updated 8/20/09

What Happened To My Barber?

Either atlantoaxial instability or vertebrobasilar insufficiency causes severe dizziness and vomiting after massage therapy, with lessons for health care consumers

by Paul Ingraham, Vancouver, Canada MORE
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Credentials and qualifications

I am a writer and retired Registered Massage Therapist (unusually well-trained for a massage therapist, a 3000-hour program). I’m almost done with a Bachelor of Health Sciences degree. I am a peer reviewer for The Natural Standard, and a copyeditor for Science-Based Medicine. My most important qualification is more than a decade of workaholic post-graduate study, clinical experience, and constant conversations with readers from around the world, including many experts who have provided countless suggestions and criticisms.

For more information, see: Who Am I to Say? More information about my qualifications, credentials and professional experiences for my readers and customers.

My barber recently confided that he’d had a severe negative reaction to the first and last massage he’d ever had — not in my office, but from another Registered Massage Therapist. He had sought help for chronic headaches, and the massage felt good at the time. But he was so dizzy afterwards that he couldn’t stand or drive properly, and he vomited several times when he arrived home.

“Uh oh,” I said. “What did the therapist tell you?”

“He told me that the massage had released lots of toxins into my bloodstream. Is that true?”

Absolutely not true! Repeat after me, everyone: severe dizziness and repeated vomiting is not a normal reaction to massage therapy!1 Nor is it a normal reaction to any other kind of physical therapy. Anyone experiencing such symptoms should consult a physician promptly.

This is a disturbing case. It’s troubling to think that a professional with the same training I had could tell a client something so irresponsible — in theory, we know better. My barber has been walking around with a potentially lethal misconception of what is going on in his neck! It is a classic example of how alternative health care professionals with inadequate training may put their patients at risks by failing to recognize ominous signs and symptoms, or take them seriously.

Severe dizziness and vomiting is not a normal reaction to massage therapy!

What really happened to my barber? Probably atlantoaxial instability

The details of his case are a good match with compression of the brain stem, as could be caused by atlantoaxial instability (AAI, or more descriptively called upper cervical instability). It’s also possible that he had a problem with impairment of blood flow to the brain, which I’ll discuss in the next section.

AAI is a loss of the integrity of the joint between the top vertebrae of the cervical spine — called the “atlas” — and the one beneath it, the “axis.” AAI may be caused by an old injury to the neck. If this is what my barber has, when he moves his neck in a certain way, a small, finger-like projection of bone from his second cervical vertebrae could poke him in the brain stem, with consequences ranging from unpleasant to lethal.

This rogue piece of bone, called the dens, is normally held down by a strap of ligament, which is sometimes broken in accidents, or eroded and loosened by some kinds of arthritis, or by cancer. His severe chronic neck pain and headaches — the reason he went for a massage in the first place — could be the result of his neck muscles working tirelessly to keep everything stable. His body knows — even if he doesn’t — that this is a life-threatening situation!

AAI is a complex condition, with many possible causes. It does not necessarily cause any problem. Even patients with severe instability may have no symptoms at all, while others with relatively minor instability experience significant problems.2 It is impossible to reliably diagnose AAI “by feel,”3 as I was trained to do.

So it may well be possible for patients with AAI to lead normal lives, and if they suffer from chronic neck pain or headaches they can probably be treated cautiously with massage therapy — but it is crucial that they understand the nature of their problem. Careless massage therapy and spinal manipulative therapy are obviously dangerous. Athletic activities like skiing need to be reconsidered when a mild fall could end your fun forever!

Could it have been a case of vertebrobasilar insufficiency?

In addition to the large carotid artery, small arteries in the side of the neck supply the brain with blood. These arteries are somewhat vulnerable to being pinched off or even torn. If the flow of blood is impaired, it’s called vertebrobasilar insufficiency, or VBI. If the artery actually tears, which can cause brain damage due to the loss of blood supply to the brain, it’s called vertebral artery “dissection,” or VAD.

VBI & VAD can also cause the kinds of symptoms my barber had, and worse — even death.

However, it’s somewhat unlikely that this was the cause of my barber’s terrible experience: dizzyness and vomiting are somewhat more typical of brain stem lesions. His history of severe neck tension and headaches tends to point towards atlantoaxial instability. And the lack of other typical VBI/VAD symptoms is also an indicator. VBI is more likely to cause persistent symptoms in a variety of circumstances. VAD is often even more serious than what he experienced, although there is such a thing as a “small” stroke (even asymptomatic ones).

There’s no way to know for sure, of course. But whatever happened, it was for damn sure not “toxins”?

Can chiropractic adjustment do this also?

