Current Issues in the ChiropracTIC Profession
Current Issues in the
As the thought leader in the chiropractic profession Life University is pleased to provide important details, analysis and interpretation of current events and issues in and around the chiropractic community.
We have designed this page to be a resource for you and your colleagues. Please feel free to make use of the information provided–with appropriate attribution when indicated. In addition please feel free to share this information with anyone concerned about the issues and events discussed by Life University.
The Katie May Discussion
FROM PRESIDENT RIEKEMAN
The media coverage we are experiencing regarding Ms. Katie May’s tragic death is not unlike related events in our past. The reporting is tinged with fear, expresses foggy science, misrepresents facts and includes personal emotions and political agendas. In some cases, the Coroner’s references for example, outright inaccuracies have been expressed. Unfortunately, by the time all of this is ferreted-out the public relations damage is done.
There are three stages to our response as a profession…
The immediate response to the media and the lack of research and fair reporting.
There were some excellent responses from our colleagues, colleges, insurance providers and researchers. I want to personally thank them for how they represented us and the pride we have for the chiropractic profession.
WE HAVE ORGANIZED THE BEST OF THESE RESPONSES TO ALLOW YOU EASY ACCESS TO THEM FOR YOUR OWN KNOWLEDGE AND TO HELP YOU ADDRESS YOUR PATIENTS’ QUESTIONS.
Prepare for the new expressions of concern and media activity.
New information will continue to become available for some time. The first round of acute media attention has subsided, but, there are likely more articles coming in magazines and journals as well as opinion pieces related to this situation. We need to get our ducks lined up and be proactive. As more information comes out we will likely find details that serve to lessen a focus on chiropractic care as the cause of the initial problem. LIFE UNIVERSITY WILL CONTINUE TO MONITOR RELATED EVENTS AS THEY EVOLVE AND KEEP YOU UPDATED.
Finally, we need to make sure we are clinically and academically prepared for this and future events/questions.
TO THIS END WE HAVE ASKED LIFE UNIVERSITY’S DR. GERRY CLUM TO PROVIDE A SEMINAR/WEBINAR TYPE PRESENTATION SO YOU CAN SHARPEN YOUR CLINICAL UNDERSTANDING AND EXPERTISE WITH RESPECT TO CERVICAL SPINE ADJUSTING AND ARTERIAL ISSUES.
Life University will continue to work with others in our profession on this issue and you can always come back to Today’s Chiropractic Leadership (TCL) magazine/web site for new/accurate information.
One last suggestion….don’t get drawn into requests from the media for your response/reaction to these matters unless you have had media training. You don’t want to expose yourself to the potential to have your words misused to abuse you and to distort your intentions. IF YOU RECEIVE SUCH A REQUEST, PLEASE REFER THEM TO LIFE UNIVERSITY, OR ONE OF THE SOURCES WE’VE LISTED HERE FOR AN ACCURATE AND APPROPRIATE RESPONSE.
Let us know how we can continue to support you and your patients.
Guy Riekeman, DC
The Katie May Discussion on the Dr. Oz Show – Aired November 16, 2016
The profession owes a bid of thanks to 1996 LIFE University graduate, Dr. Steven Shoshany for his ninth and most important appearance on The Dr. Oz Show. In the past, shows would be taped and then aired 7-10 days later. This time, the show was taped on November 15 and aired on November 16 placing it in the heart of “sweeps week” when viewership is carefully assessed. This is a statement about the number of people to whom this show would be of interest as the show explored the role, if any, between the death of Ms. Katie May and the care she received from a chiropractor.
Dr. Shoshany reached out to a select few experts in the profession when this opportunity presented itself to make sure he was up to date and current with the literature and thinking of the day on the nexus between cervical spine adjustment and cervical artery dissection and stroke. Thanks are due to Jason Deitch, D.C. and Gerard Clum, D.C. both of Life University who spent hours reviewing the science, role-playing the interview and refining Dr. Shoshany’s preparation for this moment.
