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Re: chiros causing strokes
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Re: chiros causing strokes - June 4, 2007 7:58:00 AM
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3.5fig
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Ditto for me...on both counts
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Re: chiros causing strokes - June 4, 2007 8:30:00 AM
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orthotherapist
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If your written informed consents have in it that adverse outcomes may result and may include the potential for stroke/death, and this form is reviewed verbally with the patient (we all know pepole do not fully read all forms when they register as a new patient at a clinic) and the patient wishes to preceed then that is their choice.
Now if it is just a blanket form that gives you the right to treat and does not list potential consequneces of the treatment then I would have issues with this. IMO most "informed consent" forms fall in this category.
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Re: chiros causing strokes - June 4, 2007 8:53:00 AM
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JCOY
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http://www.cevantive.com/informed/informed.asp
This is the consent form/procedure developed and being advocated by state associations, and malpractice cos, and being taught and used in the schools. It is also a mandated topic in yearly CE requirements.
Perhaps you could detail "Informed Consent" as practiced in your office, and in PT in general.
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Re: chiros causing strokes - June 4, 2007 8:53:00 AM
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Alex Brenner PT MPT OCS
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[QUOTE]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? [/QUOTE]JCOY, I hear you and agree with this especially in other areas of the body that we treat such as the lumbar spine. For me, however, with cervical manipulation it is just not worth the risk. Especially when I feel that I can accomplish a lot with cervical pain with a lower grade cervical mobilization, t-spine manipulation and other less risky interventions.
_____________________________
Alex Brenner, PT, MPT, OCS
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Re: chiros causing strokes - June 4, 2007 2:08:00 PM
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ginger
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Those of you familiar with mobilisation know it to have very good effects on the troubling issues that drive patients to seek treatment. Those familiar with the CM method will know also that this method provides excellent long term results, both to the local cervical pain and movement problem , as well as a means to reveal and eliminate referred neural events associated with cervical facet hypomobility. The combination with CM is so much better , as well as being safer than manipulation , that there seems little reason to ever manipulate. At least not clinical reasons. Other reasons, however may include. Therapist doesn't know CM.
Therapist is in a hurry to see a caseload of biblical proportions and has only five minutes .
Therapist actually believes in subluxation theory and sees manipulations as "putting joints back into place"
Patient insists on being cracked and is willing to pay for that alone.
others?
_____________________________
Ubi est mea anaticula cumminosa?
The Grand Pediculator
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Re: chiros causing strokes - June 4, 2007 4:42:00 PM
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PTupdate.com
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Have to agree with Alex, and I like his analogy. Why do something with a minor but serious risk, when something else can achieve the same goal? There is nothing in the literature that I've read that indicates "BLAM!!! NECK MANIPULATION BLOWS AWAY ANY OTHER TREATMENT"
For those few that do not resolve with my therapy, or others as well, and they are facing the knife, I often tell them that manipulative therapy may be an option, albeit a risky one, and leave the decision up to them. I have yet to have anybody come back and indicate that something miraculous happened.
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 - June 5, 2007 4:13:00 AM
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orthotherapist
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JCOY
Looked over the consent form - nice format but interesting that insurance companies are pushing it (obviously they know there is a risk and they are trying to minimize their potential for having to pay a lawsuit settlement).
I also took a CEU course on the website - it was a free one about Stroke and Manipulation. Per an article that they cite the incident rate is 1.3 cases of vertebral artery disection/occulsion per 100,000 individuals receiving chiropratic manipulations. For those aged less than 45 it showed that VBA (vertebrobasilar accidents) to be 5x more likely than controls to have visited a chiro within one week of the VBA (95 CI).
The evidence is there about the risk of death/disability from manipulations.
When there is exists more than one means to an end I for one will always chose the one that is safest for my patients. Above all else do no harm.
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Re: chiros causing strokes - June 5, 2007 11:19:00 AM
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james097
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Rare as catastrophies seem to be, the real test of a manipulators beliefs would be to continue using the same maneuver shortly after causing death or crippledom of a previous patient.