Evidence suggests that cervical spinal manipulative therapy — neck cracking — could be dangerous.4 Not only can chiropractic adjustments of the neck be dangerous for people with atlantoaxial instability, they are also “associated with” VBI/VAD. All the experts agree about this — even chiropractic authorities agree that “there are considerable case studies describing the onset of vertebral artery injury following a manipulation.”5

Athough the risk of such serious complications is very low, it must be considered, because the benefits of joint cracking in the neck are either fairly minor or highly controversial,6 7 and unfortunately chiropractors often perform neck adjustments for reasons that cannot be defended scientifically.8 “If the risk is death and the benefit is zero, then it is unacceptable to proceed.”Or, as a group of Canadian neurologists put it, “Is a headache worth dying for?”9 Massage therapy for the neck, at least, is less dangerous and more beneficial.

As with my barber’s massage therapist, the dismissive attitude that chiropractors sometimes have about these hazards can be quite disturbing. Consider this story that I came across not long after hearing my barber’s story:

Following manipulation the patient said, “Oh, that was awful, something terrible has happened to me. That’s awful. Let me up. I don’t want anymore; I can’t stand anymore.” The chiropractor then said “you will be all right. Let me get this other one.” The patient then said “I have had enough, don’t, stop.” The chiropractor continued to manipulate the patient. Immediately following the adjustment she was unable to walk, her vision was impaired, she vomited, and she had a partial paralysis of the throat and vocal cords.
Vertebrobasilar stroke following manipulation, by A Terrett

Shudder.

Why did my barber’s therapist fail?

My barber’s therapists probably failed because he was, like most massage therapists, simply was not well-trained enough to know any better, despite the unusually high certification standards for massage therapists in this part of the world.10

The state of the art is a moving target, and I was taught obsolete information. I learned the basic manual tests for AAI in school in 1998 or so, a couple years after Swinkels et al had already published a review showing that the tests were pretty much totally unreliable.

The idea of such testing is to basically just to cautiously feel for the looseness of the joint, and to watch for the signs of brain stem impingement. In theory, we were taught the tests so that we could identify patients that might be accidentally injured or killed by careless manipulation of the neck — an extremely important safety issue!

The patient walked in the door and said, “I have AAI. If you’re not careful with my neck, I’ll throw up for a day, and you could kill me.” And it still happened.

And yet I don’t remember and particular emphasis being placed on the testing, and I do clearly remember being frustrated that I graduated with several people who didn’t really seem to “get it.” And what a thing not to get!

It was particularly shocking given that one of our own classmates actually had symptomatic post-traumatic AAI and was actually injured by another classmate in our student clinic — someone who didn’t even have to do the testing, because the patient walked in the door and said, “I have AAI. If you’re not careful with my neck, I’ll throw up for a day, and you could kill me.” And it still happened.

I became the only student in the class she would accept treatments from. Today, one of my own clients has the same condition, and he also receives safe and effective treatment from me in spite of this extraordinary risk. So I have some first hand experience with this condition. The tests may be unreliable — especially because of therapist incompetence — but the warnings signs are fairly clear.

When starting to treat someone with AAI, a good therapist should sense that something is not right: they will notice an ominous combination of case history clues, perhaps combined with unusually guarded movement of the neck and high tone in the neck muscles. Once that concern is triggered, a therapist must switch into better-safe-than-sorry mode. Why not? No harm is ever done by slowing down and investigating a little more carefully. All therapists should do so whenever they encounter certain signs.

When starting to treat someone with atlantoaxial instability, a good therapist should sense that something is not right.

It is still possible to miss the problem, though. Not every case is severe or symptomatic, and the work is complex — what if the patient doesn’t even have a history of odd AAI-ish problems? Or what if the patient doesn’t take his or her symptoms seriously and doesn’t report them? Patients will often minimize or even conceal important clues, for all kinds of reasons.

The really unforgiveable failure in my barber’s case was what he was told by his therapist after reporting a nasty negative reaction: a dubious rationalization that even my barber thought was kind of fishy! Why would a therapist brush off such severe consequences of a treatment? A combination of ignorance, and probably a desire to save face and salvage a potentially profitable relationship.

It didn’t work, of course. My barber never went back. Thank goodness.

Licensing is not enough

This is depressing to contemplate, but it contains an important lesson for health care consumers: not only is it important to seek alternative health care services only from licensed professionals, you must do your best to discriminate between the good ones and the not-so-good ones. Licensing alone does not guarantee skilful and responsible health care!

Why would a therapist brush off such severe consequences?

It’s a frustrating reality of our system that marginalized alternative health care professionals must compete in the marketplace in order to make a living, which unquestionably skews our judgement from time to time. I know from personal experience that it can be difficult to be objective if you are trying to pay the rent. However, good therapists quickly build up a large enough clientele that this ceases to be a problem, and even in my first year I was never so desperate that I compromised the safety of my clients by ignoring ominous symptoms!

So what’s a customer to do?

Here’s a quick checklist of things to watch for, and things to avoid. It applies specifically to massage therapists, but many of them also apply to any health care professional, especially physiotherapists and chiropractors.