The preparation paid off! Dr. Shoshany was articulate, at ease, confident, and effective as he represented LIFE as an alumnus as well as the chiropractic community at large on this critically important national stage. Congratulations Dr. Shoshany!
On Tuesday, November 15, 2016, The Dr. Oz Show filmed two segments addressing the death of Ms. Katie May. The first segment involved the family of Ms. May who believe Ms. May’s death was a result of the care she received from a chiropractor. The second segment involved Dr. Oz, Dr. Carolyn Brockington, a neurovascular surgeon, Mt. Sinai Hospital in New York and Dr. Steven Shoshany, a practicing chiropractor from New York.
While the consideration of any adverse outcome associated with our care is unflattering, the manner in which this situation was addressed by all three panelists was fair, constructive and informative for the public. There was no condemnation of chiropractic, and there was no statement, in this segment, that the chiropractor caused this problem. To the contrary, there was a thorough discussion of vertebral artery dissection, including its rarity in association with chiropractic care, its ability to present in seemingly healthy middle-aged persons, discussion that most dissections do not evolve into a stroke and finally that death from arterial dissection is extremely uncommon.
Three questions were posed to Dr. Shoshany in the six-and-a-half-minute segment including:
- Did cervical manipulation play a role in the circumstances of Katie May?
- How important is a patient history in helping to understand this problem?
- What are chiropractors doing to address these situations?
Dr. Shoshany expressed condolences to the family of Ms. May and went on to explain that the best science available suggests that this was a dissection in progress that occurred during the photo-shoot involving Ms. May. He used a Bow-Hunter’s Stroke as an example of the mechanism of causation—that is the strain of maintaining a stressed position for a period yielded the injury. He related how rare these events are in chiropractic.
The discussion moved to comments from Dr. Brockington, the neurovascular surgeon. She was asked point blank by Dr. Oz “do you think manipulation caused the dissection?” She did not say the chiropractor caused this stroke. She did not raise undue concern about cervical spine adjusting.
In response, she related that she, as a stroke specialist, sees strokes every day. Some of the strokes she sees have known causes and many don’t. She related that she recently saw a gentleman who developed an arterial dissection while painting. She noted that these conditions can occur in seemingly healthy persons in their 30-50s with no prior history. She reviewed an angiogram to show what a dissection looked like on imaging and to explain how it was related to blood flow and oxygenation of the brain. She discussed that most dissections don’t lead to stroke, but cervical artery dissection did account for 1 in 5 strokes in middle-aged persons.
The conversation moved to the second question about the value of a patient history. Dr. Shoshany related that, as a clinician, Dr. Oz appreciated that the patient history was the most valuable tool we have to work with. He related the importance of knowing about a history of stroke, aneurysm, dissection, collagen disorders, etc. Dr. Oz then walked the audience through the 5 Ds, the 3 Ns and the A associated with cervical artery dissection:
- Drop Attacks
The advice given was that one should think of their neurologist or visiting the emergency room rather than chiropractor when one has neck pain with these additional symptoms.
The third question about what the profession is doing about this problem allowed Dr. Shoshany to explain that the profession has been addressing this situation for decades. He also added that he has delivered more than 200,000 cervical adjustments in his 20+ years of practice in Manhattan without a single occurrence of this problem. He added that Life University, the largest single campus chiropractic program in the world, has provided an estimated 4.5 million cervical adjustments during the past 25 years without any incident of this nature. Finally, he added that among the 17 chiropractic educational programs in the United States, there has not been a single incident, to his knowledge, of this nature in the past 20 years.
Dr. Oz read a statement from the American Chiropractic Association (ACA) commenting on how DCs are educated and trained in differential diagnosis based on history, examination, etc., and that they are trained to refer when necessary for further evaluation or emergency intervention.
Dr. Shoshany again emphasized the safety of chiropractic and offered the view that when you consider our safety record in light of 45 people dying every day of opioid use and abuse, chiropractic care is even safer than first thought.
The segment ended with Dr. Oz offering the following comments:
- Cervical artery dissections happen; this doesn’t mean you need to avoid going to your chiropractor.
