Dispelling the Myths about Stroke and Manipulation

by Dr. Matt Fontaine

risk of stroke with manipulation

What the research really tells us about the inherent risks of stroke with manipulation…

The definitive research study on the risks of stroke and manipulation was published in SPINE in 2008, Spine. 2008; 33(45):S176-183.  They concluded that patients with a VBA stroke are likely to consult with their primary care physician (PCP) or chiropractic physician because of their symptoms, meaning the stroke incident was already underway. 8

I have attached two PDF documents below which point out some of the latest and most compelling research on the topic.

Stroke & Manipulation

Stroke Risk Patient Resource

With the recent emerging media coverage and sensationalism with regard to the safety of manipulation and the risk of stroke, I wanted to speak out on the issue with some of the latest, most compelling research.  People should avoid extreme ideologies and binary black and white thinking.  This is an important issue and the latest research contributes to a framework guiding the safe and effective use of manipulation for neck pain.

Where do I start?

Armed with the latest Evidence Based Research, you and your doctor can have an educated discussion on whether manipulation is right for you.  Understanding what the research tells us puts risk in proper perspective and allows us to make better clinical decisions in partnership with our doctors to insure we get the safest, most effective treatment possible.

The Evidence Supports the Use of Manipulation

Chiropractic physicians routinely treat patients who present with mechanical neck pain and headaches with manipulation.  Many do so in conjunction with other soft tissue manual therapies as well as employing corrective exercises.  The evidence supports the use of manipulation for mechanical neck pain and various types of headaches, including cervicogenic and tension type headaches, and even migraine headaches.  The potential for rare but serious adverse reactions does exist and practitioners can effectively mitigate that risk by understanding the latest research surrounding those risks.

Below is an excerpt from one of the definitive studies, published in Spine 2008.

Risk of vertebrobasilar stroke and chiropractic care: results of a population-based case-control and case-crossover study.

A new study by Cassidy et. Al, which was part of the Bone and Joint Decade 200-2010 Task Force on Neck Pain and Its Associated Disorders project, is now the definitive study on the subject of stroke risk and cervical manipulation. This study looked at all the residents of Ontario, Canada over a 9-year period (1993-2002). This represents the equivalent of 109 million person-years of observation. Their design looked at not only visitations to chiropractic physicians in the period preceding the stroke, but also visits to their primary care physician (PCP). The idea in this design is that a PCP, in their work up of patients, is unlikely to subject them to a maneuver that might produce a stroke. They concluded that the odds ratio (statistic of probability) was about the same for both groups. They concluded that patients with a VBA stroke are likely to consult with their PCP or chiropractic physician because of their symptoms, meaning the stroke incident was already underway.



  • Results of a 2008 best evidence synthesis by the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders found that manual therapy combined with exercise was more effective than other noninvasive interventions for neck pain.1
  • In a 2012 randomized controlled trial, spinal manipulative therapy was more effective than medication for acute and sub-acute neck pain for both short and long term outcomes.2


  • Studies indicate that spinal manipulative (SM) therapy is effective for cervicogenic and migraine headaches.3,4
  • A 2008 literature review suggests that spinal manipulative therapy of the cervical spine may prevent migraines as well as amitriptyline and may be effective for tension-type headaches.5
  • Spinal manipulative therapy may be as effective as propranolol and topiramate for prophylaxis of migraine headache.6



  1. Hurwitz EL, Carragee EJ, van der Velde G, et al. Treatment of neck pain: noninvasive interventions: results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. Spine (Phila Pa 1976). Feb 15 2008;33(4 Suppl):S123-152. http://www.ncbi.nlm.nih.gov/pubmed/18204386
  2. Bronfort G, Evans R, Anderson AV, et al. Spinal manipulation, medication, or home exercise with advice for acute and subacute neck pain. Annals of Internal Medicine. 2012;156(1):1–10. http://www.ncbi.nlm.nih.gov/pubmed/22213489
  3. Bronfort G, Haas M, Evans R, et al. Effectiveness of manual therapies: the UK evidence report. Chiropractic & Osteopathy. 2010;18(3):1–33. http://www.ncbi.nlm.nih.gov/pubmed/20184717
  4. Bryans R, Descarreaux M, Duranleau M, et al. Evidence-based guidelines for the chiropractic treatment of adults with headache. J Manipulative Physiol Ther. Jun 2011;34(5):274-289. http://www.ncbi.nlm.nih.gov/pubmed/21640251
  5. Sun-Edelstein C, Mauskop A. Complementary and alternative approaches to the treatment of tension-type headache. Current Pain Headache Report. 2008 Dec;12(6):447-50. http://www.ncbi.nlm.nih.gov/pubmed/18973739
  6. Chaibi A, Tuchin PJ, Russell MB. Manual therapies for migraine: a systematic review. J Headache Pain. Apr 2011;12(2):127-133. http://www.ncbi.nlm.nih.gov/pubmed/21298314
  7. Hurwitz EL, Aker PD, Adams AH, Meeker WC, Shekelle PG. Manipulation and mobilization of the cervical spine. A systematic review of the literature. Spine. 1996;21(15):1746-59. http://www.ncbi.nlm.nih.gov/pubmed/8855459
  8. Cassidy JD, Boyle E, Cote P, He Y, Hogg-Johnson S, Silver F, Bondy S. Risk of vertebrobasilar stroke and chiropractic care: Results of a population based-control and cross-over study. Spine. 2008; 33(45):S176-183
  9. Coulter ID, Hurwitz EL, Adams AH, Meekr WC, Hansen DT, Mootz RD, Aker PD, Genovese BJ, Shelkelle PG. The appropriateness of manipulation and mobilization of the cervical spine. 1 ed. Santa monica: The RAND Corporation; 1996.
  10. Wolf SMea. Worst Pills, Best Pills. A Consumer’s Guide to Avoiding Drug-Induced Death & Illness. New York: Simon & Schuster, Inc. 2005
  11. Lazarou J, Pomeranz BH, Corey PN. Incidence of adverse drug reactions in hospitalized patients: a meta-analysis of prospective studies. JAMA. 1998;279(15):1200-5.
  12. Gross AR, Goldsmith C, Hoving JL, Haines T, Peloso P, Aker P, Santaguida P, Myers C. Cervical Overview Group. Conservative management of mechanical neck disorders: a systematic review. J Rheumatol. 2007;34(3):1083-102.