Perspectives: An Overview of Comparative Considerations
of Cerebrovascular Accidents
PETER L. ROME
╪
ABSTRACT: This paper seeks to contrast reports concerning major adverse side effects, viz. cerebrovascular
accidents (CVAs) attributed to cervical spine manipulation, within a broad perspective of medical procedures.
It also seeks to correlate the incidence rates of other adverse events and medical procedures with the general
incidence rate of CVAs. On analysis, an accurate position would indicate that cervical spinal manipulation is
one of the more conservative, least invasive and safest of procedures in the provision of human health care
services. The paper also alludes to the political connotations on the subject.
INDEX TERMS: MeSH: ARTERIES; CEREBROVASCULAR DISORDERS; CERVICAL VERTEBRAE; CHIROPRACTIC;
MANIPULATION, ORTHOPEDIC; IATROGENIC DISEASE; ORTHOPEDICS; OSTEOPATHIC MEDICINE; PERSUASIVE
COMMUNICATION; PHYSICAL THERAPY; SPINE; VERTEBROBASILAR ACCIDENTS.
╪
Peter L. Rome, D.C.
Private practice of chiropractic Mount Waverley, Victoria
Received 26 March 1999, accepted 14 May 1999.
Chiropr J Aust 1999; 29 (3): 87—102
INTRODUCTION
There can be a risk involved with virtually all medical procedures, from the taking of blood samples, 1 use of
vitamins 2 and "natural" medications, 3 to vaccinations, 4 drugs 2 and surgery. 5 At times, these risks seem to
be either disregarded or categorised as an acceptable adverse side effect — the risk/benefit ratio. For instance,
the Australian College of Ophthalmologists has issued a policy relating to laser surgery to correct myopia “...
with low and acceptable rates of complications.” 6 A further study on endarterectomies stated that, “On
average, the immediate risk of surgery was worth trading off against the long-term risk of stroke without
surgery (but only) when the stenosis was greater than about 80% diameter...” 7 Currently, there is a greater
move towards “informed consent” so that such risk factors are understood by patients.
White defines apoplexy as brain damage where there is “... an acute neurological deficit resulting in death, or
lasting more than 24 hours and classified by a physician as a stroke.” 8
In his literature search, Terrett found that historically, the first adverse accident related to bone-setting was
recorded in 1871 — almost a quarter century before chiropractic was founded in 1895. The first vascular
accident following manipulation was reported in 1934 — almost 40 years after our profession was founded. 9
It has been estimated that the incidence of apoplexy in Australia is likely to rise by 70% in the next twenty
years, due to the ageing of the population.10 The relative prevalence of such incidents is further exemplified
by the indication that “everyone had some degree of stroke risk.” 10 This statement is reflected later in this
paper, citing Myler, who calculated that the rate of fatal cerebrovascular accidents (CVAs) in the general
population is greater than that of manipulated patients.11
Concern at the serious nature of CVAs should also be tempered by the knowledge that a significant proportion
of those who experience an adverse reaction to spinal manipulative therapy (SMT) undergo complete or
partial recovery,12 similar to those who experience vertebral artery dissection (VAD) due to other causes. 13-15
This paper also compares the mortality rates of nonsteroidal anti-inflammatories (NSAIDs) and other medical
procedures with SMT. The relative incidence rates show SMT to be considerably more favourable than
NSAIDs from a safety viewpoint. 16
To castigate or reject spinal manipulative therapy as inappropriate or comparatively dangerous is not only
unwarranted, but conveniently overlooks the morbidity and mortality rates of other interventions. Such
concern would seem out of proportion to that involved with everyday articular release of an intervertebral
facet fixation — a vertebral manipulation.
Concern over, and considerations of, spinal manipulation does, however, also serve to emphasise the potential
for positive integrated influences associated with important neurological and vascular elements within the
dysfunction of dynamic vertebral segments — the vertebral subluxation complex.
METHOD
This paper was compiled from a number of sources as ongoing research over some years. These sources
included reference lists, Index Medicus, manual searches and computer searches as well as news items. The
network of citations obtained led to further searches. As this paper was being prepared for submission,
relevant papers continued to appear in the literature. It was necessary 10 “draw the line,” so these further
references had to be omitted.
Information thus gleaned was collated and reviewed in an attempt to assess a comparative risk of CVAs
attributed to SMT. A contrast of morbidity and mortality rates of other medical procedures and health
conditions has been considered as a means of illustrating the risk factor of various therapeutic procedures and
interventions.
To gain a more accurate perspective of the claimed adverse events attributed to chiropractic, a comparison has
been made of the apparent high rate of adverse events of some medical procedures with the apparent low rate
of adverse events involving spinal manipulation.
As a further perspective, the incidence rates of CVAs associated with everyday events are also noted.
Table 1
INCIDENCE RATES OF CEREBROVASCULAR ACCIDENTS
ASSOCIATED WITH SPINAL MANIPULATIVE THERAPY
YEAR
1963
1968
1972
1980
1981
1983
1985
1991
1992
1993
1993
1994
AUTHORS
Cyriax 17
Livingstone 18
Maigne 19
Jaskoviak 20
Hosek et al. 12
Gutman 12,21
Dvorak & Orelli 12,21
Patjin 16
Shekelle 22
Carey 23
Haldeman 16
Haynes 24
1995
1996
Carlini 16
Lauretti 25
1996
Lauretti 26
INCIDENCE
1: 1 0,000,000
“Few” in “possibly 75,000,000” p.a.
1 :” "Several tens of millions”
(over 15 yr) 0:5,000,000
1:1,000,000
1 :400,000
2-3:1,000,000
1 :518,000
1:100,000,000 (cauda equina/lumbar manipulations)
1:3,846,153
1-2: 1,000,000
1:100,000 (N.B.: This statistic applies to the ratio per patient, not per
visit)
1 :500,000
1 :2,000,000 (National Chiropractic Mutual Insurance
Company per cervical manipulation)
1:1,000,000
(1 neurological complication per 1 million patient
visits)
* Manipulation-related mortality rate averaged for all professions is 1 in 2 years, 34 over 61 years, worldwide.
21
** Spinal Mobilization: In 1993, the physiotherapist Michaeli reported a “...similarity in the nature and
prevalence of complications following cervical mobilisation and manipulation...” In some instances the
reported incidence rate of adverse effects was higher for mobilisation than manipulation. 27
LIMITATIONS OF THIS REVIEW
A review such as this is limited in the consideration of such factors as the patient's age and underlying health
status, frequency of the procedure involved, necessity for a particular procedure, and available options to a
particular procedure against the benefit/outcome.
Consideration has been given to the following:

Some of the references are not recent, however it has been noticed that morbidity and mortality rates in
many medical procedures have altered little in 20-30 years.

While it is difficult to draw direct comparisons on a topic such as this, the inference from published
medical papers is that SMT has a high incidence rate — presumably compared to medical care and
procedures. In researching this topic it appeared that there were more papers published on the side
effects of medical procedures than on the prevention of such side effects.

While it may be argued that medicine is involved with more serious conditions, this paper is an attempt
to portray certain perspectives only. It is relevant to compare one procedure with another to be able to
rate its risk in perspective — to know where it stands in the overall picture.

Consideration was also given to various forms of CVA and the sites of CVA lesions. Rather than
differentiate these, it was decided to conduct a general overview at this stage.
It could be argued that in relation to SMT, incidence figures relate only to published reports, however the
same can also be said for the incidence rates involving all professions, as not all adverse side effects are
necessarily recorded in the literature.
REVIEW
The incidence rate of serious neurological compromise associated with manipulation is remarkably low in
itself. Estimates range from as low as 1:10 million 17 (see Table 1). The incidence rate gains an even lower
perspective when comparisons are made with other medical procedures, and when considered in light of
incidents associated with some everyday circumstances (see other tables). In relation to SMT, it is rare that a
serious side effect occurs. 16,28,29 A significant proportion of these appear to be of minor severity and
transient in nature. 28,30
Michaeli also states that “The vast majority of these 'accidents' (CVAs) are of a transient nature and therefore
may not have been worthy of mention in the literature.” 31
Assendelft et al. found that of the 165 patients with associated side effects of spinal manipulation, 44 (26.7%)
made a complete recovery following the initial onset and that “serious complications (are) generally
considered to be low.” This study included both cervical and lumbar complications. Some 49% of the lumbar
complications occurred during manipulation under anaesthesia (MUA). MUA is not a customary chiropractic
procedure. 28
On the positive side, clinical observations of the beneficial influence of spinal manipulation on neurological
function have already been noted. Carrick reported that certain procedures, including manipulative
techniques, can provide remarkably promising responses in assisting some patients in degrees of recovery
from central nervous system (CNS) lesions, including some forms of stroke, coma, and movement disorders
such as Parkinson's disease and Friedrich's ataxia. 32
Perspectives on CVAs
SMT Patients vs. General Population
Rather than being contraindicated in CNS conditions, Carrick's work would suggest that the association of
cervical spine adjustments upon the brain and spinal cord would, in fact appear to be a non-invasive, nondrug, potent health procedure by which to positively influence neural physiology. 33
Myler calculated that, given the statistical facts, it is less likely for a chiropractic patient to experience a fatal
vertebral artery injury than it is for a person within the general population to experience a fatal stroke. He
compared the rate of CVAs in the general population with that of chiropractic patients in the U.S. 11 “Stroke is
the third leading cause of death in the United States.” 34
Although there are no recorded deaths from chiropractic SMT in Australia, Myler has calculated the rate of
fatal vertebral artery injury after cervical manipulation in the U.S. at 0.00025% (1 :400,000), while the rate
of deaths from CVA in the general population was 0.00057% (1 : 176,900) — more than double the rate of
manipulated patients. 11 While there may well be other factors, such as age, type of apoplexy and healthier
patients attending chiropractors, his findings are still an indication of the extremely low rate of CVA incidents
in chiropractic practices.
Myler's stated rate of 1:400,000 fatal SMT-related CVAs would seem conservative. In Australia, if 3,000
chiropractors administered just 100 cervical spinal adjustments each week for 50 weeks, the procedure would
have been carried out 15,000,000 times a year, making a total of 75,000,000 cervical manipulative
procedures in five years, with no recorded deaths due to chiropractic manipulation. These figures are more in
line with Carey's Canadian study in 1993, which found no fatalities in 50 million chiropractic manipulations.
23 (see also Table 1).
SMT Patients vs. Patients Prescribed NSAIDs
In their paper comparing CVA risk between SMT and nonsteroidal anti-inflammatory drugs (NSAlDs), Dabbs
and Lauretti found that NSAlDs have a risk factor four hundred times greater than spinal manipulative
therapy. They found that the rate of death from gastrointestinal bleeding caused by NSAIDS (including
bleeding from abdominal ulcers) was 0.04% — 160 times greater than neck manipulation at 0.00025% (i.e.,
1:2,500 vs. 1:400,000). By comparison, the risk of a non-fatal arterial injury from manipulation was
calculated as 0.001 % (1:100,000), and from NSAIDS, 0.4% (1 :250) — also a difference of 400 times. 16
In Australia in 1992, it was stated that there were some 200 deaths alone from the use of NSAIDs. 35 Six years
