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Re: manipulation : does the risk out weighs the benefit ?
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Re: manipulation : does the risk out weighs the benefit ? - September 19, 2003 3:49:00 PM
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Bournephysio
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This is very amusing.
Are you "doctors" telling us that you can't see the weakness in your "supporting" literature.
I would have thought that doctors could critically evaluate literature.
The fact remains, physios are safe and effective manipulators, on par or better than the best chiropractors and a hec of a lot better than the subluxation/prophylactic manip/ak/etc. quacks
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Re: manipulation : does the risk out weighs the benefit ? - September 19, 2003 5:36:00 PM
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Diane
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Ditto Bournephysio.
I noticed on Teston's chiroboard thread, a list of containdications were posted. It didn't include risk factors for carotid dissection, one of which is a fibromuscular condition that predisposes neck arteries to dissection.
At this address you can read all about it. The very first cause listed for carotid dissection is manipulation (as in "chiropractic", I guess they mean the popping kind..)
[URL=http://www.emedicine.com/emerg/topic82.htm]http://www.emedicine.com/emerg/topic82.htm[/URL]
Interestingly, when one searches google for "carotid dissection" + manipulation, the very first site that comes up is chiro site that says, basically, "I looked at a whole bunch of data and it's all confusing, with confounding factors, (like connective tissue diseases) and basically the risk of manipulation causing a carotid dissection isn't high enough to worry about."
So, I'd like to ask the chiros, how do chiros test and eliminate those patients with fibromuscular disease, in order not to manipulate their necks and create a dissection of the carotid artery? I remember discussing with an emergency room nurse once, the incidence of stroke following neck manipulation, and she said that she personally saw about three a year come through. That's just one nurse in one ER in one hospital! The incidence must be huge, actually.
Who is trying to kid who?
A PT(physio), who chooses not to manipulate,
Diane
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Re: manipulation : does the risk out weighs the benefit ? - September 19, 2003 8:18:00 PM
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touchiba
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Neurolog. 2003 Jan;9(1):35-44. Related Articles, Links
Association of internal carotid artery dissection and chiropractic manipulation.
Haneline MT, Croft AC, Frishberg BM.
Spine Research Institute of San Diego, University of California at San Diego School of Medicine, San Diego, California, USA. mhaneline@cox.net
BACKGROUND: To determine the relationship between chiropractic manipulative therapy and internal carotid artery dissection, a MEDLINE literature search was performed for the years 1966 through 2000 using the terms internal carotid dissection. Literature that included information concerning causation of ICAD, as well as all case studies and series, was selected for review. REVIEW SUMMARY: In reviewing the cases of internal carotid dissection potentially related to CMT, there were many confounding factors, such as connective tissue aberrations, underlying arteriopathy, or coexistent infection, that obscured any obvious cause-and-effect relationship. To date there are only 13 reported cases of ICAD temporally related to CMT. Most ICADs seem to occur spontaneously and progress from local symptoms of headache and neck pain to cortical ischemic signs. Approximately one third of the reported cases were manipulated by practitioners other than chiropractic physicians, and because of the differential risk related to major differences in training and practice between practitioners who manipulate the spine, it would be inappropriate to compare adverse outcomes between practitioner groups. CONCLUSIONS: The medical literature does not support a clear causal relationship between CMT and ICAD. Reported cases are exceedingly scarce, and none support clear cause and effect.
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Re: manipulation : does the risk out weighs the benefit ? - September 19, 2003 11:27:00 PM
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goodlooks58
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Speaking about carotid dissection: Did John Ritter go for once-a-month-wellness-manip for neck problems/headaches? Just a thought..
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Re: manipulation : does the risk out weighs the benefit ? - September 20, 2003 12:00:00 AM
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Diane
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I thought it was an aortic dissection that John Ritter died from.
Yes, the abstract posted by Touchiba is the one I saw posted on a chiro website..the conclusion makes it sound like conditions that predispose someone to carotid dissection, like preexisting connective tissue disorders are just confounding data, and aren't the problem of the manipulators. Hmmn.
So I'd still like to know how chiros (OK, PTs too..) detect fibromuscular dysplasia, which surely must be a contra-indication for neck manips. I'm given to think (by the admittedly small and cursory amount of info collection I've done so far on this,) that the only way to determine that someone has this condition is to see the bulges on the vascular structure itself, which look like beads, on some form of imaging, presumably not just simple xray. Are there other ways to screen?
So far, thinking that neck manips at least, aren't worth doing..
