A Deadly Twist

CHIROPRACTORS ARE CAUSING STROKES IN YOUNG HEALTHY WOMEN. READ THIS BEFORE
YOUR NEXT

SELF MAGAZINE MAY 2007

Christa Heck lay crumpled on her right side in the front seat of her SUV,
staring helplessly at the dashboard. She tried to right herself, but her
body wouldn't obey her brain: One arm was limp, the other floundering
uncontrollably. Ten minutes earlier, she'd been at her chiropractor's office

for a routine follow-up. But something had obviously gone wrong. Lying
virtually paralyzed across her passenger seat, "all I could do was pray
someone would help me," she recalls. "I thought I was going to die."

Heck, a 43-year-old mother of four from Mahopac, New York, had been seeing a

chiropractor on and off for 20 years to treat headaches and lower-back pain.

A pharmaceutical representative, she spent her days driving to sales calls
and her nights working long hours at the computer. A few visits to adjust
her back and cervical spine—the bones that run up through the neck—always
relieved the strain. "I had the impression that it was good for health
maintenance," she says. "Not once had I been told there were risks
involved."

In November 2003, she'd had her first visit with a new chiropractor
recommended by a friend. He snapped her neck to one side, then to the other,

and she felt the same pop she had many times before. But 24 hours later, her

head still hurt. Then, while cooking dinner, "I turned my head to the left,
and the room started spinning and I felt nauseous. It lasted only a second,"

she says. "I thought it was an inner ear infection."

The next day, Heck returned to the chiropractor and told him about her
vertigo, nausea and hurting head. "Let me see if I can get rid of that
headache," Heck says he told her, twisting her head to one side until it
popped. When he twisted to the other side, however, it didn't crack. He told

her to take a deep breath and relax, then massaged her neck briefly before
placing his hands on both sides of her head to try again. Once more, her
neck didn't pop. "I felt this wave of nausea," Heck recalls. "I left the
office a little dazed."

Minutes later, Heck pulled her car up to a convenience store to get some
ginger ale to settle her stomach. But when she shifted her SUV into park,
she collapsed, the motor still running. She tried grabbing her cell phone,
but her hands flailed. Eventually, she inched it between her fingers and
after several tries managed to press the keys to speed-dial her husband, Ed.

"All he says he heard was me crying and slurring my words, but he couldn't
make out any of them," she says. Finally, Ed recognized two words: Red
Mills, the name of the convenience mart. "He was 45 minutes away," Heck
says. "I was terrified."

By the time her husband arrived, Heck felt a little better. She was weak but

could sit up and talk. They considered dialing 911 but knew an ambulance
would take her to a hospital where Ed once had a bad experience. So instead,

he drove her home.

The next day, Heck awoke feeling numb on the right side of her body. Her
left eyelid drooped, and the right side of her face was frozen. When she
walked, both feet dragged. Ed called family friend M. Mehdi Kazmi, M.D.,
assistant clinical professor of neurology at Albert Einstein College of
Medicine in the Bronx. As the doctor quizzed her over the phone, Heck
mentioned she'd just visited a chiropractor.

"Oh, Christa," he said. "I need to see you right away."

Dr. Kazmi examined her only a few minutes before he escorted her across the
street to Montefiore Medical Center, where doctors took scans of her neck
and brain. "Christa is lucky to be alive," he says. "I knew the moment I saw

her that she had had a stroke." And he is convinced that the stroke was
caused by Heck's neck adjustment, which tore a critical artery that keeps
blood flowing to the brain. "I see at least two cases like this or worse a
year," Dr. Kazmi says. "Cervical manipulation is a preposterous thing to do,

and it should be banned."

Americans make some 250 million visits to a chiropractor each year, and 105
million of those appointments include neck manipulations, according to the
American Chiropractic Association in Arlington, Virginia. In addition to
being used for neck, back and headache pain, the treatment is purported by
some chiropractors to ease ailments as diverse as asthma, PMS and attention
deficit disorder. Chiropractic theory holds that when vertebrae become
misaligned, they may put pressure on nerves along the spine, interrupting
the nerves' signals to the rest of the body. "Through improving the
functioning of the joints, you are at the very least improving overall
health," says ACA spokesman William J. Lauretti, assistant professor at New
York Chiropractic College in Seneca Falls. "When a spinal joint is not
functioning properly, it's a chronic irritant to the nervous system."

Introduced in the late 19th century by the founder of chiropractic medicine,

Daniel David Palmer—a Canadian schoolteacher who became famous for his
healing touch—neck adjustments are given routinely and repeatedly by U.S.
chiropractors, as well as some physicians, physical therapists and massage
therapists. But despite patients' enthusiasm for the neck adjustment—45
percent of respondents to a Self.com poll said they had seen a
chiropractor—researchers have not produced definitive proof of its medical
value. In 1996, several chiropractic groups commissioned a study from the
Rand Corporation, an independent research company in Santa Monica,
California; Rand reported that there have not been enough studies to show
long-term benefits from cervical manipulations for neck, head and shoulder
pain and only sparse evidence of short-term relief. A 2005 study in the
Journal of Manipulative and Physiological Therapeutics reached a similar
conclusion. Earlier this year, an evaluation of chiropractic visits and
other complementary treatments for lower-back pain conducted by Harvard
Medical School in Boston found the therapies "did not result in clinically
significant improvements in symptom relief or functional restoration." (The
researchers did not track whether patients were getting neck adjustments
specifically, but the ACA estimates 42 percent of appointments include
them.)

