1-C2 at the end of treatment was improved from 28° (±3.1) to 52° (±4.5). Restoration of joint space was observed in 6 patients. Overall clinical improvement was described as “good” or “excellent” in about 80% of patients. Clinical improvements in pain and range of motion were seen in 80% and 90% of patients, respectively. Conclusion Chiropractic management of atlantoaxial osteoarthritis yielded favorable outcomes for these 10 patients.