Categories
Biology Complementary and alternative medicine Medicine Quackery Science

Did chiropractic manipulation of her neck cause Katie May’s stroke?

Katie May was a model, and by all accounts a very successful one, having appeared in Playboy, Sports Illustrated, and other magazines and websites. Self-proclaimed the “Queen of Snapchat,” she also had nearly two million Instagram followers and was a major social media force, having recently parlayed her modeling and social media career into becoming an entrepreneur. She also died unexpectedly on Thursday night at the too-young age of 34, leaving behind a seven-year-old daughter. What makes May’s tragic death an appropriate topic for this blog is not so much her young age but rather the circumstances surrounding her death, particularly the cause. Basically, May died of complications of a stroke, as her family confirmed in a statement issued on Friday:

“It is with heavy hearts that we confirm the passing today of Katie May – mother, daughter, sister, friend, businesswoman, model and social media star – after suffering a catastrophic stroke caused by a blocked carotid artery on Monday,” the statement reads.

“Known as MsKatieMay on the Internet and the “Queen of Snapchat,” she leaves behind millions of fans and followers, and a heartbroken family. We respectfully ask for privacy in this this difficult time. Those wishing to contribute to the living trust being set up for the care of her young daughter may do so at her GoFundMe page.”


Given her young age, that alone makes her death curious, but what makes it discussion-worthy to me is that, having injured her neck in a fall at a photo shoot, she apparently had had two chiropractic neck adjustments before her collapse one week ago that lead to her hospitalization, deterioration, and, ultimately, the decision to take her off of life support. Indeed, starting early Friday morning, people were e-mailing me and Tweeting at me, some already having concluded that chiropractic killed Katie May. But did it?

Maybe. Or: It’s complicated. At least, it’s more complicated than just concluding that May’s adjustment caused the stroke.

Because I had decided to do something highly unusual for me and take the day off Friday in order to recover from my grant writing frenzy over the two weeks prior that had sapped my energy, I was hanging out at home when the e-mails and news reports started appearing. I almost whipped out a quick, ranty post for my not-so-secret other blog right then and there, but decided to wait for more news over the weekend and do a post, if appropriate. Doing that allowed me to construct a timeline, which leaves open the biggest question: Was it May’s neck injury or the chiropractic adjustments that caused the stroke that killed her?

Let’s dig in.

A timeline, or: Just the facts, Ma’am

In late January, Katie May was doing a photo shoot. Although the details are not clear, we do know from various sources that during that shoot she fell—hard—and apparently hit her neck on something. After the fall she complained of severe neck pain, severe enough to go to the hospital to be checked out:

Sources with direct knowledge of Katie’s situation tell us the accident happened late last week when she was shooting in Los Angeles. We’re told Katie’s neck pain after the fall was so bad, she went to a hospital to get checked out, and was released later that day.

But on Friday the pain remained — she tweeted, “Pinched a nerve in my neck on a photoshoot and got adjusted this morning. It really hurts!”

So apparently she did go back to her chiropractor on Monday, the same day she suffered her fatal stroke.

One notes that this report, as well as this report and others, conflict with what the family said about May’s death, as reported in People:

“To the best of my family’s knowledge, and we are fairly but not totally certain of this, Katie did not seek medical care prior to Monday evening; if she had, it seems reasonable to conclude, the subsequent days would have unfolded very differently,” her brother, Stephen May, says.

It is, of course, possible that Stephen May didn’t know that his sister was checked out in the emergency room, or it is possible that she never was, although, given multiple news reports indicating that she did seek medical attention, I suspect that she probably did. I haven’t been able to find out for sure. Whatever the case with respect to seeking out standard science-based medical care, we do know that May sought out a chiropractor for neck adjustment First, here’s her Tweet from January 29:

Then, on January 31 in response to a Tweet by one of her fans asking how her neck was:

Other than these Tweets, between the time of May’s initial injury on (probably) January 28 and the evening of her stroke (February 1), there was nothing on May’s Twitter or Instagram feeds to indicate that anything was wrong. Her last Instagram post was dated February 1 and included a photo of her in a swimsuit with a message, “️Hope everyone is having a great Monday! It’s very windy here today in LA ?☀️?.” Her Twitter feed abruptly went silent after 5:19 PM PT on February 1, her last Tweet being a photo with her asking her fans to help her “win most Arsenic Girl.” Remember, it was that Monday night when she apparently collapsed and was rushed to the hospital, where she was in critical condition until she was removed from life support on Thursday and died a few hours later that evening.

Given that timeline, which is as accurate as I can currently deduce based on the news reports, the next question is: What killed Katie May? Obviously, it was a stroke. But what caused the stroke that killed her? Was it chiropractic? Was it her original trauma to the neck suffered when she fell? Was it a combination? Contrary to a lot of the speculation out there, this is not nearly as straightforward a question as it sounds at first. Let’s take a look at the two main possibilities.

Chiropractic neck adjustments and stroke

Regular readers of this blog know that chiropractic is a pseudoscientific system of “healing” founded in 1895 by Daniel David Palmer, who claimed to have restored the hearing to a deaf janitor by “adjusting” a bump on his spine. It’s based on the vitalistic concept of “innate intelligence,” whose proper flow through the nervous system is interfered with by “subluxations” in the spine. To chiropractors, the way to remove this interference is to “adjust” the spine. To Palmer, the “innate” intelligence was very much similar to the vitalistic concept of the “spark of life,” the “life force,” or, as it is frequently called in Asian cultures, qi. Of course, there are some spinal conditions for which manipulation is an effective treatment, but many chiropractors go beyond that to claim that chiropractic adjustments can treat allergies, asthma, and a wide variety of other illnesses that have nothing to do with the spine. Many chiropractors are antivaccine, as well. It’s not for nothing that I have frequently referred to chiropractors as inferior physical therapists with delusions of grandeur. If you don’t believe me, consider that there is a movement among chiropractors to win the status of primary care provider, a role they are completely unqualified for.

