The Stroke and Chiropractic Page was crafted to keep our profession abreast of information that may help prevent strokes in our patients. This Introduction reviews those physical findings that may predict whether a new or existing patient is in the prodromal state of stroke onset, so that we may refer them for co-management. I hope you all will review this information closely.
Stroke is one of the leading causes of death.
The CDC reports that 700,000 people experience a stroke each year, and that 160,000 of them are fatal.
The risk of death from stroke also increases with age.
Statistics, reviewed between the years 1979 to 1991, found that the yearly incidence rates of death by stroke for those in the 25–44 years age bracket was only 3,418 deaths, whereas at the age of 65 or above, incidence rates increased to 140,938 deaths yearly. 
Stroke is characterized by the sudden loss of circulation to an area of the brain, resulting in a corresponding loss of neurologic function. Also called a “Cerebrovascular Accident” (CVA), stroke is a nonspecific term, which describes a cross–section of pathophysiologic causes, which include thrombosis, embolism, and hemorrhage. 
Chiropractors are particularly interested in strokes caused by “Vertebral Artery Dissection” (VAD). Dissections involving either the Carotid Artery (CAD) or the Vertebral Artery (VAD) are relatively rare. The combined incidence of both VAD and CAD is estimated to be 2.6 per 100,000 strokes. However, cervical dissections are the underlying etiology in as many as 20% of the ischemic strokes presenting in younger patients aged 30–45 years. Among all extracranial cervical artery dissections, Carotid Artery dissection (CAD) is 3–5 times more common than Vertebral Artery dissection (VAD). The female–to–male incidence ratio is 3:1 
Thanks to the Neuroscience Homepage
for the use of this picture!
A more accurate sketch
is available at
The path of the Vertebral Artery is well described elsewhere.  The portion referred to as Segment III follows a “tortuous" route from the transverse foramen of C2, running posterolaterally to loop around the posterior arch of C1”.
This is the most common site for VADs which have been “associated” with cervical manipulation. The rest of this page is devoted to examining the causes of Vertebral Artery Dissection. VAD has occurred following actions as trivial as coughing, rotating the head to back a car out of a driveway, and other “normal” activities like archery and visits to the hairdresser. (See the collected abstracts below).
Most reported cases of VAD have similar characteristics: The underlying and pre-existing disease of the intima of the artery, and an “initiating event” which involves rotation and/or extension of the cervical spine. Chiropractic manipulation (which is typically the diversified technique) has been labeled the “proximal event” in reported cases of stroke-after-manipulation, because of it's reliance on a rotational component. Even thought more than 90% of the profession uses that technique, the reported incidence of VAD is still only about 1 out of 3 million manipulations. 
A well-balanced report in the Canadian Medical Association Journal , states that “neck manipulation as a therapeutic strategy for head and neck pain is common and may be effective” and concludes that until methods of identification of “high risk” populations improves, chiropractors should inform all patients of possible serious complications before neck manipulation (informed-consent).
This Stroke and Chiropractic Page is devoted to demonstrating the astounding safety of the chiropractic adjustment.
When compared to most medical procedures prescribed for the same complaint (neck pain, headache), the chiropractic adjustment appears to be hundreds, to thousands of times safer! Please refer to the Comparison of Death Rates Attributed to Various Causes for comparisons.
Dr. Scott Haldeman et al. wrote a follow–up article to the Canadian Stroke Consortium piece cited above.
They reviewed a full 10 years worth of malpractice claims files in Canada for ALL 4500 chiropractors in practice. They found that:
“The likelihood that a chiropractor will be made aware of an arterial dissection following cervical manipulation is approximately 1 per 8.06 million office visits, 1 per 5.85 million cervical manipulations, 1 per 1430 chiropractic practice years and 1 per 48 chiropractic practice careers.
This is significantly less than the estimates of 1 per 500,000–1 million cervical manipulations calculated from surveys of neurologists”. .
An recent in-depth retrospective review  of patient files from reported cases of VAD attempted to evaluate the characteristics of the treatment rendered, and the presenting complaints of those patients. They found:
25% cases presented with sudden onset of new and unusual headache and neck pain often associated with other neurological symptoms that may represent a dissection in progress;
A second, earlier study  also notes vertigo or unilateral facial paresthesia is an important warning sign that may precede onset of stroke by several days.
There was no apparent dose-response relationship to these complications;
They occurred following any form of standard cervical manipulation technique, including rotation, extension, lateral flexion and non-force and neutral position manipulations, and
Based upon this review, stroke, particularly vertebrobasilar dissection, should be considered a random and unpredictable complication of any neck movement, including cervical manipulation.
The most recent in-depth review, published in the
Feb 15, 2008 Spine Journal  was completed by members of the Spine Decade Task Force. These researchers reviewed 10 years worth of hospital records, involving 100 million person-years. These clinical records revealed no increase in vertebral artery dissection risk with chiropractic, compared with medical management, and further stated that
“increased risks of VBA stroke associated with chiropractic and PCP visits is likely due to patients with headache and neck pain from VBA dissection (already in progress) seeking care before their (eventual) stroke.”
It is now apparent that chiropractors prematurely accepted the notion that cervical adjusting/manipulation could be a “causative” event for VAD. That was a reasonable and professional response to case-studies and reports in the peer-reviewed medical literature, which was
often based on a pattern of medical mis-reporting, as was later documented by Terrett. 
The recently published “Current Concepts: Spinal Manipulation and Cervical Arterial Incidents 2005” (NCMIC)  concludes in it's Executive Summary:
“Unfortunately, opinion rather than fact has tended to dominate discussions regarding CVAs and chiropractic, even though there has been no definitive evidence that chiropractic adjustments (actually) cause strokes. This monograph notes that a causative relationship between chiropractic manipulation and stroke is unlikely. There is an associative relationship between the two because people may go to chiropractors for relief of stroke-related symptoms”.
It is now recommended that chiropractors pay close attention when patients present with sudden onset of headache/neck/face pain that's different than the patient has experienced before.
If so, evaluate for a history of:
Drugs/medication (smoking, oral contraceptives);
Physical trauma (which may have damaged arterial structures);
Connective tissue diseases (autosomal dominant polycystic kidney disease, Ehlers-Danlos type IV, Marfan Syndrome, Fibromuscular Dystrophy);
Genitourinary system (frequent urinary tract infection, hematuria);
Nervous system (dysarthria, dysphagia, visual changes, dizziness, confusion, giddiness and vertigo);
Cardiovascular system (stroke, TIAs, mitral prolapse, aortic dilation, hypertension).
To differentiate “normal” head and neck pain from a possible CVA:
Transient Ischemic Attacks (TIAs)— often have similar symptoms to a CVA. If the patient suffers from carotid TIAs, get a quick medical referral. The patient may suffer a complete stroke after only a few episodes.
Dizziness, unsteadiness, vertigo, giddiness— Question the patient about:
Aggravating factors, such as neck position or head movement
If any of the other 5 Ds and 3 Ns exist (see below)
Whether new symptoms have occurred or existing symptoms aggravated by previous cSMT
Migraine headaches— When a patient presents with a migraine, stroke is uncommon and is usually in the posterior cerebral artery.
Cervicogenic headaches— primary features:
Mechanical precipitation or aggravation of head pain
facet joint tenderness
neck muscle tenderness
palpatory pressures reproducing head symptoms
If so, then evaluate for the “signs” of a stroke. Can they: smile, raise both arms, stand steady on both feet with their eyes closed. speak a simple sentence with several vowels that run together, such as “Simple Simon Says”, or stick out their tongue?
