This is a common question in my practice. The answer is YES, it is safe when you weigh the risks vs. the benefits. The reason that you may have heard otherwise is due to the fact that in some rare instances, there have been patients who have experienced a stroke after visiting their chiropractor. Some people have also had a stroke after visiting their family doctor. Or after visiting the hairdresser. Or after shoulder-checking while driving. Or while watching TV. The RELEVANT question is- did the chiropractor CAUSE the stroke? There is plenty of solid research (randomized controlled studies or RCTs which are the gold standard) that demonstrate that the answer is no, that receiving a neck manipulation (or “crack”) does not cause a stroke. It is a safe and effective treatment option for neck pain and headaches.
It was hypothesized in the past that manipulating or “cracking” the cervical spine would tear the vertebral artery wall (called a dissection) in the neck and thus cause a stroke to occur due to blood loss from the artery. In fact, the amount of rotational stress on your neck and the arteries in your neck during this treatment is minimal, less than the amount during normal range of motion turning (eg. shoulder checking). This has been shown in cadavers and also in live humans. As published recently (Oct 2012) in this kinesiology journal article, they found that injuries to the vertebral artery in the neck were higher incidence with normal range of motion testing than during a manipulation treatment.
What actually happens is that people with a stroke in progress, or transient ischemic attack (TIA or effectively, a mini-stroke), may feel like they are getting a headache that is different from their normal headaches and has other abnormal associated symptoms. They’ll seek care from their family doctor, physiotherapist, or chiropractor and some of these patients will rarely have the full stroke event during or soon after their visit (see study). The stroke in progress that is lurking in the arteries and stuck on the wall of a larger artery in the neck can become dislodged with any normal neck rotation, and then move to smaller and smaller arteries until it gets stuck. This is a stroke due to embolism (type of clot)- the clot will block blood flow to the brain tissues that are beyond the blocked artery and these tissues will start to suffer due to lack of oxygen. Picture this– the arteries are like pipes. There is a clog in one of the pipes that is sticky- too much hair product in that hair ball?- and it sticks to the side of the pipe. Any sudden force, such as running the tap on high (or normal turning of the neck to look at something to your side), can dislodge this sticky clog and force it to move along. If the pathway that it follows contains smaller and smaller pipes, eventually the clog will get stuck and block the water (or blood) from continuing forward to where it has to go. Blood carries oxygen to the brain and so if the blood supply is cut off, oxygen can’t make it to the brain which will result in brain damage.
The rate of these strokes have been shown in studies to be the same in number after visiting the MD as they are after visiting the chiropractor. Assuming that these MDs are not manipulating the neck, we can conclude that the stroke was not DUE to the treatment but instead, related to the fact that these patients were likely to experience a stroke at some point due to their risk factors and they sought care due to the preliminary symptoms. Simply put- unfortunately, they were going to have the stroke eventually and they felt funny leading up to it which made them go for treatment.
It is important for you, as a patient, to look into all the risks of the treatments you seek. Read the labels of the meds that you put into your body, read about the risks and decide if the risks are worth the benefit, ask relevant questions and try to educate yourself with more than a google search ;). Is manipulation completely RISK-FREE and void of any potential side effects? No. You could be sore afterwards (temporary), your muscles could become mildly strained, you could feel light-headed afterwards, and you could injure a disc in your spine (quite rare but possible). Will the manipulation give you a stroke if you were healthy to begin with? No. Is there another option? Of course. If you are still nervous about having your neck manipulated, many chiropractors (myself included) can mobilize the neck without rotation or use an “activator” which is a tool that provides a quick vibration to the joints. Bravo to you for being an educated patient and asking questions. That’s the reason for this blog post- to inform my patients and encourage discussions about your health!
There are many more studies on this topic. Feel free to add them to the comments or send any useful RCTS my way if you have constructive input. During my years at chiropractic school, I read countless research articles regarding the risks of spinal manipulation (again, the “crack”) vs. other treatment options. I am confident in my skills and the safety of my treatments after spending four years learning critical research evaluation during my undergrad and another four practicing adjustments as well as looking at solid research into the specific issue. Chiropractors practice more hands-on hours of spinal manipulation skills and study more hours of anatomy than MDs or physiotherapists. Chiropractors also extensively study radiology (the study of X-rays and the images they produce) and we can send for X-rays or sometimes even take them within our own clinic. So who is the most suitable practitioner to evaluate, diagnose, and adjust/manipulate your neck? The hours of study show that chiropractic graduates have the most training. Who is the best to prescribe exercises? That would be a physiotherapist. I currently work closely with several experienced physiotherapists and we compare notes on a regular basis. We refer patients to each other and do our best to keep up-to-date with the current research.
