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Good afternoon ladies and gentlemen, this is Dr. Gerry Clum. It’s a pleasure to be with you once again on behalf of ChiroSecure, and we’d like to spend the next few minutes together talking about a couple COVID-19 related issues. I’ll save the discussion about unprecedented times, and how odd the things are, and all that kind of consideration. You hear it from everybody day in and day out, we all know the reality that we’re dealing with. Today I would like to talk to you about a couple items that have been in the news and clinical details on one consideration, and then a practical matter relative to your office, and information from your office relative to the COVID-19 situation. Let’s go to the slides, please.
Thank you. Relative to the discussion today, what I’m going to be looking at is a possible relationship between COVID-19 infection and the development of ischemic and/or hemorrhagic stroke. Now, if you followed anything in the popular press you know that there has been a discussion about large vessel related strokes that have been associated with COVID-19. Large vessels, obviously the internal carotids, the vessels of cervical arteries, things of that nature have been involved in this. The question remains unanswered quite honestly, as to whether or not there is a relationship between COVID-19 and the development of these stroke situations. From where I sit, I think it’s important that you and I as chiropractors understand the basics of the possible connection between COVID-19 infection and stroke, and the likelihood of developing a stroke as an outcome of the infection itself.
We’re going to take the next few minutes and walk through some of the details, a little bit of data, but more conceptual, and hopefully we’ll answer some questions for you or at least answer more than we raise along the way. Let’s look at the discussion regarding the broad stroke consideration of COVID-19. All sorts of numbers are out there. If you look at what percentage of patients are asymptomatic, you can find reports out of China that said 5% are asymptomatic. You can find reports out of other parts of the world that say 80% are asymptomatic. I think it’s a reasonable consideration for us to look at about 50% of those that have a COVID-19 infection will not even experienced any symptoms of it or not be aware that they’re experiencing symptoms of it, and essentially blissfully move on through that process without any problems.
Now, when I talk about the idea that 50% will have an asymptomatic infection and 80% will have a mild infection, obviously we’re ruling the asymptomatics into the mild discussion at that point, but overall, 80% of persons who’ve experienced COVID-19 or approximately 80% are in generally a very mild disease process or no awareness of the disease process at all kind of configuration. We’ve all heard the discussion about social distancing, and masks, and everything else, and one of the big reasons for this is that a good many of the people, half of the people, don’t even know they’ve got this that have it, and as a result they can be in a situation where they’re in a transmissible state and not be aware of it at all. Those types of mechanical measures of hand washing to masks and so on, obviously intended to making the assumption that everybody’s got it, do if everybody uses them then we’ll stop the spread in the environment.
If we focus a little bit more closely on the remaining 20% of the population that are COVID-19 infected persons, we realize that it covers the spectrum from how a moderate, bad flu-like illness to a fatal illness. You’ve seen the news today like I have, is that we’ve broken 100,000 deaths here in the United States, and there’s all sorts of questions about how accurate the 100,000 is in terms of does anybody who dies of pneumonia, do they get automatically counted as a COVID death, and those kinds of things. We hear all sorts of crazy talk about why that is, and so on. The bottom line is regardless of whether it’s off by a factor of 10 or a factor of one or two, it doesn’t make any difference. There’s been a lot of people that have died associated with this condition. It covers the spectrum.
The early discussion was that if you didn’t have a preexisting condition, if you weren’t over 70 or over 60, you didn’t have anything to worry about. Well, in the fullness of time over the last few months, we realized that that has shifted a little bit; and that we know that there are a good number of people without any preexisting conditions or known preexisting conditions; without any existing comorbidities that have succumbed to COVID-19 infection. The idea that because you’re 19 years old, you’re healthy as a horse, you don’t have high blood pressure, you’re fit and trim, those are all things that accrue to your good fortune and your wellbeing, but they’re not insulation to say that you’re never going to have this problem and it won’t be something you have to deal with along the way.