later, a more recent estimate stated, “there would be hundreds of deaths a year from side-effects of the drugs
(NSAlDs ).” 36
General Incidence of Apoplexy and TIAs
Each year some 37,000 Australians suffer a stroke — that is more than 100 every day (1:514 = 0.195%). Of
these patients, 12,000 die (1:1,583 = .063%), while another 12,000 are permanently disabled. 37 Another study
revealed a mortality rate of 70 per 100,000 population (1:1,429 or 13,300 p.a.). 38 Some 20% of stroke
patients (7,400) have diabetes, which can be a predisposing factor. 36
Each day, some 25 Australians experience a transient ischaemic attack (TIA). 39 Based on a population of 19
million, this is a daily rate of one in 760,000 people (.00013%), and an annual rate of 9,125 patients or
1:2,082 (0.05%) (see Table 2).
Hart stated that in the U.S., "between 0.5 and 2.5 cases per year (of vertebral artery dissection [VAD]) are
reported from large referral-based hospitals." 40 In pointing out that dissection may occur at any point in the
course of the vertebral artery, he notes three categories: spontaneous, traumatic and "minor, non-penetrating
trauma/neck torsion positioned somewhere in between." This infers that any SMT-related VAD could only be
a portion of the 0.5-2.5 cases reported by these hospitals annually. Hart also noted that the course of the
condition of most patients stabilises within one to two weeks.
Insidious and Spontaneous Apoplexy
In cases of CVA, pre-existing risk factors such as inherent arterial weakness, are not always identifiable,
hence the designation, "spontaneous CVA." 9,13,40-46 The cost and risk of conclusive screening for such
conditions would seem prohibitive if not impracticable, and conducting such investigations may involve
further risk. The insidious nature of these unrecognisable conditions poses a significant underlying risk if they
are present, however incidents seem to be extremely rare 16,18,29 (see Table 1).
Table 2
INCIDENCE OF CEREBROVASCULAR ACCIDENTS
MORBIDITY
RATIO
General population
MORTALITY
%
11*
General population 36*
1:514
0.195
General population 37*
NSAIDs
1:250
16
0.4
TIAs (daily) 38
TIAs (annually) 38
Chiropractic/SMT
11,16
Chiropractic/SMT 23
RATIO
%
1:176,900
0.00057
1:1,583
0.063
1:1 ,426
0.07
1:2,500
0.04
1:760,000
0.00013
1 :2,082
0.05
1:100,000
0.001
1:400,000
.00025
1:3,840,153
0.000035
Nil:50,000,000
———
Estimated in this paper
Nil:75,000,000
* The 1000+ fold discrepancy in these figures cannot be explained.
The more insidious predisposing factors in CVAs include such conditions as asymptomatic congenital arterial
weakness, 47 obscure weakness due to previous trauma, 41,42,47 unforeseen congenital arterial anomalies,
14,48-51 and anomalous cervical muscle structure. 51-54
Due to the prevalence of previous trauma in daily life, especially motor vehicle accidents, one could expect
resultant arterial weaknesses to be a common predisposing aetiological factor in spontaneous apoplexy or in
incidents of apparent iatrogenesis.
At other times, identifiable conditions include recognisable signs, symptoms, anatomical anomalies,
pathological and pathophysiological states. 49,55,56 These are important considerations in a therapeutic field
of neurorgic influence.
The more obvious indications of risk factors can include smoking, oral contraceptives, migraines,
hypertension, arteriosclerosis, diabetes mellitus, fibromuscular dysplasia, 11,12,37 as well as colitis, 57-59 to
name a few. Terrett and Sturzenegger both state that sudden and severe onset of headache and neck pain can
be more immediate key symptomatic indicators. 55,60
Commenting on an unusual fatality where a player was struck by a cricket ball, an Australian coroner was
reported in a 1987 newspaper article as stating that, "... it was possible that a congenital weak spot in an artery
at the base of the brain had ruptured when (the patient) jerked his head. Dr Drake said everyone had such
weak spots, but they might never rupture." 47 Such an observation would suggest that some VBAs may be
coincidental.
It is further reported that other seemingly innocent activities have produced similar CVAs in rather innocuous
circumstances (Table 3). These particularly include neck extension during various normal everyday
procedures. 72,95 An interesting example of this has been reported by Goldrey as a form of "Sightseers CVA".
75 This seems somewhat similar to the anecdotal "Golden Gate Bridge Sightseers Stroke." Such examples
highlight Fogelhom and Carli's point that at times, frequent rotation and extension of the head is suspected of
aggravating a weakened vertebral artery in vulnerable patients, with the onset of CVA being virtually
impossible to predict. 61
Professions Associated with SMT
In 1992, Shekelle estimated that in the U.S., 94% of spinal manipulation was carried out by chiropractors, 4%
by osteopaths and 2% by medical practitioners. 22 Recently De Fabio claimed that physiotherapists also
conduct 2% of SMT in the U.S. 101
Calculations based on Terrett's 1995 study covering 58 years, however, showed that only 64.1 % of
78 manipulation-related "catastrophes "were attributed to chiropractors, while 8.97% were
attributed to medical practitioners, who conduct only 2% of the manipulative procedures, and
10.26% to osteopaths, who conduct only 4% of manipulative procedures in the U.S. The balance
of some 17% comprised a miscellaneous grouping. Terrett questions the reliability and accuracy of ascribing
and impugning chiropractors by incorrectly attributed involvement in "all" adverse effects through the
