Seven months after the death of social media star and Pleasant Hills native Katie May, the Los Angeles County Medical Examiner’s office last week ruled that she died from a stroke caused by chiropractic neck manipulation, including one done earlier on the day she was rushed to an emergency room near her West Hollywood home by a friend.

Given Ms. May’s celebrity status, the Feb. 4 death of the 34-year-old resulted in stories around the globe. And the autopsy finding adds to a debate in the medical world over neck manipulation by chiropractors and whether manipulation can be definitively said to cause a tear, or “artery dissection,” that leads to stroke.

For decades, chiropractors have vigorously defended themselves from these claims, and say this battle is part of a larger, ongoing struggle between chiropractors and medical doctors that has gone on since the founding of chiropractic medicine in 1895.

They point to studies that say there is no direct or “causal” relationship, that other studies say there just is not enough good data to say anything definitive, and, ultimately, their millions of satisfied patients prove that their practices are safe and effective.

“To date, no study has found causality,” said Keith Overland, a chiropractor for 35 years from Norwalk, Conn., who is a past president of the American Chiropractic Association. “I don’t see indicting a particular procedure that’s done millions of times a year without complications.”

But other medical doctors — neurologists in particular — have said that they see far too many patients who have had arterial dissections that occurred after their necks were manipulated by a chiropractor. They point to some studies that find at least an “association” — but not a direct, causal relationship — between neck manipulation and dissection, particularly among young adults under age 45.

“Although you can’t prove causation, all the strength of the evidence implies there is an association,” said Ralph Sacco, a neurologist at the University of Miami and co-author of the 2014 American Heart Association’s Stroke Council report that declared there was an association between stroke and neck manipulation.

“We weren’t indicting chiropractors” in the Stroke Council report, Dr. Sacco said. “We were just trying to bring awareness to a likelihood or an association.”

Katie May’s case

Ms. May would have seemed an unlikely candidate for a stroke.

Famously fit her entire life, she grew up in Pleasant Hills, where she was a cheerleader at Thomas Jefferson High School, the fourth and youngest child of two school teachers.

She moved to Hollywood in 2004 after graduating from Ohio University, determined to make it in the fashion business world.

After a decade of ups and downs as a businesswoman and promoter, she lost a job in 2013. Concerned about supporting her daughter, Mia, who was then 5, she started promoting herself as a fashion model, posting provocative photos of herself in swimsuits and lingerie on social media.

When she started modeling for the online magazine Arsenic in 2014, her pictures went viral. Calling herself “Ms. Katie May,” she eventually had 2 million followers on Instagram and Snapchat and was dubbed the “Queen of Snapchat.”

Social media fame led to even more mainstream modeling in GQ and Sports Illustrated.

Her success led to a modeling gig in her home on Monday, Jan. 25.

Melissa Hurkman, Ms. May’s hair and makeup assistant, as well as Kristen Corona, Ms. May’s friend and personal assistant, said that during the photo shoot the photographer asked her to hold a pose for a long time that involved arching her back and leaning her neck to the side.

It caused almost immediate pain that Ms. May thought was simply a “pinched nerve,” she later tweeted to fans.

The celebrity news website TMZ later said that Ms. May injured her neck during a “fall,” a report picked up in media across the globe, claiming that was the cause of her injury.

But Ms. Corona, Ms. Hurkman and Alex Maimon, the father of Ms. May’s daughter who shared custody with her, all said Ms. May told them that was not what happened.

“It wasn’t a work accident,” said Mr. Maimon, a Hollywood-area real estate developer. “She just held a pose and kinked her neck. I talked to her that day.”

Ms. Corona said the day after the photo shoot, Ms. May tried putting heat on the injury to ease the pain.

Ms. Hurkman said when that did not work, on either Tuesday, Jan. 26 or Wednesday, Jan. 27, for the first time she visited a chiropractor. The medical examiner’s office said the chiropractor was Eric Swartz of Back to Total Health Wellness Center, whose office is located near Ms. May’s apartment in West Hollywood, Calif.

There are various forms of adjustments, or manipulations that chiropractors perform on patients, including neck-turning techniques referred to as “high-speed, low amplitude” manipulations, “ and “low-speed, low-amplitude” manipulations, and mechanical traction that involves using weight or force to lift the neck and create separation between joints.

