The Association of New Jersey Chiropractors (ANJC) has recently reviewed the article “Is It Safe To Get Your Neck Manipulated by a Chiropractor?” by Dana Smith in the March 12, 2023 Well column of the New York Times. While we applaud the author’s efforts to present a balanced view on the safety of cervical spinal manipulation as performed by doctors of chiropractic, we have concerns about her article as it contains points of misinformation and misinterpretation. We have listed them as follows:
1. The term “chiropractic manipulation” is a misnomer. Chiropractors perform cervical spinal manipulation (cSMT), but it is a procedure that is not exclusive to the chiropractic profession. Singling out cSMT applied by chiropractors as risky appears somewhat prejudicial. Secondly, there various forms of cSMT used by chiropractors, not just high velocity low amplitude techniques. It is confusing to the public to lump all these forms of cSMT together as “chiropractic manipulation.”  
2. The focus of the article is on an extremely rare association of vertebral artery dissection (VAD) with cSMT. VAD is a rare and unpredictable event, occurring spontaneously or resulting from a combination of risk factors thought to involve a patient’s physical predisposition (e.g., connective tissue disorder) and extrinsic stimuli (e.g., mechanical trauma). Your article omitted a very important fact in this association: there is currently no strong biomechanical evidence to establish the claim cSMT causes VAD.                       In place of the evidence, the article quoted the opinions on causation from 2 neurosurgeons who may recognize an association, but assign an erroneous cause.   
Biological studies consistently show that normal movements and ranges of motion of the cervical have more VA strain than is found with cSMT. In cases of close temporal association, the risk from cervical SMT is now theorized from the movement, not the manipulation. VAD should be considered a random and unpredictable complication of any neck movement, including cSMT. The riskiest movement is end range rotation, especially coupled with extension. This can happen in a myriad of ways in common daily life that can be overlooked, especially in a 30-day look back period (as was used in one of studies cited).  Good cSMT techniques avoid the extremes of both of those motions.
3. The current research perspectives are that these cases involve an already existing VAD in process, producing head and neck pain when the patient presents to a DC’s office (or medical facility, emergency room, etc.).          The cSMT is not the cause of the stroke, but rather a noncontributing procedure performed during a developing medical crisis.
4. Your article did not include some of the latest studies showing the safety of cSMT. Some of the more recent studies have found the following:
- The largest case-control study in 2015, consisting of 39 million people, to investigate the association between chiropractic manipulation and vertebral artery stroke found, “ no significant association between exposure to chiropractic care and the risk of vertebral artery stroke”.
- A 2015 study of Medicare patients found the risk of injury to the head, neck or trunk 76 percent lower after 7 days in those visiting a chiropractic office than among those who saw a primary care physician. 
- A paper published in 2016 by neurosurgeons from Penn State Hershey Medical Center, and Johns Hopkins University who studied in depth and published a paper on the association of cSMT and cervical artery dissection stated, “There is no convincing evidence to support a causal link, and unfounded belief in causation may have dire consequences.” 
- A 2017 study found no association between chiropractic visits and stroke in those 45 years of age or older. The incidence rate was the same with both PCP and chiropractic visits. The only association in patients under 45 was seeking treatment for head and/or neck pain.
- A 2022 study found that Medicare beneficiaries aged 65 and older who received cSMT manipulation had no greater the risk of cervical artery dissection than the control groups. 
- A 2023 retrospective analysis of a large sample size of over 960,000 SMT sessions for 54,846 patients, with detailed patient information, revealed no cases of stroke. 
5. It is totally erroneous to associate the trauma of auto accidents (MVA) with the forces of cervical spine manipulation MVA forces are significantly more. Furthermore, MVA trauma produces demonstrable strain on the VA, whereas cSMT does not.
