The risk of suffering a stroke when undergoing aggressive chiropractic manipulation of the neck is not a new concern. We’ve discussed it several times on the pages of Science-Based Medicine over the years, most recently in November of 2014 when Steven Novella covered the death by chiropractor of 30-year-old Jeremy Youngblood, whose fatal brain injury occurred while seeking treatment for a sore neck. For a nice review of cervical manipulation in general, the evidence against its inappropriate use, and an assessment of the literature on this subject, check out prior posts by Dr. Hall and chiropractor Samuel Homola.

I believe that my take on the issue is in line with my fellow SBM authors. There is no role for high velocity, low amplitude (HVLA) thrust-type maneuvers that cause sudden and intense rotation of the neck in any patient, for any reason. It is not effective for neck pain, headache or any other complaint, and it is a proven risk factor for injury to the vertebral arteries and subsequent stroke. Some patients are at higher risk, such as the elderly or those with atherosclerosis or connective tissue disorders, but this type of injury can occur at any age and even in a perfectly healthy individual.

The response from the chiropractic community has largely been to circle the wagons and deny their potential role, even going so far as to claim that people who have already suffered an injury to a vertebral artery (which they don’t appear to be very capable of recognizing) are seeking out chiropractic care for the resulting pain in the neck. They frequently cite the abysmal 2008 Cassidy study as proof that they aren’t to blame. This flawed study doesn’t show what they think it shows, which is an inconvenient fact discussed by Dr. Crislip in this post. There have also been successful efforts by chiropractors to avoid having to even warn patients of the potential risk.

What is clear is that even though the chance of suffering a stroke while being manipulated by a chiropractor is low, cases are likely under reported and many likely go unrecognized. And neck manipulation is one of the most significant risk factors in patients who rarely have strokes, namely the young and healthy. Again, thankfully, these events are uncommon. But considering the lack of benefit, even a small risk is too high.

In pediatric chiropractic, use of the HVLA thrust techniques that have been linked to stroke is less common. Many chiropractors even work possible parental anxiety into their shtick, specifically pointing out how gentle their manipulations are. This video demonstrates a non-forceful neck adjustment, naturally performed after hanging a 12-week-old infant upside down by her feet, in order to cure her colic, help her make more cells, and improve her ability to talk to her parents. I particularly love the disclaimer shown as the child dangles. Also, according to the chiropractor, “God doesn’t need assistance, he just needs no interference.” Isn’t that assistance?

These “no crack” chiropractors will often use an Activator, a spring loaded device that does nothing other than make a clicking sound and a soft impact against the skin. I can say that they are very unimpressive, having had the opportunity to play with one while following a chiropractor around for a day back in residency. I’ll never forget how, after Dr. Brown regaled me with a “pro-education” stance on vaccines that amounted to simply giving patients handouts about exaggerated vaccine risks, his wife whispered in my ear that she makes sure their kids are vaccinated.

Despite this trend, many children are still subjected to high velocity thrust techniques involving the neck. A quick search online reveals numerous videos of such adjustments on young children, even infants, for reasons such as colic, neck pain after a car accident, and frequent colds. At 1:43 in this video, 2-year-old Olivia clearly experiences pain when her neck is adjusted forcibly to treat stubborn chest congestion.

Last April, a case report involving severe arm weakness in a child was published that I can’t believe I missed. Pediatric neurologist Dr. Stephen Deputy, who I actually spent some time with on a rotation while in medical school at LSU in New Orleans, reported on a six-year-old boy that presented to his clinic with a six month history of weakness in his left arm. According to Deputy, the patient had been on his way to see a medical doctor for a suspected sinus infection when his grandfather instead brought him to a chiropractor where he underwent “some degree of spinal manipulation.”

The child was first noted to have complaints of numbness and tingling, known as paresthesia, in his left arm the following night. He went on to develop weakness in that arm which led the family to seek medical care a few days later. No obvious cause was discovered at that visit.

His symptoms did not resolve, and he was eventually admitted to a local hospital for evaluation after another week had passed. During his hospitalization, based on his clinical picture and limited neuroimaging he was given a presumptive diagnosis of acute transverse myelitis and started on a long course of steroids. This is an extremely rare inflammatory process involving the spinal cord that can cause weakness and paresthesias in addition to bowel and bladder dysfunction and more serious neurological injury, although having isolated symptoms in just one extremity like this would be an atypical presentation. Also, lab evaluation of his spinal fluid was inconsistent with an inflammatory condition.