- This doesn’t mean it was caused by the chiropractor.
- It does mean anyone with neck pain needs to fully advise their chiropractor of any other symptoms or problems they are having with the neck pain.
- The family of Ms. May is naturally upset about the loss of a loved one. They are entitled to their emotional grief, and if they may choose to direct it toward our profession, so be it. There is nothing to be gained by engaging them in a discussion while they are in their emotional state.
- Have the data cited on The Dr. Oz Show from chiropractic education in mind when you speak with patients about these matters:
- Life University, 25 years, 4.5 million cervical adjustments—no dissection related issues
- Among all 17 chiropractic educational institutions, 20 years, millions of cervical adjustments—no dissection related issues
- The 25-year window at LIFE and the 20-year window across chiropractic education should not imply something happened 26 or 21 years ago, respectively. The data isn’t available for the period before those dates.
- Patients will want to chat about the 5 Ds, 3 Ns and the A
- Dysphagia, dysarthria, diplopia, drop attacks and nystagmus are important symptoms that, by themselves in the presence of neck pain, strongly suggest referral.
- Dizziness, nausea, numbness and ataxia are not as strongly associated by themselves with dissection and stroke, but you should look for the development of these symptoms in a constellation as a guide to increasing your index of suspicion.
- When patients present saying that my neck pain is “unlike any pain I ever had before in my life” or “the most unusual pain I have ever had” or “the worst pain I have ever had,” THINK about the possibility of a dissection in progress and handle accordingly.
- Chiropractic care is very safe. When it is viewed in a comparative sense with pharmaceuticals or surgery for similar types of problems, it is remarkably safe. Life has risks. There are fewer risks under chiropractic care than under medical or surgical care.
- This wasn’t discussed on The Dr. Oz Show, but it is something you should be aware of: The Coroner’s Report in the case of Ms. May noted: “Bilateral vertebral artery dissection is a rare complication of neck manipulation in one per 100,000 to one in 2 million manipulations. (South Med J. 2007 Feb; 100(2):201-3)”
- The literature cited is misquoted as follows:
- The article states “Serious complications are infrequent, with a reported incidence between one per 100,000 and one per 2 million manipulations.”
- This does not refer exclusively to vertebral artery complications.
- This does not refer to bilateral vertebral artery dissection.
- The article states “Serious complications are infrequent, with a reported incidence between one per 100,000 and one per 2 million manipulations.”
- The literature cited did not identify an arterial dissection-unilateral or bilateral on imaging or during autopsy.
- The literature cited was the weakest class of evidence, a single case study, and neglected the opportunity to refer to two more recent case-control and case-crossover studies (Cassidy, 2008) and Kosloff (2015). He also chose not to refer to a recent meta-analysis on this subject conducted by neurosurgeons at Penn State Hershey Medical Center (Church, 2016).
- Bilateral cervical artery dissection is more commonly associated with arteriopathy than with other causes.
- The literature cited is misquoted as follows:
The Next Steps
Some advice and a couple of requests:
We are all concerned when reports create a cloud of confusion or suspicion relative to our care. We find it to be unfair and unreasonable when you consider more than 100,000 deaths annually in the U.S. from PROPERLY prescribed drugs. That inequity notwithstanding, we want and need our care to be safer tomorrow than it was today. Make sure you are up to date with the current literature on this subject. Make sure your procedures fully appreciate the role of the 5 Ds, the 3 Ns and the A. Include questions about a history of stroke, aneurysm and dissection in the patient and their family in your case history and act accordingly.
This is not the time to start your media career. Unless you have had extensive media training and you are intimately familiar with the literature on this subject, pass along any inquiries you receive to your state association, your chiropractic alma mater or other trusted resource for response.
Don’t be defensive. Answer patient’s question as they arise. Respect any request they might make of you regarding their care—assuming it does not endanger them in some way.
Congratulations to Dr. Shoshany for representing the profession so well. Our thanks to Dr. Oz for a fair and balanced discussion of vertebral artery dissection. We hope you will use this as a teaching opportunity in your office and community in the best interests of the public and the profession.
