|
|
Re: Petition to stop neck manipulation
|
Logged in as: Guest
|
|
Users viewing this topic:
none
|
|
Login  | |
|
Re: Petition to stop neck manipulation - August 24, 2005 3:47:00 PM
|
|
|
jma
Posts: 2312
Joined: August 24, 2000
From: NY
Status: offline
|
Continue discussing the evidence. Nice
|
|
|
|
|
Re: Petition to stop neck manipulation - August 24, 2005 4:02:00 PM
|
|
|
UTDC
Posts: 221
Joined: December 21, 2003
Status: offline
|
Alex,
I think that the point you made is not quite as simple as it appears. Yes, rotational maneuvers are touted to be more dangerous and yes, intuitively this seem to be more likely to cause a vascular injury. The X factor in all of this is that rotational HVLA is the most commonly applied type, so one would expect a higher proportion of injuries to be caused by rotational manipulations. The chiropractic literature does list a number of types of manipulation as possibly resulting in vascular injury, including several non rotational or extension methods.
The difficult thing about answering this question is that this type of event is SO rare. In fact, with all of the cervical spine manipulations that have been in a contolled environment (studies), there has never been a vascular event.
On a side note, I present another question to the forum. Why is it assumed that mobilization, especially rotational mobilization cannot result in a vertebral artery issue? Again, intuitively this would make sense and authoritative individuals in the world of manual medicine state it as so, I'm just not willing to accept it at face value.
Jeff
|
|
|
|
|
Re: Petition to stop neck manipulation - August 24, 2005 4:12:00 PM
|
|
|
SJBird55
Posts: 2292
Joined: May 10, 2004
From: Michigan
Status: online
|
Jeff, can you rephrase your last question and last sentence?
I'm reading it as
1) rotational manipulation can cause vertebral artery issues but
2)authoritative folks disagree with #1.
My allergies are a pain at the moment, so excuse my stupidity. LOL
|
|
|
|
|
Re: Petition to stop neck manipulation - August 24, 2005 5:24:00 PM
|
|
|
PTupdate.com
Posts: 1433
Joined: October 8, 2001
From: Pittsburgh, PA USA
Status: offline
|
I am jumping into this all so late, but recently treated a life-flight nurse, someone I have treated on and off over the years, and she had two flights in one day for people with severed vertebral arteries at two different chiropractic clinics. go figure.
Duffy
_____________________________
John M. Duffy, PT
Board Certified Orthopaedic Clinical Specialist
www.PTupdate.com
|
|
|
|
|
Re: Petition to stop neck manipulation - August 24, 2005 6:26:00 PM
|
|
|
UTDC
Posts: 221
Joined: December 21, 2003
Status: offline
|
SJ,
It was probably just my long winded writing...
In that last paragraph I was referring to mobilization and the fact that many feel that it is much safer than manipulation and cannot cause vascular injury.
Jeff
|
|
|
|
|
Re: Petition to stop neck manipulation - August 24, 2005 7:35:00 PM
|
|
|
steve
Posts: 454
Joined: May 14, 2003
From: victoria, bc Canada
Status: offline
|
UTDC,
I agree, although the evidence doesn't suggest this is so. If having you hair washed and sneezing can cause vascular injury certainly mobilization is also capable of causing an injury. I have yet to see it listed as cause of VBI in the literature although it could be that, like manipulation, the treatment is not correlated with the vascular injury as an embolism could dislodge a week later. Intuitively you would think that the chance of causing vascular injury with a technique that is not high velocity and works within the physiological range of motion would be less likely to cause trauma.
Definately food for thought.
Steve
|
|
|
|
|
Re: Petition to stop neck manipulation - August 24, 2005 9:43:00 PM
|
|
|
Alex Brenner PT MPT OCS
Posts: 1057
Joined: February 29, 2004
From: Kentucky
Status: offline
|
I went to a manual therapy conference not long ago and was able to get a sneak peak on a study that is currently in review with the New England Journal of medicine titled Manipulation and Mobilization Versus Mobilization Alone for the Treatment of Mechanical Neck Disorders. Bob Boyles, Mike Walker, Joe Strunce, Brian Young, Rob Wainner.