6. The controversial association between cSMT and VAD stroke apparently originated with medical providers who observed it in individual patients. These clinicians believe they are acting in their patients’ best interests by calling attention to this issue. The professionals quoted in the article used their individual patient encounters and conjecture (including Dr. Grunch’s quote from a Tik Tok video that was used as a reliable source) instead of the evidence in assigning causation. Currently, evidence from both population studies of large groups of patients and biological investigations cannot determine that cSMT causes stroke. The evidence is also lacking that there is absolutely no association as well.
7. What was omitted from the article is the fact that the chiropractic community is well aware of the association of cSMT and VAD. Professional associations like the ANJC, and chiropractic colleges consistently provide ongoing continuing education on the safety and prevention of any potential adverse effects from cSMT, as well as identifying patients who may have conditions that are contraindicated to receiving cSMT. Individual doctors of chiropractic as a whole are acutely concerned with providing the safest treatments possible, as none wish to contribute to harming the patients under their care. Projects like SafetyNET and the chiropractic patient incident reporting and learning system (CPiRLS) are continuing to promote a patient safety culture and active surveillance of care in chiropractor’s offices.    
8. The article concludes that cSMT should be avoided if it’s performed by a chiropractor. The first line therapy recommendation of 6 weeks of over-the-counter pain medications is inconsistent with the goal of patient safety. Non-steroidal anti-inflammatory drugs (NSAIDs) have been shown to have a an absolute risk on average of 6%, and be responsible for 30% of hospital admissions for adverse drug reactions, mainly due to bleeding, heart attack, stroke, and renal damage. This is a significantly greater risk of harm than from any cSMT.    CSMT has been shown to produce a greater benefit than medication or home exercise for patients with acute and subacute neck pain. 
9. Aside from the exaggerated claims of some media,  chiropractors have an impressive safety record, equal to any health care profession. This is confirmed by our profession’s low malpractice rates.
The safety and effectiveness of any cSMT technique are variable. Good outcomes depend in large part on the skill of the practitioner performing it and the compatibility of the procedure with the patient receiving it. Rather than rejecting a very safe and effective procedure as is recommended in the article, it perhaps would have been more valuable to provide your readers with suggestions on finding a chiropractor who practices in a way that would be a good fit for them.
 Wenban AB. Inappropriate use of the title ‘chiropractor’ and term ‘chiropractic manipulation’ in the peer-reviewed biomedical literature. Chiropr Osteopat. 2006 Aug 22;14:16. doi: 10.1186/1746-1340-14-16. PMID: 16925822; PMCID: PMC1570468.
 Wenban A. Misuse of the terms chiropractic and chiropractor. J Neurol Neurosurg Psychiatry. 2004 May;75(5):794; author reply 794. PMID: 15090590; PMCID: PMC1763582.
 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. doi: 10.1159/000149578. Epub 2008 Jul 31. PMID: 18667811.
 Symons BP, Leonard T, Herzog W. Internal forces sustained by the vertebral artery during spinal manipulative therapy. J Manipulative Physiol Ther. 2002 Oct;25(8):504-10. doi: 10.1067/mmt.2002.127076. PMID: 12381972.
 Herzog W, Leonard TR, Symons B, Tang C, Wuest S. Vertebral artery strains during high-speed, low amplitude cervical spinal manipulation. J Electromyogr Kinesiol. 2012 Oct;22(5):740-6. doi: 10.1016/j.jelekin.2012.03.005. Epub 2012 Apr 5. PMID: 22483611.
 Symons B, Herzog W. Cervical artery dissection: a biomechanical perspective. J Can Chiropr Assoc. 2013 Dec;57(4):276-8. PMID: 24302772; PMCID: PMC3845472.
Herzog, W. The biomechanics of spinal manipulation, Journal of Bodywork and Movement Therapies,
Volume 14, Issue 3, 2010, Pages 280-286, ISSN 1360-8592, https://doi.org/10.1016/j.jbmt.2010.03.004.
