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.

Comments

  1. #1 Denice Walter
    February 20, 2016

    re genetic variation

    I’ve come across a few references that show more sensitivity to pain amongst the red/ ginger haired** – which of course I use to harass someone I know.

    Personally, I have experienced the phenomenon Chris describes of not always feeling much despite injury.
    My late father was quite able to tolerate much after urological surgery yet – the doctor was amazed.

    ** except for Chris, which again, illustrates genetic variation. It’s not everyone.

  2. #2 JP
    February 20, 2016

    I have injured myself and not realized until I notice a bruise and every so often I am actually dripping blood

    Yeah, I have this too. “Oh, really, I’m bleeding? Where?”

    It does help when one is getting tattoos, though, at least to an extent. There is also a certain amount of “talking oneself into it.” (“Well, I paid for this, I got myself into it, I guess it’s time to get down to business!”)

  3. #3 Chris
    February 20, 2016

    I have been told by an anesthesiologist at a brain science fair that those of us with red hair drive them crazy. Even though, alas!, my hair is no longer red (the white hairs are taking over).

  4. #4 Csp neuro
    February 21, 2016

    Please don’t make a joke of this topic. Many people have suffered the loss of loved ones at a young age due to arterial dissections. I however, survived my vertebral artery dissection. Yes, it is more common than documented. They can tear and heal asymptomatically with no long term or even noticeable complications. Yes, I saw a chiropractor whom performed neck manipulations I wish I would have know the possibility and I would never have had my neck manipulated. So, as healthcare professionals and yes I am one why don’t we work together to solving the mystery. Chiropractors have not been willing to do their part in researching the topic. It will cost money and I can assure you they will lose their ability to state any benefit that could possibly out way a stroke caused by manipulation. Yes! I now know many whom suffered chiropractic stroke. On the bright side, I utilized my experience to shift my career into neurology…nurse practitioner. Believe me, I voice concerns with my patients and always recommend they decline any form of neck manipulation. Please chiros, do the research that needs done. You should be able to afford it since your malpractice is so low, or perhaps business isn’t as good as you may lead some to believe. Please stop scaring parents out of vaccines! You are dangerous!

  5. #5 David
    New Jersey
    February 25, 2016

    I would just like to respectfully enlighten some of you about Osteopathic Physicians, or D.O.’s on this thread. This is either by ignorance and/or just that most DO’s don’t incorporate their hands anymore into medical practice. I realize that statistics show that only about 10% of the 100,000 or so practicing Doctors of Osteopathic Medicine ( D.O.’s ) in the U.S. utilize their hands-on skills of Osteopathic Manipulative Treatment, or O.M.T. in clinical practice, so it’s conceivable that DC’s/Chiropractors are the most recognized practitioners of SMT, or spinal manipulative treatment. However, there are about 700 of us in Osteopathic Medicine that have gone on to specialize in SMT by getting Board-Certified in it. Some of us, myself included, even got double- board certified in both Family Practice as well. There is only one recognized medical board in the U. S for spinal manipulation called the American Osteopathic Board Of Neuromusculoskeletal Medicine ( AOBNMM )-a branch of the American Osteopathic Association ( AOA -based in Chicago ) located in Indiana that oversees this. I have recently been re-certified for another 10 years after passing a rigorous 3 and 1/2 hr. written exam after initially passing an Oral, Practical, and Written 3 day board certification exam process. This was only after having to prove proficiency after submitting case studies to a panel of Osteopathic Manipulative specialists to prove that I had real-time patient practice experience. Also, I graduated from he founding medical school of Osteopathic Medicine in Kirksville, Missouri and had over 600 hours just in medical school and then hundred’s more hours in 3rd and 4th year followed by three more years during my residency in Family Medicine wherein Osteopathic SMT was integrated in to many phases of my medical training. Albeit, I was more interested in incorporating this form of the Osteopathic hands-on skillset into my medical practice than my colleagues. I am also an adjunct professor in about 5 medical schools and routinely teach medical students and residents and have been utilized as an expert witness because of my unique training. This is not to brag or be condescending. I wanted to both politely object and correct/enlighten the readers and writers here that there are other extremely well- trained and experienced practitioners of these skills here in the U.S. I have had far more hours and training than many, if not most chiropractors and other D.O.’s and politely object to this being omitted here. I have also been in medical practice of Integrative Family Medicine and Osteopathic Manipulative Medicine for over 24 years and enjoyed great success with my patients. I am very good at and confident in my use of manual techniques including both HVLA ( thrusting ) and non-thrusting maneuvers. One has to know when to use them and when not to. The advantage I have always had is to both step back and look at the ‘whole picture’ of a person, having the advantage of having had what is, in my opinion, a very ‘complete’ and comprehensive medical training – 7 years after college and then more board examinations and re-certifications while in practice. The success every day with millions of adjustments, whether it be Chiropractic or Osteopathic ( let me correct some of you- it is my understanding that physical therapists in the US are NOT licensed to do manipulation unless they take a rigorous 2 year extra course of training -this is rare ) proves that this is a relatively safe form of treatment, especially compared to more invasive medical procedures. However, there is no substitute nor comparison for the type of experience that I and many of my Osteopathic medical colleagues in all defferent specialities have been exposed to when it comes to evaluating patients to avoid tragedy. There are also ‘good’ and ‘bad’ physicians in every area of medicine, chiropractic, therapists in physiotherapy, massage, physical therapy, acupuncture, etc.. Each case should be construed as a unique one. This unfortunate incident has many aspects. Perhaps if the family requests it, a full investigation, including an autopsy and other aspects may need to ensue.