October, 2016. Gerard W. Clum, D.C.
October, 2016. Jack Wolfson, M.D.
November, 2016. Gerard W. Clum, D.C. and Stuart Hoffman, D.C.
First and foremost…
What has been reported in this matter?
- It has been reported that Ms. May experienced a significant fall resulting in an injury to her neck starting this series of events.
- It appears this is NOT the case. Rather her neck pain began after being requested to hold a pose during a photo shoot with her back arched and her neck leaning to the side.
- She reported on social media having a “pinched nerve” following this photo shoot.
- It was reported that Ms. May sought care from an emergency room for the neck pain and discomfort she was experiencing.
- This does NOT appear to be the case. As best we understand the situation Ms. May did not visit an emergency room or health care provider other than a chiropractor.
- It appears she was seen by a Doctor of Chiropractic on January 27, 29 and February 1, 2016.
- It has been reported she received HVLA, LVLA “manipulation” and she had “mechanical traction.”
- In the eight hours after she was treated on Feb. 1, Ms. May progressively felt worse, with dizziness growing into a headache, numbness and slurred speech.
- tPA was administered in the hospital.
- She was diagnosed as having bilateral vertebral artery dissections.
What is known about the situation?
- What is “known” to us has been gleaned from recent news reports. To our knowledge, no one in the profession has reviewed the Los Angeles County Coroner’s Report.
- The main cause of death is reported to have been listed as: “infarction of the brain;” a secondary cause of death has been reported as being: “vertebral artery dissection”; In response to the question of how the injury occurred, the coroner reported: “Neck manipulation by chiropractor.”
- According to news reports, Ms. May experienced “bilateral vertebral artery dissections.” It was also reported the left was more severe and the right more recent.
- Ms. May died on February 4, 2016.
What is yet to be learned from this case?
- At this point the profession knows nothing about:
- What symptoms did she present? How did they change during the ensuing days?
- What was done by the D.C. to assess Ms. May when she presented for care?
- What care was provided to Ms. May by the Doctor of Chiropractic and how she responded to the care over time?
- Did she present with any signs or symptoms that the Doctor of Chiropractic should have responded to but failed to?
- Did the Doctor of Chiropractic make any recommendations that Ms. May did not follow through with, such as a referral to an ER or a neurologist?
- Did Ms. May sign an informed consent to care that related an association between vertebral artery dissection and chiropractic care?
- We have not seen a copy of the coroner’s report. It has been reported that the coroner commented that he has never seen a case of this type in his career.
- This leads us to question how familiar he would be with the nuanced nature of this problem and the literature associated with it.
How does this case square with the evidence published to date?
- This case appears to fit the scenario of a dissection in progress—that is the neck pain was a sign of the dissection underway.
The critical questions are then:
- Did the Doctor of Chiropractic fail to recognize the evolving dissection, and/or,
- Did the care of the Doctor of Chiropractic worsen the evolving dissection the patient presented with?
- Ms. May did fall within the under 45 age group; she was female; she may have been on birth control medications; she may have a family history of aneurysm or vessel disorders; she may have had an undiagnosed collagen disorder increasing her predisposition for dissection.
- The unanswerable question in this matter is:
- Had Ms. May never sought care from the Doctor of Chiropractic would her fate have been the same?
What can we learn from this experience?
- To be alert to the dissection in progress possibility in patients that present with neck pain and headache of an unusual origin or nature
- To explore symptoms of neck pain and headache with patients during your assessment. Learn as much as possible about the pain, the presentation and the history of it. Look for unique characteristics in terms of the type of pain, intensity, how it arose, etc.
- Make sure your informed consent documents discuss, in language understandable to a patient, the association between chiropractic care and vertebral artery dissection.
- Make sure your delivery of the informed consent offers the patient the opportunity to go over any questions or concerns they have with you.
- Make sure your records reflect the informed consent discussion. Maintain informed consent documents signed by patients.