Gorrell, L. et al (2022) Vertebral arteries do not experience tensile force during manual cervical spine manipulation applied to human cadavers, Journal of Manual & Manipulative Therapy, DOI: 10.1080/10669817.2022.2148048
Moser N, Mior S, Noseworthy M, et alEffect of cervical manipulation on vertebral artery and cerebral haemodynamics in patients with chronic neck pain: a crossover randomised controlled trialBMJ Open 2019;9:e025219. doi: 10.1136/bmjopen-2018-025219
Thomas LC, Rivett DA, Bateman G, Stanwell P, Levi CR. Effect of selected manual therapy interventions for mechanical neck pain on vertebral and internal carotid arterial blood flow and cerebral inflow. Phys Ther. 2013 Nov;93(11):1563-74. doi: 10.2522/ptj.20120477. Epub 2013 Jun 27. PMID: 23813088.
Kranenburg HAR, Tyer R, Schmitt M, Luijckx GJ, van der Schans C, Hutting N, Kerry R. Effects of Head and Neck Positions on Blood Flow in the Vertebral, Internal Carotid, and Intracranial Arteries: A Systematic Review. J Orthop Sports Phys Ther. 2019 Oct;49(10):688-697. doi: 10.2519/jospt.2019.8578. Epub 2019 Jul 5. PMID: 31276624.
Quesnele JJ, Triano JJ, Noseworthy MD, Wells GD. Changes in vertebral artery blood flow following various head positions and cervical spine manipulation. J Manipulative Physiol Ther. 2014 Jan;37(1):22-31. doi: 10.1016/j.jmpt.2013.07.008. Epub 2013 Nov 15. PMID: 24239451.
 Kocabey B, Karagözoğlu Coşkunsu D, Güven K, Ağaoğlu MH, Yüce S. Effects of Manual Versus Instrumental Spinal Manipulation on Blood Flow of the Vertebral and Internal Carotid Arteries in Participants With Chronic Nonspecific Neck Pain: A Single-Blind, Randomized Study. J Chiropr Med. 2023 Mar;22(1):1-10. doi: 10.1016/j.jcm.2022.05.006. Epub 2022 Jul 21. PMID: 36844987; PMCID: PMC9947994.
Yelverton C, Wood JJ, Petersen DL, Peterson C. Changes in Vertebral Artery Blood Flow in Different Head Positions and Post-Cervical Manipulative Therapy. J Manipulative Physiol Ther. 2020 Feb;43(2):144-151. doi: 10.1016/j.jmpt.2019.09.001. Epub 2020 May 30. PMID: 32482436.
Al-Obaidi SM, Asbeutah AM, Alsiri NF. Changes in Vertebral Artery Hemodynamics Associated With McKenzie Therapeutic Cervical Movements: An Exploration Using Duplex Ultrasound Imaging. J Manipulative Physiol Ther. 2019 Jan;42(1):66-74. doi: 10.1016/j.jmpt.2018.09.001. Epub 2019 Apr 5. PMID: 30955908.
Leenaerts T, Molenaar W, Cattrysse E. Changes in Vertebral Arterial Blood Flow During Premanipulative Tests in Participants With Upper Cervical Spine Motion Restriction. J Manipulative Physiol Ther. 2020 Feb;43(2):134-143. doi: 10.1016/j.jmpt.2019.10.002. Epub 2020 Apr 17. PMID: 32312607.
Church EW, Sieg EP, Zalatimo O, Hussain NS, Glantz M, Harbaugh RE. Systematic Review and Meta-analysis of Chiropractic Care and Cervical Artery Dissection: No Evidence for Causation. Cureus. 2016 Feb 16;8(2):e498. doi: 10.7759/cureus.498. PMID: 27014532; PMCID: PMC4794386.
Swait G, Finch R. What are the risks of manual treatment of the spine? A scoping review for clinicians. Chiropr Man Therap. 2017 Dec 7;25:37. doi: 10.1186/s12998-017-0168-5. PMID: 29234493; PMCID: PMC5719861.