medical literature. 54
Winterstein also noted that the proportion of chiropractor-related incidents is far less than 94% of spinal
manipulation carried out by this one profession. 102
Further extrapolation of these available figures would suggest that while conducting only 1/47
of manipulative procedures, medicine has 20.89 times, and osteopathy (2/47) has 3.92 times
greater mortality rates in spinal manipulation than chiropractic.
In his 1998 study, Terrett found that in over 61 years, the practitioners reported as being associated with
major manipulative side effects in 219 examined cases were actually practitioners from quite diverse
backgrounds, education and training, not just from a chiropractic background, as mostly reported. The list
also includes physiotherapists, osteopaths, naturopaths, a barber, masseurs, and medical practitioners (see
Table 4). These major side effects comprised a total of 34 deaths worldwide over the 61 years (1: 1.8 yr). In
addition, of the 185 other, more serious side effects, 44 (23.8%) either subsided or almost completely resolved
with minor neurological deficits. 54
As a comparison to the 34 deaths associated with manipulation over 61 years worldwide, Burgess reported in
1998 that there were nine reported deaths in thirteen months due to pertussis in Australia in 1997. 4 The
pertussis deaths did not receive anything like the publicity the manipulative incidents seem to. At the
monthly rate (1.44 per million), there would be 1,054.08 pertussis deaths over the same 61 year time span-a
rate 3,100% higher.
By comparison, there have been three SMT-associated fatalities ever recorded in Australia —
all involving medical practitioners. 112
Cyriax, the doyen of medical spinal manipulation, stated that in relation to major side effects associated with
manipulation of the cervical spine, "the risk works out at about one in ten million manipulations, and provides
no argument against an attempt at manipulative reduction in suitable cases." He then goes on to discuss "The
danger of not manipulating." 17
Livingstone, in commenting on the "25,000 manipulators" in the U.S. in 1968, stated that there were
surprisingly "few reported injuries to show for possibly 75,000,000 yearly manipulations." (This appears to
be based on 3,000 per practitioner per year — 60 per week.) Livingstone does not specify whether his
calculations are based on a unilateral (single), or bilateral ( double) manipulation per visit. 18
In 1993, a Canadian study by Carey estimated that of 50,000,000 neck manipulations over a
five-year period, there were 13 serious YBA incidents and no deaths. 23 This is a VBA rate of
1:3,846,153. A U.S. insurance company has estimated the serious YBA rate at 1:2,000,000. 25
Table 3
REPORTED ACTIVITIES INVOLVING THE CERVICAL SPINE SUSPECTED OF
BEING INVOLVED WITH DISRUPTION OF CEREBRAL CIRCULATION*
Age not a factor 9
A bleeding nose 12,61
Angiography 43,62
Post-operative complications of thyroidectomy 82
Postural head changes 83,84
Radiographic procedure (VA angiography) 43
Archery (bow hunter) 12
Athletics 63
Axial traction 64
Backing up a car 44,62
Beauty parlour 65
Birth trauma 66 (see also 'childbirth')
Break dancing (see also rap dancing) 67-69
Calisthenics 70
Childbirth 'doubtful relationship' 55
Contraceptive pill 13,43
Coughing 71
Dental procedure 44
Diving into shallow water 72 (see 'falls')
During surgery 12
During x-ray examination 61
Emergency resuscitation 12
Falls (minor) 43
Falls causing hyperextension 43
Fitness exercise 71
Football 72-74
'Golden Gate Bridge' syndrome (sightseeing) 75
Gymnastics 70
Hair dressing 76
Hanging out washing 77
Head banging 43
Motor vehicle accidents 44
Neck callisthenics (Tai chi) 78
Ophthalmological perimetric visual examination 79
Overhead work 80
Painting ceiling 80,81
Rap dancing 67-69,85,86
Reversing a vehicle (see 'backing up')
Roller coaster 87,88
Self manipulation 'clicked on turning' 89
Self manipulation (rapid) 90,91
Sitting in a barber's chair 77
Sit-up exercises 24
Sliding head-first down a water slide 24
Sleeping positions 50
Spontaneous rupture of aneurisms 43
Spontaneous turning of head 40,44
Spontaneous vertebral artery dissection 9,40-46
Star gazing 16
Stooping to pick up a bucket 24
Surgery, neck positioning during anaesthesia 79
Swimming 92
Tai chi 78
Telephone call (cordless) 89
Traction of cervical spine 48,63,77
Traction and short wave diathermy 89
Trampoline 40
Trauma 94
Turning one's head 83
Turning one's head while driving 44,95
Under anaesthesia 12
Voluntary movement 96
Watching aircraft 77
Whiplash 72,96
Yawning & vigorous stretching (spinal artery) 97
Yoga ('Bridge' or 'Back push-up') 70,98
Yoga (rotating head) 98
* Adapted from Terrett 9,12,54,55
[Of tangential interest, Berger and Sheremata 99 observed persistent neurological deficits in suspected
multiple sclerosis patients; the signs were precipitated by a hot bath, They found that other aggravating
factors indicating this predisposition to acute exacerbation of signs included a lovers' quarrel and golf. The
reliability of the 'Hot Bath Test' was challenged by Davis. 100]
Table 4
REPORTED MANIPULATIVE SIDE EFFECTS ASSOCIATED WITH A
VARIETY OF OTHER PRACTITIONERS FROM DIVERSE BACKGROUNDS*
Physiotherapists 24,30,31,81,103,104
Osteopaths 77,105-107
Masseurs 54
Naturopaths 54
Medical practitioners 24,54
Kinesiotherapist 108
A barber 54
A kung-fu practitioner 54
A patient's own wife 109
Self manipulation 90,110
Unqualified practitioners designated to be 'chiropractors' without formal chiropractic education