- Update your informed consent as the literature evolves.
- Take this as an opportunity to review the literature on the relationship between cervical spine adjusting and arterial dissection— whether that be a matter of association or causation.
- Cassidy, 2008; Kosloff, 2015; Church 2016
What do I need to do differently as a Doctor of Chiropractic in light of this case?
- Patient history—explore headache and neck pain as fully as possible, looking for:
- Pain described as being unlike anything I have ever had before in my life, or, the worst pain I have ever had
- A family history of aneurysm or dissection
- Patient or family history of Marfan’s, osteogenesis imperfecta 1, Ehler-Danlos syndrome, fibromuscular degeneration, clotting disorders
- Physical examination—in headache and neck pain patients in particular, listen for bruits and look for neurological changes with cervical motion—active or passive
- 5 D’s, 3 N’s and an A
- Dizziness, diplopia, dysphagia, dysarthria, drop attacks
- Nausea, numbness, nystagmus
- If you have any concern, run through a quick cranial nerve assessment, DTR and dermatomes check.
- If you think there is a possibility for concern regarding a dissection in progress refer for consultation. Where the referral should be made will be directed by the severity of the presentation.
- Review your office procedures regarding handling an emergency situation. Put those procedures in writing and review with your staff on a regular basis. Have emergency contact information at your fingertips.
- Document, document, document.
Putting the reaction to this case in context as a chiropractor
- More than 3 people per hour are dying from opiate use/abuse.
- Thousands die annually due to surgical errors and preventable complications.
- Medical care is considered to be the 3rd leading cause of death in the United States.
- While not dismissing or discounting any death, why is the unfortunate passing of one patient, possibly as a complication of chiropractic care, national news?
- I can’t answer that definitively. I have my thoughts as I am sure you do. Nonetheless, for the moment as unfair as it may seem and as disproportionate as it may appear, it is the way it is.
- Our job is to stay focused on the patient first, second and always.
- You may feel a need to “set the record straight” or you may even feel like we as a discipline are being unfairly judged in this situation, you may be approached by local, state or national news media for comment. Resist the desire to accept the offer, refer them to the CCA and go back and take great care of your patients.
- This is not the issue, nor the time, to cut your teeth being a spokesperson for the profession. If you have not undergone considerable media training and you are not intimately familiar with the literature of this situation do not enter the fray!
- It might be heartening to read what others are saying about this situation:
As reported in the Pittsburgh Post-Gazette, October 23, 2016:
- Robert Harbaugh, M.D., Director, Penn State Institute of the Neurosciences: “the chiropractor got caught in the middle” and was unlikely to have caused the original tear. “I think the data is overwhelming that there’s a very low risk” of dissection from neck manipulation.
- Felipe Albuquerque, a Phoenix neurologist who has researched dissection after neck manipulation by chiropractors, agreed with chiropractors that Ms. May “probably injured her artery during the [modeling] pose…“But certainly it was worsened during the chiropractic maneuver,” (Emphasis added)
- Albuquerque is published in this area, Journal of Neurosurgery, January 2011
- As reported in the PeopleBodies, October 21, 2016:
- Jeff Wang, M.D., Co-director of the University of Southern California Spine Center characterized the matter as a “freak accident.”
- You know, better than anyone else, the results your patients experience under chiropractic care. You appreciate the value of cervical spine care in so many patients. You know how gentle adjustments can be and how hard you work to make sure your adjustments are delivered with great skill. You know the millions of adjustments provided daily and the safety of chiropractic care. And you know protection of your patient and acting in their best interests is the job of each and every one of us.
From Other Sources
Our sympathy goes out to the family of Katie May. With respect to the safety of neck manipulation, it’s important to understand there are risks and benefits to all treatments; however, the best available evidence indicates there is no causal relationship between neck manipulation and stroke. Millions of neck manipulations are performed safely in the U.S. every year, providing patients relief from common forms of neck pain and headache, and helping them to get back to their normal activities.