“More questions!”, you say? Does the expression on your face look as confused as Keanu Reeves when he was first introduced to the Matrix? Or just the look on Keanu’s face in general? Well, I’ll try to alleviate that with some good ol’ Q&A:
Q #1: Why do some doctors tell me to avoid neck adjustments/manipulations?
A #1: They may have heard through the (unfortunately sometimes misinformed) grapevine that it is best to avoid the manipulations. Interesting fact? Now there are weekend courses for MDs and physiotherapists on how to manipulate the neck. MDs are also sometimes told that neck manipulations are unsafe, in seminars or at school. I hate to be a conspiracy theorist but if you investigate and do your research, you will find that there was a huge lawsuit many years ago against the American Medical Association regarding this- and they lost. It is economically not in the best interest of the drug companies (specifically medications for headaches and neck pain) to support non-invasive, drug-free options that are effective at treating headaches and neck pain. Possibly your physician spoke to a neurologist who examined a patient with a stroke after being adjusted. But did the chiropractor cause the stroke? Once again, the research shows otherwise. Today, chiropractors work closely with practitioners in many different fields. I personally work with MDs, dentists, a TMJ specialist, physiotherapists, kinesiologists, and even a pharmacist!
Q #2: Do chiropractors cure ALL headaches and neck pain?
A #2: No- wouldn’t that make things too easy? One common type of headache is “cervicogenic”, which means originating from the neck. This is the type that responds most favorably to neck manipulation. Neck pain that is related to the muscles, joints, and nerves is also a good candidate for chiropractic treatments. One helpful thing that you can do before seeking treatment is to take notes. If you have recurrent headaches, keep a headache journal. It should list all the foods that you eat leading up to the headache, what time of day the headache occurred, how intense (out of 10, 10 being the worst imaginable pain) the pain was, how long it lasted, the location of the headache, how your neck and jaw felt, any other associated symptoms (dizzy? nauseaus? sensitive to light and noise?) as well as all the details that you feel are relevant.
Q #3: What about other treatment options, do chiropractors ALWAYS adjust?
A #3: There are many treatment options, most with risks. Massage, medications (anti-inflammatories, muscle relaxants, pain killers, migraine pills), mobilizations, acupuncture, magnet therapy, vibration therapy, meditation, yoga, IMS, laser therapy, corticosteroid injections, natural remedies…. well, you’ve seen the ads. Pain treatments are not in short supply. How do you know which is right for you? See a professional! Get a thorough examination done and once you have a diagnosis (not always set in concrete, but it’s a starting point), then you can work with the experts in finding the right treatment for you. For many types of headaches and neck pain, a cervical (neck) adjustment is effective… but I don’t always use it. I have many tools to work with and it is my job to determine which are the most relevant to your case. Sometimes I don’t treat you at all, I may refer you out for more studies or another more appropriate treatment, depending on what is going on in your neck.
Q #4: Who do chiropractors treat?
A #4: I treat all ages and sizes, literally. Including my entire family. The kids, the babies (the manipulation is gentle and doesn’t look the same as an adult manipulation, of course), and even my grandmother used to let me practice on her while I was in school. Basically, anyone who is not a high-risk patient already vulnerable to a stroke or other issues and who has the type of headache or neck pain that could benefit from my treatment, based on the findings of my examination.
Q #5: Should I get my neck adjusted?
A #5: I don’t know! It depends on what is found during your examination. If there’s anything to be concerned about, my aim is to discover this during the interview or we can send for more testing if necessary.
Q #6: Can you fix my issues?
A #6: It depends. I can help with many conditions including jaw pain (TMJD- see my earlier blog post), neck pain, headaches, shoulder pain, shooting nerve pain, certain types of dizziness, etc. Why don’t you define “issues”… I can’t make your significant other forgive you when you forget their birthday. Those issues require a different type of expert.
Q #7: I’m still scared!!
A #7: OK, that’s not a question! But don’t worry, I have plenty of patients that have experienced relief without having their neck manipulated. I do use specific soft tissue techniques (work on the muscles, more targeted at soft tissue correction than a regular massage), mobilizations (gentle movements to the joints), activator (the “clicker”), traction (stretching the neck), and I give plenty of advice for what you should and should not be doing at home. Yeah, I enjoy telling you what to do!