11
Adapted from Terrett 54,55
Adverse Effects from Medical Procedures
There are morbidity and mortality incidents with most prescription and non-prescription drugs, as well as
with major and minor surgical procedures. Generally, these adverse events are far higher than manipulative
procedures. The mortality and morbidity rates of certain medical procedures can be viewed to gain a
perspective on the risks involved 113-116 (see Tables 5-7).
It would be grossly irresponsible and misleading if patients were led to believe that adverse effects from
medical procedures did not exist, or were disproportionately low. It is surprising how patients seem to accept
the incidence of risks and complications from medical procedures as "normal," yet still be alarmed at the
limited possibility and significantly lower adverse incident rates ("negligible" 24) involving manipulative
procedures in chiropractic or other professions using manipulation. Unwarranted sensationalism of cases
involving chiropractors threatens to create an impression out of proportion to the actual facts. One wonders
what would happen if all medical procedures were subject to the same levels of safety, efficacy, journalistic
scrutiny and particularly inaccurate publicity.
Issues concerning the efficacy of medical care have already been raised in such respected journals as the
Lancet, British Medical Journal, the Journal of the American Medical Association and the Medical Journal
of Australia. Such controversial issues do not appear to have received general media exposure or public
discussion to any great degree. 125,172-177
What should be of serious concern, however, is the statement in one of the world's most respected journals in
1991, the British Medical Journal:
"... only about 15% of medical interventions are supported by solid scientific evidence..." and "only 1 %
of the articles in medical journals are scientifically sound and partly because many treatments have
never been assessed at all. 174
Six years earlier, in 1985, medicine was already aware of the problem when Leeder wrote in the Medical
Journal of Australia:
"Much medical practice has escaped critical appraisal...many treatment schedules, new and old, simple and
complex, have been adopted and endorsed without firm evidence that they achieve more good than harm...
(or) have never been satisfactorily evaluated... Some procedures … became entrenched in professional
mythology long ago (and) have remained unchallenged despite their appalling cost in terms of human
suffering." 175
In 1998, Moore and colleagues noted two drugs which were shown to have serious and potentially lethal
cardiac side effects. They had been on the market for twelve and fourteen years, respectively. They stated:
"Discovering new dangers of drugs after marketing is common. Over 51 % of approved drugs have serious
adverse effects not detected prior to approval. Merely discovering adverse effects is not by itself sufficient to
protect the public." 176
The International Classification of Diseases code 178 lists the following iatrogenic classifications which
include numerous headings under "misadventure" and "complications":
E850-858 - Accidental poisoning and medication errors.
E870-879 - Misadventures during surgical and medical care.
E930-949 - Drugs causing adverse effects in therapeutic use.
E977.9
- Medicine poisoning by overdose- wrong substance given or taken in error.
E995.2 - Adverse effect, correct substance properly administered.
Adverse drug reactions rank as the fifth ("between fourth and sixth") leading cause of death in
the U.S. — 106,000 deaths in 1994. 125
In relation to medical complications, a 1982 study by Steel et al. found"... a 36% incidence of iatrogenic
illnesses among 815 consecutively selected patients in a tertiary care university hospital." In 2% (16.3 of those
admitted), " … these complications were believed to have contributed to death." 114 By 1998, Lazarou and
colleagues found that there was virtually no change in the incidence rate of adverse drug reactions in the 32
years of their study. 125
A two-year study by Rankin et al. (1990-1992) found that in Australia, "Between 170 and 850 (1-5%) strokes
occur (annually as) a major iatrogenic complication of cardiopulmonary by-pass surgery." 179 Other major
surgical procedures also carry the risk of stroke (see Table 8).
In 1993, Nachemson stated that in relation to spinal surgery, "... the clinical studies have largely lacked
validity: controlled, prospective tr1als are disappointingly rare." 182
These issues alone should_overshadow and create more concern than political medicine's preoccupation with
otherprofessions which it may see as competitors.
While medicine seems interested in highlighting incidents involving spinal manipulation, it can be questioned
as to whether patients are fully cognisant of the high rates of medical incidents. This is not intended as a
criticism, but more to place the rate of incidents in context. One cannot ignore the assumption of "acceptable
statistics" in the absence of public awareness.
Table 5
MORTALITY RATES OF VARIOUS MEDICAL
PROCEDURES AND DAILY EVENTS*
SURGERY
Appendectomies
1:74 5
Cervical spine surgery
1:145 5
Cholecystectomy
1:51-200 5,116
Colon surgery
Coronary bypass surgery (up to 21 % of patients who
experienced an adverse event resulted in a fatal
outcome)
1:14-50 5
Herniated disc surgery
1:481 117
Iatrogenic cardiac arrests
1:1.7 118
Iatrogenic esophageal perforations
1:3.5 119
Lumbar discectomy
.9:1000 120
Lumbar fusion
1:50-1400 111
Lumbar laminectomies
1:204 5
Lumbar surgery
1:683 121
1:263 34
Lumbar 'procedures'
1:1,430 122
Percutaneous transluminal angioplasty
Intracranial 16.7% mortality
1:6 123
Sciatic surgery
1:684 121
Small intestine surgery
1:4.76 5
DRUGS
Drug reactions
1:230 124
1:14.9 125
1:28 124
1:312.5 125
1:67 126
1:2.86 127
1:1103 28
Hospital deaths
Drug related problems (DRPs)
1:29 129
(1/3 'not preventable')
Adverse drug reaction (17.2%)
1:5.8 129
Taking a drug for which there was no valid
medical indication
1:5.8 129
Non-compliance (50%)
1:2 129
Medication error (out-patients) 1993
1:131 130
(in-patients) 1993
1:854 130
Anti-inflammatories
1 :63,333*
HOSPITAL ADMISSIONS
Iatrogenic paediatric admissions to intensive care
1:27 131
Iatrogenic adult intensive care admissions
1:41 132
Hospital iatrogenesis - 50,000-100,000 deaths due to
pulmonary embolism in hospitalised patients
annually in the US 133
1:50 114
RADIOLOGY
Nuclear bone scan
1:3,000 134
MEDICAL PROCEDURES
Venipuncture
1:25,000 1
Spinal manipulation
see Table 1
DISEASES/CONDITIONS
Ischaemic heart disease
162:100,000 1:617
Cerebrovascular disease
