A Media Story
On June 9, 2025, a headline in the People Magazine feed stated:
“Chiropractor Tears Woman’s Artery While Cracking Her Neck”
••••
Sensational headlines exist because they grab the public’s interest and their attention. Yet, such headlines and the accompanied article may be unfair, incomplete, biased, or even flat out incorrect. Investigations into the details of such publications may show doubt, impossibilities, and/or innocence that are often missing from the sensational publication. For example, consider these points:
- Joint manipulation is the applying of a force to a joint that helps that joint move better. It is classically associated with an audible sound. All people, trained and untrained, are capable of manipulating joints and eliciting an audible sound.
- Manipulation is a lay term. It is often used synonymously with the word chiropractic. Yet, importantly, chiropractors technically do not manipulate joints. Chiropractors adjust joints. Untrained lay people manipulate joints.
- Manipulation implies the movement of a joint to the point of creating an audible sound, but the line-of-drive and the control of the amplitude (distance) is not precise. In contrast, the term for manipulation that has a specific line-of-drive direction and control of the amplitude is adjustment. Chiropractors use spinal adjusting, not manipulation. The mastery of spinal adjusting takes years of study, training, and practice. After completing college with a biological curriculum, the training to be a chiropractor takes 4 academic years at an accredited chiropractic college.
- There are 18 chiropractic colleges in the United States and many more throughout the world (1). Some of the chiropractic colleges are universities that grant academic degrees in addition to the Doctor of Chiropractic degree (DC). Others only grant Doctor of Chiropractic degrees.
- In the 1970s, the United States federal government took control of chiropractic education. The United States Department of Education oversees chiropractic education by recognizing the Council on Chiropractic Education (CCE) (1):
“CCE maintains recognition by the United States Department of Education as the national accrediting body for Doctor of Chiropractic Programs and chiropractic solitary purpose institutions of higher education.”
- All 18 of the chiropractic colleges in the United States are accredited by the Council for Chiropractic Education.
- In the United States, the licensure of chiropractors is controlled by the individual states, and all 50 U.S. states officially license chiropractors, allowing them to practice with their Doctor of Chiropractic degree (DC). Chiropractors are considered to be primary portal health care providers, which means (in part) that the public may choose chiropractic care without requiring a referral from another health care provider.
- The central core of chiropractic clinical practice is the use of mechanical care, and the primary form of mechanical care is specific line-of-drive manipulation (the chiropractic adjustment).
- A typical chiropractic visit involves an assessment of posture and joint motion (possibly with the use of x-rays), helping the chiropractor assess the manner in which his/her patient exists and functions mechanically in a gravity environment. Abnormal findings are usually treated mechanically and primarily with the use of the chiropractic adjustment.
- Chiropractors are extensively trained to be mechanical providers of care. Ninety-three percent of patients who chose to initially see a chiropractor do so for spinal pain complaints (2). Satisfaction among patients with these complaints is exceptional (2).
- The “tearing” of an artery is a lay person term, a sensational term. The technical term of healthcare providers is “dissection.” The artery with the greatest concern is the vertebral artery (3). This is because the vertebral artery is located inside the neck vertebrae.
- The adjustment that is suggested to increase the strain on the vertebral artery is called the “extension-rotation-thrust atlas adjustment.” (3) Chiropractors are taught not do this type of adjustment on patients. Lay manipulators have no such training.
- Vertebral artery dissections are known to occur spontaneously, meaning they are not in any way related to chiropractic care. The incidence of vertebral dissection in the society, unrelated to chiropractic care, is 1-1.5/100,000 persons yearly (4).
- The literature is mixed or uncertain as to whether chiropractic adjustments are associated with stroke or not. Recent evidence suggests that it is not, although the same evidence often suggests that the patient may be entering the chiropractic office for neck pain/headaches that may in fact be a spontaneous dissection of a neck artery (5).
- The incidence of chiropractic-related vertebral artery dissection is so rare that it is impossible to quantify. A publication by the American Academy of Orthopedic Surgeons suggests the incidence may be as remote as once per 10,000,000 neck adjustments (6). A large 10-year study estimated an incidence of 1 per 5.85 million neck adjustments, equivalent to 1,430 years of clinical practice (7). These statistics should not be interpreted as causation. These statistics show at best a very rare association. This association is so rare that it may represent mere chance or coincidence.
