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Re: "special skills"
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Re: "special skills" - September 17, 2006 5:56:00 PM
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jbird007
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From: USA
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Thanks for the reply proud,
1. Are you saying all Physical Therapists (as well as DC's) should avoid manipulating the cervical region?
2. Are you saying a Physical Therapist (or a DC) who uses a form of palpation to assess before manipulation is acting unethically and/or considered a form of quackery? (since you stated they are fooling their patients).
JBird
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Re: "special skills" - September 18, 2006 3:11:00 AM
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proud
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Jbird007,
To answer question one. I will start with this link:
http://www.springerlink.com/content/05a72dtd442fp072/?p=dce508813b6c4ac487cc8ff4221796a3&pi=3
And add the following:
Stoke, cerebral artery dissection and cervical manipulation, by Scott Halderman, Frank J Kohlbeck and marion mcGregor, was published in the July 2002 vol 249 no 8, pp1098-1104 edition. This study suggested that: "Strokes, particularily vertebrobasilar dissection, should be considered a random and unpredictable complication of any neck movement, including cervical manipulation. They may occur at any point in the course of treatment with virtually any method of cervical manipulation. The sudden onset of acute and unusual neck and/or head pain may represent a dissection in progress and be the reason a patient seeks manipulative therapy that the serves as the final insult to the vessel leading to ischemia"
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Re: "special skills" - September 18, 2006 3:30:00 AM
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proud
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Jbirdoo7,
To answer question two. I need clarification on what you mean by " a form of palpation". As I have stated previously that specificity of palpation is the key issue, not palpation in general.
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Re: "special skills" - September 18, 2006 5:15:00 AM
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jbird007
Posts: 297
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From: USA
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proud,
Thanks for posting the research but it wasn't necessary.
This was the Question:
"1. Are you saying all Physical Therapists (as well as DC's) should avoid manipulating the cervical region?"
yes/no will suffice.
JBird
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Re: "special skills" - September 18, 2006 6:22:00 AM
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jbird007
Posts: 297
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From: USA
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proud, IYO what type of palpation is valid and effective?
J
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Re: "special skills" - September 18, 2006 6:26:00 AM
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proud
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Jbird007,
Much debate on the topic as I am sure you know. Which I think should act as a flashing red light anyway. On one side of the fence we have those that make a living at it and on the other, those with a more cautionary approach.
The reported incidence of a severe adverse reaction varies widely from one in 20,000 to one per million procedures( Vikers and Zollman 1999), but may be as high as one in 4,500( Dunne eta al 2000).
A comparison of risks and benefits suggests that the risk of cervical manipulation outweigh the benefits. Manipulation has yet to be shown to be more effective for neck pain and headache than other interventions such as mobilization, whereas the risks, although potentially infrequent, are serious.
So Jbird007, I suggest we put down the weapon for now until we can determine if it is loaded. Do we not owe the public that? So my answer is yes...for now.
Your thoughts?
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Re: "special skills" - September 18, 2006 7:59:00 AM
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PainFree
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Proud, you quaote: "Strokes, particularily vertebrobasilar dissection, should be considered a random and unpredictable complication of any neck movement, including cervical manipulation. They may occur at any point in the course of treatment with virtually any method of cervical manipulation. The sudden onset of acute and unusual neck and/or head pain may represent a dissection in progress and be the reason a patient seeks manipulative therapy that the serves as the final insult to the vessel leading to ischemia"
I fail to see where this supports your comments to stay away from manipulating the cervical spine.
"Strokes, particularily vertebrobasilar dissection, should be considered a random and unpredictable complication of any neck movement, including cervical manipulation."
Basically this says that strokes are random and unpredictable and can occur with any neck movement (including yours and my mobilizations, my manipulations and possibly even during the history taking process when a patient shakes their head no in answer to your question).
"The sudden onset of acute and unusual neck and/or head pain may represent a dissection in progress and be the reason a patient seeks manipulative therapy"
The author seems to think that some of the patients presenting to a manual therapists's office are in the process of having a stroke even before walking into the clinic's door.
Yes, I recognize that it is important to do our best to recognize these patients, not to manipulate or mobilize them and to get them to the right practitioner ASAP.
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Re: "special skills" - September 18, 2006 8:31:00 AM
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proud
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Painfree,
Read the full atricle if you get a chance. I just do not have an electronic version. The point being the risk benefit ratio.
When you say "...it is important to DO OUR BEST to recognize these patients..."
That "do our best" statement speaks volumes.
Hey painfree. Far be it from me to tell you what to do. But how well informed are your patients about the current "debate"? Particularily with upper c-spine rotary techniques.
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Re: "special skills" - September 18, 2006 8:40:00 AM
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proud
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Painfree,
Okay, how about this one:
Spinal manipulative therapy is an independant risk factor for vertebral artery dissection by W.S Smith etal, published in Neurology 2003: 60:1424-8. The authors reviewed all patients under 60 with cervical arterial dissection and ischemic stroke or TIA from between 1995 and 2000 at two acedemic stroke centers. Controls were selected to match cases by sex and within age strata. Following both univariate and multivariate analysis, they concluded that SMT is independently associated with vertebral arterial dissection, even after controlling for neck pain.
And I might add, I am aware of the debate concerning this article. The point being, does it not give you any pause?
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Re: "special skills" - September 18, 2006 11:36:00 AM
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jbird007
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proud,
IMO, the risk-benefit ratio for cervical manip favors the benefit side. Millions of cervical manipulations are performed on a daily basis and have been for 100 years. I have read the research (pro and con) and the numbers range from 1 in 20,000 to 1 and 4 million. Almost all of it is wide open to inaccuracy and questions arise of who was actually injured from a manipulation. Where are ALL these victims who stroked out?
How many DC patients visit a DC and have a stroke the same day or the next day? Are they "victims" or were they going to have a stroke that day even if they missed their appt?( btw, I am not talking about VAD).
(and yes we could argue this point till the cows go home.)
I am not trying to avoid the topic at hand, but a comparison needs to be presented. The risks of adverse events from NSAID use are much greater than manip/stroke, yet these are highly ignored.
I could list hundreds of comparsions, which have a far greater risk but are still accepted in the medical profession.
IMO, the stroke risk is there as is the NSAIDS usage risk but neither should be outlawed. The benefits outweigh the risk. The stroke issue aimed at DC's is weak. Since many PT's have decided to manipulate they too have to accept responsibilty/blame. In reality, the finger-pointers have only targeted DC's. There is little if any mention of non-DC's who are manipulating cervicals. Too much politics and hidden agenda surrounding this issue. This is no doubt a continuation of weak attempts by the AMA and its affiliates to attack chiropractic.
JBird
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Re: "special skills" - September 18, 2006 11:46:00 AM
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jbird007
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From: USA
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proud,
If a PT is performing a non-specific general form of palpation, is he/she practicing unethically and is this considered to be quackery?
IYO, What type of palpation is specific?
Jbird
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Re: "special skills" - September 18, 2006 12:04:00 PM
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dfjpt
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[QUOTE]the risk-benefit ratio for cervical manip favors the benefit side[/QUOTE]Jbird, how can you say this with a straight face? When other ways of handling necks to reduce pain exist, ways that do NOT rely on a delivery of a sudden HVLA aimed at a joint but delivered to an artery wall, that show equal to superior results/outcomes, HOW can it be that cervical manip risk-benefit ratio "favors" manip? This just does not make sense to me. This is your opinion only. You can't possibly back this up with anything substantial. Please don't talk conspiracy here. There is no agenda other than to save lives/prevent strokes. Surely this is something you would support, if it didn't interfere with your belief systems. Bye.
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Re: "special skills" - September 18, 2006 12:14:00 PM
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PainFree
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Proud,
I have no desire to debate this topic with you since I am assuming that neither you nor I will change the current landscape. Suffice to say that I recognize the benefits of several types of manual therapies as they apply to the c spine. From the PT profession, my favorite happens to be the Mulligan technique.
I'll address some of your recent comments:
"That "do our best" statement speaks volumes."
Yes, I do my best to determine which patients are unlikely candidates for manipulative care. NCMIC, a chiropractic malpractice company, has done a good job addressing this issue and identifying patients who may have a greater risk than others. I have taken and applied this information as well as studying from additional sources.
"Hey painfree. Far be it from me to tell you what to do. But how well informed are your patients about the current "debate"?"
I provide an informed consent to my patients and provide them additional information if they request it. It really is not a big deal for me if a patient does not want HVLA manipulative care. Are they informed about the debate? Who knows. I give them an informed consent. I educate them all they want. If there are not perceived risks and I feel it will benefit them, I certainly don't try to talk them out of it at that point.
"Particularily with upper c-spine rotary techniques."
In an early post, I said "Are some areas of the cervical spine more prone to adverse reactions following an ill timed manipulation? Yes, IMO. Are some type of manipulations more prone to problems than others? Yes, IMO."
You chose to change my words when you said in an early post, "some type of manipulators are more prone to problems than others"
My only point is that I agree with you in that I have already stated that some type of manipulations are more prone to problems than others....that being upper cervical extension rotary moves....which I do not do nor do any of my close colleagues do.
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Re: "special skills" - September 18, 2006 12:31:00 PM
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jbird007
Posts: 297
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From: USA
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Anyone have the actual number of victims of a stroke directly caused by manipulation?
5,100, 1000? Is there a registry of victims?
just wonderin'
Jbird
Diane, I will address your comments tonight when I have a bit more time. I am still working.
btw: the AMA vs Wilks proved "conspiracy."
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Re: "special skills" - September 18, 2006 1:35:00 PM
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proud
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jbird007,
Good luck with all that.
http://www.neck911.com
And djfpt, really well stated. I, for one have no agenda because my cervical spine patients generally get better without the manip.
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Re: "special skills" - September 18, 2006 2:05:00 PM
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rwillcott
Posts: 397
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From: Canada
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jbird007,
Here is an interesting quote and link:
"Calling their concerns significant (neurologists), they warn that stroke and death due to neck manipulation has been reported in the scientific literature for over 50 years and that manipulation is one of the leading causes of stroke in the under 45-age group."
What was more alarming and disgusting to me was the following:
"Paralysis and other complications in infants and children following cervical neck manipulation have occurred [21]. Death has also been reported [23]."
http://www.chirobase.org/15News/neurol.html
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Re: "special skills" - September 18, 2006 2:22:00 PM
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jbird007
Posts: 297
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From: USA
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Are PT's manipulating cervicals?
Jbird
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Re: "special skills" - September 18, 2006 2:25:00 PM
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jbird007
Posts: 297
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From: USA
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I am assuming these studies have been read in detail by the posters and not just copy and pasted.
Jbird
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Re: "special skills" - September 18, 2006 2:31:00 PM
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PainFree
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Rwillcott,
I know that two wrongs do not make a right but since you and Proud make mention of the Canadian stuff....did you realize that there are twice as many strokes being recognized in children now in Canada? Did you know that the reason for this is not because of manipulations but rather due to the medical treatment of congenital heart concerns and the treatment of childhood leukemia? Oh, that and greater recognition and better imaging procedures.
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Re: "special skills" - September 18, 2006 2:49:00 PM
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proud
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jbird007,
Yes, I have read everything I have posted. Everything.
Anywhoo... I think painfree is correct. The feet are dug in here. clearly the mounting evidence will not change the minds of those convinced.
For jbird007, I understand who is an older person, likely will escape with a nice retirement. As the evidence grows exponentially, I pity new grads from chiropractic trade schools.
And I will bring this thing full circle...go get a DPT( as suggested by a chiropractor over at EIM...Sullivan I think). I'm just trying to help.
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