The issue of whether chiropractic neck adjustments can cause strokes is a question I haven’t really discussed on this blog, mainly because my friends and colleagues elsewhere have examined several times in the past, so many times that I never really felt the need to address the question myself. This case, however, is different because it poses the question of whether what killed Katie May was a stroke due to her original trauma or a complication of chiropractic adjustments. Also, it must be pointed out that her stroke would be considered atypical for a chiropractic-induced stroke, for reasons that I will discuss shortly.

What is the relationship between chiropractic neck adjustments and stroke? Given how extensively the issue has been discussed elsewhere, I don’t feel the need to go into my usual level of extreme detail, but a brief (for me) recap is certainly appropriate. First, check out this video of a chiropractor doing neck adjustments:

If you cringe when you hear the pop during the violent twist given to the neck, you’re not alone. So do I. So how could such a motion cause a stroke? To understand that, you need to know a bit more about the anatomy of the neck. I thus refer you to this figure that I stole from one of Mark Crislip’s posts on chiropractic and stroke:

Extreme rotation of the atlas on the axis (at the atlantoaxial joint) stretches the vertebral artery.  In layman's terms, 40% of a hanging.
Extreme rotation of the atlas on the axis (at the atlantoaxial joint) stretches the vertebral artery. In layman’s terms, 40% of a hanging.

Basically, two very important arteries that supply blood to the brain pass through the two highest vertebrae, the atlas (C1, so named because it was thought to support the head the way the mythical Atlas held up the earth) and the axis (C2). Another illustration shows how the vertebral arteries are tethered to the spine and make a big loop around the atlas before entering the skull and joining together to form the basilar artery (click to embiggen):

Vertebral artery anatomy. The arrows point to the vertebral artery. Note how it bends around bony protrusions.
Vertebral artery anatomy. The arrows point to the vertebral artery. Note how it bends around bony protrusions.

It’s thus not difficult to see how a rapid rotation of the head could potentially stretch the basilar arteries. Generally, chiropractors describe this as “high velocity, low amplitude” (HVLA), which it is, but, given the constraints of vertebral artery anatomy, high amplitude is not required to cause injury. With HVLA, it is quite possible to tear the intima (the lining of the artery consisting of vascular endothelial cells). Intimal tears become “sticky” for platelets, leading them to lodge there and start to form a clot. This is the same reason atherosclerotic plaques can lead to strokes; the “rough” area of the plaque is thrombogenic; i.e., has a tendency to attract platelets and cause clots. When a clot forms in such an injured area of intima, regardless of where the artery is, one of three things can happen. It can resolve completely; it can leave a narrowed segment of the artery as it resolves; or it can break off and flow further downstream, there to lodge where the artery narrows and block blood flow. When that happens in the brain, it’s called a stroke.

As much as chiropractors try (unsuccessfully) to deny it, there is a convincing correlation between chiropractic neck manipulation and vertebral artery stroke in multiple studies. The evidence has been summarized in Quackwatch. It’s been summarized by my friends and colleagues, such as Mark Crislip, Harriet Hall, Steve Novella, and Sam Homola. Clay Jones even described a case of a six year old child who suffered a stroke after chiropractic manipulation, while Harriet Hall described the case of a 40 year old woman named Sandra Nette, who suffered a stroke after a neck adjustment, leaving her in a state very closed to locked in syndrome, leading to a landmark lawsuit.

How strong is the correlation, though? Harriet points out that estimates of neck manipulation-induced strokes range from one in ten million manipulations to one in 40,000. Not surprisingly, it’s chiropractic literature that tends to downplay the risk and come up with the lower estimates of post-manipulation strokes. It’s a difficult question to study, because the incidence of vertebral artery strokes is very low to begin with; so detecting increased risk is difficult. For instance, one study of patients under 45 found that those who had this kind of stroke were more than five times more likely to have visited a chiropractor during the preceding week than control patients. Meanwhile, studies that purport to show that neck manipulation is not associated with stroke tend to have serious flaws, as Mark Crislip likes to point out.

The link between neck manipulation and basilar artery stroke is definitely plausible on anatomic considerations. There is enough evidence that it is real as to be concerned. However, it must be conceded that such chiropractic-induced strokes are admittedly very uncommon. As has been pointed out, given how rare basilar artery strokes are in young people, even a high relative risk of such a stroke after a chiropractic intervention would still be a low risk. The problem, of course, is that the consequences of such strokes, even if they are rare, are catastrophic. Balancing the lack of evidence that chiropractic neck manipulation is more effective for neck pain than, for example, mobilization with its small risk of a catastrophic complication and the fact that most chiropractors don’t provide truly informed consent about the risks of stroke after cervical manipulation, I tend to agree with Harriet Hall that “existing evidence is inadequate to conclusively determine causality, but I think it supports a high probability of causality, and the alternate explanations he [a chiropractor] offers to exonerate chiropractors are questionable.” Given that assessment, I find it hard to justify cervical manipulation as a treatment for, well, anything.

But what about Katie May?

So how does this evidence apply to the case of Katie May? Here’s the problem. By all news reports, Katie May didn’t suffer a vertebral artery stroke. She suffered a carotid artery stroke. While it is true that cervical manipulation very likely can cause vertebral artery strokes, it is not at all clear whether such manipulation can cause carotid artery strokes. From a simple anatomic standpoint, there is less plausibility, as well, but not zero. Let’s take a look at carotid artery anatomy (click to embiggen):

Carotid artery anatomy
Carotid artery anatomy

In the neck, you have two carotid arteries. More specifically, these are the common carotid arteries. Around the level of the thyroid cartilage, the common carotid artery branches into external and internal branches. The external branch supplies blood to the face and neck. The internal branch proceeds up the neck to the temporal bone, where, to put it simply, it enters a canal in the petrous portion of the temporal bone and emerges within the skull to supply the brain and other structures (such as the eye) by branching into several arteries, the end branches of which are the anterior and middle cerebral arteries. When atherosclerotic plaque builds up in this system, it most commonly builds up in the internal carotid artery just past the bifurcation of the common carotid, and that’s where vascular surgeons perform carotid endarterectomies to remove such plaques and prevent strokes.