- There are no in the office tests that a chiropractor can perform to rule-in or rule-out a vertebral artery dissection. If a vertebral artery dissection is suspected based upon history and location, the standard is to refer the patient for advanced imaging. The gold-standard is magnetic resonance angiogram (MRA).
- For decades, it has been documented that when both the professional and lay press ascribe a manipulative injury to the vertebral artery that they apply the words “chiropractic” and “manipulation” as being synonymous; they are not. Many people “manipulate” and yet they are not trained and licensed chiropractors (8, 9). One study pointed out the manipulation in question was not performed by a chiropractor, but rather by a range of lay, untrained manipulators, including (8): A Blind Masseur, An Indian Barber, A Wife, A Kung-Fu Practitioner, Self-Manipulation, A Medical Doctor, An Osteopath, A Naturopath, A Physical Therapist
In another study from 2006, the author notes (9):
“... authors suggest the care provider was a chiropractor and that each patient received chiropractic manipulation of the cervical spine prior to developing symptoms suggestive of traumatic injury.”
“In the case series, which involved twenty relevant cases, the principal researcher conceded that the term chiropractor had been inappropriately used and that his case series did not relate to chiropractors who had undergone appropriate formal training.”
“The results of this year-long prospective review suggest that the words 'chiropractor' and 'chiropractic manipulation' are often used inappropriately by European biomedical researchers when reporting apparent associations between cervical spine manipulation and symptoms suggestive of traumatic injury.”
“In those cases, reported here, the spurious use of terminology seems to have passed through the peer-review process without correction.”
“These findings provide further preliminary evidence, beyond that already provided by Terrett [8], that the inappropriate use of the title 'chiropractor' and term 'chiropractic manipulation' may be a significant source of over-reporting of the link between the care provided by chiropractors and injury.”
- A recent egregious example of the misuse of ascribing chiropractic care to obvious untrained lay manipulation appeared in the American Journal of Forensic Medicine and Pathology on June 1, 2024 (10). The article was titled:
Self-Chiropractic Cervical Spinal Manipulation
Resulting in Fatal Vertebral Artery Dissection
This title is misleading, as it implies that individuals can effectively perform chiropractic adjustments on themselves without the necessary evaluation, expertise, and personalized care provided by a trained professional. Self-spinal manipulation is never safe. While this case is very tragic, chiropractic played no role in this patient’s treatment or outcome, and hence for the sake of accuracy should have been left out of both the article and the title.
Top tier, well respected and published biomechanical experts have attempted to cause vertebral artery dissections using chiropractors to adjust human cadavers, and no injuries have occurred. These studies included the cautioned-against extension-rotation-thrust adjustment of C1 on C2 (11, 12, 13). Important comments from these studies include:
“Vertebral artery strains obtained during spinal manipulation are significantly smaller than those obtained during diagnostic and range of motion testing, and are much smaller than failure strains.” (11)
“We conclude from this work that cervical spinal manipulation performed by trained clinicians does not appear to place undue strain on vertebral arteries, and thus does not seem to be a factor in vertebro-basilar injuries.” (11)
“Based on the mechanical tests performed here, one should be able to conclude that stretching of the vertebral artery during neck spinal manipulation does not cause any damage of the vertebral arteries.” (11)
“The vertebral artery is never really strained during spinal manipulative treatments but that the vertebral artery is merely taking up slack as the neck and head are moved during spinal manipulation, but that there is no stress and thus no possibility for microstructural damage.” (11)
“The results from this study demonstrate that average and maximal vertebral artery strains during high-speed low-amplitude cervical spinal manipulation are substantially less than the strains that can be achieved during range-of-motion testing for all vertebral artery segments.” (11)
•••
“In previous studies, the effects of cervical spine manipulation (using cervical spine extension and rotation and delivered at the end-range of segmental movement) delivered by chiropractors on the vertebral artery of cadaveric donors have been reported.” (12)
“[These studies have] concluded that arterial length changes experienced during cervical spine manipulation were almost an order of magnitude lower than the length changes required to mechanically disrupt the artery and thus, a single typical manipulative thrust was unlikely to mechanically disrupt the artery.” (12)
“No segment of the VA was ever stretched during cervical spine manipulation, but merely elongated (some of the natural slack of the vertebral artery was taken up).” (12)
“[Of the 518 cervical spine manipulations applied in this study, the length change during the manipulative thrust] never came close to the failure length changes.” (12)