These are also known as the 5 D's and the 3 N's:
|| Double vision or other vision problems
Sudden numbness/weakness of face/arm/leg
Vomiting or queasiness
Loss of sensation on one side
Involuntary rapid eye movements
If you suspect that your patient may have had (or is having) a stroke, do NOT adjust their neck, and get them to a hospital for an evaluation MRI/MRA.
It's also advisable to not offer the patient anything to eat or drink, and that you do NOT allow patients who improve spontaneously to drive home.
Remember that transient ischemic attacks (TIA) are warning signs for stroke. The symptoms are similar to CVAs although they can resolve spontaneously. Protect your patient by advising an immediate medical referral.
Thanks to the Association of Chiropractic Colleges and Gerard Clum, D.C., President of Life Chiropractic College West, for supplying us with these 73 educational slides for your review. This educational PowerPoint slide show is titled:
Cervical Spine Adjusting and the Vertebral Artery.
[ 1 ]
eMedicine Journal 2001 (Aug 17); 2 (8)
[ 2 ]
Sudden Vertebral Artery Dissection
eMedicine Journal 2002 (May 30); 3 (5)
[ 3 ]
Sudden Neck Movement and Cervical Artery Dissection
CMAJ 2000; 163 (1): 38–40
[ 4 ]
Sudden Neck Movement and Cervical Artery Dissection:
The Chiropractic Experience
CMAJ 2001; 165 (7): 905–906
[ 5 ]
Stroke, Cerebral Artery Dissection, and Cervical Spine Manipulation Therapy
J Neurol 2002 (Aug); 249 (8): 1098–1104
[ 6 ]
Vertebral Artery Dissection: Warning Symptoms, Clinical Features
and Prognosis in 26 Patients
Can J Neurol Sci 2000 (Nov); 27 (4): 292-296
[ 7 ]
Misuse of the Literature by Medical Authors in Discussing Spinal Manipulative Therapy Injury
J Manipulative Physiol Ther 1995 (May); 18 (4): 203-210
[ 8 ]
Spinal Manipulation and Cervical Arterial Incidents 2005
From NCMIC ~ The Executive Summary (8 pages)
[ 9 ]
Risk of Vertebrobasilar Stroke and Chiropractic Care:
Results of a Population-based Case-control and Case-crossover Study
Spine 2008 (Feb 15); 33 (4 Suppl): S176–183
Beauty Parlor Stroke Syndrome
If you think chiropractic adjustments can cause stroke, please review this series of abstracts. Extension and rotational stressors, on an already–diseased Vertebral Artery, is the real culprit. There has been less reporting of “Beauty Parlor Stroke” than there has been for chiropractic–related strokes, but it is likely it occurs much more frequently.
Bow Hunter's Stroke
Another instance of extension and rotational stresses leading to stroke.
Iatrogenic Vertebral Artery Injury
Vertebral Arteries are also injured during a wide variety of medical procedures and surgeries.
Stroke & Essential Fatty Acids
Stroke is the third leading cause of death in the US. Fortunately, diagnostic imaging for stroke risk and stroke-prevention strategies have advanced greatly in recent years. It is now possible to reduce the artery-clogging plaque that leads to stroke, offering hope that this debilitating condition can be prevented.
The Quality of Reports on Cervical Arterial Dissection
Following Cervical Spinal Manipulation
PLoS ONE 2013 (Mar 20); 8 (3): e59170
This paper examined the quality of literature describing an association between cSMT and CAD. Case reports represented the majority of this literature. Since these reports may contribute to further understanding CADs as they relate to manual therapy, it is important that they are of the highest quality. This study has demonstrated that the literature infrequently reports useful data toward understanding the association between cSMT, CADs and stroke. As a result, the value of these reports toward informing our understanding of the relation between cSMT and CAD is minimal. We suggest that through the systematic collection of data features presented in this paper, a clearer clinical picture of the association between cSMT and CAD would be possible. This study lays the groundwork for developing a universal reporting tool for adverse events related to cSMT.
Internal Carotid Artery Strains During High-Speed, Low-Amplitude
Spinal Manipulations of the Neck
J Manipulative Physiol Ther. 2012 (Nov 6)[Epub ahead of print]
This study showed that maximal Internal Carotid Artery (ICA) strains imparted by cervical spinal manipulative treatments were well within the normal ROM. Chiropractic manipulation of the neck did not cause strains to the ICA in excess of those experienced during normal everyday movements. Therefore, cervical spinal manipulative therapy as performed by the trained clinicians in this study, did not appear to place undue strain on the ICA and thus does not seem to be a factor in ICA injuries.
Vertebral Artery Strains During High-speed, Low amplitude
Cervical Spinal Manipulation
J Electromyogr Kinesiol. 2012 (Oct); 22 (5): 740–746
Spinal manipulative therapy (SMT) has been recognized as an effective treatment modality for many back, neck and musculoskeletal problems. One of the major issues of the use of SMT is its safety, especially with regards to neck manipulation and the risk of stroke. The vast majority of these accidents involve the vertebro-basilar system, specifically the vertebral artery (VA) between C2/C1. However, the mechanics of this region of the VA during SMT are unexplored. Here, we present first ever data on the mechanics of this region during cervical SMT performed by clinicians. VA 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 VA, and thus does not seem to be a factor in vertebro-basilar injuries.
Risk Factors and Clinical Presentation of Craniocervical Arterial Dissection:
A Prospective Study
BMC Musculoskelet Disord. 2012 (Sep 3); 13: 164
This study will provide descriptive and comparative data on intrinsic and extrinsic risk factors for craniocervical arterial dissection and outline the typical clinical presentation, including the nature of early presenting features which might assist practitioners to identify those patients for whom vigorous manual therapy of the neck is inappropriate and alert them to those for whom immediate urgent medical care should be sought.
The Safety of Cervical Manipulation: Putting Stroke Risk in Perspective
Dynamic Chiropractic 2011 (May 20); 29 (11): 29, 43, 45 ~ FULL TEXT
Several studies have attempted to link chiropractic manipulation to adverse events, the most serious and widely studied being strokes following dissections of the vertebral artery. [1-6] To begin to shed light on this problem, several retrospective studies against large population bases have been conducted. As shown in Table 1, [7-15] a large sampling of such studies indicates that the number of serious complications or cerebrovascular accidents (CVAs), as established by researchers from both the chiropractic and medical professions, ranges from one case per 400,000 manipulations to zero in 5 million.
WARNING: Conducting an Orchestra Can Cause Vertebral Artery Dissection:
"Ostrich Sign" Indicates Bilateral Vertebral Artery Dissection
Journal of Stroke and Cerebrovascular Diseases 2011 (Mar 24) [Epub ahead of print]
Vertebral artery dissections (VADs) comprise about 2% of ischemic strokes and can be associated with trauma, chiropractic manipulation, motor vehicle collisions, whiplash, amusement park rides, golfing, and other motion-induced injuries to the neck. We present a case of bilateral extracranial VAD as a complication of conducting an orchestra. To our knowledge, this has not been documented in the literature. Conceivably, vigorous neck twisting in an inexperienced, amateur conductor may place excessive rotational forces upon mobile portions of the verterbral arteries, tear the intima, deposit subintimal blood that extends longitudinally, and cause neck pain and/or posterior fossa ischemic symptoms.
