Background
According to the Centers for Disease Control and Prevention of the United States (CDC), the top ten causes of yearly death are (1):
Number of deaths for leading causes of death
- Heart disease: 695,547
- Cancer: 605,213
- COVID-19: 416,893
- Accidents (unintentional injuries): 224,935
- Stroke (cerebrovascular diseases): 162,890
- Chronic lower respiratory diseases: 142,342
- Alzheimer’s disease: 119,399
- Diabetes: 103,294
- Chronic liver disease and cirrhosis: 56,585
- Nephritis, nephrotic syndrome, and nephrosis: 54,358
Stroke is number five, with a listed number of deaths at 162,890 yearly. The total number of strokes yearly in the U.S. (fatal and nonfatal) is 795,000 (2).
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A True Story
Chiropractor Dr. M••••• has been in practice for more than 30 years. She specializes in the management of traumatic cervical spine injuries (primarily whiplash mechanism injuries). She is very successful and has a referral-only practice. Her reputation within the community where she practices is flawless. She has the respect of her colleagues and works well with other health care providers.
Recently, Dr. M••••• was referred a new whiplash-injured patient. The patient was a 33-year-old female. The patient’s primary complaint was neck pain, caused by the mechanism of the collision. The examination of the patient showed that she had suffered only soft-tissue injuries (Quebec Task Force Whiplash Associated Disorder category II); there were no positive neurological symptoms or signs (Quebec Task Force Whiplash Associated Disorder category III).
Although the patient’s only complaints were neck pain, the patient politely asked Dr. M••••• not to adjust her neck. Confused, Dr. M••••• asked the patient to explain the reason(s) for her concerns pertaining to cervical spine adjustments. The patient politely replied:
“My husband is a nurse who works in the emergency department at [a local hospital]. My request for no neck adjustments is his request, based on his training at the hospital. He is concerned about the risk of stroke injury from neck manipulation.”
Apparently, hospital personnel are trained to ask all suspected stroke patients entering the emergency department if they have recently been seen by a chiropractor. If the patient answers “yes,” emergency department records often record something like “suspected stroke related to chiropractic manipulation.”
Shocked by the uninformed bias by emergency department personnel, Dr. M••••• calmly reviewed the following section from her Informed Consent:
Neck Artery Dissection and Stroke
Dissection is when the lining of a neck artery breaks down. This might happen spontaneously or from an injury or from a trivial movement (hair shampooing, checking traffic, looking up, etc.).
Dissections tend to cause neck pain and/or headache.
Dissections may form a clot that can dislodge and interfere with brain blood flow. If that happens, it is called a stroke.
Stroke means that a portion of the brain or spinal cord does not receive enough oxygen from the blood stream. The results can be temporary or permanent dysfunction of the brain, with a very rare complication of death.
The literature is mixed or uncertain as to whether chiropractic adjustments are associated with stroke or not. Recent evidence suggests that it is not (2008, 2015, 2016, 2019), although the same evidence often suggests that the patient may be entering the chiropractic office for neck pain/headaches or other symptoms that may in fact be a spontaneous dissection of a neck artery.
There are no in-the-office tests to diagnose a spontaneous neck artery dissection (2020), but they might be detectable with advanced imaging (CT/MRI, etc.). If we think you may be suffering from a spontaneous neck artery dissection and/or associated stroke, you will be immediately referred to emergency services.
Anecdotal cases suggest that chiropractic adjustments may be associated with dissection and/or stroke that arise from the vertebral artery; this is because the vertebral artery is located inside the neck vertebrae. The adjustment that is suggested to increase the strain on the vertebral artery is called the “extension-rotation-thrust atlas adjustment.” We do not do this type of adjustment on patients. Other types of neck adjustments may also potentially be related to vertebral artery strokes, but no one is certain.
It is estimated that the incidence of this type of complication ranges between 1 per every 400,000-10,000,000 neck adjustments (2004). A large 10-year study estimated an incidence of 1 per 5.85 million neck adjustments, equivalent to 1,430 years of clinical practice (2001).
After discussing this information, Dr. M••••• and her whiplash-injured patient agreed upon a compromise: Dr. M••••• would only adjust her neck with a hand-held mechanical device; there would be no traditional joint cavitation maneuvers. The patient enjoyed quick improvement and soon achieved a complete resolution of her signs and symptoms.