  6. #6 squirrelelite
    February 25, 2016

    Thanks for making that point, David.

    Most of the readers here are aware that Osteopaths in the U.S. have training roughly equivalent to that of Medical Doctors. My alma mater, Michigan State University, has a College of Osteopathic Medicine created by the state legislature during the more enlightened days of the baby boom when it was clear the state needed more doctors than Orac’s alma mater could provide.

    But this blog draws readers from around the world, and in all of those countries that I know of, osteopaths have training that is not much better than the average chiropractor.

    The key point in this article was that we do NOT know whether manipulation of the neck caused the stroke and probably can’t tell for sure.

    But it was a bad idea that was highly unlikely to have any medical benefit.

  7. #7 stra2d
    Boston
    February 25, 2016

    I’m sorry for jumping into the conversation late but was an xray or MRI taken at any point after the injury. I think that chiropractic manipulation should be only be considered after a person is cleared of any underlying or hidden condition.

    When a professional football player is injured on the field every step is taken to keep the neck, back and legs in a neutral position until an MRI can be performed,
    That said, I think that routine chiropractic manipulation is both risky and irresponsible, and could in fact worsen an injury and patients overall condition.

  8. #8 Tim Bertelsman
    Swansea, Il
    March 5, 2016

    First, we are all saddened by the loss of a life. My sympathies go out to the family. Unfortunately, this blog will not help others. In fact by misrepresenting the facts, you are dissuading people from seeking safe conservative care in place of more threatening alternatives. This bog is in contrast to the current evidence:

    The largest medical study to date (1), encompassing 100 million person years, found that strokes occur at a similar increased rate regardless of whether the patient sees a chiropractor for manipulation or their PCP for consultation. The authors found: “no evidence of excess risk of VBA stroke associated chiropractic care compared to primary care.“ Researchers discovered that patients in the developing stage of a stroke are more likely to visit a chiropractor or PCP for complaints of headache and neck pain. The study suggested that the chiropractic or PCP treatment was not the cause of the stroke, but rather a non-contributory mid-point of an undetected developing crisis.

    Another study by Kosloff et al. (2) extracted 3 years of commercial insurance and Medicare advantage plan data for approximately 39 million insured patients- representing approximately 5% of the total US population. The study analyzed a potential correlation between chiropractic visits, PCP visits, and stroke. The study found: “No significant association between VBA stroke and chiropractic visits. We conclude that manipulation is an unlikely cause of VBA stroke.” The study did however find “a significant association between PCP visits and VBA stroke. The positive association between PCP visits and VBA stroke is most likely due to patient decisions to seek care for the symptoms (headache and neck pain) of arterial dissection.” Like the Cassidy study, this study strengthens the premise that chiropractic manipulation may not increase the risk of VBAI stroke; rather, impending VBAI stroke patients may have a higher likelihood to seek care from a variety of providers, including chiropractors.

    I hope that you will drop your unfounded bias toward manipulation in consideration for the facts.

    1. Cassidy JD et al. Risk of vertebrobasilar stroke and chiropractic care: results of a population based case-control and case-crossover study. Spine 2008 Feb 15;33(4 Suppl):S176-83 http://www.vtchiro.org/Resources/Documents/Chiro%20Stroke%20Cassidy.pdf

    2. Kosloff TM, Elto D, Tao J, Bannister WM. Chiropractic care and the risk of vertebrobasilar stroke: results of a case–control study in U.S. commercial and Medicare Advantage populations. Chiropractic & Manual Therapies (2015) 23:19

  9. #9 Dangerous Bacon
    March 5, 2016

    “What we should not forget is that the Cassidy study was but one of several case-control studies investigating this subject. And the totality of all such studies does not deny an association between neck manipulation and stroke.”

