Testimony of Janet Levy President, Victims of Chiropractic Abuse

Prepared for Connecticut State Board of Chiropractic Examiners Public Hearing

January 5-6, 2010

Issue: Whether to require chiropractors to warn patients about a possible risk of stroke from neck manipulation

The Connecticut State Board of Chiropractic Examiners intends to hold a declaratory ruling proceeding to take place on January 5th and 6th of 2010.  VOCA and its representatives have been granted Party status and hereby submit the following testimony on its behalf.

My name is Janet Levy. I am President of VOCA, which stands for Victims of Chiropractic Abuse.  I formed VOCA a few years ago to promote awareness of chiropractic risks through advocacy and legislation.  In 2002, I had a stroke as a direct result of a chiropractic manipulation.

My Story

After sleeping wrong on a new pillow, I woke up with a sore shoulder.  A friend of mine suggested that morning that I call a chiropractor. She said that he could probably get rid of the pain very quickly.  I had an important meeting to attend to at 1:00 pm which would probably last 4-5 hours, so the possibility of eliminating the pain very quickly was appealing.  I called a nearby chiropractic office and they told me to come right down and a chiropractor would see me.  The chiropractor sat me down and took a history of any past illnesses that I might have had.  I was a very healthy, active 48 year old woman who walked 5 miles a day.

He then instructed me to lie down on his table. He left the room and then came back with a paper for me to sign.  I asked him what it was for.  He said it was just a ‘consent to treat’ form and was just a formality because what he was going to do was completely safe.  I said to him, “You are not going to crack my neck or anything, are you?”  He said, “No, not necessarily. Let’s see what the problem is first.”  He then asked me to lie on my stomach and he massaged my shoulder and neck area.  At first it was painful, and then my shoulder did feel a lot better. After a few minutes, I sat up and said, “I think you did it. My shoulder now feels so much better.”   As I got up to leave, he said that I should return again at the same time on Friday, two days later.  I told him that I thought it wasn’t necessary but he quickly stated that sometimes these kinds of pain just return days later. He said, “Just stop by quickly on Friday. Your insurance will cover the visits, no problem, so you have nothing to lose.”

The pain was indeed fully gone by Thursday morning. On Friday, I was not going to go back to the chiropractor, but since I had forgotten to cancel the appointment and his office was right on my way, so I decided to stop in to see him.  He led me straight to the room again.

I told him that he had indeed made my shoulder feel better and that further treatment wasn’t really necessary. “Well,” he said, “let’s just look at it.”  He again started to massage my shoulder and neck area, which actually felt good. Then he asked if I was relaxed.  I said yes.  And then he adjusted my neck.  I immediately said, “What did you do that for?”  He said that he had done an adjustment to fix any subluxations that I might still have in my neck area, which he said was the initial reason why my shoulder was stiff and sore; not just from sleeping on a new pillow.  I said that I had told him that I didn’t want my neck cracked and he said that it was necessary, and again reiterated how safe it was.  I was a little uneasy on my feet and my head now felt funny.  When I told the chiropractor that, he insisted that I return again on Monday.

I returned on Monday because ever since I had left his office, I had a head pain. On Monday, he told me that the reason I had a head pain now was that my body was releasing toxins and adjusting itself back to normal.  He did acervical/spinal adjustment and told me that after a few days and a few more visits I would feel better than new.

I returned on Wednesday, and he did another adjustment.  Because I had told him that I still had this nagging head pain, he had his girl attach electrodes to my neck/shoulder area and put warm towels over them.  My head pain subsided a lot.  The chiropractor told me that I would still maybe experience head pain, but not to worry. He said just take a couple of Aleve or Advil if the pain started to really bother me.  I stopped on my way home and bought some Aleve.

Early Thursday morning, I awoke feeling very nauseous.  As I left my bed to go the bathroom, my legs gave out from under me.  I crawled to the bathroom and threw up.  I was severely dizzy and nauseous and weak.  After about an hour, my husband realized that I was not in bed and came into the bathroom looking for me.  I was still lying on the floor.  I told him what had happened and he said that we should call an ambulance.  I told him not to because I was starting to feel better.  A few minutes later, my nausea was subsiding and I was able to stand up.  My husband helped me back to bed.

In the morning, I still felt very weak, so I stayed in bed all day.  I had called the chiropractor and he said that he thought that I had just had an allergic reaction to the Aleve that I had taken earlier that afternoon.  He suggested that I see him in the morning at the same time as before.

On Friday, when I saw him, I again told him what had happened to me.  He reiterated that I had probably had some sort of reaction to the Aleve, but that it was sometimes a normal reaction for people when you take certain over- the- counter medication for the first time.

I told him that on Thursday I had looked up my symptoms of the night before.  I asked, “Was he sure that I didn’t have meningitis? Could it be encephalitis? Or a stroke?”  He replied, “No…No…and No, you are too young to have had a stroke.”  Then I asked him if maybe the adjustment might have caused me to have a mini stroke or TIA, because I did not feel right ever since that first adjustment.  He said “There is absolutely no way that an adjustment could have caused you to have a stroke. Trust me, I am a doctor! I know what I am talking about.  You’ll be fine…don’t worry.  But look,” he said, “I’ll make a deal with you to put you at ease. On Monday, I will have my partner try acupuncture on you and if you don’t feel 100% better after that I will send you out for an MRI.”  He again had his girl put electrodes on my neck with a warm towel.  And again, after about 10 minutes or so, I began to feel like myself once more.

I went home, still feeling okay, but the head pain never really went away completely.  Later that night, the head pain progressively got worse.  By Saturday, the head pain was almost unbearable and I thought that this is what people must experience when they have a migraine, although I had never had one myself before.  My husband kept insisting all day that we go to a hospital.  I kept telling him, “No, I’ll be fine.”  I just saw a doctor yesterday and HE told me that I was fine.

But later that day, the strong head pain continued and I couldn’t stop vomiting. I then insisted that my husband take me to a hospital.  He called an ambulance.  My husband called my regular medical doctor and told him that I had been to a chiropractor and ever since he had done a neck adjustment I had this head pain. He ordered an MRI to check my vertebral and carotid arteries.   My medical doctor was well aware that a chiropractic adjustment could tear an artery and an MRI would be the only way to tell for sure.