Evidence implicating chiropractic manipulation as a cause of strokes arising from the carotid system is much thinner than the evidence for chiropractic-induced vertebral artery strokes. There have been case reports, such as one that Harriet Hall discussed in which a man who had known carotid disease, with calcified plaque, noticed left arm weakness and numbness 30 minutes after a chiropractic neck manipuliation. Imaging showed a calcified embolus in the right middle cerebral artery, which was strongly suggestive that neck manipulation had loosened part of the plaque an allowed this embolus to flow into the middle cerebral artery. Other sources of embolus were systematically ruled out. Another case report described a 34 year old otherwise healthy man who suffered acute left-sided numbness and loss of coordination after neck manipulation. He was found to have bilateral carotid artery dissections and a right vertebral artery dissection. (An arterial dissection occurs when there is a tear in the innermost intimal layer, allowing the shear force of flowing blood to start to pull that layer away from the muscular layer of the artery.) Other case reports exist as well, some linking dissection to collagen-vascular disease. However, larger studies have failed to find a compelling link between carotid artery strokes and chiropractic neck manipulation.

In other words, there is more uncertainty about a link between chiropractic manipulation and stroke from carotid arteries, which makes the case for link between Katie May’s two neck manipulations and her stroke harder to argue.

Post-traumatic stroke

Another possibility is that Katie May died as initial reports suggested before people noticed that she had Tweeted about undergoing neck adjustment and reports came out that she had undergone two such adjustments between injuring her neck and suffering her massive stroke; that is, of a post-traumatic stroke. The annual incidence of spontaneous internal carotid artery dissection is around 2.5-3 per 100,000, making it pretty rare, although the true incidence of dissection is probably higher because this number doesn’t take into account injuries without neurologic symptoms. The most common initial symptoms of a dissection include neck pain and headache, the former of which May definitely had. Crissey et al described four main mechanisms leading to carotid injury:

  • Neck hyperextension associated with rotation (which May might have had from her manipulation).
  • Direct blow to the neck (which May almost certainly appears to have had from her fall).
  • Blunt intra-oral trauma (which May didn’t have).
  • Basilar skull fracture involving the carotid canal (which May also didn’t have, at least not as far as we know).

Carotid artery dissection has also been reported after sports injuries, the sports including judo, skiing, yoga, ice hockey, rowing, wrestling, horse riding, soccer, jogging, and others—even after treadmill running. In other words, although they are rare, trivial trauma can cause carotid dissections in young, healthy people.

Once such an injury occurs, the latency period for an ischemic event (i.e., stroke) is such that 80% of strokes arise within the first seven days (which May’s did), but post-dissection strokes can still occur as long as five months later.

What killed Katie May

So what killed Katie May? The bottom line is that we don’t know for sure. We can’t know for sure. If you leave out the chiropractic manipulations of her neck, her clinical history—at least as far as I can ascertain it from existing news reports—is classic for a dissection due to neck trauma. She was, after all, a young person who suffered a seemingly relatively minor neck injury that, unbeknownst to her, could have caused a carotid artery dissection, leading to a stroke 4 or 5 days later. Even if May were examined in the emergency room shortly after her injury, in the absence of neurological symptoms it would have been very easy to miss the possibility of an intimal tear that ultimately could lead to a dissection. Absent focal neurological findings, there’s really nothing on physical exam that can raise the index of suspicion for a dissection, and given how rare dissections are after trauma doing an ultrasound or angiography would have been hard to justify absent more worrisome symptoms.

Thus, it seems jumping to conclusions for May’s friend Christina Passanisi to say that May “really didn’t need to have her neck adjusted, and it killed her.” Don’t get me wrong. I completely agree that May didn’t need to have her neck adjusted, particularly after having suffered trauma to it. I just can’t be so sure that it was the manipulation that killed May, given that May’s history also fits with that of a traumatic carotid dissection. Even if there were an autopsy that found an internal carotid artery dissection, there would be no good way to tell whether the trauma from May’s fall or trauma from her two neck adjustments caused it.

That being said, don’t mistake my concluding that we can’t be sure that the chiropractic neck manipulation didn’t cause May’s stroke with my concluding that it didn’t cause her stroke. Her two sessions of chiropractic manipulation might well have either worsened an existing intimal tear or caused a new one that lead to her demise. Or they might have had nothing to do with her stroke, her fate having been sealed days before, when she fell during that photoshoot. There is just no way of knowing for sure. It is certainly not wrong to suspect that chiropractic neck manipulation might have contributed to Katie May’s demise, but it is incorrect to state with any degree of certainty that her manipulation did kill her.

By Orac

Orac is the nom de blog of a humble surgeon/scientist who has an ego just big enough to delude himself that someone, somewhere might actually give a rodent's posterior about his copious verbal meanderings, but just barely small enough to admit to himself that few probably will. That surgeon is otherwise known as David Gorski.

That this particular surgeon has chosen his nom de blog based on a rather cranky and arrogant computer shaped like a clear box of blinking lights that he originally encountered when he became a fan of a 35 year old British SF television show whose special effects were renowned for their BBC/Doctor Who-style low budget look, but whose stories nonetheless resulted in some of the best, most innovative science fiction ever televised, should tell you nearly all that you need to know about Orac. (That, and the length of the preceding sentence.)

DISCLAIMER:: The various written meanderings here are the opinions of Orac and Orac alone, written on his own time. They should never be construed as representing the opinions of any other person or entity, especially Orac's cancer center, department of surgery, medical school, or university. Also note that Orac is nonpartisan; he is more than willing to criticize the statements of anyone, regardless of of political leanings, if that anyone advocates pseudoscience or quackery. Finally, medical commentary is not to be construed in any way as medical advice.

