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RE: Chiropractic and Stroke (Hmmm...)

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RE: Chiropractic and Stroke (Hmmm...) - June 20, 2007 12:12:00 PM   


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Expert Opinion Consensus:
Chiropractic Adjustments Not Cause of Stroke!

"Seven of the Worlds foremost experts testify that Chiropractic is not the cause of stroke."

Please read these short excerpts from sworn testimony taken from the Ontario Coroners Inquest into the death of Lana Dale Lewis

Expert Testimony Has Included the Following:

A) Neurologist Testifies Death Unrelated to Chiropractic Care
Evidence was provided by Neurologist Dr. Scott Haldeman, DC, MD, PhD, FCCS©, and FRCP©, who was acting as an expert witness for the coroner's office. Dr. Haldeman spoke of the "huge scientific body of knowledge on the value of manipulation from chiropractic" accumulated over the past 20 years and underlined the "rapid expansion on interaction between medical researchers and chiropractors". When questioned by counsel, Dr. Haldeman reiterated his position that the most likely cause of stroke was not an adjustment but atherosclerosis with thrombosis of the vertebral artery.

Dr. Haldeman offered three opinions with respect to the cause of death of Ms. Lewis:
1.Trauma from manipulation causing bleeding into an atherosclerotic plaque is without scientific validity.

2.A dissection in the adventitia caused by chiropractic manipulation is not consistent with the current literature?s understanding of dissections following neck manipulation or trauma.
3.The most consistent explanation for the death of Lana Lewis is that the stroke resulted from thrombosis secondary to atherosclerosis and was unrelated to the chiropractic manipulation of the neck.
Background on Dr. Haldeman: Dr. Haldeman is a PhD neurologist who holds both a degree in chiropractic and medicine. The author of numerous research articles, he is currently on staff at the University of California-Irvine as a Clinical Professor of Neurology. He is also an adjunct professor in the Dept. of Research at the Southern California Univeristy of Health Sciences in Los Angeles.

B Neuropathologist States Lewis Died of Natural Causes
Dr. Michael Pollanen, one of the original authors of the neuropathological autopsy report on Lana Dale Lewis, indicated that Ms. Lewis died of natural causes due to an advanced case of atherosclerosis. Dr. Pollanen outlined that there were three components to the cause of death: the immediate cause was an acute cerebellum infarction; the underlying cause was atherosclerosis; and the other significant contributing factors included hypertension and cardiovascular disease. The acute cerebellum infarction was caused by the natural progress of atherosclerosis. Dr. Pollanen testified "I am not aware of any finding which cannot be explained by atherosclerosis." In his opinion, she had stage 6 "end stage atherosclerosis" or "hardening of the arteries", with substantial plaque build-up particularly noted in her left vertebral artery. He explained that advanced atherosclerosis is strongly linked to stroke.

He dated the time of the dissection as approximately three days prior to her death and as such had no relation to the Chiropractic adjustment she had received. In his mind this atherosclerosis was a "big ticket item" which lead him to change his opinion.

Background on Dr. Michael Pollanen: Dr. Pollanen is an associate professor with the University of Toronto, a consultant with the Forensic Pathology Unit of the Office of the Coroner, Ontario, and a visiting medical examiner for the Office of the Chief Medical Examiner, Washington, D.C. Since 1987, he has published 51 articles in medical and scientific journals, as well as one text book. In 1995, he won a Governor General?s gold medal for his Ph.D. dissertation in neuropathology. While he has an extensive background in science and considerable experience as a neuropathologist, he did not become an M.D. until 1999.
He is considered to be a prominent pathologist whose services are in demand around the world, and he has been recognized as an expert witness at this inquest. Immediately prior to this inquest he was in East Timor where he was performing autopsies for the United Nations on possible torture victims. By 1996 he had performed nearly 1,000 autopsies.