After doing an MRI, they did discover that I had a tear in my vertebral artery.  They gave me blood thinners.  But unfortunately it was too late. The blood thinners were not able to stop the clot that formed, which eventually broke off and went to my cerebellum.  I ended up having a stroke and brain surgery to remove the clot in my cerebellum.  The last thing I remembered was that my 14 year old son was leaning over my bed crying as the nurse pulled off my jewelry to give to him.

When I woke up, I was paralyzed.  And then days later, I regained my right side, although weak. . After 6 weeks in the hospital and rehab facility, I was able to just barely walk with a quad cane.  My left arm was basically useless. The doctors predicted that I would never walk normally again.  Maybe I wouldn’t have to spend most of my time in a wheelchair, but I would certainly have to rely on a quad cane for the rest of my life.  It was not good news.

I remember laying there helpless, just praying to die most days…even though I had a great husband and 2 wonderful young boys, ages 10 and 14. I figured that my children would be better off without me.  My 14 year old son said to me one night, “Mommy, you can’t die, we need you.”  I cried all night and began asking to live. And that I did.  I was determined to be myself again.  After 2 years and working nearly 7 hours a day with PT’s, OT’s, aqua therapists and yoga therapists, and $350,000.00 of bills, I got my life nearly back to where you see me today.  It is so hard to believe that the person screaming and begging to die, over and over again was me…yet my medical records show that that was all I kept crying.

I am grateful that I was in such good shape before this happened.  I exercised all the time, ate healthy and, walked 5 miles a day.  I was always very active.  Now, however, I still have many weaknesses.  I can’t walk more than a ¼ mile now and I can’t bike without falling over.  Sometimes I walk normally for awhile and then suddenly without warning I just fall over, like I was drunk.  It is very embarrassing.  When my leg gets fatigued and I get nervous, I can’t stop my leg from shaking.  At night, I never have a restful sleep anymore because my leg and head always tingle when I am lying down.  It is the same feeling when a body part “falls asleep”.  Except that it happens to me every night.  I have a pain in the back of the left side of my head that will never go away because of the brain surgery.  My body and mind aged a good ten years.  I feel so badly that I missed out on so much in those two years, especially in my son’s lives.  I could no longer do the things with them that I had done before.  I missed most of their games at school and was unable to help them with a lot of their school projects. But I am grateful to be alive.

My cousin was a nurse at the New Britain Hospital of Special Care. She told me that there was a woman living at the hospital who was a mute quadriplegic as a result of a chiropractic manipulation.  I went to see her in 2004. Her name was Linda Solsbury.  She was a nurse and a part time ballet dancer.  She was told by a friend that a chiropractic manipulation would not only get rid of her headaches that she would sometimes have, but it would also help make her legs become more limber.  When she went to the chiropractor, he told her that she had subluxations, and that if he removed them then she would not have her headaches and her legs would indeed become more limber.  At the age of 36, Linda became a mute quadriplegic as a result of the chiropractic manipulation.

When I had gone to see her I was so impressed.  Linda Solsbury was a smart, pretty, bright young woman, with tremendous strength and character.  After this had happened to her, she sued her chiropractor and was awarded a ten million dollar judgment.  Unfortunately, the chiropractor lacked insurance coverage so she was not able to collect anything.  With the help of a local Senator, she was able to help get a law passed in Connecticut in 1993, signed by Governor Weiker that would require that chiropractors have at least a minimum amount of malpractice insurance coverage.
Linda remained in a hospital facility for more than 20 years.  She never was able to walk, talk, or swallow again. Fortunately, she was able to move her right hand ever so slightly. This was her only means of communication.

I told her at our first visit that I thought that what happened to me was a fluke or that it was rare and I was just unlucky. But Linda went on to tell me that she had found out that it had been talked about in articles, news stories and journals for decades and that she didn’t believe it was rare at all.  After all, she had a list of maybe 200 people from around the country that she had been e-mailing with, who also suffered strokes as a result of a chiropractic manipulation.  I was amazed at the number of victims.  She told me that they were all under the age of 50 and most of them were in their thirties. She let me read quite a number of their heartbreaking stories.

After leaving her that day, I knew I had to do something.  Inspired by Linda, I eventually formed VOCA in the hopes of helping prevent this from needlessly happening again.  Important information about the possibility of a stroke occurring after a chiropractic manipulation needed to be in the hands of the patient.

I, unfortunately, was not given that information which would have saved me two years out of my life.  When I had seen my chiropractor, he did have me sign a form.  He showed it to me briefly and told me that it was just a routine ‘consent to treat’ form.  And after I signed this form, he filed it with my medical file that he started to compile on me.  I never saw that paper again. That is, until, an attorney threw the paper across the table at me while we were sitting around an arbitration table and said, “You knew there was a possibility that a chiropractic adjustment could cause a stroke; you signed this consent form which lists stroke and death as a risk factor.”  But I didn’t know.  The form that he had me sign was meant to protect only the chiropractor and not me, the patient.  If I had received a discharge summary, it would have made a major difference to my life.

The judge in my malpractice case did not think that it was okay that a responsible physician had me sign a consent form with the risk of stroke on it and yet never held a conversation with me about it.  And that he never followed up or gave me advice to seek emergency medical care when I presented to him signs of an impending stroke (i.e. severe nausea and dizziness).  Instead, the chiropractor would much rather blame the NASAID that he had instructed me to take to relieve head pain instead.

A discharge summary given to me after the chiropractic manipulation would not only have made a huge difference in my outcome but it would have lessened the chiropractor’s liability as well, especially in the court’s eye.

Informed Consent

Over the last 3 years, VOCA has worked with legislators to try to get laws passed which might help patients of chiropractic.  From my own personal experience and from listening to others, it has become obvious that chiropractors need to give their patients Informed Consent to tell them about the possibility of stroke.  This is not the same as a ‘Consent to Treat Form’, which is used by many chiropractors today.  This kind of form only protects the chiropractor’s interests, NOT the patients.

True Informed Consent, which includes a written and oral discussion with patients about the potential risks of an adjustment, including the possibility of stroke, must be given by chiropractors to their patients.  Since the effects of a stroke can be so devastating, the controversy about how often it occurs should not be the primary concern. The severity of the outcome is what should matter.