A Population-Based Case-Series of Ontario Patients Who Develop a
Vertebrobasilar Artery Stroke After Seeing a Chiropractor
J Manipulative Physiol Ther 2011 (Jan); 34 (1): 15–22
Ninety-three VBA stroke cases consulted a chiropractor during the year before their stroke. The mean age was 57.6 years (SD, 16.1), and 50% were female. Most cases had consulted a medical doctor during the year before their stroke, and 75.3% of patients had at least one cerebrovascular comorbidity. The 3 most common comorbidities were neck pain and headache (prevalence, 66.7%; 95% confidence interval [CI], 57.0%-76.3%), diseases of the circulatory system (prevalence, 63.4%; 95% CI, 54.8%-74.2%), and diseases of the nervous system and sense organs (prevalence, 47.3%; 95% CI, 38.7%-58.1%). Our population-based analysis suggests that VBA stroke patients who consulted a chiropractor the year before their stroke are older than previously documented in clinical case series. We did not find that women were more commonly affected than men. Moreover, we found that most patients had at least one cardio- or cerebrovascular comorbidity. Our analysis suggests that relying on case series or surveys of health care professionals may provide a biased view of who develops a VBA stroke.
Current Understanding of the Relationship Between Cervical Manipulation
and Stroke: What Does It Mean for the Chiropractic Profession?
Chiropractic & Osteopathy 2010 (Aug 3); 18 (1): 1–9 ~ FULL TEXT
The understanding of the relationship between cervical manipulative therapy (CMT) and vertebral artery dissection and stroke (VADS) has evolved considerably over the years. In the beginning the relationship was seen as simple cause-effect, in which CMT was seen to cause VADS in certain susceptible individuals. This was perceived as extremely rare by chiropractic physicians, but as far more common by neurologists and others. Recent evidence has clarified the relationship considerably, and suggests that the relationship is not causal, but that patients with VADS often have initial symptoms which cause them to seek care from a chiropractic physician and have a stroke some time after, independent of the chiropractic visit. This new understanding has shifted the focus for the chiropractic physician from one of attempting to “screen” for “risk of complication to manipulation” to one of recognizing the patient who may be having VADS so that early diagnosis and intervention can be pursued. In addition, this new understanding presents the chiropractic profession with an opportunity to change the conversation about CMT and VADS by taking a proactive, public health approach to this uncommon but potentially devastating disorder.
Preliminary Report: Biomechanics of Vertebral Artery Segments C1-C6
During Cervical Spinal Manipulation
J Manipulative Physiol Ther. 2010 (May); 33 (4): 273–278
The results of this study suggest complex and nonintuitive strain patterns of the VA within the cervical transverse foramina. Consistent (for 2 chiropractors) and repeatable (for 3 repeat measurements for each chiropractor) elongation and shortening of adjacent VA segments were observed simultaneously and could not be explained with a simple model of neck movement. We hypothesized that they were caused by variations in the location and stiffness of the VA fascial attachments to the vertebral foramina and by coupled movements of the cervical vertebrae. However, in agreement with previous work on VA strains proximal and distal to the cervical transverse foramina, strains for cervical spinal manipulations were consistently lower than those obtained for cervical rotation.
Editorial Commentary: Strokes: Causalities and Logical Fallacies
Dynamic Chiropractic – March 26, 2010
Twenty three years ago, while trying to fall asleep, I turned my head to one side. The right side of my body went numb and the room started swirling. I remember the ambulance ride and the sheer panic of not being able to feel or move my arms and legs. Yes, I am a stroke patient, and there is absolutely no doubt in my mind that had the event occurred while I was on a chiropractic table rather than lying in bed, the stroke would have been attributed to receiving chiropractic care. Since then, I've read the accounts that have appeared in the popular media suggesting that “chiropractic manipulation” of the cervical spine is associated with strokes. I've also reviewed all of the literature that I could that has addressed the purported relationship between chiropractic cervical adjustments and strokes. (A comprehensive review is beyond the scope of this brief article; however, resources are available for the interested reader.) [1-5]
Microstructural Damage in Arterial Tissue Exposed to
Repeated Tensile Strains
J Manipulative Physiol Ther 2010 (Jan); 33 (1): 14–19
Twenty-four test specimens from cadaveric rabbit ascending aorta were divided into 2 control groups (n = 12) and 2 experimental groups (n = 6 each). Specimens were exposed to 1000 strain cycles of 0.06 and 0.30 of their in situ length. A pathologist, blinded to the experimental groups, assessed microstructural changes in the arteries using quantitative histology. Pearson ?2 analysis (a = .05) was used to assess differences in tissue microstructure between groups. Cadaveric arterial tissues of New Zealand white rabbit with similar size, structure, and mechanical properties of human vertebral artery did not exhibit histologically identifiable microdamage when exposed to repeated mechanical loading equivalent to the strains observed in human vertebral artery during chiropractic cervical spine manipulative therapy.
Patients With Symptoms and Signs of Stroke
Presenting to a Rural Chiropractic Practice
J Manipulative Physiol Ther 2010 (Jan); 33 (1): 62–69
Patients with symptoms and signs of stroke may infrequently present to chiropractic physicians for evaluation and treatment, regardless of the interval since the last prior chiropractic treatment. Several prehospital stroke recognition instruments were introduced in the mid-1990s, including the Los Angeles Paramedic Stroke Scale, the Cincinnati Prehospital Stroke Scale, and in the United Kingdom the Face Arm Speech Test (FAST), a modification of the Cincinnati scale.  The FAST seems particularly well suited as a tool for chiropractic physicians, their staff, and for patient education; indeed, this tool is already being used by health educators and nurses to train persons for rapid stroke recognition (Table 4). 
Table 4. The Face Arm Speech Test, also known as FAST 
Face: Ask person to smile. Does one side of the face droop?
Arm: Ask person to raise both arms. Does one arm drift downward?
Speech: Ask the person to say their name or a simple sentence. Is the speech slurred or unusual?
Time: If any of these signs, call 911 or get to the nearest stroke center or hospital immediately.
Risk of Vertebrobasilar Stroke and Chiropractic Care:
Results of a Population-based Case-control and Case-crossover Study
Spine 2008 (Feb 15); 33 (4 Suppl): S176–183
VBA stroke is a very rare event in the population. There was an association between chiropractic services and subsequent vertebrobasilar artery stroke in persons under 45 years of age, but a similar association was also observed among patients receiving general practitioner services. This is likely explained by patients with vertebrobasilar artery dissection-related neck pain or headache seeking care before having their stroke.
Examining Vertebrobasilar Artery Stroke in Two Canadian Provinces
Spine (Phila Pa 1976). 2008 (Feb 15); 33 (4 Suppl): S170–175
Under the assumption that chiropractic manipulation to the cervical spine is a risk factor for VBA stroke, it is possible that the increase in incidence may have been related to an increase in the utilization of chiropractic services. However, 2 observations do not support this hypothesis. First, we found that the incidence rate of VBA strokes was similar in Saskatchewan and Ontario even though chiropractic utilization was 10 times higher in Saskatchewan than in Ontario. Second, the sharp increase in the rate of VBA stroke occurred despite a decrease in chiropractic utilization in Ontario. In Saskatchewan, the sharp increase in the incidence of VBA strokes occurred whereas the chiropractic utilization remained fairly stable. These findings are in agreement with the results of Cassidy et al who found that there was no significant added risk associated with antecedent exposure to a chiropractor before VBA compared against the risk associated with exposure to a primary care physician in the ambulatory setting. 