Chung CLR, Côté P, Stern P, L’Espérance G. The Association Between Cervical Spine Manipulation and Carotid Artery Dissection: A Systematic Review of the Literature. J Manipulative Physiol Ther. 2015 Nov-Dec;38(9):672-676. doi: 10.1016/j.jmpt.2013.09.005. Epub 2014 Jan 3. PMID: 24387889.
Guan T, Zeng Y, Qi J, Qin B, Fu S, Wang G, Zhang L. Effects of Cervical Rotatory Manipulation on Internal Carotid Artery in Hemodynamics Using an Animal Model of Carotid Atherosclerosis: A Safety Study. Med Sci Monit. 2019 Mar 31;25:2344-2351. doi: 10.12659/MSM.913351. PMID: 30928990; PMCID: PMC6454981.
Fernando CK. Re: Haldeman, et al. Unpredictability of cerebrovascular ischemia associated with cervical spine manipulation therapy. Spine 2002;1:27. Spine (Phila Pa 1976). 2002 Sep 1;27(17):1951-3; author reply 1951-3. doi: 10.1097/00007632-200209010-00033. PMID: 12221368.
 Kawchuk GN, Wynd S, Anderson T. Defining the effect of cervical manipulation on vertebral artery integrity: establishment of an animal model.J Manipulative Physiol Ther. 2004; 27:539–546.
 Biller J, Sacco RL, Albuquerque FC, Demaerschalk BM, Fayad P, Long PH, Noorollah LD, Panagos PD, Schievink WI, Schwartz NE, Shuaib A, Thaler DE, Tirschwell DL; American Heart Association Stroke Council. Cervical arterial dissections and association with cervical manipulative therapy: a statement for healthcare professionals from the american heart association/american stroke association. Stroke. 2014 Oct;45(10):3155-74. doi: 10.1161/STR.0000000000000016. Epub 2014 Aug 7. Erratum in: Stroke. 2016 Nov;47(11):e261. PMID: 25104849.
 Erhardt JW, Windsor BA, Kerry R, Hoekstra C, Powell DW, Porter-Hoke A, Taylor A. The immediate effect of atlanto-axial high velocity thrust techniques on blood flow in the vertebral artery: A randomized controlled trial. Man Ther. 2015 Aug;20(4):614-22. doi: 10.1016/j.math.2015.02.008. Epub 2015 Mar 2. PMID: 25814193.
Chaibi A, Russell MB. A risk-benefit assessment strategy to exclude cervical artery dissection in spinal manual-therapy: a comprehensive review. Ann Med. 2019 Mar;51(2):118-127. doi: 10.1080/07853890.2019.1590627. Epub 2019 Apr 6. PMID: 30889367; PMCID: PMC7857472.
Carnes D, Mars TS, Mullinger B, et al.. Adverse events and manual therapy: a systematic review. Man Ther. 2010;15:355–363
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. doi: 10.1016/s1529-9430(02)00411-4. PMID: 14589464.
Dittrich R, Rohsbach D, Heidbreder A, Heuschmann P, Nassenstein I, Bachmann R, Ringelstein E, B, Kuhlenbäumer G, Nabavi D, G: Mild Mechanical Traumas Are Possible Risk Factors for Cervical Artery Dissection. Cerebrovasc Dis 2007;23:275-281. doi: 10.1159/000098327
Terrett AGJ; Current Concepts in Vertebrovascular Complications Following Spinal Manipulation; Second Edition; NCMIC Group, 2001.
Cassidy JD, Boyle E, Côté P, Hogg-Johnson S, Bondy SJ, Haldeman S. Risk of Carotid Stroke after Chiropractic Care: A Population-Based Case-Crossover Study. J Stroke Cerebrovasc Dis. 2017 Apr;26(4):842-850. doi: 10.1016/j.jstrokecerebrovasdis.2016.10.031. Epub 2016 Nov 21. PMID: 27884458.
Thomas LC. Cervical arterial dissection: An overview and implications for manipulative therapy practice. Man Ther. 2016 Feb;21:2-9. doi: 10.1016/j.math.2015.07.008. Epub 2015 Jul 29. PMID: 26250600.
