Can Cervical Spine Manipulation Cause Immediate Thromboembolic Stroke?
Main Article Content
Abstract
Aim: The aim was to perform a narrative review of the research cited in a 2025 commentary by Wilder et al. entitled, Informed Consent in Chiropractic: Commentary on Brown & Lehman’s “Informed Consent Regarding Risk of Stroke from Cervical Spine Manipulation”. Specifically, to review research cited to support there is no evidence that cervical spine manipulation (CSM) can dislodge a thrombus from an existing cervical artery dissection (CeAD) and cause immediate thromboembolic stroke.
Results: Our review found that 24 studies were referenced as part of discussions that CSM cannot cause thromboembolic stroke, and none of those 24 references rule out CSM as a potential cause of thromboembolic stroke. Wilder et al. misinterpret Brown and Lehman’s focus on stroke risk, not CeAD causation, in informed consent. Their discussion of studies supporting that CSM cannot cause CeAD is a separate discussion from whether CSM can cause stroke. Limitations were noted in three epidemiological stroke studies due to small stroke case numbers, no immediate exposure periods, failure to exclude CSM as a cause of stroke, and inapplicability to the population most at-risk for CeAD-related stroke, those under 45 years of age. Six studies acknowledge the plausibility of the thromboembolic mechanism of causation. Two practice guidelines and one animal study do not support Wilder et al.’s opinions.
Conclusion: We conclude there is no convincing evidence that CSM can cause CeAD, but when signs and symptoms of CeAD are present, the patient must be informed and referred to medical emergency because in that clinical setting, there is a risk that CSM may dislodge a thrombus and cause thromboembolic stroke. The 24 studies reviewed by Wilder et al. fail to rule out this risk, and in some cases support it. By acknowledging this risk and prioritizing informed consent, the chiropractic profession can uphold its commitment to patient-centered, evidence-based care.
Article Details
How to Cite
BROWN, Steven; LEHMAN, James J..
Can Cervical Spine Manipulation Cause Immediate Thromboembolic Stroke?.
Medical Research Archives, [S.l.], v. 13, n. 11, nov. 2025.
ISSN 2375-1924.
Available at: <https://esmed.org/MRA/mra/article/view/7091>. Date accessed: 06 dec. 2025.
doi: https://doi.org/10.18103/mra.v13i11.7091.
Section
Editorial
The Medical Research Archives grants authors the right to publish and reproduce the unrevised contribution in whole or in part at any time and in any form for any scholarly non-commercial purpose with the condition that all publications of the contribution include a full citation to the journal as published by the Medical Research Archives.
References
1. Shah P, Thornton I, Kopitnik NL, Hipskind JE. Informed Consent. In: StatPearls. StatPearls Publishing; 2025. Accessed September 10, 2025. http://www.ncbi.nlm.nih.gov/books/NBK430827/
2. Lehman JJ, Conwell TD, Sherman PR. Should the chiropractic profession embrace the doctrine of informed consent? J Chiropr Med. 2008;7(3):107-114. doi:10.1016/j.jcm.2008.04.002
3. Whalen W, Farabaugh RJ, Hawk C, et al. Best-Practice Recommendations for Chiropractic Management of Patients With Neck Pain. J Manipulative Physiol Ther. 2019;42(9):635-650. doi:10.1016/j.jmpt.2019.08.001
4. Ahuja AS. Should RCT’s be used as the gold standard for evidence based medicine? Integr Med Res. 2019;8(1):31-32. doi:10.1016/j.imr.2019.01.001
5. Association of Chiropractic Colleges. Association of Chiropractic Colleges Informed Consent Guideline. Published online January 10, 2007.
6. Brown S, Lehman J. Informed Consent Regarding Risk of Stroke from Cervical Spine Manipulation: A Narrative Review. JIANM. 2025;1(2):2-12.
7. Brown S, Cooperstein R. The Connecticut Law on Chiropractic Informed Consent to Cervical Artery Dissection and Stroke: A Narrative Review. J Contemporary Chiropr. 2025;8:162-169.
