Educational approaches to the relationship between cervical adjusting and risk of cervical artery dissection; a survey of chiropractic faculty

Educational approaches to the relationship between cervical adjusting and risk of cervical artery dissection; a survey of chiropractic faculty | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Educational approaches to the relationship between cervical adjusting and risk of cervical artery dissection; a survey of chiropractic faculty Chad Lambert, Kathryn Ross, Christine Major, Kara Burnham, Shawn Hatch, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9096984/v1 This work is licensed under a CC BY 4.0 License Status: Under Revision Version 1 posted 10 You are reading this latest preprint version Abstract Background Cervical artery dissection (CeAD) remains a rare but clinically important condition that has generated longstanding debate regarding its potential association with cervical spinal manipulative therapy (cSMT). Although biomechanical and epidemiologic studies have examined this relationship, little is known about how chiropractic educational programs address CeAD or how faculty perceptions shape instructional practices. This study surveyed chiropractic faculty who actively teach cervical manipulation to understand how educators conceptualize CeAD risk and incorporate safety considerations into curricula. Methods An anonymous twelve-item electronic survey was distributed via Qualtrics to faculty from 28 English‑speaking chiropractic programs between February and March 2025. Snowball sampling recruited instructors who had taught hands‑on cervical manipulation within the prior five years. Survey items assessed teaching setting, beliefs about the cSMT–CeAD relationship, and whether perceived risk influenced screening procedures and technique modification. Quantitative data were analyzed using descriptive statistics and chi‑square tests; qualitative responses underwent keyword extraction and topic modeling. Results Faculty from seventeen of the 28 invited chiropractic programs participated (61% program response rate), yielding 103 responses with 75 meeting inclusion criteria; 49 were classroom faculty and 26 were clinical faculty. Teaching setting significantly influenced faculty perspectives on CeAD causation (p = 0.03). Classroom faculty more likely to report that cSMT is rarely or never causally related to CeAD (67% vs 42%), whereas clinical instructors more frequently acknowledged a causal relationship mediated by modifiable risk factors (58% vs 33%). Most faculty (73%) incorporated CeAD education through didactic instruction and case-based discussions. Qualitative analysis of free text responses were organized into four major themes: (1) Clinical Assessment & Management; (2) Risk & Safety; (3) Education & Training; (4) Evidence Base. Conclusions Teaching setting significantly influenced how chiropractic faculty conceptualize and teach CeAD risk. Findings reveal opportunities to strengthen evidence‑aligned patient‑safety education and establish instructional guidance across chiropractic programs. The collection method used in this study makes calculating response rate difficult, limiting generalizability. Manipulation Spinal Questionnaires and Surveys Education Risk Management vertebral artery dissection Figures Figure 1 Figure 2 BACKGROUND Early biomechanical studies suggested that upper cervical manipulation (cSMT) involving rotation may impart mechanical stress on the vertebral artery, potentially precipitating cervical artery dissection [ 1 ] [ 2 ]. However, more recent cadaveric studies demonstrate that during cSMT the vertebral artery experiences elongation but not pathological stretch [ 3 ], with greater tensile forces occurring during normal range of motion than during manipulation [ 4 ] [ 5 ]. The V3 segment, travelling through the transverse foramen of C2, through the C1 transverse foramen and then crossing the posterior arch of C1, is frequently implicated in traumatic vertebral artery dissections [ 6 ]. This segment may experience tensile forces during neck rotation, impacting vascular flow [ 7 ]. However, Gorrell et al [ 3 ] found no evidence that cSMT produces forces sufficient to damage vascular structures. Despite numerous reports documenting cases of CeAD temporally associated with cSMT, the literature infrequently reports adequate details to further our understanding of the relationship between cSMT, CeADs and stroke [ 8 ]. Grainger [ 9 ] stated that dissection is a result of “extension and rotation of the neck beyond the physiological range of motion.” Rotation and/or extension has been cited as potential risk factors in existing literature both supporting and questioning a causal link between cSMT and CeAD [ 3 ]. This ongoing debate has likely influenced practice behaviors among chiropractors, yet it remains unclear whether educational institutions have integrated this evolving evidence into their curricula or modified instructional delivery of cervical manipulation accordingly. Currently, no published research has evaluated whether chiropractic programs adapt cSMT instruction in response to CeAD risk factors or broader patient safety concerns [ 10 ]. Little is known about how curricula address CeAD when teaching cervical manipulative procedures, or whether faculty independently modify techniques to mitigate perceived risks. This study is the first to survey chiropractic faculty who actively teach cervical manipulation, examining how perceived CeAD-related risks influence instructional approaches in both classroom and clinical settings. METHODS Participants Faculty from 28 English-speaking chiropractic programs in the United States, Australia, and the United Kingdom were invited to complete an anonymous electronic survey. Initial institutional contacts—typically deans or research directors— were identified through program website searches. Using snowball sampling, these contacts then distributed the survey to faculty with relevant teaching experience. Survey Instrument The survey instrument was developed by the lead author, a faculty member at a chiropractic educational program in the US with more than a decade of experience instructing students on cervical spine evaluation and management. The instrument was built and distributed using Qualtrics, a cloud-based online survey platform (Qualtrics, Provo, UT). Survey items were informed by current literature on the cSMT – CeAD relationship and the lead author’s instructional expertise in cervical assessment and technique. Face validity was assessed by four chiropractic faculty members with subject-matter expertise, along with an IRB administrator who evaluated readability and adherence to human subjects’ requirements. This study was deemed exempt from full IRB review at the lead author’s institution due to the anonymous, deidentified nature of the data collected. The twelve-item survey began with a screening question confirming hands-on experience with cervical manipulation instruction within the past five years; only eligible respondents continued. Subsequent items captured the primary teaching setting (classroom or clinic), followed by multiple choice questions assessing respondents’ perceptions of the cSMT – CeAD relationship and how their views influence instructional practices (e.g., screening, technique selection). The full survey instrument is provided in Appendix A. Quantitative Data Analysis Descriptive statistics, including frequencies, percentages, and totals, were used to summarize responses across all survey items. Bivariate associations between related responses were examined using cross-tabulations and Pearson’s chi-square tests, excluding cases with missing responses in either variable. Qualitative Data Analysis Free-text responses to the final survey question – “Is there anything else you would like to describe regarding your approach to teaching chiropractic technique and cervical artery dissection?” – were analyzed using keyword extraction and topic modeling techniques. A multi-level n-gram frequency analysis (uni-, bi-, and trigrams) identified common linguistic patterns after removing stop words using regular expression coding. In parallel, keyword-based thematic analysis was conducted using a manually developed dictionary of themes and associated keywords. Each response was scored by keyword frequency to quantify thematic presence, and this keyword-theme mapping provided the framework for thematic development. Response lengths were summarized by word and character counts, and exploratory visualizations included bar charts of the most frequent words and thematic categories and a histogram of word count distributions. RESULTS Participants Of the 28 chiropractic programs contacted via email, two programs declined participation, and nine did not respond, yielding faculty survey responses (n = 103) from 17 programs (61% institutional response rate). After data cleaning, 28 individual submissions were excluded due to ineligibility or