“During cervical spine manipulations (using cervical spine extension and rotation), arterial length changes remained below that slack length, suggesting that the vertebral arteries elongated but were not stretched during the manipulation.” (12)
“The results of this study, in conjunction with previously published results that vertebral artery length changes during spinal manipulation are about half of those experienced during normally achievable head and neck movements, suggest that the vertebral artery cannot be mechanically damaged by elongation that occurs during cervical spinal manipulation (using cervical spine extension and rotation).” (12)
•••
“None of the vertebral artery elongations (n = 108 elongation measurements) measured during cSMT testing approached or exceeded the maximal vertebral artery elongations obtained during the range of motion testing.” (13)
“If we assume that elongations of the vertebral artery within the normal ranges of motion of the head and neck do not result in stretch-induced damage to the vertebral artery, a feasible assumption it would appear, then we might safely conclude that even the greatest strains, and greatest elongations of the vertebral artery experienced during spinal manipulation are safe from stretch-induced injuries, as they are small compared to the stretches of the vertebral artery that may occur many times in a normal day.” (13)
“Even peak strains/elongations experienced during spinal manipulation are small compared to the strains/elongations experienced by vertebral arteries on a daily basis during normal head and neck movements.” (13)
“Spinal manipulation produces mechanical strains in the vertebral artery that are substantially smaller than the strains produced during everyday head and neck movements.” (13)
“The fact that none of the spinal manipulation strains ever exceeded the corresponding strains obtained during the range of motion testing, suggests that the results presented are robust and can be generalized.” (13)
- Two recent (2022 and 2023) large studies have specifically looked at the incidence of adverse events caused by trained medical doctors and chiropractors performing spinal adjustments (specific line-of-drive manipulations). These studies involved 345,789 individual patients and 3,642,389 spinal adjustments (14, 15). The incidence of vascular injuries/events was zero. This study supports the incidence numbers cited by Haldeman above (7).
••••
Despite the sensational headlines in both the lay press and in peer reviewed scientific journals, the occurrence of a vertebral artery dissection caused by cervical spine chiropractic adjustment is not settled science. Serious investigations into this issue indicate that, at best, there may be no relationship; or, at worst, it occurs so rarely that it is impossible to study and quantify.
Lost in these discussions is this question:
Does cervical spine manipulation help patients?
As noted above (2), the primary reason people go to chiropractors is for the management of low back pain (63%). The second most common reason people go to chiropractors is for the management of neck pain (30%). Below, several studies evaluating the efficacy of spinal manipulation for the treatment of neck pain are presented.
In 2015, a study was published in the Journal of Manipulative and Physiological Therapeutics, titled (16):
Prognostic Factors for Recurrences in Neck Pain Patients
Up to One Year After Chiropractic Care
This prospective cohort study assessed 545 neck pain patients. After a course of chiropractic, they were followed up for 1 year regarding recurrence of neck pain.
Fifty-four (54) participants (11%) were identified as “recurrent.” Four hundred ninety-one (491) participants (89%) were not recurrent. The authors state:
“89% of neck pain patients had recovered from their neck pain episode up to 1 year after receiving chiropractic care.”
The results of this study show that recurrence of neck pain within one year after chiropractic intervention is low. This study indicates that chiropractic is both effective in the treatment of neck pain and that its benefits are stable and long lasting.
••••
In 2018, a study was published in the journal Complementary Therapies in Clinical Practice, titled (17):
Changes in Female Veterans' Neck Pain
Following Chiropractic Care
at a Hospital for Veterans
Thirty-four veterans with neck pain met the inclusion criteria and received chiropractic spinal adjustments. The authors found:
“Female veterans in the present study receiving chiropractic management for neck pain had demonstrable improvement which was statistically and clinically significant.”
“No significant adverse events were reported for any of the patients in the sample.”
“One potential non-pharmacological treatment option for musculoskeletal pain is chiropractic care.”
“Chiropractic management may be an effective treatment strategy for female veterans with neck pain complaints.”
••••
In 2023, a study was published in the journal Spine, titled (18):
Longitudinal Care Patterns and Utilization Among Patients
with New-Onset Neck Pain by Initial Provider Specialty
This study is a retrospective cohort design involving 777,326 patients, aged 18 to 89 years. Its objective was to compare utilization patterns for patients with new-onset neck pain by initial provider specialty. All patients had a new-onset (acute) neck pain.
