Tip Neck manipulation

[Diane]

Neil O'Connell has just had a paper published in BMJ about neck manip, about abandoning it.

Chiropractic (I think) advocates (in Canada... oh the shame associated with being Canadian at the same time as these arguers) argue against abandoning it.

[Frédéric]

for Neil.

I plan, among other things to write a letter accompanied by an article on the subject if I find the time that I will send to the concerned authorities in canada and Qc.

[zimney3pt]

I haven't read this full article, yet. But fits in here.
Safety of cervical spine manipulation: are adverse events preventable and are manipulations being performed appropriately? A review of 134 case reports

Abstract:
Background

Cervical spine manipulation (CSM) is a commonly utilized intervention, but its use remains controversial.

Purpose

To retrospectively analyze all available documented case reports in the literature describing patients who had experienced severe adverse events (AEs) after receiving CSM to determine if the CSM was used appropriately, and if these types of AEs could have been prevented using sound clinical reasoning on the part of the clinician.

Data sources

PubMed and the Cumulative Index to Nursing and Allied Health were systematically searched for case reports between 1950 and 2010 of AEs following CSM.

Study selection

Case reports were included if they were peer-reviewed; published between 1950 and 2010; case reports or case series; and had CSM as an intervention. Articles were excluded if the AE occurred without CSM (e.g. spontaneous); they were systematic or literature reviews. Data extracted from each case report included: gender; age; who performed the CSM and why; presence of contraindications; the number of manipulation interventions performed; initial symptoms experienced after the CSM; and type of resultant AE.

Data synthesis

Based on the information gathered, CSMs were categorized as appropriate or inappropriate, and AEs were categorized as preventable, unpreventable, or unknown. Chi-square analysis with an alpha level of 0·05 was used to determine if there was a difference in proportion between six categories: appropriate/preventable, appropriate/unpreventable, appropriate/unknown, inappropriate/preventable, inappropriate/unpreventable, and inappropriate/unknown.

Results

One hundred thirty four cases, reported in 93 case reports, were reviewed. There was no significant difference in proportions between appropriateness and preventability, P = .46. Of the 134 cases, 60 (44·8%) were categorized as preventable, 14 (10·4%) were unpreventable and 60 (44·8%) were categorized as ‘unknown’. CSM was performed appropriately in 80·6% of cases. Death resulted in 5·2% (n = 7) of the cases, mostly caused by arterial dissection.

Limitations

There may have been discrepancies between what was reported in the cases and what actually occurred, since physicians dealing with the effects of the AE, rather than the clinician performing the CSM, published many of the cases.

Conclusions

This review showed that, if all contraindications and red flags were ruled out, there was potential for a clinician to prevent 44·8% of AEs associated with CSM. Additionally, 10·4% of the events were unpreventable, suggesting some inherent risk associated with CSM even after a thorough exam and proper clinical reasoning.

[John W]

If you say that with a thick, gravelly, southern drawl, you'll sound like a real trucker on his CB radio.

Additionally, 10·4% of the events were unpreventable, suggesting some inherent risk associated with CSM even after a thorough exam and proper clinical reasoning.

- bold added

How will all our good buddies in chiro, PT and osteopathy who continue to manipulate the neck explain this away?

[Jason Silvernail]

And I'll add for what seems like the 100th time, when RCTs show value of manual therapy for neck pain and headache in the absence of thrust manipulation or with equivalent outcomes between thrust and nonthrust, why are we so concerned with performing thrust techniques?
Can't remember the last time I manipulated a neck. My patients seem to do very well with gentler techniques, but that's consistent with the randomized trial results, so I guess it shouldn't be surprising...


[From my iPhone, please excuse typing]

[proud]

Now on the manipalooza, Tim Flynn, Cleland, Childs, Mitkenin (If I recall)...all were quite adamant that cervical spine manipulation was safe...even making the argument that somehow it would be more UNSAFE to withhold the treatment...

Something about the relative safety in comparison to NSAIDS if I recall.