incomplete responses (Fig. 1 ), producing a final analytic sample of 75 respondents. Of these, 41 (55%) reported teaching in classroom settings and 33 (44%) in clinical settings; one respondent preferred not to disclose their teaching role (Table 2 ). Most respondents (71%) indicated that CeAD-related concerns influenced how they taught pretreatment screening procedures for cSMT. Quantitative Results Table 1 summarizes the distribution of responses across all survey items, including faculty roles, beliefs about the CeAD – cSMT association, and reported influences on instructional practices. Responses to the item assessing expert opinion on the CeAD – cSMT relationship were recoded into three mutually exclusive categories: Association (e.g., “rarely” or “never causal”), Causal Link (e.g., “modifiable risk”), and Other (e.g., “no association”, “causal but non-modifiable”, or “Other”). No significant associations were observed between teaching setting and most categorical variables; however, key differences emerged regarding perceived causation and its instructional influence. Table 1 here- Survey Response Summary Question Response n (%) Q1: Have you taught some form of hands-on cervical manipulation or adjusting in the past 5 years at a college or university? Yes 75 (100) Q2: Please select the setting in which you teach cervical adjusting Classroom setting primarily 41 (55) Clinical setting primarily 33 (44) Prefer not to answer 1 (1) Q3: Is the reported correlation between cervical adjusting and cervical artery dissection a subject you discuss when teaching? Yes 64 (85) No 11 (15) Q4: Which of the following phrases best describes your expert opinion on this association? No association between cervical adjustments and CeAD. 3 (4) Association but it is never causal. 4 (5) Association but it is rarely causal. 25 (33) Causal link modifiable with history and exam 18 (24) Causal link – non-modifiable 1 (1) Causal link influenced by SMT technique 6 (8) Other 7 (9) No Response 10 (13) Q5: Does the risk of CeAD affect how you teach pretreatment procedures prior to adjusting? Yes 53 (71) No 20 (27) No Response 2 (3) Q6: Which of the following descriptions most closely aligns with how you teach pretreatment procedures? Questions to assessing likelihood of CeAD in progress 18 (24) Questions assessing likelihood of underlying condition modifying risk of SMT procedure 12 (16) Questions/exams assessing likelihood of underlying condition increasing SMT-CeAD risk 19 (25) Other 4 (5) No Response 21 (28) Q7: If you believe modifications to cervical adjusting technique may (or may not) influence the risk of CeAD, which resource(s) would you say most strongly influence that belief? (Choose all that apply) Personal belief/knowledge 37 (49) Clinical experience of colleagues 27 (36) Expert opinion of chiropractic educators 26 (35) Anatomic/cadaveric studies in the scientific literature 33 (44) Case reports in the scientific literature 30 (40) Narrative reviews of the literature 11 (15) Systematic reviews and meta-analyses of the literature 40 (53) Other 4 (5) Q8: Does the risk of CeAD affect how you teach adjusting technique of the upper cervical spine only or the entire cervical spine? Upper cervical spine only 11 (15) Entire cervical spine 51 (68) Neither 11 (15) No Response 1 (1) Q9: Which of the following descriptions most closely aligns with the modification(s) adjusting technique of the upper cervical spine you use when you teach? > 25% missing values Q10: Which of the following descriptions most closely aligns with the modifications to adjusting technique of the entire cervical spine you use when you teach? > 25% missing values Q11: Does the risk of CeAD affect how you teach adjusting technique of the cervicothoracic spine? Yes 30 (40) No 42 (56) No Response 2 (3) Q12: Which of the following descriptions most closely aligns with the modifications to adjusting technique of the cervicothoracic spine you use in the classes you teach? > 25% missing values Among 74 respondents with complete data, 39% (n = 29) characterized the CeAD – cSMT relationship as associational, 32% (n = 24) as causal, and 15% (n = 11) selected other; 10 provided no response (Table 2 ). Teaching setting was significantly associated with faculty perceptions on causation (p > 0.05): faculty endorsing association predominantly taught in classroom settings (72%), while those endorsing causation more often taught in clinical settings (63%). Both groups reported CeAD risk influenced pretreatment screening instruction (83%), whereas the “other” group reported substantially lower influence (45%; p < 0.05). Faculty endorsing association more frequently reported CeAD risk influenced cervicothoracic SMT instruction (59% vs 42% causal, p < 0.05), while reported influence on upper cervical spine instruction was uniformly low across groups (17% association vs 8% causal, p < 0.05). Table 2 here- Faculty beliefs about the dissection-manipulation relationship by teaching setting Teaching setting* Association (n = 29) Causal link (n = 24) Other (n = 11) No Response (n = 10) Total (n = 74) Classroom 21 (72%) 9 (38%) 5 (45%) 6 (60%) 41 (55%) Clinic 8 (28%) 15 (63%) 6 (55%) 4 (40%) 33 (45%) CeAD risk influences….. Pretreatment screening* 24 (83%) 20 (83%) 5 (45%) 4 (40%) 53 (72%) C-T SMT instruction* 17 (59%) 10 (42%) 1 (9%) 3 (30%) 31 (42%) Full c-spine SMT instruction 22 (76%) 23 (96%) 3 (27%) 4 (40%) 52 (70%) Upper c-spine SMT instruction* 5 (17%) 2 (8%) 1 (9%) 3 (30%) 11 (15%) Neither full nor upper c-spine 2 (7%) 0 (0%) 6 (55%) 3 (30%) 11 (15%) CeAD= Cervical Artery Dissection; C-T: Cervico-thoracic; SMT: Spinal Manipulative Therapy; c-spine: cervical spine; * significant difference between categories (Association vs. Causal link vs. Other) Qualitative Results Analysis of free-text responses (N = 19) identified "patient," "history," and "cervical" as the most frequently occurring words (Fig. 2 , Panel A ). Keyword-based thematic analysis using 71 unique terms across four consolidated themes revealed Clinical Assessment & Management as the dominant theme, present in 89.5% of responses and encompassing patient evaluation, screening protocols, and clinical decision-making (Fig. 2 , Panel B ). Risk & Safety appeared in 52.6% of responses, addressing potential complications and referral decisions. Education & Training (31.6%) and Evidence Base (21.1%) were less prevalent. Response lengths varied considerably (mean = 35.7 words, SD = 36.4; median = 28.0 words; range = 5-169 words; Fig. 2 , Panel C ), reflecting heterogeneity in faculty elaboration. Clinical Assessment & Management utilized the most extensive keyword set (n = 35). Representative keywords and survey responses for each theme are presented in Table 3 . Table 3 here- Thematic analysis keywords and example responses Theme Keywords Sample Response Clinical Assessment & Management patient, history, cervical, screening, manipulation, exam “We review contraindications to HVLA (relevant recent trauma, vascular pathology, signs of instability, connective tissue disorder). If a patient has acute new neck pain and or headaches we take a thorough history looking for any symptoms of neuro involvement..." Risk & Safety risk, safety, CAD, dissection, stroke, refer "Almost 100% of the CAD risk is in the patient history and not hearing the patient describe how their symptoms came on. Students need hear these warning signs and know when to refer out to stabilize an emergency situation before adjusting them." Education & Training teach, students, education, training, curriculum "I am still dissatisfied with how this is taught and would appreciate having an exhaustive search on this topic clarify how we should all collectively teach this issue." Evidence Base evidence, research, literature, study, association "Much of my discussion involves a discussion of appropriate history and physical exam. An association between manipulation and CeAD certainly exists, but I have not been exposed to robust support indicating a particular style of SMT or refrainment (limiting rot, ext, etc.) has any particular influence." DISCUSSION Chiropractic educators and the programs in which they teach serve as a critical foundation for knowledge dissemination, shaping the educational experiences of both current students and practicing clinicians. Faculty are responsible for remaining current with scientific literature, particularly regarding the techniques, efficacy, and safety of chiropractic care, and as such represent a valuable source of knowledge into modern chiropractic thought and the curricular content informing clinical practice. However, scant literature examines how chiropractic educators address specific clinical controversies within their curricular content. This study explored faculty perspectives on the potential association between cSMT and CeAD and assessed how their attitudes may influence the way the topic is presented in chiropractic education. Our analysis revealed that respondents teaching in clinical