November 2007
Patient strokes: Will you be blamed?
by Timothy Feuling, President, Chiropractic Benefit Services
Jim Mosley, 39, was
about to get married. He had been grieving for the loss of his father and
was taking Wellbutrin for depression caused by this traumatic event. His
other complaints included fatigue, memory lapses and concentration problems.
About two months
prior to visiting his chiropractor for neck pain and stiffness, Mosley's
primary care physician had placed him on Cardura for high blood pressure and
had added Prozac to his medication regimen.
Mosley's
primary‑care physician also ran lipid profiles that revealed elevated
triglycerides and other findings that placed him in a high‑risk category for
cardiovascular disease, so he was placed on Lipitor.
All together, Mosley
was taking Wellbutrin, Prozac, Cardura, Lipitor, Allegra and Tylenol for
pain.
Mosley had been
seeing his chiropractor, Dr. William Neely, on and off over the previous
year and a half for chronic neck, shoulder and low‑back pain. His visits at
this point were about once a month on an as‑needed basis.
Dr. Neely had done a
pretty thorough exam on his initial visit with Mosley a year and a half ago.
The exam included checking his cranial nerves, reflexes, muscle strength and
range of motion; taking cervical and lumbar orthopedic tests; and doing a
thorough chiropractic exam that revealed cervical, thoracic and lumbar
subluxations. Dr. Neely even noted performing Georges test, with negative
results.
On his last visit
with Dr. Neely, Mosley complained of neck and shoulder pain. The doctor
documented his subjective complaints, examined his spine, found that he had
cervical, thoracic and lumbar subluxations and adjusted him using
Diversified technique.
This included a
supine cervical rotatory adjustment to the upper cervical spine. For this,
Mosley later noted that Dr. Neely had to try more than once to "get it" and
that he felt immediate neck soreness after the adjustment.
Mosley left the
office about 4:30 in the afternoon, didn't feel well during the drive home
and ended up trying to sleep on the couch until his wife came home later
that day. Telling his wife he felt like he was "coming down with something"
he went to bed early. In the middle of the night Mosley awakened to use the
bathroom and when he arose he felt dizzy, staggered into the bathroom,
vomited and collapsed.
Hearing the
commotion, his wife ran to him, found him unconscious and called an
ambulance. Paramedics on the scene recorded his systolic blood pressure as
220. Upon arriving at the hospital he had regained consciousness, had
slurred speech, difficulty moving his extremities, especially on the right
and was complaining of dizziness.
Multiple tests were
ordered including head CT scans, brain
MRI
and magnetic resonance angiography. His wife told emergency room physicians
that he had visited his chiropractor earlier that afternoon and that he felt
like he had a cold later in the day. The attending physician immediately
suspected stroke from a dissection of the vertebral artery.
The CT and MRI
confirmed a dissection of the vertebral artery and multiple infarcts in the
brain.
Mosley spent two
weeks in the hospital and underwent outpatient rehabilitation for several
months, regaining nearly all of his function. He continued to have some
slight speech problems and some upper extremity weakness.
The patient filed a
lawsuit against Dr. Neely claiming the treatment caused a rupture of his
vertebral artery and that the doctor acted below the standard of care by not
recognizing that the patient was at a high risk for having a stroke due to
his history of high blood pressure and elevated lipids and that he either
caused or exacerbated the dissection and stroke.
Experts provided
affidavits that it was within a reasonable degree of certainty that Dr.
Neely's violations of the standard of care led directly to the patient's
subsequent stroke and resulted in permanent disability.
It was also asserted
by plaintiff's experts that Dr. Neely should have told the patient that
there was a risk of stroke from adjusting his neck.
Now for the rest of
the story
Records from
Mosley's primary care physician revealed that, at the time of his last
visit, he felt the patient's symptoms of memory loss, concentration problems
and fatigue might have a neurological basis and that they might need to be
further explored.
However, the MD
chose to medicate Mosley, increasing his Wellbutrin dosage and adding Prozac
to "see how that worked." Other than the drug treatment, his primary care
physician did not recommend that Mosley ‑‑ who weighed 240 pounds ‑‑ lose
weight, stop smoking or drinking caffeine, or be evaluated by a
cardiologist.
Further exploration
of his medical records revealed that in the months leading up to his stroke,
Mosley had visited his primary care provider several times with complaints
ranging from fullness in the ear, headache, fatigue, dizziness, depression,
moodiness, memory and concentration problems.
Dr. Neely did not
know that Mosley was even seeing a primary care physician and was unaware of
the various symptoms he was experiencing.
Other than his
visit‑by‑visit spinal examination, Dr. Neely had not done a formal
re‑examination or an updating of the patient's history, even though Mosley's
visits were sporadic and spaced weeks apart. While Mosley did check off
blood pressure problems on his initial history form, this was not explored
further and was never updated.
