Chiropractic neck manipulation, often called neck cracking, is a common treatment used by chiropractors to relieve neck pain and increase range of motion. However, there have been concerns raised over whether this treatment could cause stroke, specifically vertebral artery dissection leading to stroke. While the risk appears to be low, there is some evidence that neck manipulation may be associated with increased stroke risk in some cases.
What is Neck Cracking by a Chiropractor?
Neck cracking refers to the techniques chiropractors use to manipulate the joints in the neck. This involves applying a controlled force to the neck joints to move them beyond their normal range of motion. This causes the release of gas bubbles from the joint fluid, which makes an audible “cracking” noise.
There are several different neck cracking techniques chiropractors may use:
– High-velocity, low-amplitude (HVLA) thrust: A quick, targeted manipulative thrust is applied to a specific joint. This causes the joint to “crack” and restore mobility.
– Diversified technique: The chiropractor twists, turns or applies pressure to the neck joints using their hands. This may involve multiple neck manipulations during one session.
– Activator technique: A handheld tool called an activator delivers a targeted impulse to the joint.
– Drop table technique: The head/neck is positioned on a special table which drops slightly to manipulate the neck joints.
– Flexion-distraction: Gentle pumping action is used to move the neck joints while they are distracted or flexed. This often does not cause an audible crack.
The goal of neck cracking is to improve mobility in the neck joints, particularly the top two vertebrae (C1 and C2). It can provide short-term relief from muscle tension, stiffness, and pain. However, it does not address the underlying cause of neck problems.
Can Neck Manipulation Cause Stroke?
There has been concern raised by some researchers that neck manipulation, particularly high-velocity manipulations, may be linked to an increased risk of cervical artery dissection (CAD) leading to stroke. CAD involves a tear in the inner lining of the artery walls, which can block blood flow and lead to stroke.
Several case studies have reported stroke occurring after chiropractic neck manipulation. A systematic review published in 2016 looked at studies on the association between chiropractic cervical manipulation and CAD. The review included 18 studies and found:
– Patients who had neck manipulation were 3-5 times more likely to experience CAD within 1 week of manipulation compared to patients who had a primary care physician visit.
– The increased risk seemed to be associated specifically with neck rotation and extension techniques.
– The baseline risk of CAD is very low in patients under 45 years old. So even with a 3-5 times increased risk, the absolute risk of developing CAD from neck manipulation remains low.
– There was no conclusive evidence of a causal link between neck manipulation and CAD. The relationship may be associated but not necessarily causative.
While an association between neck manipulation and CAD has been found, there are some limitations to the data:
– Many of the studies rely on self-reported cases or surveys, which can introduce bias.
– The reported cases of stroke tend to involve young patients under 45, which indicates an underlying predisposition or risk factor may already be present.
– The baseline risk of CAD is so low in young patients that even if manipulation increases the risk several times over, the absolute risk remains very low.
– There is likely underreporting of cases. Mild cases of CAD or stroke not requiring medical intervention may be overlooked.
Overall, current evidence suggests neck manipulation can be associated with an increased risk of CAD in rare cases, but a direct causal relationship has not been clearly established. Many experts maintain the risk is low and neck manipulation remains a safe treatment option for most patients. However, caution may be warranted for at-risk groups.
Are Some Patients at Higher Risk of Stroke?
While neck manipulation only appears to increase CAD risk by a small amount for most patients, certain risk factors may predispose some people to developing CAD after neck manipulation. Patients with the following conditions could potentially be at higher risk:
| Risk Factor | Description |
|---|---|
| Past history of stroke or CAD | Having a history of stroke or CAD indicates an underlying vessel abnormality that could predispose the arteries to further damage from neck manipulation. |
| Genetic connective tissue disorders | Disorders like Ehlers-Danlos syndrome are associated with vessel wall abnormalities that may make artery dissection more likely. |
| Atherosclerosis | Neck vessels already damaged by atherosclerotic plaques are at higher risk of dissection. |
| Hypertension | Chronic high blood pressure could promote vascular changes increasing CAD risk. |
| Migraine disorder | There is some association between migraine diagnosis and CAD. |
| Recent infection | Vessel walls may become more vulnerable and susceptible to injury following infection. |
| Taking anticoagulants | Blood-thinning medication could promote bleeding if vessel damage occurs. |
Patients with these types of medical conditions may want to consider avoiding high-velocity neck manipulation or at least discussing the risks and benefits thoroughly with the chiropractor.