Safety of Chiropractic Manipulation of the Cervical Spine:
A Prospective National Survey
Spine (Phila Pa 1976). 2007 (Oct 1); 32 (21): 2375–2378
Data were obtained from 28,807 treatment consultations and 50,276 cervical spine manipulations. There were no reports of serious adverse events. This translates to an estimated risk of a serious adverse event of, at worse approximately 1 per 10,000 treatment consultations immediately after cervical spine manipulation, approximately 2 per 10,000 treatment consultations up to 7 days after treatment and approximately 6 per 100,000 cervical spine manipulations. Minor side effects with a possible neurologic involvement were more common. The highest risk immediately after treatment was fainting/dizziness/light-headedness in, at worse approximately 16 per 1000 treatment consultations.
Cervical Spine Adjusting and the Vertebral Artery (PowerPoint)
Association of Chiropractic Colleges
Thanks to the Association of Chiropractic Colleges and Gerard Clum, D.C., President of Life Chiropractic College West, for supplying us with these 73 educational slides for your review.
Putting Risk into Perspective
ACAnews ~ September 2007
Over the last three years, doctors of chiropractic in the state of Connecticut have been subject to a rash of anti-chiropractic advertisements conspicuously placed on rolling and static billboards, and in well-read statewide newspapers. Most recently, doctors saw a spate of unprecedented anti-chiropractic legislation aimed to mandate informed consent in chiropractic offices and require open access to chiropractic malpractice records.
The Benefits Outweigh the Risks for Patients Undergoing Chiropractic Care
for Neck Pain: A Prospective, Multicenter, Cohort Study
J Manipulative Physiol Ther 2007 (Jul); 30 (6): 408–418
In contrast to clinical trials of prescription medication, researchers in the area of conservative care for musculoskeletal complaints have focused their attention on treatment effectiveness and, to a much lesser degree, on adverse events. This study, consisting of patients treated in a wide variety of chiropractic practices and settings, describes both positive and negative, and short- and long-term clinical outcomes for a relatively large study population with neck pain.
Although many of the subjects (in this study) had chronic, recurrent neck pain and had undergone prior care for this complaint, many patients experienced benefit from the treatment (based upon diminished pain and disability, the percentage of patients recovered and percentage satisfied with care). Furthermore, many responded relatively quickly to treatment (48% were recovered at the fourth visit).
Inappropriate Use of the Title Chiropractor and Term Chiropractic
Manipulation in the Peer-reviewed Biomedical Literature
Chiropractic & Osteopathy 2006 (Aug 22); 14 (1): 16 ~ FULL TEXT
The results of this year-long prospective review suggests that the words chiropractor and chiropractic manipulation are often used inappropriately by European biomedical researchers when reporting apparent associations between cervical spine manipulation and symptoms suggestive of traumatic injury. Furthermore, in those cases reported here, the spurious use of terminology seems to have passed through the peer-review process without correction. Additionally, these findings provide further preliminary evidence, beyond that already provided by Terrett, that the inappropriate use of the title chiropractor and term chiropractic manipulation may be a significant source of over-reporting of the link between the care provided by chiropractors and injury.
You may also want to read this Editorial Comment by the author.
Cerebrovascular Accident Without Chiropractic Manipulation:
A Case Report
J Manipulative Physiol Ther 2006 (May); 29 (4): 330–335
A 49-year-old man with non-traumatic chronic episodic head and neck pain presented for care. Examination and plain film radiographs were unremarkable, suggesting a mechanical origin for the symptoms; however, information in the case history raised concerns. The patient was examined and not manipulated by the doctor of chiropractic but referred back to his general practitioner for a second opinion. The following week, the patient was admitted to hospital having had a cerebrovascular accident. The possible indication of the prodrome to a stroke may lie in the case history rather than the examination findings and provocative testing.
Are German Orthopedic Surgeons Killing People With Chiropractic?
Journal of Neurology 2006 (Mar 6)
Editorial Commentary: I present for your review an abstract from the Journal of Neurology. This abstract blatantly conceals the facts stated in the body of the paper when it claims that “we describe 36 patients with vertebral artery dissections and prior chiropractic neck manipulation”. When I read that sentence, I am led to believe that “real-live chiropractors” (meaning licensed Doctors of Chiropractic, who received their training at a CCE/WCCE accredited schools) were the ones to provide the “chiropractic neck manipulation”. Unfortunately, that couldn't be further from the truth!
Is It Time To Stop Functional Pre-manipulation Testing
of the Cervical Spine?
Manual Therapy 2005 (May); 10 (2): 154-158
The combined extended and rotated cervical spine position has been postulated to affect vertebral artery blood flow by primarily causing a narrowing of the vessel lumen, usually within the artery contralateral to the side of head rotation. The production of brainstem symptoms during the manoeuvre has generally been considered to be a positive test result. As a consequence, functional pre-manipulation testing of the cervical spine has been part of clinical screening undertaken by chiropractors and other manual practitioners to rule out the risk of possible injury to the vertebral artery.
Cervical Artery Dissection A Comparison of Highly Dynamic Mechanisms:
Manipulation Versus Motor Vehicle Collision
J Manipulative Physiol Ther 2005 (Jan); 28 (1): 57–63
This recent review of the literature finds: “Additionally, long-lasting abnormalities of blood flow velocity within the vertebral artery have been reported in patients following common whiplash injuries, whereas no significant changes in vertebral artery peak flow velocity were observed following cervical chiropractic manipulative therapy”. and concludes that: “The direct evidence suggests that the healthy vertebral artery is not at risk from properly performed chiropractic manipulative procedures”.
Spinal Manipulation and Cervical Arterial Incidents (2005)
NCMIC ~ Executive Summary (8 pages)
There is a growing concern and awareness of an association between chiropractic manipulation and cerebrovascular accidents (CVAs). Unfortunately, opinion rather than fact has tended to dominate discussions regarding CVAs and chiropractic, even though there has been no definitive evidence that chiropractic adjustments (actually) cause strokes. The good news is that this monograph notes that a causative relationship between chiropractic manipulation and stroke is unlikely. There is an associative relationship between the two because people may go to chiropractors for relief of stroke-related symptoms.
Defining the Effect of Cervical Manipulation on Vertebral Artery Integrity:
Establishment of an Animal Model
J Manipulative Physiol Ther 2004 (Nov); 27 (9): 539–546
Over the past 5 to 10 years, the issue of cerebrovascular accidents (CVAs) and spinal manipulation has become a debate of ever-increasing intensity. A copious number of studies have investigated spinal manipulation as a putatative causative factor of CVAs [ 1-5 ]; however, a common theme among these is the failure to consider that the majority of vertebrobasilar accidents (VBAs) may be spontaneous, cumulative, or caused by factors other than spinal manipulation. The problem is not served by the sometimes hysterical reactions apparent in the media over the past 2 years in reaction to the flawed investigations.[ 6-11 ] In light of these recent reports, the entire phenomenon of spontaneous cervical artery dissections should be revisited to put this matter into a better perspective.
How Common Are Side Effects of Spinal Manipulation And
Can These Side Effects Be Predicted?
Man Ther. 2004 (Aug); 9 (3): 151–156
Little scientific support is available concerning usual and unusual reactions after spinal manipulation although such reactions are very common in clinical practice. Fifty-nine manipulative therapists were requested to enroll 15 consecutive patients attending for their first visit to receive spinal manipulation. These patients were asked to complete a questionnaire after this first visit that asked for possible risk factors for spinal manipulation and asked about any side effects after the manipulation. The participating practitioners were asked to note medical diagnosis, manipulated spinal region, number of treated areas and type of additional treatment. Four hundred and sixty five valuable responses were analysed. Two hundred and eighty three patients (60.9%) reported at least one post-manipulative reaction. The most common were headache (19.8%), stiffness (19.5%), local discomfort (15.2%), radiating discomfort (12.1%) and fatigue (12.1%).
