Jan 7, 2014

Chiropractors and Strokes: A Sometimes Twosome, aka It All Started with a Grocer

I once went to a chiropractor. I thought he was nuts, and I thought I was nuts to let him manipulate my neck. So it didn't happen. He charged me 95 bucks for an evaluation because only in certain limited circumstances is chiropractic covered by insurance. Before I reveal the relationship between chiropractors and strokes, it's background time, to put chiropractors, bless their crazy, little hearts, in proper perspective.

D.D. Palmer, a teacher, grocery man, and magnetic healer who once said that manipulation is the cure for all diseases for the human race, founded chiropractic medicine in 1895, attempting to merge science and metaphysics, i.e., an offshoot of philosophy that studies the bottom-line structure of reality, or from Merriam Webster's dictionary, "of that which is real, insofar as it is real," and based on its tenets of naturalism, magnetism, spiritualism, voo-doo (just kidding about the voo-doo), and other things that couldn't be proved by scientific methodology. Palmer's chiropractic treatise on spinal manipulation likened the body to a machine whose disguishable parts could be aligned and ultimately fixed, using no drugs.

Calling himself a self-proclaimed doctor, "Dr." D.D. Palmer built a magnetic healing facility in Davenport, Iowa, upsetting a writer at a local paper who said, "His victims are the weak-minded, ignorant and superstitious, those foolish people who have been sick for years and have become tired of the regular physician and want health by the short-cut method…he has certainly profited by the ignorance of his victims…. His increase in business shows what can be done in Davenport, even by a quack."

The contention didn't stop Palmer. After a long battle that started in the early 1900s, the philosophy of chiropractic medicine has given society a mixed bag of chiropractors which, said Joseph Keating, Jr., a disciple of Palmer's, in Keating's book, Philosophy in Chiropractic, "Despite their emphasis of manual therapy, [chiropractors] may vary on their perceived scope of practice, interventions and their role in the health care system." And there it is. That's another way of saying that chiropractic medicine has few protocols regarding how the chiropractic industry operates.

As far back as the 1960s, the American Medical Assiciation (AMA) announced that chiropractic medicine was an "unscientific cult." That decade also brought the AMA Board of Regents' "Committee on Quackery" with the principles of eradicating chiropractic medicine to ensure that Medicare should not cover chiropractic services. (They still don't cover much today). Every decade after brought refinement and more allowed services to chiropractors and those that seek chiropractic care. Still, many medical professionals, orthopedists in particular, do not recognize the chiropractic profession at all. And most doctors don't validate, if they validate it at all, chiropractic medicine for children.

In every state in the US, there's been suits against chiropractors for one

thing or another. Let's go through a sample in the recent past:
In West Virginia, a chiropractic firm was found guilty of insurance fraud, in convincing new patients that they had serious spinal conditions, even if they did not;
In Kentucky, "Dr." Paul Hollern taught his student chiropractors to sell patients needless services.
In Texas, an accident clinic was found guilty of overtreatment and unnecessary referrals.
In New Jersey, insurance fraud busted people, including chiropractors, for involvement in "staged" accidents.
In Illinois, ten Chicago area chiropractic clinics and five chiropractors, among others, were charged with the unlicensed practice of medicine, illegal self-referrals, fee splitting, and inflated and false medical claims.
In California, a bunch of chiropractors got indicted on charges that they were involved with massage-producing prostitutes.
In Florida, charges were brought against a chiropractor and others who allegedly committed social security fraud and insurance fraud where the insurance companies were billed for massages.

Sharon Hill, an Australian writer for Doubtful.com, who mission is to expose "quacks," zeroed in on many, uh, let's say, questionable techniques that chiropractors have used, some as recently as late as least year. She has written about actions taken against chiropractors who have no business, according to Hill, doing what they do. Hill covers the gamut, like a "cure" for diabetes in her August 26, 2013, edition. "Diabetic Solutions MD promises it can help cure diabetes through a step-by-step process and nutritional supplements that could cost you thousands. Don’t be misled by the MD in the title. The doctors pitching the supplements are licensed chiropractors whose practices revolve around marketing supplements and diet plans, Hill says. 

And in September 2007, Hill writes, Sandra Nette went in for a neck adjustment and wound up with a stroke. She said the chiropractor forged consent forms after the stroke. She remained in a "locked-in" position, meaning that she unable of walking and barely able to speak or swallow. She was offered an out-of-court settlement for an undisclosed amount. Or these titles: Animal chiropractic: Not all it’s cracked up to be (snakes, too. Snakes?); Chiropractic care for kids called into question; Chiropractors jumping on chance to capitalize on meningitis scare, and more.

All of those cases have some relationship to greed. I agree that I have

cast a shadow over chiropractic medicine and it's not because the chiropractic industry was founded by a grocery man. Hell, some of my best friends are in the grocery business. But there's even a darker side than greed: needless injury leading to strokes.

Science Based Medicine (SBM seen at sciencebasedmedicine.com) says one of the ways chiropractors make big money is spinal manipulation. On June 22, 2013, an article was written called Chiropractic Danger: Neck Manipulation and Strokes. The neck, the article explains, is twisted and turned in certain ways that are meant to reduce or completely eradicate pain. Many patients go back, year after year, seeking shortcuts to the chiropractors assumed with magical hands for some relief.

One report by SBM revealed that a 37-year-old woman had neck adjustment and a stroke ensued. The chiropractor didn't notice the symptoms--primarily weaknesses on one side of the body--after working on her neck. And the Internet is filled with stories like this one. Just Google "neck adjustment stroke" for the hell of it.

