That's very interesting. What exactly do you do to check the cervical ligament and for VBI? I'm curious because VBI in the ER is a major source of defensive medicine and seems to often result in a CTA. The other case of stroke case I saw was due to pre-existing VBI in a lady in her 60s or 70s. She went to the chiropractor twice and walked to her car vertiginous and ataxic both times. When she had finally had enough she came to the ER I evaluated her. On MRI she had posterior circulation strokes a few days different in age, matching her visits.If I may, the physical therapy literature approves of the use of high velocity, low amplitude thrust manipulation, however, our practice pattern ensures that we perform cervical ligament and VBI testing prior to the manipulation, and, we only thrust at midrange. Also, of note, joint mobilizations targeting the cervical spine have been shown to be equal in efficacy to HVLAT manipulation without the risk.
The way you're describing the maneuver as only in mid-range sounds pretty safe to me, though. The chiropractic maneuvers I've personally seen involved rapid rotation of the cervical spine about more than one axis for more than 15-20 degrees--high velocity and high amplitude. I'm sure not every chiropractor does it that way, but the problem is you can't generalize since it's not standardized across the discipline.
BTW, I really appreciated your lecture on back pain last year. You presented some material and science I had never seen before.
Ha! Yeah, that's real if he tried to deadlift 50 tons, the rest of his skeleton were infused with adamantine, his grip strength inherited from his grandmother on the planet Krypton and his feet semented to the floor and the weight placed on a Scrooge McDuck type exiting device on the floor, sure.
A rib or two at worst. But unless his spine is made of polystyrene this is not happening from the fall in those pictures. This is only one slice from a photoshopped CT scan, and if an injury like that are to happen I can't really see it happening by anything less than getting hit very hard by a car.
Note the cleanness of the "fracture." This seldom occurs in Nature.
I had a vertebral artery dissection at the age of 39 which caused a stroke. At the time was under the care of a chiropractor for chronic headaches. Neck adjustments one to two times a week. Had few neurologist's tell me that May have been the cause of the dissection. No direct proof but maybe. Five days in the hospital and 2 years after got to about 95% recovery. 8 years later now after dead lifts I will walk a little to the right my first 3-4 steps. Feel very lucky could have been worse.
The test is called a Vertebrobasilar Artery Insufficiency test. With the patient supine with head off end of table, you bring them into cervical extension and ipsilateral sidebending and cervical rotation with eyes open. You monitor for up to 30 seconds to see if they develop any nystagmus, nausea, dizziness / vertigo. I've had it work like a charm in the two cases I found a positive test in. One was a congenital malformation of the VB artery, and the other was found to be caused by an enlarged deep cervical lymph node that compressed the vagus nerve when placed in that position.
I can't speak for all chiropractors, but, as a general rule, it seems they are much more aggressive with cervical "adjustments" than PTs or DOs are with cervical manipulations. I use them very sparingly, always conduct a thorough screening prior to, and, speaking to the original article, I will not conduct a high velocity thrust manipulation on an individual that age (80 years old). If need be, I'll use graded joint mobilizations, which have been shown, time and time again, to be just as effective as thrust manipulations.
As usual, Will is right on the money. There are various techniques for cervical manipulation, some of which use less rotation than others and it is the rotation in the upper cervical spine that worries practitioners about potential injury.
However, it is important to note that the force required to induce a vertebral artery dissection is significant in a supposedly healthy artery (at least greater than the force of a fist punch to the head in a fashion that causes head rotation) – I have no research papers to support this due to the lack of willing subjects studied, but if our vertebral arteries were so fragile, then 50% of all boxers and MMA fighters who like to stand in the pocket would have career records of 0-1. The greater likelihood is that preexisting vascular pathology is the culprit as arterial dissections typically occur from within the blood vessel as opposed to from its exterior, except in traumatic cases. Keeping this pathology in mind, manual therapy providers should be cognizant of the fact that elderly patients (70+ years of age) are at the highest risk of cerebrovascular accidents with cervical manipulations given the definitive presence of atherosclerotic plaques and their sequellae.
Still, if an accident is going to occur, no one can predict it with certainty with the vertebrobasilar artery insufficiency test or a clinical history. I recall one year I had 6 cases with positive VBAIs and referred them on for neuro exams and MRA, which might have been overkill, but I didn’t care to take chances. All 6 were false alarms, nevertheless none of them received manipulations as part of their treatment plans.
Wow!! I wonder what Coan's X-ray like like after this. How was he able to enjoy so much continued success after what must have been such a devastating injury????
Coan PL Video Workout---Deadlift - YouTube