Cassidy JD, 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. Eur Spine J. 2008 Apr;17(Suppl 1):176–83. doi: 10.1007/s00586-008-0634-9. Epub 2008 Feb 29. PMCID: PMC2271108.
Murphy DR. Current understanding of the relationship between cervical manipulation and stroke: what does it mean for the chiropractic profession? Chiropr Osteopat. 2010 Aug 3;18:22. doi: 10.1186/1746-1340-18-22. PMID: 20682039; PMCID: PMC2922298.
Bronson MA, Perle SM, Tuchin P. Issues with vertebral artery dissections. Interv Neuroradiol. 2017 Apr;23(2):154-155. doi: 10.1177/1591019916680111. Epub 2016 Dec 14. PMID: 28304208; PMCID: PMC5433597.
Murphy DR, Schneider MJ, Perle SM, Bise CG, Timko M, Haas M. Does case misclassification threaten the validity of studies investigating the relationship between neck manipulation and vertebral artery dissection stroke? No. Chiropr Man Therap. 2016 Nov 5;24:43. doi: 10.1186/s12998-016-0124-9. PMID: 27826415; PMCID: PMC5097434.
 Smith DL, Cramer GC; LETTER TO THE EDITOR: Spinal Manipulation is Not an Emerging Risk Factor for Stroke Nor is it Major Head/Neck Trauma. Don’t Just Read the Abstract!; The Open Neurology Journal, 2011, 5, 46-47
 Kosloff TM, Elton D, Tao J, Bannister WM. Chiropractic care and the risk of vertebrobasilar stroke: results of a case-control study in U.S. commercial and Medicare Advantage populations. Chiropr Man Therap. 2015 Jun 16;23:19. doi: 10.1186/s12998-015-0063-x. PMID: 26085925; PMCID: PMC4470078
 Futch D, Schneider MJ, Murphy D, Grayev A. Vertebral artery dissection in evolution found during chiropractic examination. BMJ Case Rep. 2015 Nov 12;2015:bcr2015212568. doi: 10.1136/bcr-2015-212568. PMID: 26564115; PMCID: PMC4654207.
 Kosloff, T.M., Elton, D., Tao, J. et al. Chiropractic care and the risk of vertebrobasilar stroke: results of a case–control study in U.S. commercial and Medicare Advantage populations. Chiropr Man Therap 23, 19 (2015). https://doi.org/10.1186/s12998-015-0063-x
 Whedon JM, et al. Risk of Traumatic Injury Associated With Chiropractic Spinal Manipulation in Medicare Beneficiaries Aged 66 to 99 Years. Spine 2015;40:264–270
 Church EW, Sieg EP, Zalatimo O, Hussain NS, Glantz M, Harbaugh RE. Systematic Review and Meta-analysis of Chiropractic Care and Cervical Artery Dissection: No Evidence for Causation. Cureus. 2016 Feb 16;8(2):e498. doi: 10.7759/cureus.498. PMID: 27014532; PMCID: PMC4794386.
 Cassidy JD, Boyle E, Côté P, Hogg-Johnson S, Bondy SJ, Haldeman S. Risk of Carotid Stroke after Chiropractic Care: A Population-Based Case-Crossover Study. J Stroke Cerebrovasc Dis. 2017 Apr;26(4):842-850. doi: 10.1016/j.jstrokecerebrovasdis.2016.10.031. Epub 2016 Nov 21. PMID: 27884458.
 Whedon JM, Petersen CL, Li Z, Schoelkopf WJ, Haldeman S, MacKenzie TA, Lurie JD. Association between cervical artery dissection and spinal manipulative therapy -a medicare claims analysis. BMC Geriatr. 2022 Nov 29;22(1):917. doi: 10.1186/s12877-022-03495-5. PMID: 36447166; PMCID: PMC9710172.