From Quackwatch, for example: "Some chiropractors advocate screening tests with the hope of detecting individuals prone to stroke due to neck manipulation. These tests, which include holding the head and neck in positions of rotation to see whether the patient gets dizzy, are not reliable, partly because manipulation can rotate the neck further than can be done with the tests. Listening over the neck arteries with a stethoscope to detect a murmur, for example, has not been proven reliable, though patients that have one should be referred to a physician. Vascular function tests in which the patient's head is briefly held in the positions used during cervical manipulation are also not reliable as a screen for high-risk patients because a thrust that further stretches the vertebral artery could still damage the vessel wall ([aka a stroke])."

And this, from a former chiropractor, Rob Alexander, M.D.: "I have been

doing a vascular surgery rotation for the past month, which is part of my postgraduate medical education. During my chiropractic training, when the subject of manipulation-induced stroke was brought up, we were reassured that "millions of chiropractic adjustments are made each year and only a few incidents of stroke have been reported following neck manipulation." I recently found that two of the patients on my vascular service that suffered a cerebrovascular accident (stroke) had undergone neck manipulation by a chiropractor, one the day that symptoms had begun and the other four days afterward."

Dr. Alexander continued, "If indeed the incidence of stroke is rare, one M.D. would see a case of manipulation-induced CVA about every 10 years. But I believe I have seen two in the past month! I therefore urge my medical colleagues to question their patients regarding recent visits to a chiropractor [who did] neck manipulation when confronted with patients that present with the neurologic symptoms of stroke. I also urge potential chiropractic patients to not allow their necks to be manipulated in any way. The risk-to-benefit ratio is much too high to warrant such a procedure."

And this from SBM's Harriet Hall on April 29, 2008: "I wonder how many people have heard that chiropractic neck adjustments can cause strokes. It isn’t exactly common knowledge. One organization is trying to raise public awareness through signs on the side of city buses (Injured by a Chiropractor? Call this number) and through TV commercials. I had never heard about this phenomenon myself until a few years ago, when I heard it mentioned on an episode of Alan Alda’s Scientific American Frontiers. I questioned accuracy, but I quickly found confirmation in the medical literature."

Hall goes on. "A typical case was that of 24 year old Kristi Bedenbaugh who saw her chiropractor for sinus headaches. During a neck manipulation, she suffered a brain stem stroke and she died three days later. Autopsy revealed that the manipulation had split the inside walls of both of her vertebral arteries, causing the walls to balloon and block the blood supply to the lower part of her brain. Additional studies concluded that blood clots had formed on the days the manipulation took place. The chiropractor later paid a $1000 fine."

Hall proceeds to say that chiropractors are well aware of the risk. "They have attempted to find ways to screen patients for high risk, but there is no reliable way to do so. Strokes are a major reason for chiropractic malpractice insurance payouts – 9% of claims paid by the major chiropractic insurer in 2002, the only year for which I was able to find statistics. Some chiropractors are now asking patients to sign an informed consent form before manipulations. If asked, most chiropractors downplay the risk, saying it occurs in less than one in a million manipulations. Many (perhaps most) chiropractors do not mention the risk at all.... Heat, massage, tincture of time, exercises, and other measures may offer symptomatic relief with no associated risks."

About 4 percent of all ischemic strokes are caused by blockages in the basilar artery system. The basilar artery supplies oxygen-rich blood to some of the most critical parts of the brain. Basilar strokes have been linked to chiropractic medicine. About 20% of all basilar strokes come from spinal manipulations, or about 1300 a year in the U.S. Chiropractic treatments have been proven for carotid artery strokes. If someone dies from stroke, vertebral arteries are not usually examined at the autopsy. In 2002, a study of patients up to the age of 45 who had a stroke revealed that they were 5 times more likely to have seen a chiropractor in the week before the stroke than in the control group. A group of Canadian neurologists issued a statement in the same year urging caution, education, informed consent, and other caveats to protect the public.

And this, from Dr. Stephen Barrett in his article, "Neck Manipulation and Strokes," a piece revised on September 29, 2013: "In 1992, researchers

at the Stanford Stroke Center asked 486 California members of the American Academy of Neurology how many patients they had seen during the previous two years who had suffered a stroke within 24 hours of neck manipulation by a chiropractor. The survey was sponsored by the American Heart Association. A total of 177 neurologists reported treating 56 such patients, all of whom were between the ages of 21 and 60. One patient had died, and 48 were left with permanent neurologic deficits such as slurred speech, inability to arrange words properly, and vertigo. The usual cause of the strokes was thought to be a tear between the inner and outer walls of the vertebral arteries, which caused the arterial walls to balloon and block the flow of blood to the brain. Three of the strokes involved tares of the carotid arteries."

Dr Barrett added that in 2001, "Canadian researchers published a report about the relationships between chiropractic care and the incidence of vertebrovascular accidents (VBAs) due to vertebral artery dissection or blockage in Ontario, Canada, between 1993 and 1998. Using hospital records, each of 582 VBA cases was age- and sex-matched to four controls with no history of stroke. Health insurance billing records were used to document use of chiropractic services. The study found that VBA patients under age 45 were five times more likely than controls to (a) have visited a chiropractor within a week of the VBA and (b) to have had three or more visits with neck manipulations. No relationship was found after age 45. An accompanying editorial states that the data correspond to an incidence of 1.3 cases of vertebral artery dissection or blockage per 100,000 individuals receiving chiropractic neck manipulation, a number higher than most chiropractic estimates.

Let me say, in defense of chiropractors, they all believe in what they say. And there are bad apples in every profession. But a neck adjustment? From a chiropractic philosophy that was started by a grocer who called himself "Dr"? Heh, heh. That's crazy.