Mr. Swartz appears to have used both types of techniques, according to Ms. Corona’s and Ms. Hurkman’s recollections of what Ms. May told her.

Still complaining of pain, Ms. May returned to the clinic, first, on Friday, Jan. 29, and then again on Monday, Feb. 1.

Ms. Corona said she talked to her not long after she got home from the chiropractor around 10 a.m., and Ms. May told her she felt “out of it” and thought she was just tired.

She said Ms. May told her the chiropractor had “used a machine to lift her neck from her body after putting a band on her neck. She said it was the most painful experience.”

Four phone messages over the last five months seeking comment were left by the Post-Gazette at Mr. Swartz’s office, but they were not returned. A medical examiner’s office spokesman said that Mr. Swartz’s office also ignored requests to provide the medical examiner with documents about Ms. May’s treatment.

In the eight hours after she was treated on Feb. 1, Ms. May progressively felt worse, with dizziness growing into a headache, numbness and slurred speech, friends and family said. At about 7 p.m. — at the urging of her parents and one of her sisters through phone calls and texts — she had a friend drive her to Cedars Sinai Hospital.

According to Ms. May’s hospital records provided by her family, staff there quickly recognized she was experiencing a stroke and took action. First, after 8 p.m., they administered a drug to dissolve a clot in an artery that was blocking blood flow to the brain.

She showed improvement, but then she worsened. At about 10 p.m. surgeons performed a procedure to try to remove the clot from her vertebral artery at the back of her neck.

But she did not improve.

Her friend called Mr. May in Pleasant Hills at about midnight — 3 a.m. Eastern time — and told him: “Mr. May, you better come out here.”

Ms. May was unconscious and would never recover. By Wednesday, Feb. 3, her parents were told she was brain dead and they decided to remove life support. They waited until her two sisters and brother arrived on Thursday, when she died surrounded by her family and friends.

“It was awful,” Mr. May said recently. “It’s still painful. Every day.”

What caused the stroke?

Ms. May’s death certificate, delayed as investigators waited for toxicology results and attempted to get documents from Mr. Swartz, says the main cause of her death was “infarction of the brain,” a type of stroke.

The secondary cause was “vertebral artery dissection,” meaning she had small tears in two of the arteries that feed blood to the brain. Under a section entitled “How the injury occurred,” the attending medical examiner listed “Neck manipulation by chiropractor.”

Because of that finding, Ed Winter, the medical examiner’s spokesman, said the doctor who performed the autopsy reported Mr. Swartz to the California Board of Chiropractic Examiners this month. A board spokeswoman said they could not yet confirm whether or not a complaint was filed against Mr. Swartz.

Research has found that dissection of carotid arteries, located near the front of the neck, are about twice as common as those of vertebral arteries, located near the back of the neck.

But both types of arteries can experience tearing from seemingly innocuous movements — from sneezing, or staring at a ceiling, or holding your head under a dryer — that involve turning or jerking the neck and the arteries, either suddenly, or in an awkward position, or holding it for a long length of time in that strained position.

Hospital records show that Ms. May had bilateral vertebral artery dissections, meaning that both her left and right vertebral arteries had small tears in them that led to clots that formed naturally between the walls of the arteries to try to seal the tears. The left artery was completely obstructed, the records show.

The doctor who tried to clear the clots noted that the left dissection was worse than the right one, but the right one appeared to be a more recent dissection.

Most of the chiropractors and neurologists contacted for this story said based on the timing of the events that led to Ms. May’s death, the chiropractic manipulation might have played a role.

“It’s a chicken and egg question,” said Gerard Clum, a chiropractor for 42 years and a consultant to Chiro Secure, one of the three largest insurers of chiropractors in the country. “Was the chiropractor the cause of it? Or merely associated with it?”

Like most of the chiropractors and neurologists contacted for this story, Michael Schneider, an associate professor in the University of Pittsburgh department of physical therapy was already familiar with the Katie May case.

“I had a lot of people contacting me about that,” said Mr. Schneider, a practicing chiropractor. “My educated opinion was that she probably had a small dissection in the [modeling] pose.”

