quote:

ORIGINAL: Sebastian Asselbergs

Do not get me wrong - I am NOT arguing for the defense here - I am arguing that proving a clear causal relationship is going to be nearly impossible. 

quote:

ORIGINAL: Sebastian Asselbergs

Bonez, I happen to agree with Sacket. To prove a direct relationship between upper cervical thrust and VBI is FAR from easy - and has NOT been done. Causal relationships need a very strong level of evidence, and that is simply NOT available at this time - and may never be available.
What it ends up boiling down to, is potential risk versus possible benefit; is upper cervical thrust the ONLY tool for certain diagnoses? Or are there alternatives with less risk of potential injury? (hint: I think there are)

I personally think that at this time, a horrible personal tragedy tends to make lawsuits an emotional issue. Is the woman's care justifiably under scrutiny? Hell, yes.
Will there be enough strong evidence linking the "adjustment" with the incident? Darn unlikely. At this time, there only seems to be a time-line correlation; same as in the other reported cases of such nature. And thus far, the incidence of such events appears to be rare.

Having said that, it looks like it is time for chiropractors to drop the upper cervical thrust from their practice: first, because minimizing risk to patients - wherever possible - is always GOOD. Second, this technique is now under such scrutiny, they would be plain dumb to continue its use and open themselves up to more challenges....

I cringe when I think about the times I performed 2-person Cyriax manipulations - the forces were quite huge (check Cyriax's books for pictures - scary). Glad I was scared enough instinctively to drop those in the 80's.

quote:

ORIGINAL: proud

Bonez,

As someone on here that I have found clinically insightful and clearly knowledgeable...I am a bit shocked by your emotional response. What you have to understand is that for me....it's a risk versus benefit query. Do I have a problem with how poorly self-regulated the chiropractic community seems to be? You bet I do. But you appear to be suggesting that I am on some sort of witch hunt ignoring flawless information that contradicts my opinions.

Far from it. What I have stated is that there exists many opposing views and panels of 'learned" experts on the topic of cervical manipulation and VBI. No emotional attachment for me. In fact...I have no direct competition from the chiropractic community so it is truly not important to me.

You also seem to be suggesting that I have completely disregarded this panels work. Again an emotional response. I think their work was excellent. I simply intended to point out that taking one panels of experts work and valueing it above opposing expert opinion and systemmatic reviews is improper science as well. This panel did not put an end to the safety debate at all. It added a side to it for sure.

It's astounding to me how an otherwise itelligent individual would be willing to accept one side of a debate purely because it is consistent with a practice pattern. It's one thing to do that when it's a debatable shoulder mobilization without dire health concequences....quite another when the ongoing, unresolved debate DOES involve dire health consequences.

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If I accept that the work must be biased because he is a Chiro then all work must by extension receive the same screen and that means you will have to accept that the PT's doing studies must have their work considered less than if a neutral party had performed the study.

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Proof, evidence, or causal relationships won't likely have much of an impact on the case: It's the US legal system.

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ORIGINAL: rwillcott

I understand that it is important to research upper cervical manipulation and the risk of a VBI.  However, just take a step back and think about what has happened.  Pretend you are not a PT for a moment.  A patient went to a health professional for help.  From what I understand she was informed that she needed maintenance care.  She was informed that this technique would improve her overall health.  A technique that dates back I beleive to the 1800's.  A technique that is thought to release the bodies own innate power to heal itself.  All by twisting the head/neck to unlock 'subluxations' that are preventing the body from using it's own healing power.  How archaic does that sound? 

I could list many outdated forms of medicine that are no longer used since they were proven ineffective.  And I'm tired of hearing the one about aspirin.  This example is clearly taught in chiro schools.  Come up with something unique for pete's sack. 

Unfortunately we live in a society where if someones runs the risk of loosing money they will do everything in their power to prevent that from happening.  That includes the continued blatant deception of the public risking their health. 

It would be best if chiro's stop fighting this battle.  You have a role in the health care field in some capacity.  Take this as a sign that it's time rethink what that role is. 

quote:

 Conclusions Spinal manipulation, particularly when performed on the upper spine, is frequently associated with mild to moderate adverse effects. It can also result in serious complications such as vertebral artery dissection followed by stroke. Currently, the incidence of such events is not known. In the interest of patient safety we should reconsider our policy towards the routine use of spinal manipulation.

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ORIGINAL: TexasOrtho

From a recent 2008 article in Manual Therapy.

Manual Therapy and Cervical Arterial Dysfunction, Directions

for the Future: A Clinical Perspective

 

Key Messages

• Traditional cardinal signs and symptoms of VBI following MT are not supported by the literature.

 

• The real risk of arterial complications following MT is unknown and impossible to estimate, based on existing data.

 

• The results of blood flow studies are contradictory and inconclusive. Commonly used functional screening tests are not supported by the data available from these studies,

nor from case reports.

 

• Consideration of haemodynamics related to the cervical region may enhance clinicians’ understanding of risks and mechanisms of vascular events.

 

• Adherence to guidelines might not necessarily be a defense, and expert opinion can be over-ruled in law.

 

Recommendations

• We propose the term cervical arterial dysfunction (CAD) to embrace the whole cervical arterial system and the range of pathologies that affect this system.

 

• Consideration of atherosclerotic risk factors may assist in identifying at-risk patients and patients presenting with frank arterial pathology. We recommend the use of specific

questioning and testing—specifically blood pressure measurement—to facilitate risk-factor profiling.

 

• Knowledge of known arterial presentations will strengthen the clinician’s differential diagnosis skills. We recommend the incorporation of this knowledge, and testing

procedures such as cranial nerve examination, to facilitate differential diagnosis.

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The article should be kept near the desks of anyone who manipulates the cervical spine on a regular basis.  The risks may be small but the consequences are enormous.  I see no reason to make this a routine procedure in the absence of less risky alternatives.  I'm a pretty cautious fellow though.