Letter to the Editor

Dear Editor:

We read with interest the September 2025 article in Dynamic Chiropractic by Brandon Hoffman, BA, entitled “Recognizing and Responding to Emergencies in Your Practice – An Important Clinical Example: Stroke Symptoms.”

Mr. Hoffman rightly emphasizes that chiropractors are not expected to diagnose strokes, reinforced by the fact that strokes are also missed at emergency departments.¹ Nevertheless, as the American Stroke Association notes, clinicians should refer patients for urgent evaluation when symptoms deviate from typical musculoskeletal presentations.²

Hoffman’s case highlights how delayed recognition of vertebral artery dissection (VAD) and posterior circulation stroke can harm patients and increase malpractice exposure. Fortunately, VAD is rare and most patients recover well within three months when referred for appropriate medical treatment.³

There is no convincing evidence that cervical spinal manipulation (CSM) directly causes VAD.⁴ However, it is plausible that CSM performed in the presence of an existing dissection could worsen the condition, dislodge a thrombus and trigger an immediate thromboembolic stroke.⁵ Other cases of stroke immediately following CSM are documented in the peer-reviewed literature.^6-9

Crucially, such immediate post-manipulative strokes may be preventable by ruling out VAD prior to performing CSM. Because vascular screening tests for VAD lack reliability,¹⁰ vigilance in history-taking and clinical reasoning remains essential. A structured risk-benefit clinical assessment strategy has been published to help clinicians exclude VAD prior to CSM.¹¹ Other organizations have also contributed research to rule out vascular pathology before performing CSM.^12-14

We recommend all chiropractors become familiar with this research and adopt this framework to better recognize atypical presentations, prevent avoidable strokes, and reduce both patient harm and malpractice liability.

References

1. Arch AE, Weisman DC, Coca S, et al. Missed ischemic stroke diagnosis in the emergency department by emergency medicine and neurology services. Stroke, 2016;47(3):668-673. doi:10.1161/STROKEAHA.115.010613
2. Jauch EC, Saver JL, Adams HP, et al. Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke, 2013;44(3):870-947. doi:10.1161/STR.0b013e318284056a
3. Morris NA, Merkler AE, Gialdini G, Kamel H. Timing of incident stroke risk after cervical artery dissection presenting without ischemia. Stroke, 2017;48(3):551-555.
4. Church EW, Sieg EP, Zalatimo O, et al. Systematic review and meta-analysis of chiropractic care and cervical artery dissection: no evidence for causation. Cureus, 2016;8(2):e498.
5. Brown SP. Plausible mechanisms of causation of immediate stroke by cervical spine manipulation: a narrative review. Cureus, 2024;16(3):e56565.
6. Terrett AGJ. Current Concepts in Vertebrobasilar Complications Following Spinal Manipulation, 2^nd Edition. NCMIC, 2001.
7. Haldeman S, Kohlbeck FJ, McGregor M. Stroke, cerebral artery dissection, and cervical spine manipulation therapy. J Neurol, 2002;249(8):1098-1104.
8. Kennell KA, Daghfal MM, Patel SG, et al. Cervical artery dissection related to chiropractic manipulation: one institution’s experience. J Fam Pract, 2017;66(9):556-562.
9. Turner RC, Lucke-Wold BP, Boo S, et al. The potential dangers of neck manipulation & risk for dissection and devastating stroke: an illustrative case & review of the literature. Biomed Res Rev, 2018;2(1).
10. Hutting N, Kranenburg HAR, Kerry R. Yes, we should abandon pre-treatment positional testing of the cervical spine. Musculoskelet Sci Pract, 2020;49:102181.
11. Chaibi A, Russell MB. A risk-benefit assessment strategy to exclude cervical artery dissection in spinal manual-therapy: a comprehensive review. Ann Med, 2019;51(2):118-127.
12. Rushton A, Carlesso LC, Flynn T, et al. International framework for examination of the cervical region for potential of vascular pathologies of the neck prior to orthopaedic manual therapy (OMT) Intervention. International IFOMPT Cervical Framework, 2020. Read Here
13. Harper B, Miner D, Vaughan H. Proposing a new algorithm for premanipulative testing in physical therapy practice. J Phys Ther Sci, 2020;32(11):775-783.
14. Thomas LC, Seth T, Der A, et al. Improving the recognition of cervical arterial dissection in clinical practice: investigation of a five criteria diagnostic support tool. Physiother Theory Pract, 2023;39(6):1297-1304.

Steven Brown, DC, DIAMA
Gilbert, Ariz.

Aleksander Chaibi, DC, PT, PhD
Oslo, Norway