Cerebrovascular disease ('age adjusted') 135
70:100,000 1:1,429 38
38
(of population, not mortality rate of cases) 1988
Males
USA
1:1,739
Australia
1:1.226
Females
Greece
1:751
USA
1:1,984
Australia
1:1,355
Greece
1:725
1954
1:689
1993
1 :1,471
1954
1:593
1993
1:1,653
1996 37
1:1,429
Japan
1:1,873
Australia
1:366
Scotland
1:254
Japan
1:3,247
Australia
1:707
Scotland
1:511
Cerebrovascular disease (Australia) 135
Males
Females
Coronary heart disease ('age adjusted') 1983 135
Males
Females
CHRONIC DISEASES 1993 (Australia) 136
(per population, not morality rate of cases)
Coronary heart disease
1:624
136
Ischaemic heart disease 1996
1:617
135
Chronic obstructive airways disease 1996
1 :525(est) 135
Stroke
1:1,536
All cancers
1:555
136
136
1:704 135
Cancer - upper respiratory
1996
1:2,833 136
1:526 136
1996
Melanoma
1:21,277 136
Prostate cancer
1:2,841 136
1:7,143 (est.) 135 1996
1:3,718 136
Breast cancer
1:7,143 135 1996
1:4,098 136
Colorectal cancer
1:4,348 135 1996
1996
1:17 137
Incidence rate females 1996
1:27 137
Incidence rate males
Asthma
1 :23,256 136
Diabetes
1:7,143 136
HIV
1:1,770 136
RELATIVE RISKS DAILY CIRCUMSTANCES/
SPORT/INDUSTRY
Motor vehicle accidents
1:9,091 111 1996
Lightning strike
1 :200,000 138 (Hit by)
1 :600,000 111
1 :2,000,00o 139
Deaths
Homicide
1 :52,632 136
Acting in theatre
National workplace fatalities (Australia) 141
Injury
1:2.2 140
(597 deaths per year per no. of employees)
Forestry and logging
1:1,075
Fishing and hunting
1:1,163
Mining
1:2,778
Transport & storage
1:4,348
Agriculture
1:5,000
Construction
1:10,000
Rugby Union (participants)
1:5,000 139
Spinal cord injuries
1:6,250 142
Rugby Union
1:18,868 143
Rugby League
1 :55,556 143
Neurological deficits
1:16,667
Fatalities
1:15,000 139
Boxing fatalities (per contest)
142
1:10,000 144
* Estimation is based on 200 deaths each year in Australian population aione-all citizens including those not
taking NSAIDs = 200:19,000,000. 35 A more recent estimate Is based on '10%' of the 4,500 NSAID-related
upper gastrointestinal hospital admissions annually-between 200 and 400 deaths per annum. 145 Blower
estimates that NSAIDs could be responsible for 3,000 deaths in Great Britain. 146
Table 6
MORBIDITY RATES
ANAESTHESIA
General anaesthesia
1:1,103
174
Anaphylactoid anaesthetic reactions (restricted to life-threatening or
operation-disrupting)
1:1,000to 1:10,000
SURGERY
Atherosclerotic procedure-related complications
Idiopathic scoliosis surgery (adult)
1 :6 123
1 :2.44 minor 149
1 :4.4 serious
1:1.64 (51%) 150
Cardiac surgery
Chemonucleolysis 121
Cauda equina
New root deficits
Paraplegia
Allergic reaction to anaesthesia
Discectomy
Cauda equina
Sciatic surgery
'Wrong level'
Total complications
Lumbar disc re-operation
Successful (28%)
Repeat surgery for failed lumbar disc surgery
Percentage successful result of repeat:
Discotomy
Decompression
Stabilisation
Decompression & stabilisation
Repair of pseudoarthrosis & decompression
1:2,911
1:257
1:21,831
1:49
1 :27 120
1 :200 120
1:45
1:4
1:3.6
1:5.6
121
151
152
75.0%
27.8%
33.0%
50.0%
14.3%
DRUGS
Drug reactions
Daily use of aspirin 6% more likely to experience a stroke
111
1.67
147
25% of all reported drug reactions in the UK are associated with
NSAIDs, yet they comprise 5% of prescriptions. 153
MEDICAL
Venipuncture
Epidural (Depo-Medrol)
1 :25,000 1
1:40 - 1 :200 148
HOSPITAL
Hospital iatrogenesis
18%-30% of all hospitalised patients have a drug
reaction...resulting in doubling of hospital duration. 115
Iatrogenic paediatric admissions to intensive care
Drug complications
Surgical complication
Iatrogenic adult admissions to intensive care
Drug complications
Therapeutic error
Drug reactions
(30% of these have a second drug reaction)
1:2.78
114
1.22 131
1.22 1.68
1.23 1:77
1 :7.9 132
1:14
1:23
1:20-1:33
DISEASES/CONDITIONS — INCIDENCE 156
Measles
Pneumonia
Encephalitis
Measles-encephalitis-mortality
Brain damage
Breast cancer by age 70
After 5 or more years on HRT
VACCINATION
1.25
1:2,000
1 :20,000
1:5,000
1 :14 157
1:10 157
115
148
Diphtheria/Tetanus/Whole cell pertussis
Anaphylactic reaction
Severe reaction
Measles---€ncephalitis (expected recovery)
SPINAL MANIPULATION
VBA (non-fatal) - 'as low as'
SMT-related cauda equina syndrome
1 :50,000 4
1:2,000 4
1:1,000,000
4
1: 1,000,000 64
1:100,000,000 22
It is noted that while some of these intetentions do not necessarily compare directly with manipulative
therapies, they reflect the risk factors which exist with all procedures.
Table 7
MORTALITY AND MORBIDITY RATES OF OTHER MEDICAL PROCEDURES*
MORTALITY
Cervical manipulation
@ 1 :400,000 major
@ 1 :40,000 minor
Estimate only
General population (VBA-related deaths)
General surgery (30-day mortality #)
Orthopaedic surgery#
All surgery#
After adjustment for risk factors #
Total hip replacement
Peripheral vascular surgery
Otolaryngology surgery
Iatrogenic hospital admissions
Vaccination at wrong body location
Medication error (out-patients 1:131)
Misinterpretation of medical jargon in laboratory reports
Epidural anaesthesia
Hospital medication: Over-prescribed/ or never used
NSAIDs
MORBIDITY
0.00025% 11
0.0025% 49
0.000000096%**
0.00057% 11
5.6% 113
1.8% 113
1.2% - 5.4% 113
0.49% -1.53% 113
1.1 % 158
4.6% 113
2.9% 113
1.84%
36.0% 114
33% 159
.76% 130
80% 160
1.6% 161
16-20% 162
0.04% 16
Liposuction (US) — 100 deaths in the past 12 months 163
Adverse effects associated with traction, 164 ultrasound, 167 acupuncture, 168 intrathecal steroid injections, 169
and vaccination 4, 170-172 have all been reported.
--------------------------------------------------------------------------------------------------------------------------------* Adapted from Khuri et al.
** Based on an approximate calculation as follows:
1 00,000 man_worldwide—all professions
X 100 average cervical manipulations per week (e.g. 2 procedures/patient visit, 50 patient visits/wk)
= 10,000,000 cervical manipulations/wk
= 520,000,000 per year
@ .5 deaths per year (see Table 1)
= mortality rate of 1:1,040,000,000 = 0.000000096%
Table 8
INCIDENCE OF STROKE ASSOCIATED WITH MEDICAL PROCEDURES
Australian population Deaths from stroke
Non-stroke comparisons 180
Cancer
Suicide 15-24 yr/age
Heart disease
Motor vehicle accidents
Cardiopulmonary by-pass surgery
Open-heart surgery
Coronary by-pass surgery
Percutaneous transluminal angioplasty 123
Intracranial
Stroke
TIA
Mortality
Extracranial (supraorbital)
Stroke
TIA
Restenosis
1:1,639
180
1:565
1 :4,000
1:690
1 :3,125
1-5:100 179
0.3% - 5.2%
6.1% 34
181
33.3%
22.2%
16.7%
1%
2%
5.9%
DISCUSSION
It is always a most unfortunate event for any patient to suffer any side effect from any procedure or accident,
