The Chiropractic profession owes a bid of thanks to Dr. Steven Shoshany for his ninth and most important appearance on The Dr. Oz Show. In the past, shows would be taped and then aired 7-10 days later. This time, the show was taped on November 15 and aired on November 16 placing it in the heart of “sweeps week” when viewership is carefully assessed. This is a statement about the number of people to whom this show would be of interest as the show explored the role, if any, between death of Ms. Katie May and the care she received from a chiropractor.
Dr. Shoshany reached out to a select few experts in the profession when this opportunity presented itself to make sure he was up to date and current with the literature and thinking of the day on the nexus between cervical spine adjustment and cervical artery dissection and stroke. Thanks are due to Jason Deitch, D.C. and Gerard Clum, D.C. both of Life University who spent hours reviewing the science, role-playing the interview and refining Dr. Shoshany’s preparation for this moment. In addition, thanks are due to Keith Overland, D.C. of the American Chiropractic Association.
The preparation paid off! Dr. Shoshany was articulate, at ease, confident and effective as he represented the chiropractic community on this critically important national stage. Congratulations Dr. Shoshany!
On Tuesday, November 15, 2016, The Dr. Oz Show filmed two segments addressing the death of Ms. Katie May. The first segment involved the family of Ms. May who believe Ms. May’s death was a result of the care she received from a chiropractor. The second segment involved Dr. Oz, Dr. Carolyn Brockington, a neurovascular surgeon, Mt. Sinai Hospital in New York (http://www.mountsinai.org/profiles/carolyn-d-brockington) and Dr. Steven Shoshany, a practicing chiropractor from New York (www.drshoshany.com)
While the consideration of any adverse outcome associated with our care is unflattering, the manner in which this situation was addressed by all three panelists was fair, constructive and informative for the public. There was no condemnation of chiropractic, and there was no statement, in this segment, that the chiropractor caused this problem. To the contrary, there was a thorough discussion of vertebral artery dissection, including its rarity in association with chiropractic care, its ability to present in seemingly healthy middle-aged persons, discussion that most dissections do not evolve into a stroke and finally that death from arterial dissection is extremely uncommon.
Three questions were posed to Dr. Shoshany in the six-and-a-half-minute segment including:
- Did cervical manipulation play a role in the circumstances of Katie May?
- How important is a patient history in helping to understand this problem?
- What are chiropractors doing to address these situations?
Dr. Shoshany expressed condolences to the family of Ms. May and went on to explain that the best science available suggests that this was a dissection in progress that occurred during the photo-shoot involving Ms. May. He used a Bow-Hunter’s Stroke as an example of the mechanism of causation—that is the strain of maintaining a stressed position for a period yielded the injury. He related how rare these events are in chiropractic.
The discussion moved to comments from Dr. Brockington, the neurovascular surgeon. She was asked point blank by Dr. Oz “do you think manipulation caused the dissection?” She did not say the chiropractor caused this stroke. She did not raise undue concern about cervical spine adjusting.
In response, she related that she, as a stroke specialist, sees strokes every day. Some of the strokes she sees have known causes and many don’t. She related that she recently saw a gentleman who developed an arterial dissection while painting. She noted that these conditions can occur in seemingly healthy persons in their 30-50s with no prior history. She reviewed an angiogram to show what a dissection looked like on imaging and to explain how it was related to blood flow and oxygenation of the brain. She discussed that most dissections don’t lead to stroke, but cervical artery dissection did account for 1 in 5 strokes in middle-aged persons.
The conversation moved to the second question about the value of a patient history. Dr. Shoshany related that, as a clinician, Dr. Oz appreciated that the patient history was the most valuable tool we have to work with. He related the importance of knowing about a history of stroke, aneurysm, dissection, collagen disorders, etc. Dr. Oz then walked the audience through the 5 Ds, the 3 Ns and the A associated with cervical artery dissection:
- Drop Attacks
The advice given was that one should think of their neurologist or visiting the emergency room rather than chiropractor when one has neck pain with these additional symptoms.
The third question about what the profession is doing about this problem allowed Dr. Shoshany to explain that the profession has been addressing this situation for decades. He also added that he has delivered more than 200,000 cervical adjustments in his 20+ years of practice in Manhattan without a single occurrence of this problem. He added that Life University, the largest single campus chiropractic program in the world, has provided an estimated 4.5 million cervical adjustments during the past 25 years without any incident of this nature. Finally, he added that among the 17 chiropractic educational programs in the United States, there has not been a single incident, to his knowledge, of this nature in the past 20 years.