Two groups randomized into a either a manipulation and mob group or moblizatoin only group. NDI scores and cervical VAS scores were used to measure outcome.
Scores were taken at baseline, 3 weeks, 6 weeks, and 1 year post treatments. No differences between mobilzation or manipulation groups were noted in short term or long term.
The study had low statisitcal power but was still a well designed study. This, of course, is nothing to "build a house on" but is still better than nothing. Should be published soon.
_____________________________
Alex Brenner, PT, MPT, OCS
|
|
|
|
|
Re: Petition to stop neck manipulation - August 25, 2005 3:22:00 AM
|
|
|
JLS_PT_OCS
Posts: 1684
Joined: January 30, 2005
From: USA
Status: offline
|
Jeff-
You make a good point here about mob vs manip and risk. Darn your rational mind!!
I do not believe as manual medicine practitioners we can simultaneously make the point that a VBI can happen spontaneously, and also that mobilization is definitely safer than manipulation. I don't think we can state that with any certainty (like anything at all related to VBI).
I think the argument that mobilization is safer than manipulation comes from theoretical constructs of techniques, a few reports a VBI near in time to manipulative treatment, and studies showing more overall adverse events (pain, soreness, headache, etc... nothing serious) from manip vs mob.
I think from my perspective that given the above information, mob should be the preferred treatment, but I think in fairness to those who prefer manip/HVLA(of any type), we should say we don't have convincing safety data to drive that decision.
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**
|
|
|
|
|
Re: Petition to stop neck manipulation - August 25, 2005 4:09:00 AM
|
|
|
Diane
Posts: 1491
Joined: March 9, 2001
From: Vancouver, B.C., Canada
Status: offline
|
There exists in/ from Australia a long list of VADs that were tracked to cause, and one cause was a shiatsu treatment, done too forcefully I presume. If shiatsu can rip an vertebral artery so could mobilizations done too forcefully, logic would suggest.
(I shake my head at the perceived need amongst treaters [of any persuasion] to do anything forceful to neck vertebrae or tissues whatever in any manner.)
|
|
|
|
|
Re: Petition to stop neck manipulation - August 25, 2005 4:50:00 AM
|
|
|
Randy Dixon
Posts: 744
Joined: August 6, 2004
Status: offline
|
Although the passive nature of mobilizations and manipulations of the cervical spine may make people more susceptible to injury, I think that claims of the fragility of the neck can be exaggerated. I know Jason does Jiu-jitsu, as do I, and I have choked people unconscious and been choked unconscious several times, I have placed peoples necks in the most uncomfortable position I could find and then cranked with all my might,(no making fun of my might)including lifting them off the ground with the neck as a lever, and I have seen others do so literally hundreds if not thousands of times, with no serious injury.
I'm not suggesting that this is particularly relevant to clinical applications or populations but perhaps to keep the dangers in perspective.
|
|
|
|
|
Re: Petition to stop neck manipulation - August 25, 2005 5:47:00 AM
|
|
|
drbuddy
Posts: 429
Joined: July 30, 2005
From: Pennsylvania
Status: offline
|
I have been checking this thread on occassion and just saw a few things that stuck out:
"Intuitively you would think that the chance of causing vascular injury with a technique that is not high velocity and works within the physiological range of motion would be less likely to cause trauma."
True, the high velocity could add more risk to a procedure, however, I beleive that manipulations are taught within the normal physiological range of motion. I was alway taught to "lock out" segments, which causes the end range for joints to occur well within the normal physiological ROM limits (this is why I prefer short lever adjustments). On the other hand, I would say that mobilization takes the c-spine to end range and could be just as or more dangerous than a 'properly' performed HVLA maneuver.
Dont confuse 'normal physiologic range of motion' with taking a particular joint 'beyond its normal physiolgic range of motion' that was discussed in another thread.
What we fail to remember, and thanks to the poster who pointed this out, is that vascular events can occur from a variety of movements such as hair washing at the salon, turning the head to back out of the driveway, etc. None of these are HVLA maneuvers, but happen to cause vascular events in people whose artery walls are already weakened for one reason or another. We were even taught that maneuvers commonly used to test for deficiency can actually cause vascular events. These are manuevers such as extending and rotating the head (and the numerous variations).
