Retinal and Cerebral Artery Embolism After “Shiatsu” on the Neck

HomeStrokeVol. 32, No. 10Retinal and Cerebral Artery Embolism After "Shiatsu" on the Neck Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessLetterPDF/EPUBRetinal and Cerebral Artery Embolism After "Shiatsu" on the Neck Koji Tsuboi, MD, DMSc Kazuho Tsuboi, MD Koji TsuboiKoji Tsuboi Department of Neurosurgery, Institute of Clinical Medicine, University of Tsukuba, Ibaraki, Japan Kazuho TsuboiKazuho Tsuboi Department of Ophthalmology, Kensei General Hospital, Ibaraki, Japan Originally published7 Apr 2018https://doi.org/10.1161/str.32.10.2441Stroke. 2001;32:2441To the Editor:We read with great interest the articles by Ernest1 on the life-threatening complications of spinal manipulation and by Rothwell et al2 on the relation of chiropractic manipulation and stroke, as we recently experienced a case of serious complication caused by acupressure "shiatsu" on the neck. With the great demand throughout the industrialized world for complementary and alternative medicine, not only chiropractic and spinal manipulation but also shiatsu, an oriental technique of massage, are becoming increasingly popular in western countries as a support for general health and well-being.3,4 There are many accupoints on the body surface for shiatsu known as "tsubos," and it is accepted that by applying pressure on these tsubos one can achieve physically healing effects with hardly any serious side effects.5 There are two such tsubos on the nape, and shiatsu on these is known to improve tension headache due to neck and shoulder stiffness5; however, we recently experienced a very suggestive complication of shiatsu on these tsubos.Transient ischemic attack was diagnosed in an 80-year-old man after he experienced a sudden onset of weakness in his left hand in December 1999. Although he was asymptomatic on admission, MRI demonstrated a small infarction in the right frontal lobe. MR angiography demonstrated bilateral internal carotid artery stenoses just distal to the carotid bifurcation. Cerebral angiography with contrast media was not performed at that time due to mild renal impairment. After anticoagulant therapy with argatroban for 7 days, he was discharged, free of any neurological symptoms, with a prescription for ticlopidine hydrochloride. On the evening of the day of discharge, he received shiatsu massage on the neck in a prone position, with his face buried in a pillow, for approximately 10 minutes to improve a mild headache associated with neck and shoulder stiffness. Immediately after rising, he was aware that the nasal half of his right visual field was impaired. When this ocular symptom did not improve, he returned to our hospital the following morning. Ophthalmologic examination disclosed that his right visual acuity was only counting fingers at 10 cm, and neurological examination showed slight left hemiparesis dominant in the upper extremity. Fundus examination disclosed diffuse retinal edema with multiple emboli in many branches of the central retinal artery, and fluorescein angiography was compatible with multiple branch occlusions of the central retinal artery (Figure, left). Fluid-attenuated inversion recovery MRI of the brain showed multiple small infarctions in the right frontoparietal lobe (Figure, right). The patient was hospitalized and treated with intravenous infusion of urokinase for 7 days, with almost full recovery of left hemiparesis and minimal improvement of ocular symptoms. Download figureDownload PowerPointLeft, Fluorescein retinal angiography demonstrates multiple branch occlusions of the central retinal artery with extravasations of the fluorescein. Right, Fluid-attenuated inversion recovery MRI of the brain shows multiple small infarctions in the right frontoparietal lobe.As Ernest1 mentions, it is important to generate reliable incidence figures on complications of spinal or chiropractic manipulations. The same holds true for shiatsu; however, very few serious complications of shiatsu therapy could be found in the literature. Mumm et al6 reported an interesting case of probable traumatic zoster that might have resulted from direct trauma to the nerve or nerve roots during shiatsu massage. On the other hand, direct pressure to or around the extracranial carotid artery, such as carotid sinus massage, can cause embolic accidents, especially in elderly people.7 It would not be unexpected that shiatsu on the neck could cause similar complications; however, we were unable to find any medical reports of cerebral or retinal artery embolisms directly caused by shiatsu. We are not denying the traditional healing effects of shiatsu, but we would like to call to attention the fact that it may cause serious neurological symptoms in patients with atherosclerotic extracranial carotid artery disorders, the incidence of which is greater in Caucasians than in Japanese,8 and the potential risk of embolic accidents associated with shiatsu may be higher than generally accepted. Although Rothwell et al2 successfully demonstrated objective data on the association of vertebrobasilar accidents and chiropractic manipulation by a population-based case-control study, they mention that the rarity of vertebrobasilar accidents makes this association difficult to study. The same problem can be predicted when studying the association between shiatsu and embolic accidents originating in the extracranial carotid artery. However, it should be stressed that these complications can be avoided if patients at high risk are properly informed beforehand of the potential association between embolic stroke and manipulation on the neck.1 Ernst E. Life-threatening complications of spinal manipulation. Stroke. 