In SELF's online poll, more than 20 percent of women who visited the
chiropractor said they felt no better afterward. Eight percent said they
felt worse. Injuries that can occur on a chiropractor's table include soft
tissue damage, joint dislocations and bone fractures in the neck and back.
The most common problem is disk injury in the neck or lower back, which can
be extraordinarily painful. (In 1999, Karen Santorum, wife of former
Pennsylvania Senator Rick Santorum, won $175,000 in court after suffering a
herniated disk at the hands of a chiropractor.) But only neck manipulation,
not back adjustments, can cause the life-altering side effect Christa Heck
had.

According to Heck's medical records, the chiropractor's neck adjustment left

a 4.5-centimeter tear in her left vertebral artery, one of four pathways
that control blood flow to the brain (the others are the right vertebral
artery and the left and right carotid arteries). Extreme or abrupt twisting
of the neck can damage the inner layer of these arteries, creating a blood
clot. If the clot travels north, it can cut off blood flow to part of the
brain—the definition of a stroke. In fact, Dr. Kazmi believes Heck had two
strokes, one the day after her first neck adjustment, and another
immediately following her second. "The damage was done after the first
manipulation, then she started throwing clots," he says. Heck's chiropractor

(who Heck asked not be identified for fear of jeopardizing a legal
settlement) said through his lawyer, Stephen P. Haber of White Plains, New
York, that Heck's version of events was contradicted by "sworn deposition
testimony, records of care and test results to say nothing of established
principles of chiropractic and medical science" and that he looks forward to

trying the matter in court.

Heck's vertigo and queasiness after her first appointment should have been
red flags because both are symptoms of stroke. Chiropractors should tread
carefully and do extra screening tests before manipulating the neck of a
patient who complains of unusual dizziness, vertigo or nausea, according to
an instructional guide published by National Chiropractic Mutual Insurance
Company in Clive, Iowa, the nation's largest chiropractic insurer. "A good
chiropractor doesn't merely grab people's necks and crack them," the ACA's
Lauretti says. "You take a thorough exam. If there is a history of
dizziness, stroke, visual or auditory disturbances, and to a certain extent
a history of migraine, I'm going to be much more cautious."

Wade S. Smith, M.D., director of the Neurovascular Service at the University

of California at San Francisco, was the lead author of a 2003 study in the
journal Neurology that confirmed the connection between cervical
manipulation and stroke. In the study, Dr. Smith says, patients with strokes

caused by torn arteries were nearly five times more likely to have had a
recent neck adjustment than those with strokes caused by something else,
indicating that "recently seeing a chiropractor is an independent risk
factor for stroke." And although researchers aren't sure why, young women
tend to have slightly more of the injuries. Brittmarie Harwe, 40, of
Wethersfield, Connecticut, received an out-of-court settlement of $900,000
after a 1993 manipulation that permanently paralyzed one of her vocal cords
and left her unable to swallow food; she nourishes herself through a stomach

tube. In December 2006, Rachelle Smith, a 32-year-old mother of five in
Olathe, Kansas, settled a case with her chiropractor for undisclosed damages

and $70,000 in medical costs. She says that when she began to vomit after a
neck adjustment—a sign of what would turn out to be a stroke—the
chiropractor assured her that her body was simply "releasing toxins."

"I've seen more cases of vascular injury following chiropractic
manipulations than just about anybody, and these people's lives are ruined,"

says Alan Bragman, an Atlanta chiropractor who has served as an expert
witness in some 900 chiropractic cases in the United States, Canada and
Puerto Rico. "I've known of seven or eight people who died right on the
table or shortly thereafter," he adds. Kristi Alaine Bedenbaugh, 24, of
Little Mountain, South Carolina, died in 1993 three days after a cervical
manipulation for a sinus headache and a few months before her wedding. In
1998 in Saskatoon, Saskatchewan, 20-year-old restaurant supervisor Laurie
Jean Mathiason fell into a coma on her chiropractor's table minutes after a
neck manipulation she received for a tailbone injury; she was dead three
days later. "The twist was so violent that it tore her artery clear
through," says her mother, Sharon Mathiason. "In our wildest dreams, our
family had never imagined that a perfectly healthy kid in the prime of her
life could have a stroke. But at the hospital, we were bombarded with
doctors coming into the waiting room and saying, 'Don't you know that [if
you go to the chiropractor], never let them touch you above the shoulders?'
I have made it my life's campaign to warn people of the risks of
chiropractic neck adjustment."

