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Re: chiros causing strokes
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Re: chiros causing strokes - June 7, 2007 1:59:00 AM
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SJBird55
Posts: 2438
Joined: May 10, 2004
From: Michigan
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I don't understand why no one has interviewed or questioned the provider in the cases that a severe adverse reaction occurred or death occurred. Couldn't someone videotape the procedure that was performed? Couldn't there be some observational analysis of those videos and then some statistics run to see if there were certain techniques or components that were definite commonalities? I doubt if any research review board would allow some "live" study... but why not an attempt at a retrospective study?
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Re: chiros causing strokes - June 7, 2007 6:49:00 AM
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TMondale
Posts: 131
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From: Newton-Wellelsley Hospital
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Alex,
It is true that the prediction rule did not utilize a rotational lever in their thrust; it was a side bend gapping technique. However I would be very skeptical that the actual technique had/has much to do with the safety.
SJ,
What I would like to see is what are the charicteristics that are identifiable of a VAD in progress. We know these happen with even normal movements, but how do we identify besides neck pain that it is happening before we might entertain the notion of thrust manipulating those people.
If I could just relate a story that I just heard last night as I stupidly stayed up to watch my Red Sox lose yet another game. I'll try to keep it brief. The Sox are in Oakland and are being made to look silly by the Oakland pitcher; a rather rotund lefty. The NESN sports casters launch into this story about the guys history with a painful process affecting his back in the scapular region; it went on for months; 3 MRI's (can you believe that),they went on and on. Hopefull that our professions name will come up in a helpful manner my ears perk up. They go on--- he tried everything --- I don't remember them mentioning PT, but I would be shocked if we didn't have a first crack (no pun intended) at this case. "finally he went to a chiropractor and got better".
Now this is a telecast going out to probably hundreds of thousands of homes. Why couldn't we help this guy? There should be nothing a chiro can offer that we can't; we should be able to offer more. Now maybe it was a timing thing, ie the time was just right; that's possible.
I leap to the conclusion that it was a case of PT not having the skill set, or not being willing to intervene with appropriate manual therapies and exercise to help out.
It kills me to hear this kind of thing, but it's not rare. I think if the chiro's weren't percieved as such a goofy lot they would be beating our brains out (sorry for the vulgar word imagery) with this kind of thing.
If anyone knows more about this case I would love to hear it.
I only relate this story out of frustration; both with the Red Sox, and with my profession.
Chiros aren't our biggest competition, or problem, we are. They in turn are their own worst enimies. We had better turn our ship before they do.
I think this whole story relates to the subject here, because we are so quick to dismiss something because chiro defends it, or some neurologist/physiatrists/orthopedist,etc says it must be dangerous.
We've got to get better.
Tim
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Re: chiros causing strokes - June 7, 2007 7:16:00 AM
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proud
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Tim,
I think we need to keep in perspective what is being stated. I don't think anyone here has implied that cervical manipulation does not have clinical merit. I recall I had nice results with it.
But the key is how does it compare against other modes of treatment? It appears as though it does not produce improved results. Yet the jury is out on possible uncharted cases of adverese events. So why choose a potentially harmful Tx when equally beneficial options are available. why would one do that? What would be the motivation to do that?
I suspect sooner rather than latter, we will have that answer to the real frequency of adverse events and it will not be nice.
I still recommend my challange to those so inclined. The results I think would suprise the "cervical manipulation" group.
But I agree with your last post completly. There is no excuse for a Phsical Therapist NOT knowing simple manipulation procedures. I also know many PT who continue with modality based treatment and could really care less about evidence based practice. We have PT's stretching skin, doing cranio-sacral therapy etc...that needs to stop.
