Dear Editor:
The profession has lost a truly commanding and dedicated person in the loss of Dr. Lorraine Golden, director of the Kentuckiana Chiropractic Center and a chiropractor in Louisville.
I do not believe I have ever known a more dedicated person to the cause in which she believed. I was associated with the clinic and assisted in having the government give her free title to a bit over three acres where the center is located. This was a very happy day in her life.
Because Dr. Golden lived, literally thousands of children are better off physically and emotionally.
William Harris, DC
Alpharetta, Georgia
Torticollis: "A Plea for Help"
Dear Editor:
In response to Dr. Michael Cocilovo's letter (see "We Get Letters," DC, Dec, 14, 1998) expressing concern and outrage at the advice from medical columnist Paul Donohue for the condition torticollis (cervical dystonia), I, through personal experience and grave disappointment, must stand on the side of Dr. Donohue. I also question whether or not Dr. Cocilovo has ever treated a case of true torticollis. I'm not talking about "wry neck," which presents as acute cervical pain, muscle spasm and restriction of movement which can also be called torticollis. This type of torticollis is very responsive to chiropractic adjustments. However, cervical dystonia (torticollis) at best is marginally, if at all, responsive to chiropractic adjustments/procedures.
Four years ago, I received a call from my 68-year-old mother expressing concern that her neck seemed to be moving to the left side and was doing it out of her control. Initially, I was not concerned and figured she was out of adjustment, something I would take care of during her next visit in a few weeks (I live in Georgia, she lives in New York).
To my shock, and despite 20 years of practice experience, I was not prepared for the presentation of my mother's problem: uncontrollable and fairly forceful involuntary movement of the head and neck to the left side. It is only in textbooks that I had ever seen or read of conditions like this before.
My mother has been to no less than six chiropractors (two of whom are nationally respected in their fields); eight neurologists; one neurosurgeon; three physical therapists; and one acupuncturist. She has also tried numerous prescription medicines, Chinese herbal medicine and other forms of nutritional supplementation. We have tried Botox injections and all different forms of exercises and visual stimulation of the brain. I am probably forgetting some things that we have tried, they have been so numerous.
I can say beyond a shadow of a doubt that my mother's condition has done nothing but get worse. Torticollis (cervical dystonia) is not a condition related directly to the vertebral subluxation complex although there may be indirect connections. It appears to be a problem involving the postencephalitic extra pyramidal system of a lesion of the lenticular nucleus.
I am not writing to discredit one doctor over another or one profession over another. This is actually a plea for help. My mother and I have cried together for hours over this situation which appears to be hopeless. The contractions of her neck are so forceful now that they almost keep her head completely rotated to the left with her chin in the downward position. Short of a risky and questionable surgical procedure, we know of nothing else that might help her.
Does anyone out there know of something to successfully help this condition? If you do, please contact me.
Steven Garber, DC
Cartersville, Georgia
Tel: (770) 386-7707
"Persistent Misconception"
Dear Editor:
Dr. Hammer's suggestion for a new test for vertebrobasilar insufficiency in the November 16, 1998 Dynamic Chiropractic, I believe furthers a persistent misconception among the chiropractic profession, i.e., that vertebrobasilar insufficiency/stroke due to manipulation is caused by a mechanical obstruction to blood flow in the vertebral artery due to rotational manipulation. This has been postulated by DeKleyn and others based on studies performed on cadavers demonstrating a decrease in flow through the vertebral arteries.1 In vivo studies have not been so clear, the most recent being Licht et al. comparing pre- and post-manipulation blood flow into the vertebral arteries with Doppler ultrasound in normal healthy subjects. They found no significant differences among pre- and post-manipulation in vertebral artery blood flow.
If one is to examine the case literature, particularly from 1980 onward when the use of angiography became usual and customary to evaluate what is happening to the arteries in question, or to look at autopsy findings in pre-angiography fatal cases, it becomes clear that the mechanism of injury in manipulation induced stroke is injury to the intima of the arterial wall, subsequent tear of the intima and dissection of the vertebral artery resulting in VBI or stroke.1,3,4
Dr. Leahy's hypothesis that previous trauma with subsequent adhesion to the vertebral artery may have merit. To quote Terret, "The VAS (vertebral arteries) are not freely moveable at the C1 and C2 transverse foramen, but are relatively fixed to the transverse processes by fibrous tissue."1
It may be true that arteriosclerosis, osteophytic or congenital atresia of the vertebral artery are possible causes of vertebral basilar insufficiency. This does not appear to be true in analysis of the case literature which indicates that the population experiencing manipulation-induced stroke is relatively young (20-50 years old), exactly the same population that is generally prone to spontaneous vertebral artery dissection.1
George's test is based on tendencies for stroke in the normal population prone to stroke, 65 years or older. The constant carotid bruit is not necessarily indicative of stroke, TIAs are not common in the 20-50-year-old group, neither is osteophyte formation impinging on the vertebral artery. The functional tests measure for occlusion of the vertebral artery which is probably not involved in manipulation-induced stroke.
It is probably true that 58 percent of Americans have congenital anomalies of one vertebral artery, but the opposite artery is generally much larger and collateral circulation is established well enough to show no overall decrease in vertebral artery blood flow to the brain.
