AAN Calls for End to Choke-, Strangleholds by Police

The American Academy of Neurology (AAN) is calling for an end to chokeholds and strangleholds by law enforcement.

In a newly released position statement, the AAN urges police at federal, state, and local levels to stop the practice and encourages policymakers to classify such neck restraints as “deadly force.”

These findings “clearly indicate that restricting blood flow or oxygen delivery to the brain, even briefly, can cause permanent and profound injury, including stroke, cognitive impairment, and death,” AAN President Orly Avitzur, MD, told Medscape Medical News.

“Neurologists and neuroscience professionals have a responsibility to work toward improving the health of all members of society and to educate the public on how to prevent neurologic injury,” Avitzur added

The statement was published online June 9.

“No Failsafe”

The AAN first considered developing a position statement shortly after the December 2020 publication of an editorial in JAMA Neurology, Avitzur noted.

As reported at the time by Medscape Medical News, the editorialists reviewed carotid artery physiology and the neurologic sequelae resulting from restricting blood flow or oxygen to the brain ― conditions that occur with the neck restraints commonly used in law enforcement.

“The [new] position statement acknowledges that the killing of George Floyd and Eric Garner and other instances in which neck restraints were used in law enforcement had called into question whether neck restraints used in law enforcement are controllable, safe, and nonlethal,” said Avitzur.

“In fact, there is no failsafe for bilateral loss of carotid artery blood flow,” she added. “In as little as 4 seconds, there can be a loss of consciousness. Unconsciousness resulting from these maneuvers is a manifestation of catastrophic global brain dysfunction.”

Prior to its approval by the AAN board of directors, the position statement was reviewed by four AAN committees: Ethics, Law, and Humanities; Advocacy; Science; and the Equity, Diversity, and Inclusion Joint Coordinating Council.

Avitzur noted that the statement “draws on our organization’s aggregate expertise in brain health.”

Entirely Preventable

The statement encompasses chokeholds, defined as “a physical maneuver that restricts an individual’s capacity to breath for the purposes of incapacitation by using pressure on the trachea to restrict oxygen to the brain,” and “vascular neck restraints,” or strangleholds.

The latter is “a technique that can be used to incapacitate individuals by restricting the flow of blood to the brain by using pressure to the carotid arteries.”

Avitzur said the neurologic consequences that result from limiting blood flow or oxygen to the brain because of chokeholds or strangleholds “are potentially irreversible and entirely preventable.”

She also described these techniques as “inherently dangerous” and emphasized that there is “no amount of training or method of application of neck restraints that can mitigate the risk of death or permanent severe damage to the brain.”

In particular, individuals with underlying cardiovascular risk factors are “more vulnerable to suffering significant neurological injury from neck restraint techniques; and the burden of cardiovascular disease in the United States, particularly in communities of color, remains high,” the statement notes.

Accordingly, “the AAN recommends prohibiting the use of neck restraints in law enforcement,” Avitzur said.

The statement “strongly encourages” that at the very least, law enforcement at federal, state, and local levels classify neck restraints as a “form of deadly force,” she reiterated.

Deadly Force

Commenting on the position statement for Medscape Medical News, Bill Smock, MD, a police surgeon at Louisville Metro Police Department, Louisville, Kentucky, said he is “happy that the neurologists are coming on board” with the issue.

“A lot of people don’t recognize that you can have a carotid dissection from a vascular neck restraint. Physiologically, it is strangulation, and there is no difference,” he said.

Smock, who was not involved in developing the position paper, “completely agrees that the application of pressure to the neck is deadly force and the application of pressure in the neck by a police officer should be reserved for a deadly force encounter only.”

In a “deadly force encounter,” the officer must say that his or her life or someone else’s life was in danger, Smock noted.

“Using a neck restraint is synonymous or analogous with pulling your gun and shooting, because a bullet can kill, and so can the application of pressure to your neck,” he said.

The risk associated with vascular neck restraints affects not only the general public but also the officer themselves, according to Smock, who is also the medical director of the Training Institute on Strangulation Prevention.

He noted that he is on a “crusade” to educate police departments across the country to stop training officers in the use of vascular neck restraints because “they are deadly, and the officers themselves are at risk of stroke and death during the training because they practice on each other.”

Stroke Risk

Smock has personally witnessed three cases in which law enforcement trainees who had been subject to neck restraints during training subsequently died.

“The training partner did not even render them unconscious, just applied a little pressure to the side of the neck,” he said. Subsequently, plaque broke off and the trainees suffered a stroke. In two cases, the trainee died immediately; the third stroke occurred a little less than 24 hours after the training.

“Trainees can be shown proper arm position by practicing on mannequins but should never practice on another human being,” said Smock, who is also a clinical professor of forensic medicine at the University of Louisville and was formerly a professor of emergency medicine.

He emphasized that a carotid dissection from a vascular neck restraint can take place days, weeks, or months later.

“Patients who have had neck restraint or have undergone strangulation must have their carotid and vertebral arteries evaluated in the emergency department and undergo a CTA [CT scan with angiography] to make sure there is no tear from the application of pressure to the neck,” Smock recommended.

Avitzur and Smock have reported no relevant financial relationships.

AAN: Position statement. Published online June 9, 2021. Full text

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