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Joint Manipulation
Joint manipulation is the applying of a force to a joint that helps that joint move better. It is classically associated with an audible sound; lay people often refer to the sound as a “crack” or “pop.” All people, trained and untrained, are capable of manipulating joints and eliciting an audible sound.
Manipulation is a lay term. It is often used synonymously with the word chiropractic. Yet, importantly, chiropractors technically do not manipulate joints. Chiropractors adjust joints. This is known as the chiropractic adjustment.
The Chiropractic Joint Adjustment
Manipulation implies the movement of a joint to the point of creating an audible sound, but the line-of-drive and the control of the amplitude (distance) is not precise. In contrast, the term for manipulation that has a specific line-of-drive direction and control of the amplitude is adjustment. Chiropractors use spinal adjusting, not manipulation. The mastery of spinal adjusting takes years of study, training, and practice. After completing college with a biological curriculum, the training to be a chiropractor takes 4 academic years at an accredited chiropractic college.
Chiropractic Accreditation
and the Council on Chiropractic Education (CCE):
In the United States, there are 18 chiropractic colleges, and throughout the world there are many more (3). Some of the chiropractic colleges are universities that grant academic degrees in addition to the Doctor of Chiropractic degree (DC). Others only grant Doctor of Chiropractic degrees.
In the 1970s, the United States federal government took control of chiropractic education. The United States Department of Education oversees chiropractic education by recognizing the Council on Chiropractic Education (CCE) (3):
“CCE maintains recognition by the United States Department of Education as the national accrediting body for Doctor of Chiropractic Programs and chiropractic solitary purpose institutions of higher education.”
All 18 of the chiropractic colleges in the United States are accredited by the Council on Chiropractic Education.
In the United States, the licensure of chiropractors is controlled by the individual states, and all 50 U.S. states officially license chiropractors, allowing them to practice with their Doctor of Chiropractic degree (DC). All 50 U.S. states require graduation from a CCE accredited college to sit the licensing examination. Chiropractors are considered to be primary portal health care providers, which means (in part) that the public may choose chiropractic care without requiring a referral from another health care provider.
As a result of their education and examination procedures, chiropractors are legally allowed to provide a number of services to their patients. These include physical therapy, exercise, tissue work, dietary advice, use of supplements, the taking of and the interpretation of x-rays, etc. The central core of chiropractic clinical practice is the use of mechanical care, and the primary form of mechanical care is specific line-of-drive manipulation (the chiropractic adjustment).
A typical chiropractic visit involves an assessment of posture and joint motion (possibly with the use of x-rays), helping the chiropractor assess the manner in which his/her patient exists and functions mechanically in a gravity environment. Abnormal findings are usually treated mechanically and primarily with the use of the chiropractic adjustment.
In the early stages of chiropractic education (about the first 50 years, approximately 1900-1950), chiropractors were instructed that the physiological foundation of their mechanical care was in treating the compressive neuropathology (aka the “pinched nerve”). Although some chiropractic patients do suffer from compressive neuropathology, the majority (90+%) of their patients do not suffer from nerve compression (4).
It is now largely accepted that chiropractic adjustments mechanically activate a neurological sequence of events that close the pain gate, and pain syndromes are improved (4, 5, 6).
Mechanical integrity in a gravity environment is important for how people feel and function. Chiropractic adjusting influences mechanical integrity in a positive way. Chiropractors are extensively trained to be mechanical providers of care; this is the primary emphasis of chiropractic college and the reason for obtaining biological training prior to acceptance to chiropractic college. Ninety-three percent of patients who chose to initially see a chiropractor do so for spinal pain complaints (7). Satisfaction among patients with these complaints is exceptional (7).
The 2021 Nobel Prize in Physiology or Medicine
The 2021 Nobel Prize in Physiology or Medicine was awarded to two esteemed scientists, David Julius, PhD, and Ardem Patapoutian, PhD (8, 9). Dr. Julius is a professor and chairman of the department of physiology at the University of California, San Francisco. Dr. Patapoutian is a professor at Scripps Research in La Jolla, California.
Their groundbreaking Nobel Prize -winning research centered on the intricate molecular mechanisms underlying the body’s ability to perceive mechanical forces, including how the body senses position and movement.
The importance of the neurological sensing of the mechanics of position and movement has been the core interest of the chiropractic profession since 1895. The chiropractic profession has held steadfast to its mechanical/neurological roots. Since 1895, chiropractic clinicians and scientists have continued to explore and refine their mechanical applications of care, especially as related to musculoskeletal pain syndromes. The 2021 Nobel Prize in Physiology or Medicine supports a century of data used by the chiropractic profession.
