Strokes Due to Chiropractic Cervical Manipulation:
Informed Consent to Cervical Manipulation

Informed Consent to Cervical Manipulation

 Most claims against chiropractors arising out of a patient’s vertebral artery dissection (VAD) following treatment will be based on lack of informed consent about the risk involved. It may or may not be the lack of skill in executing a cervical manipulation which causes the VAD. Rather it may be the procedure as performed according to chiropractic training.

State law on informed consent varies and observations made here are necessarily quite general. As noted above, evidence for the benefit of cervical manipulation is slim for neck pain. This bears emphasis in any risk versus benefit analysis. Moreover, to the extent a chiropractor's diagnosis is subluxation-based (and it often is), integral to the issue of benefit is the issue of whether the condition diagnosed exists at all, for how can a treatment benefit a non-existent condition?

Unfortunately, in those states with a "reasonable physician" standard, what the chiropractor deems relevant to informed consent prevails. However, with growing criticism of the lack of evidence for the subluxation, and admittance of this in chiropractic texts, an argument could be made that even the "reasonable" chiropractor would have to disclose these shortcomings. In addition, there are now studies showing that spinal manipulation is not efficacious for a number of conditions widely claimed to benefit from manipulation, such as: enuresis (bedwetting). otitis media (earache). asthma and dvsmennorhea (painflul menstrual periods).

As to the issue of risk, chiropractors are now touting one study, saying it shows that a visit to a chiropractor is no greater a risk factor for VAD than a visit to a primary care physician. Cassidy D., et al., "Risk of Vertebrobasilar Stroke and Chiropractic Care: Results of a Population-Based Case-Control and Case-Crossover Study," Spine 33, no. 4S (Supplement, February 2008) S 176. Based on this, chiropractors are saying that the VAD was already in progress before the patient visited the chiropractor. An epidemiologist or other scientist trained in analysis of studies will be able to speak to the flaws of this study. There is also a cogent criticism of the study at www.sciencebasedmedicine.org. The most you will likely get out of the literature at this time is that VAD is a known but (apparently) rare complication, although all valid studies will say further research is needed to determine the incidence, itself an indication that the question is unsettled. Also regarding risk, as a comparison to other treatments, a favorite argument of chiropractors is that NSAIDS are riskier than cervical manipulation, but they are usually looking at the overall risk (e.g., how many people using NSAIDS die in a year) and fail to control for, e.g., the health of the patient, what they were taking NSAIDS for, whether they were using them properly, etc. Thus, these defenses are easily refuted.

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© 2009 Jann Johnson Bellamy, J.D., (jbellamy@alternativemedsafety.org), Campaign for Alternative Medicine Consumer Safety. Reprinted by The Abelson Law Firm with permission. Further reproduction prohibited without permission of the author.