C) Top Neurosurgeon Agrees Death was from Natural Causes
Dr. Richard J. Moulton testified that Lana Lewis died of natural causes and firmly rejected any association between her death and her chiropractic treatment.
Dr. Moulton agreed with previous experts called by the coroner including Dr. Michael Pollanen, Dr. Scott Haldeman, and Dr. Hamilton Hall, that Ms. Lewis? stroke was caused by atherosclerosis or advanced hardening of her vertebral arteries. However, he went on to testify that the actual cause of her death was not the stroke, but a series of blood clots in the venous blood system inside her brain. These clots blocked fluids from draining from the brain causing it to swell and precipitated her death. This was noted in the original pathology report on Ms. Lewis written in 1997 by Drs. Deck and Pollanen.
Dr. Moulton stated that based on his review of the pathology and medical records, it was evident that this swelling of the brain due to clots in the venous system was the primary cause of death, not the stroke, and therefore it was his opinion that, especially in light of an absence of a dissection, there was no evidence whatsoever to associate Ms. Lewis? neck adjustment with her stroke or her death. He outright rejected any association between her death and her chiropractic treatment.

Background on Dr. Richard J. Moulton: Dr. Moulton is a senior, and widely respected, neurosurgeon who is the Head of the Division of Neurosurgery, and Medical Director of the Trauma Centre at St. Michael?s Hospital in Toronto. He is also an Associate Professor at the University of Toronto and the author of at least 29 papers and articles, which have appeared in peer-reviewed, medical or scientific journals.

D) Epidemiologist Debunks Flawed Stroke Research
Dr. David Sackett, an officer of the Order of Canada and member of the Canadian Medical Hall of Fame, described Dr. John Norris, former Chair of the Canadian Stroke Consortium, as "incompetent" in scientific research and "irresponsible" with regard to the Consortium?s work attributing strokes to neck adjustment.

Dr. Sackett led the jury at the Lana Lewis inquest through a primer on the criteria for conducting sound medical research and concluded that the Consortium?s study couldn?t tell the jury anything about the relationship between neck adjustment and stroke. Dr. Sackett pointed out that Dr. Norris had publicly misrepresented the study and that it was not a prospective study as Norris had claimed, but a series of cases which Dr. Sackett explained are highly prone to bias and "can?t begin to address causation".

Dr. Sackett testified that Dr. Norris? description of the Consortium study as simultaneously retrospective and prospective was "scientifically nonsensical."

When asked if he considered Dr. Norris to be an expert in conducting research on causation, Dr. Sackett responded, "He?s incompetent as a scientist in the study of causation."

Regarding Dr. Norris? use of a news conference to announce a lawsuit against the chiropractic profession as the occasion to publicly release very preliminary findings from the Consortium study, Dr. Sackett indicated that such behaviour "represented scientific irresponsibility." He also testified that Dr. Norris had "no science to back the statements" he made in the media putting the incidence of stroke related to neck adjustment far higher than any other research has found.

"He is making claims for which he has no scientific value...he is wasting your time," said Dr. Sackett of Dr. Norris? statements. "I think he has contributed nothing of scientific value...he has caused enormous confusion," said Dr. Sackett.

When asked how he would evaluate Dr. Norris? use of newspaper reports as the foundation for his opinion that Ms. Lewis? stroke was related her neck adjustment, Dr. Sackett testified, "It flunks."

Dr. Sackett indicated that he had reviewed the literature cited in the press release from the sixty neurologists, and that 8 of the 10 references were from level IV studies and two were from level IV case reports. Dr. Sackett noted that from an epidemiological perspective, this is not the sort of high-level evidence one would want to possess before making such statements. He stated that, in his opinion, the research cited did not support such claims, in that they were low-level studies. He further indicted that claims warning Canadians of the debilitating and fatal neurological damage that can result subsequent to upper neck manipulation were misleading and inflammatory.

Background on Dr. David Sackett: Dr. Sackett is a world-renowned professor and expert in Epidemiology and applied human research. Holding both a masters in science degree and a medical degree, Dr. Sackett is currently a professor emeritus at McMaster University. Dr. Sackett was confirmed as an expert witness in the field of Epidemiology and applied human research.