    “Much more important is the fact that a re-analysis of the Cassidy data found that prior studies grossly misclassified cases of cervical dissection and mistakenly dismissed a causal association with manipulation. The authors of this new paper found a classification error of cases by Cassidy et al and they re-analysed the Cassidy data, which reported no association between spinal manipulation and cervical artery dissection (odds ratio [OR] 5 1.12, 95% CI .77-1.63). These re-calculated results reveal an odds ratio of 2.15 (95% CI.98-4.69). For patients less than 45 years of age, the OR was 6.91 (95% CI 2.59-13.74). The authors of the re-analysis conclude as follows: If our estimates of case misclassification are applicable outside the VA population, ORs for the association between SMT exposure and CAD are likely to be higher than those reported using the Rothwell/Cassidy strategy, particularly among younger populations. Future epidemiologic studies of this association should prioritize the accurate classification of cases and SMT exposure.
    I think they are correct; but my conclusion of all this would be more pragmatic and much simpler: UNTIL WE HAVE CONVINCING EVIDENCE TO THE CONTRARY, WE HAVE TO ASSUME THAT CHIROPRACTIC NECK MANIPULATION CAN CAUSE A STROKE.”

    http://edzardernst.com/2015/01/chiropractic-neck-manipulation-can-cause-stroke/

    The Kosloff study has its problems too, as even a defender of chiropractic has acknowledged:

    “The authors acknowledge certain limitations of their study due to the nature of insurance claims data. These data do not code for what specific treatment was rendered or immediate responses to treatment. Thus it is not known if chiropractic manipulation was performed during any office visit and if there was any immediate adverse response. Further, the accuracy of the VBA stroke diagnoses is unknown. Finally as the authors note there is a loss of “contextual information surrounding clinical encounters between chiropractors and Primary Care Physicians and their patients.” This limits the knowledge of other known risk factors.”

    http://blogs.biomedcentral.com/on-health/2015/06/19/chiropractic-care-and-the-risk-of-vertebrobasilar-stroke/

    There remains no good justification for forceful neck cracking, which is particularly alarming when inflicted on patients who have suffered acute neck trauma.

  10. #10 David
    New Jersey
    March 7, 2016

    first, thanks for your comment #211 ( I don’t know your name-sorry ). You’re right- if this is read by people all over the world, then they might not know that DO’s in other countries as opposed to the US are generally limited to only Osteopathic spinal manipulation and do not have a full plenary medical license as do we in the United States. ‘Osteopaths’ , as they are generally referred to in other countries, are at the same level as chiropractors.
    That said, I am familiar with the cited articles above by Cassidy as well as Shekelle and Cherkin in 1998 and 1999, for ex. in the NEJM as well as the articles on Osteopathic manipulation in the NEJM by Anderson, et al in 1999 and in 2000 with follow-up commentary, and the ‘Beauty parlor Syndrome ‘ reports in The Lancet and I believe JAMA or NEJM. All of this does not preclude that experienced DO’s such as myself who are also board-certified in providing this type of clinical skill, perform this almost every day in our offices with great success and to the relief of our patients. My Osteopathic adjustment techniques, albeit, are apparently very different from my chiropractic colleagues, as I am told by my patients, colleagues and my own observations of Chiropractic adjustments. I also have the distinct advantage of a formal medical background/training so that I am keenly aware of a patient’s medical history and thus possible elements of complications.
    I do believe, from the story as I read it, that no manipulation of any kind should have been attempted after this woman fell and had a neck injury. I believe I would have at least consulted a
    neurologist/neurosurgeon after a bonafide workup with radiology ( X-rays, Ct vs. MRI ) to make sure there was no sustained evidence of any bony or neurologic trauma. Any type of forcible trauma like this to the neck deserved a thorough medical investigation by specialists. If the chiro saw the patient after she was cleared by a specialist, then we may have heard about it and that would lend some creedence, but it doesn’t sound like that happened. We need more information. The timeline doesn’t make sense.

  11. #11 squirrelelite
    United States
    March 8, 2016

    You’re welcome, David.

    I’ve read that osteopathic manipulation is more gradual and gentle than chiropractic manipulation, but don’t really know.