8. Brown SP. Plausible Mechanisms of Causation of Immediate Stroke by Cervical Spine Manipulation: A Narrative Review. Cureus. 2024;16(3):e56565. doi:10.7759/cureus.56565
9. Mas JL, Henin D, Bousser MG, Chain F, Hauw JJ. Dissecting aneurysm of the vertebral artery and cervical manipulation: a case report with autopsy. Neurology. 1989;39(4):512-515. doi:10.1212/wnl.39.4.512
10. Norris JW, Beletsky V, Nadareishvili ZG. Sudden neck movement and cervical artery dissection. The Canadian Stroke Consortium. CMAJ. 2000;163(1): 38-40.
11. Cassidy JD, Boyle E, Côté P, et al. Risk of vertebrobasilar stroke and chiropractic care: results of a population-based case-control and case-crossover study. Spine (Phila Pa 1976). 2008;33(4 Suppl):S176-183. doi:10.1097/BRS.0b013e3181644600
12. Terrett AGJ. Current Concepts in Vertebrobasilar Complications Following Spinal Manipulation. 2nd ed. NCMIC; 2001.
13. Haldeman S, Kohlbeck FJ, McGregor M. Stroke, cerebral artery dissection, and cervical spine manipulation therapy. J Neurol. 2002;249(8):1098-1104. doi:10.1007/s00415-002-0783-4
14. Kennell KA, Daghfal MM, Patel SG, DeSanto JR, Waterman GS, Bertino RE. Cervical artery dissection related to chiropractic manipulation: One institution’s experience. J Fam Pract. 2017;66(9):556-562.
15. Turner RC, Lucke-Wold BP, Boo S, Rosen CL, Sedney CL. 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). doi:10.15761/BRR.1000110
16. Gorrell LM, Sawatsky A, Edwards WB, Herzog W. Vertebral arteries do not experience tensile force during manual cervical spine manipulation applied to human cadavers. J Man Manip Ther. 2023;31(4):261-269. doi:10.1080/10669817.2022.2148048
17. Wilder J, Demetrious J, Conway P, Graber D, Tuchin P. Informed Consent in Chiropractic: Commentary on Brown & Lehman’s “Informed Consent Regarding Risk of Stroke from Cervical Spine Manipulation.” JCC. 2025;8(1):265-295.
18. Freeman MD, Rossignol AM, Hand ML. Forensic Epidemiology: a systematic approach to probabilistic determinations in disputed matters. J Forensic Leg Med. 2008;15(5):281-290. doi:10.1016/j.jflm.2007.12.009
19. Krueger BR, Okazaki H. Vertebral-basilar distribution infarction following chiropractic cervical manipulation. Mayo Clin Proc. 1980;55(5):322-332.
20. Haldeman S, Kohlbeck FJ, McGregor M. Risk factors and precipitating neck movements causing vertebrobasilar artery dissection after cervical trauma and spinal manipulation. Spine (Phila Pa 1976). 1999;24(8):785-794. doi:10.1097/00007632-199904150-00010
21. Smith WS, Johnston SC, Skalabrin EJ, et al. Spinal manipulative therapy is an independent risk factor for vertebral artery dissection. Neurology. 2003;60(9): 1424-1428. doi:10.1212/01.wnl.0000063305.61050.e6
22. Schwartz NE, Vertinsky AT, Hirsch KG, Albers GW. Clinical and radiographic natural history of cervical artery dissections. J Stroke Cerebrovasc Dis. 2009;18(6):416-423. doi:10.1016/j.jstrokecerebrovasdis.2008.11.016
23. Albuquerque FC, Hu YC, Dashti SR, et al. Craniocervical arterial dissections as sequelae of chiropractic manipulation: patterns of injury and management. J Neurosurg. 2011;115(6):1197-1205. doi:10.3171/2011.8.JNS111212
24. Tuchin P. Chiropractic and stroke: association or causation? Int J Clin Pract. 2013;67(9):825-833. doi:10.1111/ijcp.12171
25. Thomas LC. Cervical arterial dissection: An overview and implications for manipulative therapy practice. Man Ther. 2016;21:2-9. doi:10.1016/j.math.2015.07.008
26. Neeb L, Reuter U. Stroke after chiropractic manipulations. In: Tsiskaridze A, Lindgren A, Qureshi A, eds. Treatment-Related Stroke. 1st ed. Cambridge University Press; 2016:123-129. doi:10.1017/CBO9781139775397.013
27. Reggars JW, French SD, Walker BF, et al. RISK MANAGEMENT FOR CHIROPRACTORS AND OSTEOPATHS: Neck Manipulation & Vertebrobasilar Stroke. Australas Chiropr Osteopathy. 2003;11(1):9-15.