Dr. Oz read a statement from the American Chiropractic Association (ACA) commenting on how DCs are educated and trained in differential diagnosis based on history, examination, etc., and that they are trained to refer when necessary for further evaluation or emergency intervention.
Dr. Shoshany again emphasized the safety of chiropractic and offered the view that when you consider our safety record in light of 45 people dying every day of opioid use and abuse, chiropractic care is even safer than first thought.
The segment ended with Dr. Oz offering the following comments:
- Cervical artery dissections happen; this doesn’t mean you need to avoid going to your chiropractor.
- This doesn’t mean it was caused by the chiropractor.
- It does mean anyone with neck pain needs to fully advise their chiropractor of any other symptoms or problems they are having with the neck pain.
- The family of Ms. May are naturally upset about the loss of a loved one. They are entitled to their emotional grief, and if they may choose to direct it toward our profession. There is nothing to be gained by engaging them in a discussion while they are in their emotional state.
- Have the data cited on The Dr. Oz Show from chiropractic education in mind when you speak with patients about these matters:Life University, 25 years, 4.5 million cervical adjustments—no dissection related issues have been reported. Among all 17 chiropractic educational institutions, 20 years, millions of cervical adjustments—no dissection related issues have been reported. The 25-year window at LIFE and the 20-year window across chiropractic education should not imply something happened 26 or 21 years ago, respectively. The data isn’t available for the period before those dates.
- Patients will want to chat about the 5 Ds, 3 Ns and the A
- Dysphagia, dysarthria, diplopia, drop attacks and nystagmus are important symptoms that, by themselves in the presence of neck pain, strongly suggest referral.
- Dizziness, nausea, numbness and ataxia are not as strongly associated by themselves with dissection and stroke, but you should look for the development of these symptoms in a constellation as a guide to increasing your index of suspicion.
- When patients present saying that my neck pain is “unlike any pain I ever had before in my life” or “the most unusual pain I have ever had” or “the worst pain I have ever had,” THINK about the possibility of a dissection in progress and handle accordingly.
- Chiropractic care is very safe. When it is viewed in a comparative sense with pharmaceuticals or surgery for similar types of problems, it is remarkably safe. Life has risks. There are fewer risks under chiropractic care than under medical or surgical care.
- This wasn’t discussed on The Dr. Oz Show, but it is something you should be aware of: The Coroner’s Report in the case of Ms. May noted: “Bilateral vertebral artery dissection is a rare complication of neck manipulation in one per 100,000 to one in 2 million manipulations. (South Med J. 2007 Feb; 100(2):201-3)” The literature cited is misquoted as follows:
The article states “Serious complications are infrequent, with a reported incidence between one per 100,000 and one per 2 million manipulations.”
This does not refer exclusively to vertebral artery complications.
This does not refer to bilateral vertebral artery dissection.
The literature cited did not identify an arterial dissection-unilateral or bilateral on imaging or during autopsy.
The literature cited was the weakest class of evidence, a single case study, and neglected the opportunity to refer to two more recent case-control and case-crossover studies (Cassidy, 2008) and Kosloff (2015). He also chose not to refer to a recent meta-analysis on this subject conducted by neurosurgeons at Penn State Hershey Medical Center (Church, 2016).
Bilateral cervical artery dissection is more commonly associated with arteriopathy than with other causes.
The Next Steps
Some advice and a couple of requests:
We are all concerned when reports create a cloud of confusion or suspicion relative to our care. We find it to be unfair and unreasonable when you consider more than 100,000 deaths annually in the U.S. from PROPERLY prescribed drugs. That inequity notwithstanding, we want and need our care to be safer tomorrow than it was today. Make sure you are up to date with the current literature on this subject. Make sure your procedures fully appreciate the role of the 5 Ds, the 3 Ns and the A. Include questions about a history of stroke, aneurysm and dissection in the patient and their family in your case history and act accordingly.
This is not the time to start your media career. Unless you have had extensive media training and you are intimately familiar with the literature on this subject, pass along any inquiries you receive to your state association, your chiropractic alma mater or other trusted resource for response.
Don’t be defensive. Answer patient’s question as they arise. Respect any request they might make of you regarding their care—assuming it does not endanger them in some way.
Congratulations to Dr. Shoshany for representing the profession so well. Our thanks to Dr. Oz for a fair and balanced discussion of vertebral artery dissection. We hope you will use this as a teaching opportunity in your office and community in the best interests of the public and the profession.
Original Source: Life
Additional Links: Katie May: A Response