At the time the patient was seen by Dr. Deputy, there had been no improvement despite the course of steroids and six months of physical therapy. This is also unusual in cases of transverse myelitis, which almost always improve considerably if not fully resolve. He was found to have significant loss of muscle in the involved extremity, complete loss of strength in several muscles of the shoulder and arm, and at least some degree of weakness in the rest of them. He also had complete loss of normal tendon reflexes in the left biceps and triceps and diminished reflexes in the other muscles. Finally, nerve conduction studies and electromyography were consistent with a pure motor neuronopathy of the fifth cervical through the first thoracic spinal nerves.

So, considering the timing of the patient’s onset of symptoms within 36 hours of having his neck adjusted by a chiropractor, and the rarity of transverse myelitis, Deputy was appropriately skeptical of the diagnosis. Add the soft clinical findings for that condition and inconsistent spinal fluid studies, as well as the finding of a pure neuronopathy of C5-T1 on EMG, and he was probably sold. But he was also able to compare MRI images of his patient’s spinal cord with those of a young woman who suffered a proven vertebral artery dissection and found them to be identical. That allowed him to more confidently conclude that the culprit was “vascular compromise to the vertebral arteries resulting in anterior (spinal) cord ischemia” rather than an inflammatory disease.

Healthy children, with very rare exceptions, do not spontaneously suffer a stroke. There are conditions, such as congenital heart defects and hematologic abnormalities like sickle cell disease, that do predispose some children. Most cases of pediatric stroke occur in children with known risk factors or who have been diagnosed with an acute illness that increases their risk. Unfortunately, because of the uncommon occurrence of stroke in children, the diagnosis is often delayed, sometimes for months, as it likely was in this case.

Trauma to the neck is a well-known cause of pediatric stroke, and HVLA chiropractic manipulation certainly falls into that category. The patient in question was brought to a chiropractor for treatment of suspected sinusitis, a condition for which there is no plausible connection with the position of the vertebral bodies or the function of spinal nerves. The only evidence supporting any chiropractic technique for the treatment of sinusitis is anecdotal.

A lack of legitimate evidence hasn’t slowed them down unfortunately, as shown in this video of a chiropractor who believes that rubbing his hands along the cheekbones will help drain the maxillary sinus. This is utter nonsense but at least he didn’t adjust the patient’s neck. This chiropractor does, however, and appears to gloat about how much pain he can inflict and how loud a crack he can cause when jerking a patient’s neck. Watching the entire video certainly caused me a great deal of pain.

I can’t say with certainty that the child in Dr. Deputy’s case report had a vertebral artery dissection during chiropractic care. Imaging of the blood vessels of the neck was eventually ordered, but enough time had passed that the negative results couldn’t rule anything out. But given what we know about the risk of this type of injury in general, and the specifics of this case, it is definitely the most likely etiology of the patient’s symptoms.

The bottom line is that you should never let a chiropractor, or anyone else for that matter, perform high velocity neck manipulation on yourself or your children. The evidence is clear that this type of adjustment is not more effective than safer options for neck pain, and the evidence is nonexistent when it comes to indications, like sinusitis, that have no plausible connection to the spine. This particular child could have been paralyzed or even killed. Instead, he will only have substantially diminished function in his left arm, although I doubt that fact will be much consolation.



Posted by Clay Jones

Clay Jones, M.D. is a pediatrician and a regular contributor to the Science-Based Medicine blog. He primarily cares for healthy newborns and hospitalized children, and devotes his full time to educating pediatric residents and medical students. Dr. Jones first became aware of and interested in the incursion of pseudoscience into his chosen profession while completing his pediatric residency at Vanderbilt Children’s Hospital a decade ago. He has since focused his efforts on teaching the application of critical thinking and scientific skepticism to the practice of pediatric medicine. Dr. Jones has no conflicts of interest to disclose and no ties to the pharmaceutical industry. He can be found on Twitter as @SBMPediatrics and is the co-host of The Prism Podcast with fellow SBM contributor Grant Ritchey. The comments expressed by Dr. Jones are his own and do not represent the views or opinions of Newton-Wellesley Hospital or its administration.