[Bas Asselbergs]

Ah yes, proud. The old warhorse "NSAIDS" gets pulled out as comparison.
I can hear it now: "there are many more deaths related to the use of NSAIDS ....Blah Blah.." Apples and hazelnuts.

[advantage1]

Now on the manipalooza, Tim Flynn, Cleland, Childs, Mitkenin (If I recall)...all were quite adamant that cervical spine manipulation was safe...even making the argument that somehow it would be more UNSAFE to withhold the treatment...

I am very suprised to hear this from this group of researchers. What do you think could be their motivation for this quote?

[proud]

Originally Posted by advantage1

I am very suprised to hear this from this group of researchers. What do you think could be their motivation for this quote?

I can't tell...was that a sarcastic query?

Afterall...I was on a course called the MANIPalooza....

Seriously though...I am sure that they were being sincere in their opinion

[TexasOrtho]

Originally Posted by advantage1

I am very suprised to hear this from this group of researchers. What do you think could be their motivation for this quote?

I'm not 100% sure but I imagine the primary reason rhymes with "kit-road of honey".

[Greg Lehman]

What does everyone think about Cassidy's work suggesting that the VBIs are all a merely a correlation with a manipulation as the patient is perhaps already having a stroke and is presenting with neck pain and headache to their chiro or md. Hence, they both have the same odds ratio of being related to the stroke.


I recognize, and ascribe to, the argument that we should not bother with manips since lower force techniques are just as effective so why take the risk, no matter how minimal? Cassidy and perhaps Flynn et al think that this argument isnt fair because there is no risk at all, not even a tiny one that needs to be avoided.

The only thing that needs to be avoided is not identifying a patient that presents with signs of a vbi.

I dont know much more than this, i may not be the best champion of necj manipulations. Ive stopped doing them although i admit i used to quite enjoy delivering them, albeit rarely delivered (sorry Diane, please dont send a horses head to my bed, i dont do them anymore).

Gregrrr

[Diane]

Originally Posted by Greg Lehman

i may not be the best champion of necj manipulations. Ive stopped doing them although i admit i used to quite enjoy delivering them, albeit rarely delivered (sorry Diane, please dont send a horses head to my bed, i dont do them anymore).

Gregrrr

Thank you for deciding to not (no matter how small the chance) add any more stroke victims to the planet.

I don't send horse heads to beds. I like animals..

[Greg Lehman]

Please dont send a tofu horse head either

[Jason Silvernail]

Did somebody say Tofu?

I think the NSAID argument is pretty fair actually - small effect sizes limited overall evidence of effectiveness and adverse events very clearly tied to the delivery of the intervention itself.

I've grown more comfortable with Cassidy's argument over time but I have to say it didn't convince me to regularly use this treatment. We may never know for sure how closely related these events are but how much evidence do we need to stop doing this in routine practice if there's no evidence of benefit over low velocity techniques?


[From my iPhone, please excuse typing]

[John W]

Rod's right about the "kit-road of honey" aspect. EIM is all in on manipulation. It's a big part of their branding. What they fail to appreciate, however, is how inconsistent manipulation is with with an interactor approach to care. They'd rather go toe-to-toe with the chiros, and crow about all the tooth fairy science they've churned out.

At some point, Steve George is going to have to make a choice about how impactful his research career is going to be. As long as he hangs with these operator-mentality guys at EIM, he won't be able to move the science forward in the direction it will inevitably go.

But someone- perhaps from another profession- will.


---
I am here: http://tapatalk.com/map.php?fjxxj4
John Ware, PT, FAAOMPT

Sent from my iPhone using Tapatalk

[ian s]

Diane, thanks for that --i added a reply to the UK Huff post . I did put some things that i don't entirely agree with re acupuncture to appease but posted the quack watch article on neck thrust techniques. I said that the simon singh case is relevant as there will no doubt be an attempt to ridicule or negate the message...

[Diane]

Originally Posted by Jason Silvernail

I've grown more comfortable with Cassidy's argument over time but I have to say it didn't convince me to regularly use this treatment.

Pop-along Cassidy...
(Sorry, couldn't resist.)

