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Re: Petition to stop neck manipulation
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Re: Petition to stop neck manipulation - August 22, 2005 12:23:00 PM
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Diane
Posts: 1480
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From: Vancouver, B.C., Canada
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Sebastian, thank you.
Wagner, you are totally off topic. Stop, focus, and try again some other day (maybe catch some sleep first.)
Jeff;
[QUOTE]Sebastian,
Regarding your comment: "Diane is to my knowledge, anti-fraud and quackery, wherever it is practiced - including PT."
While Diane may have good intentions, her lack of knowledge on this particular subject makes her a poor candidate to become a "crusader" against neck manipulat...(etc.)[/QUOTE]and..
[QUOTE]Despite my inherent bias, I do believe that it possible to take an objective stance on this issue. Unfortunately, I do not see this demonstrated by the originator of this post or by the webpage displaying the petition.[/QUOTE]Just can't let go of personally ad hominenizing me, can you?
Really Jeff, get a grip. The originator of the webpage had a stroke for pete's sake.. there's no reason to suspect any funny business here except on the part of the practitioner or barber that presumably gave it to him!
IMHO I think the guy has the right to be subjective about this. As a therapist, there are some things I have a right to be subjective about, and minimizing practitioner harm to patients, especially through any sort of reduction or warning of possible harm that may/could come of it, is a bandwagon I'll leap onto in a flash, especially since neck manipulation is so unnecessary, and does nothing to reduce pain, which is usually the main complaint (see Bogduk.)
Finally I would like to point out the irony inherent in the fact that you call me subjective among other things (as if subjectivity was always something bad) while you are;
1. very subjectively defending something as ultimately non-essential as neck manipulation (see Bogduk)
2. very subjectively taking offence to anything and everything I say and have ever said
3. very obtusely refusing to understand how something as simple as muscle energy technique might work (from endless old round and round conversations that grew very boring.)
I suppose I must seem some sort of threat to you (yeah right, as if..) that you find yourself resorting so consistantly to personal innuendo and open adhomeninosis. Please get over yourself and stop it from now on. Thank you.
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Re: Petition to stop neck manipulation - August 22, 2005 12:36:00 PM
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UTDC
Posts: 221
Joined: December 21, 2003
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Dr. Wagner,
I have not seen it happen personally, however I was a consultant on a malpractice case in which a chiropractor allegedly caused a pneumo with a needle through the posterior thorax. I also have a physician friend who states that he has seen it happen a couple of times. There are a few reported cases in the literature. There is the belief in acupuncture circles that the needles are so thin that this is not possible, however I would disagree.
Jeff
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Re: Petition to stop neck manipulation - August 22, 2005 1:32:00 PM
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nari
Posts: 1568
Joined: November 14, 2003
From: Australia
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This thread has a subtitle:
Shoot the messenger.
Why? I find this rather odd....
Nari
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Re: Petition to stop neck manipulation - August 22, 2005 1:46:00 PM
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Jon Newman
Posts: 1690
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From: Amherst, WI
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On the humorous side, the "ads by gooooogle" advert at the top of the petition reads "Find a chiropractor--over 1000 listings of back pain specialists across the country".
jon
_____________________________
[URL=http://www.sonymusic.com/clips/selection/30/064887/064887_03_03_30.wav]Evidence[/URL]
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Re: Petition to stop neck manipulation - August 22, 2005 3:34:00 PM
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karmzack
Posts: 181
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From: Hawaii
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Jon, that's pretty funny. The topic may be important, but the petition is not a serious call for action. Read some of the signers comments, some are sad, but some folks are really clueless.
_____________________________
Zack Solomon MPT, OCS, CSCS
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Re: Petition to stop neck manipulation - August 22, 2005 4:17:00 PM
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UTDC
Posts: 221
Joined: December 21, 2003
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Hi Diane,
Sorry if I've upset you. My statement was not an Ad Hom, however I was under the impression that you admitted your lack of knowledge on the subject. I did accuse you of not being objective, but I'm not sure this qualifies as an ad hom, does it? I guess some are more thin skinned than others (oops did I just do it again?).