28. Haneline MT, Lewkovich G. Identification of internal carotid artery dissection in chiropractic practice. J Can Chiropr Assoc. 2004;48(3):206-210.
29. Paulus JK, Thaler DE. Does case misclassification threaten the validity of studies investigating the relationship between neck manipulation and vertebral artery dissection stroke? Yes. Chiropr Man Therap. 2016;24:42. doi:10.1186/s12998-016-0123-x
30. Symons B, Herzog W. Cervical artery dissection: a biomechanical perspective. J Can Chiropr Assoc. 2013;57(4):276-278.
31. Whedon JM, Song Y, Mackenzie TA, Phillips RB, Lukovits TG, Lurie JD. Risk of stroke after chiropractic spinal manipulation in medicare B beneficiaries aged 66 to 99 years with neck pain. J Manipulative Physiol Ther. 2015;38(2):93-101. doi:10.1016/j.jmpt.2014.12.001
32. Haynes MJ, Vincent K, Fischhoff C, Bremner AP, Lanlo O, Hankey GJ. Assessing the risk of stroke from neck manipulation: a systematic review. Int J Clin Pract. 2012;66(10):940-947. doi:10.1111/j.1742-1241.2012.03004.x
33. Kosloff TM, Elton 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. Chiropr Man Therap. 2015;23:19. doi:10.1186/s12998-015-0063-x
34. 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). Published online 2020. https://www.jospt.org/doi/10.2519/jospt.2022.11147
35. Haldeman S, Kohlbeck FJ, McGregor M. Unpredictability of cerebrovascular ischemia associated with cervical spine manipulation therapy: a review of sixty-four cases after cervical spine manipulation. Spine (Phila Pa 1976). 2002;27(1):49-55. doi:10.1097/00007632-200201010-00012
36. Wynd S, Anderson T, Kawchuk G. Effect of cervical spine manipulation on a pre-existing vascular lesion within the canine vertebral artery. Cerebrovasc Dis. 2008;26(3):304-309. doi:10.1159/000149578
37. Church EW, Sieg EP, Zalatimo O, Hussain NS, Glantz M, Harbaugh RE. Systematic Review and Meta-analysis of Chiropractic Care and Cervical Artery Dissection: No Evidence for Causation. Cureus. 2016;8(2):e498. doi:10.7759/cureus.498
38. Whedon JM, Petersen CL, Li Z, et al. Association between cervical artery dissection and spinal manipulative therapy -a medicare claims analysis. BMC Geriatr. 2022;22(1):917. doi:10.1186/s12877-022-03495-5
39. Whedon JM, Petersen CL, Schoellkopf WJ, Haldeman S, MacKenzie TA, Lurie JD. The association between cervical artery dissection and spinal manipulation among US adults. Eur Spine J. Published online July 8, 2023. doi:10.1007/s00586-023-07844-9
40. Symons BP, Leonard T, Herzog W. Internal forces sustained by the vertebral artery during spinal manipulative therapy. J Manipulative Physiol Ther. 2002;25(8):504-510. doi:10.1067/mmt.2002.127076
41. Haynes MJ, Cala LA, Melsom A, Mastaglia FL, Milne N, McGeachie JK. Vertebral arteries and cervical rotation: modeling and magnetic resonance angiography studies. J Manipulative Physiol Ther. 2002;25(6):370-383. doi:10.1067/mmt.2002.126130
42. Wuest S, Symons B, Leonard T, Herzog W. Preliminary report: biomechanics of vertebral artery segments C1-C6 during cervical spinal manipulation. J Manipulative Physiol Ther. 2010;33(4):273-278. doi:10.1016/j.jmpt.2010.03.007
43. Herzog W, Leonard TR, Symons B, Tang C, Wuest S. Vertebral artery strains during high-speed, low amplitude cervical spinal manipulation. J Electromyogr Kinesiol. 2012;22(5):740-746. doi:10.1016/j.jelekin.2012.03.005
44. Gorrell LM, Kuntze G, Ronsky JL, et al. Kinematics of the head and associated vertebral artery length changes during high-velocity, low-amplitude cervical spine manipulation. Chiropr Man Therap. 2022;30(1):28. doi:10.1186/s12998-022-00438-0
45. Fagundes C, Herzog W. Strain of the vertebral artery during passive neck movements and spinal manipulation of the cervical spine: An observational study. Journal of Bodywork and Movement Therapies. 2024;40:569-574. doi:10.1016/j.jbmt.2024.05.011
46. Biller J, Sacco RL, Albuquerque FC, et al. Cervical arterial dissections and association with cervical manipulative therapy: a statement for healthcare professionals from the american heart association/american stroke association. Stroke. 2014;45(10):3155-3174. doi:10.1161/STR.0000000000000016
47. 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. doi:10.1080/07853890.2019.1590627
48. Tuchin P. What Evidence Can Case Reports on Spine Manipulative Therapy and Cervical Artery Dissection Provide? JCC. 2024;7(1):132-140.