Whatever happened to "first, do no harm".. ?

[Diane]

Cassidy himself:



From this link,
'What alternative health practitioners might not tell you' at ebm-first.com.

[John W]

I wanted to post the link to his brief video (click on the "Start Watching" button on the right just below the banner) before it disappears on Saturday. In it, Louie Puentedura, someone who I like and admire in many ways, states, "The kind of manual therapy that I want to talk about is this thrust joint manipulation- or cervical spine manipulation-the kind where the intent is to achieve a cavitation in the neck." I thought the intent of manual therapy was to reduce a patient's pain?

This is part of a Medbridge continuing education promotion, which includes courses from other PT's like Chad Cook. I have to say that I'm very disappointed that Louie has gone down this path of so ardently supporting cervical spine manipulation when we know that mobilization is likely just as effective and certainly less potentially harmful. Furthermore, his reference to the cavitation being the "intent" of performing manipulation flies in the face of much the research demonstrating that a cavitation is not an important predictor of a positive outcome with manipulation.

Louie, what in the world are you doing!

[Barrett Dorko]

My personal past experience with this man leaves me unsurprised.

[joebrence9]

Louie, what in the world are you doing!

Agreed John. I highly respect Louie too and occasionally correspond back and forth about stuff. It appears that this came out of an article he published in JOSPT last year regarding the effects of cervical manipulation being better than thoracic manipulation for individuals with mechanical neck pain. Not sure why he did this study (someone was prone to compare these two at some point) but it doesn't seem to fit in with his understanding of "pain science".

[Diane]

His interview with Karen Litzy was also all rah-rah neck manip, I noticed.

[John W]

It looks like he's wearing a shirt with the ISPI logo on it. This is Adriaan Louw's group, which is closely associated with NOI. I think Louie is listed as a faculty member for NOI. Does NOI have a current position on the use of cervical manipulation I wonder?

Kory,
Based on your ties and experience with ISPI, what's your take on Louie's embrace of cervical manipulation? Does Adriann manipulate the c-spine?


I guess I'm getting a bit weary with all the talk of pain science and the importance of patient understanding and the empowerment that brings, and then I see stuff like this where all of that seems to fly right out the window.

There's a duplicity here that is gnawing at me. Is it all about the money?

[Anthony Distano]

Originally Posted by Jason Silvernail

And I'll add for what seems like the 100th time, when RCTs show value of manual therapy for neck pain and headache in the absence of thrust manipulation or with equivalent outcomes between thrust and nonthrust, why are we so concerned with performing thrust techniques?
Can't remember the last time I manipulated a neck. My patients seem to do very well with gentler techniques, but that's consistent with the randomized trial results, so I guess it shouldn't be surprising...


[From my iPhone, please excuse typing]

I re-conceptualized my use of thrust manipulation after taking a Maitland course 5 years ago and one of the principles were: choose a technique with the least force necessary, then assess the comparable sign. Seems simple and maybe common sense in the PT world but this was a novel concept to me and drastic contrast to my thrust manipulation training/thinking. I remember thinking, "wow....what a concept (honestly)". That has been my thinking ever since and agree that starting with less force (different grades of mobilization), I have not needed thrust manipulation. Of course, I spend a lot of time educating patients that have went to other DCs who plead with me "to crack their neck" about my gentle approach.....and they look at me like I have 10 heads as if I am the quack. I have turned patients away because I would not comply with there request, even after doing my best to educating them. Good thing this is a rare occurence. And shows there will always be a market for the "rack em and crack em" quacks.

[keithp]

Originally Posted by John W

Does Adriann manipulate the c-spine?

I cannot find it now, but I recall being surprised that he was an author on a CSp HVTM study that was (or is going to be) co-authored by some EIM folks. Will keep looking...

ETA: Here is the abstract:

OBJECTIVE:
To determine the predictive validity of selected clinical examination items and to develop a clinical prediction rule to determine which patients with neck pain may benefit from cervical thrust joint manipulation (TJM) and exercise.

