Answers to Questions about Chiropractic:
Should a Chiropractor Provide Informed Consent
before Manipulating Someone's Neck?

Samuel Homola, D.C.

Question

I have been seeing a chiropractor who manipulates my neck on every visit. I initially went to him for back pain. He says that it's important to keep my neck vertebrae in alignment to prevent the development of "subluxations" in order to maintain good health.

I read on your site that neck manipulation can cause a stroke. Are the health benefits of neck manipulation worth the risk of having a stroke? Should I continue with neck adjustments even though I do not have neck pain? My chiropractor says that the treatment is safe and necessary. I could sure use some advice about what to do.

Answer

Few people are aware that neck manipulation, often routinely performed in chiropractors' offices, can cause stroke by injuring vertebrobasilar and carotid arteries. Such injury is not common, andthe true incidence of injury is not known. But the number of strokes that have occurred immediately following neck manipulation is great enough to justify a requirement that every patient read and sign an Informed Consent statement before submitting to any kind of neck manipulation by any kind of practitioner.

Manipulation of the upper cervical spine should be reserved for carefully selected musculoskeletal problems that do not respond to such simple measures as time, massage, mobilization, or traction. The vertebral arteries thread through the transverse processes of the first cervical vertebra and then turn sharply to enter the skull. Because of this tortuous route, neck rotation forced by manual manipulation should not exceed 45 or 50 degrees to avoid kinking these arteries. Rapid manual rotation of the cervical spine might also cause damage by overcoming the arteries' normal elasticity. The slow stretching of mobilization within a normal range of movement may be less damaging to arteries than the rapid movement required to rotate the cervical spine beyond its normal range of motion or to move joints enough to produce a "popping" sound.

There is no credible evidence to indicate that neck manipulation is any more effective for neck pain than a number of other physical treatment modalities. There is certainly no justification for its routine use to "improve general health." All things considered, manual rotation of the cervical spine beyond its normal range of movement is rarely justified. The neck should never be manipulated to correct a "chiropractic subluxation" or an undetectable "vertebral subluxation complex" for the alleged purpose of restoring or maintaining health or relieving symptoms not located in the neck. There is no evidence that such subluxations exist. When a painful orthopedic subluxation (partial dislocation) occurs, manipulation might occasionally be helpful but is most often contraindicated.

The bottom line is that while there might an occasional need for appropriate, properly controlled neck manipulation in the treatment of an uncomplicated musculoskeletal problem that results in loss of mobility, there is no justification for the use of such treatment based on the chiropractic vertebral subluxation theory. Patients should always be informed of the danger of neck manipulation performed for any reason. Consultation with an orthopedist or a neurologist should be part of a consensus that determines the need for such treatment, weighing benefit against risk. When a sudden onset of neck pain occurs, it is absolutely essential that an attempt be made to rule out a pre-existing vertebral artery dissection before neck manipulation is done, lest manipulation releases a blood clot that will travel to the brain. Such a careful approach would be unlikely among chiropractors who base diagnosis and treatment upon detection and correction of vertebral subluxations.

Since it may be difficult or impossible to determine beforehand who might be vulnerable to vertebral artery dissection or stroke caused by upper neck manipulation, and even more difficult to find a practitioner who uses manipulation appropriately, my advice for the average person would simply be to avoid neck manipulation of any kind. Some chiropractors claim to be able to correct disease-causing "subluxations" in the cervical spine by tapping on misaligned vertebrae with a hand-held adjusting instrument, thus avoiding dangerous rotation of the neck. These chiropractors, like those who routinely manipulate the neck, should be avoided, informed consent or not.

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Dr. Homola is a second-generation chiropractor who has dedicated himself to defining the proper limits on chiropractic and to educating consumers and professionals about the field. His 1963 book Bonesetting, Chiropractic, and Cultism supported the appropriate use of spinal manipulation but renounced chiropractic dogma. His 1999 book Inside Chiropractic: A Patient's Guide provides an incisive look at chiropractic's history, benefits, and shortcomings. Now retired after 43 years of practice, he lives in Panama City, Florida.

This article was posted on March 14, 2009.