    The bottom line in this case is that there are too many unknowns to draw a clear judgment, but visiting a chiropractor was a bad idea.

  12. #12 SMT_PT
    Texas
    March 9, 2016

    In response to David:

    “( let me correct some of you- it is my understanding that physical therapists in the US are NOT licensed to do manipulation unless they take a rigorous 2 year extra course of training -this is rare )”

    That is incorrect. Physical Therapists have been performing Thrust Joint Manipulation since the 1920s and have been heavily involved in the reasearch into its efficacy since at least the early 1960s. A physical therapist does not require a license to perform manipulation. We are taught SMT in our respective entry-level educational programs. Most therapists however attend continuing education programs (such as the excellent Spinal Manipulation Institute founded by James Dunning. http://www.spinalmanipulation.org/) in order to acquire high level skills in spinal manipulative therapy necessary to safely perform these treatments. And Physical Therapists perform thorough exams prior to performing any SMT on a patient (i.e., evidence based medicine). Certain state practice acts do not allow for a PT to perform Joint Manipulation. PTs in Texas can perform Spinal Manipulation pending a physician signs off on the plan of care.

  13. #13 David
    New Jersey
    March 14, 2016

    In response to SMT_PT,

    Thank you for the enlightening response #217 and I assume you are indeed Dr James Dunning himself. I did my due diligence and referenced the website link you wrote of and many other reputable sites. First, I applaud you for winning your case in Alabama against the ASBCE and also that your training includes Physiotherapy and Osteopathic training in the UK. It appears very similar to the type of Osteopathic spinal manipulation that I have been privy to learning.
    However, it with all due respect that while we all probably agree that there are positive benefits to spinal manipulation in general, there is wide variation amongst our respective training. I reviewed your course outline for a 2 day course after which you offer ‘certificates’. I would like to ask you how many hours you teach and what are required to certify one to actually perform such varied and complicated techniques as HVLA?
    I had over 800 hours integrated into my medical school curriculum at ATSU- The Kirksville College Of Osteopathic Medicine, much of which is emulated at the British School Of Osteopathy since my school was the founding school of Osteopathic Medicine in the U.S.. During and after medical school ( 4 years med school plus 3 years of residency in one field and 2 years in another -that’s a total of 5 years post-graduate) I had to prove my competence as they do now to my peers by passing three national board exams as well as a practical exam in my first specialty of Family Medicine by the American College Of Osteopathic Family Practice to demonstrate proficiency. After this, I went on to become even further board-certified by the American Academy Of Osteopathy’s ( AAO ) American Osteopathic Board Of Neuromusculoskleletal Medicine ( located in Indianapolis ) after passing a 1 week-long set of board examinations that included the presentation of 3 peer-reviewed case histories/studies submitted to the board for review prior to taking an Oral, Practical ( real patients/demonstrating hands-on skill proficiency ) , and a 3 1/2 hour written exam following a Residency/Fellowship. Recertification requires a rigorous written examination every 10 years plus Continuing Medical Education. It also qualifies us to be expert witnesses in the subject. This is the ONLY Board in the US that certifies physicians- now open only to D.O.’s in the US. The AAO has started courses to teach MD’s as we merge the ACGME in the coming years.

    Dr. Dunning advertises that his ‘institute’ as the ‘Worldwide Leader in spinal manipulation education’. I see that a typical ‘certificate’ take 12-18 months to complete. he also calls them ‘Osteopractors’, a mash-up of Osteopathic and Chiropractic disciplines, but claiming that it is not the same. Funny, he also must base his principles on that of Osteopathy, from which he received training and whose principles are rooted in American Osteopathic Medicine in Kirksville, Missouri by Andrew Taylor Still, MD begun in 1874 ( the school began in 1892 ).

    While you may have some expertise in a field that few MD’s and PT’s possess, please don’t pretend or profess to be the ‘worldwide leader’ or ‘experts’ in spinal manipulation when your training far shadows that of a formal medical residency/fellowship in the US in hours, course clinical correlation and years, not ‘months’ of training. I have been doing this for almost 30 years integrating and teaching these skills into real-world everyday outpatient and inpatient medicine. I am also a professor at several medical schools in this subject.
    Like I said, although I applaud you and other PT’s and even MD’s ( I can’t believe some DO’s would actually need to take this, but I guess they might need to feel they can sharpen the skills they were already taught -it’s their $ ) for taking an interest and I’m sure you are sincere, there is already a bonafide and well-accepted specialty board in spinal manipulation in the US and it’s Osteopathic true to it’s roots. I still maintain the PT’s are not allowed to perform spinal manipulation unless they are certified by a governing and accepted board. As your thread states in the last sentence, a ‘physician’ ( what kind and what is their certification/background? ) in TX must sign off on their care. Please be more specific and scientific/fact-based before passing yourself off as an expert.