BACKGROUND:
TJM to the cervical spine has been shown to be effective in patients presenting with a primary report of neck pain. It would be useful for clinicians to have a decision-making tool, such as a clinical prediction rule, that could accurately identify which subgroup of patients would respond positively to cervical TJM.

METHODS:
Consecutive patients who presented to physical therapy with a primary complaint of neck pain completed a series of self-report measures, then received a detailed standardized history and physical examination. After the clinical examination, all patients received a standardized treatment regimen consisting of cervical TJM and range-of-motion exercise. Depending on response to treatment, patients were treated for 1 or 2 sessions over approximately 1 week. At the end of their participation in the study, patients were classified as having experienced a successful outcome based on a score of +5 ("quite a bit better") or higher on the global rating of change scale. Sensitivity, specificity, and positive and negative likelihood ratios were calculated for all potential predictor variables. Univariate techniques and stepwise logistic regression were used to determine the most parsimonious set of variables for prediction of treatment success. Variables retained in the regression model were used to develop a multivariate clinical prediction rule.

RESULTS:
Eighty-two patients were included in data analysis, of whom 32 (39%) achieved a successful outcome. A clinical prediction rule with 4 attributes (symptom duration less than 38 days, positive expectation that manipulation will help, side-to-side difference in cervical rotation range of motion of 10° or greater, and pain with posteroanterior spring testing of the middle cervical spine) was identified. If 3 or more of the 4 attributes (positive likelihood ratio of 13.5) were present, the probability of experiencing a successful outcome improved from 39% to 90%.

CONCLUSION:
The clinical prediction rule may improve decision making by providing the ability to a priori identify patients with neck pain who are likely to benefit from cervical TJM and range-of-motion exercise. However, this is only the first step in the process of developing and testing a clinical prediction rule, as future studies are necessary to validate the results and should include long-term follow-up and a comparison group.

Respectfully,
Keith

[TexasOrtho]

If I recall correctly, David Butler is fine with thrust techniques provided its provided in a neuroscientific explanatory context.

If we were to probe the deepest depths of pro-cervical thrust / neurosciency PTs, I imagine we'd see a lot of "anchoring". Once you've latched yourself onto a technique or therapeutic algorithm, its tough to let go.

I can attest to this difficulty with the role of "exercise". Not so much with thrust as it wasn't my original background.

So the ultimate answer might be that they are flawed human beings. Just like me.

[John W]

Ok, I just reviewed the study that Joe was referring to above, and I'm not impressed. First of all, the sample sizes were very small: 10 in the thoracic manip group and 14 in the cervical manip group. Secondly, the duration of neck pain was less than 3 weeks in the thoracic group and less than 2 weeks in the cervical group; therefore, since there was not a control group, it's likely that the improvements seen in both groups were due to natural progression/regression to the mean. Thirdly, the initial scores on the disability instruments were relatively low to begin with: NDI~13/15, FABQ-PA <10, and so was the pain rating scale: <5/10. Therefore, this particular patient population is not necessarily typical of the patients seen in most outpatient PT clinics. Indeed, he addresses the fact that the study that this one was based on- the cervical spine manipulation CPR by Cleland et al- included patients with duration of onset in the average range of 6 to 10 weeks, rather than 2-3 weeks as in this study.

Three different techniques were used on the thoracic group, including the technique where patients have to grasp the back of the head while the therapist pulls them into neck and thoracic flexion and then applies a thrust in the upper thoracic/CT region. Is it any wonder that these patients with neck pain might have more treatment side effects, i.e. soreness, following the intervention? You have to wonder, in fact, if the reason the thoracic group didn't improve as much was because of the treatment itself! Louie provided all the treatments, and he's a big, burley guy. Do you think the force production he produced on the patient's thoracic spine might have been considerably higher than the forces produced on the neck? Perhaps this would be part of his argument for performing cervical instead of thoracic manipulation. This is rife with confirmation bias as well, since he is both the lead author and treating therapist. On some level, all authors want to find significant results. He should've had a different therapist perform the interventions.

