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Types of Strokes | Statement of Concern | Physicians 
Statement of Concern
STATEMENT
OF CONCERN TO THE CANADIAN PUBLIC FROM CANADIAN NEUROLOGISTS REGARDING
THE DEBILITATING AND FATAL DAMAGE MANIPULATION OF THE NECK MAY CAUSE TO
THE NERVOUS SYSTEM.
We Canadian neurologists hereby express our strong concern and thereby
issue this warning to Canadians. The public must be made aware that the
neurological damage that can result subsequent to upper neck
manipulation can be debilitating and fatal.
We make the following recommendations for the attention of the Canadian
public, the practitioners of manipulation, the medical community, the
provincial Ministries of Health and the health care professional
regulatory bodies.
Our concerns are significant. Stroke and death due to neck manipulation
has been reported in the scientific literature for over 50 years.
(1,2,3,4,5,6,7,8,9,10). New deaths, in the past few years, have been
reported to the Canadian Stroke Consortium. (11). The Canadian Stroke
Consortium recently published a major prospective study. (12) The
latest data from the Stroke Consortium indicates that “more than 100
cases of dissection per year are associated with neck manipulation”
(13). The resulting stroke and debilitation from such a large number is
very significant.
A recent study by the Institute of Clinical Evaluative Sciences (ICES
Ontario) indicates that patients with posterior circulation strokes
under the age of 45 are 5 times more likely than controls to have
visited a chiropractor within one week of the event (14).
CONCERN NUMBER ONE
PHYSICIANS NEED GREATER DIAGNOSTIC AWARENESS OF THE NEUROLOGICAL COMPLICATIONS THAT MAY RESULT FROM NECK MANIPULATION
Many physicians are not aware of the risks associated with neck
manipulation and thus fail to undertake the appropriate investigations
(15.) A history of neck manipulation or severe neck pain accompanied by
signs or symptoms of stroke should prompt an immediate referral to a
neurologist for examination and appropriate investigation.
Multiple neurological complications can result subsequent to neck
manipulation. The most dramatic is arterial dissection leading to
stroke and death. Cervical manipulation most commonly causes stroke
occurring in the back part of the brain. This can be particularly
disabling as it can affect such basic functions as swallowing, speaking
and walking.
We recommend that the neurology community undertake an educational
program for primary care and emergency room physicians to increase
diagnostic awareness of the dangers of neck manipulation and its
multiple neurological complications.
CONCERN NUMBER TWO
THERE IS AN URGENT NEED FOR THE PUBLIC TO BE FULLY AND PROPERLY INFORMED OF THE DANGERS OF NECK MANIPULATION.
Members of the public are largely unaware of the complications of neck
manipulation. Well-documented complications include damage to the
nerves in the neck, compression of the spinal cord by unstable discs,
tearing of the arteries in the neck, stroke and death.
The most significant complication of manipulation is stroke secondary
to torn arteries in the neck. The first symptom may be sudden neck pain
following neck manipulation (12). Patients often ignore this pain, as
it may have been neck pain that prompted the visit in the first place.
Other important symptoms suggestive of stroke include visual
disturbances, nausea, dizziness, poor co-ordination, and weakness or
numbness on one side of the body. The onset of these symptoms should
prompt an immediate medical assessment. Under no circumstances should
an individual allow their necks to be manipulated if any of these
symptoms are present.
We recommend that the medical community undertake an information
campaign to increase public awareness of the risks of neck
manipulation. Special attention should be paid to increasing awareness
of the symptoms of stroke following manipulation.
CONCERN NUMBER THREE
THE INDIVIDUAL PATIENT NEEDS TO BE FULLY AND DIRECTLY AWARE THAT SERIOUS RISKS DO EXIST.
We endorse the major recommendations of the 1998 inquest into the
manipulation-induced death of Laurie Jean Mathiason of Saskatoon,
Saskatchewan. This Inquest recommended that the "risk of stroke and
other inherent risks associated with chiropractic treatment be visible
and available in the reception area of every chiropractic facility".
(16)
We further recommend that other practitioners of manipulation therapy,
including physiotherapists, should have a warning posted in their
offices about the risks of neck manipulation.
Qualified epidemiologists, medical scientists and legal experts should
develop a patient information form that it truly reflective of the
risks. This should be presented to every patient. This should include
up to date scientific information on the risks per individual patient
rather than dated, non-scientific claims that significantly
underestimate the risk to the individual patient.
CONCERN NUMBER FOUR
WE ARE CONCERNED THAT CURRENT AUTOPSY PROCEDURES FAIL TO DIAGNOSE ALL CASES.
In the course of a routine autopsy, the vertebral arteries in the neck
are almost never removed and examined. Cases of death due to neck
manipulation have been missed. (17). It is important to know the true
incidence.
As there may be a significant time delay between manipulation and
stroke, any person dying of stroke within three months of a neck
manipulation should have their carotid and/or vertebral arteries
examined by a pathologist. This is especially important in those
patients under the age of 45 in whom a clear cause for stroke cannot be
identified. (14).
Suspicious cases should be reported to the office of the regional
Coroner. This will allow a better estimate of the true incidence of
stroke and death secondary to cervical manipulation.
