Bizarre Therapy Leads to Patient's Death

Stephen Barrett, M.D.

In 2003, Joanne M. Gallagher, D.C., who practiced for close to 20 years in Hazleton, Pennsylvania, pled guilty to one count of mail fraud. In 2004, she was sentenced to prison. The case arose following the death in 1999 of 30-year-old Kimberly Lee Strohecker, who had consulted Gallagher about epileptic seizures. Gallagher persuaded Strohecker to stop taking the anticonvulsive medication prescribed by her neurologist and, as a result, Strohecker's condition deteriorated and she died from multiple seizures and complications [1]. This article describes what happened and the extent to which the circumstances reflect what other chiropractors do.

Gallagher's Background and "Philosophy"

Joanne Gallagher, 43, is one of two chiropractors who operated the Life Expression Chiropractic Center. The center's Web site stated that she graduated in the top ten from Bishop Hafey High School in Hazleton, Pennsylvania in 1977, completed pre-chiropractic studies at Bloomsburg University, and graduated summa cum laude from Sherman College of Straight Chiropractic in 1982. Licensed in Pennsylvania in 1983, she practiced at the Degenhart Chiropractic Health Clinic in Hazleton until she and a colleague moved their practice to a new building in Sugarloaf, Pennsylvania. While at Sherman, she received the "B.J. Palmer Philosophy Award" for "dedication to chiropractic philosophy." [2] Before her trouble occurred, she and her colleague were members of Sherman's "Board of Regents," a group of approximately 175 chiropractors and chiropractic advocates who gave at least $750 per year to the school.

Gallagher's philosophy is similar to that of chiropractic's founders. Her Web site stated:

Chiropractic is a primary contact healing art established in 1895. As a healing art, it is comprised of a philosophy, science and art. The philosophy of chiropractic is based on vitalism. This philosophy teaches that within all of life there is a vital energy that organizes, controls and expresses organization. There is an inherent power of organization within life designed to express optimal integrity. There is an inherent healing power within each cell of the human body. The organization within the body is designed to adapt and heal at optimal potential possible.

The science of chiropractic is based on the science of the nerve system. The human nerve system controls, co-ordinates and adapts all the systems and healing itself. It is vitally important that there is no interference to this governing system for best function of the body and best healing of each organ and system within the body. The nerve system is structurally protected by the skull and spine. Traumas or injuries sustained in life can cause insult to the spine causing misalignments of the joints to occur. This insult is called a vertebral subluxation. Vertebral subluxations cause interference to the neurological function of the body.

The art of chiropractic is the corrective adjustment employed to correct vertebral subluxations of the spine which interfere with the function of the nerve system. A chiropractic adjustment is a gentle, manual correction done by hand to allow correction of the vertebral subluxations. Once corrected, the nerve system is best able to adapt and heal and maintain proper function.

As Chiropractors, we do not diagnose or treat disease. Chiropractic is a unique healing art in that our objective is to locate, analyze and correct vertebral subluxations. This allows restoration of optimal neurological function and proper spinal biomechanics of the human frame. It is our global vision that each child be balanced with chiropractic throughout a lifetime so that they can express optimal function of design [3].

Practitioners who communicate this way typically suggest that patients see them periodically for life so their "subluxations" can be detected and "adjusted" with spinal manipulation. But Gallagher promised more:

In the last ten years, we have gone into a post-graduate adjustment involving correction and balance of the meninges. The meninges are three structural membranes that sheath the brain and spinal cord underneath the skull and spine. The meninges also sheath each cranial and spinal nerve root and also scaffold into the center of the brain. They protect the brain and spinal cord from outside and inside compression. Correction of the meninges complements and stabilizes the spinal adjustment and allows more optimal balance to occur to the brain and spinal cord. It is a gentle, non-force correction along the skull and spine. The correction allows structural balance of the spine and meninges for optimal function of the nerve system needed for optimal healing. Our objective is that you achieve and maintain neurological integrity throughout your lifetime [4].

The phrase "correction of the meninges" refers to concepts of "craniosacral therapy" (also called cranial therapy) advocated by the late John E. Upledger, D.O., who headed the Upledger Institute in Palm Beach Gardens, Florida. The meninges are the membranes that sheath the brain and spinal cord. Cranial therapy advocates claim that many ailments are caused by blockages in the flow of cerebrospinal fluid (the fluid that surrounds the brain and spinal cord) and that such blockages can be detected and relieved by pressing lightly on the skull. According to Upledger, "Using a soft touch generally . . . about the weight of a nickel, practitioners release restrictions in the craniosacral system to improve the functioning of the central nervous system." [5] Upledger also claims to be able to communicate with the patient's "inner physician." Chapter 2 of his book, CranioSacral Therapy: Touchstone of Natural Healing describes how he asked questions aloud and believes that he can determine "yes/no" answers by feeling a "cranial pulse" with his fingertips [6].

