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Re: Petition to stop neck manipulation
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Re: Petition to stop neck manipulation - August 23, 2005 8:00:00 AM
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Sebastian Asselbergs
Posts: 1106
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From: Barrie, Canada
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Informed consent is a standard and central issue in our physiotherapy practice in Ontario. It does NOT stand up as a blanket protection against lawsuit or liability, BUT without it, you'd be lost from the start if sued....
The key is to make sure that as Nari said, with each and every change in technique or approach, the patient is informed as to why, what and what dangers. Every time. Verbal is considered enough by our standards for that kind of consent - but you HAVE to give the patient a direct option - "You have a choice".
There IS no legally foolproof protection.
Having said all that, I still think there are risks in any manual handling of patients. I just have to remember the one whose neck I cradled gently in my hands, and she had her eyes roll up in the sockets, started having seizures and became unconscious. This had NOTHING to do with the technique, other than the fact that she relaxed for the first time in 28 hours (I found out later!), and her system just went ga-ga (a new medical term y'all need to learn). Luckily, she felt more foolish than lawsuit ready - phew!
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Mundi vult decipi
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Re: Petition to stop neck manipulation - August 23, 2005 8:30:00 AM
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JLS_PT_OCS
Posts: 1684
Joined: January 30, 2005
From: USA
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Jeff-
I see where you're coming from there. You see a written informed consent being the same as standard of care (and in your profession I'm sure you're right).
That's not always the case for us, and I'm not sure why that is. I'm also not sure it's wrong.
Having had lengthy discussions with the Risk Managers /Legal Advisors in several hospital systems I have been credentialed in, they see manipulation (of any part) and anything noninvasive done in the physical medicine world as small potatoes and not worth their time.
Especially given the other methods, both procedure and medication based, being used.
I had one risk manager actually laugh when I brought up the issue.
However, in the end (as Sebastian alludes to above) being sued and the grounds thereof may have as much to do with what the patient feels like doing than anything else. What a sad statement that is.
I still think a general written IC as Jeff and Greg mention seems to be the closest thing to a perfect solution.
J
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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 8:35:00 AM
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Jon Newman
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From: Amherst, WI
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Jason I agree except that if you're going to cite "physical therapy" burns you ought to also cite "chiropractic" strokes.
jon
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[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 23, 2005 9:01:00 AM
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UTDC
Posts: 221
Joined: December 21, 2003
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Jon,
Hah! Fair enough. I thought that might come up, to be honest I did not even notice it untill after I had posted it here. I suppose this is a good example of chiro's referring using "PT" as per our previous conversation. The text of the consent actually comes from a malpractice insurance company, although I am hesitant to change it, I agree that "physical modalities" would be a better choice of words.
Jeff
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Re: Petition to stop neck manipulation - August 23, 2005 10:04:00 AM
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JLS_PT_OCS
Posts: 1684
Joined: January 30, 2005
From: USA
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Thanks Jeff...
Good catch, Jon.
If only everyone (including those in Arkansas) got along as well as we do here...one only wonders what kinds of good things could happen...
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 10:38:00 AM
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paulpt
Posts: 164
Joined: May 31, 2005
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Hard to believe that 'Bring Back American Gladiators' got 7800 signatures, while the neck manipulation one generated only 134.
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Re: Petition to stop neck manipulation - August 23, 2005 10:40:00 AM
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UTDC
Posts: 221
Joined: December 21, 2003
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[QUOTE]If only everyone (including those in Arkansas) got along as well as we do here...one only wonders what kinds of good things could happen...[/QUOTE]Jason,
I gotta tell you, I've had the opportunity to work alongside some very talented manual PT's, it was a great experience for me. I wish this was a more common form of collaboration- for both professions.
Jeff
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Re: Petition to stop neck manipulation - August 23, 2005 11:50:00 AM
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Jeep
Posts: 353
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From: USA
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Cervical Spine Manipulation
Risk/Benefit Analysis
Evidence behind the safety and benefit of cervical spine manipulation is explored.
By Ken Johnson, DO and George Pasquarello, DO, FAAO
Recently there has been an increasing concern about the safety of cervical spine manipulation Specifically, this concern has centered on devastating negative outcomes such as stroke.
Benefits
Spinal manipulation has been reviewed in meta-analysis published as early as 1991, showing a clear benefit for low back pain.1 There is less available information in the literature about manipulation in regards to neck pain and headache, but the evidence does show benefit.2, 3, 4, 5, 6 There have been at least 12 randomized controlled trials of manipulative treatment of neck pain.