The Stroke Issue:
Paucity of Valid Data, Plethora of Unsubstantiated Conjecture
J Manipulative Physiol Ther 2004 (June); 27 (5): 368–372
Chiropractic can be proud of its exemplary standards in the areas of informed consent and the allocation of funding for research to study issues of safety. As a responsible, ethical, and caring profession, chiropractic must continue to look into the issue regarding the potential risk of chiropractic adjustment. At this time, it cannot be scientifically stated that there is no risk of VBA dissection from chiropractic cervical adjustment. It can, and in my opinion must, be scientifically stated that there is neither valid evidence of a causal relationship between chiropractic cervical adjustment and VBA dissection nor any valid data to estimate a risk of VBA dissection associated with chiropractic cervical adjustment. It can also be stated that the data that are available regarding the total number of adjustments performed each year, the total number of VBA dissections and occlusions that occur in the absence of chiropractic adjustment each year, and the data that indicate a chiropractic cervical adjustment represents less force to the vertebral artery than movement within the normal range of motion make it more logical to assume a temporal rather than causal link between these 2 events.
Spontaneous Cervical Artery Dissections and Implications for Homocysteine
J Manipulative Physiol Ther 2004 (Feb); 27 (2): 124–132 ~ FULL TEXT
As shown in Table 1, the annual incidence of spontaneous VADs in hospital settings has been estimated to occur at the rate of 1 to 1.5 per 100,000 patients.  The corresponding VAD incidence rate in community settings has been reported to be twice as high. [16,17] Using an estimated value of 10 from the literature to represent an average number of manipulations per patient per episode,  it becomes apparent that the proposed exposure rate for CVAs attributed to spinal manipulation is equivalent to the spontaneous rates for cervical arterial dissections as reported. [15-17] If the threat of stroke or stroke-like symptoms is to be properly assessed, therefore, at least half our attention needs to be directed toward the spontaneous events instead of primarily or solely on spinal manipulation.
Motor Vehicle Accidents:
The Most Common Cause of Traumatic Vertebrobasilar Ischemia
Can J Neurol Sci 2003 (Nov); 30 (4): 320–325
There were 80 patients whose vertebrobasilar ischemia was attributed to neck trauma. Five were diagnosed as due to chiropractic manipulation, but the commonest attributed cause was motor vehicle accidents (MVAs), which accounted for 70 cases; one was a sports injury, and five were industrial accidents. In some cases neck pain from an MVA led to chiropractic manipulation, so the cause may have been compounded. In most vehicular cases the diagnosis had been missed, even denied, by the neurologists and neurosurgeons initially involved. The longest delay between the injury and the onset of delayed symptoms was five years.
Vertebrobasilar Ischemia and Spinal Manipulation
J Manipulative Physiol Ther 2003 (Sep); 26 (7): 443–447
This pratitioner examine(d) cerebral arterial blood flow in 2 patients exhibiting signs of vertebrobasilar arterial ischemia (VBI) before and after spinal manipulative therapy. Improvements in arterial flow following spinal adjusting led the author to surmise: “Spinal manipulation may have a normalizing effect on the sympathetic nervous system, allowing for a change in vasospastic cerebral vascular arteries”.
Cerebrovascular Accidents: The Rest of The Story
Anthony L. Rosner, PhD., Research Director for FCER ~ June 20, 2003 ~ FULL TEXT
During the past decade, the issues of cerebrovascular accidents [CVAs] and spinal manipulation have become linked in a debate of ever-increasing intensity. A copious number of studies have investigated spinal manipulation as a putative causative factor of CVAs; however, a common theme among these is the failure to adequately explore the possibility that the majority of CVAs may be spontaneous, cumulative, or caused by factors other than spinal manipulation itself. The problem is only exacerbated by the sometimes hysterical reactions apparent in the mass media over the past three years in reaction to the flawed investigations. This paper was presented Friday June 20, 2003 at the International Spinal Trauma Conference in Chicago, IL. Thanks to Dr. Rosner and the FCER for permission to reproduce this FULL TEXT article exclusively at Chiro.Org!
You may also enjoy Dr. Rosner's recent articles: Stroke Revisisted: The “Chinatown” Syndrome and his article Informed Consent: If You Come to a Fork in the Road, Take It.
Response to Vertebral Artery Dissection Study: Synopsis Paper
by Smith et al. Published in May 13, 2003 Issue of Neurology
FCER ~ May 18, 2003
The recent publication by Smith et al. in Neurology addressing vertebral artery dissection represents another episode of regrettable studies which, despite serious flaws which raise substantial questions as to their internal validity, go at great lengths to selectively disparage the advisability of performing cervical manipulations as a means of patient care while obscuring the larger picture.
Association of Internal Carotid Artery Dissection
and Chiropractic Manipulation
Neurologist 2003 (Jan); 9 (1): 35–44
In reviewing the cases of internal carotid dissection potentially related to CMT, there were many confounding factors, such as connective tissue aberrations, underlying arteriopathy, or coexistent infection, that obscured any obvious cause-and-effect relationship. To date there are only 13 reported cases of ICAD temporally related to CMT. Most ICADs seem to occur spontaneously and progress from local symptoms of headache and neck pain to cortical ischemic signs. Approximately one third of the reported cases were manipulated by practitioners other than chiropractic physicians, and because of the differential risk related to major differences in training and practice between practitioners who manipulate the spine, it would be inappropriate to compare adverse outcomes between practitioner groups.
VAD Following Cervical Manipulation: D.C. vs M.D. Experiences
Affect Perception of Risk
FCER ~ January 13, 2003
Examination of the database of the Canadian Chiropractic Protective Association (CCPA, which provides malpractice insurance for 83% of chiropractors in Canada) for the period 1988 to 1997 found 23 cases of VAD. Retrospective review of these cases and a survey of chiropractors suggests an estimated 134,466,765 cervical manipulations were performed during the 10-year period. Records from these reported VAD cases indicates that in a 30 year practice, only one in 48 chiropractors would be aware of a vascular incident following cervical manipulation. In contrast, examination of the records show that these 23 VAD patients saw a total of 216 physicians, including 69 neurologists.
International Expert Debunks Stroke Consortium Chief's Claims
About Link Between Stroke and Neck Adjustment
Canada Newswire; Nov 18, 2002
ORONTO, Nov 18, 2002 (Canada NewsWire via COMTEX) -- A leading world expert on scientific methodology and research, Dr. David Sackett, an officer of the Order of Canada and member of the Canadian Medical Hall of Fame, today described Dr. John Norris, former Chair of the Canadian Stroke Consortium, as “incompetent” in scientific research and “irresponsible” with regard to the Consortium's work attributing strokes to neck adjustment.
Is Cervical Spinal Manipulation Dangerous?
J Manipulative Physiol Ther 2002 (Oct); 25 (8): 504-510
It appears that the risk of cerebrovascular accidents after cervical manipulation is low, considering the enormous number of treatments given each year, and very much lower than the risk of serious complications associated with generally accepted surgery. Provided there is a solid indication for cervical manipulation, we believe that the risk involved is acceptably low and that the fear of serious complications is greatly exaggerated.
Internal Forces Sustained by the Vertebral Artery During
Spinal Manipulative Therapy
J Manipulative Physiol Ther 2002 (Oct); 25 (8): 504–510
SMT resulted in strains to the VA that were almost an order of magnitude lower than the strains required to mechanically disrupt it. We conclude that under normal circumstances, a single typical (high-velocity/low-amplitude) SMT thrust is very unlikely to mechanically disrupt the VA.