49. Tavakoli SG, Britt TB, Agarwal S. Vertebral Artery Dissection. In: StatPearls. StatPearls Publishing; 2025. Accessed August 26, 2025. http://www.ncbi.nlm.nih.gov/books/NBK441827/
50. Goodfriend SD, Tadi P, Koury R. Carotid Artery Dissection. In: StatPearls. StatPearls Publishing; 2022. Accessed October 9, 2022. http://www.ncbi.nlm.nih.gov/books/NBK430835/
51. Alwood BT, Dossani RH. Vertebrobasilar Stroke. In: StatPearls. StatPearls Publishing; 2023. Accessed August 17, 2023. http://www.ncbi.nlm.nih.gov/books/NBK556084/
52. 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. doi:10.1161/STROKEAHA.116.015185
53. Lee VH, Brown RD, Mandrekar JN, Mokri B. Incidence and outcome of cervical artery dissection: a population-based study. Neurology. 2006;67(10): 1809-1812. doi:10.1212/01.wnl.0000244486.30455.71
54. Griffin KJ, Harmsen WS, Mandrekar J, Brown RD, Keser Z. Epidemiology of Spontaneous Cervical Artery Dissection: Population-Based Study. Stroke. 2024;55(3):670-677. doi:10.1161/STROKEAHA.123.043647
55. Cassidy JD, Boyle E, Côté P, Hogg-Johnson S, Bondy SJ, Haldeman S. Risk of Carotid Stroke after Chiropractic Care: A Population-Based Case-Crossover Study. J Stroke Cerebrovasc Dis. 2017;26(4):842-850. doi:10.1016/j.jstrokecerebrovasdis.2016.10.031
56. Brown S. Cervical Spine Manipulation, Immediate Stroke, and the Diagnosis of Dissection: A Commentary on Cassidy 2008. JIANM. 2024;21(1):46-49.
57. Rubinstein SM, Peerdeman SM, van Tulder MW, Riphagen I, Haldeman S. A systematic review of the risk factors for cervical artery dissection. Stroke. 2005;36(7):1575-1580. doi:10.1161/01.STR.0000169919.73219.30
58. Guyatt GH, Sackett DL, Sinclair JC, Hayward R, Cook DJ, Cook RJ. Users’ guides to the medical literature. IX. A method for grading health care recommendations. Evidence-Based Medicine Working Group. JAMA. 1995;274(22):1800-1804. doi:10.1001/jama.274.22.1800
59. 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. doi:10.1589/jpts.32.775
60. 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. Physiotherapy Theory and Practice. 2023;39(6):1297-1304. doi:10.1080/09593985.2022.2035033
61. Thomas L, Fowler M, Marsh L, Chu K, Muller C, Wong A. Validation of a diagnostic support tool for early recognition of cervical arterial dissection in primary care. Clin Neurol Neurosurg. 2024;247:108627. doi:10.1016/j.clineuro.2024.108627
2. Lehman JJ, Conwell TD, Sherman PR. Should the chiropractic profession embrace the doctrine of informed consent? J Chiropr Med. 2008;7(3):107-114. doi:10.1016/j.jcm.2008.04.002
3. Whalen W, Farabaugh RJ, Hawk C, et al. Best-Practice Recommendations for Chiropractic Management of Patients With Neck Pain. J Manipulative Physiol Ther. 2019;42(9):635-650. doi:10.1016/j.jmpt.2019.08.001
4. Ahuja AS. Should RCT’s be used as the gold standard for evidence based medicine? Integr Med Res. 2019;8(1):31-32. doi:10.1016/j.imr.2019.01.001
5. Association of Chiropractic Colleges. Association of Chiropractic Colleges Informed Consent Guideline. Published online January 10, 2007.