regardless of which profession is concerned. One cannot help but feel empathy, regret and sadness for any
involved patient and their family. However, the degree of inherent risk associated with all health interventions
is distinct from professional negligence, which is unacceptable.
Due to the lack of "bias" 28, 183 or partiality of discussions raised on the issue of CVAs as a result of
manipulation, it may be reasonable to assume that by now most patients would be aware of the possible risks
associated with manipulative procedures.
The chiropractic profession is at the forefront in recognising the possible complications associated with SMT;
similar awareness should apply to all procedures. The established manipulative professions would seem to be
qualified to recognise and minimise the risk to potentially vulnerable patients exhibiting signs and/or
symptoms. Various studies on the topic have been published; these have been collated recently by Terrett,
who has published extensively on the subject. 55
The chiropractic profession actively seeks to keep practitioners aware of all aspects of risks. As well as
informative seminars and journal papers, chiropractors' basic training prepares them for preventive
iatrogenic considerations. This includes careful case history taking, learning pre-manipulative testing and
appropriate manipulative skills in the serious area of possible iatrogenic complications.
The chiropractic profession was recognised in a 1979 New Zealand government study as being the profession
best qualified to carry out spinal manipulative procedures. This independent study also found that "Spinal
manual therapy in the hands of a registered chiropractor is safe." 184
It is quite irresponsible for medicine to condemn spinal manipulation when the potential for incidents is, by
its own standards, extremely rare. Even diagnostic investigations have a risk/benefit ratio. 39,114,134 The
double standard is evident when in fact generally, drugs and surgical procedures have risks of side effects with
a significantly higher fatality rate than spinal manipulation. It has been stated that "... all medications, even
so-called natural, can cause adverse reactions." 185
Because of medicine's self-serving publicity about SMT, discerning patients may see through what appears to
be the charade of biased scaremongering. Nevertheless, the demand for qualified manipulative care continues
to expand. A significant proportion of the population — almost 50% 186 of patients — actively seek an
appropriate alternative approach to their health problems. One must assume this option is exercised either as
a preference, a search for results, or choosing not to accede to chemical or surgical intervention.
In 1998, Wilks expressed surprise at the limited exposure of a 1987 American federal court finding that the
American Medical Association "... was dishonest, untrustworthy (and) not objectively reasonable" when it
acted to neutralise the competition and influence of chiropractic on the health care scene. 187 The referenced
literature and media similarly appear to have been noticeably reticent on this particular issue of a single
profession's (medicine's) domination of the entire health field. Strangely the media, and society in general, do
not appear to want to seriously question medical philosophy, paradigm, monopolisation, efficacy, costs or
procedures. 188
Medicine has adopted terms suggesting procedures have an "acceptable risk." These include "risk-adjusted
mortality rates," "net clinical benefit" and "risk/benefit ratio," yet there seems a reluctance to concede the
application of these terms to procedures outside the medical profession. 172 It seems that at times "such rates
have been condoned" — at least in relation to dural puncture, 189 or in immunisation programs where "the
benefits of preventing the disease far outweigh the risks of vaccination." 172
Lack of Government Standards or Guidelines
Regardless of the low rate of incidents in the manipulative sciences, the material reviewed warrants advocacy
of further caution and awareness, with continued endeavours towards risk elimination. It is fundamental for
the manipulative professions to maintain the maximum available level of recognised safety, training and
education before employing their conservative manipulative procedures. 190
As mentioned, although some SMT-related accidents may be unforeseen, 28,61,191 for the vast majority there
are procedures for both recognising and determining patients at risk. Essential education has been
established for this purpose.
Despite the importance of public interest in standards of care, the Australian state legislatures have created a
distinct anomaly through standardisation and mutual recognition of registration acts for health professions.
For instance, the Victorian government's Chiropractors Registration Act and the Osteopathic Registration Act
have, through an implication by considered omission, sought no standards or requirements placed upon
unregistered practitioners who attempt spinal manipulation. 192 That is, any person in Victoria may carry out
neck manipulation so long as he does not present himself as a chiropractor, osteopath, physiotherapist or
medical practitioner.
Australian state governments do not require minimal training standards for the manipulative procedures
utilised by non-registered practitioners — only for registered manipulative professionals who specialise in the
field. This also allows medical practitioners to attempt to manipulate the spine, even if they have no training
whatsoever in the procedures. This would seem incongruous when "protection of the public" and "standards"
were two of the primary criteria for establishing registration for the manipulative professions in the first place,
as would seem to be the case with all health professions. 193-195
Such a fundamental safeguard would seem even more important in health care where primary contact care
practitioners are responsible for the diagnosis as well as the safe and effective management of patients'
welfare and health problems. As has been indicated earlier, practitioners not formally trained or qualified in
SMT have been associated with incidents of CVAs 54,111 (see Table 4).
The kind of legislative policy that currently exists would tend to support the questionable assertion that
practitioners need not be qualified to render SMT, that there is relatively little concern for any danger from
any SMT side-effects, or indeed, that there is any perceived danger at all.
SUMMARY
While there are some stated limitations to this type of review, a number of matters were discussed in
attempting identify related issues:

