Robert A. Leach, DC, MS, CHES
National University of Health Sciences,
Starkville, MS, USA.
OBJECTIVE: The purpose of this article was to present a retrospective case series of patients with symptoms and signs suggesting a stroke or prodrome and discuss the potential for health education and promotion initiatives in chiropractic that might affect this serious disease.
METHODS: A database and hand search of records from a rural Mississippi chiropractic practice was performed to identify all cases of patients presenting with symptoms and signs of stroke during the past 4 years, as well as stroke mortality among active patients during the same period.
RESULTS: Six subjects met inclusion criteria of about 500 active patients during any given year of the 4-year study period, including patients who had stroke symptoms or signs (n = 4) or who died as a result of stroke without presenting to the office (n = 2). Records and magnetic resonance angiograms were obtained after referral was made for a 77-year-old white female, 71-year-old white male, 59-year-old white male, and 24-year-old Hispanic female. Three of the 4 surviving patients were eventually diagnosed with stroke, and one with seizure disorder. Common presenting complaints were unilateral arm weakness and slurred speech; other complaints included episodic loss of vision, dysphagia, dysphonia, and same-sided leg weakness.
CONCLUSIONS: Patients with symptoms and signs of stroke may infrequently present to chiropractic physicians for evaluation and treatment. Prevention, screening, early identification of stroke symptoms and signs, and referral for prompt treatment are cornerstones of the national stroke policy as espoused by the Centers for Disease Control. Chiropractic physicians have opportunities for practice-related health education initiatives focusing on the role of health and wellness in stroke prevention and for prompt lifesaving referral of emergency presentations.
From the Full-Text Article:
Patients with symptoms and signs of stroke may infrequently present to chiropractic physicians for evaluation and treatment, regardless of the interval since the last prior chiropractic treatment (Table 2). In this series, 2 of 3 active patients ultimately diagnosed with having stroke had slurred speech or unilateral arm weakness as their initial prodrome. Other stroke symptoms or signs in this series of cases included episodic loss of vision, dysphagia, dysphonia, and ipsilateral leg weakness. Further exploration of mortality among active patients (ie, about 500 in any given year) attending the same rural Mississippi chiropractic clinic revealed that in 2 of the 4 years studied an additional patient had died of stroke (Table 3). Both of the deceased patients received chiropractic adjustments for low back pain, and only one had received any neck manipulation and that treatment was a year before the death.
Four patients in this series of cases either contemplated or sought chiropractic care despite the presence of symptoms and signs suggesting a stroke prodrome or event. Case no. 1 and 4 presented to the office within 1 to 3 hours of the onset of symptoms and signs and no. 3 contemplated a visit to our office but was redirected to the emergency department by her daughter, again within 1 to 3 hours of the onset of symptoms and signs. Case no. 2 sought care here after a return of symptoms and signs, several hours after an earlier 1- to 3-hour period of symptoms and signs. Both case no. 3 and 4 were seen promptly by the same emergency department and have had remarkable recoveries with seemingly no neurologic sequelae. These cases illustrate the need for chiropractic physicians, their staff, and patients and caregivers to make rapid assessments and obtain optimal treatment at the emergency department. The consequences of delay or inaction on the part of chiropractic physicians or other first health care responders can be devastating because 2 million brain cells may die each minute a stroke is left untreated, and stroke is the leading cause of adult disability when it is not fatal. 
Other than case no. 2 that was ultimately diagnosed with seizure disorder, the other cases in this series were non–dissecting-type strokes. Notably, one of the primary risk factors for the most common ischemic type stroke is advancing age. In contrast, risk factors for VAD include an age less than 45 years, perhaps a history of trivial trauma, and typically symptoms include neck pain and suboccipital headache. This makes the differential diagnosis problematic for this patient population because chiropractic physicians typically treat patients presenting with these same symptoms and signs that are musculoskeletal in origin. [24, 25] Issues remain to be investigated. For example, can chiropractic manipulation aggravate or worsen VAD or nondissecting stroke in progress? Are there patients presenting to chiropractic physicians with VAD or nondissecting stroke in progress that are missed, but the condition is not aggravated by chiropractic? The lack of definitive answers to these and other questions and the gravity of the stroke problem in our present society underscore the need for further research to enhance patient care and safety.
Preliminary epidemiologic research to estimate the prevalence of background (ie, noncausative) strokes in a population have been attempted elsewhere. Recently, Cashley and coworkers  determined that the estimated number of background strokes in a projected population of 554 975 patients receiving neck adjustments over the course of a year was 1645 and within 1 and 3 days of manipulation was 36 and 108, respectively. Given these findings, they concluded that it would not be surprising that some patients presenting to neurologists with stroke had a recent history of chiropractic cervical manipulation. Similarly, according to CDC data drawn from the county where the present case series drew most of its patients, the prevalence of 139 cases of stroke mortality per 100 000 persons per year was well above the national rate of 121 cases per year and closer to the Mississippi rate of 140 cases per year, for the most recent years data are available (1991-1998).  Hence, a chiropractor treating 500 different patients in Mississippi should expect 0.7 background cases of stroke mortality per year or 2.8 in 4 years. Given this relatively high prevalence in the population of Mississippi, of which this case series is illustrative (ie, 2:2027, or about 100:100 000)—the present study offers further support to the call by Cashley and coworkers26 for prospective research to determine whether there are risks associated with chiropractic and for an “… education programme for the recognition of early signs of stroke in chiropractic clinics.”
