Sarah Ritter belonged to a club for triathletes. When she developed what she described as “knots in the muscles along her shoulders and thighs,” some of her fellow club members told her about active release technique being an effective treatment for her condition. Sarah researched practitioners of the active release technique and began treating with Matthew Linaman, DC.
Posted in Risk Management on Wednesday, June 1, 2022
During her visits, Dr. Linaman used a metal bar to work the muscles in Sarah’s shoulders, her thighs and under her arm. She also had chiropractic adjustments to her spine and received physical therapy in the form of electrical stimulation, roller bed and manual therapy. Dry needling and cupping were also provided, on occasion.
A Lapse in Care
At one point, Sarah went 10 months without seeking care from Dr. Linaman. During that time, she had gastric bypass surgery and, as a result, lost 50 pounds. She then participated in a triathlon and admitted that she had not trained for the event, but still did well because of her weight loss. She reported being “quite sore” afterward because of the lack of training.
After the triathlon, she was again seen by Dr. Linaman. At that appointment, he asked about Sarah’s bypass surgery and if there had been any other changes in her physical health or condition since he had last treated her. He also evaluated Sarah by placing her in front of the full-length mirror. He noted that she had a forward head carriage and that her right shoulder level was higher than the left. He also found that Sarah’s left hip level was higher.
Dr. Linaman next tested for flexion and extension of the neck and also lateral flexion and rotation of the neck. The range of motion of Sarah’s elbow would be tested with regard to flexion, extension, pronation and rotation. Dr. Linaman also performed tension tests, orthopedic tests and hip rotation testing as well as distraction tests, foraminal compression tests and Jackson's compression test. He saw no evidence of a herniated disc.
Dr. Linaman noted tenderness in the cervical region, as well as increased muscle tone. Cervical adjustment was recommended and performed because Sarah had what the doctor felt was nerve root tension. This was described as stress on the nerves that come out of the neck to the arm. Tension on those nerves causes the muscles to tighten which can then cause subluxations of the spinal joints.
Sarah later recalled that the care she received at that appointment was similar to what she had received from Dr. Linaman in the past. She said there were no headaches or any other adverse reactions to the care provided.
After the Visit
Following the appointment, Sarah returned to her place of employment working a normal week from Tuesday to Friday. Late Friday afternoon, she and friends went to the beach for the weekend. She went out to some bars before returning home Sunday afternoon. She had a date on Sunday night and went to work on Monday. She had a date on Monday night and returned to work on Tuesday. Afterward, she went to happy hour with some friends, where they remained until after dinner. She visited a friend’s home until midnight before returning to her home.
On Wednesday, Sarah woke up and got ready to go to work but when she went to her car, she could not get the key into the door lock. She returned to her apartment with a severe headache and went back to bed. Sarah’s boss asked a co-worker to call Sarah to find out why she was not at work. When she explained her symptoms to the coworker, the coworker asked if she had too much to drink the night before and Sarah admitted that that was a possibility. She went back to sleep and did not get up until 4 p.m.
After she woke up, Sarah began moving boxes out of her apartment. She had moved recently and was still unpacking. She then went back to bed until 7 p.m. and woke up to walk her dog for the first time that day. On the walk, Sarah visited with a neighbor who noticed that one side of her face was drooping and insisted on taking her to the hospital.
Sarah recalled that by the time she arrived at the hospital, she could say nothing but the word “yes.” She learned that she’d had a stroke and her treating neurologist indicated that chiropractic adjustments had caused it. Dr. Linaman had performed cervical adjustments on each visit up to and including the office visit closest to Sarah’s hospitalization.
Recovery
After being released from the hospital, Sarah was prescribed Coumadin. She also had extensive speech and occupational therapy. She made progress and was close to getting her driver's license back but experienced a setback when she had a seizure. She subsequently had three more seizures, and as a result, Sarah was not qualified to regain her driving privileges.
The inability to drive caused a major change in Sarah’s physical activity. She had not gone back to her running and swimming regimen. The medication she was taking to combat the seizures made her drowsy and irritable. She also claimed to be fearful of getting pregnant while taking this medication.
Sarah’s most notable disability was aphasia, which made it difficult for her to communicate and affected her ability to do her job. She claimed that a supervisor was considering demoting her. Her duties had been changed to accommodate her disability. Sarah became quite emotional when talking about the difficulties that she had performing her job and her perceived risk of losing it.
The Cost of Chiropractic Care
At trial, Sarah claimed that she had incurred nearly $500,000 of medical expenses to date, would lose income of over $3 million over the next 35 years, and presented a life care plan for future medical and therapeutic needs, which required funding of $2 million.
Dr. Linaman was not certain whether he had verbal discussions with the patient about the risk of stroke with chiropractic adjustments, but Sarah did sign consent forms that stated such prior to the first period of care.