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Re: chiros causing strokes - June 7, 2007 10:29:00 AM
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TMondale
Posts: 131
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From: Newton-Wellelsley Hospital
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Proud,
Thanks for the response. You've made clear your belief that you think what we know, or think we know is just the tip of the ice berg in terms of catastrophic results of cervical thrust manipulation. You may be right. I don't think so. If it were we would have had that evidence long ago. You are of course correct that evidence is sparse with regards to thrust being far superior to non thrust. What I think you also miss is we don't know if non thrust is any safer than thrust manipulation in the neck.
As I see it we have two choices: We iether take what we know, exagerate it and leap to unfounded conclusions with the end game being we don't develop the skill set and understanding to provide this service. Or the other option is we stay engaged, be the leaders in investigating subgroups, efficacy, and safety in the c-spine and everywhere else, and be THE neuromusculoskeletal experts we claim we are.
Proud, I respect your opinion, and all those who agree with you, and have no doubt that your outcomes are at least equal to mine. If you practice to the evidence that's how it should be. However, I seriously doubt that the manual service you provide for neck pain patients is one bit safer than that that I provide.
By the way we teach our interns to thrust manipulate including the c-spine. We don't make them utilize it in their treatments, that's up to them. We did have a transient reported case of peri-oral numbness once many years ago, but that was after an SI regional technique in a patient that met the CPR for manipulating the low back for acute low back pain; go figure.
Tim
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Re: chiros causing strokes - June 7, 2007 1:44:00 PM
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proud
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Tim,
I think I understand your suggestion that we do not know if non thrust manipulation is safer than thrust manipulation in the cervical spine. I assume you are speaking from purely a "show me the evidence" perspective. I get that.
I don't know if you have had a chance to read the full text of the abstracts I posted, or any of the work from the Canadian stroke Consortium? Within those, the "anatomy of vertebral artey dissection" is well described. In terms of neurolgical protective mechanisms in the C-spine when comparing thrust Vs Non thrust...there is an obvious difference.
The anatomy is adequately suggestive. You know, some things we have enough knowledge about to understand without absolutes...and err on the side of caution. Without question when patient saftey is the debate. No one has ever studied the effectivness of parachutes but I know if I jump out of a plane...I'm using one.
To extend the parachute analogy further, all I know is if I am jumping out of a plane and someone said I had a choice between two types of parachutes. Both will land you safely. But "this" particular parachute "might" have have a few malfunctions but we are looking into it...which one would you choose?
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Re: chiros causing strokes - June 7, 2007 3:32:00 PM
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PTupdate.com
Posts: 1478
Joined: October 8, 2001
From: Pittsburgh, PA USA
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Tim: The case you are mentioning may be one where the PT's that are staffed have to listen to the orders of the team physician, and may not have had the ability (clinically, or via orders) to perform this. As much as I love sports, I could never have that mindset where I just GOTTA be treating these primadonnas. Perhaps those that have this fetish are not the best of what our profession has to offer
When Charlie Batch of the Steelers broke his hand, he stood there with it hanging down for the rest of the game. Of course I was not surprised when the papers noted his delay due to persistent swelling...duh
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 7, 2007 5:01:00 PM
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TMondale
Posts: 131
Joined: January 3, 2005
From: Newton-Wellelsley Hospital
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Proud,
I did read the abstract you posted. All I can say is it's the same stuff. Haldeman (1999 spine), same stuff. Really I'm not saying we should carry on as if it means nothing, but we should also not carry on as if we even closely understand what is going on here. In the end if we do nothing we're being pretty safe, beyond that there is risk. It's like a court scene from a few good men; I'll concede that on very rare occasion Thrust manipulation and VAD seem to have some link, as long as you concede we have little idea beyond that the vertebral arteries make a turn in the upper cervical spine, what that link may be.
How many of those patients do you suppose came to practitioners with no neck pain, were thrust manipulated in the neck, and stroked; now that to me would be fairly ****ing. As I said we need to be better at identifying those in danger, and our tools at this point are not good.
John,
Perhaps you are right, but a very poor statement on the degree of our overall supposed professional development.