This study was the first evaluation of a national sample of the care patterns of patients with acute neck pain with classifications by initial provider specialty, including:
- Chiropractor 45%
- Primary care 33%
- Emergency medicine 8%
- Orthopedics 5%
- Physical therapy/occupational therapy (PT/OT) 3%
- Neurology 3%
- Rehabilitation medicine 3%
The authors state:
“Compared with patients initially seen by physician providers, patients treated initially by chiropractors or therapists received fewer and less costly imaging services and were less likely to receive invasive therapeutic interventions during follow-up.”
“Starting with a chiropractor was associated with lower rates of invasive therapeutic interventions and surgery, our study suggests initial care for new-onset neck pain by chiropractors is likely associated with lower longer-term care intensity and costs.”
“Our findings raise the question whether more frequent referrals from physicians to chiropractors or PT/OTs might enhance the efficiency of care for patients with new-onset neck pain.”
“Even after extensive adjustment for sociodemographic and clinical characteristics, patients who started with an orthopedic surgeon, ... had substantially higher rates of therapeutic injection and major surgery within 180 days of follow-up than patients who started with a chiropractor.”
“Within [this] large, national cohort of patients with new-onset neck pain, we found that chiropractors were the initial provider for a plurality of patients and that patients with chiropractor or PT/OT as initial providers received fewer and less costly imaging services and were less likely to receive invasive therapeutic interventions, such as injection or major surgery, during follow-up.”
“Health systems may also seek means of engendering more frequent referrals from primary care or specialist physicians to chiropractors for patients with new-onset neck pain.”
••••
On May 1, 2025, a study was published in the journal Systematic Reviews, titled (19):
Efficacy and Safety of Spinal Manipulative Therapy
in the Management of Acute Neck Pain:
A Systematic Review and Meta?analysis
The objective of this study was to evaluate the efficacy and safety in treating acute neck pain (ANP) with spinal manipulation (SMT). Assessed outcomes included pain intensity, cervical range of motion (CROM), and disability. Eight randomized controlled trials (RCTs) with 965 patients were included. The authors state:
“Despite the well—documented clinical benefits of SMT, the exact magnitude of its efficacy in alleviating pain, reducing disability, and enhancing overall functional outcomes remains inadequately explored.”
“This systematic review has several strengths that contribute to its validity. The review includes a comprehensive search across five significant databases, ensuring a thorough examination of the existing literature.”
“Spinal manipulative therapy (SMT) is frequently used to manage neck pain.”
“[SMT] treatment can restore structural integrity in dysfunctional regions of the spine, alleviate pain, and initiate the body’s natural healing process.”
“No serious adverse events were reported.”
“SMT has been reported as a widely applicable treatment for various types of neck pain, regardless of the stage (acute, subacute, or chronic).”
“Numerous studies have demonstrated that SMT is a safe treatment option for chronic neck pain.”
“The evidence supports the use of SMT as an effective and safe intervention for reducing pain, improving CROM, and decreasing disability in patients with ANP.”
“In practical and clinical applications, SMT can be considered as an effective treatment option for ANP.”
“The results of the systematic review and meta-analysis indicate that overall, SMT has positive effects in terms of reducing pain and disability and improving CROM in patients with ANP.”
“Additionally, the occurrence of minor adverse effects associated with SMT was rare.”
SUMMARY
Despite sensational headlines that can be scary, evidence presented here show that spinal manipulation is both safe and effective for the management of neck pain. This is especially true when the provider is well-trained, such as a chiropractor.
REFERENCES
- cce-usa.org; accessed March 23, 2024.
- Adams J, Peng W, Cramer H, Sundberg T, Moore C; The Prevalence, Patterns, and Predictors of Chiropractic Use Among US Adults: Results From the 2012 National Health Interview Survey; December 1, 2017; Spine; Vol. 42; No. 23; pp. 1810–1816.
- Terrett AGJ; Current Concepts in Vertebrobasilar Complications Following Spinel Manipulation; NCMIC; 2001.
- Kwan-Woong Park, Jong-Sun Park, Sun-Chul Hwang, Soo-Bin Im, Won-Han Shin, Bum-Tae Kim; Vertebral Artery Dissection: Natural History, Clinical Features and Therapeutic Considerations; Journal of the Korean Neurosurgical Society; September 2008; Vol. 44; No. 3; pp. 109–115.