Seriously though, I don't have a problem with your views, I even recognized some of the names on that petition who happen to be people I have respect for. I do have a problem with this petition as an attempt to influence the way that healthcare is delivered to the patient (no matter how silly it is). I also have a problem with your repeated slams of manipulation while at the same time recommending treatment that is anything but mainstream. I mean honestly, craniosacral, muscle energy, etc are a bit whoo whoo. "Alternative physical therapy" come on now. I would have to say that if we are going to talk about the literature, manipulation has more behind it than your approach- no?.....Which leads us to our friend Nikoli. I agree that he does not feel manipulation to be a worthwhile treatment for back pain. That being said, do you happen to know what his views are in regard to exercise? How about SCS?
Do I blame the petition guy for being subjective (biased)? No. You on the other hand are supposed to be a professional with some scientific training. I would in fact expect you to look objectively on any treatment which had the ability to help/harm your patient.
You mentioned: [QUOTE]very obtusely refusing to understand how something as simple as muscle energy technique might work (from endless old round and round conversations that grew very boring.)[/QUOTE]Those conversations would end the moment that you would produce a reasonable amount of data on just how miraculous MET is. I have asked for this numerous times. In regard to MET, I could see how it could work actually. From my experiece with similar techniques, I believe there is something to it. The fact remains that you hold manipulation to a very high standard (not necessarily a bad thing) while at the same time requiring very little from your own disclipline.
Jeff
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Re: Petition to stop neck manipulation - August 22, 2005 5:19:00 PM
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Diane
Posts: 1480
Joined: March 9, 2001
From: Vancouver, B.C., Canada
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There goes Jeff making up stuff. Who said anything about cranial? I know you consider any form of soft tissue approach "whoo-whoo" (sic). Does patient education rate up there with "whoo-whoo"(sic) also, because it's done with little or no contact?
I suspect your insistance on research on MET is a form of trying to turn the tables (although it won't work) when the issue here is neck manipulation and how it
a) can cause strokes
b) doesn't work for pain.
Darn right it should be held to a high standard when it can injure trusting patients. Darn right people need to be educated and those using neck manipulation techniques need a consent form signed up front.
Meanwhile if anyone has any great studies on MET to throw to Jeff, be my guest.
His baiting continues to be annoying, but understandable, if manipulation oops I mean adjusting is all he's got. Like so many chiros, he's getting the the profession itself mixed up with the technique it relies on.
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Re: Petition to stop neck manipulation - August 22, 2005 7:26:00 PM
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chiroortho
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All things considered I don't think that it is unreasonable to disclose to patients that stroke may be caused by cervical manipulation. The fact that it appears to be very rare (I know that there are a lot of folks that like to speculate that it isn't as rare as DCs/DOs say it is, but as far as I'm concerned the speculation is just that) does not sufficiently mitigate the fact that when a VAD does occur proximate to a cervical manipulation that it's a potentially devastating condition.
With that in mind I have no problem with advising patients of the possibility, using the data that has been PUBLISHED, rather than speculated.
My informed consent procedure SOP is to have the patient sign a general acknowledgement of risks, and I obtain verbal consent after reviewing the risks of manipulation personally with the patient in much more detail, which I note in the patient's chart. It's really not an issue with me.
We all have personal biases. We all tend to look more favorably upon our own form of treatment for various reasons.
What I don't appreciate are the implications made by some that claim that those performing cervical manip are doing it solely for financial gain, rather than accepting the fact that the jury is still out on this procedure, Dr. Bogduk notwithstanding. The procedure is taught to DCs and DOs, performed thousands of times uneventfully every day, with benefit perceived by the patient.
So do I have a problem with advising the patient that my cervical manipulations may cause a stroke? No. I have debated this at much length with my own colleagues on a different forum. But has the EVIDENCE risen to the level of causing me to stop providing this procedure? No.
_____________________________
Greg Priest, DC, DABCO
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Re: Petition to stop neck manipulation - August 23, 2005 2:11:00 AM
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JLS_PT_OCS
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From: USA
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Excellent, even-handed post, Greg.