Tim
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Re: chiros causing strokes - June 7, 2007 5:07:00 PM
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proud
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Sorry Tim, I meant to ask if you have read the full text of the articles?
But I think you saying we don't know... is exactly the point. But a link has been demonstrated.
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Re: chiros causing strokes - June 7, 2007 5:07:00 PM
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PTupdate.com
Posts: 1478
Joined: October 8, 2001
From: Pittsburgh, PA USA
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Tim: Define what you meant regarding a poor statement?
Duffy
_____________________________
John M. Duffy, PT
Board Certified Orthopaedic Clinical Specialist
www.PTupdate.com
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Re: chiros causing strokes - June 8, 2007 1:54:00 AM
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TMondale
Posts: 131
Joined: January 3, 2005
From: Newton-Wellelsley Hospital
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John,
I didn't mean yours was a poor statement, but rather that it was a poor reflection on our profession that there are those of us out there practicing in a sub standard manner.
I thought your comments were well thought out.
Tim
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Re: chiros causing strokes - June 8, 2007 7:29:00 AM
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Marc Bronson
Posts: 113
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From: Toronto
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Looking at this from a biomechanical perspective, Herzog et al have done some good work studying the forces applied to the vertebral artery during thrust manipulation at the C-spine:
Internal forces sustained by the vertebral artery during spinal manipulative therapy.Symons BP, Leonard T, Herzog W.
Human Performance Laboratory, Faculty of Kinesiology, University of Calgary, Canada.
BACKGROUND: Spinal manipulative therapy (SMT) has been established as a clinically effective modality for the management of several musculoskeletal disorders. One major issue with the use of SMT is its safety, especially with respect to neck manipulation and the risk of stroke in the vertebrobasilar system. OBJECTIVES: Our objectives were to quantify the strains and forces sustained by the vertebral artery (VA) in situ during SMT. Study Design: This was a cadaveric study. METHODS: Six VAs were obtained from 5 unembalmed postrigor cadavers. The cephalad/distal (C0-C1) and caudad/proximal (C6-subclavian artery) loops of the VA were carefully exposed and instrumented with a pair of piezoelectric ultrasonographic crystals. The strains between each crystal pair were recorded during range of motion testing and diagnostic tests and during a variety of SMT procedures. The VA was then dissected free and strained on a materials testing machine until mechanical failure occurred. RESULTS: SMT performed on the contralateral side of the cervical spine resulted in an average strain of 6.2% +/- 1.3% to the distal (C0-C1) loop of the VA and a 2.1% +/- 0.4% strain to the proximal (C6) loop. These values were similar to or lower than the strains recorded during diagnostic and range of motion testing. Failure testing demonstrated that the VAs could be stretched to 139% to 162% of their resting length before mechanical failure occurred. Therefore the strains sustained by the VA during SMT represent approximately one ninth of the strain at mechanical failure. CONCLUSIONS: SMT resulted in strains to the VA that were almost an order of magnitude lower than the strains required to mechanically disrupt it. We conclude that under normal circumstances, a single typical (high-velocity/low-amplitude) SMT thrust is very unlikely to mechanically disrupt the VA.
PMID: 12381972 [PubMed - indexed for MEDLINE]
There is also some current research right now occuring at CMCC studying in-vivo affects of cervical SMT by Triano et al. As long as the patient provides informed consent and the practitioner has a skill set to be able to gauge the amount of force required, the overwhelming odds is there should be no problem. A careful history screen is the best we can do to help rule out patients for SMT. Last time I read, high homocysteine levels were the only thing that may be predict future VBA.
Personally, I try to do everything first prior to make sure the joint restriction/pain can be dealt with before SMT (in particular manual soft tissue techniques, PNF, muscle relaxtion techniques (reciprocal inhibition response), etc.. My two cents.
_____________________________
BSc (Hon), DC, Dipl. Med. Ac. CSCS
Integrative Manual Medicine
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