Healthy People 2010 has the following stated goal with regard to cardiovascular disease: “Improve cardiovascular health and quality of life through the prevention, detection, and treatment of risk factors; early identification and treatment of heart attacks and strokes; and prevention of recurrent cardiovascular events.”  Individual objectives include reducing stroke deaths, reducing disparities associated with stroke morbidity and mortality, and reducing risk factors (tobacco, obesity, poor nutrition, decreased physical activity, diabetes, elevated cholesterol, and high blood pressure). The 2010 target for stroke mortality in the United States was 50 per 100 000, and this target was met midway through the decade for whites, Hispanics, and American Indians but not for African Americans. Reducing the percentage of Americans with high blood pressure to 14% was a key goal that instead worsened by 2004 for all ethnic groups and sexes. 
Many chiropractors have established themselves as “portal of entry” providers in US states and territories. In addition, wellness-oriented efforts and health promotion activities have been advocated in the profession and have a positive impact on chiropractic patients. [30-33] The extent to which chiropractic physicians and their staff use prevention and wellness strategies that might affect the prevalence of stroke among their patients, such as counseling regarding regular fitness and nutrition, is unknown, although survey research indicates that as many as 80% of practitioners may be involved in such activity. [34, 35] Furthermore, the rate at which chiropractic physicians and their staff—as well as medical physicians and other first responders—are able to correctly screen for risk factors such as high blood pressure and identify stroke symptoms and signs is unknown. Problems associated with stroke care and dosing of t-PA have been identified in other professions such as nursing.  If the profession chooses to embrace the CDC goals, a necessary first step might include chiropractic health education evaluation research to determine the current interest; competencies; and delivery of stroke prevention, screening, detection, and referral procedures by chiropractic physicians and their staff. 
Several prehospital stroke recognition instruments were introduced in the mid-1990s, including the Los Angeles Paramedic Stroke Scale, the Cincinnati Prehospital Stroke Scale, and in the United Kingdom the Face Arm Speech Test (FAST), a modification of the Cincinnati scale.  The FAST seems particularly well suited as a tool for chiropractic physicians, their staff, and for patient education; indeed, this tool is already being used by health educators and nurses to train persons for rapid stroke recognition (Table 4).  Moreover, at least one study found good agreement between paramedic and physician-recorded neurologic signs using the FAST test in 278 suspected stroke patients, of whom 217 had confirmed stroke (n = 189) or TIA (n = 28).  If chiropractic evaluation research reveals gaps in stroke-related knowledge and a need for training chiropractic physicians, their staff, and patients, standardized recognition instruments may be combined with already available literature from the CDC and American Heart Association to address those deficiencies.
Table 4. The Face Arm Speech Test, also known as FAST 
|F||Face: Ask person to smile. Does one side of the face droop?|
|A||Arm: Ask person to raise both arms. Does one arm drift downward?|
|S||Speech: Ask the person to say their name or a simple sentence. Is the speech slurred or unusual?|
|T||Time: If any of these signs, call 911 or get to the nearest stroke center or hospital immediately.|
Of course there are numerous limitations to presentation of a case series, and no causal inferences may be inferred; even the prevalence of 5 active patients having stroke morbidity or mortality (of 6 presenting or having those symptoms or signs) during a 4-year period in this practice cannot be generalized to other practices, states, or countries, and despite the safeguards previously cited, there may have been a failure of the database and hand search to even identify all cases in this practice. Indeed, prevalence may have been overstated or understated, and only cross-sectional and other epidemiological research can determine the true impact of stroke on chiropractic patients throughout the United States.
Patients with symptoms and signs of stroke may infrequently present to chiropractic physicians for evaluation and treatment. This report highlights a potential need for chiropractic health education research aimed at evaluation of whether training of chiropractic physicians, staff, and patients may further goals envisioned by the CDC regarding reducing stroke deaths and health disparities associated with this disease. As portal of entry providers, prevention, screening, early identification of stroke symptoms and signs, and referral for prompt treatment are cornerstones of the national stroke policy as espoused by the CDC, which the chiropractic community may choose to embrace. Chiropractic physicians have opportunities for practice-related health education initiatives focusing on the role of health and wellness in stroke prevention and for prompt lifesaving referral of emergency presentations.
Patients with symptoms and signs of stroke may present to chiropractic physicians.
Chiropractic physicians, their staff, and patients must be informed regarding stroke risk factors, prevention, screening, and early recognition of symptoms and signs to avoid potentially catastrophic delay in receiving possibly lifesaving treatment, if not help prevent this disease entirely.