Microstructural Damage in Arterial Tissue
Exposed to Repeated Tensile Strains

This section is compiled by Frank M. Painter, D.C.
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FROM:   J Manipulative Physiol Ther 2010 (Jan); 33 (1): 14–19 ~ FULL TEXT

Neal Austin, BSc, Lisa M. DiFrancesco, MD, Walter Herzog, PhD

Walter Herzog, PhD, KNB
402 Human Performance Laboratory,
The University of Calgary,
Faculty of Kinesiology,
2500 University Drive NW,
Calgary, AB, Canada T2N 1N4

Objectives   Vertebral artery (VA) damage has been anecdotally linked to high-speed, low-amplitude spinal manipulative treatments (SMTs) of the neck. Apart from a single study quantifying the maximum stresses and strains imposed on the VA during cervical SMT, there are no data on the mechanics of the VA for this treatment modality, and there is no information on the possible long-term effects of repeat exposure to cervical SMT. The purpose of this study was to quantify microstructural damage in arterial tissue exposed to repeat strain loading of a magnitude similar to the maximum strains measured in the VA during high-speed, low-amplitude cervical SMT.

Methods   Twenty-four test specimens from cadaveric rabbit ascending aorta were divided into 2 control groups (n = 12) and 2 experimental groups (n = 6 each). Specimens were exposed to 1000 strain cycles of 0.06 and 0.30 of their in situ length. A pathologist, blinded to the experimental groups, assessed microstructural changes in the arteries using quantitative histology. Pearson χ2 analysis (a = .05) was used to assess differences in tissue microstructure between groups.

Results   Control and 0.06 strain tissues were statistically the same (P = .406), whereas the 0.30 strain group showed microstructural damage beyond that seen in the control group (P = .024).

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Conclusions   We conclude that cadaveric rabbit arterial tissue similar in size and mechanical properties of that of the human VA can withstand repeat strains of magnitudes and rates similar to those measured in the cadaveric VA during cervical SMT without incurring microstructural damage beyond control levels.

From the Full-Text Article:


Vertebral artery (VA) damage is commonly thought to occur as a result of everyday tasks such as turning the head while backing up a vehicle, lifting objects, coughing, sport-related injuries, and undergoing spinal manipulative therapy. [1] It is reported that the incidence of VA damage associated with cervical manipulation is between 1 and 1.5 cases per 100,000 people annually, and the population in which it is primarily identified in is middle-aged men and women. [2-3] Although the occurrence of VA damage is low, the consequences of injury are invariably serious. [4]

The anatomical orientation of the VA is thought to leave it prone to injury during cervical high-speed, low-amplitude manipulation because of neck rotation. [5] The VA runs from the subclavian artery through the transverse foramen of the cervical vertebrae before forming the vertebral loop between C1 and the foramen magnum. [6] The vertebral loop is thought to accommodate stretch of the VA during neck rotation and could theoretically be prone to injury during spinal manipulation. In an experiment involving 5 un-embalmed geriatric cadavers and 1 chiropractic clinician, the internal forces and associated strains acting on the VA during cervical spinal manipulation were quantified. [7] In this experiment, it was found that the VA is “slack” when the head is in a neutral position and is only unraveled or stretched toward the end of passive neck motion. [7] The head position during passive neck motion, which would cause a stretch in the VA, is not reached during normal spinal manipulative procedures; therefore, it has been suggested that a single neck treatment has no ill effect on the mechanical integrity of the VA. [7] However, a chiropractic patient may receive a dozen or more cervical spinal manipulations per year, [8] and the possible mechanical effects of repeat exposure to arterial strain remain unknown, because the possible microstructural changes due to such mechanical loading have never been quantified to our knowledge.