Diane
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Re: manipulation : does the risk out weighs the benefit ? - September 20, 2003 8:57:00 AM
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touchiba
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Diane,
Look at it this way, if you have a patient that is taking pain meds consistently about 3-4 days a week because of some sort of neck pain or headaches, and neck manipulation along with exercises and stretching could provide improvement, don't you think it is worth it?
As far as neck manipulation without a neck complaint... Maybe it's really not worht it.
However, for that patient that tends to get neck pain every so often, and they find that getting adjusted every so often keeps it from occurring, is it worth it? Perhaps.
As for the fibromuscular dysplasia, how prevelant is this is the general population? What patient population has the highest incidence of this disease? Do PTs screen for this before doing any kind of cervical mobilization? Hypothetically, a "thrust" is not needed to cause damage to the arterial walls in a person with this disease.
I understand your concern, and quite honestly I thank you for bringing this up. It is something that chiropractors, PTs, and other manual therapists must conisder when treating certain regions. I think your main question is if manipulation is appropriate in the abscence of clinical symptoms. For a person with no head or neck pain, or no other conditions that could possibly relate back to the c-spine biomechanics, or that do not have relapses, then the answer is probably no.
As with any other healthcare procedure, it is risk vs reward while also considering other options and their associated risks.
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Re: manipulation : does the risk out weighs the benefit ? - September 20, 2003 10:00:00 AM
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nrl
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“neck manipulation along with exercises and stretching could provide improvement, don't you think it is worth it?”
NO.
When the risk, even a very slight risk, is a stroke. If you’ll tell your patients the risk of a stroke, as been presented in research, do you think they’ll go for manipulation?
I will not allow anyone, no matter his expertise, to manipulate my neck. even if proven to be much more effective then evidence suggests at this time, risk is simply too severe.
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Re: manipulation : does the risk out weighs the benefit ? - September 20, 2003 10:15:00 AM
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Diane
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Thank you for your reply Touchiba. You said,
"Look at it this way, if you have a patient that is taking pain meds consistently about 3-4 days a week because of some sort of neck pain or headaches, and neck manipulation along with exercises and stretching could provide improvement, don't you think it is worth it?"
I see people like this daily, and they are exactly the people that I suspect having some sort of vascular component to their problem. I treat (I said "treat", not stretch and exercise) soft tissue first (remembering vascular components ARE soft tissue, and are embedded in other soft tissue) and get to joints later, if necessary (most of the time, not even necessary, or easily treated with muscle energy or some other benign form of joint approach.) Joints are at the "bottom", still have to get through all the soft tissue to get to the joints... It might not be faster but I'm convinced it's safer.
I know a lot of people including most PTs aim at treating joints first and expect all soft tissue problems to magically fade away, but I stubbornly think that's just a conceptual construct and not longterm body reality. The tensile force of untreated soft tissue will easily pull joints into dysfunctional positions all over ( and over and over and over) again.
I intend to get all the way through this career with never having caused a stroke in any patient.
Still think risk outweighs benefit,
Diane
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Re: manipulation : does the risk out weighs the benefit ? - September 20, 2003 10:35:00 AM
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Bournephysio
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Back Talk,
As a group our manual therapists are as good or better at the skill of manipulation than chiropractors. Our best manipulators are as good or better than your BEST manipulators. One of my instructors has been asked several times to teach his techniques to chiropractors.
Our advantage over the quacks is not the skill of manipulation, but the decision to manipulate or not and the choice of techniques. Whether you like it or not there are many chiropractors who still use questionable techniques. A recent tv show on stroke and chiropractic showed two memorial (Canada) instructors showing cervical manipulations. One did a perfectly reasonable technique, the other used excessive rotation and amplitude. If you can't do diffential diagnosis how can you manipulate safely?
Our advantage over most chiropractors is that we view manipulation as a small part of treatment not THE treatment.
There are diminishing returns to practice. I am still a very good manipulator even though I currently practice very little (You'll know I'm back at school if you follow this board)
Either way, you've admitted that trained physios are safe and effective, which is good enough for me. I'm a physio because I believe in our training, knowledge and treatment philosophy. I assume your a chiro for the same reasons. I expect us to disagree and healthy competition is good. The teritorial crap between our professions isn't.
Now back to my thesis...
Doug
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Re: manipulation : does the risk out weighs the benefit ? - September 20, 2003 2:08:00 PM
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touchiba
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Diane,
I guess we will have to just disagree on this one.
If I assume correctly, you might place some other healthcare procedures in the same category. For example, carpal tunnel surgeries, back surgery, cosmetic surgery(basically any type of non-emergency or life saving type of surgery), some vaccines(flu, chickenpox, measle, etc.), and others.