6. Brown S, Lehman J. Informed Consent Regarding Risk of Stroke from Cervical Spine Manipulation: A Narrative Review. JIANM. 2025;1(2):2-12.
7. Brown S, Cooperstein R. The Connecticut Law on Chiropractic Informed Consent to Cervical Artery Dissection and Stroke: A Narrative Review. J Contemporary Chiropr. 2025;8:162-169.
8. Brown SP. Plausible Mechanisms of Causation of Immediate Stroke by Cervical Spine Manipulation: A Narrative Review. Cureus. 2024;16(3):e56565. doi:10.7759/cureus.56565
9. Mas JL, Henin D, Bousser MG, Chain F, Hauw JJ. Dissecting aneurysm of the vertebral artery and cervical manipulation: a case report with autopsy. Neurology. 1989;39(4):512-515. doi:10.1212/wnl.39.4.512
10. Norris JW, Beletsky V, Nadareishvili ZG. Sudden neck movement and cervical artery dissection. The Canadian Stroke Consortium. CMAJ. 2000;163(1): 38-40.
11. Cassidy JD, Boyle E, Côté P, et al. Risk of vertebrobasilar stroke and chiropractic care: results of a population-based case-control and case-crossover study. Spine (Phila Pa 1976). 2008;33(4 Suppl):S176-183. doi:10.1097/BRS.0b013e3181644600
12. Terrett AGJ. Current Concepts in Vertebrobasilar Complications Following Spinal Manipulation. 2nd ed. NCMIC; 2001.
13. Haldeman S, Kohlbeck FJ, McGregor M. Stroke, cerebral artery dissection, and cervical spine manipulation therapy. J Neurol. 2002;249(8):1098-1104. doi:10.1007/s00415-002-0783-4
14. Kennell KA, Daghfal MM, Patel SG, DeSanto JR, Waterman GS, Bertino RE. Cervical artery dissection related to chiropractic manipulation: One institution’s experience. J Fam Pract. 2017;66(9):556-562.
15. Turner RC, Lucke-Wold BP, Boo S, Rosen CL, Sedney CL. 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). doi:10.15761/BRR.1000110
16. Gorrell LM, Sawatsky A, Edwards WB, Herzog W. Vertebral arteries do not experience tensile force during manual cervical spine manipulation applied to human cadavers. J Man Manip Ther. 2023;31(4):261-269. doi:10.1080/10669817.2022.2148048
17. Wilder J, Demetrious J, Conway P, Graber D, Tuchin P. Informed Consent in Chiropractic: Commentary on Brown & Lehman’s “Informed Consent Regarding Risk of Stroke from Cervical Spine Manipulation.” JCC. 2025;8(1):265-295.
18. Freeman MD, Rossignol AM, Hand ML. Forensic Epidemiology: a systematic approach to probabilistic determinations in disputed matters. J Forensic Leg Med. 2008;15(5):281-290. doi:10.1016/j.jflm.2007.12.009
19. Krueger BR, Okazaki H. Vertebral-basilar distribution infarction following chiropractic cervical manipulation. Mayo Clin Proc. 1980;55(5):322-332.
20. Haldeman S, Kohlbeck FJ, McGregor M. Risk factors and precipitating neck movements causing vertebrobasilar artery dissection after cervical trauma and spinal manipulation. Spine (Phila Pa 1976). 1999;24(8):785-794. doi:10.1097/00007632-199904150-00010
21. Smith WS, Johnston SC, Skalabrin EJ, et al. Spinal manipulative therapy is an independent risk factor for vertebral artery dissection. Neurology. 2003;60(9): 1424-1428. doi:10.1212/01.wnl.0000063305.61050.e6
22. Schwartz NE, Vertinsky AT, Hirsch KG, Albers GW. Clinical and radiographic natural history of cervical artery dissections. J Stroke Cerebrovasc Dis. 2009;18(6):416-423. doi:10.1016/j.jstrokecerebrovasdis.2008.11.016
23. Albuquerque FC, Hu YC, Dashti SR, et al. Craniocervical arterial dissections as sequelae of chiropractic manipulation: patterns of injury and management. J Neurosurg. 2011;115(6):1197-1205. doi:10.3171/2011.8.JNS111212
24. Tuchin P. Chiropractic and stroke: association or causation? Int J Clin Pract. 2013;67(9):825-833. doi:10.1111/ijcp.12171
25. Thomas LC. Cervical arterial dissection: An overview and implications for manipulative therapy practice. Man Ther. 2016;21:2-9. doi:10.1016/j.math.2015.07.008
26. Neeb L, Reuter U. Stroke after chiropractic manipulations. In: Tsiskaridze A, Lindgren A, Qureshi A, eds. Treatment-Related Stroke. 1st ed. Cambridge University Press; 2016:123-129. doi:10.1017/CBO9781139775397.013
27. Reggars JW, French SD, Walker BF, et al. RISK MANAGEMENT FOR CHIROPRACTORS AND OSTEOPATHS: Neck Manipulation & Vertebrobasilar Stroke. Australas Chiropr Osteopathy. 2003;11(1):9-15.