The relationship between the number of spinal manipulations a patient receives and the side effects resulting from repeat treatments has been studied and has been found to not exist. [9] Furthermore, investigation into the effects of cervical spinal manipulation on preexisting arterial lesions has been made, but no significant differences in arterial lesion dimensions (length, cross-sectional area, and volume) could be detected after 20 treatments. [10] Biomechanical research on cervical spinal manipulations has focused on the external forces applied by chiropractors on patients during cervical spinal manipulative treatment (SMT). [7, 11, 12] Only a single study focused on the stresses and strains on the VA for a variety of high-speed, low-amplitude cervical SMTs. [7] The average peak forces applied externally to the neck region of subjects during spinal manipulation range from approximately 100 to 150 N and are achieved within approximately 100 milliseconds. For these external forces and neck manipulations, it was found that cervical spinal manipulation resulted in average peak strains of cadaveric VAs of 0.06 from their lengths with the head and neck in the neutral position. [7]

Experiments designed to investigate VA microstructural damage due to straining and/or repeat exposure to manipulative treatments have been unsuccessful in humans. Furthermore, questions pertaining to the relationship between repeat cervical spinal manipulation and its effect on VA microstructural damage have arisen in court, specifically the inquest into the death of Lana Dale Lewis. [13] The purpose of this study was to investigate the effects of repeat strain application on the microstructural integrity of arterial tissue.


Groups 1 and 2 control specimens showed some microstructural tissue damage. Specifically, both control groups contained 4 normal samples and 2 samples with mild damage. The mild tissue damage found in the control tissues is likely associated with the dissection and handling of the arterial tissues.

Group 3 specimens (0.06 strain) were statistically the same as the control samples (Table 1 and Fig 3), suggesting that the repeat straining of cadaveric rabbit arterial tissue similar to that experienced by the cadaveric VA during chiropractic neck manipulations does not cause microstructural damage.

Microstructural damage in group 4 specimens (0.3 strain) was significantly greater than those observed in the control group providing a positive control for our test procedures. This result illustrates that repeat strain exposure of arterial tissues might produce microdamage that is not observed in mechanical assessments of tissue integrity in a single loading cycle. [7]

Cerebrovascular accidents associated with neck manipulation likely have a mechanical origin. It has been speculated that chiropractic SMT might cause VA dissection possibly leading to stroke. Our previous work on the mechanics of the VA in human cadavers during high-speed, low-amplitude cervical spinal manipulative therapy suggests that this is not possible in a normal VA. [7] However, it is well established that biological tissues can fail because of microstructural damage when exposed to repeat mechanical loading that in itself is not damaging for a single loading bout. [30, 31] Thus, it has been argued that repeat exposure to chiropractic neck manipulations might predispose the VA to microstructural damage that might lead to stroke. [13] This study cannot refute this argument as we used an animal model rather than human vertebral artery and performed instrumented testing rather than performing repeated chiropractic manipulations. Nevertheless, we can conclude from this study that cadaveric rabbit arterial tissue of similar size, structure, and mechanical properties to the human VA does not incur microstructural damage when exposed to 1000 strain cycles of magnitude and speed corresponding to the maximal values observed in the human cadaveric VA during chiropractic SMT to the neck.


There are a number of limitations that need to be kept in mind when interpreting the results of this study. First, the strain magnitude (0.06) and the strain rate (0.6 strain/s) of the test specimens were based on a study using cadaveric specimens. This study had a limited number of independent observations (n = 6) that measured the surface strains in a nonperfused artery. [7] However, in the absence of any other data on the mechanical stresses and strains of VAs during cervical spinal manipulations, these remain the only data of relevance to this study and thus were used here as our starting point. Second, the rabbit ascending aorta is not the human VA, independent of the similarities in structure and mechanical behavior. Therefore, the results should not be translated to the human VA without due consideration. Third, the strain measurements of our experimental specimens were measured as the average change in length between the tissue clamps during the mechanical testing and were not done directly at the site of histologic analysis. Although not ideal, the assumption that the tissue strain was homogeneous across the experimental specimen was made and further ensured by preparing the arterial specimens into rectangular pieces. This method was chosen to achieve the necessary strain while minimizing the damage to the arterial specimen from any other factor than the mechanical strain applied. Fourth, the 1000 repeat loading cycles were performed in a single session, whereas a patient would receive maybe 2 or 3 repeat manipulations per session before receiving further neck manipulations at a later date. In the meantime, the arterial tissue in a patient would have the possibility to adapt to any imposed loading; thus, the protocol used here must be considered a worst-case scenario in producing microstructural damage to the VA that would likely not occur in real life. Finally, the histologic scale used to grade the experimental tissue was developed specifically for this study and has not previously been validated in the literature. Although the scale has not been validated, we are confident in its sensitivity. The pathologist, who was blinded to the purpose of the project, the mechanical testing, the experimental groups, and the number of experimental groups, identified significant differences in microstructural damage between the 0.30 strain group and the control and 0.06 strain groups.