The theory underlying craniosacral therapy is erroneous because the sphenoid and occipital bones (important for "cranial" practitioners) fuse by the end of adolescence, many other skull bones begin to fuse by age 25 or 30, and no scientific research has demonstrated convincingly that manual manipulation can move the individual bones of an adult human skull or that lightly touching the head has any therapeutic value [7]. Nor is there any credible evidence that "the rhythms of the craniosacral system can be felt as clearly as the rhythms of the cardiovascular and respiratory systems," as an Upledger Institute brochure claims [8]. In short, the theory and practice of cranial therapy and "correction of the meninges" have no basis in reality [9,10].

Fatal Advice

Strohecker saw Gallagher for about 40 visits between October 1998 and April 1999. During this time, Gallagher repeatedly advised Strohecker to stop taking her anticonvulsive medication. Gallagher also assured Strohecker that once she did this, she would experience approximately three days of seizures, would fall into a deep sleep, and would wake up healed of her seizure disorder. When Strohecker stopped her medicine, she began to experience frequent seizures, including one in Gallagher's office. Strohecker became unable to walk, severely dehydrated, and, shortly before her death, unconscious [1:7]. The autopsy report states that during her final days, friends watched her laying on a mattress on the floor, wearing disposable diapers, with a suction apparatus nearby [11].

Between April 26 and April 29, 1999, Gallagher reassured others that the seizures were "normal" and "supposed to happen" and that Strohecker was merely getting the drugs out of her system. Gallagher warned Strohecker's fiancé that if Strohecker were taken to the hospital, she would be given anticonvulsant drugs that could kill her. On April 29, at a local hospital, Strohecker was pronounced dead as a result of uncontrolled epilepsy combined with dehydration and pneumonia caused by stomach contents sucked into her lungs during a seizure [1:8,11]. Her survivors filed a "wrongful death" malpractice suit and reportedly collected $500,000 in an out-of-court settlement [12].

The Criminal Charges

According to the indictment, Gallagher submitted claim forms to Medicaid that falsely described Strohecker's treatment as spinal manipulation for the treatment of neck pain, shoulder neuritis, and five other neck and shoulder diagnoses [1:12]. Pennsylvania's Medicaid covers evaluations and treatment by manual manipulation of the spine to adjust misaligned or displaced vertebra. It does not cover cranial therapy or the treatment of diseases such as epilepsy. Strohecker's actual treatment was also outside the legal scope of chiropractic, which the pertinent part of Pennsylvania law defines as:

A branch of the healing arts dealing with the relationship between the articulations of the vertebral column, as well as other articulations, and the neuro-musculo-skeletal system and the role of these relationships in the restoration and maintenance of health. The term shall include systems of locating misaligned or displaced vertebrae of the human spine and other articulations; the examination preparatory to the adjustment or manipulation of such misaligned or displaced vertebrae and other articulations; the adjustment or manipulation of such misaligned or displaced vertebrae and other articulations; the furnishing of necessary patient care for the restoration and maintenance of health; and the use of board-approved scientific instruments of analysis, including X-ray . . . . [13]

The Pennsylvania Chiropractic Practice Act also requires chiropractors to refer patients to other licensed practitioners for consultation or treatment when their diagnosis indicates that such a referral is needed [14]. The indictment states that Gallagher never manipulated Strohecker's neck but billed Medicaid for spinal manipulation for "cervical subluxation" and then billed a second time for the same services after Strohecker died [1:9].

Gallagher got into additional difficulty in connection with a 5-year-old girl with Down's syndrome. According the the indictment, Gallagher told the child's mother that the treatments would increase the child's intelligence, make her appearance more normal, and cause her "slanted eyes" to "fade away." [1:12] However, there is no scientific evidence that cranial therapy or anything else that chiropractors do can improve the intelligence or appearance of Down syndrome patients. The treatment of epilepsy by chiropractors is not permitted under Pennsylvania law or covered by Medicaid. But, as with Strohecker, Gallagher billed Medicaid for services that she had not performed [1:9]. The child's mother told an investigator that despite the billing, she had paid cash for the treatment [15].

The indictment charged Gallagher with one count of health-care fraud, one count of making false statements, and seven counts of mail fraud. The maximum penalty for health care fraud involving the death of a patient is life imprisonment and a $250,000 fine.

Tedd Koren's Report

In March 2003, Tedd Koren, D.C., whom Gallagher retained as an expert witness, claimed in a report that she "had practiced within the accepted standards of the state of Pennsylvania" and had "limited her care to the location and correction of vertebral subluxations." Koren also suggested that part of her legal difficulty was semantic:

Traditional chiropractic, which Drs. Gallagher and [her associate] practice, does not medically diagnose or treat any condition or disease. Instead it is limited to the analysis and adjustment (correction) of vertebral subluxations. From that perspective neither doctor would claim to practice medicine nor diagnose nor treat medical conditions such as epilepsy.