    I am certainly not being haughty or disrespectful when I write this, but after you or a self-proclaimed ‘expert’ in spinal manipulation with years of experience and rigorous proven training spends time in ‘my shoes’, please make the correct comparison. This is akin to comparing an Orthopaedic Surgeon ( MD or DO- 4 years of med school, plus a 5 year surgery residency and perhaps a 2 year fellowship -includes board Certfication ) to a PA or Physician’s Assistant in Orthopaedics ( 3 years of graduate level training ).

    Remember- ‘Apples to Apples’ here in the US.

  14. #14 SMT_PT
    Texas
    March 16, 2016

    Man, you are really into yourself. Just calm down. There are more people other than yourself performing Spinal Manipulation worldwide. There are plenty of clinicians in all disciplines that have superior skills. You should know that and maybe have a little humility, before you make assumptions that physical therapists do not have the training or expertise to perform spinal manipulation. I am not James Dunning, but why don’t you call him yourself? Pretty sure he could enlighten you and maybe even teach you something.
    There are states where PTs have direct access to care, in which they do not require a physician (MD, DO) to refer patients to them. If spinal manipulation benefits a patient/client, and the clinician who is examining them has the skills (not only in the specific techniques, but in differential diagnosis as well (which btw, most PTs possess), does it matter if the treatment is performed by an Osteopath or a Physical Therapist?

  15. #15 david
    new jersey
    March 16, 2016

    First, I apologize for making it seem that, ” I am into myself…” that’s just not true and I feel your comments about my humility are unnecessary, but you do have a right to express your opinion, as do I. I also qualified my statement in the last paragraph by stating I was not trying to be disrespectful. I never made an ‘assumption’- I am citing facts. i also happen to have a excellent professional relationship with my neighbors who have a large PT practice right next door to me referring them a lot of business. I believe in and they appreciate the combination advantage that PT and OMT ( Osteopathic Manipulative Treatment ) offers patients. We both know our limitations.
    I was defending a misconception enlightening you and others that there is a clear difference in the amount of skill and training required. You have also not identified yourself as either a professional or a patient here- your honesty is appreciated. If you are a practitioner vs. a patient, this is important. Patients/people are always doing their due diligence by internet or calling/having a consultation and they have a right to know the extent of the person claiming their expertise. That’s common sense and client safety and courtesy as they are consumers.
    I agree that there are others performing this skill, albeit in different ways and that there are good and bad practitioners all over.
    Third, when a patient is receiving spinal manipulation , it does actually matter, on a case by case basis whether it is performed by a PT or other practitioner- at least in New Jersey it is. This is especially true when I refer a patient to a physical therapist, so we’re not duplicating services, plus it is by referral only, so it’s a professional courtesy to let the referring doctor know as it is part of the medical record/documentation.
    You are correct that in certain states PT’s don’t require a referral as is the case in NJ. However, if they would like another referral from the doctor that they see a patient from despite a referral, they are always coming over to introduce themselves to garner new business.
    I am not arguing with you about whether SMT benefits a patient or not, but I do contend that it does matter what type of practitioner does it because it is related to the treatment plan timeline and outcome.
    I stand by my background and extensive training and challenge you to compare it to yours or others. That’s why physicians and others take these courses and training to justify and prove the best proficiency available. otherwise it can be detrimental, as is why we’re all interested on this thread in the first place.

  16. #16 SMT_PT
    Texas
    March 16, 2016

    If you must know, yes, I am a Physical Therapist with a clinical Doctorate in Physical Therapy from an American accredited public institution and I have been doing this for several years. I have certifications in manual therapy, diagnosis and treatment and I could care less about word soup. My patients and fellow clinicians know I am capable and safe in providing treatment with good outcomes and our physicians know we treat and diagnose only neuromusculoskeletal disorders and when a patient does not fall under those 3 systems, we refer the patient back to the physician. This is best practice and what the public deserves. If you are still unsure what Physical Therapists do, I challenge you to go to one of Dr. Dunning’s courses or any advanced courses taught by Peer reviewed clinicians who are bonafied experts. Dunning’s group is a great example and the IAOM-US (They teach physician based clinical examination based on James Cyriax and PT, Dos Winkel’s work) is another. Don’t fall into Dogma; “You don’t know what you don’t know.”