We’ve shifted the emphasis away from the; if people took care of themselves they wouldn’t have a problem with this infection, to the idea that this seems to be an equal opportunity environment and for whatever reasons, there are 100 year old people that survive this and do well, and there are 20 year old people who don’t. Time and a lot of searching will tell us why perhaps over time. Let’s look into the group of people that are infected that seem to have a little bit more severe environment their level of infection. We’re setting aside the asymptomatics, we’re setting aside the mild disease persons, and we’re looking at that 20%. Of the 20% who have been more involved disease process, up to 50% of them have some type of neurological symptom associated with their COVID-19 infection. Whether that’s headache, whether that’s dysautonomia, whether that’s a loss of smell, a loss of taste, whether that’s stroke, seizures, encephalitis, you name it, it covers the spectrum of neurological symptoms.
Obviously the discussion that we’re interested in, or the part of this discussion that we’re most interested in, is the stroke related consideration. If we look across the literature, you can find literature in the range of about 2% to 5.7% of hospitalized COVID-19 cases may experience a stroke. Keep in mind, let’s look at the numbers again from the top, 50% asymptomatic, 80% mild problem or asymptomatic problem, 20% a severe problem or potential for severe problem. Of the 20%, half of those patients exhibit some neurological symptoms, and of those patients that are hospitalized with a moderate to severe form of COVID-19 infection, 2% to a little bit less than 6% of them will develop a stroke of some kind along the way. When I say some kind, the strokes fall into both categories of being ischemic an/or hemorrhagic.
It’s not just one type of stroke, it’s across the spectrum of strokes that we need to be concerned in this discussion. I said in the beginning that this was an unanswered question at this point, and you might be sitting there scratching your head saying, “Well, if 2% to about 6% of patients that are hospitalized experience a stroke, why wouldn’t we say that there is a direct relationship between the two?” Well, if we look at the patients in both groups, those that have ischemic or hemorrhagic strokes, and those that have COVID-19, we find that both groups, particularly the more severely infected and involved patients, their risk factors begin to overlap considerably.
Both the stroke community, apart from any COVID discussion, as well as the COVID community itself, COVID infected community, the higher the rate of diabetes, the higher rate of hypertension, the higher rate of obesity, and the higher rate of heart disease, means you’re going to have more complications to the COVID-19 infection, and those are also risk factors for ischemic and/or hemorrhagic stroke. We also know that both problems, the ischemic or hemorrhagic stroke and COVID-19 infection, both increase with age. When we get into dealing with a population that’s 60, 70, 80, 90 years old, they experience many more strokes than people in their 20s, 30s, and 40s. We know that, but we also know that persons that are infected with COVID-19 in the 60, 70, 80, 90 category and above, they’re more at risk for the disease processes and more complication factors involved. We need to parse out, is the stroke incidents that’s occurring in the COVID-19 population, the strokes that more or less would have occurred in the same population absent COVID? Or were they in fact caused, complicated, aggravated or increased because of COVID-19?
One of the things that we do know is that infection, whether it’s the flu or whether it’s COVID-19, infection in general has a tendency to increase the odds of stroke by a factor of 1.4. Forget what type of infection, infection in general causes stroke ratios to go up over time. All of these factors to cloud the question as to whether or not the COVID’s causing the stroke, whether the stroke is incidental to the COVID, et cetera, and go from there. Let’s look at some literature associated with this, and I’m not really not go into many articles, just a couple of them to give you some basic data and some background. I’m also going to ask ChiroSecure if they’ll be kind enough to post this article for you so that you can access it readily. You can see here from the front page of the article that this was accepted for publication on April 29th, 2020, so it’s just about as current as you’re going to get as far as any literature associated with the issue of ischemic infection and Coronavirus 2.
Just as an aside before we get into some of the detail, when you see people write about SARS-CoV-2 infection, they’re talking about the virus itself. When they’re talking about COVID-19, they’re talking about the infection itself. So, the reference to SARS-CoV-2, that’s the organism, the virus, and COVID-19 is the infectious process that results from contact with the virus and the impact of the virus on us. In this article, they talk about the idea that put that there are a number of potential links, and we’ll go take a look at a series of them here in just a second from across the board that will potentially tie the connection between the COVID-19 infection and the development of stroke.