To contact Orac: [email protected]

228 replies on “Did chiropractic manipulation of her neck cause Katie May’s stroke?”

This story illustrates how difficult it is to determine whether or not chiropractic is involved in strokes following both injury and neck manipulation. I’m glad you pointed out the nuances of this case and that we can’t be certain which was responsible. It reminds us to question our own reactions, just as much as we question the quacks.

I’ve seen 2 carotid artery dissections in young women after fairly mild injuries- one was from a flexion/hyperextension injury at an amusement park. The other was from a severe coughing fit.

I’m sorry for the friends and family of Katie May.

@Todd: What I was surprised to learn in my reading for this post is that the incidence of spontaneous carotid artery dissections in young people is higher than I would have guessed.

Orac,
Following this blog for a few years, I’ve seen the occasions when you have examined the details of a number of unfortunate deaths of young people and been castigated by those that see you as an threat to their belief in alternative medicine. I humbly suggest that in future, any such attacks on you can be met by directed them to this post so they can see how much you are led by the evidence when others might have just leapt to an easy conclusion that chiropractic did it.

This post is a true example of what it means to be a skeptic. Sorry if I sound sycophantic but I truly admire what you wrote.

“For instance, one study of patients under 45 found that those who had this kind of stroke were more than five times more likely to have visited a chiropractor during the preceding week than control patients.”

1) This is a very specific sub-case, ” those whose “Most recent cervical chiropractic visit,” was within one week. 2) the numbers directly don’t indicate anything staggering, just that one very small percentage of risk was bigger than another…

Doesn’t this just obfuscate more than clarify or indict?

Whether going to the chiropractor caused her stroke or not, we may not know. However, going to the chiropractor certainly did not (and could not) prevent that stroke. We also don’t know if the problem would have been caught if she had gone to the ER for her pain instead, but there was certainly a much better chance of it happening there than in the chiros office. Especially after the first adjustment didn’t help, she needed the services of a real doctor.

Whether or not it was the chiropractic, hopefully the publicity will caution people, especially with neck injuries.

While at medicare.gov yesterday, I saw this:

Medicare Part B (Medical Insurance) covers manipulation of the spine if medically necessary to correct a subluxation when provided by a chiropractor or other …
https://www.medicare.gov/coverage/chiropractic-services.html

And this (for clarification )
subluxation (when one or more of the bones of your spine move out of position) when provided by a chiropractor or other qualified provider.

I actually am curious just what is meant by “out of position”?

@#6 MarryMeMindy-

It might have been caught in the ER, but these presentations are real zebras. Unless someone did a CT angio of the neck, it’s unlikely to be caught. It’s an easy miss, and unfortunately one that can have a catastrophic outcome.

Yeah, I pointed that out in my post. Given how rare these are, it’s hard to fault anyone for not doing a CT angio, although a carotid duplex might also have picked up the intimal tear, particularly if a clot had already formed.

And this is where it is best to have ER docs doing it, because the one thing ER docs do better than others is to look for the worst. When Arnold goes to the ER with a headache, they are going to make sure it’s not a tumor.

How long does pain from a “pinched nerve” typically last? WebMD says that if the pain persists or is severe, see your doctor. But what counts as persistent?

” Of course, there are some spinal conditions for which manipulation is an effective treatment” Huh? I don’t think so.

Um, yes, I do think so. Physical therapists frequently do spinal manipulation. They just do it in an evidence-based fashion—unlike the vast majority of chiropractors.

@ Marry Me, Mindy: How long does pain from a “pinched nerve” typically last? WebMD says that if the pain persists or is severe, see your doctor. But what counts as persistent? IANAD, but I’ve had “trigger point” pain that has lasted for 2-3 weeks before I had it treated…(yes, I’m stubborn). Persistent pain is generally considered to be more than 2-3 days at the same level that nothing is relieving or is worsening.

Orac said “Um, yes, I do think so. Physical therapists frequently do spinal manipulation. They just do it in an evidence-based fashion—unlike the vast majority of chiropractors.”

Yeah, you don’t know what you’re talking about. Chiros are better educated and more skilled in manipulation than PTs. 80% of chiropractors are evidence-based these days. May want to learn more about what you’re actually talking about.

@Stanimal032: yeah, if you go to Science-Based Medicine, you’ll see lots of posts about how “evidence-based” most chiropractors are. And Reasonable Hank has quite a good series about many Australian chiros and their “evidence-based” practices, too. The only evidence most of them believe in is what fills their wallets.

By the way…you don’t happen to be Stan Mrak, do you?

she did go to the ER and they released her so.

Yes, she apparently initially went to the ER. I am talking about her lack of followup care. Not even going to the chiro the first time, but more the second.

If it was still hurting that bad after the chiro adjustment, that’s when it’s time to get back to the ER and say, “That didn’t work.”

If you cringe when you hear the pop during the violent twist given to the neck, you’re not alone.

I’d guess that the *popping* is the same mechanism as cracking knuckles — That is, it is pulling a vacuume and producing cavitation in the synovial fluid of the joint.

In the 1970s, most experts thought it had to do with the collapse of air bubbles in the synovial fluid that lubricates joints. But new evidence suggests the sound is actually caused by precisely the opposite: the formation of a gas-filled cavity when the bones in joints stretch apart.

http://www.wired.com/2015/04/watch-gross-mri-knuckle-cracking/

^^That’s probably not the best link, but it does sport a knarly, knuckle video demonstrating that the ‘crack’ happens upon collapse of the bubble.

Interestingly, I do find that after the induced popping of the whole spine by somebody holding a pole above and *lightly walking* down it does seem to relieve various feelings of limbs tingly, ‘falling asleep’. — For me, this pinched nervedness used to occure after a set amount of time on the interstate; This would yeild a consistant distance traveled every day before my throttle hand went dead and I’d have to raise and swing it around some.

speaking of *lightly*,

Lohse and his colleagues recorded a flash of light that occurs when the bubble collapses.

