Atlantoaxial Instability: What Happened To My Barber? – by Paul Ingraham – Apr 2017
Either atlantoaxial instability or vertebrobasilar insufficiency causes severe dizziness and vomiting after massage therapy, with lessons for health care consumers.
My barber has this story: he had an incredibly severe negative reaction to the first and last massage he’d ever had.
This is similar to my experience when I received a wonderfully skilled massage to loosen the tight muscles in my neck and upper back. After leaving the office and driving partway home, a blinding headache forced me to pull over. I had to take extra pain medication and wait almost an hour for it to take effect before I could drive the rest of the way home.
“Uh oh,” I said. “What did the therapist tell you?”
“He told me that massage had released a lot 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!
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 risk by failing to recognize ominous signs and symptoms, or take them seriously.
What really happened to my barber? Probably atlantoaxial instability.
Atlantoaxial (top vertebrae in our neck) instability is common among those of us with EDS.
Our lax ligaments allow these crucial vertebrae upon which our skulls are perched to “wiggle around” and potentially pinch other tissues, which then cause tremendous headaches.
The details of his case are a good match with compression of the brain stem, as could be caused by a loose upper spine (known as atlantoaxial instability, AAI for the rest of this article, or more descriptively called upper cervical instability).
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.
This can also result in a “Chiari malformation”, in which the overly elastic connective tissue of EDS patients can allow the brain stem to “sag” and become pinched in the uppermost area of the neck.
- List of Chiari Malformation Symptoms
- Chiari Malformation with abnormal clivo-axial angle
- Neurological and Spinal Manifestations of EDS
His body knows — even if he doesn’t — that this is a life-threatening situation!
AAI is a complex condition, with many possible causes.
And EDS is definitely one of these causes.
It does not necessarily cause any distress. Even patients with severe instability may have no symptoms at all, while others with relatively minor instability experience significant problems.
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.
They are clearly vulnerable, regardless of whether they have obvious symptoms, and careless massage therapy and spinal manipulative therapy are obviously dangerous.
Could it have been a case of artery damage?
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.
This is exactly what happens with many EDS patients.
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. Also, alarmingly, sometimes it only causes pain, which is disturbingly little indication of a very serious problem. This isn’t common, but it’s not rare either
it’s a serious problem that can almost perfectly mimic an ordinary, common one.
But it’s not a perfect mimic: the pain is usually dramatically bad, weird, very one-sided, throbbing, and constrictive… and stroke-like symptoms get steadily more likely as time goes on.
Can chiropractic adjustment do this also?
Evidence suggests that cervical spinal manipulative therapy — neck cracking — might be dangerous, with minimal benefits to justify the risk.
Not only can chiropractic adjustments of the neck be dangerous for people with atlantoaxial instability for obvious mechanical reasons,neck adjustments are also “associated with” VBI/VAD, as well as a fairly high rate of less dangerous but still rather unpleasant side effects.
Pain may be the only symptom these vulnerable patients have — and yet, ironically, they seek the kind of treatment most likely to cause much greater harm.
And yet pain is increasingly ignored these days because the assumption is that a persistent pain is “just” chronic pain, which is “just” a mental construct.
Patients complaining of “only pain” are simply told they must learn to live with it and are shunted off to various “alternative” treatments, which are exactly what can dramatically worsen this situation.
Both patient or chiropractor may not realize the nature of the pain until it’s too late.
Experts actually mostly agree on this topic. Even chiropractic authorities acknowledge that “there are considerable case studies describing the onset of vertebral artery injury following a manipulation.”
Massage therapy for the neck, at least, is less dangerous and probably more beneficial — at the very least, it can be pleasant and relaxing. As long as a loose vertebrae is not disturbed!
Just 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. Please note that this anecdote was originally published by a chiropractor:
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
Why did my barber’s therapist fail?
My barber’s therapist probably failed because he was, like most massage therapists, simply not well-trained enough to know any better, despite the unusually high certification standards for massage therapist in this part of the world.
When starting to treat someone with AAI, an alert 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.
The unforgiveable failure in my barber’s case was what he was told by his therapist after reporting a nasty negative reaction.
Why would a Registered Massage Therapist brush off such severe consequences of a treatment? I leave it to your imagination, with the reminder that not everyone can graduate at the top of the class, and someone has to graduate at the bottom.
Good and bad signs when you’re getting therapy:
GOOD signs BAD signs 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
About Paul Ingraham
I am a science writer, former massage therapist, and I was the assistant editor at ScienceBasedMedicine.org for several years. I have had my share of injuries and pain challenges as a runner and ultimate player. My wife and I live in downtown Vancouver, Canada. See my full bio and qualifications, or my blog, Writerly. You might run into me on Facebook or Twitter.