settings were nearly twice as likely as their classroom-based colleagues to perceive the cSMT – CeAD relationship as causal. In contrast, classroom faculty more frequently characterized the relationship as associational – that is, rarely or never causal. Although the data did not provide direct explanations for this discrepancy, distinct contextual factors within each teaching setting may contribute to differing perceptions. Classroom faculty may rely more heavily on literature casting doubt on a causal relationship [ 11 ] [ 12 ] [ 13 ] [ 14 ] and may be less likely to engage in active clinical practice. Clinical faculty, by contrast, are actively managing patient risk while supervising clinical interns, placing them in a position where medicolegal concerns and direct patient safety responsibilities may heighten caution. Notably, despite these divergent views on causation, both groups reported equal influence of CeAD risk on pretreatment screening instruction, suggesting that regardless of how faculty conceptualize the underlying mechanism, they converge on the practical importance of thorough patient education. Further work should aim to identify the underlying factors shaping these differing perceptions among faculty subgroups. Many respondents reported modifying cervical spine adjusting techniques by minimizing rotation and extension, with a majority (61%) indicating they deliberately avoided these movements and emphasized this approach in their instruction. This adaptation may be informed by concerns about mechanical stress on the V3 segment of the vertebral artery, particularly near the C1 level [ 1 ] [ 7 ]. Notably, these modifications appear to extend beyond upper cervical techniques to other cervical regions, with CeAD risk influencing cervicothoracic SMT instruction across groups. This broader application is plausible given that multi-segmental motion has been detected several spinal segments distant from the manipulation contact point [ 15 ], despite the expectation that short-lever techniques produce localized forces [ 16 ]. Faculty may therefore be applying precautionary modifications across the cervical spine as a pragmatic response to this biomechanical uncertainty. Thorough pretreatment screening, including a detailed history and physical exam, is essential in assessing a patient’s suitability for cSMT. In this study, faculty who endorsed a causal link between CeAD and cSMT were more likely to modify their screening practices, although most respondents across groups recommended some form of CeAD-related screening. While evidence of a causal relationship remains inconclusive, clinicians must remain vigilant for concerning symptoms (e.g., atypical headache, neck pain, dizziness/vertigo) [ 17 ] as well as a medical history of conditions with known associations with CeAD (e.g., migraine headache, hypertension, genetic connective tissue disorders, recent trauma) [ 18 ] [ 19 ] [ 20 ] [ 21 ]. The dominance of the Clinical Assessment & Management theme is consistent with the finding that most respondents reported CeAD concerns influencing pretreatment screening instruction. This pattern extends beyond chiropractic education; Mourad et al. found that 70% of Italian physiotherapists reported performing additional screening prior to upper cervical manipulation, with safety perceptions varying significantly by spinal region [ 22 ]. Together, these findings suggest that heightened clinical vigilance around the cervical spine is a shared concern across professions that deliver spinal manipulation. Our findings further suggest that chiropractic faculty are actively modifying teaching strategies specific to cSMT based on perceived CeAD risk. These modifications appear to be driven more by clinical experience and precautionary instinct than by engagement with published evidence. Bridging this gap through stronger integration of evidence-based content into CeAD-related instruction and more consistent educational frameworks across programs represents an important next step. Future research with larger, more diverse samples and more targeted questions regarding the basis for faculty beliefs could further clarify the drivers of cSMT-related instructional practices. Limitations This study has several notable limitations. The snowball sampling approach precluded determination of the exact number of faculty who received the survey, preventing calculation of an individual-level response rate. While 17 of 28 invited programs participated, this convenience sampling strategy limits generalizability. To protect anonymity, no identifiable information was collected, precluding analysis of demographic factors, such as years of experience or clinical background, that may influence faculty perspectives. The qualitative component was limited to 19 free-text responses of variable length, and the cross-sectional design captures perspectives at a single point in time rather than how beliefs evolve with experience or emerging evidence. CONCLUSIONS This study demonstrates differing views about the relationship between cSMT and CeAD based on instructional setting, with clinical faculty more likely to endorse a causal relationship and classroom faculty more often viewing the association as rarely or never causal. These findings highlight the need for evidence-aligned curricular guidance to promote consistency in how CeAD-related risk is addressed across chiropractic educational programs. The collection method used in this study makes calculating response rate difficult, limiting generalizability. Declarations FUNDING No external funding was provided or utilized. ETHICS This project was presented to the IRB committee and deemed exempt. References Symons BP, Leonard T, Herzog W. Internal forces sustained by the vertebral artery during spinal manipulative therapy. J Manip Physiol Ther. 2002;25:504–10. [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;109:169–82. Gorrell LM, Sawatsky A, Edwards WB, Herzog W. Vertebral arteries do not experience tensile force during manual cervical spine manipulation applied to human cadavers. J Man Manipulative Therapy. 2023;31:261–9. Quesnele JJ, Triano JJ, Noseworthy MD, Wells GD. Changes in Vertebral Artery Blood Flow Following Various Head Positions and Cervical Spine Manipulation. J Manip Physiol Ther. 2014;37:22–31. 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Bergmann TF, Peterson DH. Chiropractic Technique: Principles and Procedures. St. Louis: Elsevier Mosby; 2011. Gottesman RF, et al. Clinical characteristics of symptomatic vertebral artery dissection: a systematic review. Neurologist. 2012;18:245–54. Metso TM, et al. Migraine in cervical artery dissection and ischemic stroke patients. Neurology. 2012;78:1221–8. Debette S, et al. Association of vascular risk factors with cervical artery dissection and ischemic stroke in young adults. Circulation. 2011;123:1537–44. Blum CA, Yaghi S. Cervical Artery Dissection: A Review of the Epidemiology, Pathophysiology, Treatment, and Outcome. Arch Neurosci. 2015;2:e26670. Trager RJ, Troutner AM, Pikus HJ, Daniels CJ, Dusek JA. Symptoms of Patients With Vertebral Artery Dissection Presenting to Chiropractors: A Systematic Review and Meta-Analysis. Cureus https://doi.org/10.7759/cureus.51297 (2023) doi:10.7759/cureus.51297. Mourad F, et al. Knowledge, beliefs, and attitudes of spinal manipulation: a cross-sectional survey of Italian physiotherapists. Chiropr Man Th. 2022;30:38. Additional Declarations No competing interests reported. Supplementary Files ChiropracticManualTherapiesManuscriptChecklistLambert.docx AppendixA.docx Cite Share Download PDF Status: Under Revision Version 1 posted Editorial decision: Revision requested 29 Apr, 2026 Reviews received at journal 28 Apr, 2026 Reviews received at journal 27 Apr, 2026 Reviewers agreed at journal 20 Apr, 2026 Reviews received at journal 15 Apr, 2026 Reviewers agreed at journal 15 Apr, 2026 Reviewers agreed at journal 08 Apr, 2026 Reviewers invited by journal 08 Apr, 2026 Submission checks completed at journal 07 Apr, 2026 First submitted to journal 31 Mar, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9096984","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":619866833,"identity":"6915b457-dc74-4ed4-8958-549508e08d35","order_by":0,"name":"Chad Lambert","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAxklEQVRIiWNgGAWjYDACCeYGBsYGIIO9AcxnbCCshRGihYfnAMlaJBKI1MI/u7Hx080dNvn2km/MJH8w2MhuOEDIkjsHm6Vzz6RZ9kjnmEnzMKQZE9RiIJHYIJ3bdtiAB6jlNgPD4URitDT/zm37b8Ajecbs5g+G/0RpaQPacsCAR4LH7AYPwwHCWiRuJLZZ555JNuA5k1b+m8cg2XgmIS38M5IP387dYWfA3n54s+GPCjvZPkJa0N1JmvJRMApGwSgYBTgAAHMjQnbRigvOAAAAAElFTkSuQmCC","orcid":"","institution":"University of Western States","correspondingAuthor":true,"prefix":"","firstName":"Chad","middleName":"","lastName":"Lambert","suffix":""},{"id":619866834,"identity":"1f5bb500-11fb-4743-8d2b-10e3a48f6785","order_by":1,"name":"Kathryn Ross","email":"","orcid":"","institution":"University of Western