Finally, Louie doesn't address the role of expectation at all in the study, and he doesn't reference any of the research on the role of expectation. I think it's fair to presume that most patients enrolling in a study to address treatments for neck pain will expect the therapist to touch their necks. If this doesn't happen, then it makes sense that their expectation has not been met, and they may lose confidence in the intervention resulting in a weaker outcome.

None of this explains his emphasis in the video on achieving a cavitation with manipulation. In fact, in the his study, he mentions that achieving a cavitation was not necessary as part of the study design. Why is he emphasizing cavitation in the video?

I'm perplexed by all of this.

[Diane]

I suspect he just wants the skill set to not die. I think that until chiro dies, manipulation won't die either, and people like Louie will always be there in PT to fan competitive flames.

I think it's a male pi$$ing war. It certainly has nothing to do with letting a patient retain a locus of control. It's about feeding their delusions about what they worry might be wrong with them.

[John W]

I think you're right, Diane. It's all about alpha males peeing around their territory to ward off any competitors. That and the money. And perhaps we might sprinkle in a little bit of ego-driven neurosis.

This study is emblematic of an underlying, across-the-board problem in current modern health care systems: medicalization. How many of these patients would've gotten better without any treatment or minimal treatment, including some education and some permission to move in various ways? Now, they are "patients who needed their necks cracked to get better".

Rod, you make a valid point, but, I think you'd agree that performing a passive intervention that poses a risk, however small, of killing or rendering someone quadriplegic is on a different plane from having patients do exercises that might make them a little sore.

[advantage1]

This study is emblematic of an underlying, across-the-board problem in current modern health care systems: medicalization.

Great point. One that many in our profession don't get. In fact in most cases it is us as health professionals that medicalize the patients pain and add to the eipdemic. What a mess. This will never change.

[TexasOrtho]

Very fair point John. Although I never got caught up in cervical manipulation, I still have trouble understanding the urge to provide a treatment that has such a devastating adverse event. However rare it may be.

I get that a lot..."It's safer than NSAIDs! It's safer than NSAIDs!" That may well be, but like many of us, I just can't get my head around providing ANY treatment that has a deadly (and totally unpredictable BTW) adverse risk. Especially when there are less and completely non-coercive alternatives.

[mrupe82]

I was able to attend manipalooza and listened to the cervical manipulation presentation. Just so you all know you could die driving your car to work and die from NSAIDS before a c-spine manipulation (tongue in cheek....).

I would appreciate if someone could explain to me why I shouldn't slap some tape on folks instead...

Saavedra-Hernández, M., Castro-Sánchez, A. M., Arroyo-Morales, M., Cleland, J. A., Lara-Palomo, I. C., & Fernández-de-Las-Peñas, C. (2012). Short-Term Effects of Kinesiotaping Versus Cervical Thrust Manipulation in Patients With Mechanical Neck Pain: A Randomized Clinical Trial. Journal of Orthopaedic and Sports Physical Therapy.

doi:10.2519/jospt.2012.4086

When I mentioned there was no difference between kinesiotape and manipulation a fellow's (faculty member) response to me was "then just manipulate the c-spine."

[Diane]

Originally Posted by mrupe82

When I mentioned there was no difference between kinesiotape and manipulation a fellow's (faculty member) response to me was "then just manipulate the c-spine."

We need a facepalm icon.

I guess he never heard of minimalism in manual therapy, why it's safer/better/preferable, etc. What a turkey.

[proud]

Uhmm...it's ALL about this

[Kyle Ridgeway]

Originally Posted by Greg Lehman

What does everyone think about Cassidy's work suggesting that the VBIs are all a merely a correlation with a manipulation as the patient is perhaps already having a stroke and is presenting with neck pain and headache to their chiro or md. Hence, they both have the same odds ratio of being related to the stroke.


I recognize, and ascribe to, the argument that we should not bother with manips since lower force techniques are just as effective so why take the risk, no matter how minimal? Cassidy and perhaps Flynn et al think that this argument isnt fair because there is no risk at all, not even a tiny one that needs to be avoided.