E) Neurologist Testifies Chiropractic Cannot Cause Strokes
Dr. Adrian Upton, Head of the Department of Neurology at McMaster University indicated that he felt that this was a relatively simple problem: a woman with many risk factors had a stroke and died. He suggested that this should have been straightforward and he said he found it hard to understand what the enormous amount of intellectual investment in the inquest will have achieved. Finally, in looking at a previous exhibit graphically showing the extent of atherosclerotic disease in Ms. Lewis? vertebral arteries, Dr. Upton indicated that he felt Ms. Lewis had been "a walking time-bomb" who died of atherosclerotic stroke.

In discussing the suggestion made during other parts of the inquest that chiropractic neck adjustment be banned until a Level I or Level II study has been conducted, Dr. Upton indicated by way of example that there are no controlled studies to prove that antibiotics can cure meningitis. However, he suggested it would be unethical and evil to require controlled studies before providing this treatment to children and adults. He further noted that 70% of all medical procedures have not been subjected to random trials, and to ban these treatments would be impractical and would shut down health care.

Dr. Upton reviewed a list of facts and factors that led to his opinion on the cause of Ms. Lewis? death: there was no extra-cranial dissection; the stroke occurred 6 days after the last chiropractic treatment; any neck pain was described as mild; Ms. Lewis did not miss work during the week following the last treatment; and 2 days before her death she suffered a intracranial dissection. He also noted that she had numerous risk factors: atherosclerotic disease including 70% stenosis of the right vertebral artery, hypertension, a history of smoking, a family history of stroke, and migraines. As well, there was no evidence that she received a neck adjustment on the left side, and Dr. Herzog?s recent study suggested that neck adjustment involves 50% of the elongation of the vertebral artery compared with normal range of motion and places no significant stresses on the artery. In response to all of this, Dr. Upton indicated that when you remove speculation and conjecture this case is simple and there is "overwhelming evidence" in favour of Ms. Lewis dying of atherosclerosis.

It is his opinion that SMT cannot cause arterial damage and the work done by Dr. Herzog represents the only well conducted and scientifically valid studies on this matter. While Dr. Herzog?s studies were cadaveric studies, the same studies in living humans would be unethical. Dr. Herzog?s work produced solid evidence of the forces in normal SMT, and these have been found to be insufficient to cause arterial damage. He added that the arteries that go through the upper part of the neck are designed not to fail, but on occasion they do. The question is whether SMT would cause damage, and there is no evidence for this contention.

When questioned on the many conflicting pathology reports about the cause of Ms. Lewis? death. Dr. Upton said he was baffled by this inability for the pathologists to agree. When pressed that this left many unanswered questions about the death of Ms. Lewis, Dr. Upton said it did not. He referred to Exhibit 36, a detailed schematic of the pathology in Ms. Lewis arteries drawn by Dr. Pollanen, and said that was all the jury required to make their decision that Ms. Lewis died of natural causes from advanced atherosclerotic disease. He stated further that the while the jury might be confused by the conflicting pathology reports, he had confidence that the jury would come to the determination that Ms. Lewis died of natural causes.

Background on Dr. Adrian Upton: Dr. Upton has 34 years of experience, 32 of which have been in Canada, as a clinician, scientist and teacher. In reviewing this experience, several areas of Dr. Upton?s work were highlighted:

Over 30 years of research in the area of seizures has recently culminated in the experimental implementation of a "pacemaker" implant into the brain to stop events leading to seizures, so as to prevent the seizures themselves;

He played an integral part in the establishment of the Stroke Unit at Hamilton General Hospital, including the founding of the unit, the recruitment of staff, etc.;

He continues to actively practice, which means that like most neurologists a significant portion of his practice involves seeing patients who have suffered strokes;

He often does post-mortem analyses of cases from all areas within his hospital. This involves analyzing the records and care decisions related to patients who subsequently died, and presenting these analyses to medical staff in an effort to ensure the best possible care into the future.

F) Neuropathologist Agrees With Other Experts
When neuropathologist Dr. Charles Rhodes was asked to draw his conclusions after reviewing the case, he confirmed that Ms. Lewis died as a result of "a clot that formed in her vertebral artery caused by her atherosclerosis." When asked if it was difficult to decide this, Dr. Rhodes quickly and confidently answered "No".

