10 Ways for DCs to Survive a Stroke Malpractice Claim

Cases of immediate stroke following cervical spine manipulation (CSM) are documented in the medical literature, as far back as the first case report in 1947.1–8 Research suggests if CSM is performed in the presence of an existing cervical artery dissection (CAD), immediate thromboembolic or thrombotic stroke can occur.1,9-18
Two of these research studies were led by Scott Haldeman, a doctor of chiropractic.10,12 In 1999, Haldeman proposed thromboembolic and thrombotic mechanisms of stroke from CSM: “It has been suggested the cervical manipulation in many cases may have been administered to patients who already had spontaneous dissection in progress. This suggestion arises from the observation that many patients with spontaneous dissection have initial symptoms of acute neck pain and headaches that progress to infarction with passing time. Because most cervical manipulations are administered to treat neck pain and headaches, these patients with a dissection in progress on seeing a practitioner are likely to be manipulated, and in turn could precipitate a vascular occlusion or dislodge an embolus.”10

In 2002, Haldeman again proposed thrombotic and thromboembolic mechanisms of stroke from CSM:

• “The sudden onset of acute and unusual neck and/or head pain may represent a dissection in progress and be the reason a patient seeks manipulative therapy that then serves as the final insult to the vessel leading to ischemia.”
• “Our data raise the possibility that in certain cases manipulation may not be the primary insult causing the dissection but rather an aggravating factor or coincidental event precipitating ischemia.”
• “It does, however, suggest many of these dissections may be spontaneous or due to trivial trauma and manipulation may be simply the final insult that precipitated the vascular occlusion or release of a thrombotic embolism.”12

Cassidy, a doctor of chiropractic, was the lead researcher for the oft-cited 2008 study, which states:

• “We have not ruled out neck manipulation as a potential cause of some VBA strokes.”
  Cassidy proposed a plausible thromboembolic mechanism of causation: “It might also be possible chiropractic manipulation, or even simple range-of-motion examination by any practitioner, could result in a thromboembolic event [stroke] in a patient with a pre-existing vertebral artery dissection.”
• Cassidy designed their 2008 and 2017 studies taking into account CSM might cause immediate stroke: “For the chiropractic analysis, the index date was included in the hazard period, since chiropractic treatment might cause immediate stroke and patients would not normally consult a DC after having a stroke.”13,19

Cassidy concluded, “We found no evidence of excess risk of VBA stroke associated with chiropractic care compared to primary care.” However, Cassidy’s conclusion is irrelevant to cases of immediate post-manipulative stroke, occurring within seconds or minutes of CSM. Cassidy did not analyze an immediate cohort for either DC visits or PCP visits. The shortest cohort was 0-1 day. The 0- to 1-day PCP visit cohort was excluded and therefore could not be compared and contrasted to the 0- to 1-day DC visit cohort.13 This was a landmark study in the history of chiropractic research in this area; however, it is not relevant to immediate post-manipulative stroke.

It is often reported that no causal association between CSM and stroke can be established in the absence of randomized controlled trials (RCTs). However, RCTs are infeasible in these clinical settings due to the rarity and life-threatening nature of CAD and stroke. As RCTs are infeasible, physicians must use the next best external evidence to establish causation.20 Causation can be established as more likely than not using an analysis of plausibility, temporality and lack of a more probable explanation.21 In a malpractice case, the standard for causation is more likely than not.

As a profession, chiropractic needs to acknowledge the numerous studies presenting plausible mechanisms by which CSM can cause immediate stroke. Until these mechanisms are acknowledged, clinical efforts to avoid triggering these mechanisms cannot be effectively implemented. Efforts should also be made to protect the DC from professional liability if immediate post-manipulative stroke occurs. Here are 10 recommendations for DCs to survive a stroke malpractice claim.

