Putting Risk into Perspective

Connecticut DCs Counter Publicity Surrounding Chiropractic and Stroke
This section is compiled by Frank M. Painter, D.C.
Send all comments or additions to:    Frankp@chiro.org

  (Sept 2007) ~ FULL TEXT

Angela Kargus, ACA Director of Public and Media Relations

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Moshe Laub, DC, of West Hartford, Conn., remembers the day the transit bus pulled up in front of his office. For several minutes the bus idled directly across the street from his office, West Hartford Chiropractic; the message displayed prominently in purple block lettering across the full-length of the bus: “Injured by a Chiropractor? Call …”

Over the last three years, doctors of chiropractic in the state of Connecticut have been subject to a rash of anti-chiropractic advertisements conspicuously placed on rolling and static billboards, and in well-read statewide newspapers. Most recently, doctors saw a spate of unprecedented anti-chiropractic legislation aimed to mandate informed consent in chiropractic offices and require open access to chiropractic malpractice records.

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“The questions have been why us? Why Connecticut? Why now?” explains Connecticut Chiropractic Association (CCA) President Dr. Matthew Pagano. “There have been many theories; the conspiracy theorists among us, with good reason considering history, have blamed the vast medical-pharmaceutical complex, others have thought that perhaps we were a test market for an anti-chiropractic campaign from some national or international group.”

The real answer is much simpler.

In 1985, Linda Solsbury, a former nurse in Connecticut, contended that she suffered complications following chiropractic cervical manipulation. According to news reports from local newspaper The Day, Solsbury was awarded $10 million by a civil jury after it agreed that her stroke was indeed a consequence of cervical chiropractic manipulation. At the time, it was the largest award bestowed by a civil jury in New London County, Conn.

According to CCA Executive Director Kristin Kasabucki, it is believed that Solsbury’s friends pulled together to form the Chiropractic Stroke Victims Awareness Group, of which Solsbury was the co-founder. Initially they rallied to pass legislation mandating Connecticut chiropractors carry malpractice insurance, and then more recently, the group has very publicly voiced its opinions about the risks associated with chiropractic manipulation of the neck.

“This effort became a personal crusade and journey for friends of Ms. Solsbury,” Kasabucki explains. “They later began a recruitment effort in search of other purported victims.”

Two of those members—Janet Levy and Brittmarie Harwe—have most recently been the loudest advocates for not only the Chiropractic Stroke Victims Awareness Group, but also a separate organization by the name of Victims of Chiropractic Abuse.

In a May 2006 interview with WTNH-TV, Harwe was quoted as describing the Chiropractic Stroke Victims Awareness Group as “victims, family members and friends who have been traumatized” by chiropractic treatment and “whose lives have been destroyed.” According to the Victims of Chiropractic Abuse Web site, its mission is to “promote awareness of chiropractic risks through advocacy and legislation.”

Both Levy and Harwe suffer from reported complications following chiropractic manipulation, and according to public reports, Harwe received a reported out-of-court settlement of $900,000 in 1993.

Both women assert that they believed chiropractic to be a safe and natural alternative and that they were “totally unaware” of any serious risks involved.

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Forming a Strategy

From buses to billboards and even newspaper ads, the Constitution State has seen more than its fair share of negative chiropractic publicity.

Dr. Pagano explains that from the start, CCA’s strategy was to avoid a public debate in the media with regard to the safety of chiropractic neck adjustments. “Instead, we chose to use the increased media interest to tell our own positive story about chiropractic,” he says.

According to CCA’s Public Relations Committee Chair Dr. Gina Carucci, CCA instituted a public relations campaign at the association’s October 2006 meeting. The CCA general membership unanimously voted to support the campaign as well as the $600-per year assessment that would be in addition to their annual dues.

Over the past year, the association has launched a Web site, which was heavily marketed to CCA members, chiropractic patients, and elected government officials. Association officials partnered with Fox Broadcasting Company to secure several 15-second television spots each month on Fox channel 61 and CW channel 20, and they have scheduled many 15- and 20-second traffic sponsorship advertisements throughout the state. Advertisements were also placed in Connecticut Magazine.

Dr. Carucci says the public relations assessment and the results of the two-year campaign are to be reevaluated in 2008.

“Our strategy has been to get the message out about chiropractic in a positive, professional manner. We seek to educate the public as to what chiropractic is, demonstrate the effectiveness and safety of our method of treatment, and show the public that we are highly-educated professionals,” Dr. Pagano says.

Even with a concerted PR effort underway, there may be some doctors in Connecticut who feel that CCA’s efforts have not been enough to protect the profession. There are likely doctors who feel that lawsuits and boycotts should be launched against the bus companies, billboard companies or even the newspapers, says Dr. Pagano, and there are others who have advocated the need to rally the cause as a means of educating the public.

