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RISK MANAGEMENT FOR CHIROPRACTORS AND OSTEOPATHS: Neck Manipulation & Vertebrobasilar Stroke.

ABSTRACT Although rare, vertebrobasilar stroke is the best known of the possible side effects of cervical manipulation. Due to the serious sequelae that may result from cervical manipulation, chiropractors and osteopaths must take the appropriate steps to ensure the risk is minimised. This article outlines how the astute practitioner can minimise this risk. Practitioners must decide on the options for treatment of a patient with neck problems. Practitioners must also advise the patient of these options as part of an appropriate informed consent.

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    ABSTRACT: Background:  Strokes, typically involving vertebral artery dissection, can follow cervical spinal manipulative therapy, and these types of stroke occur rarely. There is disagreement about whether a strong association between neck manipulation and stroke exists. An earlier systematic review found two relevant studies of association that used controls, which also discussed the limitations of the two papers. Our systematic review updates the earlier review, and aims to determine whether conclusive evidence of a strong association exists. Methods:  PRISMA guidelines for systematic reviews were followed, and the literature was searched using a strategy that included the terms 'neck manipulation' and 'stroke' from the PubMed, Embase, CINAHL Plus and AMED databases. Citations were included if they met criteria such as being case-control studies, and dealt with neck manipulation and/or neck movement/positioning. Papers were scored for their quality, using similar criteria to the earlier review. For individual criteria, each study was assigned a full positive score if the criterion was satisfied completely. Results:  Four case-control studies and one case-control study, which included a case- crossover design, met the selection criteria, but all of them had at least three items in the quality assessment that failed to be completely positive. Two studies were assessed to be the most robustly designed, one indicating a strong association between stroke and various intensities of neck movement, including manipulation, and the other suggesting a much reduced relative association when using primary care practitioners' visits as controls. However, potential biases and confounders render the results inconclusive. Conclusion:  Conclusive evidence is lacking for a strong association between neck manipulation and stroke, but is also absent for no association. Future studies of association will need to minimise potential biases and confounders, and ideally have sufficient numbers of cases to allow subgroup analysis for different types of neck manipulation and neck movement.
    International Journal of Clinical Practice 10/2012; 66(10):940-7. · 2.43 Impact Factor
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    ABSTRACT: OBJECTIVE: To describe the development of a sham manual medicine protocol. SETTING: An academic physical medicine and rehabilitation clinic. PARTICIPANTS: Twenty-six persons with cervical tender points were included in the pilot study. Exclusion criteria entailed cervical disk herniations or diskitis, cancer, current incarceration, or any condition that prevented small-range passive neck movements. Subjects were also excluded if, in the past 3 months, they had received cervical or thoracic spine surgery, osteopathic manipulation, or workers' compensation benefits. INTERVENTIONS: The subjects were sequentially assigned to receive either sham or strain-counterstrain treatment. The subjects filled out pre- and posttreatment questionnaires. Fifteen subjects were in the sham group, and 11 were in the treatment group. MAIN OUTCOME MEASURES: Outcome measures included subject tolerance of manual medicine, change in pain level, and ability to accurately determine receipt of strain-counterstrain or sham technique. Statistical significance was set at P < .05. RESULTS: There were no adverse effects of the sham or treatment protocols. There was no statistically significant change in pain as a result of the sham manual medicine protocol (P = .222) in contrast to the strain-counterstrain group, which did have decreased pain (P = .014). The subjects were unable to determine whether they had received sham or strain-counterstrain technique (P = .850). CONCLUSION: The sham protocol developed for this study was well tolerated. The small study size and design limitations do not yet allow the sham protocol developed in this pilot study to be definitively validated as a manual medicine tool, but there are early indications that it may be useful. Larger studies that validate this sham protocol by addressing inter- and intra-rater reliability are needed, followed by studies that evaluate strain-counterstrain as a treatment modality.
    PM&R 02/2013; · 1.37 Impact Factor
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    ABSTRACT: The risk associated with cervical manipulation is controversial. Research in this area is widely variable but as yet the risk is not easily quantifiable. This presents a problem when informing the patient of risks when seeking consent and information may be withheld due to the fear of patient withdrawal from care. As yet, there is a lack of research into the frequency of risk disclosure and consequent withdrawal from manipulative treatment as a result. This study seeks to investigate the reality of this and to obtain insight into the attitudes of chiropractors towards informed consent and disclosure. Questionnaires were posted to 200 UK chiropractors randomly selected from the register of the General Chiropractic Council. A response rate of 46% (n = 92) was achieved. Thirty-three per cent (n = 30) respondents were female and the mean number of years in practice was 10. Eighty-eight per cent considered explanation of the risks associated with any recommended treatment important when obtaining informed consent. However, only 45% indicated they always discuss this with patients in need of cervical manipulation. When asked whether they believed discussing the possibility of a serious adverse reaction to cervical manipulation could increase patient anxiety to the extent there was a strong possibility the patient would refuse treatment, 46% said they believed this could happen. Nonetheless, 80% said they believed they had a moral/ethical obligation to disclose risk associated with cervical manipulation despite these concerns. The estimated number of withdrawals throughout respondents' time in practice was estimated at 1 patient withdrawal for every 2 years in practice. The withdrawal rate from cervical manipulation as a direct consequence of the disclosure of associated serious risks appears unfounded. However, notwithstanding legal obligations, reluctance to disclose risk due to fear of increasing patient anxiety still remains, despite acknowledgement of moral and ethical responsibility.
    Chiropractic & Osteopathy 10/2010; 18:27.

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May 19, 2014