Felipe Albuquerque, a Phoenix neurologist who has researched dissection after neck manipulation by chiropractors, agreed with chiropractors that Ms. May “probably injured her artery during the [modeling] pose.”

“But certainly it was worsened during the chiropractic maneuver,” Dr. Albuquerque said. “The timing certainly suggests a causative relationship” with the chiropractic maneuver earlier the same day.

Penn State neurologist Robert Harbaugh said from the evidence in the case he believes “the chiropractor got caught in the middle” and was unlikely to have caused the original tear.

“And if [the chiropractor] had dislodged [the pre-existing] clot, her neurological symptoms would have happened immediately,” he said, rather than progressing slowly over the day.

Dr. Harbaugh, director of the Penn State Institute of the Neurosciences, was lead author of the most recent large scale review earlier this year of previous studies of the possible connection between chiropractic neck manipulation and dissection.

His team’s February 2016 review of those studies found what some previous reviews have found: That the data used in most studies is poor, but the available evidence does not show a strong association.

“I think the data is overwhelming that there’s a very low risk” of dissection from neck manipulation, said Dr. Harbaugh, who was also a co-author on the Stroke Council report with Dr. Sacco.

Should anything be done?

What percentage of strokes from dissections is related to neck manipulation is not clear. Many studies point out it is very difficult to get good data on this point. As a result, the percentages vary widely, from 1 dissection for every 100,000 chiropractic neck manipulations, to 1 dissection for every 6 million chiropractic neck manipulations in a study of chiropractic malpractice data in Canada.

Chiropractors say that by any measure the number of patients who see a chiropractor and suffer a dissection as a result is very rare. Many longtime chiropractors say they have never had one patient report a dissection that may be related to neck manipulation they have done.

Insurance companies such as Chiro Secure said they occasionally have claims for such cases, but they are infrequent. None of the companies who insure chiropractors in the U.S. — including the largest one, NCMIC — would provide any data on claims involving dissection.

While neurologists concede that such incidents are rare overall, they say the fact that dissections — not just those caused by neck manipulation — make up as much as 25 percent of strokes caused by clots in people 45 and younger, means it is important to understand what may be causing them, and to be wary of any potential causes.

Yet, given a lack of data showing a direct, causal relationship between chiropractic manipulation and dissections, should any action be taken?

Dr. Sacco’s committee thinks so.

It recommends at a minimum that chiropractors and others who do neck manipulation should take neck pain as a possible sign of a prior dissection, and they should warn their patients of the “statistical association” between neck manipulation and dissection.

Some chiropractors say they do make their clients aware, but others say that would put unnecessary fear for their clients when, they believe, the evidence shows there is, at most, very little risk.

There has been a more important change with chiropractors, said Casey Phillips, a chiropractor from Pittsburgh who has worked in the field for 25 years and is president of the state association of chiropractors.

After years of debate about the issue, he said, most chiropractors now consider the possibility that “the neck pain or headache is an indication of a dissection” and do a more thorough review of their patients before any manipulation is done, he said.

Mr. Schneider, the Pitt professor, co-authored a study on a case where a Wisconsin chiropractor detected a patient with a dissection. The chiropractor became suspicious of the patient’s complaints of a headache and neck pain, and he sent the patient for an angiography, which confirmed a dissection.

He said he co-authored the study because the narrative is usually the other way around.

“Usually a neurologist would say a patient came to them with stroke-like symptoms after seeing a chiropractor and it was assumed it was the chiropractor’s fault. And the media likes a negative story, because that’s a good story,” Mr. Schneider said. “We thought it was time to put a good case in there” in the medical journals.

Whether Ms. May’s chiropractor assessed her for a possible dissection before he worked on her is not known.

But Shari Wynd, an assistant professor at Texas Chiropractic College in Pasadena, Texas, who has researched the quality of studies on manipulation and dissection, spoke for many about Ms. May’s case when she said finding out what happened to her could help the debate.

“It’s one of those things that [the chiropractor who worked on May] might have been a contributing factor, not the cause,” she said. “I hope we can understand what happened to her so it doesn’t happen again.”

Source: Post-Gazette.com

Date Posted: Monday, October 24th, 2016 , Total Page Views: 1645