Jim McGregor
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Re: chiros causing strokes - June 5, 2007 11:50:00 AM
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3.5fig
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Jim,
I think you need to expand upon your post, as it makes no sense. "Manipulators beliefs"????? What are we some wild eyed clut that runs around manipulating anyone we see without regard to anything else. We are not faith healers....!!! Have you ever known a orthopedic surgeon that had a patient die on the operating table while performing a simple rotator cuff repair?(I have). Do you think that surgeon will now never perform that surgery or any surgery again? I bet not. If it was just the maneuver that was to blame then anyone receiving a cervical manipulation would die or be a cripple, however it's not that simple is it?
If one of my patients died due to me performing a cervical manipulation, would I continue practicing? I am not sure. It would be hard to come back from something like that. If I did continue to practice, would I continue to use cervical manipulation? Yes, I would think so...hard to say since I have never been in that situation.
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Re: chiros causing strokes - June 5, 2007 1:40:00 PM
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jlharris
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3.5fig,
"What are we some wild eyed clut(sic) that runs around manipulating anyone we see without regard to anything else. We are not faith healers....!!!"
Unfortunately, were I live, that is exactly how many DC's practice. They manipulate for allergies, fevers, HTN control, DM, ear aches, colic, and just for "wellness".
As the practice act in Iowa (were I currently practice for the company I work for) does not allow PT's to manipulate I sought out a DC that I have heard of here. Spoke with him about my dilemma and the need to have someone I can refer to if manipulation is warranted. He declined stating "I don't do quick fixes. I practice health maintenance and well being". What??
This is what a few of us PT's see and tends to get stereotyped to all DC's out there. Unfair, but I'm still looking for a local DC that practices the way you preach.
_____________________________
Jason L. Harris, PT, DPT
My PT Blog
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Re: chiros causing strokes - June 5, 2007 1:45:00 PM
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proud
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I think an honest question to ask anyone around here who manipulates the C-spine( DC or PT) is...why do it when all research points to no benefit above mobilization?
Count me in as a PT who used to perform cervical manipulation. I always felt with a proper pre-manipulative screen( in depth history, cranial nerve, complete neurolgical evaluation, checking the integrity of alar ligs and dens, vertebral artery test etc), I could be very safe. After reading a great deal of the research on vertebral artery dissection I become convinced that it would be irresponsible to proceed until further research was conducted. I still feel that way.
Guess what? I still get excellent results with neck pain patients( perhaps even better).
So back to the question...Why do it? I issue a challange here to anyone who regularily manipulates the C-spine. Don't do it for one month. Go with mobilization, prediction rules for T-spine manipulation and neck pain, exercises and education...see if results are any different. I bet not.
late entry: I am adding one caveat. I do think that challange would be more difficult for the chiropractic population. Pain is a peculiiar thing with many many facets involved. Patients typically go to a chiropractor with a certain "expectation"...the "pop". Without that tremendous "percieved" skill being utilized, it may undermine the patient confidence factor, which does tend to influence outcomes. But I am sure an already established well respected chiropractor who is evidence based could do it.
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Re: chiros causing strokes - June 5, 2007 1:46:00 PM
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Rwantz
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I agree with Jason, I see this type of chiropractic practice too often. Now when approached by a DC I am immediately turned off. I may be misunderstanding what they are doing or something, but how does that take care of my allergies or any of the myriad of things that are claimed.
Fine, I accept that back pain can be relieved. Whether that is the most effeective and warranted is still out there. But wellness, allergies.................
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Re: chiros causing strokes - June 5, 2007 5:04:00 PM
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PTupdate.com
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Going to the chiro and not getting the "pop" would be as bad as going to Hooters and not getting....well, Hooters.
Duffy
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John M. Duffy, PT
Board Certified Orthopaedic Clinical Specialist
www.PTupdate.com
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Re: chiros causing strokes - June 6, 2007 3:15:00 AM
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Alex Brenner PT MPT OCS
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Or, going to the Irish Pub and not getting a Guinness.
What kind of weirdo goes to an Irish Bar and orders a Bud light?
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Alex Brenner, PT, MPT, OCS
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Re: chiros causing strokes - June 6, 2007 3:21:00 AM
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Alex Brenner PT MPT OCS
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3.5 Fig,
Unfortunately, Chiropractic carries a stigma in many areas. This is due mostly to the "straight" Chiros who practice with the subluxation model and who feel they can heal colic, allergies, etc. Doesn't your national chiro organization support this model too?