Some of the benefits shown include relief of acute neck pain, improvement in pain as measured by validated instruments in sub-acute and chronic pain compared with muscle relaxants or usual medical care. There is also short-term relief from tension type headaches.7 Manipulation relieves cervicogenic headache and is comparable to commonly used first-line prophylactic prescription medications for tension-type headache and migraine.8 Meta-analysis of five randomized controlled trials showed that there was a statistically significant reduction in neck pain using a visual analogue scale.9
Risks
Since 1925, there have been approximately 275 cases of adverse events reported with cervical spine manipulation.10,11,12,13 It has been suggested by some that there is an under-reporting of adverse events.10 A conservative estimate of the number of cervical manipulations per year is approximately 33 million and may be as high as 193 million in the US and Canada. 14, 15 The estimated risk of adverse outcome following cervical spine manipulation ranges from one in 400,000 to one in 3.85 million manipulations.16, 17, 18, 19
The estimated risk of major impairment following cervical spine manipulation is 6.39 per 10 million manipulations.20 Most of the reported cases of adverse outcome have involved “Thrust” or “High Velocity/ Low Amplitude” types of manipulation.11 However, the risk of vertebrobasilar artery stroke from manipulation is less than the risk of a spontaneous vertebrobasilar artery stroke.7
A concern has been raised by a recent report that vertebrobasilar artery stroke following cervical spine manipulation is unpredictable.10 This report is biased because all of the cases were involved in litigation. The nature of litigation can lead to inaccurate reporting by patient or provider.
However, it did conclude that vertebrobasilar artery stroke following cervical spine manipulation is “idiosyncratic and rare.” Further review of this data showed that 25 percent of the cases presented with sudden onset of new and unusual headache and neck pain often associated with other neurologic symptoms that may have represented a dissection in progress.21
In direct contrast to this concern of unpredictability, another recent report states that cervical spine manipulation may worsen preexisting cervical disc herniation or even cause cervical disc herniation. This report describes complications such as radiculopathy, myelopathy, and vertebral artery compression by a lateral cervical disc herniation.12 The authors concluded that the incidence of these types of complications could be lessened by rigorous adherence to published exclusion criteria for cervical spine manipulation.12
Manipulative treatment for neck pain is much safer than the use of NSAIDs, which are the most commonly prescribed medications for neck pain. Research in the United Kingdom has shown NSAIDs will cause 12,000 emergency admissions and 2,500 deaths per year.22 The annual cost of GI tract complications in the US is estimated at $3.9 billion, with at least 2,600 deaths and up to 20,000 hospitalizations per year.23, 24
Provocative Tests
Provocative tests such as the DeKline test have been studied in animals and humans. This test and others like it were found to be unreliable for demonstrating reproducibility of ischemia or risk of injuring the vertebral artery.25, 26, 27, 28, 29, 30
Risk Factors
Vertebrobasilar artery stroke accounts for 1.3 in 1000 cases of stroke, making this a rare event. The most common risk factors for vertebrobasilar artery stroke are migraine, hypertension, oral contraceptive use and smoking.31
A study done in 1999 reviewing 367 cases of vertebrobasilar artery stroke reported from 1966-1993 showed 115 cases related to cervical spine manipulation; 167 were spontaneous, 58 from trivial trauma and 37 from major trauma.31
Complications from cervical spine manipulation most often occur in patients who have had prior manipulation uneventfully and without obvious risk factors for vertebrobasilar artery stroke.7 “Most vertebrobasilar artery dissections occur in the absence of cervical manipulation, either spontaneously or after trivial trauma or common daily movements of the neck, such as backing out of the driveway, painting the ceiling, playing tennis, sneezing, or engaging in yoga exercises.”10 In some cases manipulation may not be the primary insult causing the dissection, but an aggravating factor or coincidental event.21
It has been proposed that thrust techniques using a combination of hyperextension, rotation and traction of the upper cervical spine will place the patient at greatest risk of injuring the vertebral artery. In a retrospective review of 64 medical legal cases, information on the type of manipulation was available in 39 (61 percent) of the cases. 51 percent involved rotation, with the remaining 49 percent representing a variety of positions including lateral flexion, traction and isolated cases of non-force or neutral position thrusts. Only 15 percent had any form of extension.21
Conclusion
Manipulation of the cervical spine is a safe and effective treatment. As with all medical procedures, practitioners should be provided with sufficient information so they are advised of the potential risks and benefits.
--------------------------------------------------------------------------------
Ken Johnson, DO is the Osteopathic DME, AOA FP Residency Director for the EMMC in Bangor, Maine. He is certified in Special Proficiency in Osteopathic Manipulative Medicine (CSPOMM) Family Practice and OMT.
George Pasquarello, DO, FAAO is an associate professor of osteopathic manipulative medicine at the UNECOM. He is certified by the AOBSPOMM and practices in Maine and Rhode Island.
This paper has been adopted by the AAO Board of Governors as an official position paper.
