Clinical Rounds. Chiropractic, Stroke & Dissection. Key Points. Inside this issue: Volume 1, Issue 1. Clinical Rounds.

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1 Volume 1, Issue 1 January 2011 Chiropractic, Stroke & Dissection Key Points Recordkeeping Chronic Headaches & Stroke Risk Communication Unusual findings after an adjustment Symptoms prior to an adjustment Secondary to a musculoskeletal cause? Listen to clinical signs and symptoms Conduct further evaluation Temporal nature of events Inside this issue: Case Overview 1 Case Overview Susan is a 38 year old Caucasian female who goes to see Justin Weeks DC with complaints of chronic headaches, neck, right shoulder and upper back pain. Dr. Weeks takes a history, does an examination and proceeds to administer chiropractic adjustments to the mid and upper cervical spine, dorsal spine and pelvis. Dr. Weeks cares for Susan for 25 visits over the course of about 3 months. Susan tells Dr. Weeks that her headaches, neck, shoulder and upper back pain improve with the adjustments but they come back. On her last visit with Dr. Weeks, Susan tells her that she has a headache and neck pain and thinks she slept wrong the past couple of nights. Dr. Weeks examines her, finds indicators for subluxation in the mid and upper cervical spine and dorsals and proceeds to adjust her. Susan reports that she has some dizziness following the cervical adjustment but it quickly subsides and Susan schedules her next visit and leaves the office. Susan fails to show up for her next appointment and when the CA calls is told by her husband that Susan suffered a vertebral artery dissection and a stroke from her last adjustment, had to be hospitalized and would not be returning. A few months later Dr. Weeks is served with a lawsuit alleging he violated the standard of care and caused Susan s dissection and stroke. Aggravating Factors Plaintiff s attorney and their experts assert that Susan had several risk factors that Dr. Weeks ignored and should have known predisposed her to dissection and stroke. In his history Dr. Weeks noted that Susan had a history of migraines, past history of high blood pressure and though not Head and neck pain are potential warning signs of dissection currently taking them had been on birth control pills in the past. She was overweight, did not exercise and smoked as a teenager through her mid 20 s. Plaintiff s experts further argued that it was also possible that the repetitious nature of the cervical spine adjustments had a cumulative effect in causing the dissection. Plaintiff s experts stated that Dr. Weeks recordkeeping was substandard, that he did not adequately explore the warning signs elicited in her history and that he did not conduct an adequate examination. Among other things, the experts stated he should have taken her blood pressure and done a more thorough orthopedic and neurological examination such as provocative orthopedic testing of the cervical spine and check her reflexes. Ongoing daily notes did Review of Case 2 Take Home Points 2 History & Exam 3 not include visit to visit assessments of her progress. On the day of the alleged event after she complained of dizziness the experts argue Dr. Weeks violated the standard of care by not taking her blood pressure and performing a focused neurological examination and then getting her to the hospital. Once she did go to the emergency room an MRA and MRI were ordered which confirmed the dissection and stroke. She was placed on thrombolytics and went through about 2 years of therapy and missed work. Her neurologist states she has permanent deficits including loss of fine motor skill in her right hand. Mitigating Factors One month prior to the last visit with Dr. Weeks Susan had visited her primary care physician with complaints of a migraine headache and vomiting. On his visit that day the doctor diagnosed her with migraine, prescribed meds and told her to follow-up the next day. Susan did not follow up with her doctor. Records from her primary care physician revealed that Susan had been complaining of headaches for about a year and that she had high blood pressure for which she was not taking her