The rate of adverse effects, namely cerebrovascular accidents related to spinal manipulative therapy, was
shown to be extraordinarily low in the overall health care scene.

The rate of SMT-related CVAs associated with the chiropractic profession is lower than for osteopathy and
medicine. Figures could not be determined for physiotherapy.

In general terms, the rate of SMT-related CVA is also lower than the rate of strokes in the general
population.

Morbidity and mortality rate of S MT is far lower than that suffered by patients taking NSAIDs.

There are both identifiable and unidentifiable anomalies, weaknesses, diseased states and conditions
which can influence the incidence of apoplexy in society.

There is a significant percentage of spontaneous apoplexy in the general population, and therefore, at
times, such a high "natural" frequency could be confused as an SMT-related incident.

The rate of preventable drug- and surgery-related iatrogenic illness in medicine is generally far higher
than for SMT, demonstrating SMT to be a safe and conservative form of intervention by comparison.

The rate of vertebrobasilar accidents associated with manipulation has been grossly exaggerated,
inaccurate and sensationalised by some ill-informed sources.

SMT in the hands of a practitioner properly qualified in this specialty is shown to be a particularly safe
procedure.

There appear to be medico-political overtones to the subject of SMT-related iatrogenesis.
CONCLUSIONS
This paper has attempted to identify perspectives of iatrogenesis and contrast levels of morbidity and
mortality with a number of elements which may adversely affect health. In drawing such comparisons, it is
worthwhile to understand where SMT is situated in relation to complications related to other forms of
intervention.
It is incumbent upon practitioners of all professions to be aware of the risks involved in every type of
procedure. Patients are also entitled to accurate information about the procedures that may be utilised in the
course of their care. Not only do practitioners have a role in providing this information, but the scientific
literature, as well as the printed and electronic popular media who report any adverse incidents must be
responsible and accurate in this duty.
This review of the evidence has indicated that a potential risk of catastrophic side-effects from SMT is
substantially less than for any of the medical procedures or interventions listed in the tables accompanying
this paper.
It is submitted that as reflected in the demand for therapy, spinal manipulation has contributed significantly
to the health and well-being of much of the world's population. Unsubstantiated published opinions and socalled scientific distortions of the facts are irresponsible. There are no "double-blind controlled scientific
studies" which reject a reasonable degree of efficacy of spinal manipulation for appropriate mechanical back
and neck conditions — indeed, quite the opposite. 196-199
In conducting this study it has been shown that the distorted impression of risk associated with cervical spinal
manipulation should be cast in the proper and minimal perspective which is its due. It would be hoped that
any reservations which dissuade qualified practitioners from utilising cervical spinal manipulation in
appropriate situations, or dissuades patients from accepting and subsequently benefiting from such
techniques, would be mitigated, and the rationale for the therapy better understood.
If medicine is to assume a scientific role, it must also record accurately, fairly and without prejudice on such
scientific matters concerning health and welfare. In this author's opinion, it is demonstrably wrong and
scurrilous to portray SMT as a highly dangerous procedure — both in its own right, and in light of the facts
concerning other procedures. It is both a judicious and propitious procedure which is safe by comparison and
may perhaps explain medicine's increasing interest in adopting SMT as one of its own regimes.
As inferred by Assendelft et al., 28 it is up to the properly informed patient and practitioner to compare the
risk/benefit ratio in choosing to seek relief through a particular type of intervention. To this end, conservative
procedures like spinal manipulation would appear to have a distinct advantage due to there inherently low
risk.
Without wishing to diminish the importance and serious nature of cardiovascular incidents related to SMT,
and with due recognition for continued caution for its potential, the miniscule risk which may be associated
with SMT is extraordinarily low and should be encouraged and endorsed as a safe front-line health procedure.
It has been suggested here that there is a relatively high incidence of CVA in the general population, that there
can be a number of predisposing conditions related to CVAs, that spontaneous CVAs are relatively common,
and that there can be a number of common activities associated with CVAs.
The professions who utilise spinal manipulation must strive for continued minimisation of possible SMTrelated side effects — indeed, their elimination — but the facts and statistics presented here suggest that given
the nature of its considered neural influence, and with all the information in perspective, spinal manipulation
in the hands of an appropriately qualified professional is both conservative and one of the safest therapeutic
procedures.
ACKNOWLEDGEMENT
The author gratefully appreciates the assistance provided by Dr Damon Willmore for his input and assistance
in the preparation of this paper.
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