As you see here the SARS-CoV-2 again, is the virus. It can enter myocardial cells, and in addition, it’s associated with the angiotensin-converting enzyme II, or ACE2 enzyme process, and the ACE2 is heavily expressed in the myocardium, in the vascular endothelium, and in arterial smooth muscle. Well, obviously two of those areas relative to stroke are very significant for our discussion; vascular endothelium and the arterial smooth muscle. The idea that the COVID-19 infectious process interferes with this enzyme activity, and this enzyme activity is present in tissues such as medium sized arteries, large arteries that we’re talking about, our antenna should go up and say, “Well, if this can affect the vascular endothelium, it can affect the arterial smooth muscle, then perhaps there’s some relationship there that we need to think about.”
Relative to the virus itself, I said before that the SARS-CoV-2 virus can cause endothelial damage, and according to this article, there is increased risk for spontaneous intracerebral hemorrhage, and microthrombosis of small penetrating arteries, and cervical artery dissection of the larger arteries. The acknowledgement here is that this could involve the very, very small penetrating arteries, it could also involve the larger medium-sized arteries that we would find, for example, in the vertebrals or larger arteries upwards to the internal carotids, things of that nature. The idea that the pathology involves the ACE2 enzyme activity, and the ACE2 enzyme activity is particularly active in the vascular endothelium, and the smooth muscle of the artery, and as a result the authors have acknowledged that microthrombosis in the penetrating arteries is an issue, as well as the dissection in the larger arteries.
Now, this is a pretty dense slide, and I’m going to ask you to pay close attention to it if you can. Let me walk you through the process. If we begin in the upper left hand corner, we’re looking at non-COVID-19 related stroke risk factors. So, if COVID-19 never existed, this is the list of risk factors that we would be looking at relative to stroke activity. Underneath that, we’re looking at COVID-19 infection in particular, and we’re looking at systemic processes that arise from the COVID-19 infection, and we’re looking at potentially a direct invasion with the SARS-CoV-2 into the vascular endothelium and the effect that it could have in the myocardium, as well as in the cervical arteries.
If we look at the top of the slide, we can see that the typical risk factors of atherosclerosis, that we’re looking at cardioembolic origins of embolism. We look at small vessel disease resulting in thrombi and emboli. We look at other determined etiologies, whether it’s [inaudible 00:17:52] something like that, and then we’re looking at the cryptogenic or the unknown origins of a stroke that happens in the population at large. Obviously these phenomenon result in ischemic stroke as we can see from the slide, and then if we look down a little bit on the slide toward the center, we see the systemic processes, and then we see the immune response that we’re concerned about. We’ve all read and heard about the cytokine storm, where the excessive overreaction and the hypersensitivity processes that go out in the process of the COVID infection cause their damage and take their toll on the person that’s infected. There also is a hypercoagulability disorder that develops associated with the COVID-19 infection.
We move on to pathologies associated with coagulation that are mediated by a metabolic acidosis, and we go on to fibrinogen related problems associated with that. Then down toward the bottom of the slide, we get into discussion about direct invasion of the tissues that are involved, and we’ve got the myocardium in terms of the ACE2 receptors, we’ve got the arrhythmias associated with the atria, and then we’ve got the development of cardiac thrombotic directly affecting the heart. Way down at the bottom we’ve got the discussion of the vascular endothelium, and here we have the point of concern for us as chiropractors, that there is the potential for cervical artery dissection, and microthrombi that will develop in the small vessel structures to the medium sized vessel structures, and then potentially result and ischemic stroke and/or hemorrhagic stroke associated with the the COVID-19 infection.
Now, the important point to think about is, is go back to those original numbers that we talked about. 80% will have an asymptomatic or a mild infection. We’re not concerned about them. I shouldn’t say that, that’s wrong. We’re obviously concerned about them, they’re not the point of this discussion today, set them aside. We look at the 20% that are moderate to severe, and within that community we look at the hospitalized community or those people that experience hospitalization as a result of the infection. We see that between 2% and 6% or 2% or 5.7% of those patients will experience a stroke. We understand that associated with COVID-19 there are mechanisms that could set the stage for the development of ischaemic stroke, as well as the development of hemorrhagic stroke, and particularly in relationship to the cervical artery dissection for us, and that’s our concern.