2001; 32: 809–810.CrossrefMedlineGoogle Scholar2 Rothwell DM, Bondy SJ, Williams JI. Chiropractic manipulation and stroke: a population-based case-control study. Stroke. 2001; 32: 1054–1060.CrossrefMedlineGoogle Scholar3 Eisenberg DM, David RB, Ettner SL, Appel S, Wilkey S, Rompay MV, Kessler RC. Trends in alternative medicine use in the United States, 1990–1997. JAMA. 1998; 280: 1569–1575.CrossrefMedlineGoogle Scholar4 Ernst E, White A. The BBC survey of complementary medicine use in the UK. Complement Ther Med. 2000; 8: 32–36.CrossrefMedlineGoogle Scholar5 Weaver MT. Acupressure: an overview of theory and application. Nurse Pract. 1985; 10: 38–42.Google Scholar6 Mumm AH, Morens DM, Elm JL, Diwan AR. Zoster after shiatsu massage. Lancet. 1993; 13: 341.Google Scholar7 Ferguson S, Ellis CJ. Monoplegia following carotid sinus massage. J Int Med. 1994; 235: 379–381.CrossrefMedlineGoogle Scholar8 Nagao T, Sadoshima S, Ibayashi S, Takeya Y, Fujishima M. Increase in extracranial atherosclerotic carotid lesions in patients with brain ischemia in Japan: an angiographic study. Stroke. 1994; 25: 766–770.CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By El Hamichi S, Graversen V, Gold A, Latiff A and Murray T (2020) Case Report: Suprachoroidal Hemorrhage after Chiropractic Manipulation of the Neck, Optometry and Vision Science, 10.1097/OPX.0000000000001533, 97:7, (482-484), Online publication date: 1-Jul-2020. Jiang Z, Zhang H, Yu T, Du Y, Qian Z and Chang F (2020) Musculoskeletal ultrasonography combined with electromyography in the diagnosis of massage-inducted lateral plantar nerve injury, Medicine, 10.1097/MD.0000000000021130, 99:28, (e21130) Paulus Y and Belill N (2018) Preretinal hemorrhages following chiropractor neck manipulation, American Journal of Ophthalmology Case Reports, 10.1016/j.ajoc.2018.04.017, 11, (181-183), Online publication date: 1-Sep-2018. (2016) Complementary and alternative medicine Meyler's Side Effects of Drugs, 10.1016/B978-0-444-53717-1.00541-2, (560-578), . Chang C, Wu Y, Chen L, Chan R, Chang S and Chiang S (2015) Massage-Induced Brachial Plexus Injury, Physical Therapy, 10.2522/ptj.20130487, 95:1, (109-116), Online publication date: 1-Jan-2015. Reckelhoff K and Miller A (2014) Interdisciplinary Management of Deep Vein Thrombosis During Rehabilitation of Acute Rupture of the Anterior Cruciate Ligament: A Case Report, Journal of Chiropractic Medicine, 10.1016/j.jcm.2014.06.001, 13:2, (121-127), Online publication date: 1-Jun-2014. Devaux A, Helstroffer A, Cormier J, Villechaise P, Douin J, Hantcherli M and Pettinari-Sturmel F (2014) Effect of Aging Heat-Treatment on Mechanical Properties of AD730™ Superalloy 8th International Symposium on Superalloy 718 and Derivatives, 10.1002/9781119016854.ch41, (521-535) Robinson N, Lorenc A and Liao X (2011) The evidence for Shiatsu: a systematic review of Shiatsu and acupressure, BMC Complementary and Alternative Medicine, 10.1186/1472-6882-11-88, 11:1, Online publication date: 1-Dec-2011. Ernst E (2016) Adverse effects of spinal manipulation: a systematic review, Journal of the Royal Society of Medicine, 10.1177/014107680710000716, 100:7, (330-338), Online publication date: 1-Jul-2007. (2006) Complementary and alternative medicine Meyler's Side Effects of Drugs: The International Encyclopedia of Adverse Drug Reactions and Interactions, 10.1016/B0-44-451005-2/01077-9, (886-899), . Sherman K, Dixon M, Thompson D and Cherkin D (2006) Development of a taxonomy to describe massage treatments for musculoskeletal pain, BMC Complementary and Alternative Medicine, 10.1186/1472-6882-6-24, 6:1, Online publication date: 1-Dec-2006. Ernst E (2005) Ophthalmological adverse effects of (chiropractic) upper spinal manipulation: evidence from recent case reports, Acta Ophthalmologica Scandinavica, 10.1111/j.1600-0420.2005.00488.x, 83:5, (581-585) Ernst E (2003) Treatments used in complementary and alternative medicine , 10.1016/S0378-6080(03)80055-7, (528-539), . Mirallas Martínez J (2003) Complicaciones vasculares cerebrales post-manipulación vertebral cervical, Rehabilitación, 10.1016/S0048-7120(03)73330-1, 37:1, (33-39), Online publication date: 1-Jan-2003. Hill M (2014) Cervical Artery Dissection, Imaging, Trauma and Causal Inference, Canadian Journal of Neurological Sciences / Journal Canadien des Sciences Neurologiques, 10.1017/S0317167100002985, 30:4, (302-304), Online publication date: 1-Nov-2003. Ernst E (2002) Manipulation of the cervical spine: a systematic review of case reports of serious adverse events, 1995–2001, Medical Journal of Australia, 10.5694/j.1326-5377.2002.tb04459.x, 176:8, (376-380), Online publication date: 1-Apr-2002. October 2001Vol 32, Issue 10 Advertisement Article InformationMetrics https://doi.org/10.1161/str.32.10.2441PMID: 11588343 Originally publishedApril 7, 2018 PDF download Advertisement

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