title: Chiropractic manipulation and stroke: a population-based case-control study.
abstract: OBJECTIVE
  Several reports have linked chiropractic manipulation of the neck to dissection or occlusion of the vertebral artery. However, previous studies linking such strokes to neck manipulation consist primarily of uncontrolled case series. We designed a population-based nested case-control study to test the association.
  
  
  METHODS
  Hospitalization records were used to identify vertebrobasilar accidents (VBAs) in Ontario, Canada, during 1993-1998. Each of 582 cases was age and sex matched to 4 controls from the Ontario population with no history of stroke at the event date. Public health insurance billing records were used to document use of chiropractic services before the event date.
  
  
  RESULTS
  Results for those aged <45 years showed VBA cases to be 5 times more likely than controls to have visited a chiropractor within 1 week of the VBA (95% CI from bootstrapping, 1.32 to 43.87). Additionally, in the younger age group, cases were 5 times as likely to have had >/=3 visits with a cervical diagnosis in the month before the case's VBA date (95% CI from bootstrapping, 1.34 to 18.57). No significant associations were found for those aged >/=45 years.
  
  
  CONCLUSIONS
  While our analysis is consistent with a positive association in young adults, potential sources of bias are also discussed. The rarity of VBAs makes this association difficult to study despite high volumes of chiropractic treatment. Because of the popularity of spinal manipulation, high-quality research on both its risks and benefits is recommended.
authors.affiliation: Institute for Clinical Evaluative Sciences, University of Toronto, Toronto,Ontario, Canada.
authors.forename: D M
authors.initials: DM
authors.lastname: Rothwell
authors.forename: S J
authors.initials: SJ
authors.lastname: Bondy
authors.forename: J I
authors.initials: JI
authors.lastname: Williams
mesh_terms: D000328:Adult; D016022:Case-Control Studies; D015984:Causality; D015897:Comorbidity; D005260:Female; D006801:Humans; D016015:Logistic Models; D008297:Male; D020393:Manipulation, Spinal; D008875:Middle Aged; D009864:Ontario / Q000453:epidemiology; D020521:Stroke / Q000453:epidemiology*; D020217:Vertebral Artery Dissection / Q000453:epidemiology*; D014715:Vertebrobasilar Insufficiency / Q000453:epidemiology*