The stories are frightening. But the actual risk for injury remains a topic
of fierce debate. Estimates vary wildly as to how many neck manipulations
will lead to a stroke—numbers from 1 in 5.8 million treatments (from an
analysis of data from the Canadian Chiropractic Protective Association, a
chiropractic malpractice insurer in Toronto) to 1 in 400,000, according to a

study published in a 1996 issue of the Journal of Manipulative and
Physiological Therapeutics. A 2003 survey of French doctors by the Hospitals

of the University of Strasbourg, France, found that the incidence of
post-manipulation vascular injuries was 30 times higher than had been
published in medical journals. One reason the numbers are so varied may be
that there is no formal system for reporting complications from chiropractic

manipulation.

Chiropractors and the organizations that represent them say the dangers of
manipulating the neck have been overplayed. In all but a handful of states,
no law or written ethical guideline requires them to alert patients about
the possibilities of damage, and most of them don't. "A stroke following a
manipulation is phenomenally rare," Lauretti says. "We want to give
information to patients to empower them, but at what point does that
information become meaningless? With this issue, we are approaching that
point."

Statistically speaking, taking aspirin or another nonsteroidal
anti-inflammatory drug for pain is potentially far more toxic than getting
one's neck cracked; NSAIDs account for about 7,500 deaths per year,
according to researchers from Stanford University in California. The
difference is that aspirin is a scientifically proven pain reliever, and
neck manipulation is not, says Brad Stewart, M.D., a neurologist in
Edmonton, Alberta, with a special interest in chiropractic stroke. "The
expectation of benefit is almost negligible. The risk, though small, is very

real," says Dr. Stewart, one of whose patients had part of her brain removed

after a cervical manipulation mangled both of her vertebral arteries. "You
can't predict who this will happen to, and for that reason alone, it just
shouldn't be done."

As Lauretti notes, almost any sudden movement of the neck can tear an
artery—leaning your head back to drink a soda, for instance, doing yoga,
stargazing or craning to check your blind spot as you back out of the
driveway. Medical journals have reported numerous cases of women who have
been seriously injured having their hair washed at a salon. According to a
study from Cedars-Sinai Medical Center in Los Angeles, one fourth of
arterial dissections are caused by abnormalities that already exist in the
connective tissue that make certain people particularly vulnerable to the
injury. "It's not a simple black-and-white issue that someone who visits the

chiropractor and then suffers a stroke can say clearly it's the
chiropractor's fault," says Wouter I. Schievink, M.D., director of the
vascular neurosurgery program at Cedars-Sinai. "It's not always clear what
came first, the dissection or the manipulation."

Given the enormous amount of chiropractic visits in this country, Dr.
Schievink says, the risk per visit is tiny. On the other hand, patients see
chiropractors an average of 10 times during treatment. "If you take into
consideration how many times they go and how many manipulations are
performed, it does become a public health concern," he says. "It's a low
risk but potentially a life-threatening one."

It's the late fall of 2006 and Christa Heck looks like any other
professional woman walking along Manhattan's East Side. Her light-brown hair

is freshly highlighted, her dark-blue pantsuit neat and stylish. But when
she steps from the street to the curb, she stumbles to the right. Certain
the fumbling has gone unnoticed, she continues to chat, but her words are
ever so slightly slurred.

To remember her meeting today, Heck says that she placed notes by her bed,
on her bathroom door and on the microwave oven in the kitchen. "Otherwise, I

might not have remembered to come," she says, pulling medical records from a

large manila envelope. She points to a 2005 neurology report that suggests
she has a generalized brain injury with symptoms such as memory loss,
impaired motor coordination and slower mental processing.

Heck speaks as if her true self was lost in the past—about her 3.97 grade
point average in college, her plans before the stroke to go to law school
and her once phenomenal ability to multitask, caring for four children while

being the sole breadwinner for her family when Ed was forced onto
disability. These days, her girls—ranging in age from 15 to 25, three of
them stepdaughters from Ed's previous marriage—don't rely on her so much. "I

can't tell you how many times I've simply forgotten to pick up my youngest
daughter from soccer practice," she says. Nor does she see her friends as
often as she used to. "I asked one of my friends if I had changed, and she
said, 'Honestly, Christa, you've changed a lot.' It breaks my heart."

Heck continued to work for two years after the stroke, her manager adjusting

her assignments to help her cope. But when her company introduced a new
product for her to sell, Heck resigned. "I couldn't handle too many things
at once," she says. She has considered a job in retail, but her psychiatrist

told her she might find it difficult when the store got busy and recommended

she take a quiet back-office job.

Meanwhile, she spends time working with Victims of Irresponsible
Chiropractic Education and Standards (VOICES), a fledgling advocacy group
comprising families of 60 victims of chiropractic stroke, five of whom have
died. The group is urging Congress to ban cervical manipulation. While
federal action seems unlikely, another group of victims in Connecticut is
supporting bills that would require that state to track chiropractic
injuries and add chiropractors to a public database of physician
credentials, disciplinary actions and malpractice suits. A third proposed
law would require Connecticut chiropractors to obtain written consent before

doing a neck adjustment, explain the risk for stroke and detail its
symptoms. "Had I known stroke was a risk, I would have recognized that
something was wrong before going back a second time," Heck says with tears
in her eyes. "I miss the old Christa so much. Had I known better, I'd still
have her."

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