A chiropractic manipulation can tear an artery and when a VAD happens.  “A latent period as long as 3 days between the onset of neck pain and the development of obvious neurological signs is not uncommon. Delays of weeks and even years have also been reported.”¹ Patients may actually leave a chiropractor’s office without knowing that they may have a tear in their artery which could ultimately lead to a stroke.  If a patient began experiencing nausea, weakness, slurred speech, numbness, dizziness etc. days, even weeks after a chiropractic visit, they might not be able to recognize that they were having a stroke. This is where a discharge summary would be of utmost lifesaving value. This is what will remind them of what they should do. This is what their family members will rely on if or when a patient begins experiencing the signs of a stroke.

The discharge summary should include the signs of a stroke on it including weakness, vomiting, head pain, nausea, weakness on one side, blurred vision, slurred speech, severe dizziness along with instructions to seek immediate emergency medical care if the patients experienced these signs.  Patients should be advised to bring this paper with them to the hospital so that emergency personnel would know exactly what they should be looking for and therefore do an MRI on that patient to save valuable time.  If a patient receives care within a couple of hours after experiencing the signs of a stroke, medications such as TPA and blood thinners when given to patients, could make the difference between a short hospital stay and  severe permanent paralysis, brain loss and even death.  This is a major difference in a patient’s life.  Time loss means brain loss when dealing with stroke.

The well known Mayo Clinic advises patients:  “Every minute counts when it comes to treating a stroke or TIA. In fact, sometimes a stroke is referred to as a “brain attack” to convey that, similar to a heart attack, quick care is important. So, don’t wait to see if the signs and symptoms go away. The longer a stroke goes untreated, the greater the damage and potential disability. The success of most stroke treatments depends on how soon a person is seen by a doctor in a hospital emergency room after signs and symptoms begin.”³²

According to Dr. Dawn Kleindorfer, assistant professor of neurology at the University Of Cincinnati School Of Medicine, “If one understands the warning signs and gets to a hospital quickly we can even possibly reverse the stroke itself.”³³

A discharge summary/information sheet could save lives and years of suffering.  A discharge summary is not new to the medical community.  Patients are handed a discharge summary to go home with them after they have had surgery, or procedures like a colonoscopy or even something as simple as a flu shot.²  Patients may not always read paperwork in depth when handed to them to sign before a procedure is done, but when something begins to go wrong at home afterwards, patients and/or family members rely on that discharge summary to tell them what symptoms they should look for and what to do if they experience these symptoms.

Informed Consent is a right of each and every American especially when it concerns their health and well being. As far back as 1914, “the U.S. Supreme Court ruled that a patient had the right to determine what was done to their body.” “Every human being of adult years and sound mind has a right to determine what shall be done with his body.”³

With this in mind, if a patient has the right to control what happens to their body, the patient  needs enough information to make that informed decision; thus to provide Informed Consent.  In regards to chiropractic therefore, it should be the patient’s right to be told of all risks, especially stroke, since the affects can be so devastating, so that patients could determine for themselves, the benefit verses the risk of that particular treatment.  A doctor’s ethical oath is to insure that patients receive the necessary information and support they need to make decisions about their healthcare.

The American Chiropractic Code of Ethics states “Doctors of chiropractic should employ their best good faith efforts that the patient possesses enough information to enable an intelligent choice in regard to proposed chiropractic treatment. The patient should make his or her own determination on such treatment.”⁴

The International Chiropractor’s Association’s (ICA) Professional Code of Conduct provides that “the patient has the right to actively participate in any and all decisions regarding his/her own health care.”  “Consumer choice and Informed Consent is the core of ICA’s public policy mission.”⁵

According to one of the largest chiropractic Insurers, NCMIC, “First, it’s crucial to understand the meaning of informed consent. Simply put, when there is risk of harm from a treatment you’re proposing to a patient, it’s your responsibility to ascertain that the risk is disclosed, understood, and accepted by the patient. Such informed consent – or making sure the patient understands, and agrees with, what you want to do to improve his or her condition – is required for ethical and legal reasons.”⁶

In an article published in the July 2006 edition of the Chiropractic Report,  which is an international  review of professional and research issues, endorsed by many chiropractic associations including the World Federation of Chiropractic, it includes: “Patient consent to treatment is always necessary. It is often implied rather than expressed. However, where there is risk of significant harm from the treatment proposed, this risk must be disclosed, understood, and accepted by the patient. Such Informed Consent is required for ethical and legal reasons. The best record of consent is one that is objectively, documented (e.g. a witnessed written consent or videotape.)”

The article urges chiropractors to give their patients Informed Consent and to disclose all material facts that a” reasonable patient”⁸ would expect to know and consider relevant to a decision to accept or reject treatment. “Key items for disclosure include ‘material risks’. These include very remote or unlikely complications that are serious-such as paralysis and death.” ⁸ It goes on to state that, “current best advice is that the risks of vertebral injury and stroke associated with cervical manipulation is about 1 in 1 million treatments… however, because the risk is a potentially serious one, it is a ‘material risk’ which should be disclosed.” “Strokes associated with chiropractic treatment, for example, are rare, but can happen following completely competent care….  Chiropractors have an ethical duty to their colleagues and the PROFESSION to take thorough and appropriate steps in the area of informed consent.”⁷

Chiropractic Associations agree that the patient has the right to participate in decisions regarding their own healthcare, but in order for a chiropractic patient to actually participate in his/her own health care, the patient must receive all pertinent information from the chiropractor.

Pertinent information should include the following;

a)  The chiropractor should explain to the patient the procedure he/she intends to provide.
b)  The chiropractor should talk about alternative treatments that could be performed; keeping in mind that one alternative that must be discussed is no treatment at all.
c)  The chiropractor should answer all of the patient’s questions concerning that particular procedure and
d)  The chiropractor must talk about material risks, that is, side effects and complications of the recommended procedures, no matter how rare a chiropractor may think the risk is.

In the 1980′s, the Supreme Court of Canada ruled in Reibi v Hughes that patients must be told about “material risks” of a procedure.   In 1986, the case of Mason v Forgie directly concerned chiropractic, the court wrote,” Even if a certain risk is a mere possibility that ordinarily need not be disclosed, yet its occurrence carries serious consequences, as for example paralysis or even death, it should be regarded as material risk requirement disclosure.”