“The knee-jerk reaction I see at times in our profession is that people want to stand up and fight. I, too, feel the desire to stand up for what I know is the safest type of health care on the planet; however, a public debate will only serve to make the community more aware that there’s a relationship between chiropractic and stroke,” Dr. Pagano explains.

Earlier this spring, CCA relied on a similar behind-the-scenes strategy when confronted with four pieces of anti-chiropractic legislation, all of which were supported by the Victims of Chiropractic Abuse. Three of the proposed bills were defeated in committee; language in the fourth bill was broadened to expand the list of health care providers in Connecticut who must report malpractice claims data to the state Department of Insurance, and as a result the signed law did not single out doctors of chiropractic.

“Last year, when the ads and buses didn’t work, the Victims of Chiropractic Abuse went the legislative route, which gave these ladies an additional platform with which to speak to the media,” says Kasabucki.

It is Kasabucki’s opinion that a recent negative article in SELF magazine was a strategic move by Connecticut-based anti-chiropractic organizations. The overwhelmingly negative article, which appeared in the May 2007 issue, detailed the stories of several patients -- particularly a 43-year-old mother of four who believes her stroke was caused by a chiropractic adjustment. In addition, the article quoted patient advocate Brittmarie Harwe and mentioned the then-proposed legislation in Connecticut.

“The article in SELF magazine was purely a strategic move on their part; it was not an informational, educational piece,” Kasabucki says.

“When you are the one who suffers a complication to any health treatment, it is very real and it can be devastating,” Kasabucki sympathizes, “but to generalize, and in effect, say that the same injury may happen to every person visiting an office is absurd.”

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The Risk of Adverse Reactions

While any form of health treatment contains a degree of inherent risk, according to available literature, the risks associated with chiropractic manipulation are minimal. The most common side-effect associated with chiropractic treatment is mild muscle soreness. Current literature shows that minor discomfort or soreness following spinal manipulation typically fades within 24 hours.

Although there have been isolated reports of stroke following chiropractic neck manipulation, the findings in the current research literature agree that adverse events such as stroke or stroke-like symptoms associated with neck adjustment are very rare. According to scientific data, the odds of suffering a serious reaction from chiropractic cervical manipulation have been shown to be less than one incident in 3.8 million to 5.85 million manipulations.

The issue of stroke related to neck adjustment focuses around an alleged injury to the vertebral artery as it passes through the sides of the upper cervical vertebrae and into the base of the skull. Rotation of the neck may injure an abnormally fragile vertebral artery along its course by partially tearing the inner artery wall (the intima). This event is called a vertebral artery dissection (VAD).

The injury to the arterial wall may lead to formation of a blood clot. Part of the clot (called an embolus) can break free and travel upward until it lodges in one of the smaller blood vessels in the base of the brain. This can result in ischemic stroke, or a lack of blood supply to these brain tissues.

“These events seem to have gotten a disproportionate amount of attention in the medical literature and in the popular media, considering how extraordinarily infrequently they occur,” says William Lauretti, DC, a faculty member at New York Chiropractic College and an ACA media spokesperson who has been interviewed by major news outlets about chiropractic risks.

A medical review published in 2002 looked at 73 studies of chiropractic care and found no serious complications reported in any of them. Studies have also shown that when an adverse reaction does occur in association with cervical manipulation, it is often the result of an improperly trained person performing the procedure - rather than a doctor of chiropractic.

Dr. Lauretti contends that the issue for any healthcare intervention is appropriateness, which involves balancing safety and effectiveness of the suggested treatment. “Several extensive reviews of the scientific literature from leading authorities have agreed that neck manipulation is safe, effective, and appropriate for patients with a number of very common complaints like neck pain and headache,” he notes.

Most recently, a literature review published in the March/April 2007 issue of the Journal of Manipulative and Physiological Therapeutics found evidence that patients with chronic neck pain enrolled in clinical trials reported significant improvement following chiropractic spinal manipulation. Researchers reviewed nine previously published trials and found that patients with chronic neck pain showed significant pain-level improvements following spinal manipulation. No trial group was reported to remain unchanged, and all groups showed positive changes up to 12 weeks post treatment.

According to Dr. Lauretti, to properly assess the risks of chiropractic treatment, it must be compared against the risks of other treatments for similar conditions. For example, the most common first-line medical treatment for neck pain are non-steroidal anti-inflammatory drugs (NSAIDs). A 1999 study published in the New England Journal of Medicine (NEJM) estimated that at least 103,000 patients are hospitalized per year in the United States for serious gastrointestinal complications due to NSAID use. More recently a separate study from NEJM estimated that at least 16,500 NSAID-related deaths occur among patients each year.