However, legal or medical terminology often uses the term "medicine" and "diagnosis" in a generic sense to mean medicine or anything done to care for patients and diagnosis is any procedure that doctors use to determine care. . . .

So if a chiropractor is asked "Do you treat epilepsy" and answers "no." That doesn't mean she or he doesn't "treat" epilepsy in a generic sense, it only means they don't medically teat a person with epilepsy. They may "treat," that is, care for a patient who has been medically diagnosed with epilepsy. But they are "treating" or adjusting their vertebral subluxations. . . .

The question arises whether chiropractors can care for ("treat") patients with epilepsy or seizures. Since the founding of chiropractic as a separate profession in 1895 and to the present time epileptics have seen chiropractors for care and have been helped. The chiropractic literature cites many such cases of epilepsy responding to care. . . . [16]

In response to a prosecution expert's report that "touching the head could not affect any misaligned or displaced vertebra," Koren said:

This statement is incredible in that it is at variance with what is known about human anatomy and physiology and hundreds of years of clinical observation in their fields of medicine, chiropractic, and osteopathy.

The head (skull) and spine are connected; the occipital bone of the skull articulates (joins) with the atlas (C-1) vertebrae. Morphologically, the occipital bone appears as a modified vertebrae. Some may argue that it is part of the spine. . . .

Any adjustment or structural work to the cranial or occipital bone must affect the atlas vertebra, since they articulate.

Further, extensive research and clinical experience reveals that upper cervical (atlas) subluxations may affect the entire spine. . . .

In fact . . . . the entire spinal column may be affected by a single upper cervical adjustment [16].

In other words, the skull bone is connected to the uppermost neck bone, which is connected to the rest of the spine, so that lightly touching the head can work wonders throughout the body. Koren also stated that various "low force" and/or "nonforce" techniques are taught at at least four chiropractic colleges (Life, Palmer, Parker, and Sherman) and in courses given by "independent researchers," one of whom (Jay Holder) has taught "meningeal chiropractic technique" to about 10,000 chiropractors.

The Legal Proceedings

Before her trial began, Gallagher asked former patients to write supportive letters to the trial judge and later reported that over 600 of them had done so. The trial started on June 20. In his opening comments, her attorney claimed that Gallagher had not told Strohecker to stop her medications—that the idea had come from Strohecker's fiancé, Troy Shade, who accompanied her to Gallagher' office. The lawyer also told the jury that Gallagher had administered spinal manipulations using a "low force" technique that was reimbursable by Medicaid. However, during the weekend, the prosecutors discovered that shortly before Strohecker died, Shade's mother had taped a telephone conversation in which Gallagher repeated the bad advice described in the indictment. The tape also revealed that Gallagher did not seem alarmed by the fact that the seizures were occurring every 10-15 minutes [17].

On June 23, the prosecutors played the tape for the defense attorney and the judge, both of whom were shocked by what they heard. Since the defense attorney had been unaware of the tape's existence, Gallagher was entitled to a new trial. The judge ended the trial, but he also advised the defense attorney to attempt to settle the case. After Gallagher and her husband heard the tape, Gallagher signed an agreement under which:

In March 2004, despite a letter-writing campaign that generated at least 600 letters, Gallagher was fined $9,100 and sentenced to 18 months in prison followed by 2 years of probation. The Harrisburg Patriot reported that the sentence was announced in a courtroom packed by nearly 200 people whom she led in prayer [19]. Soon afterward, Gallagher asked patients and supporters to urge U.S. Senator Arlen Spector and Representative Patrick Toomey to try to influence the judge to substitute a "creative service and probation." Gallagher's request was accompanied by a model letter which claimed that "even though she knew she had not committed fraud, she did this to avoid more serious problems due to the prosecution's late introduction of the controversial taped call."

In August 2004, while in prison, Gallagher wrote a letter to former patients, which stated (in part):

I have an urgent request for your assistance. I ask that you write and mail a letter to each of the eight members of the Chiropractic Board of Examiners. Write of your chiropractic experience. Express the value of your chiropractic adjustment for optimal function of the nerve system important for optimal healing. Speak of your sincere desire that each board member vote with an honest and true judgment regarding my chiropractic license.

