The paper by Wilder, et al.1 should stimulate a great deal of discussion by chiropractic physicians regarding the informed consent process. Some will agree with our article and some will not. Hopefully, all of your readers will embrace the pursuit of the truth and enhance their efforts to provide evidence-based and patient-centered care.

As a chiropractic educator for the University of Bridgeport School of Chiropractic, a CCE approved school, a board-certified chiropractic specialist, and an expert in both civil and criminal courts, I take umbrage with the accusation of my having competing interests that were not mentioned. At the time of submission of our article, I had never advertised myself as a chiropractic expert witness. As of April, of this year, I have decided to market myself as a chiropractic expert witness.

As a well-known chiropractic postgraduate educator, I have been offered many opportunities to serve as an expert witness for both sides. Because of my respect for NCMIC, I no longer accept opportunities to be an expert witness for malpractice suits if the patient is suing NCMIC. This company supports our profession, and I appreciate their support of our schools and chiropractic associations.

Although I have never been paid by NCMIC to teach postgraduate education, as the director of Health Sciences Postgraduate Education Department at the University of Bridgeport, I have taught thousands of chiropractic physicians. It is my opinion that Dr. Demetrious does have a conflict of interest that he did not mention. He is paid by NCMIC to teach postgraduate education, which enables him to market his PostGradDC company.

Regarding the allegation that Dr. Brown has a potential conflict of interest that was not disclosed. As a chiropractic expert witness, Dr. Brown accepts cases for the plaintiff and the defense, therefore, he does not consider his expert witness work a conflict of interest.

Dr. Brown and I suggest that all chiropractic physicians should rigorously evaluate patients and gain informed consent prior to performing spinal manipulation. If the patient presents with signs and symptoms of a cervical artery dissection (CAD), the patient should be informed of the condition and spinal manipulation is contraindicated, and the patient should be referred to an emergency room for care of the CAD.

Respectfully,

James J. Lehman, DC, MBA, DIANM, Steven Brown, DC, DIAMA

In Response

We appreciate the opportunity to respond to Brown and Lehman (JCC, October 2025), who once again advance the hypothesis that cervical spine manipulation (CSM) can dislodge a thrombus from a pre-existing cervical arterial dissection (CAD) and precipitate ischemic stroke. This claim remains unsubstantiated by empirical, biomechanical, and epidemiologic evidence.

Brown and Lehman’s persistent reliance on low-level evidence consisting of anecdotal, case-based, or temporal associations, to the exclusion of available higher quality evidence, exemplifies selective author bias. Their misinterpretation of the current research literature results in erroneous opinions and determinations.

Multiple authors have pointed out that the apparent temporal association of CSM with CAD in case studies is due to protopathic bias. Protopathic bias is “when an exposure is delivered in the early prodrome of a disease before it is diagnosed” as defined by Cassidy et al. This sequence can lead to a mistaken inference of causation rather than coincidence.2–8

No epidemiologic, pathological, or biomechanical studies have demonstrated that cervical CSM can cause CAD or dislodge a mural thrombus within a dissected artery.

Several highly-powered epidemiologic studies, encompassing over 500 million person-years of data, consistently indicate that patients who experience vertebral or carotid dissection are equally likely to have visited a chiropractor or a primary care physician due to symptomatic expression, typically head or neck pain. These findings strongly indicate that CSM does not increase the risk of CAD or stroke.2,3,7–12

Numerous biomechanical studies have shown that measured forces during skilled high-velocity, low-amplitude adjustments are lower than those of daily head movements and have not been shown to alter arterial integrity or blood flow.4–6,13–25 Accordingly, the thromboembolic (TE)-dislodgment theory remains physiologically implausible.

Collectively, these studies indicate that CSM has a null effect as a cause of CAD or TE events and affirm the safety of CSM when performed by skilled practitioners. While we strongly encourage clinicians to remain vigilant for neurovascular compromise, spontaneous CAD, or other unusual vascular symptoms, unsubstantiated theories should not inform clinical practice or patient consent.

Advancing a CSM -thromboembolic (TE)-dislodgment theory without methodological rigor lacks scientific credibility and undermines evidence-based discourse. Until more compelling evidence of thrombus dislodgement after CSM is collected, we urge against promoting this hypothesis. Clinical decision-making and informed consent should be guided by objective evidence, which overwhelmingly demonstrates no causal relationship between CSM, CAD, TE, and stroke.

Respectfully submitted,

Jeffrey Wilder, DC, DABCO, James Demetrious, DC, DABCO, Phil Conway, DC, BPE, FCCPOR(C), David Graber, DC, DACBSP, Peter Tuchin, DC, PhD