What Are the Symptoms of CAD After Neck Manipulation?
It is important to recognize symptoms of CAD as early as possible to get prompt emergency medical treatment. Symptoms of CAD typically begin immediately or soon after neck manipulation. They include:
– Neck pain on one side
– Headache at the back of the head or base of the skull
– Blurred or double vision
– Dizziness and vertigo
– Poor balance and coordination
– Numbness or weakness on one side of the face or body
– Difficulty swallowing
– Slurred speech
– Ringing in the ears (tinnitus)
Any of these signs appearing immediately after neck manipulation may indicate a medical emergency. Prompt evaluation is needed to check for CAD or stroke.
Does Proper Neck Cracking Technique Reduce Stroke Risk?
There is some evidence that neck manipulation performed by adequately trained professionals using proper technique is safer. Guidelines have been established for appropriate performance of cervical manipulation:
– Obtain informed consent from the patient after explaining risks.
– Screen for risk factors like hypertension or connective tissue disorders.
– Avoid overextending the neck beyond its normal range of motion.
– Apply slow, gentle rotations rather than high-velocity thrusts in at-risk patients.
– Position the head and neck properly to avoid over-rotation.
– Manipulate the upper cervical spine very carefully and conservatively.
– Stop if the patient reports any concerning symptoms like pain or neurological changes.
Adhering to appropriate standards of practice and having an experienced chiropractor perform the neck manipulation may optimize safety. However, patients with multiple stroke risk factors may still want to consider avoiding neck manipulation altogether due to the small risk involved.
Are There Alternative Treatments to Neck Manipulation?
People looking to avoid potential risks of neck manipulation do have some options for alternative conservative treatments for neck pain relief and increased mobility. These include:
– Massage therapy to relax tight neck muscles
– Heating pads or warm compresses on the neck
– Over-the-counter pain relievers like NSAIDs
– Low-level laser therapy to reduce inflammation
– Posture correction exercises and stretches
– Gentle mobilization techniques like flexing/extending the neck joints through range of motion
– Acupuncture
– Ultrasound therapy
– Transcutaneous electrical nerve stimulation (TENS)
For some types of neck pain, options like medication, hot/cold therapy, massage, and stretches may be nearly as effective as neck manipulation. Consulting with a physical therapist or massage therapist can help identify the best conservative treatments. Surgery or injections are also options for more severe cervical disc and spine issues causing chronic neck pain.
Can You Ask a Chiropractor Not to Crack Your Neck?
It is absolutely acceptable for a patient to ask a chiropractor to avoid neck cracking techniques if they are concerned about the risks. There are many other adjustments a chiropractor can perform to treat back pain, headaches, and other issues without having to crack the neck. A good chiropractor will listen to patient concerns and be willing to adapt their treatment methods accordingly.
Some points to keep in mind when communicating with a chiropractor about neck manipulation:
– Explain your particular concerns about stroke risk. Most chiropractors have techniques they can use instead of neck manipulation.
– Ask the chiropractor to walk you through other treatment methods that could be used to address your symptoms.
– Discuss any stroke risk factors you may have.
– Ask if they would perform gentle mobilization exercises rather than high-velocity thrusts.
– Request that they stop immediately if you develop any discomfort or neurological symptoms.
– Reassure them you are seeking their care, but avoiding neck manipulation specifically would make you feel more comfortable.
Open communication allows the chiropractor to provide individualized care to meet patient preferences and needs. An experienced chiropractor will have many treatment options to address symptoms without using neck manipulation techniques if a patient requests.
Conclusion
Current research suggests chiropractic neck manipulation can be associated with a small increased risk of cervical artery dissection and stroke in rare cases. While a direct causal relationship is unproven, caution may be warranted in patients with risk factors like connective tissue disorders, migraine, infection, or previous CAD. Properly trained chiropractors adhering to appropriate guidelines appear to optimize safety when performing neck manipulation. Patients should feel empowered to discuss their concerns and request no neck cracking or high-velocity thrusts if uncomfortable with this technique. With open patient-clinician communication and shared decision making regarding risks, chiropractic treatment can be safely individualized to meet each patient’s preferences and needs.