Good and bad signs when you’re getting therapy
Case history form	No case history form (very bad sign)
Detailed interview	No interview or minimal interview (another very bad sign)
Relaxed and comfortable asking you questions	No physical assessment (not necessarily a big deal, but still questionable)
Some kind of physical assessment, even if the issue seems simple	Treatment is immediately intense
Treatment is cautious and conservative initially, and never causes wincing or gasping or gritting of teeth	Treatment intensity is hard to cope with
Therapist focus is initially broad, checking in with the whole body	Therapist doesn’t ask how you’re doing, or ask for information about your experience of the treatment
Therapist communicates with you and asks for feedback about sensations, especially in the first appointment	Therapist ignores basic comforts such as temperature, volume of the music, positioning on the table, etc.
Therapist shows obvious concern for your comfort with the experience in general	Narrow treatment focus (zooms in immediately on the problem area and pays no attention to anything else)
Therapist explains things to you clearly	pseudoscientific buzzwords and excessively flaky explanations
Explanations sound sensible to you	Or, even worse, no explanations at all
No pressure to rebook, just a prognosis and a range of options to choose from	Pressure to rebook

Notes

Mild toxemia following massage therapy is possible, but also pretty trivial: the body might do some “metabolic housecleaning” when stimulated by manual therapies. However, the symptoms are generally limited to headaches, fatigue, loginess and (in the worst cases) allergy-like symptoms. In short, nothing even remotely approaching the severity of the side-effects my barber experienced! Return to text.
In 1996, Swinkels reported that “There is no correlation between the measure of hypermobility and the presence of clinical symptoms.” Return to text.
Swinkels also report that “the validity of the upper-cervical stability tests is questionable” and in 2008 this was reiterated by Mintken: “… there are very few data to inform and guide practitioners on the use of ligamentous stability tests when assessing the upper cervical spine.” Return to text.
Smith et al. Neurology. 2003. From the abstract: “This case-controlled study of the influence of spinal manipulative therapy and cervical arterial dissection shows that spinal manipulative therapy is independently associated with vertebral arterial dissection, even after controlling for neck pain.” Cervical arterial dissection is when one of the two arteries that wind through the back of the neck to the brain start to tear. The lining of the artery bleeds and forms a blood clot. This clot can easily enter the brain and cause a fatal stroke. Return to text.
Triano et al. National Chiropractic Mutual Insurance Company. 2005. Return to text.
Back in 1996, Hurwitz wrote that “cervical spine manipulation and mobilization probably provide at least short-term benefits for some patients with neck pain and headaches.” Not exactly a glowing endorsement. But more recent and thorough reviews of the literature have been even less enthusiastic. In 2004, Bronfort wrote in Spine that, “There are few studies, and the evidence is currently inconclusive,” and that for chronic neck pain mobilization/manipulation “offers at most similar pain relief to … rehabilitative exercise in the short and long term.” Going from bad to worse, in 2006 Spine published an even more authoritative review of the scientific literature from The Cochrane Collaboration, concluding that neck adjustments are “not beneficial” when used alone (it did qualify that there was evidence that neck adjustments could work when combined with exercises, which doesn’t exactly make it sound like a miracle cure). Headaches are a closely related issue, so what if we look there? Does it get any better if the goal of neck adjustment is to relieve headache pain? Unfortunately, the problems are identical. In a 2006 Fernandez-de-las-Penas wrote, “No controlled trials analyzing exclusively the effects of spinal mobilization were found,” that what does exist has “overall poor methodology.” Also in 2006, Lenssinck concluded that “there is insufficient evidence to either support or refute the effectiveness of physiotherapy and (spinal) manipulation in patients with tension-type headache.” Return to text.
Dr. Nikolai Bogduk weighs in with a paper with his conclusion right in the title: “Spinal manipulation for neck pain does not work” I take Bogduk’s opinion very seriously, as he is one of a small group of elite pain scientists in the world today, whose opinions are relentlessly well-informed and sensible. This guy is smart, and if he says neck adjustment doesn’t work, he’s got a good reason for it. Return to text.
Many “straight” (old school) chiropractors continue to treat the spinal joints because they believe that spinal adjustment can cure all kinds of health problems. This is inconsistent with everything known about anatomy and physiology, and has been debunked by countless experts. See my article Does Chiropractic Work? for a summary of the issues and evidence, or read Inside Chiropractic for an excellent critique of the chiropractic profession written by a chiropractor. Return to text.
Statement of Concern to the Canadian Public from Canadian Neurologists Regarding the Debilitating and Fatal Damage Manipulation of the Neck May Cause to the Nervous System. Neck911.com. 2009. Return to text.
BC is the only place in the world where you can get 3000 hours (3 years) of training to be a massage therapists — roughly three times more than most places, and even 6 or 8 times more than many places. Until a recent change in legislation, 3 years was the requirement for certification. See Massage Therapy In British Columbia (Canada). Return to text.