 Chu EC, Trager RJ, Lee LY, Niazi IK. A retrospective analysis of the incidence of severe adverse events among recipients of chiropractic spinal manipulative therapy. Sci Rep. 2023 Jan 23;13(1):1254. doi: 10.1038/s41598-023-28520-4. PMID: 36690712; PMCID: PMC9870863.
 Haneline M, Triano J. Cervical artery dissection. A comparison of highly dynamic mechanisms: manipulation versus motor vehicle collision. J Manipulative Physiol Ther. 2005 Jan;28(1):57-63. doi: 10.1016/j.jmpt.2004.12.003. PMID: 15726036.
 Thomas M, Swait G, Finch R. Ten years of online incident reporting and learning using CPiRLS: implications for improved patient safety. Chiropr Man Therap. 2023 Feb 15;31(1):9. doi: 10.1186/s12998-023-00477-1. PMID: 36793096; PMCID: PMC9933370.
 Wangler M, Fujikawa R, Hestbæk L, Michielsen T, Raven TJ, Thiel HW, Zaugg B. Creating European guidelines for Chiropractic Incident Reporting and Learning Systems (CIRLS): relevance and structure. Chiropr Man Therap. 2011 Apr 1;19:9. doi: 10.1186/2045-709X-19-9. PMID: 21457532; PMCID: PMC3079683.
 Funabashi M, Pohlman KA, Mior S, O’Beirne M, Westaway M, De Carvalho D, El-Bayoumi M, Haig B, Wade DJ, Thiel HW, Cassidy JD, Hurwitz E, Kawchuk GN, Vohra S. SafetyNET Community-based patient safety initiatives: development and application of a Patient Safety and Quality Improvement Survey. J Can Chiropr Assoc. 2018 Dec;62(3):130-142. PMID: 30662067; PMCID: PMC6319430.
Funabashi M, Holmes MM, Pohlman KA, Salsbury S, O’Beirne M, Vohra S, Mior S. “Doing our best for patient safety”: An international and interprofessional qualitative study with spinal manipulative therapy providers in community-based settings. Musculoskelet Sci Pract. 2021 Dec;56:102470. doi: 10.1016/j.msksp.2021.102470. Epub 2021 Oct 20. PMID: 34735865.
 Solomon DH, Husni ME, Libby PA, Yeomans ND, Lincoff AM, Lϋscher TF, Menon V, Brennan DM, Wisniewski LM, Nissen SE, Borer JS. The Risk of Major NSAID Toxicity with Celecoxib, Ibuprofen, or Naproxen: A Secondary Analysis of the PRECISION Trial. Am J Med. 2017 Dec;130(12):1415-1422.e4. doi: 10.1016/j.amjmed.2017.06.028. Epub 2017 Jul 26. PMID: 28756267.
Davis A, Robson J. The dangers of NSAIDs: look both ways. Br J Gen Pract. 2016 Apr;66(645):172-3. doi: 10.3399/bjgp16X684433. PMID: 27033477; PMCID: PMC4809680.
 Rushton A, Carlesso LC, Flynn T, Hing WA, Rubinstein SM, Vogel S, Kerry R. International Framework for Examination of the Cervical Region for Potential of Vascular Pathologies of the Neck Prior to Musculoskeletal Intervention: International IFOMPT Cervical Framework. J Orthop Sports Phys Ther. 2023 Jan;53(1):7-22.
Bronfort G, Evans R, Anderson AV, Svendsen KH, Bracha Y, Grimm RH. Spinal manipulation, medication, or home exercise with advice for acute and subacute neck pain: a randomized trial. Ann Intern Med. 2012 Jan 3;156(1 Pt 1):1-10. doi: 10.7326/0003-4819-156-1-201201030-00002. PMID: 22213489.
Al-Azdee, M., Perle, S.M. & He, B. Biased online media coverage: chiropractic and stroke in google news. Chiropr Man Therap 26, 21 (2018). https://doi.org/10.1186/s12998-018-0189-8