title: Risk of vertebrobasilar stroke and chiropractic care: results of a population-based case-control and case-crossover study.
abstract: METHODS
  Population-based, case-control and case-crossover study.
  
  
  OBJECTIVE
  To investigate associations between chiropractic visits and vertebrobasilar artery (VBA) stroke and to contrast this with primary care physician (PCP) visits and VBA stroke.
  
  
  BACKGROUND
  Chiropractic care is popular for neck pain and headache, but may increase the risk for VBA dissection and stroke. Neck pain and headache are common symptoms of VBA dissection, which commonly precedes VBA stroke.
  
  
  METHODS
  Cases included eligible incident VBA strokes admitted to Ontario hospitals from April 1, 1993 to March 31, 2002. Four controls were age and gender matched to each case. Case and control exposures to chiropractors and PCPs were determined from health billing records in the year before the stroke date. In the case-crossover analysis, cases acted as their own controls.
  
  
  RESULTS
  There were 818 VBA strokes hospitalized in a population of more than 100 million person-years. In those aged <45 years, cases were about three times more likely to see a chiropractor or a PCP before their stroke than controls. Results were similar in the case control and case crossover analyses. There was no increased association between chiropractic visits and VBA stroke in those older than 45 years. Positive associations were found between PCP visits and VBA stroke in all age groups. Practitioner visits billed for headache and neck complaints were highly associated with subsequent VBA stroke.
  
  
  CONCLUSIONS
  VBA stroke is a very rare event in the population. The increased risks of VBA stroke associated with chiropractic and PCP visits is likely due to patients with headache and neck pain from VBA dissection seeking care before their stroke. We found no evidence of excess risk of VBA stroke associated chiropractic care compared to primary care.
authors.affiliation: Centre of Research Expertise for Improved Disability Outcomes, University Health Network Rehabilitation Solutions, Toronto Western Hospital, Toronto, ON, Canada. dcassidy@uhnresearch.ca
authors.forename: J David
authors.initials: JD
authors.lastname: Cassidy
authors.forename: Eleanor
authors.initials: E
authors.lastname: Boyle
authors.forename: Pierre
authors.initials: P
authors.lastname: Côté
authors.forename: Yaohua
authors.initials: Y
authors.lastname: He
authors.forename: Sheilah
authors.initials: S
authors.lastname: Hogg-Johnson
authors.forename: Frank L
authors.initials: FL
authors.lastname: Silver
authors.forename: Susan J
authors.initials: SJ
authors.lastname: Bondy
mesh_terms: D000328:Adult; D000368:Aged; D016022:Case-Control Studies; D015984:Causality; D002684:Chiropractic / Q000706:statistics & numerical data; D015331:Cohort Studies; D015897:Comorbidity; D018592:Cross-Over Studies; D005260:Female; D006261:Headache / Q000453:epidemiology / Q000628:therapy; D006801:Humans; D007049:Iatrogenic Disease / Q000453:epidemiology*; D008297:Male; D026882:Manipulation, Chiropractic / Q000009:adverse effects* / Q000706:statistics & numerical data*; D008875:Middle Aged; D019547:Neck Pain / Q000453:epidemiology / Q000628:therapy; D010821:Physicians, Family / Q000706:statistics & numerical data; D012307:Risk Factors; D020521:Stroke / Q000453:epidemiology* / Q000503:physiopathology; D014715:Vertebrobasilar Insufficiency / Q000453:epidemiology* / Q000503:physiopathology