Dr. Linaman provided the active release technique, which is a soft tissue, hands-on technique where the patient activates the muscle and relaxes it as the tissue is stretched and massaged. He also provided Graston technique on the shoulder, wrist and thigh. Because of the shoulder involvement, he also performed a cervical adjustment in the supine position, anterior thoracic adjustments and side posture lower lumbar adjustment. In regard to therapy, an ultrasound was provided, along with traction and exercises.
Dr. Linaman claimed that the first time he learned of Sarah’s stroke was through a message on the office answering machine. He had called in to check messages and a doctor from the hospital has asked what Dr. Linaman had observed that day when the patient was adjusted. Dr. Linaman returned the call and stated that he did not have the file with him but that he had not seen the patient for at least a week. He also reported that Sarah had completed a triathlon the weekend before her last visit to the office.
The Standard of Care
Sarah’s attorneys employed three chiropractic experts, each of whom claimed that Dr. Linaman breached the standard of care.
They claimed that the evaluation conducted by Dr. Linaman failed to meet the standard of care as the doctor failed to perform any vascular screening or take Sarah’s blood pressure, in light of the history of risk factors that were available. They also criticized the completeness of the history taken and the extent of the evaluation at the return to the office after not being seen for 10 months.
These chiropractors criticized Dr. Linaman for failing to appropriately discuss risks involved with cervical adjustments under the circumstances. They agreed that the consent form, if provided with no explanation, would not meet the standard of care for informed consent.
The primary criticism provided by Sarah’s standard of care experts, was that although Sarah reported upper back, right shoulder, right elbow and right wrist symptoms, there was no neck pain, therefore there was no reason to perform cervical adjustments.
Also testifying for the plaintiff was the hospital’s treating neurologist, as well as the director of stroke research at a major stroke center. It was the neurologist’s opinion that—based on the temporal history of the development of Sarah’s stroke—the description of the quick thrust with rotation that made up the cervical adjustment administered to the patient, the dissection on the left carotid artery was caused by Dr. Linaman’s cervical adjustment. The neurologists testified that the prior dissection of the right carotid artery was more likely than not caused by earlier cervical adjustments performed by the doctor.
The neurologists admitted that dissections can occur with simple exercise, and they agreed that any activity that causes flexion or extension and/or a rapid rotational movement can cause a dissection. They were aware that the patient had completed a triathlon around the same time that she had received her last chiropractic adjustment. While the neurologists conceded that swimming involved a rotational movement, they believed that it was too slow to cause a dissection. Moreover, they did not believe that Sarah’s exercise was sufficiently strenuous enough to cause a dissection.
Both admitted that it was difficult to say when Sarah sustained the dissection of the left carotid artery. Each stated that the dissection probably occurred within two weeks of her admission to the hospital. Both neurologists claimed that in most dissections, the mean time of dissection to diagnosis is 9-10 days. Therefore, the provoking factor would be a week or two before the development of the stroke and diagnoses. They both agreed that the cervical chiropractic adjustments were the most likely cause of Sarah’s dissections.
Prior to trial, the patient’s attorneys discharged two of the chiropractors who were testifying as to the claimed breaches of the standard of care. The remaining expert only practiced part-time and his professionalism paled when compared to Dr. Linaman.
Sarah’s attorneys decided only to call the treating neurologist to claim that the patient’s dissection was caused by the chiropractic cervical adjustments. Two medical journal articles were found, authored by the treating neurologist, which indicated that in over 70% of the dissections of either the vertebral or carotid artery, significant neck pain was felt at the time of the dissection.
As Sarah said she felt no neck pain at the time of the cervical adjustments provided by the insured and the first episode of neck pain was not present until eight days after the last adjustment, at the conclusion of the weeklong trial, the jury found no negligence causing injury to the patient.
While a strenuous defense was provided with chiropractic and neurological witnesses on behalf of Dr. Linaman, it was his professionalism and the revelation that the treating neurologist’s own literature did not support his conclusions that led to a verdict.
About the Author
Paul Weber, a Hyatt & Weber partner, is an accomplished litigator with more than three decades of experience in insurance coverage, medical malpractice and personal injury law. Based in Annapolis, Maryland, Paul represents individuals and businesses, including the majority of chiropractors in the state and their insurers. He also maintains an active practice representing medical professionals in licensure disputes. His understanding of the law from the perspective of both plaintiffs and defendants makes him one of the most sought-after lawyers in the Baltimore-Washington region. Drawing on his experience representing plaintiffs in personal injury and medical malpractice litigation, Paul frequently counsels medical professionals and businesses on litigation avoidance and insurance coverage strategies. He regularly presents seminars to chiropractors and offers practical, frank advice on ways to implement best-practice tactics designed to mitigate risk.