Untwisting the Controversy of Strokes and Chiropractic
By
Dr. Thomas Patavino D.C., MS, F.I.A.M.A

Recent stories have hit local papers and magazines bringing attention to the risk of stroke with chiropractic manipulation. One of the most recent publications to look at this alarming scenario was the May 2007 issue of Self magazine1. The graphic article dramatically paints a scary picture of both stoke and the chiropractic profession. This only seems to be the latest of chain of events that unfortunately comes across more like yelling fire in a crowded theater rather than properly educating the public on a health concern. The cases of stroke are related to a condition called Vertebral Artery Dissection (VAD).

VAD is a condition characterized by a presence of a growing hemotoma (collection of blood vessels such as a bruise or blood clot) within the wall of the vertebral artery. If the hemotoma expands and there is a weakening in the wall lining of the vessel or the vertebral artery undergoes some form of trauma the potential for rupture exists leading to a stroke. VAD, along with carotid artery dissection, is the leading cause of strokes in those under the age of 45.

A handful of cases have linked VAD to cervical manipulation and have brought questions to the safety of chiropractic care. The bigger concern has to be the interpretation of information and how it is relayed to the public. For starters, the frequency should be reiterated for those who overestimate the incidence of carotid and vertebral artery dissection. The incidence appears to be approximately 2.6 people out of 100,000 people.2 That is the incidence of the condition, and not those who have visited a chiropractor. Currently, only about 10% of society utilizes chiropractic care. That would make the ratio of VAD patients likely to receive chiropractic care somewhere around 2 patients per 1 million. That’s a 2 out of a million chance of a chiropractor treating a patient with the underlying condition of VAD. You have a 1 in 700,000 chance of getting struck by lightning. Does the chance of suffering a stroke due to a chiropractic adjustment exist? Absolutely, but statistically you have a better chance of getting struck by lightning.

Here in lies a problem. The statistical chances of suffering a stroke by the hand of a chiropractor are being taken out of context by the tone of these articles that are starting to spread like an epidemic. Research shows that chiropractic manipulation is one risk linked to cervical artery dissection. Read that carefully, one risk, not the only risk. In fact there are studies that show that they cannot definitively link VAD to cervical manipulation.3 Other risks that have been linked to causing strokes in patients with an underlying VAD condition include yoga, ceiling painting, blowing your nose, judo and hyperextension. Hyperextension appears to be the big one. 48% of all cases is one study demonstrate this motion as being a predicating factor.2,4 Hyperextension is leaning your head back. That means going to a hairdresser, taking a shower, riding amusement park rides or watching the fireworks can lead to a stroke. Yoga, pilates, judo, massage therapy, physical therapy and let us not forget blowing your nose once again.4,5 Although there is a growing list of risk factors associated with stroke in this population of people, the only one getting the negative publicity is chiropractic. 10% of the population utilizes chiropractic care, yet that appears to be the main risk factor gathering headlines. What population utilizes yoga, physical therapy, goes to get their haircut, blows their nose and looks up at the fireworks display on the Fourth of July?

The truth of the matter is that all health care poses risks. Epidural injections pose a risk of causing permanent paralysis. There is a risk of not waking up from anesthesia, with any surgical procedure. There is risk of death to anaphylaxis with taking medication, as reactions cannot be predicted. Lingual nerve damage is quite common with routine dental procedures. The point is chiropractic care is no different than other health professions in that risks exist, however the negative occurrences linked to other professions don’t seem to grab the health watch sections in the media. In reality, there were a handful of cases mentioned in the Self May 2007 article relating to stroke with chiropractic manipulation. Remember Vioxx? It is estimated that between 150,000 and 200, 000 deaths were linked to the prescribing of this drug according to the FDA. About two million people in the United States contract a hospital infection each year and 90,000 of them die, estimates the Centers for Disease Control and Prevention. These harsh truths exist in healthcare. They exist without headlines and warnings scaring people from avoiding dentistry, prescription medicine, hospitals and surgery. Why is chiropractic different?

Chiropractic has long been misunderstood and a target for some members of the medical profession. Chiropractic was not welcomed or accepted by the medical community in the early days. This has changed dramatically in the last 3 decades. Many medical doctors now work along side chiropractors, make referrals and recognize the validity and value of chiropractic care. However, not all medical doctors have changed with the times and still harbor ill feelings towards the profession. This is unfortunate, but we live in a world where prejudice will exist regardless how mentally evolved we should be in modern times. Historically, we have proven that being misinformed can harvest grave results. Remember the Salem witch trials?

I don’t believe these articles of defamation will have the same result as Salem, but they do have a negative effect on chiropractic and they are failing to accurately serve the public by delivering an accurate depiction of the real health concern; VAD and not chiropractic care. Vertebral and Carotid artery dissection is a health concern, but remember the small population effected by these conditions. If there is such a huge health concern with this population, then why isn’t there a better screening process performed by the primary care physicians of these patients. Why don’t their medical doctors have them on anticoagulant therapy like other stroke risk patients? The reason is that these conditions are not as common as these articles may lead you to believe. VAD is not popping up like the common cold. You have a handful of cases. This health concern should be viewed in the same light as Aortic dissection and commotio cordis.