When you start thinking about your patient population, and you whittle down from the patients that you normally see, those patients that experienced a moderate or severe infection with COVID-19 and were hospitalized, you’re probably down to a very, very small percentage of your practice population. There’s nothing to suggest that mild infections or asymptomatic infections subsequently have greater incidences of stroke. There is a potentially greater incidence of stroke associated with moderate and severe hospitalized patients, and in this community if you see these persons down the road after their recovery, and they have had a moderate or severe event, they were hospitalized, you want to have in the back of your head the possibility that, what if? Could there be a relationship between the neck pain that they’re producing, the headaches that they’re producing, and the potential development of a COVID-19 originating vascular endothelial problem that’s resulting in a dissection process? It’s a sequelae of the infection, as opposed to the typical mechanical things that happened in the population at large.
My advice to you today is, number one, put this in perspective relative to the numbers. Number two, when you look at that very, very small segment of your patient population that had severe disease, that were hospitalized, then you want to put this in the back of your mind and say, what if? Have it there. When those patients present with cervical spine problems, particularly neck pain, headache, the typical classic signs of the dissection or associated with dissection, spend a little bit more time. Be a little bit more thorough with the neurological, be a little bit more thorough with your history, and make sure that you’ve entertained the possibility that this could be a longterm sequela.
The good news is, as I said before, there is nothing to suggest that asymptomatic infection with COVID-19 increases the risk of ischemic stroke or a hemorrhagic stroke associated with the infection. The same is true for mild infections with COVID-19. So, I hope you put that away, put it to use someplace down the road. What I’d like to do at this point is shift gears after looking at these last two points here, the take home points, and again, these are quotes from the article that we began with. It’s very important that you understand that it’s not my opinion that this question about stroke relative to coronavirus disease is unanswered, it’s the opinion of the authors and researchers in this area. An important question that remains unanswered is whether coronavirus disease 2019, COVID-19, affects the likelihood of ischemic stroke independent of stroke risk factors.
Are the strokes that COVID-19 patients experience the product of the risk factors that they came into their COVID-19 infection with, or are they the product of the COVID-19 infection? The question is unanswered. The second point that the authors want us to take away from this is the risk of stroke may be increased with patients with COVID-19 due direct damage to the heart and the endothelium, markedly elevated inflammation, and elevation of prothrombotic factors that would be associated with moderate or severe infection with COVID-19, with the SARS-CoV-2.
I’d like to shift gears and now talk about an issue that’s come up just in the last couple of weeks, and this has to do with information that you might have on your website, information that you might have and use in your office about potential relationship between COVID-19 infection and chiropractic care, or COVID-19 infection and nutrition, or COVID-19 affection and supplementation of some kind. This is a press release dated May 7th that was issued by the Federal Trade Commission, and they announced that they have sent 45 letters of warning to marketers to stop making unsupported claims that their products and therapies can effectively prevent or treat COVID-19.
Now, this is important for us because on this list there are chiropractors. Let me jump right now very quickly to a letter you don’t want to get, and you’ll notice the letter is dated April 23, 2020, and it has that hideous warning letter start to it. This is a public document, it’s public information at this point, but no need to bring any embarrassment to the party that’s involved, and we blocked the name, and so on. The issue that they’re writing about is unsubstantiated claims for coronavirus prevention. Now, this is directly from the letter that the Federal Trade Commission sent this chiropractor who happens to be in the state of Georgia, and if you look at the language that the chiropractor had in his website, you’ll find that some of it is pretty reasonable, straightforward stuff where it talks about the idea that the COVID-19 infection has captivated the news and caused much anxiety in the population. I don’t think there’s any doubt about that.
I think the FTC would probably agree with that. “The understanding of the spread of infectious disease, you need to defend yourself, and you can lessen the fear as well as your chances of being infected by using certain procedures.” Well, WHO has said that to us, they suggested we use masks, we’re washing our hands, and so on, with those understandings. Is that a true statement? Yeah, it is. Now, the next sentence is what we start to get into some problems. “Internal defenses,” first of all, it doesn’t help to have misspellings in your announcements, but, “internal defenses are those your body innately has.” Well, that’s true. “These deficiencies are the best line of defense against any sort of pathogen.” I don’t know that we can make that statement, and that may be true. I frankly don’t know if that’s true, but the bottom line is, it’s where it’s starting to get a little squishy at this point.
