Medical Hypotheses 198 (2025) 111629 Available online 26 April 2025 0306-9877/© 2025 Elsevier Ltd. All rights are reserved, including those for text and data mining, AI training, and similar technologies. Short Communication Stroke vs. toxin release after chiropractic spinal manipulation: A plausible hypothesis Steven Brown Brown Chiropractic & Acupuncture, PC, 1772 East Boston Street #107, Gilbert, AZ 85295, United States A R T I C L E INFO Keywords: Chiropractic Stroke Dissection Toxin release Manipulation ABSTRACT Multiple chiropractors report that some patients experience symptoms of dizziness/vertigo, nausea/vomiting, neck pain, headaches, sweating, fatigue, diarrhea, and fever after spinal manipulation. These chiropractors attribute these symptoms to toxic release caused by spinal manipulation. However, a literature search of three electronic databases for research supporting this claim yielded no results. These symptoms may instead represent minor thromboembolic ischemic strokes due to cervical spine manipulation performed in the presence of un- diagnosed cervical artery dissection. Cervical spine manipulation is contraindicated in the presence of cervical artery dissection. Increased education and training on cervical artery dissection and stroke is recommended for chiropractors. Introduction Numerous chiropractic physicians report on their public websites that some of their patients experience symptoms of dizziness, vertigo, nausea, vomiting, neck pain, headaches, sweating, fatigue, diarrhea, and fever following treatment with spinal manipulation. These chiropractors claim that these symptoms are the result of detoxification which is a result of spinal manipulative therapy. Spinal manipulation being a manual therapy in which a controlled, high-velocity, low-amplitude thrust is applied to the spine and induces a therapeutic stretch on the spinal joints. On their websites, these chiropractors support the toxin release hy- pothesis with various versions of the same argument. They claim that metabolic waste products accumulated in the body tissues are released by spinal manipulation causing symptoms of detoxification that resemble the symptoms of cold, flu or allergies. Some claim that toxin bubbles form in the joints and spinal cord, and spinal manipulation re- leases these toxins into the blood stream by causing the toxin bubbles to burst. Some propose that the popping sound associated with spinal manipulation is the toxin bubbles bursting. These symptoms are compared to the symptoms of detoxification from drugs. The objective of this study was twofold. First, to evaluate the research supporting the claim that these symptoms after spinal manip- ulation are the result of toxin release. Second, to propose a plausible alternative hypothesis for these symptoms of alleged toxin release. PubMed, Index to Chiropractic Literature, and Google Scholar were searched from inception to November 2024. The following keywords were searched: chiropractic, spinal manipulation, adjustment, toxin release, nausea, dizziness. All English language peer reviewed studies that sup- ported or refuted spinal manipulation causing toxin release were included. Our search yielded no results. The hypothesis These symptoms of alleged toxin release are potential symptoms of brain ischemia. Dizziness and nausea are two of the classic symptoms of brain ischemia. These symptoms of alleged toxin release may instead be an adverse event, a minor thromboembolic ischemic stroke caused by performing cervical spine manipulation in the presence of an existing cervical artery dissection. Not all strokes following neck manipulation are catastrophic. Strokes may be minor, moderate, severe or fatal [1]. A minor stroke being one that causes ischemic symptoms but minimal or no disability [2]. Patients with undiagnosed cervical artery dissection causing neck pain and/or headache may seek care from chiropractors [3,4]. 8.93 out of every 100,000 people suffer cervical artery dissection each year [5]. With 330 million people in the USA, this equates to 29,469 people in the USA every year. It is plausible that hundreds or thousands of them are seeking chiropractic care for neck pain and/or headache from undiag- nosed vertebral or internal carotid artery dissection. Thromboembolic stroke may be caused by performing neck manip- ulation in the presence of an undiagnosed cervical artery dissection [6]. E-mail address: drbrown@brownchiro.com. Contents lists available at ScienceDirect Medical Hypotheses journal homepage: www.elsevier.com/locate/ymehy https://doi.org/10.1016/j.mehy.2025.111629 Received 30 November 2024; Received in revised form 26 February 2025; Accepted 22 April 2025