Spine Adjusting and Cervical Artery Dissection; the Saga Continues
FEATURE
Stuart Hoffman
As children, we were told of Benjamin Franklin’s advice that an ounce of prevention is worth a pound of cure. This is likely an adage you have shared with a patient or two along the way as well. Ben’s advice also has great applicability in the world of professional liability protection.
When it comes to patients, of course, it is the knowledge you possess that gives them the information they need to incorporate that ounce of prevention into their lives and the lives of their families. Now, when it comes to professional liability protection, the same rules apply. You need the information—up-todate, relevant, concise information—otherwise you are unable to protect yourself, your practice, and your future.
Let’s face it: If you are like most chiropractors, you are already wearing too many hats. You are the CEO, the treating doctor, the bookkeeper, the head of the marketing department, and the public relations department, while also managing the staff, paying the bills, and, for some of you, even making the office supply run to the local Staples.
How are you going to find time to keep up with every ounce of prevention you need to know?
That brings me to the program I am most excited about known as ChiroSecure Live Events. From the comfort of your home or office, you have the opportunity to access cutting-edge information on chiropractic research, practice management, patient education, risk management, and risk avoidance. If you don’t happen to make a ChiroSecure Live Event at the time it is provided online, you can always access the presentation from the ChiroSecure Live Events Archive. These succinct, crisp, and fast-moving presentations are designed to give you the information you need, when you want it, and at a cost you can’t beat—for free!
One of the recent ChiroSecure Live Events featured Dr. Gerry Clum, president emeritus of Life Chiropractic College West and director of The Octagon at Life University. Dr. Clum provided an overview of recent activities and information related to cervical spine adjusting and vertebral artery issues—an area he has been active in for decades. It was a compelling presentation, and I learned a great deal myself!
Dr. Clum used a 2014 scientific statement on cervical artery dissection from the American Heart Association (AHA) and the American Stroke Association (ASA) to open his discussion and to set the stage for the information that followed. The AHA and the ASA noted that the purpose of the statement was . to review the current state of evidence on the diagnosis and management of cervical dissection (CDs) and their statistical association with cervical manipulative therapy (CMT).” In the course of the discussion, Dr. Clum reviewed the results presented in the statement as follows:
“Case-control and other articles have suggested an epidemiologic association between CD, particularly vertebral artery dissection, and CMT. It is unclear whether this is due to lack of recogniti on of preexisting CD in these patients or due to trauma caused by CMT.” (Emphasis added)
This important acknowledgement of the conclusions arrived at by scientists, such as J. David Cassidy, DC, PhD, at the University of Toronto, that the origin of stroke-related symptoms associated with chiropractic care could be from situations where the patient experiences an arterial dissection before ever going to a chiropractor or a medical doctor because an arterial dissection commonly produces neck pain and headache, which are conditions when patients routinely consult a chiropractor.
The conclusions offered by the AHA and the ASA in their scientific statement are equally as important and acknowledg-
ing of the preexisting condition circumstance:
“Although current biomechanical evidence is insufficient to establish the claim that CMT causes CD, clinical reports suggest that mechanical forces play a role in a considerable number of CDs and most population-controlled studies have found an association between CMT and VAD stroke in young patients.“ (Emphasis added)
Dr. Clum pointed out that the concluding statement of the AHA and ASA is consistent with the findings of Cassidy et al. in 2008, but it is also incomplete. “The ‘statistical association between CD and CMT’ referred to here is found in the Cassidy study. But, so is an association between primary care visits and CD,” commented Dr. Clum. He went on to point out the findings of Cassidy and his associates on this topic note an epidemiological association between patient visits for chiropractic as well as for primary medical care, with the association being generally stronger for the primary medical care visits.
Several take-away messages from the AHA and ASA scientific statement were summarized by Dr. Clum and offered in terms of what we can and should say relative to this scientific statement. We can comment as follows:
• There is insufficient evidence to establish the claim that CMT causes CD.
• It is unclear whether this [an epidemiological association] is due to lack of recognition of preexisting CD in these patients or due to trauma caused by CMT.
• There is an epidemiological association between patient visits for chiropractic as well as for primary medical care, with the association being stronger for the primary medical care visits.