Moreover, not treating neck and back pain carries risks as well. These may include increased rates of disability, abuse of prescription narcotics for pain relief, disruption of work and social activities, and the risk that an uncomplicated short-term pain condition will become chronic and permanent, Dr. Lauretti says.

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The Role of Informed Consent

The legal requirements regarding informed consent for healthcare procedures vary from state to state, and specific guidelines are not always well established. Therefore, it’s not surprising that the question of whether chiropractors should routinely inform all patients about the remote possibility of a stroke from a neck adjustment is a contentious one. Some clinicians feel that requiring a signed patient consent form is unwarranted because the risks associated with cervical manipulation are so minimal.

Some chiropractic experts and many plaintiff attorneys, however, say informed consent is not simply a form, but rather a process of informing the patient about a procedure which may have material risk associated with it. The process is the verbal explanation of the risks involved -- including the risk of doing nothing -- and the paper form is merely a way to document the process.

Regardless of your individual views on informed consent, “treating patients without telling them of any known risks or consequences creates potential problems in today’s legal world,” says NCMIC President Dr. Louis Sportelli.

He says that most often NCMIC sees malpractice cases coupled with another claim that involves a failure of the chiropractor to provide informed consent. “So the advice we give is consult your state association and/or personal attorney as well as knowing your practice comfort level and then decide if providing informed consent is right for your practice style,” Dr. Sportelli says.

The basis of a lawsuit involving failure to provide informed consent would be that had the patient known of all the risks, benefits and alternatives, he or she would not have agreed to the procedure and, therefore, would not have sustained the injury, he explains.

Even so, there remain doctors who argue that in other health care disciplines a one-in-a-million possibility is not even considered a risk, and therefore, little time, effort or energy is spent investigating safer alternatives. Rather than assume that posture, Dr. Sportelli says, the chiropractic profession has undertaken exhaustive research to find associations between spinal manipulation and vertebral artery dissection.

“The chiropractic profession should be applauded because not only has it not ignored the extremely rare occurrence, but it has devoted a disproportionately large amount of time and money to exhaustively research this matter,” he says, “because even one cerebral vascular incident (CVA) that could have been prevented or detected early is one too many.”

Sidebars

Educational Resources Available for Patients, Doctors She’s a patient you’ve seen for years. Now imagine the day she comes into your office with a popular magazine in hand and tells you that because of a media report she no longer wants you to adjust her neck. How would you respond? William Lauretti, DC, a faculty member at New York Chiropractic College and an ACA media spokesperson, suggests that doctors take patients concerns about safety seriously, and not be dismissive or condescending. Dr. Lauretti suggests that doctors of chiropractic start by discussing with patients the importance of balancing treatment effectiveness and safety. “For patients with many types of neck pain and headache, there is at least as much scientific evidence demonstrating the effectiveness of chiropractic treatment as there is for as any other medical or surgical treatment,” he notes. However, doctors should also acknowledge that there is some evidence that neck manipulation may be correlated with vertebrobasilar stroke; although, there is no established cause-and-effect relationship between chiropractic manipulation and cervical artery dissection. “Whenever the question comes up – whether with patients or the media – it’s responsible to admit that there’s a risk, although infinitesimally small because the research – whether we agree with it or not—supports that conclusion. To not do so, is to lose credibility,” says Matthew Pagano, DC, president of the Connecticut Chiropractic Association.

ACA Patient Resources The members’ only section of the ACA Web site provides a number of patient education resources, including: •   Research excerpts that show the positive benefits of chiropractic care •   Patient education page: “Is Chiropractic Safe?” •   Patient education page: “Chiropractic & Headaches” •   Chiropractic & stroke: Key messages for patients and the media In addition, doctors can order a copy of an informative ACA teleseminar titled, “Chiropractic and Stroke: Share the Facts with Your Patients and Community.” During the teleseminar, Dr. Lauretti discusses how to address the concerns of chiropractic patients, professional colleagues and others in the health care community who have questions about the risks associated with cervical manipulation. To order the teleseminar, visit: http://www.acatoday.org/teleseminars. Resources for Doctors, Other Health Care Providers The chiropractic profession also offers a number of resources for doctors of chiropractic and their colleagues. •   NCMIC’s Monograph “Spinal Manipulation and Cervical Arterial Incidents” available at: https://www.ncmic.com/microsites/CVA/ CVA_home.aspx •   CEvantive University – an online continuing education university, has created a two-hour course titled “Stroke and Cervical Manipulation.” The course is provided free of cost at www.cevantive.com •   The Association of Chiropractic Colleges (ACC) recently made available a lecture in DVD format titled, “Cervical Spine Adjusting and Vertebral Artery Issues.” The DVD is available for the $10 cost of shipping and handling. To order, visit: http://www.chirocolleges.org/

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