The Mechanics of Neck Manipulation With Special Consideration
of the Vertebral Artery
J Can Chiropr Assoc. 2002 (Sep); 46 (3): 134–136 ~ FULL TEXT
Before this paper was published by Herzog and Symons, the chiropractic community accepted the belief that mechanical injury to the vertebral artery was possible, but it was very, very rare occurrence; but nevertheless, accepted. And all this without a shred of scientific evidence about the mechanics of the vertebral artery during cervical manipulation. All that began to change as this group of researchers continued studying the tensile strains that occur to the vertebral artery during normal range of motion and spinal manipulation, as well as testing of the failure limits of those tissues.
Clinical Perceptions of the Risk of Vertebral Artery Dissection After
Cervical Manipulation: The Effect of Referral Bias
Spine J 2002 (Sep); 2 (5): 334–342
For the 10-year period 1988 to 1997, there were 23 cases of vertebral artery dissection after cervical manipulation reported to the CCPA that represents 83% of practicing chiropractors in Canada. Based on the survey, an estimated 134,466,765 cervical manipulations were performed during this 10-year period. This gave a calculated rate of vertebral artery dissection after manipulation of 1:5,846,381 cervical manipulations. Based on the number of practicing chiropractors and neurologists during the period of this study, 1 of every 48 chiropractors and one of every two neurologists would have been made aware of a vascular complication from cervical manipulation that was reported to the CCPA during their practice lifetime.
You may also enjoy an in-depth review of this article by the FCER.
Uneventful Upper Cervical Manipulation in the Presence
of a Damaged Vertebral Artery
J Manipulative Physiol Ther 2002 (Sept); 25 (7): 472–483
This case report demonstrates that vigorous manipulation of the upper cervical spine is possible without injuring an already damaged vertebral artery. It is suggested that the line of drive used during the single manipulation, almost pure lateral flexion with slight rotation, was responsible for the apparent innocuous response. Guidelines for the evaluation and management of vertebral artery dissection are reviewed. Because it is currently impossible to identify patients at risk of having a dissected vertebral artery with standard in-office examination procedures, rotational manipulation of the upper cervical spine should be abandoned by all practitioners, and schools should remove such techniques from their curriculums.
Vertebral Arteries and Cervical Rotation:
Modeling and Magnetic Resonance Angiography Studies
J Manipulative Physiol Ther 2002 (Jul); 25 (6): 370-383
All 16 vertebral arteries from the 8 patients displayed no changes in their lumen dimensions with full cervical rotation, although curves in each of the arteries did change. The model and cadaveric vertebral arteries demonstrated localized compression or kinking of the vessel wall with atlanto-axial rotation contralaterally but revealed no evidence of major contribution of stretching to stenosis.
Stroke, Cerebral Artery Dissection,
and Cervical Spine Manipulation Therapy
Journal of Neurology 2002 (Jul); 249 (8): 1098–1104
Stroke represents an infrequent adverse reaction associated with cervical spine manipulation therapy. Attempts to identify the patient at risk and the type of manipulation most likely to result in these complications of manipulation have not been successful. A retrospective review of 64 medical legal cases of stroke temporally associated with cervical spine manipulation was performed to evaluate characteristics of the treatment rendered and the presenting complaints in patients reporting these complications. Ninety two percent of cases presented with a history of head and/or neck pain and 16 (25 %) cases presented with sudden onset of new and unusual headache and neck pain often associated with other neurological symptoms that may represent a dissection in progress. The strokes occurred at any point during the course of treatment. Certain patients reporting onset of symptoms immediately after first treatment while in others the dissection occurred after multiple manipulations. There was no apparent dose-response relationship to these complications.
Manipulation of the Neck and Stroke:
Time for More Rigorous Evidence
Medical Journal of Australia 2002 (Apr 15); 176 (8): 376-380
In this issue of the Journal, Ernst (page 376) reviews case reports of serious adverse events associated with cervical spine manipulation. Although Ernst acknowledges the considerable doubt about a causal relationship between the manipulation and the adverse event, he is inconsistent in suggesting that the anecdotal and uncontrolled evidence of the case reports favours the adverse events, often strokes, being an effect of manipulation. Elucidating a causal relationship calls for greater clarity, less ambivalence and generally better science in the present evidence-based climate. Thus, the important question to be answered in the light of Ernst's article is whether the association between neck manipulation and stroke is actually causal and, if so, in what direction?
Transcranial Sonography and Vertebrobasilar Insufficiency
J Manipulative Physiol Ther 2002 (Mar); 25 (3): 180-183
This illustrates a case of extra-arterial mechanical compression of the vertebral arteries documented by transcranial Doppler sonography procedures. Brainstem symptoms were correlated with a documented perfusion deficit during cervical positional testing. This case also demonstrated that spinal manipulative therapy may be safely used on patients with vertebrobasilar insufficiency when the biomechanics and related flow studies are elucidated.
Unpredictability of Cerebrovascular Ischemia Associated with Cervical
Spine Manipulation Therapy: A Review of Sixty-four Cases
After Cervical Spine Manipulation
Spine 2002 (Jan 1); 27 (1): 49–55
This study was unable to identify factors from the clinical history and physical examination of the patient that would assist a physician attempting to isolate the patient at risk of cerebral ischemia after cervical manipulation. Cerebrovascular accidents after manipulation appear to be unpredictable and should be considered an inherent, idiosyncratic, and rare complication of this treatment approach.
Scientific Evidence Over-Rides the False Claims in Canadian Stroke Case
Joel Alcantara, D.C., Director of Research for the ICPA ~ FULL TEXT
The Lana Lewis inquest in Canada is well known to Canadian chiropractors as it has and will affect the practice of chiropractic in that country and possibly the world. The following is a summary from one of the expert witnesses called by the chiropractic profession, Dr. David Sackett. To some, the name may be familiar, particularly since its synonymous with the words “evidenced-based medicine”.
Arterial Dissections Following Cervical Manipulation:
The Chiropractic Experience
Canadian Medical Association Journal 2001 (Oct 2); 165 (7): 905–906 ~ FULL TEXT
Following approval by the Institutional Review Board of the Canadian Memorial Chiropractic College in Toronto, Ont., a review of malpractice data from the Canadian Chiropractic Protective Association (CCPA) was carried out to evaluate all claims of stroke following chiropractic care for the 10-year period between 1988 and 1997. There are over 4500 licensed chiropractors in Canada. The likelihood that a chiropractor will be made aware of an arterial dissection following cervical manipulation is approximately 1 in 8.06 million office visits, 1 in 5.85 million cervical manipulations, 1 in 1430 chiropractic practice years and 1 in 48 chiropractic practice careers.
New Study Puts Stroke From Neck Adjustment at Less
than 1 in 5 Million Adjustments
Toronto, October 12, 2001— A new Canadian study, reported in the October 2, 2001 issue of the Canadian Medical Association Journal (CMAJ), puts the risk of stroke following neck adjustment at 1 in every 5.85 million adjustments. The study, which is based on patient medical files and malpractice data from the Canadian Chiropractic Protective Association, evaluated all claims of stroke following chiropractic care for a ten year period between 1988 and 1997.
Chiropractic Manipulation and Stroke
Stroke 2001 (Sep); 32 (9): 2207—2208
This is the response to the Rothwell et al. article (Stroke 2001;32:1054) by Anthony Rosner, PhD of the FCER.