  17. #17 david
    new jersey
    March 17, 2016

    Ok- thanks for clarifying. It sounds like you have experience and also have gone on to earn a doctorate in your field. That is impressive. I don’t know too many PT’s who have gone on to do that and you are due recognition. I wish you had written that sooner. I am familiar with Cyriax’ work, but he generally was anti- DO and DC. I also had some training with MacKenzie’s work and also the physiotherapist, Maitland-good resources. Interestingly enough, I also found Dalton’s PT work online on YouTube fascinating, accurate, and very similar to Osteopathic training-confirmed by the fact he trained with Phil Greenman, D.O., at Michigan State College Of Osteopathic Medicine.
    If I can, one day, I’d like to see what this course is all about. Until then , I would challenge you back to come to see how the AAO ( American Academy Of Osteopathy) sets up things-they hold a Convocation annually in and around March, but but have stuff going on all year round.
    -Respect.

  18. #18 Ted Hak MD
    santa monica
    March 22, 2016

    Wow! Yours is the best description of the pathophysiology surrounding a “spontaneous” Carotid dissection i have come across in the 25 years since i suffered a similar fate. As a physician i spent years trying to deduce the cause of my stroke that left me with a right hemiparalysis. At first i speculated that my struggles with a new electric razor, or an accidental elbow during basketball, as possible causes. It was two years until i reached the still speculative conclusion that my pulling a golf cart with my left arm while hustling to clear a fairway was the origin of my fate. The group behind suddenly yelling “fore” and my natural response of quickly turning to the right, and subsequent sudden, but short lived neck pain was the start of my dissection that within the course of 1 week, would lead to my multiple seizures preceding a 5 day coma from which i awoke with dysarthria , right sided paralysis, and a massive stroke which stemmed from my middle cerebral artery and was confirmed by angiography of my carotid that showed the dissection. In those 7 days leading up to the catastrophic event i would have multiple events that i rationalized off as part of migraine even though i had no history of the same. These included a week long headache, some loss of central vision and my right thumb getting periodically numb all leading up to my confusion and subsequent seizures followed by coma. I speculate that my pulling the cart with my left arm had somewhat fixed the L subclavian so that the sudden turn towards the R could supply enough sheering force to cause the intimal tear which would ultimately harbor the clot that broke off and occluded the R middle cerebral artery. There may have been other factors such as a poorly developed anterion communicating artery with in my circle of Willis and the fact that i possessed a faint scar from my childhood chicken pox, directly over the L carotid (which there is some literature supporting intimal damage to the underlying vessel with the varicella virus in childhood) that may have contributed. But ultimately, my struggle to find a source, have lead me towards this conclusion. After 4 mts. of intensive rehab. i learned to walk with an AFO, and learned to write with my L hand and returned to my practice that we started 5 yrs earlier and would ultimately become the largest and most successful family practice in Santa Monica. This was my first exposure to your blog and i am very impressed with your understanding and final conclusions surrounding this dreadful process. You have earned a new reader!

  19. #19 Chris
    March 22, 2016

    Welcome, Dr. Hak. I hope you enjoy our little part of the internets. By the way, if you like it here you might also like another blog that a “friend” Orac is an editor and contributor: http://www.sciencebasedmedicine.org

    Join his many minions. Join us, join us, join us. 😉

  20. #20 Mark Zuckerberg
    fraudbook
    March 24, 2016

    Look up Kevin Sorbo stroke. His “doctor” cracked his neck despite him telling him not to. His response “I thought you neede it”, which is the verbatim retort they all give after a loud crack, some even say “excellent” when no crack is heard. These asshats are frauds and should be thrown into prison for making false medical claims and spewing bullshit medical jargon and disabling people. Cracking your joints does nothing for your health. You can do it yourself or have a friend help and you will not get relief. And these morons in the videos who shout out after getting “adjusted” are just bullshit. You do not feel anything. There’s even one melon farmer who says in his video that 98% of newborns have spinal defects and need adjustments.

  21. […] Did chiropractic manipulation of her neck cause Katie May … – Feb 08, 2016  · Katie May was a model, and by all accounts a very successful one, having appeared in Playboy, Sports Illustrated, and other magazines and websites. … […]

  22. #22 david
    new jersey
    April 12, 2016

    #226- what is your point/comment? I tried going to the link, but it did not work.

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