References:
Shekelle, P, Adams, A, et al. Spinal manipulation for low-back pain. Annals of Internal Medicine 1992;117(7): 590-98.
Koes, BW, Bouter, LM, et al. The effectiveness of manual therapy, physiotherapy, and treatment by the general practitioner for nonspecific back and neck complaints, a randomized clinical trial. Spine 1992;17(1):28-35.
Koes, B, Bouter, L, et al. Randomised clinical trial of manipulative therapy and physiotherapy for persistent back and neck complaints: results of one year follow up. BMJ 1992;304:601-5.
Koes BW, Bouter LM van Marmeren H, et al. A randomized clinical trial of manual therapy and physiotherapy for persistent neck and back complaints: sub-group analysis and relationship between outcome measures. J Manipulative Physio Ther 1993;16:211-9.
Cassidy JD, Lopes AA, Yong-Hing K. The immediate effect of manipulation versus mobilization on pain and range of motion in the cervical spine: A randomized controlled trial. J Manipulative Physio Ther 1992;15:570-5.
Jensen OK, Nielsen FF, Vosmar L. An open study comparing manual therapy with the use of cold packs in the treatment of posttraumatic headache. Cephalgia 1990;10:241-50.
Hurwitz EL, Aker PD, Adams AH, Meeker WC, et al. Manipulation and Mobilization of the Cervical Spine. A systematic review of the literature. Spine 1996;21(15):1746-56 .
Bronfort G, Assendelft WJ, Evans R, Haas M, Bouter. Efficacy of spinal manipulation for chronic headache: a systematic review. J of Manip & Physio Ther 2001;27(7):457-66.
Gross AR, Aker PD, Goldsmith CH, Peloso P. Conservative management of mechanical neck disorders. A systematic overview and meta-analysis. Online J Curr Clin Trials. 1996; Doc No 200-201.
Haldeman S, Kohlbeck FJ and McGregor M. Unpredictability of cerebrovascular ischemia associated with cervical spine manipulation: A review of 64 cases after cervical spine manipulation therapy. Spine 2002;27:49-55.
Assendelft WJJ, Bouter LM and Knipschild PG. Complications of spinal manipulation: A comprehensive review of the literature. J Fam Pract 1996;42:475-480.
Malone DG, Baldwin NG, Tomecek FJ, Boxell CM, et al. Complications of cervical spine manipulation therapy: 5-Year retrospective study in a single-group practice. Neurosurg Focus 13(6), 2002.
Vick DA, McKay C, Zengerle CR. The safety of manipulative treatment: review of the literature from 1925 to 1993. JAOA 1996;96(2):113-5.
Haldeman S, Carey P, Townsend M, Papadopoulos C. Arterial dissection following cervical manipulation. The chiropractic experience. CMAJ 2001;165:905-6.
Hurwitz EL, Coulter ID, Adams AH, Genovese BJ, Shekelle PG. Use of chiropractic services from 1985 through 1991 in the United States and Canada. Am J Public Health 1998;88:771-6.
Jenson et al. Complications of cervical manipulation, General Forensic
Science1987 ;32(4) :1089-1094.
Koss RW. Quality assurance monitoring of osteopathic manipulative treatment. JAOA 1990;90(5):427-433.
Dvorak J, Orelli F. How dangerous is manipulation to the cervical spine? Case report and results of a survey. Manual Med 1985;2:1-4.
Carey P. A report on the occurrence of cerebral vascular accidents in chiropractic practice. J Can Chiropract Assoc 1993;37:104-6.
Coulter ID, Hurwitz EL, Adams AH, et al. The appropriateness of manipulation and mobilization of the cervical spine. Santa Monica CA: Rand, 1996.
Haldeman S, Kohlbeck FJ, McGregor. Stroke, cerebral artery dissection, and cervical spine manipulative therapy. J of Neurol 2002;249:1098-1104.
Blower Al, Brooks A, Fenn CG et al. Emergency Admissions for Upper Gastrointestinal Disease and Their Relation to NSAIDs Use. Alimart. Pharmacology Ther, 1997, 11:283-91.
Fries JF, Miller SR, Spitz PW, Williams CA, Hubert HB, Bloch DA. Toward an epidemiology of gastropathy associated with nonsteroidal anti-inflammatory drug use. Gastroenterology. 1989;96:647-655.
Bloom BS. Direct medical costs of disease and gastrointestinal side effects during treatment for arthritis. Am J Med 1988;84(suppl 2A):20-24.
Licht PB et. al. Vertebral artery flow and cervical manipulation: an experimental study. J Manipulative Physiol Ther 1999;Sep; 22(7):431-5.
Cote P, Kreitz BG, Cassidy JD, et al. The validity of extension-rotation tests as a clinical screening procedure before neck manipulation: A secondary analysis. J Manipulative Physio Yher 1996;19:159-64.