The Concept of Motion
Much of life is dependent upon motion and mobility (10).
The movement of every joint in the body can be measured and quantified. The optimal movement for every joint in the body has been established. Increases or decreases in measured joint movements are not good. Such changes in joint movement are frequently associated with pain, degenerative joint arthritis, joint dysfunction, and weakness. These joint movement problems can cause impairments and disabilities (11).
Joint movement is divided into three categories (12, 13, 14, 15, 16):
- Active Motion
- Passive Motion
- Periarticular Paraphysiological Space Motion
Active Motion
Active motion is the type of motion joints experience when people move any part of their body. It requires active contraction of our muscles. Active motion is the typical motion joints experience when people engage in the activities of normal life (showering, dressing, preparing meals, driving, working, shopping, etc.) and exercise.
Active motion, including specific exercise active motion, only benefits the narrowest range of tissues (the active range), and as such the therapeutic benefit of active motion is limited. When a specific joint is moved through the maximum active range of motion, a natural physiological barrier is met, beyond which no additional motion is possible without passive assistance. The important concept is that joints have the ability to move beyond the active range, and this can be done without causing any stress or injury to the joint.
Passive Motion
Passive motion is the passive moving of a joint further than the motion achieved with active motion. Passive motion always affects a greater range of tissue than does active motion. This allows passive motion techniques to better address (treat, manage) tissue fibrosis and joint stiffness.
Accepted and beneficial passive motion applications include stretching, Pilates, yoga, etc. A variety of health care providers, including chiropractors, are trained and able to isolate specific joints that are lacking optimal motion and to “push” the joint beyond the active range of motion and into the passive range of motion. Again, this is accomplished without any tissue injury.
At the end of the passive range of motion, another “barrier” is encountered. This is called the elastic barrier. Movement beyond the elastic barrier is not only beneficial, it is often critically required. It is not possible to appropriately achieve motion beyond the elastic barrier without proper training and years of experience; this is the formal emphasis of the training to be a chiropractor.
Noted orthopedic surgeon WH Kirkaldy-Willis states (15):
Periarticular Paraphysiological Space Motion
“At the end of the passive range of motion, an elastic barrier of resistance is encountered.”
“If the separation of the articular surfaces is forced beyond this elastic barrier, the joint surfaces suddenly move apart with a cracking noise.”
“This additional separation can only be achieved after cracking the joint and has been labeled the paraphysiological range of motion. This constitutes manipulation.”
“[Joint manipulation adjusting] requires precise positioning of the joint at the end of the passive range of motion and the proper degree of force to overcome joint [resistance].”
“With experience, the manipulator can be very specific in selecting the spinal level to be manipulated.”
There are a number of benefits from moving joints past the elastic barrier and into the periarticular paraphysiological space range of motion. The best-documented benefit is the reduction of pain. The trick is to move past the elastic barrier and into the periarticular paraphysiological space without exceeding the limit of anatomic integrity. This skill requires training and practice. This is precisely why chiropractors have four years of training in an accredited chiropractic college, after completing undergraduate college, and are licensed by the state after successfully passing all licensing examinations.
Manipulation History
For millennia, humans have known the benefits of optimizing joint motion using manipulation. The history of joint manipulation parallels the history of civilization. An important review of manipulation through the ages was published in The Journal of Manual & Manipulative Therapy in 2007 and titled (17):
A History of Manipulative Therapy
This review makes these comments:
“Manipulative therapy has known a parallel development throughout many parts of the world. The earliest historical reference to the practice of manipulative therapy in Europe dates back to 400 BCE.”
“Historically, manipulation can trace its origins from parallel developments in many parts of the world where it was used to treat a variety of musculoskeletal conditions, including spinal disorders.”
“It is acknowledged that spinal manipulation is and was widely practiced in many cultures and often in remote world communities such as by the Balinese of Indonesia, the Lomi- Lomi of Hawaii, in areas of Japan, China and India, by the shamans of Central Asia, by sabodors in Mexico, by bone setters of Nepal as well as by bone setters in Russia and Norway.”
“Historical reference to Greece provides the first direct evidence of the practice of spinal manipulation.”
“Hippocrates (460–385 BCE), who is often referred to as the father of medicine, was the first physician to describe spinal manipulative techniques.”