A well respected chiropractor, professor and author in Connecticut, Stephen Perle agrees that: “no matter how rare the risk is and no matter how tenuous or strong the cause-and-effect relationship is between manipulation and stroke, the patient has the right to know. While it might be a legal right, I see now it is also an ethical right.” “The patient has the right to choose quality over quantity of life; the right to control what happens to their body. If one is going to control what happens to their body, one needs to have enough information to make an informed decision; thus to provide informed consent.”³

Matthew Pagano, D.C., former President of the Connecticut Chiropractic Association said “whenever the question comes up – whether with patients or the media – it’s responsible to admit there’s a risk, although infinitesimally small because the research – whether we agree with it or not – supports that conclusion. To not do so, is to lose credibility.”⁸

In an article written for the September 2007 ACA newsletter entitled, ‘Putting Risks into Perspective’ they talk about the role of Informed Consent. “The legal requirements regarding Informed Consent for healthcare procedures vary from state to state, and specific guidelines are not always well established.  Therefore, it’s not surprising that the question of whether chiropractors should routinely inform all patients about the remote possibility of a stroke from a neck adjustment is a contentious one. Some clinicians feel that requiring a signed patient consent form is unwarranted because the risks associated with cervical manipulation are so minimal. Some chiropractic experts and many plaintiff attorneys, however, say informed consent is not simply a form, but rather a process of informing the patient about a procedure which may have material risk associated with it.  The process is the verbal explanation of the risks involved–including the risk of doing nothing–and the paper form is merely a way to document the process.” Regardless of your individual views on informed consent, “treating patients without telling them of any known risks or consequences creates potential problems in today’s legal world,” says NCMIC President Dr. Louis Sportelli.⁸

In 2007, Agostino Villani, chiropractor and  then chairman of the Connecticut Chiropractic Board of Examiners, testified in public testimony at the CT LOB, that “obviously, the problem with it is, the severity of the potential consequence, and much examination of this has been done over the last 10-15 years, and indeed, I think it’s been established that there is a very small, but very real risk of this type of event occurring, and although, by all standards, medical standards, this risk has not been determined to obviate the use of the procedure. It should be something that’s disclosed to the patient as part of the due diligence with the doctor before the procedure is done. Yeah, the standard of care in Connecticut would be that the patient should be informed of all risks associated with the procedures being performed.”

On the Chirosecure web-site, Stuart Hoffman, President of Chirosecure, a Chiropractic Insurance Company, advocates that “Chiropractors be proactive and consistent on Informed Consent” He states that “chiropractors need to comply with state and provincial directions as to the degree of specificity regarding risks inherent in the procedures you are about to apply.” He then goes on to quote a landmark 2005 Wisconsin case where the state court found that:  “Chiropractors, like medical doctors, are health care professionals involved in the application of procedures and treatments to the human body. We see no reason why the scope of an individual’s right to be informed of the risk inherent in bodily intrusions via chiropractic  treatment and procedures should be any different from his right to be informed of the risk inherent in bodily intrusions in medical treatment and procedures.”⁹

According to the Guidelines for Chiropractic Quality Assurance and Practice Parameter (Mercy guidelines) authorized by the Congress of Chiropractic State Associations and edited by chiropractor, Scott Haldeman, DC, “Patient consent to treatment is always necessary. It is often implied rather than expressed. However, where there is a risk of significant harm from the treatment proposed, this risk must be disclosed, understood, and accepted by the patient. Such informed consent is required for ethical and legal reasons.”¹⁰

Preston Long, PHD., a chiropractor , a diplomat with the American Board of Forensic Examiners in the state of Arizona and the author of the guide “The Naked Chiropractor”  has stated that, “there is evidence that chiropractic neck manipulation may damage arteries and lead to increased chance of stroke.  Patients deserve to be provided a thorough informed consent by practitioners of spinal manipulation prior to any treatment being rendered.”¹¹

As of May 12, 2008, the American Chiropractic Association has stated that the chiropractic profession believes that patients have the right to know about the health risks associated with any type of treatment, including chiropractic.¹²

Discussion of Risks

For several decades, articles, books and studies have talked about the association between chiropractic cervical/spinal manipulation and stroke.  Risk of a strokes following a chiropractic manipulation have been discussed in medical as well as chiropractic journals, not only here in the United States, but Canada, U.K., Denmark, Ireland, Australia, Germany, Malaysia, Taiwan and Spain as well.

Over the last 10 years, Edzard Ernst, Professor at the University of Exeter, Department of Complementary Medicine in the U.K. has written many articles questioning the safety of spinal manipulation.  In May 2008, he wrote in the Journal of Pain and Symptom Management that spinal manipulation of the upper spine has frequently been associated with serious vascular accidents.  He believes these types of accidents have been very underreported.  He also goes on to state that Informed Consent is a serious concern in chiropractic practice.³⁵

In his 1995-2001 study entitled, ‘Manipulation of the Cervical Spine: a systematic review of case reports of serious adverse events’, concluded that serious complications of cervical spine manipulations appear to occur regularly. Their incidence is essentially unknown and should be established as a matter of urgency through adequately designed investigations.  In his article, ‘Spinal Manipulation: Its safety is uncertain’, he concluded that specific risk factors for vascular accidents related to spinal manipulation have not been identified, which means that any patient is at risk, particularly those below 45 years of age.  In 2008, he wrote a book with Simon Singh, entitled ‘Trick or Treatment’, which talks in detail about the dangers of chiropractic manipulations and the risks of stroke and death. He also concludes that the benefit of chiropractic manipulation does not outweigh the serious risks of stroke, permanent disability or death.¹³

In February 2002, 62 clinical neurologists from across Canada all certified members of the Royal College of Physicians and Surgeons, issued a warning to the Canadian public and provincial governments about the dangers of neck manipulation.¹⁴

In 2008, in European Neurology an article entitled Cerebrovascular Complications of Neck Manipulation concluded that evidence showed an association between spinal manipulation and mild adverse effects as well as with serious complications including dissection of cervical arteries most commonly involving the vertebral arteries.  Specific risk factors for cerebrovascular complications such as cervical artery dissection and stroke related to spinal manipulation have not been identified yet.  For this reason any patient may be at risk, particularly those younger than 45 years.  Patients undergoing spinal manipulative therapy should be informed of the risk of stroke or vascular injury from this procedure.¹⁵

The American Chiropractic Association in its own current Talking Points acknowledges that   “It is true that neck manipulation is a risk factor for stroke. Although all available evidence demonstrates that it is an extremely small risk, this is a subject that the chiropractic profession takes very seriously. Our profession seeks to work closely with the medical profession on this matter, in the best interests of patients.” ¹⁶

Many chiropractic colleges including, but not limited to, Life Chiropractic College West in California, also acknowledges and teaches that chiropractic manipulation is a risk factor for stroke. ¹⁷