We must be careful not to overstate the scientific statement with comments such as:
“The literature has shown there is no association between chiropractic cervical adjustments and CD.”
• This is an incorrect statement. The literature has shown that there is a statistical association between chiropractic care and cervical artery dissection and stroke. The AHA and the ASA, like Cassidy, considered a preexisting arterial dissection as a reason a patient sought care as opposed to it being an outcome of care.
“The AHA and ASA has said chiropractic cervical adjustments don ’t/can’t cause CD.”
• This is not what they said. They did say that “current biomechanical evidence is insufficient to establish the claim that CMT causes CD.” This is an important and powerful statement and we need to be careful not to go farther than the statement itself in discussing it.
“Chiropractic adjustments don ’t/can ’t cause CD and/or stroke.”
• Simply, the AHA and the ASA did not make such a statement. They did say, as previously noted, that “current biomechanical evidence is insufficient” to establish causation. Again, we need to be careful and not overspeak this statement.
A copy of a line-by-line analysis of the scientific statement of the AHA and the ASA completed by Dr. Clum is available upon request by contacting ChiroSecure.
There was a follow-up discussion about other changes in thinking regarding the origins of cervical artery dissection. Dr. Clum referenced a commentary in Neurology (2011:76:1452) by Wouter Schievink, MD, of Cedars Sanai Hospital in Los Angeles, California, who supports a change in thinking that the problem in a cervical artery dissection is not as likely to involve the tunica intima, and in spontaneous arterial dissection, it is not likely to be about forces:
“...it is not the intimai layer but rather the media and adventitia that are primarily affected in cervical artery dissection... (these findings) confirm the existence of an underlying systemic arteriopathy in patients with spontaneous cervical artery dissection and they suggest that the outer layers are primarily involved in the causation of the intramural hematoma... ”
The arteriopathy referred to in this comment from Schievink includes heritable conditions, such as Marfan syndrome, Ehler-Danlos syndrome, autosomal dominant polycystic kidney disease, osteogenesis imperfecta I, and fibromuscular hyperplasia. In addition, there are lesser-defined conditions characterized by abnormal collagen formation that may help set the stage for this problem to develop. Chiropractors should evaluate these patients with extra care and caution, keeping in mind the possibility of a collagen-related insufficiency problem.
In closing, Dr. Clum commented on the current thinking regarding informed consent in chiropractic practice. Some in the profession think that informed consent is not warranted because a causal relationship has not been established between cervical spine care and a dissection and
^The origin of stroke-related symptoms associated with chiropractic care could be from situations where the patient experiences an arterial dissection before ever going to a chiropractor or a medical doctor because an arterial dissection commonly produces neck pain and headache, which are conditions when patients
routinely consult a chiropractor. J J
stroke. Others take a more pragmatic view of the subject and feel that, in the presence of an association between our care and cervical artery dissection, a patient is due an advisement of this association. Finally, there is another group that takes the perspective that it is simply not possible to provide an informed consent because there are no firm numbers upon which to base such an advisement.
In informed consent, there are two sets of interests to be served: first, the interests of the patient and second, the interests of the provider. In the situation involving informed consent and cervical spine adjusting, both the patient’s and the provider’s interests can be served by a careful and appropriately worded disclosure of the association, such that it is, between cervical spine adjusting and arterial dissection and stroke. A statement of this nature, when properly delivered and documented, puts the patient on notice of a possible association and serves to reduce the potential for a lack of informed consent to be brought as a cause of action in a malpractice claim. Dr. Clum advised our colleagues to err on the side of caution, provide an informed consent statement and discussion, and then give the best care you can to your patient.
An informed consent template consistent with the advice offered by Dr. Clum is also available through ChiroSecure by visiting www.chirosecure.com.
Stuart Hoffman, DC Owned and operated 14 Chiropractic offices and employed many associate DCs throughout his 33 years in practice. He has served over 23 years as the Founder and CEO of ChiroSecure - Malpractice Insurance Company. To view the live event featuring Dr. Gerry Clum visit: http: www.chirosecure.com/ gerry-clum-important-studies