I'm not saying there is anything wrong with all of the above procedures because just like with manipulation, when clinically indicated the benefits far outweigh the relatively slight risk(some have more risks than other, of course).
By the way, your point is well taken that joints can not be treated without address the musculature. Most chiropractors(other than the extreme straights) would have no problem with that idea.
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Re: manipulation : does the risk out weighs the benefit ? - September 20, 2003 2:30:00 PM
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touchiba
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nrl,
What does the literature say exactly about the risk of stroke caused by manipulation when performed correctly? The literature is lacking in this area, so it makes it hard to draw rock solid conclusions about this subject.
For example, we don't know if there is an increased risk in people who have manipulation performed on them. Perhaps they were already experiencing a dissection that caused neck pain, which caused them to seek treatment. Perhaps these people could have been one of those who would have had a spontaneous artery dissection regardless. Maybe there was an underlying disease process weakening the arterial wall. Maybe in cases where manipulation was the cause of dissection of a healthy arterial wall, the chiro used improper technique. Maybe they did not consider risk factors(meds, lifestyle, etc.).
All of the above factors have not been considered in the studies I've seen. Basically, if someone strokes out within a month or so of seeing the chiro, well, it must have been the chiro's fault.
Would patients still accept treatment if they were told there was the risk of stroke. Well, at some of our schools, patients must be made aware of the risks and they sign an informed consent form. Do some refuse treatment, maybe, but most accept it.
Also, I'm confused as to why you wouldn't be comfortable with being manipulated, unless it is purely fear on your part. You know the anatomy and if you know the basic mechanics of a manipulation you can see that nothing moves outside of the normal range of motion. Motion is coupled and/or enough velocity is used to cavitate joints well away from end range of passive movement.
I have a feeling we will have to agee to disagree. Thanks for the discussion.
And one tip, dont turn your head to look when backing out of a driveway, use the mirrros(or you might dissect an artery) : )
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Re: manipulation : does the risk out weighs the benefit ? - September 20, 2003 3:16:00 PM
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Sam B
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I agree with you Touchiba, regarding the incident occurrence being very low. I think Backtalk had said in another post that the statistic was one in 300,000. I think I have heard that statistic somewhere also and would agree ( I beleive that was a discussion comparing NSAID complication rates and manipulation)
Relative risks depend on practitoner skill, not just with the technique velocity, amplitude and force, but also the discretion of the use of a technique and its relative contraindications. When I was doing my doctoral degree ( 4 years manual therapy training post-graduate), we did a search on vertebral artery accidents. Most of the accidents were from C1-2 level techniques and a higher use of rotatory techniques. The most common age for VB accident was was males in their mid 40's. Often patients upon autopsy had underlying problems that could never have been detected in an exam. One M.D in Sweden instantly killed a patient with an anomalous vertebral artery that exited the foramen at C4 and re-entered at C2. How could anyone find that if the patient was asymptomatic on testing, which he was?
When I read the literature on the subject, even though the risk is relatively low, it does make me realize what a tremendous responsibility we have to be respectful of what we are doing with our hands.
I believe most manual therapy techniques in physiotherapy are a combination of osteopathic technique and new techniques created within the profession. The term Orthopaedic Manual Physical Therapy is used to formalize the name of manual therapy as used by a physiotherapist/ PT.
Post graduate residencies in manual therapy are accredited through the APTA and a list of accredited ones can be found at AAOMPT.org ( American Academy of Orthopedic Manual Physical Therapists) Most PT's are not taught manipulation of the spine until after 2 years of study, or until they have shown competency in peripheral techniques.
I have some very good friends who are chiropractors and I can tell you that we both teach other a thing or two and we have a healthy repect for each other. The use of 6 dimensional locking techniques is something created within physiotherapy that is far more advanced than some of our predecessors. Those, who like myself have done 4 years of manual therapy training through an accredited school and passed the rigors of those very high standards can become fellows within the AAOMPT. But, like any clinician, standards vary among individuals and fellowship is just a formalization or documentation of reaching a required skill as defined by set standards within a profession.
I believe that competence defines referral patterns "most" of the time ( along with insurance plans) Turf wars are just political and created out of fear of the future. Chiropractors that continue to practice evidence based medicine and expand treatment beyonds hand on care will always have a job, just as competent PT's will. We just can't all keep hailing manipulation as some magic bullet, as the evidence will not ( and does not) support its use in chronic patients.