Consequences of Neck Manipulation Performed by a Non-professional
Spinal Cord 2001 (Feb); 39 (2): 112–113
A 30-year-old man who fainted after neck manipulation by a barber and developed spinal cord and brainstem dysfunction. His MRI revealed an extramedullary, intradural dumbbell shaped mass on the right side at C1 and C2 level compressing the spinal cord.
Vertebral Artery Dissection: Warning Symptoms, Clinical Features
and Prognosis in 26 Patients
Can J Neurol Sci 2000 (Nov); 27 (4): 292–296
Headache and/or neck pain followed by vertigo or unilateral facial paresthesia is an important warning sign that may precede onset of stroke by several days.
Vertebral Artery Dissection and Migraine Headaches in Children
J Child Neurol 2000 (Oct); 15 (10): 694–696
Risk factors for vertebral artery dissection are reviewed, with emphasis on association with migraine headaches. A review of imaging studies for the diagnosis of dissection is also presented. This case demonstrates the importance of considering arterial wall dissection in pediatric patients with a history of atypical migraines associated with new neurologic findings.
Vertebral Artery Dissection Causing Stroke in Sport
J Clin Neurosci 2000 (Jul); 7 (4): 298–300
Stroke in sport, although uncommon, is predominantly due to arterial dissection in either the vertebral or carotid arteries. Physicians involved in athlete care need to be aware of this diagnosis.
Sudden Neck Movement and Cervical Artery Dissection
Canadian Medical Association Journal 2000 (Jul 11); 163: 38–40 ~ FULL TEXT
During the past year the Canadian Stroke Consortium, a national network of stroke physicians, has been prospectively collecting detailed information on cases of dissection of the cervical arteries. Seventy-four patients have been studied so far: their age range was 16-87 years (mean 44 years), 60% were male, and there was a predominance of vertebrobasilar artery dissections compared with carotid artery dissections (72% v. 28%). Most (81%) of the dissections were associated with sudden neck movement, ranging from therapeutic neck manipulation to a vigorous game of volleyball, but some occurred during mild exertion such as lifting a pet dog or during a bout of coughing.
Is There a Role for Premanipulative Testing Before Cervical Manipulation?
J Manipulative Physiol Ther 2000 (Mar); 23 (3): 175–179
It appears that a positive premanipulative test is not an absolute contraindication to manipulation of the cervical spine. If the test is able to identify patients at risk for cerebrovascular accidents, we suggest patients with a reproducible positive test should be referred for a duplex examination of the vertebral artery flow. If duplex flow is normal, the patient should be eligible for cervical manipulation despite the positive premanipulative test.
Vertebral Artery Flow and Cervical Manipulation:
An Experimental Study
J Manipulative Physiol Ther 1999 (Sep); 22 (7): 431–435
We present an experimental model for investigations of vertebral artery hemodynamics during biomechanical interventions. We found a modest and transient effect of cervical manipulation on vertebral artery volume flow. The model may have further applications in future biomechanical research, for example, to determine whether any of several spinal manipulative techniques imposes less strain on the vertebral artery, thereby reducing possible future cerebrovascular accidents after such treatment.
Vertebral Artery Volume Flow in Human Beings
J Manipulative Physiol Ther 1999 (Jul); 22 (6): 363–367
This appears to be the first in vivo Doppler study on human vertebral artery volume blood flow. Our results indicate that in symptom-free subjects there is no change in vertebral artery perfusion during rotation in spite of significant changes in flow velocity.
Effect of Premanipulative Tests on Vertebral Artery and Internal Carotid
Artery Blood Flow: A Pilot Study
J Manipulative Physiol Ther 1999 (Jul); 22 (6): 368–375
Screening procedures that use rotation and extension may be useful tests of the adequacy of collateral circulation. A larger study is needed to determine whether subjects testing positive significantly differ from those testing negative.
Risk Factors and Precipitating Neck Movements Causing Vertebrobasilar Artery
Dissection After Cervical Trauma and Spinal Manipulation
Spine 1999 (Apr 15); 24 (8): 785–794
The literature does not assist in the identification of the offending mechanical trauma, neck movement, or type of manipulation precipitating vertebrobasilar artery dissection or the identification of the patient at risk. Thus, given the current status of the literature, it is impossible to advise patients or physicians about how to avoid vertebrobasilar artery dissection when considering cervical manipulation or about specific sports or exercises that result in neck movement or trauma.
Perspectives: An Overview of Comparative Considerations
of Cerebrovascular Accidents
Chiropractic Journal of Australia 1999; 29 (3): 87—102 ~ FULL TEXT
This paper seeks to contrast reports concerning major adverse side effects, viz. cerebrovascular accidents (CVAs) attributed to cervical spine manipulation, within a broad perspective of medical procedures. It also seeks to correlate the incidence rates of other adverse events and medical procedures with the general incidence rate of CVAs. On analysis, an accurate position would indicate that cervical spinal manipulation is one of the more conservative, least invasive and safest of procedures in the provision of human health care services. The paper also alludes to the political connotations on the subject. Thanks to the Chiropractic Journal of Australia for permission to reproduce this FULL TEXT article exclusively at Chiro.Org!
Risk Assessment of Neurological and/or Vertebrobasilar Complications
in the Pediatric Chiropractic Patient
Journal of Vertebral Subluxation Research (JVSR) 1998; 2 (2): 73–78
The estimate of risk due to the pediatric chiropractic patient in this category of complication was estimated to be 4.0 x 10 -7 % of all visits. Stated otherwise, there would be a chance of approximately 1 in 250 million pediatric visits that a N/VB complication would result. While some pre-existing conditions may predispose a pediatric patient to a higher incidence of such complications, the estimates derived in the present study are considered applicable to the general pediatric population.
Efficacy and Risks of Chiropractic Manipulation:
What Does the Evidence Suggest?
Integrative Medicine 1998; 1: 61-66
This review article drew upon the appropriateness studies conducted at RAND, which indicated efficacy of manipulation for acute or sub-acute low back pain, neck pain, and muscle-tension-type headaches. The article also reported the low risk of serious complications from lumbar and cervical manipulations. According to the literature review, the estimated risk for serious complications from cervical manipulation is 6.39 per 10 million manipulations. For lumbar manipulation, it is 1 per 100 million manipulations. These estimates compare favorably to other forms of therapy, such as cervical spine surgery or nonsteroidal anti-inflammatory drugs (NSAIDS). The risk from manipulation is low and compares favorably to other forms of therapy for the same conditions (e.g., 15.6 complications per 1000 cervical spine surgeries, 3.2 per 1000 subjects for nonsteroidal anti-inflammatory drugs)
Vertebral Artery Flow and Spinal Manipulation:
A Randomized, Controlled and Observer Blinded Study
J Manipulative Physiol Ther 1998 (Mar); 21 (3): 141–144
To the best of our knowledge, this is the first study comparing flow velocity in the vertebral artery before and after spinal manipulative therapy. We found no significant changes in otherwise healthy subjects with a biomechanical dysfunction of the cervical spine.
Tissue Plasminogen Activator in a Vertebral Artery Dissection
Can J. Neurol Sci 1997 (May); 24 (2): 151–154
We report a 49-year-old woman who presented with the rapidly progressing basilar artery syndrome who was given an intravenous dose of tissue plasminogen activator seven hours after the onset of first symptoms. Thirty minutes after the injection, a dramatic recovery of the patient's consciousness and neurological signs was noted.
Safety in Chiropractic Practice Part II: Treatment to the Upper Neck
and the Rate of Cerebrovascular Incidents
J Manipulative Physiol Ther 1996 (Nov); 19 (9): 563–569
Retrospective data were collected from questionnaires covering the period 1978-1988 inclusive; in a second survey, chiropractors provided information obtained through inspection of their own case records.