Cadaveric arterial tissues of New Zealand white rabbit with similar size, structure, and mechanical properties of human vertebral artery did not exhibit histologically identifiable microdamage when exposed to repeated mechanical loading equivalent to the strains observed in human vertebral artery during chiropractic cervical spine manipulative therapy.

Practical Applications

  • An animal model is necessary to study arterial tissue microdamage.

  • Strains similar to those occurring in the VA during SMT of the neck
    were reproduced mechanically.

  • One thousand repeat strain cycles mimicking SMT did not cause
    microdamage in arterial tissue

  • One thousand repeat strain cycles of a magnitude corresponding to
    approximately 50% of ultimate failure strain (0.30) causes
    significant microdamage in tested arterial tissue.

Funding Sources and Potential Conflicts of Interest

No funding sources or conflicts of interest were reported for this study. The Canadian Chiropractic Association, the College of Chiropractors of Alberta, and the Canadian Chiropractic Protective Agency provided financial support.


  1. Haldeman S, Kohlbeck FJ, McGregor M.
    Risk Factors and Precipitating Neck Movements Causing Vertebrobasilar Artery Dissection
    After Cervical Trauma and Spinal Manipulation

    Spine (Phila Pa 1976) 1999 (Apr 15); 24 (8): 785–794

  2. Schievink WI
    Spontaneous dissection of the carotid and vertebral arteries.
    N Engl J Med. 2001; 344: 898-906

  3. Bin Saeed A, Shuaib A, Al Sulaiti G, Emery D.
    Vertebral Artery Dissection: Warning Symptoms, Clinical Features and Prognosis in 26 Patients
    Canadian Journal of Neurological Sciences 2000 (Nov); 27 (4): 292–296

  4. Assendelft WJ Bouter LM Knipschild PG
    Complications of spinal manipulation: a comprehensive review of the literature.
    J Fam Pract. 1996; 42: 475-480

  5. Stevinson C Ernst E
    Risks associated with spinal manipulation.
    Am J Med. 2002; 112: 566-571

  6. Moore KL Dalley AF
    Clinically oriented anatomy.
    5th ed. Lippincott Williams and Wilkins, Baltimore2006

  7. Symons, B., Leonard, T.R., Herzog, W., 2002.
    Internal Forces Sustained by the Vertebral Artery
    During Spinal Manipulative Therapy

    J Manipulative Physiol Ther 2002 (Oct); 25 (8): 504–510

  8. Von Kuster T
    Chiropractic health care: a national study of cost of education, service, utilization, number of practicing doctors of chiropractic and other key policy issues. The Foundation for the Advancement of Chiropractic Tenets and Science, Washington, DC1980: 91-96

  9. Cagnie B, Vinck E, Beernaert A, et al.
    How Common Are Side Effects of Spinal Manipulation And Can These Side Effects Be Predicted?
    Manual Therapy 2004 (Aug); 9 (3): 151–156

  10. Qynd S Anderson T Kawchuk G
    Effect of cervical manipulation on pre-existing vascular lesion within the canine vertebral artery.
    Cerebrovasc Dis. 2008; 26: 304-309