In late 2006, an article in Pediatrics, the Official Journal of the American Academy of Pediatrics entitled ‘Adverse Events Associated with Pediatric Spinal Manipulation: a systematic review’ stated, “Spinal manipulation is common among children, and although serious adverse events were identified with spinal manipulation, their true incidence remains unknown. In the Interim of further studies, clinicians should query parents and children about CAM usage and caution families that although serious adverse events may be rare, a range of adverse events or delay in appropriate treatment may be associated with the use of spinal manipulation in children.”¹⁸

In July 2007 in Medical News Today it reported that “spinal manipulation should not be used routinely. Routine use of spinal manipulation on the upper spine could result in serious complications, such as stroke and even death.”¹⁹

William J. Lauretti, D.C., ACA spokesman, acknowledges that “neck manipulations carry a slight risk of stroke.”²⁰

According to an article written recently by Harriet Hall, entitled ‘Chiropractic and Stroke’ on the Science -based Medicine web-site, it states that “Chiropractors are well aware of the risk. They discuss it in their journals and online forums. They have tried to find ways to screen patients for high risk, but there is no reliable way to do so. Strokes are a major reason for chiropractic malpractice insurance payouts – 9% of claims paid by the major chiropractic insurer in 2002, the only year for which I was able to find statistics. Some chiropractors are now asking patients to sign an informed consent form before manipulations. If asked, most chiropractors downplay the risk, saying it occurs in less than one in a million manipulations. Many (perhaps most) chiropractors do not mention the risk at all.”²¹

Devastating Results of a Stroke

As President of VOCA, I feel that I have a responsibility to do everything that I can to make sure that another person does not get needlessly harmed by a chiropractic adjustment. I know firsthand the pain and suffering a stroke can cause.  It not only affects the patient, but everyone in their family.  I have heard countless stories, especially from young, healthy people in their 30′s and 40′s who have had a stroke as a result of a chiropractic manipulation.  If they were fortunate not to have died, or become an invalid, they have had to deal with financial and emotional difficulties.  Most lost their jobs, their homes or had young families and became incapable of taking care of them.  Most of their marriages have not survived as a result of the strain that is put on a family when one member of that family has a stroke.  Many are left with the “invisible” brain injury that is sometimes many times worse than having a physical disability.  Many victims with brain injury wish they were dead.

It may be hard to understand that someone who is young, good looking has a wonderful family, but was left with a brain injury as a result of a stroke, would rather be dead, but unless you have walked in their shoes, one can never truly feel the pain and hopelessness that one feels with a brain injury. That is what a stroke does.  If it doesn’t kill a person physically, it destroys that person mentally until that person becomes someone who is totally unrecognizable and helpless.  I can’t tell you the many times I have been on the phone with chiropractic stroke victims literally talking them down from a total mental breakdown, where suicide is a possible outcome.

When you go to a chiropractor, you don’t expect that he or she can actually do something to you that can cause a stroke.  But I challenge you to find a patient who would not want to know this information.  We have spoken to many chiropractors over the last few years; and quite honestly, there have been many chiropractors who say that they already warn their patients about the possibility of stroke after a chiropractic adjustment. Those same chiropractors all say that they don’t feel that they have lost any patient base because of it.  In fact, most say that their patients respect them more for it because they know that they have their best interests at heart.

Paul Carey, Secretary-Treasurer of the Canadian Chiropractic Association wrote in his article on Health Law in Chiropractic entitled ‘Informed Consent-the new Reality’, “The issue to be remembered here is not that we are trying to frighten the patient but that patients do have a right to know if there is a material risk involved to the treatment proposals we are suggesting. Many times it will be said that if you advise the patient of this risk, they will not undertake care or that they may leave you. It has been my experience however, that in informing patients and discussing with them openly the question of possible risk and injury, that they are very understanding, generally have a few questions but are more than willing to accept the treatment.”²²

According to the July 2006, “Chiropractic Report” , ” a common fear for those considering use of such a clear consent form for the first time is that patients will be upset and discouraged from proceeding with chiropractic care. Experience proves that fear to be wrong.”  The article ends by saying, “The message? Clinicians must be conscientious about the process of informed consent but, because patients are generally more comfortable about it than you and because of the inherent worth and safety of chiropractic care compared with most other options, lighten up about the subject and ‘just do it’.”⁷

Accepting Responsibility

Some chiropractic associations feel that they are being blamed for something that they didn’t do. They say that patients are coming to them already with a stroke in progress.  But since most patients see chiropractors for head and neck pain AND head and neck pain might be a sign that a stroke is in progress AND since there is no simple test that exists that chiropractors can do to determine whether or not the patient has a torn artery without the means of an MRI, then chiropractors should definitely have a responsibility and duty as physicians to tell their patients that there might be a risk of stroke with a chiropractic adjustment.  To quote William J. Lauretti, ACA spokesperson, “no simple or inexpensive screening test exists that can reliably determine if a patient’s neck symptoms are being caused by a vertebral artery dissection or a much more common cause such as muscular tightness or joint stiffness.” ¹ A 2008 study published in the Spine journal agrees,” Unfortunately, there is no acceptable screening procedure to identify patients with neck pain at risk of VBA stroke.”

Some chiropractors say that by taking a patient’s history they reduce the likelihood that the patient has a torn artery.  But chiropractors also like to say that people get torn arteries just by going to a hair dresser, or after having looked at the stars etc. …and THEN they come to a chiropractor because their head/neck hurts.  So how then will taking a history help eliminate the possibility of a torn artery on these patients?  Many chiropractors advertise that they can help people who have been injured in a car accident and have had whiplash, but again, doing a cervical adjustment on an already injured, fragile neck might only make the injuries worse.

According to an article by Edzard Ernst, chiropractic manipulation might not be the safest thing to do for a person suffering with whiplash.  Most chiropractors will adjust the already damaged neck of a whiplash victim. These whiplash victims would be very susceptible patients to a VAD (vertebral artery dissection). A discharge summary given to them would at least allow them to protect themselves from more serious damage, if they did experience the signs of a stroke after they left a chiropractor’s office.²³

Even a highly trained chiropractic professional cannot determine with 100% certainty, that the patient who is coming into their office with head and neck pain does not already have a VAD or if that patient has a “weakened artery”.  Therefore, they have a responsibility to either not adjust a patient’s neck and suggest they seek medical intervention or they must tell their patients that a manipulation could cause a VAD leading to stroke and hand them a discharge paper which would tell patients what to do in the event they begin to experience the signs of a stroke.  A chiropractor’s duty as a physician must put the patient’s health first.