Manipulation and Mobilization of the Cervical Spine.
A Systematic Review of the Literature
Spine 1996 (Aug 1); 21 (15): 1746–1760
The combination of three of the randomized controlled trials comparing spinal manipulation with other therapies for patients with subacute or chronic neck pain showed an improvement on a 100-mm visual analogue scale of pain at 3 weeks of 12.6 mm (93% confidence interval, -0.15, 25.5) for manipulation compared with muscle relaxants or usual medical care. The highest quality randomized controlled trial demonstrated that spinal manipulation provided short-term relief for patients with tension-type headache. The complication rate for cervical spine manipulation is estimated to be between 5 and 10 per 10 million manipulations.
Safety in Chiropractic Practice, Part I: The Occurrence of Cerebrovascular
Accidents After Manipulation to the Neck in Denmark from 1978–1988
J Manipulative Physiol Ther 1996 (Jul); 19 (6): 371–377
Although the incidence of CVA after chiropractic SMT was confirmed to be low, there seems to be sufficient evidence to justify a firm policy statement cautioning against upper cervical rotation as a technique of first choice.
The Validity of the Extension-rotation Test as a Clinical Screening Procedure
Before Neck Manipulation: A Secondary Analysis
J Manipulative Physiol Ther 1996 (Mar); 19 (3): 159–164
We were unable to demonstrate that the extension-rotation test is a valid clinical screening procedure to detect decreased blood flow in the vertebral artery. The value of this test for screening patients at risk of stroke after cervical manipulation is questionable.
A Risk Assessment of Cervical Manipulation vs. NSAIDs
for the Treatment of Neck Pain
J Manipulative Physiol Ther 1995 (Oct); 18 (8): 530–536
As for comparative safety, the best available evidence indicates that NSAID use poses a significantly greater risk of serious complications and death than the use of cervical manipulation for comparable conditions. In conclusion,
the best evidence indicates that cervical manipulation for neck pain is much safer than the use of NSAIDs, by as much as a factor of several hundred times. There is no evidence that indicates NSAID use is any more effective than cervical manipulation for neck pain.
Misuse of the Literature by Medical Authors
in Discussing Spinal Manipulative Therapy Injury
J Manipulative Physiol Ther 1995 (May); 18 (4): 203–210
The words chiropractic and chiropractor have been incorrectly used in numerous publications dealing with SMT injury by medical authors, respected medical journals and medical organizations. In many cases, this is not accidental; the authors had access to original reports that identified the practitioner involved as a non–chiropractor. The true incidence of such reporting cannot be determined. Such reporting adversely affects the reader's opinion of chiropractic and chiropractors.
Letter to the Editor, The New York Times,
Regarding the Jane Brody article of April 3, 2001
Anthony L. Rosner, Ph.D. ~ FULL TEXT
Jane Brody's recent article [“When Simple Actions Ravage Arteries”, 04/03/01] is an unfortunate and careless portrayal of a healthcare intervention which was specifically designed to avoid the more serious and often irreversible sequelae of the more invasive tools of orthodox medicine: drugs and surgery. Emphasizing the body's own capacity to heal, chiropractic management of patients is based upon the diagnosis, treatment and prevention of disorders of the musculoskeletal system and how they are reflected upon general health through the nervous system.
A Review of the Significant Shortcomings in the Reporting of Stroke
Associated with Cervical Manipulation
Clinical Practice Guidelines, Chapter 9: Patient Safety
In the case of strokes purportedly associated with manipulation, the panel noted significant shortcomings in the literature. A summary of the relevant literature follows. For example: “In a letter to the editor of the Journal of Manipulative and Physiological Therapeutics, Myler(9) wrote, I was curious how the risk of fatal stroke after cervical manipulation, placed at 0.00023%(10) compared with the risk of (fatal) stroke in the general population of the United States. According to data obtained from the National Center for Health Statistics, the mortality rate from stroke in the general population was calculated to be 0.00057%. If these data are correct, the risk of a fatal stroke following cervical manipulation is less than half the risk of fatal stroke in the general population.”
The Benefits and Risks of Spinal Manipulation
Paul G. Shekelle, MD, PhD; Reed B. Phillips, DC, PhD; Daniel C. Cherkin, PhD; William C. Meeker, DC, MPH
This chapter summarizes what has been learned from clinical trials about the benefits of spinal manipulation for specific problems and from case reports about the risks of spinal manipulation. In addition, findings of studies examining the ability of spinal manipulation to increase patient satisfaction, decrease cost, or increase cost-effectiveness of care are summarized.
This is the 11th chapter of “Chiropractic in the United States:
Training, Practice, and Research”, a publication (Dec 1997) by the Agency for Health Care Policy and Research (AHCPR).
What are the Risk of Chiropractic Neck Treatments?
William J. Lauretti, DC ~ FULL TEXT
Every published study which has estimated the incidence of stroke (CVA) from cervical manipulation has agreed that the risk is 1 to 3 incidents per million treatments. Dvorak, [ 1 ] in a survey of 203 practitioners of manual medicine in Switzerland, found a rate of one serious complication per 400,000 cervical manipulations, without any reported deaths, among an estimated 1.5 million cervical manipulations. Jaskoviak [ 2 ] reported approximately 5 million cervical manipulations from 1965 to 1980 at The National College of Chiropractic Clinic in Chicago, without a single case of vertebral artery stroke or serious injury.
Response to Vertebral Artery Dissection Study:
Canadian Journal of Neurological Sciences
FCER & Anthony L. Rosner, Ph.D. ~ December 22, 2000 ~ FULL TEXT
A recent publication addressing vertebral artery dissection in The Canadian Journal of Neurological Sciences  is surprisingly anecdotal and sketchy in its depiction of both the possible causes and etiology of the subject it is intended to discuss. As such, it is laden with severe methodological deficiencies which severely undercut its credibility and create misleading impressions of vertebral artery dissection and raise more fundamental questions as to how retrospective studies should be conducted. There are at least five critical issues which need to be brought into consideration in order to more fully understand this particular study in a broader perspective.
Acupuncture and Stroke Recovery
Johansson et al (1993) investigated the effectiveness of acupuncture as a supplement to physical therapy in recovery from stroke. Pang (1994) investigated two particular scalp acupuncture techniques in order to compare their effectiveness in treating apoplexy following stroke.
A Review of the Reported Complications from Spinal Manipulation
John J. Triano, D.C., Ph.D.
In general, chiropractic treatment has little associated risk. Table TX5 displays the complications of spinal manipulation that have been reported [Haldeman, Haldeman, LeBoeuf-Yve]. Nearly all reactions to manipulation are mild and self-limiting, lasting less than 24 hours. Rarely, significant injury can result from injudicious or inappropriate use. The incidence of serious complication is less than 1:1,000,000.
Claims of Risk From Chiropractic Care For Neck Pain Are Exaggerated
Say Experts At The Texas Back Institute
Plano, TX - May 10, 2000 -- Periodic claims posed in the public and professional media that Chiropractic treatment to the neck poses a high risk for stroke are unwarranted say the experts at the Texas Back Institute.
Stroke Prevention Guidelines Issued
“Stroke is... killing about 160,000 Americans each year,” Dr. Ralph Sacco of the departments of neurology and public health at Columbia University in New York told reporters at a telephone
press conference on Thursday. “About 700,000 people will have a new or recurrent stroke each year,” he added, “and stroke incidence seems to be on the rise”. To reduce risk of stroke,
the NSA offers these basic recommendations.