The flashing phenomenon is thought to be similar to sonoluminescence, in which bubbles that are in a liquid driven by a strong sound field emit light. The researchers have dubbed the shrimp activity shrimpoluminescence.

http://news.nationalgeographic.com/news/2001/10/1003_SnappingShrimp.html

^^ Whatever is going on inside the small bubbles must be pretty violent because the light given off is into the ultraviolet — I wonder if someone’s joint fluid were replaced with all tritium-based waters… never mind.

addendum:

I must wonder if some relief is derived of the in situ popping serving as a microscopic, local lithotrypter.

Medicare Part B (Medical Insurance) covers manipulation of the spine if medically necessary to correct a subluxation when provided by a chiropractor or other …

So if a chiropractor provides a subluxation, creating the medical necessity to correct it, Medical insurance will cover the cost of repairing the chiropractor’s incompetence?

Perhaps I am reading this too literally.

Currently in the state where I practice (evidenced based chiropractic), we have two specific legal cases currently in the system in regards to spinal manipulation of the cervical spine. In both cases, a stroke occurred two days afterward. In both cases, the courts have not been able to demonstrate that the adjustment was or was not the factor that caused it to occur. AND in both cases, the adjustment was performed by non-chiropractors. An MD and a PT (which do not even have the legal right in the state to do so) to be exact. I enjoyed the article since I am very open to others opinions of my profession. But you spent the entire article with the sole purpose of wanting to lead people to believe that the adjustment caused the stroke. The whole thing is saying it was the factor and then you throw in the last line “well we can never know for sure”. This is a well written article and nice opinionated discussion.

Because there is a evidence that chiropractic neck manipulation could cause stroke, wouldn’t it make sense to do some sort of imaging of the vertebral and the carotid arteries prior to any manipulation? It could protect both the patient and the chiropractor. Shouldn’t this be mandated?

If she had the symptoms of a carotid artery occlusion we can”t say for sure exactly what caused the stroke without a cerebral angio or autopsy. Both the carotid and the vertebrals connect through the circle of Willis and it has large person to person variablilty. So a a plaque can migrate to another area and a moderate restriction of one artery, say the carotid, can be asymptomatic until another, say the vertebral, becomes compromised.

“wouldn’t it make sense to do some sort of imaging of the vertebral and the carotid arteries prior to any manipulation? It could protect both the patient and the chiropractor. Shouldn’t this be mandated?”

Adding expensive imaging studies to supposedly make an unnecessary and (in a low but alarming percentage of cases) hazardous maneuver safer doesn’t sound like a proper solution to me. (also, who would allow a chiro to touch their neck if they acknowledged potential for harm in that overt a fashion?)

I agree that there’s no good way for outside observers (or even probably for an M.E.) to tell if the catastrophic outcome in this particular case was due to the initial neck trauma, or to creation of or worsening of existing injury to the carotid artery by chiropractic manipulation.

I question the justification for doing any forceful “adjustment” maneuver in the event of acute spinal injury, whether to the neck or back. It sounds like an invitation for trouble. We don’t know exactly what chiropractic intervention was done in this instance, but I cringe at the thought of a neck “popping” adjustment being performed on someone with a recent history of cervical trauma.

In the 1970s, most experts thought it had to do with the collapse of air bubbles in the synovial fluid that lubricates joints. But new evidence suggests the sound is actually caused by precisely the opposite

Gilbert, you are under-estimating the laziness of Wired journamalists, and their willingness to make stuff up. The original PLoS article does not say “most experts”… the authors cite cavitation as the original, default explanation for knuckle-cracking, but then note a couple of dissidents coming up with their own bubble-collapse theory in 1971. Hence lack of consensus; unanswered questions; yadda yadda, as a rationale for the authors spending MRI time on a IgNobel-prize-worthy project.

Some mook at Wired turns that into “scientists have never really understood the physics behind…” and “most experts thought it had to do with [straw-man wrong theory]” because spreading ignorance is central to his job description.

Granted, herr doktor bimler #27. Stil, it is more plausible than what my 3’rd grade teacher chastised us with back in the day — “Stop that right now! Don’t you know that you’re breaking calcium bindings in your knuckles and will give yourself crippling arthritis by keeping that up? … Are you chewing gum?”

I can almost guarantee that “individual” is indeed the troll from Science-Based Medicine.

It wouldn’t be too hard for me to ask a “friend” to compare the IP address with those from the troll’s comments at SBM. 🙂

I have been going to my chiro for 30 years. If not for him I believe I would be in bad shape after being hit with a guy on a surf board right on my neck. Did my chiro adjust my neck then? Absolutly not! He took exrays and we did some therapy to help the pain and it was a while before he did manipulations. Now years late he does not manipulate my neck ….he said in the condition of my neck it could cause a stroke. He uses an activator but knows how to use it and it gets my neck back where it belongs. Sometimes when my hip or sacrum slip, nothing takes the pain away but my chiro adjustments. There are good chiros and bad chiros, good doctors and bad doctors, good cops and bad cops! It’s up to you to do your homework and find an honest one who knows what they are doing and where YOU come first not their pocket book!

And with all of that said….Chiropractic physicians have seen over 30% of the entire population with over 100million cervical adjustments performed every yr and continue to have the lowest malpractice Insurance premiums of any health care practitioner out there. Critical thinking (no, common sense) tells an upright bipedal that this would NOT be the case if Chiropractic had even an inkling of a possibility of causing a stroke. No evidence to prove this without being legitimately rebutted by evidence to the contrary……Ridiculous!!

@Jacki Hawes – as long as your chiropractor sticks to doing things he can actually do that is all to the good. I would suggest being cautious if he starts discussing cures for things other than back and spine conditions.

