BALLWIN, Mo. — A woman from Ballwin, Missouri, is speaking up about a controversial issue: the safety of forceful chiropractic neck adjustments. According to the American Chiropractic Association, risks are extremely low. But many argue there are potentially deadly consequences that could be prevented.
Ashley Nelson’s 40th birthday celebration was a dream come true -- a visit to New York City to see Hamilton on Broadway. But her fun and carefree trip soon took a terrifying turn.
“I napped on the plane, kind of in a funky position, and I had a stiff neck after that," she said.
She returned home to Ballwin in pain and sought relief from a chiropractor.
“He got me right in. And, you know, he started doing the manipulations … And as soon as I opened my eyes, my vision was completely crossed," Nelson said.
She left in an ambulance.
“Then my face started becoming numb as well," she said.
At the hospital, she discovered what went wrong.
“My right vertebral artery had been torn. And with that tear, a little piece broke off and went to my brainstem. And that's what was causing the stroke," Nelson said.
Medical experts we consulted for this report explained the innermost lining of Nelson’s vertebral artery, the intimal layer, was torn. When that happened, it was most likely that a blood clot formed at the site of the tear and then traveled to her brain, causing a stroke.
“It was really scary," Nelson said.
Nelson is now one of multiple people around the country suing chiropractors over strokes, all after rapid force was applied to their necks. Their complaints focus on the industry’s alleged failure to communicate the risks and prevent them.
Causation or correlation?
Research estimates strokes from the tearing of a neck artery happen to about 1 in 100,000 people, according to the American Chiropractic Association. The industry group argues chiropractors do not cause strokes, and they would have happened anyway. Many chiropractors tell the I-Team that vertebral artery dissections, a rare cause of stroke in the general population, can cause neck pain, and people with neck pain see chiropractors, so the artery damage was likely already there before the visit. But many legal and medical experts disagree, saying it’s no coincidence that vertebral artery dissections are identified after neck manipulation.
Chiropractors tell us while there is good evidence that manipulations can relieve pain and improve mobility, there are potential dangers for certain people with specific pre-existing conditions that increase the risk of damage to blood vessels leading to the brain.
St. Louis-based attorney Josh Tolin, who has represented people who have been victims of strokes after chiropractic neck manipulations, said the majority of chiropractors benefit people in accidents or with back pain.
“A common theme that I have seen in my two cases and speaking with other trial attorneys throughout the country who have had similar cases, have a common thread … little or no exam done," Tolin said.
How often does this happen?
It's hard to know how often strokes following chiropractic visits actually happen. Scott Haldeman, a neurologist on faculty at the University of California, Irvine, and president of the nonprofit the World Spine Care, said there were around two stroke cases a year in Canada and about 20 cases a year in the United States about a decade ago.
Attorney Ryan Krupp, who is representing Ashley Nelson, said he has talked to several experts who have testified about these cases, noting there have been dozens of these types of cases over the years.
Steven Arkin, a neurologist at Miami Valley Hospital in Dayton, Ohio, said he is aware of dozens of people who have suffered strokes following chiropractic manipulations.
Some attorneys and physicians argue that in very rare cases, the result of chiropractic neck manipulation can be fatal. Playboy model Katie May died in 2016 after a stroke. Her autopsy report revealed it happened after a visit to a chiropractor.
Attorney Ronald Richards represented May. He said she had an injury that was not diagnosed from a photoshoot, which was exacerbated by the chiropractic treatment. Her lawsuit alleged she was not diagnosed correctly. Instead of referring May to further treatment, the chiropractor was alleged to have misdiagnosed the issue. Richards said neck manipulation is relatively safe. But he said there are a lot of misdiagnoses. If there is a bleed or injury during a chiropractic visit, the issue could get worse. May’s lawsuit was settled.
Emily Wall, a 34-year-old homemaker and mother based in Wellsville, Utah, died two days after a chiropractic neck manipulation in May 2021. Utah-based attorney Walter Mason, who is suing the chiropractor on behalf of the family, said that Wall showed signs of a stroke immediately after the chiropractic treatment. He said she was taken to the hospital, but died as a result of brain swelling caused by the stroke. That lawsuit is ongoing.
