Spinal manipulation is generally viewed as a safe and effective option for the management of mechanical neck and back pain. Although rare, one of the more sobering risks associated with spinal manipulation is vertebrobasilar stroke. Studies estimate that approximately 1 in 1 million patients will experience a stroke in the days following cervical manipulation. (See this ACA infographic) Unfortunately, when a chiropractic patient suffers a stroke (for any reason) the public perceives those odds as much higher.
The Katie May story is one of tragedy and sadness. The startling circumstances are certain to bring a new round of media scrutiny to those who provide care for cervical spine injuries, particularly chiropractic cervical manipulation. Our professional character is defined by our ability to manage challenges. Please consider the following three-step plan for responding to questions about the safety of cervical spine manipulation:
1. Be Prepared. Know the facts and be ready to answer questions with a truthful, compassionate, proactive, and evidence-based response. Also, make sure that every staff member knows how to deal with these sensitive patient questions. In a situation that the patient perceives as life and death- you should be the go to person. Staff members should know the facts, but then direct those patient questions back to you. Have a written internal policy for dealing with touchy questions. In most situations, offices should not initiate painful conversations that were not necessary.
2. Be Compassionate and Truthful. Although repeating the same story a dozen times in a day can become frustrating, providers need to view each new inquiry from the patients perspective- life and death. Listen first, then respond carefully. Be willing to take as much time as needed to fully address their concerns. Be human and sympathetic, acknowledge the loss and sadness, then move that conversation forward to provide confidence and trust through understanding of the facts. Keep your emotions and frustration in check- never speculate or provide flippant, baseless comments that only serve to undermine your credibility. Conversations can begin with acknowledgement of the situation: “I can’t imagine the sorrow that family is feeling. I’m glad you asked about this, because it’s very important. Here’s what we know…” Then provide the facts:
The largest medical study to date (1), encompassing 100 million person years, found that strokes occur at a similar increased rate regardless of whether the patient sees a chiropractor for manipulation or their PCP for consultation. The authors found: “no evidence of excess risk of VBA stroke associated chiropractic care compared to primary care.“ Researchers discovered that patients in the developing stage of a stroke are more likely to visit a chiropractor or PCP for complaints of headache and neck pain. The study suggested that the chiropractic or PCP treatment was not the cause of the stroke, but rather a non-contributory mid-point of an undetected developing crisis.
Another study by Kosloff et al. (2) extracted 3 years of commercial insurance and Medicare advantage plan data for approximately 39 million insured patients- representing approximately 5% of the total US population. The study analyzed a potential correlation between chiropractic visits, PCP visits, and stroke. The study found: “No significant association between VBA stroke and chiropractic visits. We conclude that manipulation is an unlikely cause of VBA stroke.” The study did however find “a significant association between PCP visits and VBA stroke. The positive association between PCP visits and VBA stroke is most likely due to patient decisions to seek care for the symptoms (headache and neck pain) of arterial dissection.” Like the Cassidy study, this study strengthens the premise that chiropractic manipulation may not increase the risk of VBAI stroke; rather, impending VBAI stroke patients may have a higher likelihood to seek care from a variety of providers, including chiropractors.
3. Look to Improve. As responsible chiropractors, we should not dismiss the risk of stroke or any other reasonable threat- and we must inform our patients about potential risks through a sensible informed consent process. We must continue to carefully assess each patient’s history, adequately screen for vascular pathology prior to treatment, recognize & refer patients who require medical consultation and choose alternatives to cervical manipulation for higher risk patients. By remaining clinically vigilant, we will continue to provide patients with safe, effective treatment options. Our discussion should include that commitment to improving: “So the overwhelming facts tell us that we are not the cause of the situation, but we’ll act as if we are and do all we can to eliminate these events- that means finding better ways to identify warning signs and directing patients to the right treatment immediately.”
1. Cassidy JD et al. Risk of vertebrobasilar stroke and chiropractic care: results of a population based case-control and case-crossover study. Spine 2008 Feb 15;33(4 Suppl):S176-83 http://www.vtchiro.org/Resources/Documents/Chiro%20Stroke%20Cassidy.pdf
2. Kosloff TM, Elto D, Tao J, Bannister WM. Chiropractic care and the risk of vertebrobasilar stroke: results of a case–control study in U.S. commercial and Medicare Advantage populations. Chiropractic & Manual Therapies (2015) 23:19
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