arteriopathy in patients with spontaneous cervical artery dissection and they suggest that the outer layers are primarily involved in the causation of the intramural hematoma…” This article details the likelihood of an underlying abnormality in the histology of the arterial wall (arteriopathy) that greatly predisposes persons to dissection in their arteries, including the vertebral artery. “Vertebral artery strains during high speed low amplitude, cervical spinal manipulation”, Herzog, Journal of Electromyography and Kinesiology;22:12 740-746 “Vertebral artery strains obtained during SMT are significantly smaller than those obtained during diagnostic and range-of-motion testing, and are much smaller than failure strains. We conclude from this work that cervical SMT performed by trained clinicians does not appear to place undue strain on the VA, and thus does not seem to be a factor in vertebrobasilar artery injuries.” Herzog et al. have compared the strains created on a vertebral artery during a diversified cervical spine adjustment. They compared this to the strains found when doing a routing cervical range of motion study and they compared both with the level of strain needed to injure a healthy vertebral artery. The level of strain needed for the artery to fail was nine times greater than the forces created during the spinal adjustment. The cervical range of motion study was found to create more strain than the cervical spine adjustment but again well less than the forces required for arterial failure. “Chiropractic and stroke: association or causation?” Tuchin, Int J Clin Pract, September 2013, 67, 9, 825-833 Conclusion: There is lack of compelling evidence that SMT is causally associated with stroke. Physical triggers, including SMT, can serve as plausible final link between the underlying disease and stroke (for instance, in case of arterial dissection with existing connective tissue weakness). It appears few of Hill’s criteria for causality appear connected with VAD and chiropractic. “There may be some links or association with SMT and VAD in untrained practitioners, but this has not been established with chiropractors. The quality of evidence suggesting causation between chiropractic and VAD is mostly weak. Therefore, causality between chiropractic and vascular accidents has not been determined. It is possible that healthcare practitioners are not taking a thorough history to determine the cause of the VAD after SMT. Healthcare practitioners are probably missing many clinical facts, because they now only record the patient having SMT.” “They should enquire about other possible causes or circumstances for VAD. This may include minor neck trauma, a change in chronic neck pain or headache, recent infection or other predisposing lifestyle factors such as smoking, hyperlipidaemia, hypertension, and hyperhomocysteinaemia. Therefore, it is important that healthcare practitioners take a thorough clinical history to determine the cause of VAD. Systematic prospective studies are
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