Refshauge KM. Rotation: A valid premanipulative dizziness test? Does it predict safe
manipulation? J Manipulative Physio Ther 1994;17:15-19.
Stevens A. A functional Doppler sonography of the vertebral artery and some considerations about manual techniques. J Manual Med 1991;6:102-5.
Theil H, Wallace K, Donat J, et al. Effect of various head and neck positions on vertebral artery blood flow. Clin Biomech 1994;9:105-10.
Weingart JR, Bischoff HP. Doppler sonography of the vertebral artery with regard to head positions appropriate to manual medicine. J Manual Medicine 1992;6:62-5.
Haldeman S, Kohlbeck FJ, McGregor M. Risk factors and precipitating neck movements causing vertebrobasilar artery dissection after cervical trauma and spinal manipulation: Spine 1999;24:785-94. [B][/B]
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Re: Petition to stop neck manipulation - August 23, 2005 12:57:00 PM
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Randy Dixon
Posts: 744
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American Gladiators? There's going to be 7801 now!
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Re: Petition to stop neck manipulation - August 23, 2005 1:16:00 PM
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dosrinc
Posts: 335
Joined: December 9, 2004
From: Bonita Springs
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I really liked STAR, she was a beast!
Rick
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Re: Petition to stop neck manipulation - August 23, 2005 3:04:00 PM
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Diane
Posts: 1491
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From: Vancouver, B.C., Canada
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Here is the [URL=http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14622659]Ernst article[/URL] commented on by Bogduk.
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Re: Petition to stop neck manipulation - August 23, 2005 5:23:00 PM
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UTDC
Posts: 221
Joined: December 21, 2003
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Finally, the long awaited reference by Diane, sweet. Hold on, this does nothing to substantiate her form of treatment...Oh well, I guess I'll just have to keep waiting.
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Re: Petition to stop neck manipulation - August 23, 2005 5:30:00 PM
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Jon Newman
Posts: 1697
Joined: April 24, 2004
From: Amherst, WI
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Jeff, you are quite right about that. However if she is able to get people better with no risk of stroke or death versus a small risk wouldn't it be a better treatment in that aspect?
jon
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[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 23, 2005 5:40:00 PM
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UTDC
Posts: 221
Joined: December 21, 2003
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Jon,
If it is as effective with less complications, absolutely.
Jeff
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Re: Petition to stop neck manipulation - August 23, 2005 8:29:00 PM
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Alex Brenner PT MPT OCS
Posts: 1057
Joined: February 29, 2004
From: Kentucky
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From what I have read the technique that consistently seems to damage the vertebral artery is a HVLA where the neck is placed in extension and a rotational force is applied aimed at the upper cervical spine. If you look anatomically and biomechanically it is easy to see how the vertebral artery can potentially be damaged.
I dont perform this technique. For those that do this type of technique, I am curious to know what you are trying to achieve with this type of motion. Is it possible to achieve the same results with a different technique and avoiding an extension and rotational force?
I don't think we should ban cervical manipulation all together but I do think that the HVLA motions described above should be avoided at all costs.
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Alex Brenner, PT, MPT, OCS
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Re: Petition to stop neck manipulation - August 24, 2005 3:09:00 AM
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JLS_PT_OCS
Posts: 1684
Joined: January 30, 2005
From: USA
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That report Jeep posted seems to summarize the issues pretty well. The most recent article by Childs et al in the JOSPT that Jeff posted is a worthwhile read as well.
I doubt technique is really as big an issue, but the overutilization issue and the use of Cx manipulation to treat those without upper quarter complaints is really the central issue, in speaking of risk.
For my DC colleagues- what do you all think of this issue (possible overutilization and possible use to treat unrelated/nonexistent complaints) in your profession, and your thoughts on the orthopractic or NACM (www.chiromed.org) type guidelines?
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 24, 2005 7:15:00 AM
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steve
Posts: 454
Joined: May 14, 2003
From: victoria, bc Canada
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Alex,
I always read about the rotational forces at the upper C-spine as being more dangerous and from a theoretical/anatomical point of view this would seem to be accurate. I belief that of the manipulations implicated in causing a CVA (I think around a 100 documented cases) only about 50% of the time it was an upper cervical rotational technique. Anyone have anymore info to substantiate technique playing a roll in CVA?
Nice to see this thread starting to discuss evidence in a civicl manner and not bashing other professions.
Steve
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Re: Petition to stop neck manipulation - August 24, 2005 10:34:00 AM
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chiroortho
Posts: 655
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[QUOTE]HVLA where the neck is placed in extension and a rotational force is applied aimed at the upper cervical spine.[/QUOTE]There you go.
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Greg Priest, DC, DABCO
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