- Cassidy JD, Boyle E, Côté P, He Y, Hogg-Johnson S; Silver FL, Body SJ; Risk of Vertebrobasilar Stroke and Chiropractic Care: Results of a Population-Based Case-Control and Case-Crossover Study; Spine; February 15, 2008; Vol. 33; No. (4S); pp. S176-S183.
- Fischgrund JS; Neck Pain, Monograph 27; American Academy of Orthopaedic Surgeons; 2004.
- Haldeman S, Carey P, Townsend M, Papadopoulos C; Arterial Dissections Following Cervical Manipulation: The Chiropractic Experience; Canadian Medical Association Journal; October 2, 2001; Vol. 165; No. 7; pp. 905-906.
- Terrett AG; Misuse of the Literature by Medical Authors in Discussing Spinal Manipulative Therapy Injury; Journal of Manipulative and Physiological Therapeutics; May 1995; Vol. 18; No. 4; pp. 203-210.
- Wenban AB; Inappropriate use of the title ‘chiropractor’ and term ‘chiropractic manipulation’ in the peer-reviewed biomedical literature; Chiropractic and Osteopathy; August 22, 2006; Vol. 14; No. 16.
- Fink C, Bryce CH, Knight LD; Self-Chiropractic Cervical Spinal Manipulation Resulting in Fatal Vertebral Artery Dissection: A Case Report and Review of the Literature; American Journal of Forensic Medicine and Pathology; June 1, 2024; Vol. 45; No. 2; pp. 172-176.
- Herzog W, Leonard TR, Symons B, Tang C, Wuest S; Vertebral Artery Strains During High-speed, Low Amplitude Cervical Spinal Manipulation; Journal of Electromyography and Kinesiology; October 2012; Vol. 22; No. 5; pp. 740-746.
- Gorrell LM, Sawatsky A, Edwards WB, Herzog W; Vertebral Arteries Do Not Experience Tensile Force During Manual Cervical Spine Manipulation Applied to Human Cadavers; Journal of Manual & Manipulative Therapy; August 2023; Vol. 31; No. 4; pp. 261-269.
- Fagundes C, Walter Herzog W; Strain of the Vertebral Artery During Passive Neck Movements and Spinal Manipulation of the Cervical Spine: An Observational Study; Journal of Bodywork & Movement Therapies October 2024; Vol. 40; pp. 569–574.
- Kim S, Kim G, Kim H, Park J, Lee J, and nine more; Safety of Chuna Manipulation Therapy in 289,953 Patients with Musculoskeletal Disorders: A Retrospective Study; Healthcare; February 2, 2022; Vol. 10; No. 2; Article 294.
- Chu E, Trager RJ, Lee L, Niazi IK; A Retrospective Analysis of the Incidence of Severe Adverse Events Among Recipients of Chiropractic Spinal Manipulative Therapy; Scientific Reports; January 23, 2023; Vol. 13; No. 1; Article 1254.
- Langenfeld A, Humphreys K, Swanenburg J, Peterson CK; Prognostic Factors for Recurrences in Neck Pain Patients Up to 1 Year After Chiropractic Care; Journal of Manipulative and Physiological Therapeutics; September 2015; Vol. 38; No. 7; pp. 458-464.
- Corcoran KL, DC; Dunn AS, Green BN, Formolo LR, Beehler GP; Changes in Female Veterans' Neck Pain Following Chiropractic Care at a Hospital for Veterans; Complementary Therapies in Clinical Practice; February 2018; Vol. 30; pp. 91-95.
- Fenton JJ, Fang SY, Ray M, Kennedy J, Padilla K, Amundson R, Elton D, Haldeman S, Lisi AJ, Sico J, Wayne PM, Romano PS; Longitudinal Care Patterns and Utilization Among Patients with New-Onset Neck Pain by Initial Provider Specialty; Spine; October 15, 2023; Vol. 48; No 20; pp. 1409–1418.
- Diao Y, Liu Y, Pan J, Chen J, Pan J, Liao M, Liu H, Liao L; Efficacy and Safety of Spinal Manipulative Therapy in the Management of Acute Neck Pain: A Systematic Review and Meta?analysis; Systematic Reviews; May 1, 2025; Vol. 14; No. 1; Article 97.
“Authored by Dan Murphy, D.C. Published by ChiroTrust® – This publication is not meant to offer treatment advice or protocols. Cited material is not necessarily the opinion of the author or publisher.”
