Skip to main content

Advertisement

Log in

Risk of Vertebrobasilar Stroke and Chiropractic Care

Results of a Population-Based Case-Control and Case-Crossover Study

European Spine Journal Aims and scope Submit manuscript

Study Design

Population-based, case-control and case-crossover study.

Objective

To investigate associations between chiropractic visits and vertebrobasilar artery (VBA) stroke and to contrast this with primary care physician (PCP) visits and VBA stroke.

Summary of Background Data

Chiropractic care is popular for neck pain and headache, but may increase the risk for VBA dissection and stroke. Neck pain and headache are common symptoms of VBA dissection, which commonly precedes VBA stroke.

Methods

Cases included eligible incident VBA strokes admitted to Ontario hospitals from April 1, 1993 to March 31, 2002. Four controls were age and gender matched to each case. Case and control exposures to chiropractors and PCPs were determined from health billing records in the year before the stroke date. In the case-crossover analysis, cases acted as their own controls.

Results

There were 818 VBA strokes hospitalized in a population of more than 100 million person-years. In those aged <45 years, cases were about three times more likely to see a chiropractor or a PCP before their stroke than controls. Results were similar in the case control and case crossover analyses. There was no increased association between chiropractic visits and VBA stroke in those older than 45 years. Positive associations were found between PCP visits and VBA stroke in all age groups. Practitioner visits billed for headache and neck complaints were highly associated with subsequent VBA stroke.

Conclusion

VBA stroke is a very rare event in the population. The increased risks of VBA stroke associated with chiropractic and PCP visits is likely due to patients with headache and neck pain from VBA dissection seeking care before their stroke. We found no evidence of excess risk of VBA stroke associated chiropractic care compared to primary care.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

References

  1. Borghouts JA, Koes BW, Vondeling H, et al. (1999) Cost-of-illness of neck pain in The Netherlands in 1996. Pain 80:629–36

    Article  PubMed  CAS  Google Scholar 

  2. Côté P, Cassidy JD, Carroll L. (1998) The Saskatchewan Health and Back Pain Survey. The prevalence of neck pain and related disability in Saskatchewan adults. Spine 23:1689–98

    Article  PubMed  Google Scholar 

  3. Côté P, Cassidy JD, Carroll L. (2000) The factors associated with neck pain and its related disability in the Saskatchewan population. Spine 25:1109–17

    Article  PubMed  Google Scholar 

  4. Côté P, Cassidy JD, Carroll L. (2000) Is a lifetime history of neck injury in a traffic collision associated with prevalent neck pain, headache and depressive symptomatology?. Accid Anal Prev 32:151–9

    Article  PubMed  Google Scholar 

  5. Côté P, Cassidy JD, Carroll LJ, et al. (2004) The annual incidence and course of neck pain in the general population: a population-based cohort study. Pain 112:267–73

    Article  PubMed  Google Scholar 

  6. Côté P, Cassidy JD, Carroll L. (2001) The treatment of neck and low back pain: who seeks care? who goes where?. Med Care 39:956–67

    Article  PubMed  Google Scholar 

  7. Hurwitz EL, Coulter ID, Adams AH, et al. (1998) Use of chiropractic services from 1985 through 1991 in the United States and Canada. Am J Public Health 88:771–6

    PubMed  CAS  Google Scholar 

  8. Hurwitz EL, Chiang LM. (2006) A comparative analysis of chiropractic and general practitioner patients in North America: findings from the joint Canada/United States Survey of Health, 2002– 03. BMC Health Serv Res 6:49

    Article  PubMed  Google Scholar 

  9. Aker PD, Gross AR, Goldsmith CH, et al. (1996) Conservative management of mechanical neck pain: systematic overview and meta-analysis. BMJ 313:1291–6

    PubMed  CAS  Google Scholar 

  10. Gross AR, Kay T, Hondras M, et al. (2002) Manual therapy for mechanical neck disorders: a systematic review. Man Ther 7:131–49

    Article  PubMed  CAS  Google Scholar 

  11. Hurwitz EL, Aker PD, Adams AH, et al. (1996) Manipulation and mobilization of the cervical spine. A systematic review of the literature. Spine 21:1746–59

    Article  PubMed  CAS  Google Scholar 

  12. McClune T, Burton AK, Waddell G. (2002) Whiplash associated disorders: a review of the literature to guide patient information and advice. Emerg Med J 19:499–506

    Article  PubMed  CAS  Google Scholar 

  13. Peeters GG, Verhagen AP, de Bie RA, et al. (2001) The efficacy of conservative treatment in patients with whiplash injury: a systematic review of clinical trials. Spine 26:E64–E73

    Article  PubMed  CAS  Google Scholar 

  14. Norris JW, Beletsky V, Nadareishvili ZG. (2000) Sudden neck movement and cervical artery dissection. The Canadian Stroke Consortium. CMAJ 163:38–40

    CAS  Google Scholar 

  15. Ernst E. (2002) Manipulation of the cervical spine: a systematic review of case reports of serious adverse events, 1995–2001. Med J Aust 176:376–80

    PubMed  Google Scholar 

  16. Haldeman S, Kohlbeck FJ, McGregor M. (1999) Risk factors and precipitating neck movements causing vertebrobasilar artery dissection after cervical trauma and spinal manipulation. Spine 24:785–94

    Article  PubMed  CAS  Google Scholar 

  17. Rubinstein SM, Peerdeman SM, van Tulder MW, et al. (2005) A systematic review of the risk factors for cervical artery dissection. Stroke 36:1575–80