It wouldn’t be too hard for me to ask a “friend” to compare the IP address…

Boggles the mind that the most of the posers haven’t figured this out yet.

We must wait for the medical professionals to make their determination We cannot speculate without their medical diagnosis Let’s be compassionate to her grieving family and get educated to prevent this from happening again and causing such a tragedy

That’s part of the issue, though. It’s highly unlikely that medical professionals will be able to tell for sure whether it was the trauma or the chiropractic neck manipulation that caused the stroke. Even if an autopsy were done and showed a carotid dissection, it would probably not be possible to tell which caused the dissection.

Good article. No blame on chiropractic, no blame on the medical doctors who didn’t catch the potential problem before she went for the chiropractic adjustment. I will point out that chiropractic is used by millions of people worldwide with little malpractice compared to conventional medicine. You may check yourself that more than 60,000 deaths in the US are due iatrogenic cause. Iatrogenic means “induced by medical treatment”. But most of us will not take on medical doctors or conventional medicine and suggest that they are quacks because they are helping many others. As far as I know, chiros are far better trained in human anatomy than medical docs. That’s why many medical docs go for an specialty in one organ or system. Osteopaths are medical docs who manipulate the spine and neck, but their training hours is far less than chiros. For the most part, health providers regardless of the field of practice do their best to help people, but sometimes fatalities occur. Good article, though. My prayers go to the family for this irreparable loss.

What concerns me is that there are lots of people who believe that seeing a chiropractor is the same as seeking medical attention. I hope she did go to the ER and not straight to a chiropractor believing that they are medical doctors as people are led to believe by their self imposed title of Dr.

[email protected]

…believing that they are medical doctors as people are led to believe by their self imposed title of Dr.

It always bothered me that ‘doctor’ is not a protected title in the US. Not that that would make much of a difference. ‘Physician’ is protected and that doesn’t stop chiros without the requisite qualifications from calling themselves chiropractic physicians.

Not that that would make much of a difference it would solve the problem.

Although they exist I see far fewer unqualified chiropractic/naturopathic physicians than DC/ND’s.

“‘Physician’ is protected and that doesn’t stop chiros without the requisite qualifications from calling themselves chiropractic physicians.”

One of my favorites is “chiropractic neurologist”.

I would take this article more seriously if the author wouldn’t use the phony word “embiggen.” It was invented for a Simpsons episode. The real word is “enlarge.”

Chiropractic physicians have seen over 30% of the entire population with over 100million cervical adjustments performed every yr and continue to have the lowest malpractice Insurance premiums of any health care practitioner out there.

Not true in Canada, at least. A chiropractor pays about the same malpractice premium as an office-based family doctor. Citation pending later tonight.

Chiropractic physicians have seen over 30% of the entire population

Population of where? That sounds high for the U.S., but I don’t have the tools to easily reduce the 2012 NHIS “COM_EVER” data (and IHIS doesn’t include these in the SDA, unlike 12-month utilization).

with over 100million cervical adjustments performed every yr

With 7.6% utilization, for the U.S. population that would mean that more than 1 in 4 chiropractic visits entail cervical adjustment. Is there a math section in the NCBE exams?

I’m so disappointed in you Orac, you missed a perfectly cromulent opportunity.

All of these people who show up to defend the obviously quacky chiropractic cracking make me extremely tempted to gin up some kind of alt med nonsense, since it obviously won’t matter how many times it gets disproved. Oil may fall, stocks might crash, but apparently stupidity is a non-stop money maker.

It always bothered me that ‘doctor’ is not a protected title in the US.

It is. Varies by state.

My question is whether her follow up visits to a chiropractor led to important signs being missed.

The sympathetic innervation of the pupil runs down to the T1 sympathetic ganglion, and then back up along the internal carotid artery which is envelops with a plexus.

If you have disturbance of the ICA it can potentially cause ipsilateral miosis (pupil constriction) though it is more classically seen with ICA aneurysm than stroke.

If she had developed a pupillary defect, one wonders had she gone back to the ER instead of a chiropractor if this could have been caught.

http://image.slidesharecdn.com/pupil-141114005351-conversion-gate01/95/pupil-6-638.jpg?cb=1415926481

Perhaps I have missed something, but in a young woman like this I would wonder about a hemorrhagic stroke from a ruptured aneurism. Less likely, but still possible (especially if this poor woman had been using OCPs, or even been pregnant, and moreso if a smoker) could be a DVT and a paradoxical embolus – patent foramen ovale not that uncommon. I assume the information we have is not informed by postmortem results (and really, at the end of it all, is it really our business?)

A completely informed nuanced and intelligent examination of this tragedy you will find no place else. I became aware of this vertebral artery tear chiropractic caused stroke scenario when working on a neurologic floor in about 2010. I have had a curiosity for rare trauma injuries since I learned about Commotio Cordis: to think a baseball could kill a healthy child if the ball hits the chest in a 30 millisecond window before the peak of a T-wave is just a mind blowing anomaly of rare coincidence. Yet it is completely true and scientifically proven. (S. M. Yabek M.D. Stuart Berger M.D.) One look at the anatomy of the vertebral artery as it snakes its way through the C1-C2 vertebrae and it is clear a HVLA manipulation of the cervical neck is exactly -40% of a hanging- To put it in terms that a Chiro-quacker might understand: it is what it is. “It is what it is” rates as my least favorite phrase because I notice it seems to be the favored phrase of the least intelligent. My observation is completely anecdotal but doesn’t that perfectly explain the science behind “subluxation” and the general Quackery of Chiropractic “Doctors”: Anecdotal. Read anything written by these Chiro=quacks and you will see defensiveness, flawed thinking, and bad science. But why would you expect anything less from a pseudoscience based on a guy who was a magnetic healer and spiritualist.