28. Haneline MT, Lewkovich G. Identification of internal carotid artery dissection in chiropractic practice. J Can Chiropr Assoc. 2004;48(3):206-210.
29. Paulus JK, Thaler DE. Does case misclassification threaten the validity of studies investigating the relationship between neck manipulation and vertebral artery dissection stroke? Yes. Chiropr Man Therap. 2016;24:42. doi:10.1186/s12998-016-0123-x
30. Symons B, Herzog W. Cervical artery dissection: a biomechanical perspective. J Can Chiropr Assoc. 2013;57(4):276-278.
31. Whedon JM, Song Y, Mackenzie TA, Phillips RB, Lukovits TG, Lurie JD. Risk of stroke after chiropractic spinal manipulation in medicare B beneficiaries aged 66 to 99 years with neck pain. J Manipulative Physiol Ther. 2015;38(2):93-101. doi:10.1016/j.jmpt.2014.12.001
32. Haynes MJ, Vincent K, Fischhoff C, Bremner AP, Lanlo O, Hankey GJ. Assessing the risk of stroke from neck manipulation: a systematic review. Int J Clin Pract. 2012;66(10):940-947. doi:10.1111/j.1742-1241.2012.03004.x
33. Kosloff TM, Elton 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. Chiropr Man Therap. 2015;23:19. doi:10.1186/s12998-015-0063-x
34. 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). Published online 2020. https://www.jospt.org/doi/10.2519/jospt.2022.11147
35. Haldeman S, Kohlbeck FJ, McGregor M. Unpredictability of cerebrovascular ischemia associated with cervical spine manipulation therapy: a review of sixty-four cases after cervical spine manipulation. Spine (Phila Pa 1976). 2002;27(1):49-55. doi:10.1097/00007632-200201010-00012
36. Wynd S, Anderson T, Kawchuk G. Effect of cervical spine manipulation on a pre-existing vascular lesion within the canine vertebral artery. Cerebrovasc Dis. 2008;26(3):304-309. doi:10.1159/000149578
37. Church EW, Sieg EP, Zalatimo O, Hussain NS, Glantz M, Harbaugh RE. Systematic Review and Meta-analysis of Chiropractic Care and Cervical Artery Dissection: No Evidence for Causation. Cureus. 2016;8(2):e498. doi:10.7759/cureus.498
38. Whedon JM, Petersen CL, Li Z, et al. Association between cervical artery dissection and spinal manipulative therapy -a medicare claims analysis. BMC Geriatr. 2022;22(1):917. doi:10.1186/s12877-022-03495-5
39. Whedon JM, Petersen CL, Schoellkopf WJ, Haldeman S, MacKenzie TA, Lurie JD. The association between cervical artery dissection and spinal manipulation among US adults. Eur Spine J. Published online July 8, 2023. doi:10.1007/s00586-023-07844-9
40. Symons BP, Leonard T, Herzog W. Internal forces sustained by the vertebral artery during spinal manipulative therapy. J Manipulative Physiol Ther. 2002;25(8):504-510. doi:10.1067/mmt.2002.127076
41. Haynes MJ, Cala LA, Melsom A, Mastaglia FL, Milne N, McGeachie JK. Vertebral arteries and cervical rotation: modeling and magnetic resonance angiography studies. J Manipulative Physiol Ther. 2002;25(6):370-383. doi:10.1067/mmt.2002.126130
42. Wuest S, Symons B, Leonard T, Herzog W. Preliminary report: biomechanics of vertebral artery segments C1-C6 during cervical spinal manipulation. J Manipulative Physiol Ther. 2010;33(4):273-278. doi:10.1016/j.jmpt.2010.03.007
43. Herzog W, Leonard TR, Symons B, Tang C, Wuest S. Vertebral artery strains during high-speed, low amplitude cervical spinal manipulation. J Electromyogr Kinesiol. 2012;22(5):740-746. doi:10.1016/j.jelekin.2012.03.005