    Article  PubMed  Google Scholar 

  18. Inamasu J, Guiot BH. (2005) Iatrogenic vertebral artery injury. Acta Neurol Scand 112:349–57

    Article  PubMed  CAS  Google Scholar 

  19. Schievink WI. (2001) Spontaneous dissection of the carotid and vertebral arteries. N Engl J Med 344:898–906

    Article  PubMed  CAS  Google Scholar 

  20. D’Anglejan-Chatillon J, Ribeiro V, Mas JL, et al. (1989) Migraine—a risk factor for dissection of cervical arteries. Headache 29:560–1

    Article  PubMed  CAS  Google Scholar 

  21. Pezzini A, Caso V, Zanferrari C, et al. (2006) Arterial hypertension as risk factor for spontaneous cervical artery dissection. A case-control study. J Neurol Neurosurg Psychiatry 77:95–7

    Article  PubMed  CAS  Google Scholar 

  22. Savitz SI, Caplan LR. (2005) Vertebrobasilar disease. N Engl J Med 352:2618–26

    Article  PubMed  CAS  Google Scholar 

  23. Lee VH, Brown RD Jr, Mandrekar JN, et al. (2006) Incidence and outcome of cervical artery dissection: a population-based study. Neurology 67:1809–12

    Article  PubMed  Google Scholar 

  24. Rothwell DM, Bondy SJ, Williams JI. (2001) Chiropractic manipulation and stroke: a population-based case-control study. Stroke 32:1054–60

    PubMed  CAS  Google Scholar 

  25. Smith WS, Johnston SC, Skalabrin EJ, et al. (2003) Spinal manipulative therapy is an independent risk factor for vertebral artery dissection. Neurology 60:1424–8

    PubMed  CAS  Google Scholar 

  26. Arnold M, Bousser MG, Fahrni G, et al. (2006) Vertebral artery dissection: presenting findings and predictors of outcome. Stroke 37:2499–503

    Article  PubMed  Google Scholar 

  27. Maclure M. (1991) The case-crossover design: a method for studying transient effects on the risk of acute events. Am J Epidemiol 133:144–53

    PubMed  CAS  Google Scholar 

  28. Kelman CW, Kortt MA, Becker NG, et al. (2003) Deep vein thrombosis and air travel: record linkage study. BMJ 327:1072

    Article  PubMed  CAS  Google Scholar 

  29. Mittleman MA, Maclure M, Tofler GH, et al. (1993) Triggering of acute myocardial infarction by heavy physical exertion. Protection against triggering by regular exertion. Determinants of Myocardial Infarction Onset Study Investigators. N Engl J Med 329:1677–83

    CAS  Google Scholar 

  30. Redelmeier DA, Tibshirani RJ. (1997) Association between cellular-telephone calls and motor vehicle collisions. N Engl J Med 336:453–8

    Article  PubMed  CAS  Google Scholar 

  31. Janes H, Sheppard L, Lumley T. (2005) Overlap bias in the case-crossover design, with application to air pollution exposures. Stat Med 24:285–300

    Article  PubMed  Google Scholar 

  32. Janes H, Sheppard L, Lumley T. (2005) Case-crossover analyses of air pollution exposure data: referent selection strategies and their implications for bias. Epidemiology 16:717–26

    Article  PubMed  Google Scholar 

  33. Efron B, Tibshirani RJ. (1993) An Introduction to the Bootstrap. New York, Chapman and Hall/CRC

    Google Scholar 

  34. STATA/SE [computer program]. College Station, Tex: Stata Corp, 2006.

  35. Liu L, Reeder B, Shuaib A, et al. (1999) Validity of stroke diagnosis on hospital discharge records in Saskatchewan, Canada: implications for stroke surveillance. Cerebrovasc Dis 9:224–30

    Article  PubMed  CAS  Google Scholar 

  36. Boyle E, Côté P, Grier AR, et al. Examining vertebrobasilar artery stroke in two Canadian provinces. Spine, in press.

  37. Côté P, Kreitz BG, Cassidy JD, et al. The validity of the extension-rotation test as a clinical screening procedure before neck manipulation: a secondary analysis. J Manip Physiol Therap 1996;159–64.

  38. van der Velde G, Hogg-Johnson S, Bayoumi A, et al. (2008) Identifying the best treatment among common non-surgical neck pain treatments: a decision analysis. Spine 33(Suppl):S184–S191

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to J. David Cassidy DC, PhD, DrMedSc.

Additional information

Supported by Ontario Ministry of Health and Long-term Care. P.C. is supported by the Canadian Institute of Health Research through a New Investigator Award. S.H.-J. is supported by the Institute for Work & Health and the Workplace Safety and Insurance Board of Ontario.

The opinions, results, and conclusions are those of the authors and no endorsement by the Ministry is intended or should be inferred.

The manuscript submitted does not contain information about medical device(s)/drug(s).

University Health Network Research Ethics Board Approval number 05-0533-AE.

Reprinted with permission from Lippincott Williams & Wilkins, 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, Volume 33, Number 4S, pp S176–S183

Rights and permissions

Reprints and permissions

About this article

Cite this article

Cassidy, J.D., Boyle, E., Côté, P. et al. Risk of Vertebrobasilar Stroke and Chiropractic Care. Eur Spine J 17 (Suppl 1), 176–183 (2008). https://doi.org/10.1007/s00586-008-0634-9

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00586-008-0634-9

Keywords

Navigation