Ask yourself this question. Why does a chiropractor make you sign an indemnity waiver?
This sounds more like a dissected artery causing a stroke than a blocked carotid. In my work i see strokes aplenty frequently after chiropractic manipulations. Yet you cannot prove anything as who is to say it wouldnt have happened anyway? Thats what they argue. Seems like tgere are an awful lot of “coincidences” though. Time for more scrutiny. Neck manipulations should carry a regulated warning. Most chiros that ive met just gloss over the issue when asked, dont explain anything and when asked about risks just get snotty and refuse to “treat” you if they cant crunch your neck.

I am a chiropractor of seven years in private practice. I will have to admit that I agree totally with this article. I might point out however, that not all of us are quacks and properly limit ourselves to low risk musculoskeletal therapy. And some of us even use common sense. One of the biggest problems in this case was that the chiropractor manipulated her at all after a recent neck trauma. I think one of the real issues with neck manipulation associated stroke is under reporting due to the time lag between events. Also, I think in some of these cases they are similar to Mays case in there is an existing problem and the manipulation makes it worse. I have had two potential cases where the client was showing neurological deficits associated with vertebrobasilar insufficiency following neck trauma and a careful screening along with cranial nerve testing meant they were promptly referred for medical care and likely saved their lives.
Just saying that at least some of us are diligent, well trained and responsible …

“Chiropractic physicians have seen over 30% of the entire population”

Pretty sure that isn’t the case here: where are we talking about? Citation needed and all that?

And the bit about malpractice etc insurance premiums: mebbe, just mebbe, those who use chiros and the like are less likely to sue as they are True Believers who cannot/will not see that a chiro could ever do anything wrong?

And as for chiros studying more anatomy than a real medic: has the bod who suggested that ever looked at a medical school curriculum? Or seen how long medical training is before the “specialising in one organ”? Especially as many of the basic principles of chiro have no basis in generally recognised anatomy or physiology…

i have been to chiros all my adult life, always had my neck done. 3 yrs ago, had my neck manipulated. Next day, woke up deaf in my left ear. Had a basilar artery stroke otherwise known as a labyrinthine infarct. Luckily, only a Teeny Tiny artery involved

Please can we stop the direction just toward chiropractors. HVLA manipulation in Australia is performed by physiotherapists, osteopaths, naturopaths and even general practioneers that have done “workshops” in the area. The techniques are very similar and have the same inherent risks.
Unfortunately any practitioner with a sensible approach, if a trauma is in the acute inflammatory stage should not have performed such a technique based simple on the time frame. The hospital should not have release her without an MRI to rule out dissection or other injuries ( fractures, lig tears, disc injuries etc…). Unfortunately drs aren’t trained in musculoskeletal injuries enoughto be able to clearly discern the difference between musculoskeletal injuries and others and rely on scans. Therefore hopefully they did do an MRI on the initial presentation, but I doubt it. And with the severity of pain she shouldn’t have been discharged, thus never making to her chiropractor. The blame game will go on but unfortunately it doesn’t change the fact that she is gone, is a terrible tragic event.

With the previous statement on the anatomical study, within Australia gross Anatomy is becoming an elective in medical degrees. Which personally is appalling. The physio, osteo and Chiro degrees in Australia would do a lot more gross structure anatomy and neurology than gps. To get that level of training they have to go on to specialize in sports med or orthopaedics. It’s understandable when you look at the amount of info needed to train doctors on disease and treatments, there is a lot the need to keep abreast of, and musculoskeletal issues don’t tend to generally life threatening.

Any way back to the original point. Please stop just singling out the chiropractic industry, I know many chiros that do not practice HVLA because of the risks. And I know many physiotherapists, osteopaths, naturopaths and a few gps that still perform the technique. I understand that chiropractic may have made a reputation on this but please understand esp in Australia there are many professions that perform this technique. Perhaps as a society we should look at the technique and not the industry. As a false sense of safety could come out of ” it’s dangerous if a Chiro performs the technique but it’s ok because my physiotherapist just cracks my neck”

I suffered a carotid artery dissection 11 days after visiting a chiropractor for a neck manipulation in April of this year… RIP Katie.

You are LITERALLY more ignorant than there are words when it comes to your knowledge of chiropractic medicine. “Completely unqualified as PCPs”? They are essentially DOs without a prescribing license. Didn’t DOs go through this very same fight? I agree, there ARE quack chiropractors, but there are terrible MDs & DOs that over-prescribe pain medications and botch surgeries. Don’t put all chiropractors in one box, I know you wouldn’t do that to ALL *other* doctors.
P.S. – a “hanging” results from a fracture to the odontoid or posterior process of the Axis (2nd vertebra), you can’t fracture this by moving (adjusting) the head left/right, only by hyperextending the neck, but thanks for playing.

I can’t believe this article that based it’s facts on someone who puts an spinous process on C1 (the atlas). Did anyone else catch this on the figure that was stolen from one of Mark Crislip’s posts? But what do I know about anatomy… I am just some chiropractor. BTW, not all chiropractor schools teach innate intelligence. Most schools use evidence based medicine.

I am not here to play the blame game. Just do better research next time or don’t write at all!

Thanks

So many fallacies, so little time…

No, chiropractors are NOT essentially DOs without a prescribing license. They do not go through the pharmacy classes and residencies required of MDs in the USA. If I had a back ache, I might see a chiro (not likely) or a physical therapist (more likely). But for other health issues, I’m going to go to someone trained and educated to take care of them.

As for the Australian chiro defenders: If your chiro is a member of Chiropractic Australia, then I’ll believe they practice evidence-based care. If not, then I doubt it.

Oops…meant to say ” do not go through the pharmacy classes and residencies required of MDs and DOs in the USA.” I recognize that a DO in other countries is not the same as a DO in the USA.

That is incorrect about the pharmacy classes MI Dawn. My chiro education consisted of pharmacology classes taught by a person with a phd in pharmacology… same person who also teaches medical schools. Just facts…

So, Kevin, which hospital did you do a three year residency?

DOs actually do residency programs.