States","correspondingAuthor":false,"prefix":"","firstName":"Kathryn","middleName":"","lastName":"Ross","suffix":""},{"id":619866835,"identity":"a59a1afd-97dc-4bae-ac72-7e56cc8c953d","order_by":2,"name":"Christine Major","email":"","orcid":"","institution":"University of Pittsburgh","correspondingAuthor":false,"prefix":"","firstName":"Christine","middleName":"","lastName":"Major","suffix":""},{"id":619866836,"identity":"40f30dc8-b1d3-4dfe-9c09-48418af99fc1","order_by":3,"name":"Kara Burnham","email":"","orcid":"","institution":"University of Western States","correspondingAuthor":false,"prefix":"","firstName":"Kara","middleName":"","lastName":"Burnham","suffix":""},{"id":619866837,"identity":"649bb629-67d7-48a7-8da3-7bf6db806a49","order_by":4,"name":"Shawn Hatch","email":"","orcid":"","institution":"University of Western States","correspondingAuthor":false,"prefix":"","firstName":"Shawn","middleName":"","lastName":"Hatch","suffix":""},{"id":619866838,"identity":"43ab7154-a736-40fc-83e9-293800de8501","order_by":5,"name":"Brian Anderson","email":"","orcid":"","institution":"University of Pittsburgh","correspondingAuthor":false,"prefix":"","firstName":"Brian","middleName":"","lastName":"Anderson","suffix":""}],"badges":[],"createdAt":"2026-03-11 17:23:26","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9096984/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9096984/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":107243336,"identity":"d9713c24-4f4c-49d1-a9c0-5cd90b6f4274","added_by":"auto","created_at":"2026-04-19 07:50:51","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":27511,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ehere-Survey flow diagram\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-9096984/v1/5ac5628319106041c8e38abd.png"},{"id":107243338,"identity":"9f1bf79c-cf91-4d43-9a60-72b6a122089b","added_by":"auto","created_at":"2026-04-19 07:50:51","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":50835,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ehere - Free-text response analysis: (A) word frequency, (B) thematic distribution, and (C) response length.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-9096984/v1/720993b6826ee3be577919cc.png"},{"id":107487136,"identity":"5f326560-d77e-4d94-921a-1e8f735a7dd3","added_by":"auto","created_at":"2026-04-22 02:39:50","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":484418,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9096984/v1/582d72f2-890c-4a2c-8eb8-71917bac853c.pdf"},{"id":107243337,"identity":"570db2df-4402-4288-af55-4664b6b7d8e7","added_by":"auto","created_at":"2026-04-19 07:50:51","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":28247,"visible":true,"origin":"","legend":"","description":"","filename":"ChiropracticManualTherapiesManuscriptChecklistLambert.docx","url":"https://assets-eu.researchsquare.com/files/rs-9096984/v1/133a7bdf0633cb01825e7ade.docx"},{"id":107484393,"identity":"9fcb43db-771c-416d-bd7f-92efa792018b","added_by":"auto","created_at":"2026-04-22 02:31:51","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":20297,"visible":true,"origin":"","legend":"","description":"","filename":"AppendixA.docx","url":"https://assets-eu.researchsquare.com/files/rs-9096984/v1/6c19f8ac255f9bb54703c563.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Educational approaches to the relationship between cervical adjusting and risk of cervical artery dissection; a survey of chiropractic faculty","fulltext":[{"header":"BACKGROUND","content":"\u003cp\u003eEarly biomechanical studies suggested that upper cervical manipulation (cSMT) involving rotation may impart mechanical stress on the vertebral artery, potentially precipitating cervical artery dissection [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. However, more recent cadaveric studies demonstrate that during cSMT the vertebral artery experiences elongation but not pathological stretch [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e], with greater tensile forces occurring during normal range of motion than during manipulation [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. The V3 segment, travelling through the transverse foramen of C2, through the C1 transverse foramen and then crossing the posterior arch of C1, is frequently implicated in traumatic vertebral artery dissections [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. This segment may experience tensile forces during neck rotation, impacting vascular flow [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. However, Gorrell et al [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] found no evidence that cSMT produces forces sufficient to damage vascular structures.\u003c/p\u003e \u003cp\u003eDespite numerous reports documenting cases of CeAD temporally associated with cSMT, the literature infrequently reports adequate details to further our understanding of the relationship between cSMT, CeADs and stroke [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Grainger [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] stated that dissection is a result of \u0026ldquo;extension and rotation of the neck beyond the physiological range of motion.\u0026rdquo; Rotation and/or extension has been cited as potential risk factors in existing literature both supporting and questioning a causal link between cSMT and CeAD [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. This ongoing debate has likely influenced practice behaviors among chiropractors, yet it remains unclear whether educational institutions have integrated this evolving evidence into their curricula or modified instructional delivery of cervical manipulation accordingly.\u003c/p\u003e \u003cp\u003eCurrently, no published research has evaluated whether chiropractic programs adapt cSMT instruction in response to CeAD risk factors or broader patient safety concerns [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Little is known about how curricula address CeAD when teaching cervical manipulative procedures, or whether faculty independently modify techniques to mitigate perceived risks. This study is the first to survey chiropractic faculty who actively teach cervical manipulation, examining how perceived CeAD-related risks influence instructional approaches in both classroom and clinical settings.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eParticipants\u003c/h2\u003e \u003cp\u003eFaculty from 28 English-speaking chiropractic programs in the United States, Australia, and the United Kingdom were invited to complete an anonymous electronic survey. Initial institutional contacts\u0026mdash;typically deans or research directors\u0026mdash; were identified through program website searches. Using snowball sampling, these contacts then distributed the survey to faculty with relevant teaching experience.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eSurvey Instrument\u003c/h3\u003e\n\u003cp\u003eThe survey instrument was developed by the lead author, a faculty member at a chiropractic educational program in the US with more than a decade of experience instructing students on cervical spine evaluation and management. The instrument was built and distributed using Qualtrics, a cloud-based online survey platform (Qualtrics, Provo, UT). Survey items were informed by current literature on the cSMT \u0026ndash; CeAD relationship and the lead author\u0026rsquo;s instructional expertise in cervical assessment and technique. Face validity was assessed by four chiropractic faculty members with subject-matter expertise, along with an IRB administrator who evaluated readability and adherence to human subjects\u0026rsquo; requirements. This study was deemed exempt from full IRB review at the lead author\u0026rsquo;s institution due to the anonymous, deidentified nature of the data collected.\u003c/p\u003e \u003cp\u003eThe twelve-item survey began with a screening question confirming hands-on experience with cervical manipulation instruction within the past five years; only eligible respondents continued. Subsequent items captured the primary teaching setting (classroom or clinic), followed by multiple choice questions assessing respondents\u0026rsquo; perceptions of the cSMT \u0026ndash; CeAD relationship and how their views influence instructional practices (e.g., screening, technique selection). The full survey instrument is provided in Appendix A.\u003c/p\u003e\n\u003ch3\u003eQuantitative Data Analysis\u003c/h3\u003e\n\u003cp\u003eDescriptive statistics, including frequencies, percentages, and totals, were used to summarize responses across all survey items. Bivariate associations between related responses were examined using cross-tabulations and Pearson\u0026rsquo;s chi-square tests, excluding cases with missing responses in either variable.\u003c/p\u003e\n\u003ch3\u003eQualitative Data Analysis\u003c/h3\u003e\n\u003cp\u003eFree-text responses to the final survey question \u0026ndash; \u0026ldquo;Is there anything else you would like to describe regarding your approach to teaching chiropractic technique and cervical artery dissection?