Do chiropractic
adjustments cause strokes?
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 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 affect the results and conclusions drawn
from case‑control studies. An association, no matter how strong, does not
prove causation. Other criteria must be used to determine whether an
association is actually causative
Due to the rarity
with which vertebrobasilar accidents (VBAs) occur, experimental evidence in
humans and prospective cohort studies examining the hypothesis that
chiropractic adjustments cause stroke simply do not exist.
If such studies were
to be carried out, they would take a number of years to complete and would
require thousands of subjects because of the rarity of the occurrence.
As for advising
patients about the "risk" of stroke, a risk should be disclosed if a
reasonable person (in what the doctor knows or should know to be the
patient's position), would be likely to attach significance to the risk in
deciding whether to forego the proposed therapy.
Patients and doctors
must make this decision based upon appropriate information. Since
there is no human experimental evidence that chiropractic adjustments or
neck manipulations are causally related to strokes, why would we require a
doctor to suggest that such a risk exists?
What is causing
these strokes?
Because the signs
and symptoms of a stroke or an impending stroke may be similar to common
complaints seen by chiropractors, there is a temporal association playing
itself out. In other words, the patient is already experiencing a stroke or
the prodromal signs when he or she walks into your office. The key is
recognizing these signs, being suspicious of them and doing something about
it.
First, be aware of
what are called the five "Ds" and Three "Ns" as well as any ataxia (see
chart).
Since chiropractors
have patients presenting with one or more of these symptoms all the time,
it's important to note that just because they are present does not mean that
a dissection is in process. You need to be aware of a grouping of these
symptoms (one or more that are unusual) as well as how severe the symptoms
are.
Look and listen for
the classic signs of these types of problems such as slurred speech,
giddiness, changes in voice patterns, speech problems, inappropriate
reactions, etc. One characteristic that is promoted as being almost
pathognomonic is a phrase from your patient that the pain in his or her neck
and/or head is unlike anything he or she has ever had before.
While you should
absolutely be alert to such signs, symptoms and statements as described
above, the majority of the stroke and dissection cases displayed what the
doctor thought to be garden‑variety neck or head pain, fullness in the ear
or other such symptoms that did not necessarily grab their attention.
This is why you have
to pay close attention in these cases. The big red flags will always jump
out at you, but you also need to be sensitive to the more subtle warning
signs that require you to do a little more sleuthing.
In patients who have
suffered headache or neck pain in the past, you have to determine if the
current headaches are different in any way, even if they aren't more
severe. Do they "just not feel right" and do they have other symptoms that
would make you think of a constellation of symptoms as opposed to
garden‑variety musculoskeletal pain?
Ask them about the
pain. Ask them if it feels different or if they have any pressure,
dizziness, etc. You also need to make sure you stop for a second and review
your patient's history if they have not been in to see you in a while. (What
constitutes a while? That depends on the patient, but a lot can happen in a
month and a lot more in two or three.)
So, let's say a
patient comes in and reports a new onset of neck or head pain that she
hasn't had before or in a while. You stop, slow down and ask your questions.
She tells you it's different than before or in the past or maybe she isn't
even sure. She just feels a little "off" and is fatigued.
Is this a
garden‑variety headache or a dissection in progress? Your options at this
point are to do a little more of a work up. You could, for instance, examine
her neurologically, check her blood pressure, etc. If you don't offer those
types of medically oriented tests, you could send her to someone who does.
Get on the phone with her internist or GP if she has one. If she doesn't
have one, refer her to one ‑‑ right away. Not later, not tomorrow, but
immediately.
What about symptoms
after an adjustment?
If your patient
experiences symptoms of a dissection or stroke following an adjustment, how
you manage and document things become crucial to reducing injury, mortality
and liability.
Pay attention to the
patient's symptoms and if he or she is experiencing any of the five D's or
three N's, these are obvious red flags. But don't limit your assessment to
those signs and symptoms. The mildness or severity of the symptoms will
determine whether you should simply monitor the individual for resolution or
consider emergency medical services.
Monitor his or her
vital signs and assess them neurologically. If the symptoms come and then
resolve relatively quickly, you may just want to monitor the patient over an
extended period. Think about the adjustment you did and consider if other
procedures may be more beneficial in the future.
If the symptoms
don't resolve, continue the monitoring, staying with the patient at all
times. Monitor additional signs and symptoms if they develop. If the
symptoms do not wane or if they get worse, consider emergency medical
services. Continue to monitor the patient while waiting for
EMS.
This next point is
crucial. Regardless of how tempting it might be, at no time following the
patient experiencing these signs and symptoms should you readjust the
patient. If the patient is experiencing a dissection, he or she needs
emergency pharmaceutical intervention.