In an article written by Gina Shaw, contributing Writer for the American Chiropractic Association news, writes that chiropractors should document everything under the heading “Physician, Protect thyself.”  Whatever happened to “Physician, Protect thy Patient”?  Shouldn’t responsible healthcare providers put the interests of their patients first? ³⁷

“A patient who might have a VAD should never be manipulated.” One of the largest chiropractic insurance carriers, NCMIC, can’t stress this enough with their subscribers.  If a patient already has an existing torn artery, and is presenting signs of head & neck pain, a manipulation can and will only serve to make the tear worse and increase the likelihood of that patient having a major stroke.²⁴

Luigi DiRubba, the Vice President and former President of the Connecticut Chiropractic Council and CT State Representative of the ICA states, “Those who are critical of chiropractic attempt to frighten the public. Their main tactic is to suggest that chiropractic is unsafe or that neck adjustments can lead to a stroke. It’s just not true. Chiropractic is so safe that no “warning label” is necessary. Chiropractic is so safe that it doesn’t need a page of fine-print disclaimers. Chiropractic is so safe that even newborns and the elderly can benefit. Chiropractic is so safe that the side effects are well…positive effects!”

Chiropractors need to stop concentrating on how important it is for them to say that chiropractic manipulation is safe and concentrate on how they can make it as safe as they can for their patients.

According to an article written by Stephen Perle, D.C., “the chiropractic profession has long suffered from difficulties with honesty. Not that organized medicine has always been forthcoming, as reports from the Institute of Medicine often have pointed out.  But as is often said, two wrongs don’t make a right. Therefore, we call upon the profession to be stringently honest when discussing risks and benefits.  This should hold true whether we are discussing procedures that we clearly should be the authority on such as spinal manipulation. “²⁵

How rare is the risk of stroke?

There has never been any scientific studies done thus far that can definitively say just how rare a stroke is after having received  a chiropractic adjustment, as seen by the wide range of statistics given out by the chiropractic community itself.  It is just assumed that it is a rare occurrence.  Many people, including myself, feel that it is very underreported.  Since after a VAD, the signs of an impending stroke on a patient can take hours, days, even weeks to appear, most patients might not even relate their stroke back to the chiropractic adjustment.

Due to this lack of any definitive scientific studies, chiropractors have only “guesstimated” what they think the odds are of having a serious adverse event occurring as a result of a chiropractic manipulation.  Chiropractic figures range from 1 out of 5,000 adjustments to 1 out of 1,000,000 to 1 out of 2,000,000 to 1 out of 4,000,000, to even much higher.  No one really knows what the correct number is.

The American Chiropractic Association’s media spokesperson, William J. Lauretti, compares the risk of death or major neurological complications from cervical manipulation (1 in 2,000,000) to other unrelated activities, such as death in a plane crash (1 in 4,000,000), and death in a motor vehicle accident (1 in 4,000,000). In actuality, one risk can and should not be compared to other unlike activities. First of all, most people are well aware of the risk they take when they get on a plane or drive a car. But most people are unaware of the risk of death with a chiropractic manipulation. ¹

Secondly, it would be more beneficial to a patient’s decision making process when concerning their own body if a chiropractor, when comparing risks, stayed within that particular treatment and state the benefits verses the risk of having or not having a cervical manipulation.  Patients when undergoing any procedure would want to know the risk they are taking in having the procedure done verses not having the procedure, rather than the unrelated risk they might have say, driving or flying. Stephen Perle, author, chiropractor and professor at the University of Bridgeport Chiropractic College states that “informing a patient of a risk is consistent with the duty of non-maleficence, but any explanation of risk needs to be conducted within the context of similar risks.”²⁵

The World Chiropractic Alliance states that “numerous published scientific and medical studies indicate that the incidence of CVA or stroke is estimated at between 1 to 3 incidents per million adjustments.”²⁶ The ICA states that “the process of chiropractic adjustments is a safe, efficient procedure which is performed nearly one million times every working day in the U.S.”²⁷

Using the above information, it means that at least almost 100 – 200 people a year suffer unnecessary, needless, serious complications from a chiropractic manipulation.  In medicine, it takes less data than this to bring a drug under scrutiny to decide if the benefits are worth the potential risks of a therapy.

Harriet Hall, M.D., who contributes to Science-based Medicine.org writes, “How often can a stroke be attributed to neck manipulation? We really don’t know. Estimates have varied from one in ten million manipulations to one in 40,000. I should clarify that only one specific type of stroke, basilar stroke, has been linked to chiropractic. It has been estimated that about 20% of all basilar strokes are due to spinal manipulations. This would work out to about 1300 a year in the U.S. But we just don’t know, because it has not been properly studied. Carotid artery strokes have also been reported after chiropractic treatments. Chiropractors do not follow up on every patient. Patients who have delayed strokes may never see their chiropractor again, so chiropractors would naturally tend to underestimate the risk. Many of these diagnoses are missed because the vertebral arteries are not typically examined on autopsy.”²¹

Whether the chiropractic associations can agree on the odds  about whether a stroke happens following a chiropractic adjustment 1 out of a 100,000 adjustments , or 1 out of a million adjustments or even one out of 5 million adjustments is immaterial.  And it certainly is immaterial to the poor unfortunate person who has a devastating stroke as a consequence.  Louis Sportelli, President of the one of the largest Chiropractic Insurance Companies, NCMIC says, “Even one cerebral vascular incident that could have been prevented or detected is one too many.”⁸

The International Chiropractic Association advocates that children as young as infants should be adjusted to prevent disease.  But until scientific studies can definitively say there is absolutely NO risk of stroke with a chiropractic adjustment, the question becomes, why would we subject our children to this, without thoroughly reviewing the risk factors with a parent or guardian of that child?

Contradictions

Luigi DiRubba, Board member and Past President of the Connecticut Chiropractic Council, has stated that chiropractic manipulation is so safe that no warning sign is necessary. Yet, this same chiropractor believes that people should be warned about the dangers of vaccinations.