Sincerely,
Sam
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Re: manipulation : does the risk out weighs the benefit ? - September 21, 2003 8:17:00 AM
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Diane
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Me again. [URL=http://www.emedicine.com/radio/topic280.htm]http://www.emedicine.com/radio/topic280.htm[/URL]
I decided to come back on the board with this link to an article re: fibomuscular dysplasia, one of the predisposing conditions that can lead to carotid artery dissection.
What struck me was the incidence of this condition in the general population, about 0.6%, and at autopsy 1.1% (whatever that might mean. Sounds slightly sinister to me..)
The problem concerns a defect of tissue in arterial walls, most often the renal arteries and next often the carotids; sort of like the genetic equivalent of bad tires, the layers separate with shearing forces. Blood will enter between layers, balloon them out or burst the walls. Or a thrombus (blood clot) which has formed to try to heal an inner lining of an artery, lets go and travels to the brain, lodges there and causes death of neurologic tissue, which is a stroke, plain and simple.
Vascular tissue in general seems to present with a lot of general sorts of problems, malformations, variations in its strength and long term reliability. Why? It seems to be a weak link.
Embryologically the vascular system has to be very adaptable. The body seems to make arteries and veins out of secondhand stuff a lot of the time, leftovers..whatever's handy after the fact, anything to get O2 to a rapidly expanding cell mass. Mesoderm is very obedient about making sure there is a blood supply everywhere..
Mesoderm is notable for being idiosyncratic and creative in lots of other ways too, odd hookups for muscles and ligaments, lots of variation in tissue quality..lots of kinds of fascial thicknesses, not every kind supremely functional.. people vary. Evolution couldn't care less as long as a given individual lives long enough to reproduce. As far as mesoderm is concerned, evolution seems to use the equivalent of baling twine and chewing gum to hold the body and bits of the body together in many cases.
In the carotid arteries, natually, the likelihood of a stroke is quite high. An incidence of 0.6% means that 60 out of every 1000 patients that enter the office have this predisposition.
The ratio of females to males that have it is 3:1. Isn't that about the same gender ratio of people with chonic neck/shoulder/headache pain?
As for not linking stroke to neck manipulation, it seems to me that this is simple denial more than anything. The ER nurses know, the neurologists know, the patients know. Because a stroke sometimes doesn't occur right away, (because often the body has tried to heal with a thrombus, which is oftem the actual cause of the stroke..) or a stroke usually isn't dxed until some time after the causitive factor, hours or days or even longer, it can't be specifically linked to that last neck twist that was delivered by the friendly and genuinely trying-to-be-helpful chiro. In some cases, many, someone may have been receiving neck manipulation for years with no problem, and then one day, boom. Accumulative injury plus aging body plus weakening tissue.
I just can't see the point of manipulating necks at all. Treating them yes, absolutely. Gently. Using the huge amount of reflex sensitivity that exists there. Not a HVLA of any sort. Elsewhere in the spine is probably OK, but the neck? Like kicking a highly sensitive appliance, e.g., a computer, to try to get it to work better. Somewhat overwhelming and undernecessary, given the sensitive structures that all lie very close to the upper cervical spine, so responsive to soft tissue/skin contact. Including a patch of tissue by the external ear that directly has cutaneous vagal innervation.
Nirit, you can still count me out as a neck HVLA manipulator.
Diane
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Re: manipulation : does the risk out weighs the benefit ? - September 21, 2003 9:58:00 AM
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touchiba
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Some of your points are well taken, Diane.
The only thing I have left to say is that cervical manipulation isn't forceful if done correctly, and also if done correctly, comes nowhere near to the end range of normal ranges of motion. For some people it may require a little bit more of a thrust, but that's when we have to step back and think if it's worth it. As for PTs/DOs/DCs that use too much force and improper technique, no I wouldn't want them to touch my cervicals either.
You seem to question the clinical effectiveness of cervical manipulation(a valid one). For the practioner(PT/DC/DO) that uses this type of therapy, it's not so much of a risk compared to the benefits. Remember, evidence based medicine is using clinical experience and expertise while taking into consideration the most current scientific literature. It's not doing only what the scientific literature has substantially proven to be fact. Also, one has to consider the value of a study and the ability to clinically correlate that to everyday practice. I mention that because people seem to throw evidence on the table and say if it's not in the literature or a few studies say one thing, then they think it must be true and anyone not following it is a quack. Someone here posted that manip was found by some studies not to be good for acute or chronic condition or whatever. Then they take that along with the slight risk and look at it like "Ok, no benefit, some risk.... no way it should be done."