So... I agree with those that say that the evidence is not there to ban this procedure. Plus, I feel that cause is related to the condition of the arteries(vascular/connective tissue dx) going into the procedure and the position of the procedure and not necessarily the forces involved.
However, if you think the evidence is there to ban the procedure, then I think you also need to look at other procedures such as taking patients through passive (or active for that matter) cervical range of motion and expecially passive ROM with mobilization, no matter how gentle or slow you thrust.
|
|
|
|
|
Re: Petition to stop neck manipulation - August 25, 2005 6:20:00 AM
|
|
|
SJBird55
Posts: 2292
Joined: May 10, 2004
From: Michigan
Status: online
|
Has anyone seen any studies on the frailness of the vascular structures? Meaning, we know that the tests that can be used at the c-spine, and a lot of us were taught to use, to rule out a potential of a vertebral artery dissection are pretty much meaningless. So, by any chance are there other more creative ways to assess the strength of the vasculature or the properties of that tissue and any outward findings that might indicate a high likelihood of tissue failure? Not necessarily in the PT literature.... maybe in vascular literature? Like... maybe - history of easily bruising, history of vericose veins, what about the amount of plaque build up...
|
|
|
|
|
Re: Petition to stop neck manipulation - August 25, 2005 6:58:00 AM
|
|
|
UTDC
Posts: 221
Joined: December 21, 2003
Status: offline
|
SJ,
Although tangentially related to your question, this study was done a few years back in the attempt to see what forces were placed on the VA during manipulation.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12381972&query_hl=7
Historical factors that seem to be related include age <30, female gender, BCP's, smoking, and hypertension.
Another X factor is that the type of vascular injury being debated is know to happen spontaneously. The most common presenting symptoms are cervical spine pain and headache. One theory that has been tossed about is that patients may be presenting to health care practitioners with dissections in progress and the treatment may have nothing to do with the stroke.
Lots of work to be done in this area.
Jeff
|
|
|
|
|
Re: Petition to stop neck manipulation - August 25, 2005 6:58:00 AM
|
|
|
dosrinc
Posts: 335
Joined: December 9, 2004
From: Bonita Springs
Status: offline
|
SJ,
I would think only an MRA of the subcranial structures could give us any reasonable security here but it would be interesting if someone reviewed cases and came up with some type of CPR for subcranial "frailty". A cluster of red flags so to speak. Along those lines, how many here are willing to treat say post whiplash patients without at least x-rays being done? Are x-rays alone enough for us to feel comfortable even testing end range active/passive motion? Glad to see this thread has returned to the educational mode.
Rick
|
|
|
|
|
Re: Petition to stop neck manipulation - August 25, 2005 8:07:00 AM
|
|
|
Jon Newman
Posts: 1697
Joined: April 24, 2004
From: Amherst, WI
Status: offline
|
If a neurophysiological process is responsible for the anlagesic effect of manipulation (versus fixing an alignment problem) do you suppose the HVLA is needed to produce this effect? Are neurophysiologic effects specific to each different manipulaton technique?
jon
_____________________________
[URL=http://www.sonymusic.com/clips/selection/30/064887/064887_03_03_30.wav]Evidence[/URL]
|
|
|
|
|
Re: Petition to stop neck manipulation - August 25, 2005 8:10:00 AM
|
|
|
SJBird55
Posts: 2292
Joined: May 10, 2004
From: Michigan
Status: online
|
Rick... I don't know if that's the gold standard or not, but it's probably not realistic for every patient presenting with cervical pain and or headaches to have that procedure. Yeah, I was thinking along the lines of CPR (just wasn't verbalizing it very well).
Jeff, what's a BCP?
I was reading something on heart rate... heart rate combined with cholesterol were variables in the elastoviscosity of vessels.
I would expect X-rays post whiplash. I wouldn't personally do any hands-on assessments or procedures until I knew the radiographs were negative. I'm comfortable with testing end range motion actively, in particular with sidebending and rotation... in the early stage, I'd be more hestitant with flexion and extension though. Passively, my comfort level would be to progress as the body allowed and I wouldn't fight the protective mechanisms that sometimes occur.