Agreed.
J
_____________________________
Jason Silvernail DPT, OCS, CSCS
"It isn't what you're able to do that requires your courage but rather what you have come to understand and are willing to express." - Barrett Dorko,PT
**I no longer post on RehabEdge**
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Re: Petition to stop neck manipulation - August 23, 2005 2:25:00 AM
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SJBird55
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From: Michigan
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Can I ask a really stupid question on the informed consent? Greg (or anyone)... do you do the informed consent the first time and then that's good enough? Just curious as to how far the informed consent is taken.
It is interesting to the degree of informed consent... my "form" is very general and very unspecific... but when I talk, I'm telling them - but then the problem with talking is that it is never going to be consistent. Australia seems to be WAY ahead of us with the informed consent deal.
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Re: Petition to stop neck manipulation - August 23, 2005 3:11:00 AM
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nari
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From: Australia
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What I am NOT sure about is how well a piece of paper with aims and goals and signatures would stand up in court. A physio-solicitor whom I know has suggested it would not hold water in court unless it was absolutely proven that the PT was negligent or incompetent; in that case, no piece of paper is worth anything, but in a grey case, say, a patient accused a PT of causing damage due to a particular standard and well known exercise, I am not even sure the signature would hold water.
SJ, in my city a consent is required EVERY time the PT does anything different - change in method, aim, goal....remembering to do it is a challenge and a half.
Nari
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Re: Petition to stop neck manipulation - August 23, 2005 3:53:00 AM
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Diane
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From: Vancouver, B.C., Canada
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Nice post Greg.
Nari, SJ, I don't see the point of having consent forms or warnings posted for things that patients do to themselves, operating within their own locus of control. I totally see the point for things that are done TO patients, partcularly to the neck, particularly at a high velocity; they truly do have to give over their locus of control to someone doing something like a neck manip.
Maybe the warning should read:
Warning: Neck Manipulation carried out here. An historical artifact of social grooming, Neck Manipulation requires that you place your neck in the hands of someone for a quick twist/jerk/pop. During Neck Manipulation you will be completely separated from your own inner locus of control for a brief period of time which will startle your brain. Causing your brain to startle and then recover seems to be the only point of Neck Manipulation which is known to be of no benefit in pain reduction. Neck Manipulation may help soothe some deep unconscious urge on your part to be dominated by another or place your life in another's hands, if only for a split second. Any such soothing effects are likely to be shortlived and diminish with repeated exposure. Although deemed to be rare anecdotally, Neck Manipulation can tear delicate and vital membranes within the arteries of the neck which in turn could lead to stroke or death.
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Re: Petition to stop neck manipulation - August 23, 2005 3:56:00 AM
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chiroortho
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SJ, I'm obviously not qualified to give legal advice, so please take what I say with a HUGE amount of salt, but I'm happy to offer my opinion in answer to your question.
Yes, the IC is obtained (by me) only at the first visit. Your point of the 'degree' of IC is a very important one and quite valid. In fact, I daresay that should an untoward event occur, one of the primary issues likely to arise is just how diligently IC was obtained, whether or not it was in writing/signed by patient, and especially the detail given during the IC discussion (or how well it was outlined on the IC form).
Nari, another good comment. How well something stands up in court can be a crapshoot. There is NO ironclad protection and anyone can sue you for anything. Sometimes good doctors/therapists lose cases despite the fact that they've done everything right. My advice would be to accept this intellectually, refuse to worry about it, and continue to serve your patients to the best of your ability. It's just part of healthcare.
Let's face it - if OJ Simpson can get off scott-free just about anything can happen.
_____________________________
Greg Priest, DC, DABCO
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Re: Petition to stop neck manipulation - August 23, 2005 3:57:00 AM
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ehanso
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From: Minnesota
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I can't remember who said this but it does hit home ocassionally.
"It has been my experience that sometimes the most passionate opinions are espoused by the least informed."
