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A Chiropractic Perspective: Spinal Manipulative Therapy Is Not Causally Related to Stroke

Published/Copyright: January 1, 2014
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Journal of Osteopathic Medicine
From the journal Journal of Osteopathic Medicine Volume 114 Issue 1

Tuchin P. Chiropractic and stroke: association or causation? Int J Clin Pract.2013;67(9):825-833. doi:10.1111/ijcp.12171.

Concern about severe adverse neurovascular events as a result of cervical manipulation has appeared in the scientific literature since the 1960s,1 with full-blown debate on the issue starting around 2002.2 In a recent review and commentary, Australian professor Peter Tuchin discussed these concerns about spinal manipulative therapy (SMT) from the chiropractic perspective. Specifically, the author reviewed the evidence on SMT and stroke and evaluated the causal relationship according to specific criteria including strength, plausibility, and other explanations.

First, Tuchin observed that there is not a strong association between SMT and vertebral artery dissection (VAD) and stroke. In many case reports and reviews that describe severe adverse events after SMT, the SMT was provided by either a chiropractor or a general medical practitioner. Tuchin made the argument that the neck pain leading to the chiropractor or general medical practitioner visit was probably caused by a VAD or stroke already in progress. One article3 reported, “…two of the dissection patients had VAD within seconds of receiving SMT.” Tuchin points out, “This would suggest that the VAD must have been present before the SMT, as it seems impossible for a thrombus to instantly form, dislodge, travel to the cerebral cortex to cause a stroke ‘…within seconds of receiving SMT’.”

Second, Tuchin questioned the plausibility of the SMT-VAD association by citing a study4 that revealed the force exerted on the vertebral artery during SMT was not enough to produce any tearing of the vertebral artery. In the same study, the SMT forces were shown to be less than the forces used during diagnostic and range of motion testing.

Third, Tuchin noted that the critics of SMT have not adequately reported other explanations and risk factors of stroke that could be causes of serious adverse events. For example, morbidities associated with VAD and stroke that have been cited in the literature include hypertension, hyperlipidemia, hyperhomocysteinemia, recent infection, smoking, diabetes mellitus, migraine, atrial fibrillation, obesity, cardiovascular disease, hormone replacement therapy, heavy drinking, illicit drug use, lupus anticoagulant, active malignancy, recent trauma, and genetic factors. Any of these morbidities could cause stroke and precede SMT.

Tuchin concluded that there is a lack of compelling evidence that SMT is causally associated with stroke. Because professional liability carriers often associate osteopathic manipulative treatment with SMT, the American Osteopathic Association has addressed these concerns and determined that osteopathic manipulative treatment of the cervical spine is safe (American Osteopathic Association House of Delegates reaffirmed Resolution H-257 [A/2004—Osteopathic Manipulative Treatment of the Cervical Spine]).5

References

1 Hipp E . The hazards of chiropractic and osteopathic treatment [in German]. Med Klin. 1961;56:1020-1022.Search in Google Scholar

2 Haldeman S Kohlbeck FJ McGregor M . Stroke, cerebral artery dissection, and cervical spine manipulation therapy. J Neurol.2002;249(8):1098-1104.10.1007/s00415-002-0783-4Search in Google Scholar PubMed

3 Smith WS Johnston SC Skalabrin EJ et al. . Spinal manipulative therapy is an independent risk factor for vertebral artery dissection. Neurology. 2003;60(9): 1424-1428.10.1212/01.WNL.0000063305.61050.E6Search in Google Scholar

4 Herzog W Leonard TR Symons B Tang C Wuest S . Vertebral artery strains during high-speed, low amplitude cervical spinal manipulation[published online April 5, 2012]. J Electromyogr Kinesiol.2012;22(5):740-746. doi:10.1016/j.jelekin.2012.03.005.10.1016/j.jelekin.2012.03.005Search in Google Scholar PubMed

5 King HH . Safety and efficacy of cervical spinal manipulation. Presented at: American Osteopathic Association Osteopathic Medical Conference & Exposition; 1008, 2012; San Diego, CA.Search in Google Scholar
Published Online: 2014-01-01
Published in Print: 2014-01-01

© 2014 The American Osteopathic Association

This work is licensed under the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.

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  1. Abstracts
  2. 2013 SOMA Abstracts and Poster Competition
  3. 2013 BIOM Abstracts and Poster Competition
  4. Editorial
  5. Our Past, Present, and Future Are in Our Hands
  6. Letters
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  8. Original Contribution
  9. The Persistence of Lumbar Somatic Dysfunction and Its Association With Bone Mineral Density
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  11. Patterns of Misrepresentation of Clinical Findings on Patient Notes During the COMLEX-USA Level 2-PE
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  14. A Research Primer, Part 2: Guidelines for Developing a Research Project
  15. Case Report
  16. A Case of Seasonal Recurrent Myopericarditis
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  19. OMT Relieves Severe Chronic Low Back Pain
  20. Abdominal Muscles Are the Front Side of the Low Back
  21. Systematic Review Paints Incomplete Picture of OMT Research
  22. Manual Therapy or Exercise Effective for Hip or Knee Osteoarthritis
  23. Review of Severe Adverse Events From Spinal Manipulative Therapy of the Lumbopelvic Area
  24. A Chiropractic Perspective: Spinal Manipulative Therapy Is Not Causally Related to Stroke
  25. Clinical Images
  26. Abducens Palsy
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https://doi.org/10.7556/jaoa.2014.014
Creative Commons
BY-NC-ND 4.0

Articles in the same Issue

  1. Abstracts
  2. 2013 SOMA Abstracts and Poster Competition
  3. 2013 BIOM Abstracts and Poster Competition
  4. Editorial
  5. Our Past, Present, and Future Are in Our Hands
  6. Letters
  7. Osteopathic Manual Treatment and Ultrasound Therapy for Chronic Low Back Pain: An Illustration of Osteopathic Semantic Confusion
  8. Original Contribution
  9. The Persistence of Lumbar Somatic Dysfunction and Its Association With Bone Mineral Density
  10. Medical Education
  11. Patterns of Misrepresentation of Clinical Findings on Patient Notes During the COMLEX-USA Level 2-PE
  12. Special Communication
  13. A Degree of Difference: The Origins of Osteopathy and First Use of the “DO” Designation
  14. A Research Primer, Part 2: Guidelines for Developing a Research Project
  15. Case Report
  16. A Case of Seasonal Recurrent Myopericarditis
  17. A Case of Idiopathic Colonic Varices
  18. The Somatic Connection
  19. OMT Relieves Severe Chronic Low Back Pain
  20. Abdominal Muscles Are the Front Side of the Low Back
  21. Systematic Review Paints Incomplete Picture of OMT Research
  22. Manual Therapy or Exercise Effective for Hip or Knee Osteoarthritis
  23. Review of Severe Adverse Events From Spinal Manipulative Therapy of the Lumbopelvic Area
  24. A Chiropractic Perspective: Spinal Manipulative Therapy Is Not Causally Related to Stroke
  25. Clinical Images
  26. Abducens Palsy
  27. In Your Words
  28. No Place Like HOME
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