  11. Herzog W Conway PJ Kawchuck GN Zhang Y Hasler EM
    Forces exerted during spinal manipulative therapy.
    Spine. 1993; 18: 1206-1212

  12. Triano J Schultz A
    Loads transmitted during lumbosacral spinal manipulative therapy.
    Spine. 1997; 22: 1955-1964

  13. Ontario Hospital Association
    Inquest into the death of: Lana Dale Lewis. Coroner's jury verdict and recommendations
    Ontario, Toronto Canada. (Available at)

  14. Wolinsky H Glagov S
    A lamellar unit of aortic medial structure and function in mammals.
    Circ Res. 1967; 20: 99-111

  15. Mitchell J
    Differences between left and right suboccipital and intracranial vertebral artery dimension:
    an influence on blood flow to the hindbrain?
    Physiother Res Int. 2004; 9: 85-95

  16. Abd El-Bary TH Dujovny M Ausman JI
    Microsurgical anatomy of the atlantal part of the vertebral artery.
    Surg Neurol. 1995; 44: 392-401

  17. Thiel, HW (1991).
    Gross morphology and pathoanatomy of the vertebral arteries.
    J Manipulative Physiol Ther 14:133:141.

  18. George B Laurian C
    The vertebral artery pathology and surgery.
    Springer-Verlag/Wein, Austria1987

  19. Sato T Sasaki T Suzuki K Matsumoto M Kodama N Hiraiwa K
    Histological study of the normal vertebral artery. Etiology of dissecting aneurysms.
    Neurol Med Chir (Tokyo). 2004; 44: 629-636

  20. Fawcett DW Bloom W
    A textbook of histology.
    W.B. Saunders Company, Philadelphia1986

  21. Nagal A
    Die mechanischen eigenschaften der kapillerwand und ihre bezeihungen zum bindegewebslager.
    Z Zellforsch Mikrosk Anat. 1934; 21: 376-387

  22. Mann T Refshauge KM
    Causes of complications from cervical spine manipulation.
    Aust J Physiother. 2001; 47: 255-266

  23. Piffer CR Zorzetto NL
    Microscopy anatomy of the vertebral artery in the suboccipital and intracranial segments.
    Anat Anz. 1980; 147: 382-388

  24. Sokolis DP Kefaloyannis EM Kouloukoussa M Marinos E Boudoulas H Karayannacos PE
    A structural basis for the aortic stress-strain relation in uniaxial tension.
    J Biomech. 2006; 39: 1651-1662

  25. Johnson CP How T Scraggs M West CR Burns J
    A biomechanical study of the human vertebral artery with implications for fatal arterial injury.
    Forensic Sci Int. 2000; 109: 169-182

  26. Vernhet H Demaria R Juan JM Oliva-Lauraire MC Senac JP Dauzat M
    Changes in wall mechanics after endovascular stenting in the rabbit aorta: comparison of three stent designs.
    AJR Am J Roentgenol. 2001; 176: 803-807

  27. Gefen A Haberman E
    Viscoelastic properties of ovine adipose tissue covering the gluteus muscles.
    J Biomech Eng. 2007; 129: 924-930

  28. Nyiendo J Haldeman S
    A prospective study of 2000 patients attending a chiropractic college teaching clinic.
    Med Care. 1987; 25: 516-527

  29. Thiel H Bolton J
    Estimate of the number of treatment visits involving cervical spine manipulation
    carried out by members of the British and Scottish Chiropractic Associations over a one-year period.
    Clin Chiropr. 2004; 7: 163-167

  30. Wang XT Ker RF
    Creep rupture of wallaby tail tendons.
    J Exp Biol. 1995; 198: 831-845

  31. Wang XT Ker RF Alexander RMcN
    Fatigue rupture of wallaby tail tendons.
    J Exp Biol. 1995; 198: 847-852


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