The only thing that needs to be avoided is not identifying a patient that presents with signs of vbi.

I dont know much more than this, i may not be the best champion of necj manipulations. Ive stopped doing them although i admit i used to quite enjoy delivering them, albeit rarely delivered (sorry Diane, please dont send a horses head to my bed, i dont do them anymore).

Gregrrr

Obviously, performing a tightly controlled prospective study of this is not only unfeasible, but not ethical.

The question is are neck manipulations causing or correlated with these incidents? Although, accurate I think that is not analyzing the situation appropriately enough.

That being said, there are likely 3 distinct scenarios happening when a neck manipulation "correlates" with a stroke.

1. Active or developing dissection or stroke is correlated with neck manipulation
In this instance, a patient with neck pain, headaches, or other symptoms presents to a practitioner and receives a cervical manipulation. The manipulation did not cause nor further the dissection or stroke.

2. Active or developing dissection or stroke is worsened, exacerbated, or accelerated with neck manipulation
In this instance, a patient with neck pain, headaches, or other symptoms presents to a practitioner and receives a cervical manipulation. The patient is actively in the process of a developing dissection or stroke. The manipulation did not cause the dissection or stroke, but accelerates or worsens it.

3. Dissection or stroke is caused by neck manipulation.
Patient has neck pain, neck is manipulated. Dissection and stroke are direct result of the manipulation.

Hypothethical > In my opinion, even if scenario 1 and 2 were the only possibilities AND we knew for sure that cervical manipulation never caused a dissection or CVA, the risk of accelerating or worsening a dissection is too high in comparison to it's effectiveness to justify the intervention. I think this stance can be supported by Cleland et al's paper investigating adverse events with c-spine manip and the fact that even with proper screening you can't eliminate all risk. Further, the trials comparing it directly to other interventions raises the question "Why risk it? EVER?" when we know other "interventions" including generic KT taping are likely equally efficacious?

Lastly, it seems our profession has misunderstood risk vs. benefit analysis. Sure, comparing cervical manipulation adverse event types and adverse event rates in relation to other MEDICAL interventions is tempting. And, sure, it does hold some value for comparing intervention risks, benefits, and efficacy within the spectrum of care and the overall medical field (NSAIDs, opiates, surgery, conservative measures, etc). But, within our profession we should be comparing the risk, invasiveness, and benefit of our interventions to other interventions we use (both generally and for that specific condition/complaint). On the grounds of efficacy, risk, and reward when compared to our other interventions specifically for neck pain, I can't understand an argument for cervical manipulation. Further, when taking into account the training cost and time it takes for most to become competent and comfortable, it does not make sense to advocate for this intervention.

[Kyle Ridgeway]

Originally Posted by proud

Uhmm...it's ALL about this

Proud,

To insert a You Tube Video click the TV screen icon on the far right upper menu and paste the letters following "=" in the you tube url.

For example, the video above's URL was: http://www.youtube.com/watch?v=i-j3xITvYQY

Paste i-j3xITvYQY between the two sets of closed brackets.

[zimney3pt]

Originally Posted by John W

Kory,
Based on your ties and experience with ISPI, what's your take on Louie's embrace of cervical manipulation? Does Adriann manipulate the c-spine?


I guess I'm getting a bit weary with all the talk of pain science and the importance of patient understanding and the empowerment that brings, and then I see stuff like this where all of that seems to fly right out the window.

There's a duplicity here that is gnawing at me. Is it all about the money?

Louie still does and teaches cervical manipulation. Louie's background is very much based in manual manipulative therapy and more recently has been taking on the pain science aspect. I have talked with him and I think it will be very hard for Louie to abandon completely cervical manipulation because of his successes with it and interest from a research standpoint as well. I do think he pushes for therapist's to be very selective in when it should be done and to screen patients very carefully before proceeding with it. From my conversations with him he still sees it as an appropriate intervention with a select population (see his study on CPR on cervical manip). His clinical judgement sees value in it for improved outcomes if proper patient selection and screening is done. And this has been an area of clinical research for him.