If you are visiting a doctor of chiropractic and have upper neck pain or headache, be very specific about your symptoms. This will help your doctor of chiropractic offer the safest and most effective treatment, even if it involves referral to another health care provider. If the issue of stroke concerns you, do not hesitate to discuss it with your doctor of chiropractic. Depending on your clinical condition, he or she will recommend the most appropriate and safest treatment for your particular condition. Treatments may include joint mobilization, therapeutic exercise, soft-tissue techniques or other therapies.
According to the various media reports, Katie May, a well-known model dubbed “The Queen of
Snapchat,” suffered a trauma to her neck to which she sought care from a chiropractor.
According to news sources, her father has made remarks that suggest that her chiropractic care
played a role in her untimely death.
As you have likely seen in the news this week, there are reports revealing that the Los Angeles Coroner’s Office cited injury from neck manipulation as a factor in the accidental death of celebrity Katie May, who passed away in February. CCA has been monitoring the news closely and we are available to provide comments, should media inquire more about the situation.
Should you or your office be contacted by the media, we encourage you to forward those inquiries to Cris Forysth, CCA Director of Governmental Affairs and Communications and we will respond accordingly. Please do not comment as a representative of CCA.
Someone in America dies from stroke every four minutes. While many people are familiar with the signs and symptoms of the most common forms of stroke, which tend to disproportionately affect older adults, there has been less public outreach regarding Cervical Artery Dissection (CAD), which can lead to a rare form of stroke that affects adults aged 45 or younger. The vast majority of CAD cases are spontaneous, meaning that the underlying cause is unknown.
Because there are documented cases in which a patient has sought chiropractic care prior to experiencing CAD, some medical physicians have hypothesized that spinal manipulative therapy may result in CAD and stroke. However, neither the clinical or basic science research available on this issue has established a cause-and-effect relationship. (See the video from the Palmer Center for Chiropractic Research for more information.)
Some years back, the Journal of the American Medical Association published a study indicating that in the hospital, taking the correct drug for the correct diagnosis in the correct dosage resulted in the death of 106,000 Americans per year (the upper range was 137,000). These are considered non-error deaths, as the drug, diagnosis and dosage were all correct. The article notes that this number constitutes the fouth to sixth leading cause of yearly death in the United States. Again, assuming that a similar number of deaths occur from taking the correct drug in the correct dose for the correct problem outside of the hospital setting (extended care facilities, nursing homes, at home, etc.), the number of yearly non-error deaths from medical care would be approximately 212,000. Adding the error deaths and the non-error deaths from medical care
would total approximately 714,000 yearly.
Interestingly, from the Journal of the American Medical Association article, 2,216,000 Americans suffer serious adverse reactions from correctly taken drugs in the hospital yearly, but don’t die. The authors defined a serious adverse reaction as one that requires a hospital stay to recover and/or an event that resulted in a lifelong disability. In comparison, Chiropractic is exceedingly safe.
J. David Cassidy, DC, PhD, DrMedSc, Eleanor Boyle, PhD, Pierre Coˆte´, DC, PhD, Yaohua He, MD, PhD, Sheilah Hogg-Johnson, PhD, Frank L. Silver, MD, FRCPC, and Susan J. Bondy, PhD (2008) Risk of Vertebrobasilar Stroke and Chiropractic Care. Results of a Population-Based Case-Control and Case-Crossover Study, SPINE Vol 33, Number 45. pp (S176–S183)
Thomas M. Kosloff, David Elton, Jiang Tao, and Wade M. Bannister (2015) Chiropractic Care and the Risk of Vertebrobasilar Stroke; Results of a Case-Control Study in U.S. Commercial and Medicare Advantage Populations, Chiropractic and Manual Therapies Vol 23, Number 19.
Ephraim W. Church , Emily P. Sieg , Omar Zalatimo , Namath S. Hussain , Michael Glantz, Robert E. Harbaugh (2016) Systematic Review and Meta-analysis of Chiropractic Care and Cervical Artery Dissection: No Evidence for Causation, DOI: 10.7759/cureus.498.