The Connecticut Chiropractic Council “supports each individual’s right to select his or her own health care and to be made aware of the possible adverse effects of vaccines upon a human body.”²⁹

The International Chiropractic Association’s official policy statement on vaccination states that, “…the use of vaccines is not without risk. The ICA supports each individual’s right to select his or her own health care and to be made aware of the possible adverse side effects of vaccines upon the human body…”²⁸ This is not a chiropractic issue; it is a public health and accountability issue. ICA’s policy is not one of opposition to or promotion of vaccination; it is one of informed consent and personal freedom.”²⁹

The risk of serious adverse effects regarding vaccines is comparable to the risk of serious adverse effects regarding chiropractic manipulation. If chiropractic members of the ICA support each individual’s right to select his or her own health care and insist that the public is to be made aware of the possible adverse side effects of vaccines upon the human body, then they must also support each individual’s right to be made aware of the possible adverse side effects of a chiropractic manipulation which carries the same risk.

According to the World Chiropractic Alliance (WCA) web-site, the association believes that in regards to vaccinations, doctors have a moral and legal obligation to obtain informed consent from patients and must advise their patients of any and all side effects. If they believe that this holds true for vaccinations then they would be very hypocritical if they didn’t also believe it to be true for manipulation.³⁰

Stephen Perle, chiropractor and contributing author to Chiropractic Dynamics, states that “There appear to be many in our profession who are opposed to mandatory vaccination. We find any suggestion that there is an ethical duty to inform patients and the public about the hazards of vaccination, and that getting adjusted is an alternative to vaccination, to be completely disingenuous, illogical, and completely unethical coming from most chiropractors.”  Dr. Perle states that the risk of stroke with a chiropractic adjustment is equivalent to a serious side effect with a vaccination. “Obviously, we believe that it is unethical to recommend avoiding vaccinations while also recommending adjusting because of the comparable level of risk. If a chiropractor tells a patient that vaccination is too risky, then ethically, they must also tell them not to get adjusted”.   “Given the fact that most chiropractors who would recommend avoiding vaccinations also recommend maintenance care, which can consist of monthly to weekly adjustments, it is obvious that the small risks (of stroke) with a manipulation are then compounded by repeated use.” ²⁵

The WCA also suggests “adjusting, as an alternative to vaccination.” In 2005, Stephen Perle, D.C., writes, “Repeated cervical adjustments are worth that risk when the benefits are great, such as getting rid of neck pain or headaches. However, right now, lacking compelling evidence that maintenance care is beneficial, the risk outweighs the benefit.”²⁵

In an article entitled ‘ICA Joins with SAMHSA and FDA To Educate Public on Prescription Drug Dangers’, the International Chiropractic Association states “that the public needs to know that just because a medication is safe and even life-saving when used appropriately, it is not harmless if used inappropriately.” The ICA advertises that chiropractic is safe. VOCA feels that just because someone advertises that chiropractic is safe when used appropriately, it is not harmless if used inappropriately.³¹

Why the State Board of Chiropractic Examiners must take action

Some chiropractors over the years in public testimony in Hartford have said that they don’t mind giving Informed Consent or even a discharge summary to their patients.  They just feel that they should not be singled out and if they are mandated to give Informed Consent, so too should the medical community be mandated either by Law or by their Medical Board to give Informed Consent.  However, the medical community is required to give Informed Consent to their patients.  And they must specifically warn patients about the risks of any procedure that carries a severe and devastating risk such as a stroke.  Unlike the chiropractic community, all of their medical colleges teach Informed Consent, their medical associations enforce it, and the hospitals they work in require it, as do their insurance companies, and organizations such as JCAHO (The Joint Commission on the Accreditation of Healthcare Organizations) and the FDA.  They do have mechanisms in place which oversee that medical physicians give their patients Informed Consent.

The chiropractic community on the other hand is very fractured.  Licensed chiropractors in Connecticut belong to different associations which have different philosophies, i.e. ACA, ICA, and WCA.  There is no unified body.  Various philosophies can range from basic cultism, which the ACA disavows in its literature… to the idea that if your spine is aligned then the patient will not get any disease….. to chiropractors who are willing to work alongside the medical community for the health and welfare of their patients.  Chiropractors can be either straights, mixers or objective straights.  Various chiropractic colleges teach different ways to treat people. Therefore, not all chiropractors use a conservative approach.  Not all chiropractors believe that patients need to know that there is a risk of stroke at all.  In fact, at the University of Bridgeport, some chiropractors are still writing articles discussing whether or not they should give Informed Consent, ³⁴ while other chiropractors like Stephen Perle, who is also a consultant to the Connecticut Department of Public Health, feels that it is time that chiropractors discuss the risks of stroke with their patients. ³

Frank Zolli, a CT licensed chiropractic physician and Dean at the University of Bridgeport, testified in front of the Public Health Committee in early 2009 that he fully supports Informed Consent.  In his discussions with Senator Harris he conceded that not every chiropractor in the State of Connecticut gives Informed Consent. He said; “not everybody belongs to any one Association that has that kind of regulatory enforcement ability.  (To enforce Informed Consent) I think that the only real mechanism would be for the board to say, you have to do it”.

How can the public protect itself or ever expect to be given the right information if and when they decide to go to a chiropractor? How would they know who they are going to and what philosophy that particular chiropractor adheres to? This alone can be very harmful to the patient who is unaware that chiropractors do not all uphold the same basic principles and beliefs.

Conclusion

We could debate how often a chiropractic manipulation causes a person to have a stroke for years. We could quote different statistics all day long; how often one group thinks it happens, or how often another group thinks it doesn’t happen. But the reality, and all sides agree, that it DOES happen. And people are getting severely injured.

Michael Kane (President of the CT Chiropractic Association ), although he was aware of the stroke victims who testified on SB-90 , made an incorrect statement at a May 8 hearing of the Chiropractic Board, telling Board members that there had been no chiropractic stroke victims in CT within the last 10 years.  This is simply not true. ³⁸

Every licensed chiropractor in the State of Connecticut needs to give their patients Informed Consent and tell them about the risks of stroke along with giving them a discharge summary to take home with them. This may not only save a life but it will save many people from a lifetime of disability.

It is time that chiropractors put aside the debate, and do what is morally and ethically right. As licensed healthcare providers their patient’s health and well-being must be put first.  Chiropractors have long sought out the right to be able to use the title “DOCTOR”.  But with that title, comes a responsibility in that “First, do no harm”.  While some chiropractors do abide by the highest of ethical standards, not all chiropractors agree or are willing to abide by these standards.  Therefore, the State Board of Chiropractic Examiners must step in and ensure that the public receives the standard of care that they are entitled to in the State of Connecticut.