Considering that the causes of spontaneous vertebral artery dissection have been related to conditions that weaken arterial walls, such as Marfan's syndrome, fibromuscular dysplasia, and being familiar with the technique that Drs. Horrigan, Leahy and Glum developed. I would be very hesitant to perform that kind of deep soft tissue to the neck in the vicinity of the carotid or vertebral arteries. I would also not make the assumption that a negative VATT test offered me any safety net against manipulation induced stroke.
Samuael Auyong, DC
Associate Clinical Professor
Los Angeles College of Chiropractic
References
- Terre AG. Malpractice Avoidance for Chiropractors: Vertebrobasilar Stroke Following Manipulation. NCMIC, 1995.
- Licht PB, Christensen HW, Hojgaard P, Marwing J. Vertebral artery flow and spinal manipulation: a randomized control and observer blinded study. JMPT, 1998, 21(3)141-144.
- Jaskovich P. Complication arising from manipulation of the cervical spine. JMPT, 1980, 3(4)213-219.
- Krueger BR, Okazaki H. Vertebrobasilar distribution infarction following chiropractic cervical manipulation. Mayo Clinic Proc, 1980, 55;322-332.
"It is ridiculous to claim that there is no research supporting AK"
Dear Editor,
I was surprised to read yet another letter from Dr. John McDaniel asserting that there is no research on applied kinesiology. I find this curious, since his initial letter was a response to a letter I had written in which several studies were listed. A simple search of the indexed literature will reveal several studies. Anyone who wants reprints of the papers form the indexed medical literature listed below may retrieve them using any of several search programs like MEDLINE, PubMed, or others. Those not equipped to search the literature may contact the administrative office of the International College of Applied Kinesiology -- USA Chapter (913) 384-5336. Copies of the papers will be sent to you.
The studies listed below are in the literature and are supportive evidence for the practices used in AK. It is ridiculous to claim that there is no research supporting AK. No credible scientist would say such a thing.
One might criticize any paper in the literature for flaws in design or randomization, etc. Every published study on any topic has some strengths and weaknesses. It is the nature of research. Chiropractors are seeing that kind of dialogue now with the release of the papers on manipulation published in the New England Journal of Medicine.
Dr. McDaniel's comment that "surely something is testable" lacks any credibility, since there are studies showing significant correlation comparing manual muscle testing with somatosensory evoked potentials and with EMG.1,2,3 No amount of hand-waving on Dr. McDaniel's part will make those studies go away.
It would be interesting and productive to print letters which discuss specific strengths and weaknesses of papers on AK or any other topic from the point of view of epidemiology, research design, or other specific, scientific issues of substance. But to simply deny that the papers exist or claim without specifics that the research is "all poorly done, wrongly interpreted, or just plain wrong" is folly, not science. The editorial boards of the journals that chose to publish these papers clearly disagree with Dr. McDaniel. Papers are accepted in peer review journals because they meet standards of scientific quality and research design.
As an aside, Dr. McDaniel refers to me as the research director of ICAK. This is ant accurate either. I am a research advisor, not the director.
Papers in the literature are:
- Leisman G, Shambaugh P, Ferentz A. Somatosensory evoked potential changes during muscle testing. International Journal of Neuroscience, 1989;45:143-151.
- Leisman G, et al. Electromyographic effects of fatigue and task repetition on the validity of estimates of strong and weak muscles in AK muscle testing procedures. Perceptual and Motor Skills, 1995;80:963-977.
- Perot C, Meldener R, Gouble F. Objective measurement of proprioceptive technique consequences on muscular maximal voluntary contraction during manual muscle testing. Agressologie, 1991;32,10:471-474.
- Esposito V, Leisman G. Neuromuscular effects of temporomandibular joint dysfunction. International Journal of Neuroscience, 1993;68:3-4.
- Esposito V, Leisman G, Frankenthal Y. Nonforce manual therapeutic effects on disc herniation. Journal of Orthopaedic Medicine, 1997;19:3,71-77.
- Lawson A, Calderon L. Interexaminer agreement for AK manual muscle testing. Perceptual and Motor Skills, 1997;84:539-546.
The following papers have been accepted for publication, that is, they have been through a journal's peer review process successfully, and is scheduled for publication in an upcoming issue. When the journal comes out, the paper is listed in the Index Medicus and may be retrieved through MEDLINE, etc. After acceptance and before printing, papers are cited as "in press." The level of evidence is the same as for a paper already published.
- Esposito V, et al. AK manual therapeutic effects on disc herniation with real time magnetic resonance imaging. Journal of Manual and Manipulative Therapy, 1999 (in press).
- Schmitt WH, Leisman G. Correlation of AK muscle testing findings with serum immunoglobulin levels for food allergies. International Journal of Neuroscience, 1999 (in press).
- Motyka T, Yanuck S. Expanding the neurological examination using functional neurologic assessment, Part I: Methodological considerations. International Journal of Neuroscience, 1999 (in press).
- Schmitt W, Yanuck S. Expanding the neurological examination using functional neurologic assessment, Part II: Neurologic basis of AK. International Journal of Neuroscience, 1999 (in press).
Good science is careful and incremental. Making sweeping, insupportable declarations about the value or lack of value of a whole range of issues is not scientific. Stirring people up with emotional comparisons to Dr. Koren, etc., is not at all scientific; it does not contribute to clear scientific thinking. Those are not the statements of a scientist. For our profession to progress, we need to learn how to discuss these issues in a credible, scientific way.
Samuel Yannuck, DC, FIACA
Research Advisor
International College of Applied Kinesiology