Protecting Chiropractic from Bad Science and Bias

Written by: James Demetrious, DC, DABCO

Board Certified Chiropractic Orthopedist

Following is a critical assessment of the article titled “Status migrainosus as the only manifestation of vertebral artery dissection due to osteopathic neck manipulation” by Romozzi et al. (2025), with annotated references and counterpoints that dispute the assertion that chiropractic or osteopathic spinal manipulation is a direct cause of cervical artery dissection (CAD):

Critical Assessment and Rebuttal

1. Misuse of Temporal Association as Causation

The article relies on a single case report of vertebral artery dissection (VAD) following neck manipulation. However, temporal proximity does not establish causality. Many case reports lack sufficient biomechanical or diagnostic evidence to support manipulation as the true etiology of the dissection. Cassidy et al. (2008) conducted the largest case-control study to date and found that patients were just as likely to see a primary care physician as a chiropractor before a VAD-related stroke, suggesting that patients were already experiencing symptoms of dissection when they sought care, not that the care caused the dissection [Cassidy JD et al., Spine, 2008].

2. Reliance on Low-Level Evidence and Anecdotal Reports

Unqualified opinions drawn from narrative reviews, case reports, commentaries, and case series are forms of evidence that are subject to reporting and confirmation bias and do not establish causation. Conclusions drawn from narrative reviews should be interpreted with caution and are insufficient to define clinical norms. According to Sackett’s hierarchy of evidence represents the weakest basis for informing clinical standards .

3. Diagnostic Ambiguity and Migrainous Predisposition

The patient had a 10-year history of migraine, which is itself a known risk factor for spontaneous arterial dissection. Daghlas et al. confirmed that migraine, particularly without aura, is independently associated with increased risk of cervical artery dissection, likely due to underlying vascular connective tissue vulnerability [Daghlas I et al., Neurology Genetics, 2022].

4. Unsupported Generalizations About Chiropractic Technique

The authors describe “osteopathic” manipulation but link their conclusions to general chiropractic high-velocity, low-amplitude (HVLA) techniques without defining the actual procedure used. This conflates multiple manual therapy disciplines and misattributes risk. Whedon et al. (2015) found no increased risk of cervical artery dissection or stroke associated with chiropractic spinal manipulation in a population-based analysis [Whedon JM et al., J Manipulative Physiol Ther., 2015].

5. Lack of Biomechanical Plausibility

Biomechanical studies suggest that the strain placed on vertebral arteries during cervical manipulation is significantly below the failure threshold necessary to cause dissection. Herzog et al. (2012) used cadaveric models and demonstrated that even forceful chiropractic adjustments do not produce arterial strain sufficient to cause damage [Herzog W et al., JMPT, 2012].

6. Literature Oversight: Absence of Balanced Review

Romozzi et al. do not cite major epidemiologic studies or systematic reviews that exonerate cervical manipulation as a significant causal factor, creating an unbalanced portrayal of risk. Church et al. (2016) conducted a systematic review and concluded that the quality of evidence supporting cervical manipulation as a cause of dissection is very low, and most data are speculative [Church EW et al., Cureus, 2016].

Conclusion

The case presented by Romozzi et al. (2025) is anecdotal, lacks mechanistic validation, and overstates the risk of cervical manipulation by inferring causality based solely on timing. The patient’s history of migraine, a known risk factor, along with the lack of a control or comparator arm, limits the generalizability of this report.The continued citation of low-level evidence to support claims of chiropractic-induced stroke misguides public perception and distracts from the more critical issue of recognizing early dissection symptoms, which often masquerade as common musculoskeletal complaints.

Disclosure

The information provided in this article and all PostGradDC coursework should not be considered standards of care. We offer this information for educational purposes only. This information is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or qualified healthcare provider with any questions you may have regarding medical conditions or treatment. Seek the opinion of your legal representative.

Conflict of Interest Statement

Dr. James Demetrious is a board-certified chiropractic orthopedist and the founder and owner of PostGradDC (PostGradDC.com), a privately operated provider of chiropractic continuing education. He develops and delivers postgraduate coursework on clinical examination, diagnosis, patient safety, and risk management, including content related to cervical artery dissection and informed consent. Dr. Demetrious has published peer-reviewed research on these topics and provides consultation services to chiropractic physicians, attorneys, and professional organizations. This commentary was written independently and without external funding. While his educational and advocacy activities promote evidence-based chiropractic practice, the views expressed herein are his own and are based on interpretation of the current scientific literature.

PostGradDC offers advanced post-graduate chiropractic continuing education. Our founder, Dr. James Demetrious, is a distinguished board-certified chiropractic orthopedist, educator, author, and editor. Register for 10-hour, Cervical Artery Dissection Certification© at PostGradDC.com.

Disclosure

The information provided in this article and all PostGradDC coursework should not be considered standards of care. We offer this information for educational purposes only. This information is not intended to be a substitute for professional medical opinion, advice, diagnosis, or treatment. Always seek the advice of your physician or qualified healthcare provider with any questions you may have regarding medical conditions or treatment.