\u0026rdquo; \u0026ndash; were analyzed using keyword extraction and topic modeling techniques. A multi-level n-gram frequency analysis (uni-, bi-, and trigrams) identified common linguistic patterns after removing stop words using regular expression coding. In parallel, keyword-based thematic analysis was conducted using a manually developed dictionary of themes and associated keywords. Each response was scored by keyword frequency to quantify thematic presence, and this keyword-theme mapping provided the framework for thematic development. Response lengths were summarized by word and character counts, and exploratory visualizations included bar charts of the most frequent words and thematic categories and a histogram of word count distributions.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003eParticipants\u003c/p\u003e \u003cp\u003eOf the 28 chiropractic programs contacted via email, two programs declined participation, and nine did not respond, yielding faculty survey responses (n\u0026thinsp;=\u0026thinsp;103) from 17 programs (61% institutional response rate). After data cleaning, 28 individual submissions were excluded due to ineligibility or incomplete responses (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e), producing a final analytic sample of 75 respondents. Of these, 41 (55%) reported teaching in classroom settings and 33 (44%) in clinical settings; one respondent preferred not to disclose their teaching role (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Most respondents (71%) indicated that CeAD-related concerns influenced how they taught pretreatment screening procedures for cSMT.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eQuantitative Results\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e summarizes the distribution of responses across all survey items, including faculty roles, beliefs about the CeAD \u0026ndash; cSMT association, and reported influences on instructional practices. Responses to the item assessing expert opinion on the CeAD \u0026ndash; cSMT relationship were recoded into three mutually exclusive categories: \u003cem\u003eAssociation\u003c/em\u003e (e.g., \u0026ldquo;rarely\u0026rdquo; or \u0026ldquo;never causal\u0026rdquo;), \u003cem\u003eCausal Link\u003c/em\u003e (e.g., \u0026ldquo;modifiable risk\u0026rdquo;), and \u003cem\u003eOther\u003c/em\u003e (e.g., \u0026ldquo;no association\u0026rdquo;, \u0026ldquo;causal but non-modifiable\u0026rdquo;, or \u0026ldquo;Other\u0026rdquo;). No significant associations were observed between teaching setting and most categorical variables; however, key differences emerged regarding perceived causation and its instructional influence.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ehere- Survey Response Summary\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQuestion\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eResponse\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQ1: Have you taught some form of hands-on cervical manipulation or adjusting in the past 5 years at a college or university?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e75 (100)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eQ2: Please select the setting in which you teach cervical adjusting\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eClassroom setting primarily\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e41 (55)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eClinical setting primarily\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e33 (44)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePrefer not to answer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eQ3: Is the reported correlation between cervical adjusting and cervical artery dissection a subject you discuss when teaching?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e64 (85)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (15)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"7\" rowspan=\"8\"\u003e \u003cp\u003eQ4: Which of the following phrases best describes your expert opinion on this association?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo association between cervical adjustments and CeAD.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAssociation but it is never causal.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAssociation but it is rarely causal.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25 (33)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCausal link modifiable with history and exam\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18 (24)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCausal link \u0026ndash; non-modifiable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCausal link influenced by SMT technique\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo Response\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (13)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eQ5: Does the risk of CeAD affect how you teach pretreatment procedures prior to adjusting?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e53 (71)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20 (27)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo Response\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003eQ6: Which of the following descriptions most closely aligns with how you teach pretreatment procedures?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eQuestions to assessing likelihood of CeAD in progress\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18 (24)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eQuestions assessing likelihood of underlying condition modifying risk of SMT procedure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12 (16)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eQuestions/exams assessing likelihood of underlying condition increasing SMT-CeAD risk\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19 (25)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo Response\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21 (28)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"7\" rowspan=\"8\"\u003e \u003cp\u003eQ7: If you believe modifications to cervical adjusting technique may (or may not) influence the risk of CeAD, which resource(s) would you say most strongly influence that belief? (Choose all that apply)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePersonal belief/knowledge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e37 (49)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eClinical experience of colleagues\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27 (36)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eExpert opinion of chiropractic educators\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26 (35)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAnatomic/cadaveric studies in the scientific literature\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e33 (44)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCase reports in the scientific literature\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30 (40)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNarrative reviews of the literature\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (15)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSystematic reviews and meta-analyses of the literature\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40 (53)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eQ8: Does the risk of CeAD affect how you teach adjusting technique of the upper cervical spine only or the entire cervical spine?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUpper cervical spine only\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (15)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEntire cervical spine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e51 (68)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNeither\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (15)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo Response\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQ9: Which of the following descriptions most closely aligns with the modification(s) adjusting technique of the upper cervical spine you use when you teach?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;25% missing values\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQ10: Which of the following descriptions most closely aligns with the modifications to adjusting technique of the entire cervical spine you use when you teach?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;25% missing values\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eQ11: Does the risk of CeAD affect how you teach adjusting technique of the cervicothoracic spine?