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Re: Petition to stop neck manipulation - August 23, 2005 4:36:00 AM
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SJBird55
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From: Michigan
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Greg, I didn't mean to put you on the spot... and I wasn't focusing on legal advice. You know, just the curious aspect of the degree of consent for treatment.
Nari, wow.... now THAT is a ton of paperwork. I'd fail in that kind of system because I'd forget what was signed and then forget something new needed to be signed. I don't know, that kind of set up seems to be a bit overkill. But, you have to do what the system requires, so it doesn't do much good to argue logic at times.
Diane, I do think the manipulation technique performed does need to be considered. I wasn't taught a quick twist kind of thing. The spine is basically in neutral, or slightly outside of neutral, but definitely not to the extreme of the motion and definitely not a gross range of motion type of technique.
I'm going to change gears somewhat... You know what I am finding really interesting, which kind of ties into manipulation... but not exactly... but I'm reading and thinking about Josh Cleland's book. From his compilation of reviewing research out there, it appears that any time we do anything manual in the form of tests or measures there is very low inter-examiner reliability. .88 might be the highest inter-rater reliability I think I recall seeing at the top of my head (and that high of a figure doesn't happen very often with what Josh reviewed). I'm probably going to take somewhat of a leap and extrapolate the lack of inter-examiner reliability with tests and measures and assume that the same lack of inter-therapist reliability exists with the performance of treatment procedures. Meaning... there isn't going to be any reliability of Therapist A with Therapist B with Therapist C with Therapist D in the performance of the various grades of mobilization on up to manipulation. So to extrapolate that even more... if the manual performance of procedures by therapists isn't reliable, then technically, no real assumptions can be made on the actual safety of the procedure because there is too much variability in performances. Just some thoughts.
I do believe informed consent is important. I'm not sure what degree is necessary though. In a backwards way, even though there is a risk to manipulation, generally speaking people take risks every day... autos, planes, smoking... granted, they are the ones in control of those activities, but it doesn't seem to stop them. When you really think about life, we really aren't in control of anything, even though we like to think that we are. Things can go so very wrong even when we thought we planned and decided and made every attempt for things to go right.
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Re: Petition to stop neck manipulation - August 23, 2005 6:26:00 AM
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JLS_PT_OCS
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From: USA
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Good post on the reliability, SJ. Very good stuff to think about.
I think Greg's description of a sort of generic informed consent form at first visit, or the one Jeff posted, is probably coming the closest to answering the issue without unnecessarily burdening ourselves and scaring patients. Which in my opinion is what the standards Nari mentions seem to do.
I think that this may depend state to state and province to province based on whatever board we're talking about and the legal history/precedents there. This would be a good topic for a state/provincial association meeting.
In my opinion, the DCs have always done a pretty good job of doing IC, at least the ones I've worked with.
And if we're going to be doing it for neck manipulation, we should sure be doing it for thermotherapy, maximal exercise or sports retraining, any manual techniques (see SJ's post above), and for sure any cardiovascular training or conditioning.
I suppose at the end of the day, if IC doesn't matter in a legal setting (ie it won't hold up as a practical matter), there may be no need to do it at all if appropriate standards are being applied. Which begs the question of what IC is really for, the patient or the lawyers?
J
_____________________________
Jason Silvernail DPT, OCS, CSCS
"It isn't what you're able to do that requires your courage but rather what you have come to understand and are willing to express." - Barrett Dorko,PT
**I no longer post on RehabEdge**
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Re: Petition to stop neck manipulation - August 23, 2005 7:05:00 AM
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Jeep
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From: USA
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Now that those here have been amply informed on the "no new news" of IC for DCs(it's been part of our practices for years) Y'all can now see the ridiculous worthlessness of the "petition".
Good discussion on IC in general though(minus the cheapshot from Diane).
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Re: Petition to stop neck manipulation - August 23, 2005 7:07:00 AM
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UTDC
Posts: 221
Joined: December 21, 2003
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Oh Diane.