44. Gorrell LM, Kuntze G, Ronsky JL, et al. Kinematics of the head and associated vertebral artery length changes during high-velocity, low-amplitude cervical spine manipulation. Chiropr Man Therap. 2022;30(1):28. doi:10.1186/s12998-022-00438-0
45. Fagundes C, Herzog W. Strain of the vertebral artery during passive neck movements and spinal manipulation of the cervical spine: An observational study. Journal of Bodywork and Movement Therapies. 2024;40:569-574. doi:10.1016/j.jbmt.2024.05.011
46. Biller J, Sacco RL, Albuquerque FC, et al. Cervical arterial dissections and association with cervical manipulative therapy: a statement for healthcare professionals from the american heart association/american stroke association. Stroke. 2014;45(10):3155-3174. doi:10.1161/STR.0000000000000016
47. 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. doi:10.1080/07853890.2019.1590627
48. Tuchin P. What Evidence Can Case Reports on Spine Manipulative Therapy and Cervical Artery Dissection Provide? JCC. 2024;7(1):132-140.
49. Tavakoli SG, Britt TB, Agarwal S. Vertebral Artery Dissection. In: StatPearls. StatPearls Publishing; 2025. Accessed August 26, 2025. http://www.ncbi.nlm.nih.gov/books/NBK441827/
50. Goodfriend SD, Tadi P, Koury R. Carotid Artery Dissection. In: StatPearls. StatPearls Publishing; 2022. Accessed October 9, 2022. http://www.ncbi.nlm.nih.gov/books/NBK430835/
51. Alwood BT, Dossani RH. Vertebrobasilar Stroke. In: StatPearls. StatPearls Publishing; 2023. Accessed August 17, 2023. http://www.ncbi.nlm.nih.gov/books/NBK556084/
52. 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. doi:10.1161/STROKEAHA.116.015185
53. Lee VH, Brown RD, Mandrekar JN, Mokri B. Incidence and outcome of cervical artery dissection: a population-based study. Neurology. 2006;67(10): 1809-1812. doi:10.1212/01.wnl.0000244486.30455.71
54. Griffin KJ, Harmsen WS, Mandrekar J, Brown RD, Keser Z. Epidemiology of Spontaneous Cervical Artery Dissection: Population-Based Study. Stroke. 2024;55(3):670-677. doi:10.1161/STROKEAHA.123.043647
55. Cassidy JD, Boyle E, Côté P, Hogg-Johnson S, Bondy SJ, Haldeman S. Risk of Carotid Stroke after Chiropractic Care: A Population-Based Case-Crossover Study. J Stroke Cerebrovasc Dis. 2017;26(4):842-850. doi:10.1016/j.jstrokecerebrovasdis.2016.10.031
56. Brown S. Cervical Spine Manipulation, Immediate Stroke, and the Diagnosis of Dissection: A Commentary on Cassidy 2008. JIANM. 2024;21(1):46-49.
57. Rubinstein SM, Peerdeman SM, van Tulder MW, Riphagen I, Haldeman S. A systematic review of the risk factors for cervical artery dissection. Stroke. 2005;36(7):1575-1580. doi:10.1161/01.STR.0000169919.73219.30
58. Guyatt GH, Sackett DL, Sinclair JC, Hayward R, Cook DJ, Cook RJ. Users’ guides to the medical literature. IX. A method for grading health care recommendations. Evidence-Based Medicine Working Group. JAMA. 1995;274(22):1800-1804. doi:10.1001/jama.274.22.1800
59. 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. doi:10.1589/jpts.32.775
60. 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. Physiotherapy Theory and Practice. 2023;39(6):1297-1304. doi:10.1080/09593985.2022.2035033
61. Thomas L, Fowler M, Marsh L, Chu K, Muller C, Wong A. Validation of a diagnostic support tool for early recognition of cervical arterial dissection in primary care. Clin Neurol Neurosurg. 2024;247:108627. doi:10.1016/j.clineuro.2024.108627