1. Legible documentation. If you do not have an EHR/EMR system, get one. Illegible documentation does not impress a judge or jury.
2. Obtain verbal and written informed consent to the risk of thromboembolic or thrombotic stroke from CSM. The risk of causation of stroke by CSM is low; however, as it carries serious consequences including paralysis and death, it should be regarded as a material risk requiring disclosure. This is the standard of care (SOC) per research and the Association of Chiropractic Colleges.22,23
3. Obtain verbal and written informed consent to the risk of CAD from CSM. CAD and stroke are separate medical conditions. CAD is a tear in the inner lining of a cervical artery; stroke is a decrease in blood supply to the brain. CAD can lead to a stroke; however, generally CAD will heal spontaneously when left alone and has a good clinical prognosis when treated in routine clinical fashion.11,24,25 Church found no convincing evidence to support a causal link between CSM and CAD in a healthy cervical artery.26Numerous other studies support Church’s conclusions.27-32 However, if the patient enters the office with an unhealthy cervical artery which is prone to dissection, CSM could cause CAD. Therefore, informed consent to the risk of CAD from CSM is the SOC.
4. Perform a thorough history-taking and examination. History-taking, especially regarding the time of symptom onset, is the single most important factor for detecting CAD.33 There is no single screening test for CAD. The chiropractic physician must know the clinical symptoms of CAD to make the diagnosis.34 Confirming the diagnosis requires a high index of suspicion and good vascular imaging.13
5. Record vital signs as recommended by practice guidelines.35 High blood pressure and a high BMI are risk factors for stroke. A low BMI is a risk factor for CAD. The physician needs this information for correct medical decision-making and to demonstrate clinical competence in the event of a malpractice claim.
6. Perform a differential diagnosis to rule out CAD before performing CSM.33 Research supports the SOC is to include CAD in a differential diagnosis whenever neck pain, headache or dizziness are present, even if they are the only presenting symptoms.34,36,37
7. If the patient presents with neck pain and headaches suspicious for CAD, the SOC is an immediate referral to the medical emergency department.33 Do not adjust the patient. If the patient refuses a referral to medical emergency, the liability shifts to the patient, and away from you. Keep in mind, some ER physicians will not order cervical artery imaging if ischemic symptoms are not present. If so, order the imaging yourself. Time is of the essence if a CAD is present. If you do not know the imaging to order, educate yourself. There are at least 29 postgraduate courses on manipulation and stroke for DCs.
8. If the patient presents with neck pain and headache suspicious for CAD and ischemic symptoms, the SOC is an immediate referral to the medical emergency department.33 Do not adjust the patient. Do not attempt to order the cervical artery imaging yourself. If the patient is having ischemic symptoms, it is not just a CAD, it is a stroke.
9. If the patient develops symptoms of immediate post-manipulative ischemic stroke, most commonly dizziness and vomiting, the SOC is an immediate referral to the medical emergency department. Call 911. Do not “re-adjust” the patient. Do not assume the patient has low blood sugar or the flu. Do not assume the patient is having a “reaction to the adjustment.” Do not attempt to drive the patient to the emergency department. If you call EMS and the patient refuses an ambulance, the liability shifts to the patient, and away from you. Report the incident to your chiropractic malpractice insurance carrier immediately.
10. Complete chart notes promptly with an electronic date and time signature stamp. In a malpractice case, you must show you did not alter your documentation after the fact in an effort to decrease your liability. Do not change your chart notes, ever. If a stroke occurs after CSM in your office, you should document the incident in an electronically signed and dated addendum to your chart note. When in doubt, document. However, never alter an existing chart note. An audit report from your EHR/EMR software will show every change made to a chart note, sometimes down to the exact keystroke and the exact second.

STEVEN BROWN, DC, DIPL MED AC, is a chiropractic expert witness for the plaintiff or defense emphasizing cases of manipulation, dissection, stroke, pneumothorax and spinal cord injury. He lectures nationally on manipulation and stroke and can be reached at drbrown@brownchiro.com.

References

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2. Pratt-Thomas HR, Berger KE. Cerebellar and spinal injuries after chiropractic manipulation. J Am Med Assoc. 1947;133(9):600–603. JAMA. https://jamanetwork.com/journals/jama/article-abstract/291970. Accessed Jan. 9, 2024.
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