Response To The Lifescript Article on Stroke

The following letter to the editor was submitted in April, 20015:

Dear Editor,

By way of correction in your otherwise very informative April 20, 2015 Lifescript article, “One Flip of Her Head Led to Symptoms of Stroke”, the following statement is in need of amending:

“Neck traumas and neck manipulations by chiropractors and other health practitioners may be linked to stroke, according to the American Heart Association.”

The American Heart Association (AHA) 2014 statement, “Cervical Arterial Dissections and Association with Cervical Manipulative Therapy”, did not single out Chiropractors in their report.[i] Your article’s statement as listed above serves to give the reader the erroneous impression that Chiropractors are the more endangering practitioners. In fact, of all practitioners who utilize cervical spinal manipulation, the Chiropractic profession has been the most studied and has been shown to have the strongest evidence of safety.[ii] [iii] [iv]This includes studies that have been published after the information reviewed in the AHA statement.[v]

Associating neck traumas with neck manipulation is unwarranted and false.[vi] All studies attempting to find a biological and physiological mechanism for how a neck manipulation could cause a vertebral artery dissection have been fruitless.[vii][viii][ix][x][xi] Further, the AHA paper postulated only one cervical manipulation maneuver that may be questionable. Your statement implies that all neck manipulations are a factor.

As your article mentioned, vertebral artery dissection is a potentially life-threatening condition. Being extremely rare and coupled with the known reporting bias in regards to cervical manipulation, accurate information on its causation is difficult. [xii] [xiii] [xiv]As someone who teaches safety protocols for cervical manipulation I will be happy to assist you in the future.


David I Graber, DC

Chairman, Council on Chiropractic Technique and Clinical Excellence

Association of New Jersey Chiropractors


NB. The article that this letter to the editor responded to has been taken down.


[i] Cervical Arterial Dissections and Association With Cervical Manipulative Therapy: A Statement for Healthcare Professionals From the American Heart Association/American Stroke Association. Published online before print August 7, 2014

[ii] Cassidy DJ, Boyle E, Côté P, He Y, Hogg-Johnson S, Silver FL, Bondy SJ:  Risk of vertebrobasilar stroke and chiropractic care: results of a population-based case-control and case-crossover study. J Manipulative Physiol Ther 2009, 32(2S):S201-208.

[iii] Thiel, H, Bolton, J, et al , Safety of Chiropractic Manipulation of the Cervical Spine: A Prospective National Survey, Spine, Volume 32(21), October 2007,

[iv] Todd, AJ, et al Adverse Events Due to Chiropractic and Other Manual Therapies for Infants and Children: A Review of the Literature. JMPT 2014 Oct 30

[v] Whedon JM, Song Y, Mackenzie TA, et al. Risk of stroke after chiropractic spinal manipulation in Medicare B beneficiaries aged 66 to 99 years with neck pain. JMPT. 2015;38(2):93-101.

[vi] Smith DL, Cramer GD. Open Neurol J. 2011;5:46-7. Spinal Manipulation is Not an Emerging Risk Factor for Stroke Nor is it Major Head/Neck Trauma. Don’t Just Read the Abstract!

[vii] Wynd S, Anderson T, Kawchuk G. Effect of cervical spine manipulation on a pre-existing vascular lesion within the canine vertebral artery. Cerebrovasc Dis. 2008;26(3):304-9.

[viii] Quesnele J, Triano J, et al. JMPT, 2014. Changes in vertebral artery blood flow following various head positions and cervical spine manipulation.

[ix] Symons, B.,Herzog W ., J Can Chiropr Assoc  2013. Cervical artery dissection: a biomechanical perspective.

[x] Thomas LC , Rivett DA, et al. Phys Ther. 2013 Nov;93(11):1563-74. Effect of selected manual therapy interventions for mechanical neck pain on vertebral and internal carotid arterial blood flow and cerebral inflow

[xi] Wuest S, Symons B, Leonard T, Herzog W. Preliminary report: biomechanics of vertebral artery segments C1–C6 during cervical spinal manipulation. J Manipulative Physiol Ther. 2010;33:273–278

[xii] Haldeman S., Kohlbeck F.J., McGregor M. Stroke, cerebral artery dissection, and cervical spine manipulation therapy. J Neurol. 2002;249(8):1098–1104.

[xiii] Haldeman S, Carey P, Townsend M, Papadopoulos C. Clinical perceptions of the risk of vertebral artery dissection after cervical manipulation: the effect of referral bias. Spine J. 2002 Sep-Oct;2(5):334-42. PubMed PMID: 14589464.

[xiv] Terrett AG: Misuse of the literature by medical authors in discussing spinal manipulative therapy injury. J Manipulative Pysiol Ther 18:203 210, 1995




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