2 Page 2 Stroke Case Susan was also being seen by her primary care physician medication. The MRA also revealed atherosclerosis of the carotid and vertebral arteries. CT angiography performed following the MRA revealed the right vertebral artery to be congenitally narrower than the left. Blood work performed at the time of admission revealed elevated cholesterol over 300. Review of Case manifestations of it. These issues were either not being properly managed by her primary care physician and/or Susan was not following his recommendations. In addition she had some congenital arterial problems which may have aggravated her situation. Experts for Dr. Weeks testified that she more likely than not was already experiencing a dissection secondary to her genetic, environmental and lifestyle issues when she entered Dr. Weeks office on her last visit. Susan not only was at risk for vascular disease but had active Take Home Points Susan not only was at risk for vascular disease but had active manifestations of it. ο Starting with the most basic - make sure your recordkeeping procedures are consistent with the acceptable standard of care. ο Even someone with chronic headaches may be at risk for dissection and stroke and just because they have been helped in the past by chiropractic adjustments does not mean that this time it isn t different. ο Communicate with your patients about their other health care providers and the care they are receiving so you have the full picture of what is going on with their health. ο If a patient experiences something unusual after an adjustment make sure you evaluate them. If they have dizziness, slurred speech, blurred vision, nystagmus or other neurological signs and symptoms don t waste any more time get them to a hospital for further evaluation. ο If they have these types of symptoms prior to you adjusting them this does not necessarily mean they are having a dissection or other vascular event but you should determine whether or not the signs and symptoms are secondary to a musculoskeletal cause. If so, adjustments may be indicated. If not, listen to these clinical signs and symptoms and either conduct a further evaluation yourself or get them to someone who will. Even though there is no evidence that cervical adjustments cause Take Home Points Con t Take Home Points dissections, this does not mean that people won t be coming into your office in the midst of one. If you recognize it, not only will you help a patient but you will avoid several years of litigation and the expense, stress and disruption in your life that it causes. The Bottom Line The issues surrounding chiropractic and vascular injuries such as dissection and stroke are complicated and nuanced. Even the seasoned chiropractor with years of education and experience caring for thousands of patients tends to get confused by all the information in the literature and popular press. What is the bottom line for the practicing chiropractor? There is no human, experimental evidence that chiropractic adjustments or neck manipulations are causally related to strokes. The claims and statements that have been made and that have been interpreted by plaintiff attorneys and plaintiff experts to contend a link are based largely on case controlled studies. A multitude of systematic distortions (biases) may effect conclusions drawn from case-control studies. Other criteria must be used to determine whether an association is actually causative because an association, no matter how strong, does not prove causation. At this point in time due to the rarity with which vertebro-

3 Volume 1, Issue 1 Page 3 Take Home Points Con t basilar accidents occur, experimental evidence in humans and prospective cohort studies examining the hypothesis that chiropractic adjustments cause stroke - do not exist. A risk should be disclosed if a reasonable patient, in what the doctor knows or should know to be the patient s position, would be likely to attach significance to the risk or cluster of risks in deciding whether to forego the proposed therapy. Patients and doctors must make this decision based upon appropriate information. You need to be aware of the clinical issues surrounding a potential dissection or cerebrovascular accident. In our experience, claims that chiropractors caused a stroke are really a timing issue this is known as temporality. In other words, the patient was already in the midst of a dissection or stroke or was going to have one anyway and just so happened to have seen a chiropractor during that time frame. The good news is that this is exactly where you can reduce the risk that you will be accused of causing the event and perhaps help your patient avoid the devastating consequences of a dissection or stroke. You probably remember being told over and over again in school and in continuing education programs that you always need to be considering cancer, infection and fracture in patients presenting to you for care especially if those patients are in pain. Add one more critical item to that list: Vascular problems. When you have a patient come in to see you complaining of head, face and/or neck pain (especially pain that is different or more severe than they have had before), take an alternate approach. There is no human, experimental evidence that chiropractic adjustments or neck manipulations are causally related to strokes History & Examination You need to differentiate this pain from the garden variety mechanical neck pain and/or cervicogenic headache. This patient could be presenting a potential dissection or impending stroke. History If the history and examination lead you to suspect even the outside possibility of a dissection or stroke DO NOT adjust or manipulate the patient call 911, get them to a hospital, have them lay down and monitor the patient while you wait. Don t give them anything to eat or drink and do not allow them to go home if they improve while laying there. Same goes if they have stroke like symptoms after a treatment. You are better safe than sorry to order an MRA and an MRI to rule out dissection and stroke. As a chiropractor your number one goal is to help people. Many patients come to see you with neck pain and headaches. You feel confident you can help them. In some cases those complaints are secondary to vascular problems that may already be in process. Recognize this so you can make sure your patient gets the right care. If those complaints are coupled with history and/or physical exam findings that suggest dissection or stroke: Stop, Look and Listen more intently and err on the side of caution. Stop, Look & Listen When You Suspect a Vascular Problem History & Examination STOP LOOK LISTEN...

