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Re: chiros causing strokes
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Re: chiros causing strokes - May 30, 2007 12:38:00 PM
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drbuddy
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From: Pennsylvania
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(I know, I said I wouldnt post again on this thread)
Proud, it is very possible that this patient was presenting with stroke like symptoms from the beginning. So, it's difficult for anyone to determine, even the most giften coroner in the world, to comment as to the cause of the artery damage. This is one of the hot button issues regarding stroke and manipulation. In many cases it appears that symptoms causing the person to present for treatment are symptoms of stroke itself (neck pain and headaches, a common presentation). This person could have just as easily ended up being treated by a PT with the same result after performing exercises or being mobilized.
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Re: chiros causing strokes - May 30, 2007 1:37:00 PM
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jlharris
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I also think that using "weekend seminar" as a means to describe PT's education and training is a deliberate attempt by DC's to discredit our ability to provide straight forward, effective manipulation to the subset of pts that have been shown by the literature to benefit from it.
One has to watch complaining about one parties tactics and then turning around and doing just the same or worse. You can lose credibility and respect when you most likely have a lot to offer to this community.
_____________________________
Jason L. Harris, PT, DPT
My PT Blog
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Re: chiros causing strokes - May 30, 2007 1:59:00 PM
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proud
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My point is...something is going on. The so called "low numbers" is open for debate. Many well educated people suggest the risks are low. Many well educated individuals suggest the risks may be quite a bit higher( significant adverse events that may not have been linked to manipulation). It's all debatable.
So as practitioners interested in the well being of our patients, I fail to see how someone would choose manipulation over mobilization until all the facts are in. Makes no sense to me.
And I'm with Jason....fig, if you think manipulation requires extensive years of training to be safe and effective...you have some literature to review.
By the way, many PT's spend a great deal of time learning joint play analysis with special manipulation skills being the ultimate objective(see the ortho division in Canada for an example). I think that is equally unnecessary. And I have taken those courses...
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Re: chiros causing strokes - May 30, 2007 2:40:00 PM
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3.5fig
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I am not sure, but I do not think that Jason's post was directed towards me. I never mentioned weekend seminar in any of my posts.
I don't see how the low numbers can still be debated when the research has been done and the worst I have seen out there is 1 out of 400,000 manipulations will there be a stroke...While we can debate the benefits of manipulation till the cows come home and neither of us will change our minds, I don't think there is any debate on the risk of stroke with manipulation. Unless you can show me some literature that shows a higher risk than all of the studies out there...I don't see a debate. Believe me, if it was that risky then my malpractice insurance premium would be much higher than it is...I believe that it is close to the cost of a PT premium...
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Re: chiros causing strokes - May 30, 2007 5:24:00 PM
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PTupdate.com
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From: Pittsburgh, PA USA
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Interesting points all. Consider: Manipulation does have it's place in the treatment of both cervical and lumbar patients. It's being strongly supported in our own literature.
While the risk of stroke is present, perhaps the strong term "stroke" and it's sequelae somehow overshadow what others have noted here....thousands die each year or are sick due to NSAID therapy. If we crusade against manipulative therapy for the neck, should we not do the same for NSAIDs?
Personally, I don't manipulate the neck....at least high velocity thrust. I do perform mobilization, traction, and passive stretching. For all I know, 10 patients may have gone home over the years and had CVA's from what I do, or what others have done similar to my own treatments.
We need to take this information and use it to ours and the patients benefit. Try standard treatments, and if no luck, consider manipulation while educating the patient as to the reason behind this decision, and the risks involved. Document accordingly, and then treat using best practice standards and CPR's
John Duffy, PT OCS
[URL=http://www.PTupdate.com]www.PTupdate.com[/URL]
_____________________________
John M. Duffy, PT
Board Certified Orthopaedic Clinical Specialist
www.PTupdate.com
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Re: chiros causing strokes - May 30, 2007 7:57:00 PM
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Rwantz
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From: Middletown, PA
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This has ended up to be a very interesting thread. I think that some very good points have been raised, among the punches.
The percentage is low, however I think that 1 in 1-3 million is probably not accurate (and extremely broad). I would like to say that despite DCs believing that they are the only ones qualified to manipulate is irresponsible. I have met many patients that feel that they have been taken by a DC for continued care. It is not appropriate to think that a person needs to be treated for an extended period of time for manipulations. The idea that manipulation is chiropractic is the same idea that rehabilitation is only physical therapy. Neither is an exclusive service of either.
I do agree that mobilization is preferred prior to the use of manipulation.
I do hope that the thread takes to heart the risk of cervical manipulation and educating patients about anything to be aware of. I personally do not do cervical manipulations. Mainly I do not subscribe to overuse of manipulations. Maybe that is because of my strong dislike for the theory of what it stands for.
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Re: chiros causing strokes - May 31, 2007 2:06:00 AM
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proud
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Duffy,
That NSAID comparison does not hold water. The fact is that NSAID usage is typically in the hands of the patient.They are given all appropriate dosing instructions etc. The facts indicate that patient error and significant pre-disposing health issues contribute to NSAID adverse events.
People who present for cervical spine manipulation are 1)otherwise healthy individuals. And 2) The entire procedure is in the hands of the clinician. Thus, the onus is on the clinician.
There is a difference.
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Re: chiros causing strokes - May 31, 2007 6:30:00 AM
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3.5fig
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Proud,
1) What facts are you referencing that patient error and significant pre-disposing health issues contribute to NSAID adverse events? I have yet to see a study on NSAID adverse events that lay the blame on the patient. I have personally seen at least 3 healthy 20 yo males with no pre-disposing health issues have emergency surgery for GI bleeds directly related to NSAIDs and they were taking it in the proper dosage. That being said, alot of people that have adverse events do have underlying health issues. Knowing that and the inherent danger with NSAIDs in the general population, should more tightly regulate their usage?
2) Where do you get your data or the idea that people who present for cervical manipulation are otherwise healthy individuals? That would be news to the majority of the Chiropractors nationwide. My patient base is has all sorts of patients...healthy and unhealthy. That is one reason I use so many different techniques when treating patients. I will use a different technique on a patient with hypertension than I will on someone without hypertension. Same goes with someone with fibromyalgia as opposed to someone without fibromyalgia...or MS, or CP, or osteoporosis, the list goes on and on....I don't think you have a real good idea of the typical patient base of the typical chiropractor.
Rwantz,
I agree with alot of what you have said, however I would like to give you a perspective on long term care of patients. I have numerous patients that come in once a month or every 6 weeks or so for an adjustment(manipulation). They cover every demographic...elderly, middle age, young, very active, couch potatoes, healthy, and unhealthy, but the one thing they have in common is that they have had spinal pain(lumbar, thoracic, or cervical) issues in the past. The other thing they have in common is that they all say that a regular treatment stops their pain from reaching the 10/10 level and that they don't have to take as much or any medication. In fact one of the chiros in our office has a kid who has CP and he comes in once a month. He and his mother both state that it really helps relieve his discomfort and he is more active because of the regular treatments. I believe that I am doing those patients a valuable service and yes they have all being instructed in home exercise programs as well, so it is not all passive care. I have no problem treating like this and believe it is very ethical way of treating. Many chiros treat the same way, so when you hear of someone going in once per month for a treatment don't be too quick to dismiss it...this is what may be happening
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Re: chiros causing strokes - May 31, 2007 6:49:00 AM
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proud
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Fig,
1. NSAIDS are controled well. From the prescribing physician to the dispensing pharmacist, there are checks and balances. Many people take NSAIDS that their spouse had prescribed, bought over the counter, etc. I will look for a reputable source on patient error. But the NSAID example has been proven a poor one over and over.
2. By otherwise healthy I mean that the patient presented to either a PT or a DC for simple neck pain. I am certain they did not come to you for treatment OF hypertension...or MS, or CP. They had aggrevating NON LIFE THREATENING neck pain. A simple little unfortunate part of being human...Pain.
They did not come to you or I for treatment of POTENTIALLY life threatening hypertension. Thus the dispension of medication is more risky...it can be utilized for REAL life concering matters. Not neck pain. The comparison of the risks involving medication versus cervical manipulation is poor.
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Re: chiros causing strokes - May 31, 2007 6:55:00 AM
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3.5fig
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I agree that they did not come to me for treatment of life threatening neck pain. However, I disagree with you regarding the comparsion of risks between manipulation and NSAIDs as many otherwise healthy people are daily takers of NSAIDs for non-life threatening neck pain. The same people that present for manipulation.
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Re: chiros causing strokes - May 31, 2007 8:21:00 AM
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TMondale
Posts: 131
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From: Newton-Wellelsley Hospital
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I have to agree with the chiros on this one. These are very sensational and tragic occurances, but they are by all abilities to determine, very unusual to say the least. The truth is we don't know if non thrust manipulation manipulation of the c-spine ( upper,middle, or low) carries any less risk than thrust. We are in the process of designing an RTC to look at effectiveness of each, and also adverse events. We think it's going to be extremly difficult to get it through our IRB. The best hedge against any possible event/s is to pay attention to the symptom response and not to proceed if there is emergence of symptoms of neurologic event.
I've said this before; there are PT's and probably chiros that advocate bending someones head back over the end of a table to treat neck pain, and home instructing in the same. Now that I would not do.
Tim
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Re: chiros causing strokes - May 31, 2007 10:27:00 AM
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proud
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Tim,
I respect that. But I have read a great deal of work completed by neurologists around the world on this and they tell a very different story. I will locate some of the work if I can and post it here.
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Re: chiros causing strokes - May 31, 2007 2:04:00 PM
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proud
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"....it's difficult to get a man to understand something when his salary depends upon him not understanding it..."
Upton Sinclair(prolific American author)
In any case..here are a couple of articles. I have the hard copies only.
http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=Retrieve&db=PubMed&list_uids=14586598&dopt=Abstract
http://www.neurology.org/cgi/content/abstract/60/9/1424
I have a few others but running out of time.
It's about risks and do we understand the risks well enough? I would argue not just yet...and the courts in Canada would agree with me.
By the way...one of the articles keeps saying "chiropractic manipulation". That of course is misleading suggesting that only chiropractic manipulation could have adverse consequences. Which of course is not the case. Would have been better to simply say cervical manipulation.
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Re: chiros causing strokes - May 31, 2007 2:29:00 PM
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3.5fig
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I don't see anything that I would disagree with in those two studies. I do agree that they should say cervical manipulation instead of chiropractic manipulation. And I am just going to ignore that Upton Sinclair quote as hopefully not directed at me...
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Re: chiros causing strokes - May 31, 2007 3:01:00 PM
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proud
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No, the Upton Sinclair quote I just think applies in general...not to you fig as you seem to put intelligent thought into your practice.
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Re: chiros causing strokes - May 31, 2007 4:16:00 PM
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TMondale
Posts: 131
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From: Newton-Wellelsley Hospital
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Proud,
Thanks for the abstract links. I hate to sound like a chiro here, but again we know there are risks. These two studies only support that patients with vertebral artery dissection tend to have neck pain. They can't say that these dissections weren't in progress prior to the manipulation. Now it sure would be helpful to be able to pick this up prior to manipulating them if that is the case. What I would like to know is if the presenting complaints, or findings on exam. give any clues to a dissection in progress.
We all struggle with this question.
Tim
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Re: chiros causing strokes - May 31, 2007 4:49:00 PM
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Rwantz
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fig, I would like to ask you, why do people need to be adjusted so frequently and chronically. Is there a reason that they seem to need adjusted? Focusing on purely manipulative techniques is largely not the problem with the majority of spine patients. I would have to say that people are not in pain because of malalignments necessarily.
Just like an anteriorly rotated pelvis is not necessarily the cause of hip pain. But how many people focus on that anterior rotation.
I will not deny a patient testimonial. However, my doubts are much too strong.
What about the concerns of causing hypermobility in the facet from chronic treatments? What about degeneration of the joint and disc?
I am sure that there are DCs that are excellent and are knowledgeable, however I feel very unsure about DCs that ask patients to come in frequently (or even infrequently) to be manipulated. This is setting them up for problems and in the end is not really helping.
I do not doubt that people get relief, but the inhibition will gradually subside and will make the person unstable and in pain (from the origin and from the hypermobility).
I am not trying to stomp on your profession because I cannot say that this is the way that you treat. But for the examples that I am very well aware of, I cannot recommend chiropractic treatment. It may just be me.
Just wondering, how many people suggest or recommend chiropractic to their patients? Do you have a relationship with one that you trust and refer to?
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Re: chiros causing strokes - May 31, 2007 4:59:00 PM
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proud
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Tim,
"...We all struggle with this question...."
I would say you just nailed it there. Detection tests/questions lack validity. Yet we see the anantomy of the region clearly lends itself to potential problems.
So if lower grade techniques can have similiar effects( cochrane collaboration), why not just go with that route?
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Re: chiros causing strokes - May 31, 2007 6:32:00 PM
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supender
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If we look at the recent literature, it becomes clear Thoracic Manipulation has high likelihood of improving Neck pain and CPRs have been developed for that too.And also it carries far lower risks of stoke( in fact none reported).I think as responsible practioners( both PTs AND cHIROS) should shift towards thoracic manipulation for neck pain in interest of the patients.
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