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30 (40)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e42 (56)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo Response\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQ12: Which of the following descriptions most closely aligns with the modifications to adjusting technique of the cervicothoracic spine you use in the classes you teach?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;25% missing values\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eAmong 74 respondents with complete data, 39% (n\u0026thinsp;=\u0026thinsp;29) characterized the CeAD \u0026ndash; cSMT relationship as associational, 32% (n\u0026thinsp;=\u0026thinsp;24) as causal, and 15% (n\u0026thinsp;=\u0026thinsp;11) selected other; 10 provided no response (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Teaching setting was significantly associated with faculty perceptions on causation (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05): faculty endorsing association predominantly taught in classroom settings (72%), while those endorsing causation more often taught in clinical settings (63%). Both groups reported CeAD risk influenced pretreatment screening instruction (83%), whereas the \u0026ldquo;other\u0026rdquo; group reported substantially lower influence (45%; p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Faculty endorsing association more frequently reported CeAD risk influenced cervicothoracic SMT instruction (59% vs 42% causal, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05), while reported influence on upper cervical spine instruction was uniformly low across groups (17% association vs 8% causal, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ehere- Faculty beliefs about the dissection-manipulation relationship by teaching setting\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cem\u003eTeaching setting*\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAssociation\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;29)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCausal link\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;24)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;11)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNo Response\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;10)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;74)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClassroom\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21 (72%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (38%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5 (45%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6 (60%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e41 (55%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClinic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (28%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15 (63%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6 (55%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4 (40%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e33 (45%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCeAD risk influences\u0026hellip;..\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePretreatment screening*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24 (83%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20 (83%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5 (45%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4 (40%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e53 (72%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eC-T SMT instruction*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17 (59%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (42%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3 (30%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e31 (42%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFull c-spine SMT instruction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22 (76%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23 (96%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (27%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4 (40%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e52 (70%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUpper c-spine SMT instruction*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (17%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3 (30%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e11 (15%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNeither full nor upper c-spine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6 (55%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3 (30%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e11 (15%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e\u003cem\u003eCeAD= Cervical Artery Dissection; C-T: Cervico-thoracic; SMT: Spinal Manipulative Therapy; c-spine: cervical spine; * significant difference between categories (Association vs. Causal link vs. Other)\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eQualitative Results\u003c/h3\u003e\n\u003cp\u003eAnalysis of free-text responses (N\u0026thinsp;=\u0026thinsp;19) identified \"patient,\" \"history,\" and \"cervical\" as the most frequently occurring words (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, \u003cb\u003ePanel A\u003c/b\u003e). Keyword-based thematic analysis using 71 unique terms across four consolidated themes revealed \u003cem\u003eClinical Assessment \u0026amp; Management\u003c/em\u003e as the dominant theme, present in 89.5% of responses and encompassing patient evaluation, screening protocols, and clinical decision-making (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, \u003cb\u003ePanel B\u003c/b\u003e). \u003cem\u003eRisk \u0026amp; Safety\u003c/em\u003e appeared in 52.6% of responses, addressing potential complications and referral decisions. \u003cem\u003eEducation \u0026amp; Training\u003c/em\u003e (31.6%) and \u003cem\u003eEvidence Base\u003c/em\u003e (21.1%) were less prevalent. Response lengths varied considerably (mean\u0026thinsp;=\u0026thinsp;35.7 words, SD\u0026thinsp;=\u0026thinsp;36.4; median\u0026thinsp;=\u0026thinsp;28.0 words; range\u0026thinsp;=\u0026thinsp;5-169 words; Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, \u003cb\u003ePanel C\u003c/b\u003e), reflecting heterogeneity in faculty elaboration. \u003cem\u003eClinical Assessment \u0026amp; Management\u003c/em\u003e utilized the most extensive keyword set (n\u0026thinsp;=\u0026thinsp;35). Representative keywords and survey responses for each theme are presented in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ehere- Thematic analysis keywords and example responses\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTheme\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eKeywords\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSample Response\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClinical Assessment \u0026amp; Management\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003epatient, history, cervical, screening, manipulation, exam\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026ldquo;We review contraindications to HVLA (relevant recent trauma, vascular pathology, signs of instability, connective tissue disorder). If a patient has acute new neck pain and or headaches we take a thorough history looking for any symptoms of neuro involvement...\"\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRisk \u0026amp; Safety\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003erisk, safety, CAD, dissection, stroke, refer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\"Almost 100% of the CAD risk is in the patient history and not hearing the patient describe how their symptoms came on. Students need hear these warning signs and know when to refer out to stabilize an emergency situation before adjusting them.\"\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEducation \u0026amp; Training\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eteach, students, education, training, curriculum\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e\"I am still dissatisfied with how this is taught and would appreciate having an exhaustive search on this topic clarify how we should all collectively teach this issue.\"\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEvidence Base\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eevidence, research, literature, study, association\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e\"Much of my discussion involves a discussion of appropriate history and physical exam. An association between manipulation and CeAD certainly exists, but I have not been exposed to robust support indicating a particular style of SMT or refrainment (limiting rot, ext, etc.) has any particular influence.