4 History & Examination Con t Neurological: Does the patient have any double vision or other visual problems? Is there any dizziness, vertigo or lightheadedness? Are there more dramatic symptoms such as drop attacks, sudden weakness or numbness of the head, face or extremities? Is there any unilateral numbness anywhere in the body? Does the patient have any difficulty with speech or swallowing? Is there any problem with walking, balance or coordination? Is there any nausea, vomiting or upset stomach? Is there any nystagmus or involuntary rapid eye movements? Is there any giddiness does the patient appear nervous or confused? Cardiopulmonary: Does the patient have a history of TIA s, stroke or any heart disease or hypertension? Is there a history of chronic lung disease or recent upper respiratory infection? Any pertinent family history? Skin: Is there a history of easy bruising, bleeding disorders or problems with wound healing? Musculoskeletal: Does the patient have a history of chronic joint pain in the spine or extremities? Is this pain different than the past? Gastrointestinal/Genitourinary: Is there a history of blood in the urine or stools, or urinary tract infections? Trauma: Have they experienced any trauma that may have injured blood vessels? Connective Tissue Disorders: Do they have a history of any of the following: polycystic kidney disease, Type IV Ehlers- Danlos, Marfans, or fibromuscular dystrophy? Other: Are they taking any drugs or medications - especially oral contraceptives? What is their tobacco use history? Any previous hospitalizations? Are they under 45 years old? Are they overweight? Exam Can the patient smile, frown and puff out their cheeks? Can they raise their arms and legs? Can they stand with their feet together and their eyes closed (stand close by them)? Can they say a tongue twister? Can they stick out their tongue and move it around? Does mechanical stimulation of the neck or palpation reproduce their head or neck pain? Is there facet joint and neck muscle tenderness? If they have dizziness or vertigo does neck motion or movement aggravate it or bring it on?

5 Page 5 You do not want to focus on the negative, and dealing with malpractice insurance and risk can be negative. We offer a partnership approach to our members, designed to focus on your practice needs, and to deliver an optimal patient experience. At ChiroFutures, we will bring a different experience than you have had with your malpractice insurer in the past. Beyond providing a quality, comprehensive, competitive malpractice liability policy, we will proactively assist you with tools and ideas to help minimize the inherent risks of growing your practice. Contact Us 4390 Bells Ferry Road Kennesaw, GA Phone: Fax: drmccoy@chirofutures.org Check Out Our Website chirofutures.org ChiroFutures Co-Founders - Anthony Carrino, DC, FICPA and Matthew McCoy DC, MPH, both in practice over 20 years, have unmatched experience serving as consultants and expert witnesses defending chiropractors in malpractice cases and regulatory board actions throughout their careers. In our combined careers, we have developed insight from the toughest malpractice cases. We have had the experience of working with chiropractors hand in hand through the nightmares that occur when patients are unhappy. ChiroFutures commitment is to share our seasoned experience with you. This will assure that you are not only protected by a financially strong carrier and broad coverages, but can grow a busy practice full of happy patients. Please take some time to explore ChiroFutures. We look forward to partnering with you and your practice.