Just an addendum to my thoughts.
In regard to that study, Jeff... are the viscoelastic properties of cadavers comparable to live tissue? And... stress is good, but the timing of the stress or the speed in which the stress is applied is important... and also the directional forces of the stress - is straight line stress response the same as a multi-directional stress response?
|
|
|
|
|
Re: Petition to stop neck manipulation - August 25, 2005 10:21:00 AM
|
|
|
JLS_PT_OCS
Posts: 1684
Joined: January 30, 2005
From: USA
Status: offline
|
SJ, BCPs are Birth Control Pills. They come in so many varieties and dosages, I just write "BCP" on the history form...
I am not certain how closely correlated cadaver studies are to live humans. I think those studies provide a valuable backdrop, but in the end we can only guess at what's going on.
Buddy-
I don't think there's any way we can tell what a "physiological" vs "paraphysiological" zone or ROM is in any joint. These are merely unproven theoretical constructs. All Arkansas business aside, I don't think we can use these terms as if they are well understood or these ranges of movement and their delineations have been shown to exist.
I think Jeff drives that point home well when he talks about the supposed difference in risk (even difference in definition?) between mob and manip. I don't think those theoretical ranges of motion are going to be useful in determining risk of a VBI.
I recall some WAD guidelines published by a few authorities...I think the Canadian CSpine rule (ah, those clever Canucks) is very useful, and any trauma type patient who comes to my office who meets the criteria definitely gets the films done that day (we can order Rad studies, etc in the military).
I think one WAD guideline called for no HVLA stuff for at least 6 weeks, and I used to consider that a reasonable thing, until Jeff has gone and made me think about it closer (I'll get you for that...), in that a low velocity movement is not necessarily better or worse than a higher velocity one.
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**
|
|
|
|
|
Re: Petition to stop neck manipulation - August 25, 2005 12:33:00 PM
|
|
|
drbuddy
Posts: 429
Joined: July 30, 2005
From: Pennsylvania
Status: offline
|
Jason,
I was just trying to clarify myself. I am saying that the way I was taught manipulation is within the normal range of motion. If you take my set up and compare it to end range of motion, there is a big difference.
As for tests we can do to rule out connective tissue dx, I beleive C-Reactive Protein (CRP) elevation has been associated with an increase chance of stroke.
|
|
|
|
|
Re: Petition to stop neck manipulation - August 25, 2005 12:49:00 PM
|
|
|
UTDC
Posts: 221
Joined: December 21, 2003
Status: offline
|
SJ,
[QUOTE]In regard to that study, Jeff... are the viscoelastic properties of cadavers comparable to live tissue? [/QUOTE]I don't know, it's beyond my abilities, apparently the authors thought it was reasonable. This study did generate some controversy from what I recall.
[QUOTE]And... stress is good, but the timing of the stress or the speed in which the stress is applied is important... and also the directional forces of the stress - is straight line stress response the same as a multi-directional stress response?[/QUOTE]I think that the key here was that the simulated HVLA's produced significantly less strain than the simulated range of motion testing.
Jeff
|
|
|
|
|
Re: Petition to stop neck manipulation - August 25, 2005 4:55:00 PM
|
|
|
chiroortho
Posts: 655
Joined: February 18, 2004
Status: offline
|
[QUOTE]I have choked people unconscious and been choked unconscious several times, I have placed peoples necks in the most uncomfortable position I could find and then cranked with all my might,(no making fun of my might)including lifting them off the ground with the neck as a lever[/QUOTE]Wow Randy, remind me not to mess with you!
_____________________________
Greg Priest, DC, DABCO
|
|
|
|
 New Messages |
 No New Messages |
 Hot Topic w/ New Messages |
 Hot Topic w/o New Messages |
 Locked w/ New Messages |
 Locked w/o New Messages |
|
 Post New Thread
 Reply to Message
Post New Poll
Submit Vote
Delete My Own Post
Delete My Own Thread
Rate Posts |
|
0.125
|
Printable Version
All Forums >> [RehabEdge Forum] >> Open Forum >> Re: Petition to stop neck manipulation 
