HenrikWulﬀ$Christensen$ Nordic$Instute of Chiropracc and ... · 1. Lumbal diskus syndrom inkl....

Bør cervikalcolumna manipuleres?

Henrik Wulff Christensen Nordic Ins<tute of Chiroprac<c and Clinical Biomechanics (NIKKB) Odense, Danmark

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


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


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)

Shekelle PG. What role for chiropractic in health care? N Engl J Med 1998;339:1074-5

»cervical manipulation arouses far more concern about safety than the use of

lumbar manipulation«

»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 1/560.000 2/5 cervikale behandlinger

Patient karakteristik?

Age distribution

Tidsfaktor mellem SMT og CVA

69 % umiddelbart under SMT 3 % minutter efter SMT 9 % < 1 time efter SMT

8 % 1 - 6 timer efter SMT 5 % 7 - 24 timer efter SMT 6 % > 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

Sidney Rubinstein, Thesis 2008

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


•  Miljøfaktorer –  infek.oner (svag associa.on), p-‐piller (posi.v associa.on)

METODEPROBLEMER: selek.onsbias, manglende blinding, manglende stra.ficering.

Rubinstein 2008


•  Traume – manipula.on (stærk associa.on) METODEPROBLEMER: små studier (n=7), selek.ons og informa.ons bias.

Rubinstein 2008


•  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

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

Case-‐series Case-‐reports

Cross-‐sec<onal

Case-‐control

Cohort

Prævalens, incidens, prognose, risiko

Clinical observa<on

Designed studies

47

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.

48

Presentation • Stroke and Chiropractic

• Past Studies

• Study Methods

• Study Results

• Discussion

49

Cervical Artery Dissections

Vertebral

Internal Carotid

50

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

51

Chiropractic Stroke?

Over 80% of patients with vertebral artery dissection present with neck and/or headache (Lee et al., Neurology, 2006).

Vertebral Dissection

VBA Stroke

C1-2 Rotation

52


53


54

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)

Past Case-Control Study

582

stroke cases

2,328 different control subjects

Past Chiropractic Service within one week?

yes

yes

no

no

Time

* Rothwell et al., Stroke 2001

Ontario 1993-1998 (pop.~11 M)

< 45 years old: OR=5.03 (95% CI=1.32-43.87)

56

Past Case-Control Study

26 CAD 51 VAD N=100

Other Strokes N=100

Past Chiropractic Service within 30 Days?

yes

yes

no

no

Time

Smith et al., Neurology 2003 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

57


• Past Studies

• Study Methods

• Study Results

• Discussion

•  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)

Study Population

•  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

Methods

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

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.

Designs

Case-Control Design

818

stroke cases

3,164 different control subjects

Past DC or GP Service within x days?

yes

yes

no

no

Time

Ontario 1993-2002

(pop.~12 M)

Stratified by < 45 years and >= 45 years old

Cassidy et al, Spine 2008

Case-Crossover Design

Multiple past control times

yes

yes

no

no

Time Ontario

1993-2002 (pop.~12 M)

Past DC or GP Service within x days?

Stratified by < 45 years and >= 45 years old

818 stroke cases

time prior to stroke

0-7 days week week 2 week washout 2 weeks

Stroke (index) date: Exposure window:

Washout period:

Control periods:

0 1 year

Case-Crossover Design


• Past Studies

• Study Methods

• Study Results

• Discussion

•  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

Results VBA

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%)

High Cholesterol 62 (7.6%) 200 (6.3%)

At least one risk factor 515 (63.0%) 1,294 (40.9%)

* Ambulatory diagnoses from data during the one-year period preceding the index date

Comorbid Conditions

* Unable to estimate

Case Control: DC

Exposure window

Case Control 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

Case Control: GP

Exposure window

Case Control 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


Exposure window

Case Crossover 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

Case Crossover: GP

Exposure window

Case Crossover 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


Services month before index date

All cases

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

Chiropractic services

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

General practitioner services

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

Number of Services


• 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?

Neck Pain Headache

Chiropractic Manipulation

Stroke Vertebrobasilar Dissection

1. Chiropractic causes dissection

Causal Pathways?

Neck Pain Headache

Chiropractic Manipulation

Stroke Dissection

2a. Chiropractic causes thrombus

Thrombus

Causal Pathways?

Neck Pain Headache

DC/GP visit

Stroke Dissection

2b. DC or GP causes thrombus

Thrombus

Causal Pathways?

Neck Pain Headache

DC/GP visit

Stroke Dissection

3. DC or GP visit not causal

Thrombus

Protopathic Bias

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 % (27.000 ptt)

Hofte alloplastik 4,0 % - 20,9% 1,1 % - 1,9 % (16.000 ptt)

TUR-P 1,1 % (85.000 ptt)

Hemorrhoidectomy 11 % (+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 ?

•  Email: [email protected]

[email protected]

[email protected]

•  Web sites: www.uhnresearch.ca

www.nikkb.dk

•  Acknowledgements: •  David Cassidy – for providing most of the slides

More Information?

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

HenrikWulﬀ$Christensen$ Nordic$Instute of Chiropracc and ... · 1. Lumbal diskus syndrom inkl....

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