The American Chiropractic Association’s spokesperson Dr. William Lauretti told us: “Neck manipulation is a safe and effective non-drug treatment for common forms of neck pain and headache performed by not only chiropractors but also osteopaths and physical therapists. The chance of experiencing a serious adverse event following neck manipulation is extremely low. The chiropractic profession relies on the largest and most credible research studies on this topic to date, which have not found a causal relationship between neck manipulation and arterial dissection leading to stroke. About 35 million people in the U.S. visit a chiropractor each year; millions of neck manipulations are performed safely, providing pain relief and helping patients get back to their normal activities. Patients visiting a chiropractor with upper neck pain or headache should be very specific about their symptoms and include details about any previous injuries. This will help the doctor to offer the safest and most effective treatment. Besides neck manipulation, many chiropractors offer a variety of gentle treatments for neck problems, such as soft tissue muscle massage, low-force mobilization techniques or other non-force manual options.” He said right now, there is no clear and reliable way to detect an imminent stroke for many people with neck pain and a headache.
Lauretti said, “Any time a patient suffers a complication from a chiropractic treatment it is an unfortunate tragedy for all involved.” He noted that the research shows the risk of strokes associated with chiropractic neck manipulation is extremely low. Research published in 2016 from a group of neurosurgeons and a neurologist affiliated with Penn State University concluded that, "There is no convincing evidence to support a causal link between chiropractic manipulation and cervical artery dissection (CAD), an umbrella term that includes vertebral artery dissection. Other research published in 2022 concluded, "Among Medicare beneficiaries aged 65 and older who received cervical spinal manipulation, the risk of cervical artery dissection is no greater than that among control groups." Additional research published in 2023 followed 960,140 chiropractic treatment sessions for 54,846 patients and found no cases of strokes.
Dr. Ephraim W. Church, a cerebrovascular neurosurgeon and assistant professor of neurosurgery, radiology and neurology at Penn State University, told us in an email: “As a cerebrovascular neurosurgeon who routinely cares for patients with cervical artery dissection, I have seen a handful of patients presenting with stroke following chiropractic manipulation over the years. In each case, the neck pain preceded the visit to the chiropractor. Since neck pain is the principal initial symptom of dissection, we suspect the dissection occurred prior to the visit with the chiropractor. Unfortunately, some physicians and legal professionals misinterpret this association as causal, when in fact the evidence for a causal relationship between manipulation and dissection is poor at this time.”
Alleged industry flaws
“Mistakes are being made," chiropractic expert Steven Brown said.
Brown is a chiropractor in Arizona who is blowing the whistle on what he calls a serious flaw in the industry.
His views on stroke following neck manipulation were published in a medical journal last month. He said there is no convincing evidence that properly performed neck manipulation can damage a healthy neck artery. However, if a patient comes to a chiropractor with neck pain and/or headache from an undiagnosed tear in the inner lining of a neck artery, referred to as a cervical artery dissection (CAD), there could potentially be deadly problems. We asked if neck manipulation results in worsening CAD. Brown said people who already have CAD, may undergo neck manipulation from chiropractors without a thorough history-taking and examination. "The contraindicated neck manipulation may aggravate an existing dissection and dislodge a blood clot, which can travel to the brain and cause a stroke that could have been avoided," he said. Brown said this often happens in high-volume chiropractic offices.
“What do you think needs to change to make this industry safer?” Senior Investigative Reporter Paula Vasan said.
“I think all these strokes are completely avoidable if chiropractors did a proper history and examination prior to adjusting the patient," Brown said.
Robert Cooperstein, who most recently worked at the Palmer Center for Chiropractic Research, said these strokes are “mostly” avoidable, not completely avoidable.
Brown believes some chiropractors are manipulating the most vulnerable part of the spine indiscriminately, without enough screening or any medical imaging.
“You need to slow down, take a better look at it and order the imaging if it is indicated," said Brown.
Lack of guidance
The I-Team discovered there’s no clear guidance from the country’s leading medical groups.
We reached out to the American Medical Association, the American Academy of Neurology, the American Heart Association, and the American Stroke Association. We also reached out to the Missouri Board of Chiropractic Examiners and the National Board of Chiropractic Examiners.