“Claudius Galen (131–202 CE), a noted Roman surgeon, provided evidence of manipulation including the acts of standing or walking on the dysfunctional spinal region.”
“Avicenna (also known as the doctor of doctors) from Baghdad (980–1037 CE) included descriptions of Hippocrates’ techniques in his medical text The Book of Healing.”
“Nobody questions these early origins of manipulative therapy.”
Contemporary History
Prior to the modern era, for hundreds of years in developed and primitive societies throughout the world, practitioners of manipulation were known as bonesetters (17). All of this changed in 1874, and the global seat of change was in the United States of America.
Andrew Taylor Still, MD, was a second-generation physician who became disillusioned with medicine following the death (from disease) of three of his children. Dr. Still conceived a theory whereby health could only be maintained and, therefore, disease defeated, by maintaining normal function of the musculoskeletal system (17).
By 1874, “Still referred to himself, in what was a very successful clinical practice, as the ‘Lightening Bone Setter.’” Note this description from reference #17:
“His drugless, non-surgical approach to the treatment of disease rapidly gained acceptance among the general public. He soon found that he was unable to treat the growing numbers of patients and decided he would have to train others to help him in his work.”
“In 1892, he was confident enough in his beliefs that he established the American Osteopathic College in Kirksville, Missouri.”
“He based his theories of disease and dysfunction on the ‘disturbed artery’ in which obstructed blood flow could lead to disease or deformity. This would become known in Osteopathy as the Law of the Artery.”
“As Still’s methods continued to grow in popularity, more colleges were opened and by the time of his death in 1917, 3,000 Doctors of Osteopathy had been graduated.”
The second great addition to the practice of joint manipulation occurred in 1895. Daniel David Palmer was “well educated and an avid reader of all things scientific especially with regard to the healing arts.” Palmer became a self-trained “natural healer.” (17)
It was Palmer that pioneered the benefits of the specific line-of-drive manipulation, or what today is known as the chiropractic adjustment. In 1897, in Davenport, Iowa, Palmer opened his first college, The Palmer College of Cure, now known as the Palmer College of Chiropractic.
In 1907, one of the graduates was Palmer’s son Bartlett Joshua or BJ Palmer. In 1910, BJ Palmer introduced the use of X-rays into chiropractic. Reference #17 states:
“The G. I. Bill at the end of World War II enabled thousands of returning soldiers to bolster the ranks of the chiropractic profession.”
“This influx seemed to provide an impetus that would propel the chiropractic profession to today’s status where it boasts 35 schools and colleges worldwide and, in the Western world at least, it is second only to the medical profession as a primary care healthcare provider.”
Confusing Manipulation with Chiropractic Adjustment
Conscientious health care providers keep their eye on the published scientific literature in order to best serve their patients. Yet, problems arise when this literature is confusing, misleading, or completely wrong. One might ask (from our story above):
Why would an emergency department nurse believe that chiropractors cause strokes?
Apparently, the answer is that the literature on the topic is often confusing, misleading, or completely wrong. Many people “manipulate,” yet they are not trained and licensed chiropractors. These people do not have:
- The understanding of the unique anatomy of the cervical spine and the blood vessels that pass through it.
- They have no training in biomechanics of delivering a carefully applied force to the human body.
- They have no training or coaching as to how to carefully and precisely control the speed (velocity) and distance (amplitude) of the applied force.
- They are clueless as to how to perform and interpret any relevant orthopedic and neurological assessments that may have critical importance before or after any applied forces.
It is established that both the professional and lay literature use the word “manipulation” and “chiropractic” synonymously, when they are in fact very different. When an untrained lay person injures someone when performing a manipulation and the publication erroneously claims that the manipulation was done by a trained and licensed chiropractor, it biases the reader against chiropractors and the chiropractic profession. This includes the emergency department nurse from our story above.
This misleading abuse of the chiropractic profession has been chronicled for decades (18, 19), yet it continues through today, 2024 (20).
Chiropractic “Stroke” Safety
Two recent (2022 and 2023) large studies have specifically looked at the incidence of adverse events caused by trained medical doctors and chiropractors performing spinal adjustments (specific line-of-drive manipulations). These studies involved more than 300,000 individual patients and more than 3.5 million spinal adjustments (21, 22). The incidence of vascular injuries and/or strokes was zero, there were none.
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Much of the lay population and many healthcare professionals are uninformed as to the history, education, training, safety, and practice of chiropractic. Recent analysis reveals that chiropractic care is unique, safe, and effective.