It would be interesting to see what has happened to those past Chiros that were found to have killed/disabled individuals with cervical manipulation. In my area, they would have been run out of town. An orthopaedic surgeon, on the other hand, carries a certain prestige and it would be more accepted if someone died in their hands. I am not saying that this is right, but it is just the reality.
_____________________________
Alex Brenner, PT, MPT, OCS
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Re: chiros causing strokes - June 6, 2007 11:15:00 AM
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orthotherapist
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I agree with others that state chiros carry a stigma, etc.
I just had a patient today that had recently visited a chiro and was told that he had unnecessary surgery on his thyroid. He was informed by the chiro that if he had come to him first that he would have been "healed" after a series of adjustments. The chiro also said that his son did not need surgery to repair a hernia as a "quick manipulation or two" would take care of it. Now I am the first to know that patients sometimes do not always "hear" what they are told but in this case I beleive the patient.
With individuals like this practicing as chiropractors you can see why the profession is not always thought of in the best light.
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Re: chiros causing strokes - June 6, 2007 3:48:00 PM
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TMondale
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All,
Chiros stigmas not whithstanding, I wonder what we as physical therapists are going to say, and what do we say now to the fact that there is a CPR for neck pain immediate responders to thrust manipulation. That means that there is a subgroup established. Yes, it still need to be validated, and again compared with other proven treatment. However, there is ample evidence that thrust manipulation is effective in treating neck pain, particularly when combined with exercise
For those among us who feel that no evidence would ever be enough, and every cervical thrust manipulation teeters on the brink of catastrophy, are we again going to be left with our hats in our hands when sub groups are validated that clearly benefit a greater degree from thrust compared to non-thrust, or any other reference standard; we've already established it in the T-spine. I say again because we were very late and still resisting the benefits clearly established in the lumbar and thoracic spines of thrust manipulation.
I think in many ways we have to resist our reactionary instincts when we speak and think about provocative concepts like c-spine thrust manipulation and safety. Just because chiros believe in it doesn't mean it's bad. Let's let the neurologists, etc be reactionary; we are trying to help the people that they can't, very effectively. As per the AAOMPT marketing motto goes; you've got surgery, you've got medication, or you've got us. All were working from now is a lot of theory, anecdote, opinion and fear but not much good guiding evidence.
Let's be good and responsible scientists and proceed/progress with caution while investigating the dangers as well as the benefits.
Tim
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Re: chiros causing strokes - June 6, 2007 6:57:00 PM
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Marc Bronson
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From: Toronto
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Great post, Tim.
Ortho, Alex:
As a fresh grad from Canada, I can only lament the total stigma that the "straights" have cast upon the evidence-based wing who clearly stick to manual and conservative methods of treating neuromusculoskeletal disorders. I honestly never knew of the 2 headed monster that is may very well rip my profession apart. If I could do it all over again I would go into PT; especially since there is an increased focus on manual treatments and an increasing scope of practice and eventual doctorate status in Canada (currently at the Master's level).
The thing that sucks is that I totally got a legitimate education at CMCC but that is far overshadowed by the whack jobs who claim to "cure" visceral issues.
M.
(sorry about the depressing post, the Senators just lost the Cup Finals to Anaheim. So typically Canadian, eh? ;)
_____________________________
BSc (Hon), DC, Dipl. Med. Ac. CSCS
Integrative Manual Medicine
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Re: chiros causing strokes - June 6, 2007 7:26:00 PM
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ONstudentPT555
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Marc,
One of my clinical tutors was a chiro and went back to school to become a PT.. so its never too late. His wife was also a chiro but she now works as a teacher.
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Re: chiros causing strokes - June 7, 2007 1:50:00 AM
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Alex Brenner PT MPT OCS
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Tim,
Great post and I agree. I have held this back from the discussion because I can't seem to find where it is documented, but I believe that the cervical manipulation technique that has been shown to be the culprit in vertebral artery dissections is one with a rotary force coupled with extension. Research in this area would have some merit. We need to identify which specific technique that is causing the strokes and replace it with a technique that has been shown to equally effective. I believe the CPR study with cervical manipulation that you refer to does not utilize a rotational manipulation. Correct?
Until we can eliminate the risk of stroke associated with cervical manipulation by identifying with certainty which specific type of technique or force that causes it, I will have to leave this intervention on the back shelf even if a CPR exists for it.
_____________________________
Alex Brenner, PT, MPT, OCS
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