Chiropractic Neck Manipulation Harbors Stroke Risk

A joint statement by the American Heart Association (Dallas, TX, USA) and the American Stroke Association (Dallas, TX, USA) warns against a possible association between cervical arterial dissections (CDs) and cervical manipulative therapy (CMT).

The joint statement advises that although the incidence of CD in patients who have previously received CMT is not well established, and probably low, practitioners should strongly consider the possibility, and patients should be warned before chiropractic manipulation of the neck that the technique has been linked to cervical dissection, which can cause stroke. Clinical reports suggest that the mechanical forces of the quick or slow thrust often used by physical therapists, chiropractors, or osteopaths may play a role in the development of CDs.

The statement adds that although current biomechanical evidence is insufficient to establish a causative claim, clinical reports suggest that mechanical forces play a role in a considerable number of CDs, and most population controlled studies found an association between CMT and vertebral artery dissection (VAD) stroke in young patients. The statement recommends that patients with neck pain or headache with focal neurological symptoms after any minor trauma, including CMT, should get immediate medical evaluation for possible stroke from CD. The statement was published in the October 2014 issue of Stroke.

“Most population-controlled studies have suggested an association, but reverse causation was possible,” concluded writing chair José Biller, MD, of Loyola University (Chicago, IL, USA), and colleagues. “Because patients with vertebral artery dissection commonly present with neck pain, it is possible that they seek therapy for this symptom from providers, including cervical manipulative therapy practitioners, and that the vertebral artery dissection occurs spontaneously, implying that the association ... is not causal.”

CDs are among the most common causes of stroke in young and middle-aged adults. Patients with CD may present with unilateral headaches, posterior cervical pain, or cerebral or retinal ischemia attributable mainly to artery-artery embolism, CD cranial nerve palsies, oculosympathetic palsy, or pulsatile tinnitus. Diagnosis of CD depends on a thorough history, physical examination, and targeted ancillary investigations. Although the role of trivial trauma is debatable, mechanical forces can lead to intimal injuries of the vertebral arteries and internal carotid arteries, resulting in CD.

Related Links:
American Heart Association
American Stroke Association
Loyola University