My point, Chris, was to merely state that pharmacology classes are included in some chiro schools education. No where did I state that I, or other chiros, did a residency.

But.. I did intern at a VA hospital!

Andrew

I might point out however, that not all of us are quacks

Bofa’s Law of Professions: If your defense of a profession/group consists of “not all of them are bad” then that is a sign of a serious problem.

And chiropractors are the poster child for it.

I have to ask, Andrew, why do you put up with it? You admit you have a bunch of complete quacks who are making your profession look bad. How can you accept that? What are you doing to get rid of them? Do you go to chiro internet boards and call them out and tell them to go away?

Your profession has a serious problem. Your admission that “not all of them are quacks” shows that. Do something about it.

TBruce: “A chiropractor (in Canada) pays about the same malpractice premium as an office-based family doctor.”

I wonder if people are aware that in most states in the U.S., chiros are not required to carry malpractice insurance.
That fact might affect lawsuit incidence and overall malpractice insurance costs.

@Kevin: I’m glad you had a pharmacology class in your program. From the chiros I have spoken with, that’s pretty rare. You still can’t compare the training you received to the training the MD/DO students received unless you were in the same class and know that the same information was taught.

I can vouch that my pharmacology class, as a CNM, was not the same as what any MD/DO program. We had to learn about far fewer medications and drug interactions, as well as biochemical interactions.

I wonder if people are aware that in most states in the U.S., chiros are not required to carry malpractice insurance.

This is very, very bad, of course. It lets the chiros shirk their professional responsibility to their patients, because one of the most important parts of being a professional is accountability. If you screw up, there needs to be recourse. However, by not having malpractice insurance, it is left to cash, and it’s easy to have nothing available, so there is nothing to sue and lawyers won’t take it. Whoops, patient, I may have screwed up, but there’s nothing you can do about it.

This actually happened to my brother in law. He got his next adjusted, immediately was nauseous couldn’t walk straight, dizzy (this is when the artery got torn). Next day he felt better, brushed it off – his doc said it was an allergic reaction (ok we all know that isn’t possible). He worked out, got the same symptoms, now he couldn’t walk straight and his eye and mouth drooped. This is the stroke part due to the blood clot moving. He went to the hospital and they determined he was having a stroke. They were able to treat him and he recovered but it was a close call.

How do we know that she had manual manipulation? She very well could have had instrument manipulation that creates absolutely zero rotation and extension in the cervical spine. AGAIN, media jumping to conclusions.

I can’t believe this article that based it’s facts on someone who puts an spinous process on C1 (the atlas). Did anyone else catch this on the figure that was stolen from one of Mark Crislip’s posts?

Here’s another version of the same diagram — perhaps the original — at Painter’s “Comprehensive Review of Chiropractic Research”:
http://www.chiro.org/LINKS/FULL/GRAPHICS/ROSNER/Rosner_2010_Figure_11.jpg

Another version:
http://www.chiro.org/LINKS/CVA/Figure_I.jpg

There is a significant fault in this article.

You show a video of a rotary cervical adjustment and imply that this was the exact adjustment given by the chiropractor. How do you know that? Have you seen the chart notes?

Many chiropractors adjust the cervical spine in very different ways. Atlas Orthogonal, Grostic, NUCCA, even Gonstead (which is more of “aggressive popping”) do not rotate the head during the delivery of the adjustment

@Marry me, Mindy.

How do I put up with it? With great difficulty, Mindy. My profession does have a serious problem. I do call out the anti vaccine chiros, those that treat outside the scope of their practice. I’ve donated money to evidence based research and am a member of Chiropractic Australia.

A large percentage of my referrals are from local medical doctors who trust my judgement, that I practice safely and refer when necessary. I largely use soft tissue work and mobilization of joints. I do manipulate when appropriate and safe and obtain informed consent whenever I do it.

I have often laid awake at night pondering why I joined a profession that is constantly at war with itself. But I do think the profession has a lot to offer and that in order to save itself it needs to pull registration away from the quacks who refuse to change, who, like Christian fundamentalists still clinic to the tenets of a magnetic healer from over a century ago.
The medical profession needs to extend an olive branch to those of us willing to work with you, for the good of the patient, not the practitioner.

There are good chiros and bad chiros, good doctors and bad doctors, good cops and bad cops! It’s up to you to do your homework and find an honest one who knows what they are doing

If a doctor does not know what he or she is doing, we tend to expect (rightly or wrongly) the professional body to do something about it… rather than shrug it off, and advise the patients’ families that they should have done their homework.

As for bad cops, it would be nice if we could shop around and avoid them. Word would get out not to consult Officer X who keeps shooting people.

About 15 years ago, I started having intermittent pain, numbness, and tingling in both shoulders, arms, and hands. I went to a doctor, who sent me to physical therapy, which did not help. Another doctor just gave me pain meds. Desperate, I went to see a chiropractor recommended by a massage therapist. He insisted on taking an x-ray, something neither of the doctors had done. On seeing that there was very little space between C5 and C6, he declined to treat me, and he sent me to a sports medicine specialist, who did an MRI. Turns out the disk between those two vertebrae was in pieces, and pieces were extruded into the foramen on both sides, impinging on the neurovascular bundle. I ended up having C5 & C6 surgically fused by a neurosurgeon. That chiropractor did two things: he didn’t make me worse, and he got me to an appropriate specialist. I still don’t think much of chiropractic in general, but I’m grateful to that guy for not inflicting the various injuries that could have been caused by spinal manipulation and for starting my recovery process.

Odd that we haven’t yet seen a typical chiro justification for neck cracking – that it supposedly alleviates hypertension.

The only source for this claim that I’ve ever seen was a single small pilot study involving a specialized technique. But it’s flogged as supposedly conclusive evidence supporting generalized neck cracking, just as other small studies (usually in chiro journals) are cited to support adjustments for infant colic and various other non-musculoskeletal indications.

Comments are closed.

%d bloggers like this: