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Re: chiros causing strokes
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Re: chiros causing strokes - May 31, 2007 8:57:00 PM
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3.5fig
Posts: 97
Joined: July 13, 2005
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Rwantz,
Good questions. I will try to answer them as best I can.
Is there a reason they need to be adjusted? It seems to be many reasons. The main reason they come in is for pain relief. Mind you this answer comes from my own experience with my patients. Most patients I see come to me as a last resort...they tried everything else and it didn't work. Those that come in once a month or every 6 weeks come in because the adjustment keeps them out of pain. That is the main reason. Remember I have them all doing exercises and also send some to the PT and the MD for co-management.
I do not treat for malalignments...no bone out of place for me.
I do have concerns for hypermobility and if I suspect that I do not adjust the majority of the time. There will be certain times that an adjustment of a hypermobile joint will reduce pain so that someone can then perform a stabilization exercise program, but I never continuously adjust a hypermobile joint.
Some of the best results I get are with patients that have DJD/DDD. I believe that it is because the manipulation is restoring normal motion which reduces pain and enhances joint nutrition(think movement of the joint and the production of synovial fluid). Now you need to take it patient by patient. Assess they degree of DJD/DDD, pain levels, neurological function, co-morbid states, overall health, past history, etc...
Regarding asking patients to come in once a month for maintenance care...the way I do it is after they are done with a certain treatment plan we then discuss their goals...always taking into account their past history of pain/symptoms/health. If we decide that they are fine with a home exercise program and they just want to come in when needed, that is how we do it. However, if it is a continuing problem that it seems the adjustment helps control their pain and keeps them off meds, at work, and leading a active life, I have no problem seeing them on a regular basis. It doesn't cost much, the risks are small, and the benefit to them is huge. I think of one of my patients who is in her 60s with a long history of back pain. Many times in the hospital and on heavy meds for severe low back pain. Since she has been coming in every 6 weeks she hasn't had a bad flare up for 4 years. Do I know exactly why? No, I don't'. But I am not going to tell her to not come in(please excuse the double negative). She has advance DJD to her lumbar spine and it seems that the adjustments keep her going, out of the hospital, and off the meds.
I am not sure in your post who you are referring to when you ask if I have someone I trust and refer to....do you mean a chiro or MD? I have family practictioners, orthos,and physiatrists(sp)
who refer to me. The office I work in has a good relationship with one of the top ortho shops in town. We send them alot of our surgical patients and they send us the ones that they can't fix...we tend to be the last resort place which makes it challenging, yet fun...
I hope that answers your questions...
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Re: chiros causing strokes - May 31, 2007 9:33:00 PM
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james097
Posts: 178
Joined: January 27, 2005
From: West Vancouver BC
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fig
I have heard this quite frequently from chiropractors and physical therapists,"patients who come to see me come as a last resort,they send us the ones they can't fix". Well this can only be true at the beginning of a new practice. If you are curing the almost incurable, in no time at all you will be inundated with the more easily curable, at least that is what I have always found. But you can't turn away the easy ones because you could only find out they were easy once you examined and treated them.
Jim McGregor
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Re: chiros causing strokes - June 1, 2007 1:55:00 AM
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JCOY
Posts: 34
Joined: April 13, 2006
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Jim-
Your example(as I understand your post) would only hold true in a constant population. But that is impossible. People move in, move out, have babies, grow old, sustain new injuries, change jobs, embark on new activies............
If you are curing the almost incurable
There are many patients with permanent chronic conditions that cannot be "cured", but can be managed very sucessfully.(see Fig's example above)
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Fig-
I think those here may consider--> "Spinal manipulation is manipulation is manipulation"..........That being, "master" cervical, thoracic or lumbar HVLAs, as seen in this example: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1421401
and do not fully understand manipulation as practiced by a DC. AND ALSO---- That there are many non-HVLA manips DCs use.
One I use extensively is:
Cox Flexion/distraction
http://www.coxtechnic.com/FlashOpen2.swf
Don Murphy recently published this great paper on: "A non-surgical approach to the management of lumbar spinal stenosis: A prospective observational cohort study" Using F/D with neural mobilization.
http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1397818
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Re: chiros causing strokes - June 1, 2007 4:40:00 AM
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jlharris
Posts: 476
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From: Nebraska
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JCOY,
Not sure what you are getting at with the first article by Cleland. The point of it is to see if it really matters. The CPR for LBP used a lumbo-sacral manip and some clinicians like to use the million-dollar roll or a straight PA. So, Cleland wants to find out if it makes a difference. His hypothesis is that it doesn't. We'll have to see.
Thanks for the link to the Cox Flexion/Distraction Mob. Always interested in seeing clinicians "perferred" mobilizations.
So was it the manip or the neural mob that did the trick in 16.5 months to get a 1.6pt change in pain? This is a problem in many PT studies and with MSK and Neuromuscular care in general, the inability to control the majority of variables. This disallows making conclusive statements about what definitively caused the effect seen. Of course we won't get into the no control aspect either :p
_____________________________
Jason L. Harris, PT, DPT
My PT Blog
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Re: chiros causing strokes - June 1, 2007 4:57:00 AM
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Alex Brenner PT MPT OCS
Posts: 1057
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From: Kentucky
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Buddy
[QUOTE] When performed on patients appropriately by a properly trained clinician (DC or other), the benefits outweigh the risks.[/QUOTE]I find this very hard to comprehend. A patient comes in with say, 5 out of 10 neck pain found to be related to DDD at various levels of the C-spine. The provider determines that manipulation may be effective to reduce the pain. The manipulation is performed and the patient dies the next day. The benefit outweighs the risk? How can you say that? The patient was killed because he had a little neck pain. This is hard to comprehend especially in light of other viable treatment options that could successfully treat the pain.
3.5fig,
The risk may be small but when it occurs it has a dramatic, horrible effect. Cervical manipulation is definitely not worth the risk in my opinion even though I agree with you that there is benefit; especially when there are so many other safer interventions that can be applied that can result in similar positive outcomes. I personally would not be able to live with a death on my hands especially if all I was treating was neck pain. Could you live with that? I am pretty sure if I killed someone with my hands that came to me with simple neck pain I would find it very hard to continue to practice my profession. Now, if I was a neurosurgeon trying to remove a life-threatening brain tumor and he died on my operating table then I may be able to live with that. But for neck pain, no way.
I have read all the literature that we currently have on the risks and reported incidence rate and I personally feel that the numbers reported are much lower than the actual level of incidence. The reason is that it is very difficult to capture the data retrospectively and be able to report this accurately.
_____________________________
Alex Brenner, PT, MPT, OCS
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Re: chiros causing strokes - June 1, 2007 5:07:00 AM
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JCOY
Posts: 34
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Jason-
It did not take 16.5 mos of treatment. FU was at 16.5 mos after the end of treatment.
.... clinically meaningful improvement in disability was seen in over two-thirds of the patients, and the improvement appeared to be maintained over an average of 16.5 months after cessation of treatment. The sustained improvement over the long term may relate to the emphasis in the management strategy on treatments that are designed to specifically address the known pathophysiology of LSS and on exercise that was designed to compliment the DM and NM, with continuous monitoring of compliance with home exercise throughout the treatment process. However, this study's design does not allow for firm conclusions to be drawn regarding this. Only two patients went on to require surgery, suggesting that the treatment approach studied here may be an effective alternative to surgery for patients with LSS.
I think this study is excellent for a number of reasons. LSS is very problematic, and surgery has not proved to be very successful. This study certainly provides effective options before considering surgery. Both PTs and DCs see LSS very frequently- this study offers a sound treament approach/strategy for LSS, in that only two patients went onto surgery. BTW- it also illustrates DC and PT working together for better patient outcomes- a recent topic here that Fig has posted on.
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Re: chiros causing strokes - June 1, 2007 12:30:00 PM
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Lehmkuhler
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Alex;
How about a surgeon performing surgery with the singular goal of pain reduction? Surgery of any kind carries a higher risk (of death) than manipulation. So is all surgery inappropriate when it's goal is pain reduction? Obviously the answer is NO.
Yes, the safest alternative in PT/DC practice is always to do absolutely nothing. After all, nobody will die at our hands that way......
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Re: chiros causing strokes - June 2, 2007 2:29:00 AM
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proud
Posts: 941
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Lehmkuhler,
Not an argument that really holds water either. In one case( surgeon), they have established the underlying pathology( significant degenerative process in the knee for example). While the other has no real established "thing" that is being "fixed".
So one is atempting to "fix" an underlying pathology...while the other is doing...who knows what?
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Re: chiros causing strokes - June 2, 2007 7:35:00 PM
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3.5fig
Posts: 97
Joined: July 13, 2005
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Proud,
Surgeons perform surgery all the time for pain reduction when they don't really know what is causing the pain. Just the fact that someone has underlying pathology does not equate with pain. Identifying an underlying pathology like degeneration many time establishes nothing. We have all had patients with shoulder pain that has been resistant to all conservative forms of treatment and the MRI shows no tears only some AC joint degeneration and some tendonosis. The surgeon performs surgery hoping to relieve the pain and it is unsuccessful. I would say that the underlying pathology is so often not the cause of pain, that it can be considered not "real" as well. Or you could just as easily say that the PT/DC is treating the underlying pathology(significant degenerative process) just as the surgeon is...In that case Lehmkuhler's argument does hold water...
By the way, how many surgical procedures have been scientifically proven. Last I heard, spinal fusion has no proven benefit...yet it is performed everyday...
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Re: chiros causing strokes - June 3, 2007 2:54:00 AM
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proud
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To be clear..We are comparing against cervical manipulation? No question PT/DC has it's benefit's over surgery. But we are talking cervical manipulation here...correct?
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Re: chiros causing strokes - June 3, 2007 7:04:00 AM
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3.5fig
Posts: 97
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I think Lehmkuhler was was comparing the risk/benefits of cervical manipulation vs. surgery when done for the singular goal of pain reduction. He was responding to the post of Alex Brenner.
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Re: chiros causing strokes - June 3, 2007 11:22:00 AM
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proud
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It's a stretch...comparing cervical manipulation to surgery.
Sure some orthopedic surgeries have suspect outcomes. However, great benefits abound.
In the case of cervical manipulation, we have a mode of treatment with no known benefits over and above any other form of treatment for neck pain....with clear risks.
How many significant adverse events have occured that have not been linked back to the manipulation? I wonder. So does the Canadian stroke consortium.
No known benefits, why do it? Unless Upton Sinclair's quote applies...
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Re: chiros causing strokes - June 3, 2007 7:12:00 PM
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3.5fig
Posts: 97
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What are the known benefits, scientifically proven mind you, of orthopedic surgery. Lets just pick spinal fusion. What "proven benefit" is there to spinal fusion? I am amazed at your statement, "sure some orthopedic surgeries have suspect outcomes, However great benefits abound." Are those great benefits measured on a case by case basis? Are they proven scientifically? What orthopedic surgeries have suspect outcomes?
Comparing the unknown benefits of surgery with the unknown benefits of cervical manipulation is very easy. We have two modes of treatment. One, cervical manipulation which has not so clear risks(you yourself state that you are not even sure how many adverse events related to manipulation have occurred) and the other, surgery which has many clear risks.
Both benefit patients by reducing pain and both need much more research. The risk of surgery far outweighs the risk of cervical manipulation...I am sure you will agree to that. And, don't get me wrong...I am not calling for spinal fusion surgery to be banned.
I think that it is self-evident that when one is comparing surgery and cervical manipulation done only for pain reduction, surgery has much higher risk. Lehmkuhler was stating that surgery with the singular goal of pain reduction carries a much higher risk than cervical manipulation. Your statement that the surgeon has identified an underlying pathology does not hold water when one considers all of the failed surgeries that were done to "fix" a underlying pathology that ended up not being the pain generator in the first place. And, if you consider DJD to be an underlying pathology, cervical manipulation treatment for the DJD is just as much of a treatment as surgery. Tell me how surgery "fixes" DJD anyways? I would love to point my patients to the surgeon who can fix DJD. That guy should win the noble prize. The only fix for DJD of the knee I know of is cutting the whole thing out and putting in a replacement.
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Re: chiros causing strokes - June 3, 2007 7:52:00 PM
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Lehmkuhler
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I have patients, in fact dozens of them in very recent memory that have responded to manipulation when other interventions failed. Will research support my confidence that manipulation was the single best intervention, maybe not. Does that mean that it wasn't the best intervention, not necessarily.
We must also ask whether something unsupported by the research is due to a deficiency of efficacy of the treatment, or simply a limitation and deficency of the research. Research, while tremendously important, is not perfect nor infalliable under any circumstance. Comprende...
And as far as surgeons identifying the specific pathology in regards to surgery, you're kidding, right??? Either that or you have a serious delusion as to the specificity and accuracy of surgeons as to identiying and eliminating the cause of pain. Otherwise we'd pretty much all be out of business...
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Re: chiros causing strokes - June 4, 2007 12:29:00 AM
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proud
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Again, I think you have missed my point. TKR/THR are examples of surgeries. Frank disc herniation and subsequent discectomy have proven outcomes. Do a pubmed search and you will find plenty of orthopedic surgeries with solid evidence. Not all of course.
Cervical manipulation over other modes of treatment? None.
They key here is "other modes of treatment". Sure we can continue to run from the research, claim it's not "good enough". But I am certain as the research progreses, it will prove that cervical manipulation carries more risk than benefit. That is what is down the pipe.
Now THAT is what this discussion is about really. Risk/benefit. If the risks are still a little shady( they are), and we can use mobilization instead with equal results...why manipulate?
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Re: chiros causing strokes - June 4, 2007 1:28:00 AM
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Alex Brenner PT MPT OCS
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From: Kentucky
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If we are going to compare cervical manipulation to ortho surgery then here is my illustration to help clarify my point of view.
My mom just had bilateral knee replacements. When the pain first started about 20 years ago she was able to control it with diet, exercise and weight management. That worked for about 10 years until she had moderate medial knee compartment narrowing and subsequent osteophytosis and increased pain. She then went to physical therapy (from the advice of her son :) ) and was treated with manual techniques, muscle strengthening and aquatic therapy. This seemed to work well until last year when all of a sudden nothing seemed to work. Not only could she no longer do her favorite hobbies such as gardening, playing golf and taking walks with her dog; but she couldn’t work. At this point in her life, she was ready to take the risk of surgery. As I watched her quality of life disintegrate, I didn’t blame her.
In this illustration many other interventions were utilized successfully initially before the higher risk intervention was provided as an option.
Now compare the patient who has had mild to moderate neck pain and headaches for about a month. They saw their physician who prescribed a soft cervical collar. They wore that for about two weeks and it didn’t work. Then, from the advice of their neighbor, decide to come in to your chiro clinic. You decide from the physical exam that cervical manipulation could help reduce the headaches and neck pain (this is pretty standard first time intervention in most chiro clinics, right?). You determine that there are no contraindications for cervical manipulation and you manipulate the patient (by the way, we have no way to screen a patient to know if they are at risk to a vertebral artery dissection). They have a stroke on the way home from your clinic and die the next day.
I guess my question is; why would you go straight to an intervention with known detrimental risks when there are many other safe and effective interventions that could be applied? I am not saying that cervical manipulation should be banned, but should it be held as a last option similar to my mom’s knee replacements?
_____________________________
Alex Brenner, PT, MPT, OCS
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Re: chiros causing strokes - June 4, 2007 2:48:00 AM
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JCOY
Posts: 34
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I guess my question is; why would you go straight to an intervention with known detrimental risks when there are many other safe and effective interventions that could be applied? I am not saying that cervical manipulation should be banned, but should it be held as a last option similar to my mom’s knee replacements?
Why waste time on procedures that are likely to yield less than optimal result? Why take a month to do something that can be accomplished in a week?--(Upton Sinclair?)
I think we can both agree that THAT is why we spend so much time in school and in postgrad seminars and required CEs.......
So that when a patient presents- we can collect the important information(hx, exam etc) evaluate it, and make an efficacious clinical decision of the best treatment plan/best practice, without dillydallying around with time/procedures/money wasted on procedures less likely to achieve the desired goal.
but should it be held as a last option similar to my mom’s knee replacements?[/
Regarding your mothers knee replacement- although I can appreciate your line of thinking and would do exactly the same thing in your mother's case, I don't consider it a good example in this case. Per your mother- her's was a slowly progressive, chronic degenerative condition.......
And may have very little in common with your example of a patient with neck pain and HAs of 1 mo. duration.
An interesting study on this topic:
J Manipulative Physiol Ther. 2006 Sep;29(7):511-7.
Immediate effects on neck pain and active range of motion after a single cervical high-velocity low-amplitude manipulation in subjects presenting with mechanical neck pain: a randomized controlled trial.
Results suggest that a single cervical HVLA manipulation is more effective in reducing neck pain at rest, and in increasing active cervical range of motion, than a control mobilization procedure in subjects suffering from mechanical neck pain.
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Re: chiros causing strokes - June 4, 2007 5:57:00 AM
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orthotherapist
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Interesting discussion.
For the chiros out there that do manipulations - are your patients informed of the risks of cervical manipulations? My bet is that most do not however I am confident in saying that most chiros inform the patient of the benefits of manipulation.
If I had neck pain and was informed that I could stroke out with a manipulation (even though it would be relatively low risk) my decision to have one would be very different than if I did not know that risk.
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Re: chiros causing strokes - June 4, 2007 7:11:00 AM
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orthotherapist
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As my grandpa used to say "there is more than one way to skin a cat"
There is more than one way to treat a cervical pain patient. Risks/benfits must be weighed when clinicians are deciding on how best to treat the patietn once a thorough evaluation is complete. As long as the patient is aware of the potential risk and they wish to proceed so be it. I for one would not do a procedure that carries a risk for death but that is just me. Does that mean I do my patients a disservice - IMO NO.
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Re: chiros causing strokes - June 4, 2007 7:53:00 AM
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Lehmkuhler
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Yes I provide written informed consent that has never been a problem. Had one patient refuse c-manip. So .01% I guess...
And to clear up my earlier thought, I was primarily referring to ortho surgery on the spine. And even though surgery has some definite risks, it's invaluable in many instances. I'm not anti-surgery so long as it's used appropriately.
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