Despite this, in March 2005, the chiropractic board revoked her license "based upon her criminal convictions and for displaying gross incompetence, negligence or misconduct in the profession, committing unprofessional conduct and failing to refer a patient." She was released from prison in July 2005. A few months later, she enrolled in a 730-hour course in massage therapy at the Fortis Institute, in Scranton, Pennsylvania, from which she graduated in May 2006. Then, because craniosacral therapy (CST) is considered a modality in the massage therapy profession, she began doing it at the Life Expression Wellness Center, in association with her former partner, another chiropractor two massage therapists, and an acupuncturist. Gallagher said that (a) she treated about 1,500 people, (b) about half of were former patients of her chiropractic practice, and (c) she stopped practicing in Pennsylvania on December 31, 2012, but subsequently practiced in West Virginia, New Jersey, Indiana, Texas and Illinois.

Pennsylvania's massage therapy law was enacted in October 2008 and took effect January 1, 2011. In January 2012 Gallagher obtained permission from the U.S. District court to apply for a Pennsylvania massage license and did so. When her application was denied, she appealed and requested a full hearing by the board. In December 2012, the board again denied her application in a 55-page order that minced no words [20]. Among other things, the board concluded:

Put another way, the massage therapy board did not want to proide Gallagher with a license that would enable her to administer treatment similar to what got her into trouble years ago.

How Typical Is This Case?

What does this case imply? Do many chiropractors use cranial therapy? Do many chiropractors claim to treat serious diseases? Do many chiropractors advise patients to stop their medication? Would many chiropractors fail to recognize when a patient is in extreme danger? Here's what I believe:

In a given case, the degree of danger depends upon the nature of the problem and the beliefs of the patient and chiropractor. Most people whose medical treatment keeps them alive are not prone to regard chiropractic treatment as an "alternative." Most chiropractors, even though they may suggest that their treatment can help, are smart enough not to tell epileptics (and severe diabetics) to stop their medication. These factors probably combine to keep the number of deaths from chiropractic mismanagement fairly low. However, as this case illustrates, the combination of a naive patient, a disease that requires medical care, and a practitioner who knows few limitations can be deadly.

References

  1. Superseding indictment. United States of America v. Joanne M. Gallagher. In the U.S. District Court for the Middle District of Pennsylvania, Criminal No. 1:CR-02-253, filed Feb 26, 2003.
  2. About Dr. Joanne. Life Expression Chiropractic Center Web site, accessed July 2, 2003.
  3. About chiropractic. Life Expression Chiropractic Center Web site, accessed July 2, 2003.
  4. About our practice. Life Expression Chiropractic Center Web site, accessed July 2, 2003.
  5. Upledger JE. CranioSacral Therapy: Touchstone of Natural Healing. Berkeley, California: North Atlantic Books, 1999, p 51-58.
  6. CranioSacral Therapy. Upledger Institute Web site, accessed Aug 15, 2001.
  7. Hartman SE, Norton JM. Interexaminer reliability and cranial osteopathy. Scientific Review of Alternative Medicine 6(1):23-34, 2002.
  8. Workshop catalog, Upledger Institute, 1995.
  9. Barrett S. Cranial therapy. Quackwatch, revised March 26, 2003.
  10. Hall HA. Wired to the kitchen sink: Studying weird things for fun and profit. Skeptical Inquirer 26(1):46, 2003.
  11. Binde RP. Autopsy findings, Kimberly Lee Strohecker, April 29, 1999.
  12. Mocarsky S. Massage license is denied: Decision from March upheld. Times-Leader, December 13, 2012.
  13. Pa. Chiropractic Act, 63 P.S. Section 625.102
  14. Pa. Chiropractic Act, 63 P.S. Section 625.506 (a) (19).
  15. Riley JW. Sunday R. Report of interview with Dorothy Briggs, Dec 19, 2002.
  16. Koren T. Report to Attorney Matthew R. Gover, March 7, 2003.
  17. Shade/Gallagher telephone call. Transcript, release by U.S. Attorney's office.
  18. Plea agreement. United States of America v. Joanne M. Gallagher. In the U.S. District Court for the Middle District of Pennsylvania, Criminal No. 1:CR-02-253, July 1, 2003.
  19. Shellem P. Charismatic chiropractor gets 1 1/2 years. Harrisburg Patriot News, March 9, 2004.
  20. Adjudication and order. In the matter of the application for licensure as a massage therapist of Joanne M. Gallagher. Docker No 0585-72-12, Dec 11, 2012.
  21. Association of Chiropractic Colleges. A position paper on chiropractic. Journal of Musculoskeletal and Physiological Therapeutics 19:634-637, 1996.
  22. Barrett S. Improper claims on chiropractic college Web sites. Chirobase, March 4, 2004.
  23. McDonald W. and others. How Chiropractors Think and Practice: The Survey of North American Chiropractors. Ada, Ohio: Institute for Social Research, 2003.
  24. Christenson MG and others. Job Analysis of Chiropractic: A Project Report, Survey Analysis, and Summary of the Practice of Chiropractic within the United States. Greeley, CO: National Board of Chiropractic Examiners, 2000.

This article was revised on December 13, 2012.

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