\"\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eChiropractic educators and the programs in which they teach serve as a critical foundation for knowledge dissemination, shaping the educational experiences of both current students and practicing clinicians. Faculty are responsible for remaining current with scientific literature, particularly regarding the techniques, efficacy, and safety of chiropractic care, and as such represent a valuable source of knowledge into modern chiropractic thought and the curricular content informing clinical practice. However, scant literature examines how chiropractic educators address specific clinical controversies within their curricular content. This study explored faculty perspectives on the potential association between cSMT and CeAD and assessed how their attitudes may influence the way the topic is presented in chiropractic education.\u003c/p\u003e \u003cp\u003eOur analysis revealed that respondents teaching in clinical settings were nearly twice as likely as their classroom-based colleagues to perceive the cSMT \u0026ndash; CeAD relationship as causal. In contrast, classroom faculty more frequently characterized the relationship as associational \u0026ndash; that is, rarely or never causal. Although the data did not provide direct explanations for this discrepancy, distinct contextual factors within each teaching setting may contribute to differing perceptions. Classroom faculty may rely more heavily on literature casting doubt on a causal relationship [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] and may be less likely to engage in active clinical practice. Clinical faculty, by contrast, are actively managing patient risk while supervising clinical interns, placing them in a position where medicolegal concerns and direct patient safety responsibilities may heighten caution. Notably, despite these divergent views on causation, both groups reported equal influence of CeAD risk on pretreatment screening instruction, suggesting that regardless of how faculty conceptualize the underlying mechanism, they converge on the practical importance of thorough patient education. Further work should aim to identify the underlying factors shaping these differing perceptions among faculty subgroups.\u003c/p\u003e \u003cp\u003eMany respondents reported modifying cervical spine adjusting techniques by minimizing rotation and extension, with a majority (61%) indicating they deliberately avoided these movements and emphasized this approach in their instruction. This adaptation may be informed by concerns about mechanical stress on the V3 segment of the vertebral artery, particularly near the C1 level [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Notably, these modifications appear to extend beyond upper cervical techniques to other cervical regions, with CeAD risk influencing cervicothoracic SMT instruction across groups. This broader application is plausible given that multi-segmental motion has been detected several spinal segments distant from the manipulation contact point [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], despite the expectation that short-lever techniques produce localized forces [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Faculty may therefore be applying precautionary modifications across the cervical spine as a pragmatic response to this biomechanical uncertainty.\u003c/p\u003e \u003cp\u003eThorough pretreatment screening, including a detailed history and physical exam, is essential in assessing a patient\u0026rsquo;s suitability for cSMT. In this study, faculty who endorsed a causal link between CeAD and cSMT were more likely to modify their screening practices, although most respondents across groups recommended some form of CeAD-related screening. While evidence of a causal relationship remains inconclusive, clinicians must remain vigilant for concerning symptoms (e.g., atypical headache, neck pain, dizziness/vertigo) [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] as well as a medical history of conditions with known associations with CeAD (e.g., migraine headache, hypertension, genetic connective tissue disorders, recent trauma) [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe dominance of the \u003cem\u003eClinical Assessment \u0026amp; Management\u003c/em\u003e theme is consistent with the finding that most respondents reported CeAD concerns influencing pretreatment screening instruction. This pattern extends beyond chiropractic education; Mourad et al. found that 70% of Italian physiotherapists reported performing additional screening prior to upper cervical manipulation, with safety perceptions varying significantly by spinal region [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Together, these findings suggest that heightened clinical vigilance around the cervical spine is a shared concern across professions that deliver spinal manipulation.\u003c/p\u003e \u003cp\u003eOur findings further suggest that chiropractic faculty are actively modifying teaching strategies specific to cSMT based on perceived CeAD risk. These modifications appear to be driven more by clinical experience and precautionary instinct than by engagement with published evidence. Bridging this gap through stronger integration of evidence-based content into CeAD-related instruction and more consistent educational frameworks across programs represents an important next step. Future research with larger, more diverse samples and more targeted questions regarding the basis for faculty beliefs could further clarify the drivers of cSMT-related instructional practices.\u003c/p\u003e \u003cp\u003eLimitations\u003c/p\u003e \u003cp\u003eThis study has several notable limitations. The snowball sampling approach precluded determination of the exact number of faculty who received the survey, preventing calculation of an individual-level response rate. While 17 of 28 invited programs participated, this convenience sampling strategy limits generalizability. To protect anonymity, no identifiable information was collected, precluding analysis of demographic factors, such as years of experience or clinical background, that may influence faculty perspectives. The qualitative component was limited to 19 free-text responses of variable length, and the cross-sectional design captures perspectives at a single point in time rather than how beliefs evolve with experience or emerging evidence.\u003c/p\u003e"},{"header":"CONCLUSIONS","content":"\u003cp\u003eThis study demonstrates differing views about the relationship between cSMT and CeAD based on instructional setting, with clinical faculty more likely to endorse a causal relationship and classroom faculty more often viewing the association as rarely or never causal. These findings highlight the need for evidence-aligned curricular guidance to promote consistency in how CeAD-related risk is addressed across chiropractic educational programs.\u003c/p\u003e \u003cp\u003eThe collection method used in this study makes calculating response rate difficult, limiting generalizability.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eFUNDING\u003c/p\u003e\n\u003cp\u003eNo external funding was provided or utilized.\u003c/p\u003e\n\u003cp\u003eETHICS\u003c/p\u003e\n\u003cp\u003eThis project was presented to the IRB committee and deemed exempt.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eSymons BP, Leonard T, Herzog W. Internal forces sustained by the vertebral artery during spinal manipulative therapy. J Manip Physiol Ther. 2002;25:504\u0026ndash;10.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e[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\u0026ndash;82.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGorrell LM, Sawatsky A, Edwards WB, Herzog W. Vertebral arteries do not experience tensile force during manual cervical spine manipulation applied to human cadavers. J Man Manipulative Therapy. 2023;31:261\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eQuesnele JJ, Triano JJ, Noseworthy MD, Wells GD. Changes in Vertebral Artery Blood Flow Following Various Head Positions and Cervical Spine Manipulation. J Manip Physiol Ther. 2014;37:22\u0026ndash;31.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFagundes C, Duarte FCK, Herzog W. STRAIN in vertebral artery during passive cervical range of motion and spinal manipulation therapy: A systematic review and meta-analysis. Clin Biomech Elsevier Ltd. 2025;130:106685.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePlachinski SJ, Gliedt JA, Sacho R, Schneider MJ, King JA. Spinal manipulative therapy and cervical artery dissection: A retrospective comparison with spontaneous, traumatic, and iatrogenic etiologies at a single academic medical center. Clin Neurol Neurosurg. 2021;209:106941.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMoser N, et al. Effect of cervical manipulation on vertebral artery and cerebral haemodynamics in patients with chronic neck pain: a crossover randomised controlled trial. BMJ Open. 2019;9:e025219.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWynd S, Westaway M, Vohra S, Kawchuk G. The Quality of Reports on Cervical Arterial Dissection following Cervical Spinal Manipulation. PLoS ONE. 2013;8:e59170.