Aortic dissection was the hidden condition that took the life of John Ritter. This was an unforeseen weakening in the wall of the aorta that led to cardiovascular failure. Commotio Cordis, which means commotion to the heart, the condition that has caused young athletes to die due to blunt trauma to the chest. The blunt trauma affecting these adolescent and teenage children was contact by playing baseball, hockey and football. Are these sports going to be outlawed due to these findings? Absolutely not. Society is able to see that a small risk should not create an epidemic. VAD due to chiropractic care has to be looked at the same way.

Some things that should be considered with looking at chiropractic and stroke risk are the facts related to the profession. For starters you have education. Chiropractors go to school for 8 years after high school, just as doctors of medicine, dentistry, and veterinary medicine. They have to pass 4 parts of national boards and their designation is D.C., Doctor of Chiropractic. Chiropractic care is a recognized and reimbursable form of healthcare recognized by every major health insurance company. If chiropractic was quackery and a huge health risk, would it be a covered treatment paid for by health insurance companies? If stroke was a huge risk, why are we reading about only a handful of cases? Wouldn’t there be more?

There are 16 chiropractic schools in the United States with an estimated enrollment of 15,000 students. Students are required learn and perform cervical manipulation on each other under the supervision of their instructors. That’s 15,000 students performing cervical adjustments daily, year after year, until they hone their craft. Consider this, these adjustments are performed by novices who are not yet professionals. They are nearly all under the age of 45 years old. That would put them in the age bracket of those most prone to VAD. Let’s conservatively say each chiropractor student performs 200 adjustments during their schooling. That would be 300,000 cervical adjustments performed at any given year by students. If manipulation was a high risk factor for stroke, wouldn’t there be numerous cases of strokes within this population? These are students just learning the technique, not licensed professionals. Chances are you would see a greater risk of strokes within this setting compared to manipulation performed by licensed physicians. The reason you haven’t heard of many cases is that there aren’t any.

The next thing to consider is the malpractice premiums for chiropractors. Chiropractors are required to carry a minimum of 1 million dollars of liability insurance. This will cost the chiropractor anywhere from $1600 to $2500 a year for that coverage. The average medical doctor has a premium ranging from $10,000 up to several hundred thousand dollars a year. If chiropractic was causing that many strokes wouldn’t the malpractice insurance be significantly higher instead of fractions of that of the medical profession. These are factors not considered when realistically looking at the actual risk. Truth be told, malpractice and health insurance companies tend not to be very generous with the use of their money if they feel there is significant risk.

Finally, for those who state there is no scientific evidence of patients improving with chiropractic manipulation, this can be answered with an article search in the national library of medicine.6 Granted that there is limitation of published studies looking at the cervical spine because most studies focus on the low back, that should no way be misinterpreted as an invalid health benefit. There are no medically conducted studies or written articles looking at the benefit of removing a sliver from a finger or a pebble from a shoe to reduce pain, but we know otherwise. If there was no benefit from chiropractic care, would there be a chiropractic office in most cities with patients in those offices every day?

Connecticut legislature may pass a law in October 2007 requiring chiropractors to list stroke as a possible risk with manipulation on their consent forms. I support this as long as the risk is appropriately and accurately depicted to the patient. The truth is there is a small risk of stroke with chiropractic care, just as there is a risk of stroke with massage therapy, physical therapy, yoga, martial arts, sports, hairdressing etc., etc., etc. People who are concerned if they may have VAD, should have their primary care physicians decide if diagnostic testing or anticoagulant therapy is recommended rather than avoid the growing list of risk factors that have been linked to stroke. People who are a known risk for stroke should avoid cervical manipulation. For the rest of the population, know that risks exists with all forms of health care treatment; some are small, others more common. One never knows. As physicians it is our job to accurately relay the potential for risk factors in healthcare because they exist in all professions. Painting partial pictures and creating public alarm fails to do that. Chiropractors should inform their patients of the risk, no matter how small and other professionals should not exaggerate the risks because it is an injustice to healthcare. Health concerns should be just that and not serve as a forum for another agenda.

References
1. Wolff, J. A deadly twist Chiropractors are causing strokes in young, healthy women. Read this before your next appointment: Self 2007 May; 224-227,242.
2. Lang, E., Afilalo,M., Dissection, Vertebral Artery: E medicine from Web MD,2006 May.
3. Haneline, M; Croft, Arthur C., Frishberg, B, Association of Internal Carotid Artery Dissection and Chiropractic Manipulation. Neurologist. 9(1):35-44, January 2003.
4. Stahner SA, Raps EC, Mines DI. Carotid and vertebral artery dissections. Emerg Med Clin N Am 1997;15:677-98.
5. Schievink WI. Spontaneous dissection of the carotid and vertebral arteries. N Engl J Med 2002;12:898-906
6. Garner MJ, Aker P, Balon J, Birmingham M, Moher D, Keenan D, Manga P. Chiropractic care of musculoskeletal disorders in a unique population within Canadian community health centers. J Manipulative Physiol Ther. 2007 Mar-Apr;30(3):165-70.