The Model Code of Ethics for Members of Regulatory Boards for the Licensed Professions, which was supported by the Federation of Chiropractic Licensing Boards, was founded for the sole purpose to ensure that the public has access to competent, safe, and ethical practitioners within the profession. It states that members of a regulatory Board must always give recommendations, make decisions, and take actions, “always in the interest of the public; that is, for the common good and not just for the good of some.  Members must understand and embrace the central mission of the regulatory board as protecting the public, not advocating for the profession.”³⁹

We sincerely hope that The State Board of Chiropractic Examiners will remember this as they vote on whether or not to issue a declaratory ruling on Informed Consent and the Discharge Summary, which together would insure that licensed chiropractors in Connecticut will begin to protect the health and well being of their patients and not just protect their profession.

Additional Testimonies:

• Testimony of Michael McCormick
• Testimony of Christa Heck
• Testimony of Susan Hoffman

 

References

1. Lauretti, William  What are the Risks of Chiropractic Neck Adjustments?  {online document}Pg. 4
2. Colonoscopy discharge instructions . Vaccine 2008-09 discharge summary.CDC.
3. Perle,Stephen. DC. Informed Consent. Dynamic Chiropractor; March 26, 2007.pg.1 & 2
4. ACA Stated code of ethics
5. ICA’s Vision and Mission: Building a Strong Tomorrow for You! {online document}.pg. 2
6. NCMIC. Informed Consent. More Than Just a Form {online document} pg. 1
7. The Chiropractic Report. July  2006 {online document}www.chiropracticreport.com.pg. 1 &2
8. Kargus,Angela Putting Risks into Perspective. {online document} pg. 3 &4
9. Hoffman, Stuart DC. Be Proactive & Consistent on Informed Consent. American Journal of Clinical Chiropractic .pg. 1&2
10. Haldeman, Scott DC, Chapman-Smith, David, Peterson, DonaldGuidelines for Chiropractic Quality Assurance and Practice ParametersJones and Bartlett, 2005 Pg. 90
11. Long, Preston DC. PHD. Stroke and Manipulation  Pg.1
12. American Chiropractic Association. Risks Associated with Chiropractic Neck Adjustments. Media Messages. Pg.1
13. Ernst Edzard, . Manipulation of the Cervical Spine: a systematic review of case reports of serious adverse advents. Pg. 1-33   Spinal Manipulation: Its safety is uncertain. Pg. 1& 2 .Ernst, Edzard,  Singh, Simon. Trick or Treatment
14. Stewart, Brad MD. Canadian Neurologists Warn Against Neck Manipulation  {online document} www.chirobase.org/15News/neurol.html. pg 1-4
15. Paciaroni, Maurizio. Bogousslavsky, Julien. Cerebrovascular Complications of Neck Manipulation  European Neurology 2008pg. 113,115,116
16. American Chiropractic Association. Talking Points. Chiropractic Cervical Manipulation and Informed Consent. Pg. 4
17. Vohra,Sunita MD, Johnston,Bradley ND, Humphreys, Kim DC Pediatrics.Adverse Events Associated with Pediatric Spinal Manipulation: A Systematic Review 2006 pg. 1-18
18. Nordqvist, Christian. Medical News Today. Spinal Manipulation Should Not be Routinely used, new study warns. July 2007. pg.1
19. Hall, Harriet. Science-Based Medicine. Chiropractic and Stroke 2008 {online document} www.sciencebasedmedicine.org/?p=94 .pg. 1-2
20. Carey, Paul DC Journal of the CCA, Health Law in Chiropractic. Informed Consent-the new reality pg. 91-93-94
21. Edzard Ernst. Chiropractic Spinal Manipulation for whiplash injury? A systematic review of controlled clinical trials. Pg. 1-3 http://beta.medicinescomplete.com/journals/fact/current/fact1402a05t01.htm?q=
22. NCMIC. Warning Signs of a Potential Dissection/CVA. Attached to “Current Concepts.”
23.  Perle, Stephen DC. What’s Good for the Goose..Ethics and Vaccinations.  {online document} www.chiroweb.com pg 1-4
24. World Chiropractic Alliance. Chiropractic and the Risk of Stroke. {online document} www.worldchiropracticalliance.org/consumer/strokes.htm. pg 1
25. International Chiropractic Association. Chiropractic Quick Facts { online document} www.chiropractic.org/index.php?p=chiroinfo/main pg.2
26. Connecticut Chiropractic Council. Immunization Policy  2006. pg.1
27. International Chiropractors Association . ICA Responds to Time Magazine Editorial on Chiropractors and Vaccination. {online document}  . pg.1 www.chiropractic.org/index.php?p=news/times_release
28. World Chiropractic Alliance . Press Release. Parents Not Receiving Full Information on Vaccines. Chandler, Az. Pg.1
29. International Chiropractic Association.  ICA Joins with SAMHSA (Substance Abuse and Mental Health Services) and FDA to educate Public on Prescription Drug Dangers  Arlington,Va . pg 1
30.  Mayo Clinic. Stroke Symptoms {online document} . pg.2www.mayoclinic.com/health/stroke/DS00150/DSECTION=symptoms
31.  Kleindorfer, Dawn MD. National Stroke Association. Women and Stroke.Unique Symptoms in Women. Pg.3
32. Lehman, James DC. Conwell, Timothy DC Sherman, Paul DC Journal of Chiropractic Medicine. Should the chiropractic profession embrace the doctrine of informed consent? University of Bridgeport pgs. 1-8 of article
33. Ernst, Edzard.  Journal of Pain and Symptom Management. Chiropractic: A Critical Evaluation.  2007.. Vol.35 No. 5 May 2008  pgs. 544-562
34. American Chiropractic Association (ACA)  Current Policies. www.amerchiro.org/level2_css.cfm?T11D=10&T2ID=117
35. Shaw, Gina. Avoiding Risky Business. American Chiropractic Association   downloaded 10/21/09
36. Connecticut State Board of Chiropractic Examiners. Meeting Minutes. May 28, 2009
37. Bowen, Hal DC. Temple, Vernon DC. Cohen, Norman. Liewer, Donna.  Task Force to Develop a Regulatory Code of Ethics. Federation of Chiropractic Licensing Boards.  April 17, 1999 . pgs. 2,3,5,7,14