REFERENCES
- https://www.cdc.gov/nchs/fastats/leading-causes-of-death.htm; accessed May 3, 2024.
- https://www.cdc.gov/stroke/facts.htm; accessed May 3, 2024.
- cce-usa.org; accessed March 23, 2024.
- Kirkaldy-Willis WH, Cassidy JD; Spinal Manipulation in the Treatment of Low back Pain; Canadian Family Physician; March 1985; Vol. 31; pp. 535-540.
- Vicenzino B, Collins D, Wright A; The Initial Effects of a Cervical Spine Manipulative Physiotherapy Treatment on the Pain and Dysfunction of Lateral Epicondylalgia; Pain; November 1996; Vol. 68; No. 1; pp. 69-74.
- Savva C, Giakas G, Efstathiou M; The role of the descending inhibitory pain mechanism in musculoskeletal pain following high-velocity, low amplitude thrust manipulation: a review of the literature; Journal of Back and Musculoskeletal Rehabilitation; 2014; Vol. 27; No. 4; pp. 377-382.
- Adams J, Peng W, Cramer H, Sundberg T, Moore C; The Prevalence, Patterns, and Predictors of Chiropractic Use Among US Adults: Results From the 2012 National Health Interview Survey; December 1, 2017; Spine; Vol. 42; No. 23; pp. 1810–1816.
- Roland D, Abott B; Nobel Prize in Medicine Awarded for Work on Senses; Wall Street Journal; October 5, 2021.
- Zylka MJ; A Nobel Prize for Sensational Research; New England Journal of Medicine; December 16, 2021; Vol. 385; No. 25; pp. 2393-2394.
- Korr IM; The Sympathetic Nervous System as Mediator Between the Somatic and Supportive Processes (1970), in The Collected Papers of Irvin M. Korr; American Academy of Osteopathy; 1979; pp. 170-174.
- Cocchiarella L, Anderson GBJ; Guides to the Evaluation of Permanent Impairment; Fifth Edition; American Medical Association; 2001.
- Sandoz R; Some Physical Mechanisms and Effects of Spinal Adjustment; Annals of the Swiss Chiropractic Association; 1976; Vol. 6; pp. 91-141.
- Haldeman S; Modern Developments in the Principles and Practice of Chiropractic; Appleton-Century-Crofts; New York; 1980.
- Kirkaldy-Willis WH; Managing Low Back Pain; Churchill Livingston; (1983 & 1988).
- Kirkaldy-Willis, WH, Cassidy JD; Spinal Manipulation in the Treatment of Low-Back Pain; Canadian Family Physician; March 1985; Vol. 31; pp. 535-40.
- Fischgrund JS; Neck Pain, Monograph 27; American Academy of Orthopaedic Surgeons; 2004.
- Pettman E; A History of Manipulative Therapy; The Journal of Manual & Manipulative Therapy; Vol. 15; No. 3; (2007); pp. 165–174.
- Terrett AG; Misuse of the literature by medical authors in discussing spinal manipulative therapy injury; Journal of Manipulative and Physiological Therapeutics; May 1995; Vol. 18; No. 4; pp. 203-210.
- Wenban AB; Inappropriate use of the title ‘chiropractor’ and term ‘chiropractic manipulation’ in the peer-reviewed biomedical literature; Chiropractic and Osteopathy; August 22, 2006; Vol. 14; No. 16.
- Fink C, Bryce CH, Knight LD; Self-Chiropractic Cervical Spinal Manipulation Resulting in Fatal Vertebral Artery Dissection: A Case Report and Review of the Literature; American Journal of Forensic Medicine and Pathology; February 1, 2024; Epub.
- Kim S, Kim G, Kim H, Park J, Lee J, and nine more; Safety of Chuna Manipulation Therapy in 289,953 Patients with Musculoskeletal Disorders:
- A Retrospective Study; Healthcare; February 2, 2022; Vol. 10; No. 2; Article 294.
- Chu E, Trager RJ, Lee L, Niazi IK; A Retrospective Analysis of the Incidence of Severe Adverse Events Among Recipients of Chiropractic Spinal Manipulative Therapy; Scientific Reports; January 23, 2023; Vol. 13; No. 1; Article 1254.
“Authored by Dan Murphy, D.C.. Published by ChiroTrust® – This publication is not meant to offer treatment advice or protocols. Cited material is not necessarily the opinion of the author or publisher.”