Dr. Rhodes explored this apparent straightforwardness in more detail. Dr. Rhodes told the court that the possible confusion in this case arose from the fact that Ms. Lewis had received chiropractic neck treatment more than a week beforehand. However, that this treatment had occurred in relative temporal proximity to her stroke and ultimate death was simply coincidental. This is not, stated Dr. Rhodes, "a complicated case."

When asked about the contention by some that a chiropractic adjustment had caused Ms. Lewis? stroke, Dr. Rhodes told the court that he "looked for it", but that a dissection is "just not there". The slides did not reveal what he might have expected to see (i.e., a dissection and a tract of blood) and therefore there was no evidence of an injury sustained by a chiropractic adjustment. Instead, what the slides show, was an obvious cause of death: end stage atherosclerosis causing stroke.

Background on Dr.Charles Harker Rhodes: Dr. Rhodes graduated from Harvard University with a BA in 1975. He then went to medical school at Cornell University where he graduated in 1982. He completed a PhD in neuro-anatomy at Rockefeller University and undertook further specialized training at the University of Pennsylvania. He is currently an Associate professor at Dartmouth University?s medical school. Dr. Rhodes has 51 peer-reviewed publications including chapters in two books. He was qualified as an expert witness in neuropathology.

G) Biomechanics Specialist Explains Impossibility of Stroke Risk
Biomechanician Dr. Walter Herzog?s most recent research, in regards to spinal manipulative therapy (SMT), concludes that damage to the vertebral artery from SMT is "not a possibility".

Reviewing his findings, Dr. Herzog confirmed that as SMT only creates 6% elongation, SMT is very unlikely to disrupt the vertebral artery, as stretch and force do not begin until 12.5%. "I have a strong opinion", testified Dr. Herzog, "that the vertebral artery cannot be damaged during SMT".

When queried if this research had been published and peer reviewed, Dr. Herzog testified that it had and that it has not been challenged. When asked "Why is your research good for the jury?", he responded "Because it addresses the very issue with which they are charged".

Dr. Herzog was challenged agree that there is some case literature that supports a direct link between neck manipulation and stroke, if a stroke happens right there on the adjusting table. Dr. Herzog stated that in a good research study, all variables are controlled as best as possible, you perform tests and make observations. The research does not connect manipulation to stroke. The case literature it is very different. These are situations unobserved by the researcher, and anything can happen within the space of time before and after the manipulation which may impact the outcome. Dr. Herzog suggested that, in his opinion, if there was a direct cause and effect relationship one would expect to see 200 deaths in a 2 week period.

Dr. Herzog concluded by reiterating that in every day of life, every time you move your head the vertebral artery is stretched more, often twice as much, as it is during a neck manipulation.

Dr. Herzog explained that while chiropractic adjustment might elongate the vertebral artery it does not stretch it. He was referred to testimony from Drs. Deck and Norris which indicated that chiropractic cervical adjustment was unique, in that, it subjects the vertebral artery to unusual stretching which could lead to damage to the intima. Dr. Herzog testified that this is not the case since there is no stretching of the artery involved in a cervical adjustment. Concerning his apparent disagreement with Dr. Deck, Dr. Herzog testified that he would accept evidence of pathology but only if it made scientific sense. He reiterated that if there was no force there could not be any stress and therefore, it was not possible to damage the vertebral artery during cervical adjustment.

Upon being challenged on the use of the expression ?not possible?, concerning the potential for damage to a vertebral artery during cervical adjustment. Dr. Herzog testified that this is the language of scientific papers. On suggestion that he should change his testimony in that regard, Dr. Herzog finally relented and agreed that he would change "not possible" to "very, very, very, very? to the ?nth? degree unlikely." When pressed that chiropractic adjustment could be implicated in an embolism because even the normal range of motion involved in combing one?s hair or turning to the rear to reverse an automobile could cause spontaneous dissection, Dr. Herzog testified that this was so, but that the normal range of motion exceeded the range of motion involved in a cervical adjustment.