[QUOTE] There goes Jeff making up stuff. Who said anything about cranial? I know you consider any form of soft tissue approach "whoo-whoo" (sic). Does patient education rate up there with "whoo-whoo"(sic) also, because it's done with little or no contact?[/QUOTE]Patient education? Come on, now you are just being silly. Regarding soft tissue techniques, I think that some are valid. If you would bother to actually read what I say prior to taking offense, I have mentioned this before (in fact I did this in my last post).
[QUOTE]I suspect your insistance on research on MET is a form of trying to turn the tables (although it won't work) when the issue here is neck manipulation and how it
a) can cause strokes
b) doesn't work for pain. [/QUOTE]I'm not baiting, merely asking for some shred of substantiation for your "alternative physical therapy" approach. I have asked very straightforward questions and yes even challenged you. I'm sorry that you find this annoying, to me it is one of the best aspects of a discussion forum such as this. I have gone rounds with Jason and others and we always seem to enhance each others understanding. You should not be so threatened.
So you believe that cervical spine manipulation does nothing for pain? Really? Wow, I guess you detailed analysis of the conflicting results of the literature can come to a conclusion that the rest of us can not reach. I think that most rationale individuals would say that some results are positive, some negative, and the amount of benefit is unknown at this time (I think this conflicts with empirical experience).
[QUOTE]Meanwhile if anyone has any great studies on MET to throw to Jeff, be my guest. [/QUOTE]Why are you asking others to provide studies to back up your approach? You sound as though you are an expert in the treatment of pain with such modalities, constantly asked to teach these techniques, and yet you are not familiar with the literature on the subject? I find this surprising.
[QUOTE]His baiting continues to be annoying, but understandable, if manipulation oops I mean adjusting is all he's got. Like so many chiros, he's getting the the profession itself mixed up with the technique it relies on.[/QUOTE]Talk about baiting...In terms of manipulation being "all [I've] got," let's just say that I disagree.
In any case you managed not to address a number of significant questions/points I posed to you.
- Manipulation has more substantiation than your approach to the treatment of pain. (outcomes not neurophys theory)
- You referred to Bogduk several times, how does he view your approach to treatment? How about physical therapy in general? Would it not be safe to say that we are all in the same boat in Bogduk view?
- As a professional you should approach a treatment and its risk/benefit ratio in an objective manner, not in your admittedly subjective way.
- I was under the impression that you thought favorably about craniosacral. Why don't you set me straight, what are your thoughts on the subject?
Jeff
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Re: Petition to stop neck manipulation - August 23, 2005 7:14:00 AM
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UTDC
Posts: 221
Joined: December 21, 2003
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[QUOTE]I suppose at the end of the day, if IC doesn't matter in a legal setting (ie it won't hold up as a practical matter), there may be no need to do it at all if appropriate standards are being applied. Which begs the question of what IC is really for, the patient or the lawyers?[/QUOTE]Hey Jason,
I hear what you are saying, however....
When it comes to the chiropractic profession, if you get sued for causing a CVA, a signed and verbal consent does not give one blanket protection. Informed consent is however considered to be the "standard of care," therefore if it is not done, one is really up the creek.
Bottom line is; even if the IC. does not save you in a malpractice environment, at least it prevents you from violating the standard of care.
Jeff
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Re: Petition to stop neck manipulation - August 23, 2005 7:28:00 AM
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OAK
Posts: 183
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"Maybe the warning should read:
Warning: Neck Manipulation carried out here. An historical artifact of social grooming, Neck Manipulation requires that you place your neck in the hands of someone for a quick twist/jerk/pop. During Neck Manipulation you will be completely separated from your own inner locus of control for a brief period of time which will startle your brain. Causing your brain to startle and then recover seems to be the only point of Neck Manipulation which is known to be of no benefit in pain reduction. Neck Manipulation may help soothe some deep unconscious urge on your part to be dominated by another or place your life in another's hands, if only for a split second. Any such soothing effects are likely to be shortlived and diminish with repeated exposure. Although deemed to be rare anecdotally, Neck Manipulation can tear delicate and vital membranes within the arteries of the neck which in turn could lead to stroke or death."
Really professional Diane!
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