We write concerning the recently published article by Klougart\u00a0 et al, (Klougart N; Leboeuf-Yde C, Rasmussen LR. Safety in chiropractic\u00a0 practice. Part II: Treatment to the upper neck and the rate of\u00a0 cerebrovascular incidents. J Manipulative Physiol Ther 1996; 19:563-9<\/a>).\u00a0 The authors should be commended for their exhaustive efforts in\u00a0 evaluating the occurrence of cerebrovascular incidents in chiropractic\u00a0 practice, a topic of great interest and importance to the profession (1,\u00a0 2). Based on earlier conclusions by these authors (1); their\u00a0 present study (2) and the findings of other authors (3-5), cervical\u00a0 spine .rotational maneuvers have been found to be clearly more\u00a0 associated with cerebrovascular accidents (CVAs) and cerebrovascular\u00a0 incidents (CVIs), after spinal manipulation than other techniques.\u00a0 Perhaps because of this fact, and the knowledge of the effects of\u00a0 rotation upon vertebral artery blood flow (6), the authors attempted to\u00a0 classify technique procedures as \u201crotation\u2019. or \u201cnonrotation\u201d in their\u00a0 retrospective analysis to estimate the occurrence of CVI s after\u00a0 chiropractic treatment to the cervical spine.<\/p>\n Although the authors had good intentions in their survey to\u00a0 attempt to identify what techniques might be associated with CVIs,\u00a0 inherent problems exist in administering such a. survey to\u00a0 chiropractors. The shortcomings may include (a) the failure to report\u00a0 the use of several different techniques in a given treatment session (7,\u00a0 8); (b) the reporting of a practitioner that they are using a\u00a0 particular system (i.e., Gonstead), when in actuality they are not using\u00a0 the appropriate protocols, screening procedures, case management,\u00a0 set-ups, lines of drive, segmental contact points and vectors or\u00a0 magnitude of force as taught and recommended by such a system and (c) a\u00a0 wide variation of competency among practitioners (9). These issues\u00a0 complicate the meaningfulness of any evaluation of a particular\u00a0 chiropractic technique.<\/p>\n Although the authors acknowledged that \u201cthe unwanted side\u00a0 effects\u201d of the Gonstead technique may have been due to a modification\u00a0 of the technique by the chiropractor, and that it may \u201cinclude a\u00a0 stronger element of rotation\/extension than is generally thought,\u201d\u00a0 several questions still arise. Pertaining to the six cases reportedly\u00a0 classified as \u201cGonstead,\u201d were any of the treating practitioners trained\u00a0 in the Gonstead technique, and how many hours of study were dedicated\u00a0 to such training? Were any of the chiropractors certified in the\u00a0 Gonstead technique? Did the practitioners use the protocols and\u00a0 screening procedures suggested by the Gonstead system (10)? Did the\u00a0 reported \u201cGonstead\u201d practitioners use elements of rotation in the\u00a0 set-up, or thrust procedure and to what degree (e.g.,-in case 10 it was\u00a0 reported that no rotation was used, but in the other 5 cases it was not\u00a0 mentioned whether rotation was used or not).<\/p>\n Moreover, assuming that \u201crotation\u201d refers to rotation of the\u00a0 cervical spine, or + or \u2013 0 Y designation suggested by White and Panjabi\u00a0 (11), for any valid conclusions to be made in a study of technique\u00a0 comparison, differentiation must be made between techniques that provide\u00a0 a thrust at the end range of the motion and those that only exhibit\u00a0 limited + or \u2013 0 Y rotation in the set-up and thrust. Classification of a\u00a0 particular technique into one of three categories (rotational, low\u00a0 rotational or nonrotational) instead of two (rotational or\u00a0 nonrotational) would be more appropriate for significance. The authors\u00a0 classified Gonstead as \u201cmainly nonrotation,\u201d yet elements of + or \u2013 0 Y\u00a0 are routinely included in both the set-up and thrust procedures for the\u00a0 cervical spine in the Gonstead technique (10). Gonstead, therefore,\u00a0 should have been classified under rotational or \u201clow rotational,\u201d which\u00a0 would have significantly affected the extrapolated estimates for\u00a0 rotation and nonrotation treatments regarding risk estimates for CVIs\u00a0 among technique procedures.<\/p>\n To expound further, another case in question, specifically case\u00a0 6, was considered a case of \u201cdefinite nonrotation,\u201d which involved a\u00a0 patient who developed CVI-related symptoms after receiving \u201cTraction\u201d\u00a0 and \u201cActivator\u201d combined in the treatment. The authors used this data to\u00a0 formulate their conclusion, \u201calthough there seems to be a link between\u00a0 upper cervical rotation manipulative techniques and cerebrovascular\u00a0 incidents, treatment to the lower neck and the use of other techniques\u00a0 are implicated. as well.\u201d<\/p>\n Because both traction and Activator were used in the treatment\u00a0 of the patient in case 6, and the methodology of neither treatment was\u00a0 neither explained nor discussed, it is impossible to draw a conclusion\u00a0 specific to the use of Activator or a \u201cnonrotation\u201d technique in this\u00a0 case, which deserves mention. The authors failed to provide discussion\u00a0 of this issue, as they did pertaining to \u201cGonstead technique\u201d in the\u00a0 preceding paragraph regarding the modification of the technique by the\u00a0 individual chiropractor. We want to make it clear that practitioners\u00a0 trained in use of the Activator Adjusting Instrument (AAI) and Activator\u00a0 Methods Chiropractic Technique (AMCT) are not taught to incorporate\u00a0 traction into treatment regimens and, furthermore, that cervical spinal\u00a0 adjustments\/manipulations are performed in the prone neutral position\u00a0 (12-14). Because there are several types of traction in use in\u00a0 chiropractic practice, some of which contain postures away from neutral\u00a0 including flexion and extension (15), the authors understandably\u00a0 referenced how the vertebral artery can be affected through traction\u00a0 (16). They further noted that \u201ctoggle\u201d and \u201cActivator\u201d techniques seem\u00a0 not to be under suspicion in CVIs after spinal manipulation.<\/strong><\/p>\n J Manipulative Physiol Ther.<\/a> 1997 Oct;20(8):567-8. [PMID:9345689<\/a>]<\/p>\n Author information:\u00a0Colloca CJ, Fuhr AW. Activator Methods International Ltd., Phoenix, AZ.<\/p>\n
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