When asked about the organization's position on chiropractic neck manipulation and the risks involved, the American Medical Association deferred to the American Academy of Neurology. The American Academy of Neurology told us it does “not have a position statement on this topic.” The association’s president Dr. Carlayne E. Jackson provided this response to our request for comment:
“The American Academy of Neurology is committed to ensuring high-quality patient care from a team led by a neurologist with the appropriate education and training to accurately diagnose and treat patients. Neurologists complete four years of medical school followed by one year of internal medicine internship, three years of neurology residency, and often several years of subspecialty fellowship training. It is crucial that a medically qualified physician work with patients to diagnose and manage any neurologic condition that could cause irreversible damage if treated improperly.”
The American Heart Association (AHA) and American Stroke Association, a division of the American Heart Association, told us: “The American Heart Association does not currently have an official position on chiropractic manipulation therapy in relation to stroke. More research review is needed before the Association is able to develop official guidance. Individuals should always speak with their health care professional regarding any health concerns or prior to a change in their health regime. People considering chiropractic manipulation should discuss any potential reasons for avoiding cervical maneuver ahead of any treatment.”
A spokesperson with the Missouri Department of Commerce and Insurance, representing the Missouri Board of Chiropractic Examiners, told us: “Outside of filing any specific patient complaint, the Board takes no ‘position’ on this and is restricted by the authority granted it by its enabling statutes. Under that authority, the Board is unable to express general opinions about specific treatments or risks associated with the practice of Chiropractic.”
The National Board of Chiropractic Examiners said it had no information on strokes resulting from chiropractic neck manipulation and deferred to local boards.
We reached out to the St. Louis area’s biggest hospital systems: BJC Healthcare, SSM Health, Mercy, and St. Luke’s Hospital. We asked them about medical risks associated with chiropractic neck manipulation and any position on the topic. None agreed to an interview.
“It doesn't seem like there's a lot of awareness," said Nelson.
Spreading awareness
Since her stroke, Nelson said her life took a dark turn. She was once a nearly straight-A student, on track to become a nurse practitioner. She withdrew from school.
“I couldn't handle the workload anymore. I wasn't able to focus or retain new information," she said.
As she continues her recovery with the support of her husband, she hopes her story is a warning.
“Your body's really fragile, and, you know, a high-velocity manipulation, there's so much that can go wrong with that," she said.
The American Chiropractic Association told the I-Team neck adjustments are safe and effective in decreasing pain and increasing mobility. But neurologists tell us they advise strictly avoiding forceful chiropractic neck manipulation because the result could be devastating.
The I-Team decided not to identify the name of the chiropractic group Ashley Nelson visited. Based on dozens of interviews with attorneys, researchers, chiropractors, and other medical experts, the I-Team discovered that complaints about people with undiagnosed tears in their neck arteries not being properly screened at chiropractic visits are not specific to any one chiropractor or group. The I-Team did reach out to the chiropractic group that performed Nelson’s neck manipulation. It did not agree to an on-camera interview, saying it could not comment on private health information.
In a statement, the office told us: “… The health of our patients and the integrity of the service we provide are always our highest priorities. As a healthcare provider, we cannot comment on any private or protected health information nor confirm whether one individual is or was a patient …”
Stroke signs
SSM Health said recognizing stroke symptoms is key to getting the right care quickly. The phrase "BE FAST" is an easy way to remember what to look for.
Balance: Is the person suddenly having trouble with balance or coordination?
Eyes: Is the person suddenly experiencing blurred or double vision or a sudden loss of vision in one or both eyes without pain?
Face: Ask the person to smile. Is there a droop on one side (an uneven smile)?
Arm: Ask the person to raise both arms with their eyes closed. Does one arm drift down because of weakness? Is there arm numbness?
Speech: Ask the person to repeat a simple sentence. Can he/she repeat it? Is speech slurred or difficult to understand?
Time: Call 911 and get to a hospital/stroke center immediately. The faster treatment is administered, the better the outcome.
In addition, sudden stroke symptoms may include:
Numbness or weakness of the face, arm or leg, especially on one side of the body.
Difficulty speaking and understanding conversation.
Confusion or difficulty speaking or understanding.
Trouble seeing in one or both eyes.
Trouble walking, dizziness, loss of balance or coordination.
Severe headache without a known cause.
All of the above warning signs may not occur with each stroke. Do not ignore any of the warning signs, even if they go away--take action immediately.
If you want to get in touch with Paula Vasan, leave a voice message at 314-444-5231 or email her directly at pvasan@ksdk.com.