The next sentence is where it gets very squishy. “Functioning at 100%, your immune system is nearly impenetrable to pathogens that can make you sick.” I don’t know how a person would define nearly impenetrable. Ebola, marburo, some pretty nasty stuff, still falls in the category of infectious processes and pathogens. Clearly not what we’re talking about here, but that is the broadest possible application, and begins to invalidate the kind of statement that he’s making. “The key here is having your immune system functioning as close to 100% of its innate potential as possible.” Well, that’s helpful, but I don’t know if that’s the key. “Raising your innate immunity,” the chiropractor goes on to talk about, and then he goes into a discussion about your immune system is controlled by your nervous system. Not exclusively, but it’s influenced.
“Anything that interferes with proper nerve system function will have a negative impact on your immune system.” That’s a pretty broad statement about proper nerve system function will have an impact on your immune system. It may have, and proper nerve system function, that could be everything from multiple sclerosis, to a brain tumor, to a subluxation, and so on. The language here is pretty wide, pretty loose, pretty freewheeling, and starting to get this fella into some difficulties with the FTC. He goes on to say, “Chiropractic has been shown to be the most effective form of healthcare for restoring proper nerve system function.” Again, proper nerve system function can include anything of a neurological nature going on in the body. From brain tumors, to multiple sclerosis, to myasthenia gravis, you name it. And the statement that the gentlemen made just simply isn’t correct.
I understand that context he’s coming from. I understand the perspective he’s coming from as a chiropractor, but the language he’s using is way too wide, way too broad, and far too encompassing. “The purpose of chiropractic care is to correct interference in your nervous system, the most common cause of interference to the nerve system is from vertebral subluxation.” Again, not an accurate statement. I don’t know that. I don’t know if the most common cause of interference to nervous system is subluxation. Personally, I’m of the opinion that it’s a significant and a meaningful disturbance in my nervous system, but I don’t know that I can say with any degree of accuracy that it’s the most common cause. “Subluxations can cause your system to function at less than optimum, therefore have a negative effect on your immune system.” We theorize that. We haven’t proven that.
“Correcting subluxations through specific scientific chiropractic adjustments will help your nervous system,” and by implication, help with your COVID infection. Again, we haven’t established that either. Sorry that the type got a little bit smaller in this version. “Therefore your immune system are functioning as close to their maximum innate potential as possible.” Obviously with chiropractic care is gentleman’s assertion. “This increases your defenses against outside pathogens, and increases your potential to stay healthy.” I personally believe that, I practice that in my life, but I don’t have the scientific evidence to say that I can demonstrate that in a clinical trial. Again, if you read further on into the discussion, what the requirements are relative to the Federal Trade Commission, you’ll see that’s part of the discussion as well.
My advice, my counsel, my hope, and my prayer is talking about health, general wellbeing. Great. The closer you get to talking about specifics of viral infection, and then most specifically a coronavirus infection, the more you run the risk of getting into difficulty, and problems down the road. Since this has come out on May 7th, there has been activity on the part of the Food and Drug Administration and the Federal Trade Commission together to deal more directly with supplement manufacturers. They have put out cease and desist warnings to a number of manufacturers for their claims associated with their products, and again, this is nothing unique to chiropractors. Of the 45 letters that were sent by the Federal Trade Commission, 44 of them were sent to other providers other than chiropractors, predominantly acupuncturists.
This is an issue that people are using very general concepts to talk about a very specific situation, and they’re using language that’s broader than the reality that they can defend and back up. So, please be careful. Be as positive, be as excited, and as hopeful as you can with your patients. But when it comes to your advertising in particular, you want to be careful that you can defend, and you can document what you’re saying on your website, and in another materials. With that being said, I’ll say thank you for your time today. Hope you’re all well and getting ready for the summer of 20. We’ll all see together how usual, unusual, bizarre, or wonderful it’s going to be. Look forward to it. Thank you again for your support and for your interest, and thanks to ChiroSecure for providing this opportunity to share these thoughts with you. Thank you very much.
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