My point is, it's a lot more complex than some make it sound. It's academically dishonest to lay a blanket statement out there like "No one should ever get their neck manipulated", just as its equally academically dishonest to say, "There is absolutely no risk to cervical manipulation."
On a personal level, no problem. That's up to individual choice. However, it becomes problematice to present these views as an absolute to people who could benefit from such treatment.
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Re: manipulation : does the risk out weighs the benefit ? - September 21, 2003 1:04:00 PM
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nrl
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From: israel
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Touchiba,
“Performed correctly” – this might be said about any technique that’s being investigated. You can always say doubt any research on the basis of that.
“Why you wouldn't be comfortable with being manipulated” I’d rather have a stiff /painful neck/headache for a few days longer than take the slightest chance of a severe injury. Personal choice. Nothing else.
“Don’t turn your head to look when backing out of a driveway, use the mirrors “. I always use the mirrors. Don’t need to turn my head since I’m a living proof to the non-controversial fact that women are better drivers.
(Diane & Coloradojulie, I think I’ll need your support here).
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Re: manipulation : does the risk out weighs the benefit ? - September 21, 2003 5:02:00 PM
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Diane
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Nirit, you have my support. And those of us who turn our heads and extend them fully every day should retain that capacity into old age, I should think.. And use the car mirrors as well..
There is a whole group of eye exercises that work well for facilitating upper neck motion, leading with the non-dominant eye to stir up cortical representation, and keeping the eyes closed to better sense the motion.
BackTalk wondered:
"Is a physiotherapist the same thing as a physical therapist? Is
there a difference between the two? It seems the profession outside of the states goes by
physiotherapist and those within the states go by physical therapist. Why is that?"
Backtalk, physiotherapist = physical therapist. I don't know why American PTs chose to Anglicize the word. I think it works just fine as a Latin word. But it means the same thing in any country.
Diane (Canadian, therefore a physiotherapist)
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Re: manipulation : does the risk out weighs the benefit ? - September 22, 2003 10:28:00 AM
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OAK
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Dear nrl,
Just to throw in my $0.02. You mentioned a few times how you won't have your neck manipulated because the risk of a serious injury is too high (a reasonable statement). However in your last post you discussed driving your vehicle. Now given that the chance of getting a serious injury from an MVA is 100 times more likely than from a cervical manipulation why do you still drive?
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Re: manipulation : does the risk out weighs the benefit ? - September 22, 2003 12:00:00 PM
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Scanner
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[QUOTE]As for not linking stroke to neck manipulation, it seems to me that this is simple denial more than anything. The ER nurses know, the neurologists know, the patients know. Because a stroke sometimes doesn't occur right away, (because often the body has tried to heal with a thrombus, which is oftem the actual cause of the stroke..) or a stroke usually isn't dxed until some time after the causitive factor, hours or days or even longer, it can't be specifically linked to that last neck twist that was delivered by the friendly and genuinely trying-to-be-helpful chiro. In some cases, many, someone may have been receiving neck manipulation for years with no problem, and then one day, boom. Accumulative injury plus aging body plus weakening tissue.
[/QUOTE]
Actually, this is just a case of competitive, wishful thinking on the part of neurologists and ER nurses - a search to explain the unexplained.
I am sure eating Ho-ho's and Sour Cream n' Onion chips with smoking and taking HRT had nothing to do with Mary getting a stroke. It was the chiropractor, lol.
Do this experiment:
Ask your next 50 patients if they have had an immunization shot lately? If they say yes, then ask if they had flu-like symptoms following the shot in 3 days? If they say yes, declare:
"Golly, gee, those immunizations probably gave you the flu."
Really, it's a nice little seeds-of-doubt planting the local ER's are doing just like some chuckleheaded DC's do with immunization.
But then again, if someone comes in with severe flu-like symptoms, I'll lay $50 the ER doc doesn't ask with serious Marcus Welby like tone:
"Mary, have YOU had one of those immunizations in the last 3 days?"
The truth is there are risks to getting immunized - death - about the same as getting your c-spine manipulated. You may counter with, "Well, a little neck pain ain't no big deal - dying from pertussis is" (risk/benefit ratio)
Tell that to my patient Ann Mary who couldn't ride a rollercoaster with her kids for fear of precipitating a headache that would last for days before receiving chiropractic care.
The ER nurse who saw 3 patients/year from a chiropractic stroke - I have never known any colleague of mine to have a CVA case. I'm sure it happens but it's rare.
My patients know it. I know it.
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