I would say that all of the instructors with ISPI are on different levels with how far they have crossed the chasm. Many (probably most) are straddling both sides and some still are much more meso then ecto. I believe Adriaan still manipulates the cervical spine. Louie does most of the teaching in these classes with ISPI, Adriaan has been primarily doing more of the pain courses at this time. I have seen Adriaan becoming more pain focused in the last year or two I have worked with him and less tissue based. But he has a very strong Maitland manual therapy background but is making that switch to cross the chasm further based on his newsletter post a month ago. Adriaan did mention listening to Eyal Lederman a few months ago when they both presented (I believe in Norway, don't quote me on which country) and how the information was the best presentation he has heard in a long time and made him really think about things.

[Jason Silvernail]

On the neck manip vs thoracic manip study: wait when they have neck pain they feel better when you do something to their neck versus their thoracic spine? Wow, amazing.

On the clinical prediction rule: it's just a case series. No randomization, no experimental controls. A case series. We have higher level RCT evidence from both the physical therapy and chiropractic communities that thrust is not better than nonthrust. If you fancy yourself "evidence-based" what is your argument for thrust manipulation of the neck then?

[Diane]

Cervical manipulation consent: found in an email from WCPT.

Oh yeah... If you must crack peoples' necks, and possibly stroke them out, , against all logic provided by pain science and PLENTY of PT science suggesting there is no point in harder/faster/noisier when it comes to manual therapy... if you must do that to your patients who seek domination from an alpha primate social groomer, at least obtain informed consent.

So, there is an app for that.

[nari]

.....if you must do that to your patients who seek domination from an alpha primate social groomer, at least obtain informed consent.

I'm surprised at this statement. PTs here have had to obtain informed consent for manipulation of the neck for over a decade. Not only neck manip, but for any invasive procedure such as palpation of the coccyx, TMJ mobilisation etc. I had thought it was mandatory.

Nari

[Diane]

Apparently not..

[Greg Lehman]

Its not INFORMED consent here in canada with PTs. A component oF the consent is that the patient undergoes faulty VBI testing or some sort of stress testing that has no predictive ability to assess ones risk of stroke. This is part of the "advanced" manual therapy course here. Utter nonsense, completely unethical and often justified with the response " what would you have us do? Its better than nothing". It is actually nothing, and is worse than nothing.

Its crack roulette. That is your informed consent.

Greg

[Barrett Dorko]

Greg, Where did you get that "crack roulette" phrase?

It's unbelievably good.

[Jason Silvernail]

Greg is 100% right about VBI testing and it's a major issue in the Canadian OMT programs that are so biomechanically based, despite the evidence and literature moving the other way.

[proud]

Further proof that the Canadian ortho stream is behind..way behind. I've been aware of this for some 6 years now.

I remain amazed that it's considerd the gold standard for orthpeadic Physiotherapists in Canada.

My advice to any Canucker on board...head the the USA if you want at least some semblance of an evidence based and science-informed orthopeadic curriculum.

[Jason Silvernail]

US manual therapy conferences are jam-packed with neurophys lectures and mechanism talks. What's up Canada, eh?

[Diane]

Originally Posted by Jason Silvernail

US manual therapy conferences are jam-packed with neurophys lectures and mechanism talks. What's up Canada, eh?

Not much eh? Hey wanna brewskie?

[Greg Lehman]

Greg, Where did you get that "crack roulette" phrase?

It's unbelievably good.

Three cans of Stella combined with that bitter taste in my mouth

[Bas Asselbergs]

You have good taste - especially in beer!
Great line Greg - you have added to the growing Soma contributions to rehab lexicon!

[NickPT]

In addition to the NSAID argument, which seems legitimate, is the argument that preventing neck surgery, which also carries significant risk including death, may be prevented with the manipulations.

This argument resonated with me, especially having just seen a patient whose orthopod wants to do a THA to a hip that is no longer having pain and doesn't have ROM restrictions. Surgeons gonna surge I guess.

I still wouldn't manip a neck though.