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGrainger RG, Strohecker K. Deaths after Chiropractic: A Review of Published Cases. in (2010).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePohlman KA, Salsbury SA, Funabashi M, Holmes MM, Mior S. Patient safety in chiropractic teaching programs: a mixed methods study. Chiropr Man Th. 2020;28:50.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCassidy JD, et al. Risk of Vertebrobasilar Stroke and Chiropractic Care: Results of a Population-Based Case-Control and Case-Crossover Study. Spine. 2008;33:S176\u0026ndash;83.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCassidy JD, et al. Risk of Carotid Stroke after Chiropractic Care: A Population-Based Case-Crossover Study. J Stroke Cerebrovasc Dis. 2017;26:842\u0026ndash;50.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChurch EW et al. Systematic Review and Meta-analysis of Chiropractic Care and Cervical Artery Dissection: No Evidence for Causation. \u003cem\u003eCureus\u003c/em\u003e \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.7759/cureus.498\u003c/span\u003e\u003cspan address=\"10.7759/cureus.498\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e (2016) doi:10.7759/cureus.498.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWhedon JM, et al. The association between cervical artery dissection and spinal manipulation among US adults. Eur Spine J. 2023;32:3497\u0026ndash;504.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAnderst WJ, et al. Intervertebral kinematics of the cervical spine before, during, and after high-velocity low-amplitude manipulation. Spine J. 2018;18:2333\u0026ndash;42.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBergmann TF, Peterson DH. Chiropractic Technique: Principles and Procedures. St. Louis: Elsevier Mosby; 2011.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGottesman RF, et al. Clinical characteristics of symptomatic vertebral artery dissection: a systematic review. Neurologist. 2012;18:245\u0026ndash;54.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMetso TM, et al. Migraine in cervical artery dissection and ischemic stroke patients. Neurology. 2012;78:1221\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDebette S, et al. Association of vascular risk factors with cervical artery dissection and ischemic stroke in young adults. Circulation. 2011;123:1537\u0026ndash;44.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBlum CA, Yaghi S. Cervical Artery Dissection: A Review of the Epidemiology, Pathophysiology, Treatment, and Outcome. Arch Neurosci. 2015;2:e26670.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTrager RJ, Troutner AM, Pikus HJ, Daniels CJ, Dusek JA. Symptoms of Patients With Vertebral Artery Dissection Presenting to Chiropractors: A Systematic Review and Meta-Analysis. \u003cem\u003eCureus\u003c/em\u003e \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.7759/cureus.51297\u003c/span\u003e\u003cspan address=\"10.7759/cureus.51297\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e (2023) doi:10.7759/cureus.51297.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMourad F, et al. Knowledge, beliefs, and attitudes of spinal manipulation: a cross-sectional survey of Italian physiotherapists. Chiropr Man Th. 2022;30:38.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"chiropractic-and-manual-therapies","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"chmt","sideBox":"Learn more about [Chiropractic \u0026 Manual Therapies](http://chiromt.biomedcentral.com/)","snPcode":"12998","submissionUrl":"https://submission.springernature.com/new-submission/12998/3","title":"Chiropractic \u0026 Manual Therapies","twitterHandle":"@ChiroManTher","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Manipulation, Spinal, Questionnaires and Surveys, Education, Risk Management, vertebral artery dissection","lastPublishedDoi":"10.21203/rs.3.rs-9096984/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9096984/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eBackground\u003c/p\u003e\n\u003cp\u003eCervical artery dissection (CeAD) remains a rare but clinically important condition that has generated longstanding debate regarding its potential association with cervical spinal manipulative therapy (cSMT). Although biomechanical and epidemiologic studies have examined this relationship, little is known about how chiropractic educational programs address CeAD or how faculty perceptions shape instructional practices. This study surveyed chiropractic faculty who actively teach cervical manipulation to understand how educators conceptualize CeAD risk and incorporate safety considerations into curricula.\u003c/p\u003e\n\u003cp\u003eMethods\u003c/p\u003e\n\u003cp\u003eAn anonymous twelve-item electronic survey was distributed via Qualtrics to faculty from 28 English‑speaking chiropractic programs between February and March 2025. Snowball sampling recruited instructors who had taught hands‑on cervical manipulation within the prior five years. Survey items assessed teaching setting, beliefs about the cSMT–CeAD relationship, and whether perceived risk influenced screening procedures and technique modification. Quantitative data were analyzed using descriptive statistics and chi‑square tests; qualitative responses underwent keyword extraction and topic modeling.\u003c/p\u003e\n\u003cp\u003eResults\u003c/p\u003e\n\u003cp\u003eFaculty from seventeen of the 28 invited chiropractic programs participated (61% program response rate), yielding 103 responses with 75 meeting inclusion criteria; 49 were classroom faculty and 26 were clinical faculty. Teaching setting significantly influenced faculty perspectives on CeAD causation (p = 0.03). Classroom faculty more likely to report that \u0026nbsp;cSMT is rarely or never causally related to CeAD (67% vs 42%), whereas clinical instructors more frequently acknowledged a causal relationship mediated by modifiable risk factors (58% vs 33%). Most faculty (73%) incorporated CeAD education through didactic instruction and case-based discussions. Qualitative analysis of free text responses were organized into four major themes: (1) Clinical Assessment \u0026amp; Management; (2) Risk \u0026amp; Safety; (3) Education \u0026amp; Training; (4) Evidence Base.\u003c/p\u003e\n\u003cp\u003eConclusions\u003c/p\u003e\n\u003cp\u003eTeaching setting significantly influenced how chiropractic faculty conceptualize and teach CeAD risk. Findings reveal opportunities to strengthen evidence‑aligned patient‑safety education and establish instructional guidance across chiropractic programs.\u003c/p\u003e\n\u003cp\u003eThe collection method used in this study makes calculating response rate difficult, limiting generalizability.\u003c/p\u003e","manuscriptTitle":"Educational approaches to the relationship between cervical adjusting and risk of cervical artery dissection; a survey of chiropractic faculty","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-19 07:50:40","doi":"10.21203/rs.3.rs-9096984/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-04-29T08:26:09+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-28T12:59:02+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-27T21:47:52+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"294713121154694215533203595196881592432","date":"2026-04-20T13:46:57+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-15T18:05:43+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"201901261919293473542206796141496861140","date":"2026-04-15T15:07:57+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"313061701356971668216195922732654992132","date":"2026-04-08T19:22:12+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-08T08:09:38+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-04-07T09:11:26+00:00","index":"","fulltext":""},{"type":"submitted","content":"Chiropractic \u0026 Manual Therapies","date":"2026-03-31T18:59:03+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"chiropractic-and-manual-therapies","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"chmt","sideBox":"Learn more about [Chiropractic \u0026 Manual Therapies](http://chiromt.biomedcentral.com/)","snPcode":"12998","submissionUrl":"https://submission.springernature.com/new-submission/12998/3","title":"Chiropractic \u0026 Manual Therapies","twitterHandle":"@ChiroManTher","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"4216370a-baeb-4cb2-b763-485bd5f2a618","owner":[],"postedDate":"April 19th, 2026","published":true,"recentEditorialEvents":[{"type":"decision","content":"Revision requested","date":"2026-04-29T08:26:09+00:00","index":"","fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"in-revision","subjectAreas":[],"tags":[],"updatedAt":"2026-04-29T08:40:00+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-19 07:50:40","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9096984","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9096984","identity":"rs-9096984","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}