CONCERN NUMBER FIVE
PROVINCIAL MINISTRIES OF HEALTH SHOULD ACKOWLEDGE AND ACT UPON THE
STRONG CONCERNS AND RECOMMENDATIONS OF THE SCIENTIFIC PEDIATRIC
COMMUNITY REGARDING SO-CALLED “PEDIATRIC CHIROPRACTIC”
Chiropractors in Canada perform cervical manipulation in children for
the "treatment" of infantile colic, inner ear infections, bedwetting
and a myriad of other paediatric illnesses. Chiropractic authorities
claim that parents should bring their new-born baby to a chiropractor
“as soon as possible after birth” (18.) Such claims and recommendations
have no scientific basis and only expose infants and children to
unwarranted neck manipulation.
Strong concerns have been expressed by the Chiefs of Paediatrics of our
Canadian Hospitals (19) and by the Canadian Paediatric Society
regarding chiropractic manipulation on the spines of infants and
children (20).
Paralysis and other complications in infants and children following
cervical neck manipulation have occurred. (21) Death has also been
reported. (23)
We strongly recommend that each provincial Ministry of Health order the
immediate banning of all spinal manipulation of infants and children.
CONCERN NUMBER SIX
WE EXPRESS OUR STRONG CONCERN ABOUT THE MANY NON-SCIENTIFIC CLAIMS MADE
AS TO THE CONDITIONS THAT PURPORTEDLY MAY BENEFIT FROM NECK
MANIPULALTION.
There are endless non-scientific claims being made as to the uses of
neck manipulation. The public must be made aware that the very great
majority of these claims have little or no evidence to support them.
We call upon the responsible governmental health authorities to conduct
a full inquiry into the dubious claims being made. Representatives of
all concerned parties should be brought together in such an inquiry.
This should include an examination of the information being taught at
all schools and courses dealing with manipulation therapy.
1. Pratt-Thomas HR, Berger KE: Cerebellar and spinal injuries after
chiropractic manipulation. Death case. J Amer Med Assoc 1947;
133(9):600-3
2. York v. Daniels. Medicolegal abstracts. Chiropractors Injury to
spinal meninges during adjustments. Death case. J. Amer. Med Assoc.
1955; 159 (8) 809
3. Smith RA, Estridge MN. Neurological complications of head and neck
manipulations. (Death case) J. Amer. med. Assoc. 1962; 182 (5) 527-31
4. Lorenz R, Vogelsang HG Thrombose der arteria basilaris nach
chiroprakitschen manipulationen. Death case. Deutsche Med.
Wochenschrift 1972; 97:36-43
5. Beatty RA. Dissecting hematoma of the internal carotid artery
following chiropractic cervical manipulation. J. Trauma 1977; 17 (3):
248-9
6. Easton JD, Sherman DG. Cervical manipulation and stroke. Stroke 1977; 8(5) 594-7
7. Nyberg-Hansen R, Loken AC, Tenstad O. Brainstem lesions with coma
for five years following manipulation of the cervical spine. Death
case. J. Neurol 1978; 218: 97-105
8. Zak SM, Carmody RF. Cerebellar infarction from chiropractic neck
manipulation: Death case. Case report and review of the literature.
Ariz. Med. 1984; 41 (5) 333-7
9. Mas JL, Henin D, Bousser MG et al. Dissecting aneurysm of the
vertebral artery and cervical manipulation. Death case. A case report
with autopsy. Neurology 1989; 39 (4) 512-5
10. Sullivan EC. Brain stem stroke syndromes from cervical adjustments.
Report on five cases. Death case. J. Chiro Res. & Clin.
Investigation 1992; 8 (1) 12-16
11. Norris JW, Beletsky V. SPONTADS data. Canadian Stroke Consortium. 2001
12. Norris JW, Beletsky V. Zurab G. Nadareishvili. Sudden Neck Movement and cervical artery dissection.
C.M.A.J. 2000 (07) 163. 38-40
13. SPONTADS. Canadian Stroke Consortium. May 2001
14. Rothwell DM, Bondy SJ, Williams I. Case control study of chiropractic manipulation and stroke. Stroke 2001 (5) 1054-1060
15. Chan M. Nadareishvili Z. Norris. J. Diagnostic Strategies in Young
Patients With Ischemic Stroke. Can J Neurol. Sci 2000; 27; 120-124
16. July recommendations. Inquest concerning the death of Laurie Jean
Mathiason. September 1998. Saskatoon, Saskatchewan. Canada.
17. D.C.F. Ontario.
18. Chiropractic and Children: Infants and Toddlers. Ontario
Chiropractic Association. Distributed from Canadian Memorial
Chiropractic College, Toronto. 2001.
19. A Statement by the Chairman of the Departments of Pediatrics of Pediatric Hospitals in Canada. August 1994.
20. Spiegelblatt L. Francoeur E. Letter correspondence. Professor
Michael de Robertis. York University. Canadian Pediatric Society. 1988
Nov. 17.
21: Shafir. J. Pediatrics 1992; 120:226-9
22. Nickerson HJ, Silberman TL. Journal of Pediatrics 1992. Letter.
23. Klin Padiatr. 2001 March-April; 213(2): 76-85
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