Ut was suggested that Dr. Herzog?s study did not rule out the possibility that there could be microscopic damage done to a vertebral artery which might cause a thrombus to be formed in 1/100 of a millisecond during a cervical manipulation which could cause an unfortunate chain of events which could lead to a stroke. Dr. Herzog again stated emphatically that "there is no force and therefore, there can be no damage".

Background on Dr. Walter Herzog: Dr. Herzog is a full professor and the Associate Dean of Research in the faculty of Kinesiology with adjunct positions in the faculties of medicine and Engineering at the University of Calgary.

NB: The information referenced above has been taken from transcripts of the testimony given at the Coroners Inquest, and have been accessed from files provided by the CCWG and major public news media
Post #: 1
Re: RE: Chiropractic and Stroke (Hmmm...) - June 20, 2007 9:25:00 PM   
Marc Bronson


Posts: 113
Joined: January 14, 2007
From: Toronto
Status: offline

Ths story does't sell papers. NEXT! ;)


Admins: Glad to see the forum is back, thanks again for making this a great resource for ALL conservative therapists...


BSc (Hon), DC, Dipl. Med. Ac. CSCS
Integrative Manual Medicine

(in reply to Lehmkuhler)
Post #: 2
Re: RE: Chiropractic and Stroke (Hmmm...) - June 20, 2007 9:54:00 PM   


Posts: 1834
Joined: March 23, 2006
Status: offline
Interesting reading. I have read it before.

So lets move on to the next:

Again, "chiropractic manipulation" needs to be removed from the title of these things as it suggests that only chiropractic manipulation can have these effects. Which is false of course. my opinion.

(in reply to Lehmkuhler)
Post #: 3
Re: RE: Chiropractic and Stroke (Hmmm...) - June 20, 2007 10:54:00 PM   
Marc Bronson


Posts: 113
Joined: January 14, 2007
From: Toronto
Status: offline

It's my understanding that the DC in question misdiagnosed the patient. She was having stroke in progress and, bluntly, he finished her off. Clearly, no SMT was warranted in this case, an immediate referral to the ER was. This was a "medical negligence" plain and simple.

On a separate note, it's weird that Canada has 3 relatively large stroke incidences with DC's involved in cervical manipulation of the last 10 years and no such scrutiny, really, (i.e. inquiry) in the US despite the fact that there's 10x the DC's out there.

For all those who don't know, informed consent prior to ANY manipulation is MANDATORY for all DC's practicing in Canada. In fact, during my board exams last year that was a station specifically dealing with this issue. I can say from my experience that I'm much more prone to mob first or adjust the upper thoracic spine, but I'll be happy when researchers and clinicians can more definitely identify those who benefit the most from manipulation in contrast to mobilization (the reason I say this is because isn't the CPR for neck pain specifically for the lower C-spine or C/T junction? I'm having a brain cramp...)



BSc (Hon), DC, Dipl. Med. Ac. CSCS
Integrative Manual Medicine

(in reply to Lehmkuhler)
Post #: 4
Re: RE: Chiropractic and Stroke (Hmmm...) - June 21, 2007 6:11:00 AM   


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Joined: March 23, 2006
Status: offline
Yes marc, I agree. This DC clearly proceeded when all signs pointed to 'NO".

However these examples indicate that cervical manipulation "can" have these results.

And although the signs in this case should have been clear, we do not have reliable predictive tools to rule out these potential "at risk" patients with perhaps less obvious signs. That should be the overall point and motivation enough for us as professioanls to stop...and evaluate a little deeper before we "assume" anything.

The above media clippings are just that...assumption. The debate continues with no clear answer.

(in reply to Lehmkuhler)
Post #: 5
Re: RE: Chiropractic and Stroke (Hmmm...) - June 21, 2007 5:08:00 PM   


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Joined: December 15, 2005
Status: offline
I believe a host of neuro experts when they're all singing the same tune... Bad things can happen with ANY intervention.

(in reply to Lehmkuhler)
Post #: 6
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