Petition to stop neck manipulation

[dswayze]

Originally Posted by Diane

Swayze, we are not talking "Innate" here. We're talking brain research since 25 years ago.

Straw man fallacy. We are talking about manual therapy, specifically manipulation affecting the nervous system. It's not PT, it's not osteopathy (rule of blood). You inadvertently just justified chiropractic. I found it amusing given your historical stance on the subject.

DS

[Diane]

DS,

I was referring to Childs et al. study on the subset who best respond to SMT.

I think that study was just for L spine, not neck.

[Jason Silvernail]

DS-
Diane's right, Childs' study was the lumbar spine.

My interpretation of your statement was that even though there are other methods of lowering blood pressure, you felt there was "a subset who respond much better to manipulation".
I had thought you were saying there would be people with high blood pressure that would do better with manipulation than with medications or meditation or dietary changes.
I was curious as to your rationale for thinking that, if that's indeed the point you were making.

[bernard]

I do not know if it was already posted but it's terrific!

[jnb300]

I did my seminar in manual therapy and when we went up to the cervical spine the first thing we learned is to do vrterbral artery test and not to proceed if the pt has postive test.

[SMEGC]

Hands up who thinks that the VAT is just as dangerous as an adjustment

[Jason Silvernail]

Unfortunately, vertebral artery testing has not been been shown to be of much value in making decisions about cervical manual therapy. There was an editorial in JOSPT about manual therapy and the presence of uncertainty that summarized the evidence nicely.

J Orthop Sports Phys Ther. 2005 May;35(5):300-6.
Screening for vertebrobasilar insufficiency in patients with neck pain: manual therapy decision-making in the presence of uncertainty.
Childs JD, Flynn TW, Fritz JM, Piva SR, Whitman JM, Wainner RS, Greenman PE.

US Army-Baylor University Doctoral Program in Physical Therapy, Fort Sam Houston, San Antonio, TX, USA. childsjd@sbcglobal.net

Growing evidence supports the effectiveness of manual therapy interventions in patients with neck pain; however, considerable attention has also been afforded to the potential risks such as vertebrobasilar insufficiency (VBI). Despite the existence of guidelines advocating specific screening procedures, research does not support the ability to accurately identify patients at risk. The logical question becomes, "How does one proceed in the absence of certainty?" Given the lack of clear direction for decision making in the peer-reviewed literature, this commentary discusses the uncertainties that exist regarding the ability to identify patients at risk for VBI. The authors hope that this commentary adds additional perspective on manual therapy decision-making strategies in the presence of uncertainty.

[Javier Gonzalez]

I have found this video of neck manipulation in children and I think is terrific, the boy rotate his lumbar spine when the man do the neck manipulation...

http://www.youtube.com/watch?v=UQfiEuWiQ9U

[matt c]

javier im not sure if your serious or not, but that is an excessive amount of rotation to take the cervicals into "even with lumbar rotation" as you say, why do chiros feel the need to take manipulations into such end range or massive rotation positions?
seems unnecessary
matt (aussie osteopath)

[wjrein]

Particularly since the Dens in a child isn't completely developed until around the age of 12. It seems a bit risky to be manipulating an inherently unstable cervical spine. When you talk about cost/benefit ratio in manipulating a child's neck I think its a no brainer.

Bill

[oljoha]

Originally Posted by matt c

javier im not sure if your serious or not, but that is an excessive amount of rotation to take the cervicals into "even with lumbar rotation" as you say, why do chiros feel the need to take manipulations into such end range or massive rotation positions?
seems unnecessary
matt (aussie osteopath)

From: http://www.theage.com.au/news/Nation...329483571.html

Dr Dennis Richards, president of the Chiropractors' Association of Australia, said the results should not turn people off manipulative therapy.

"These physiotherapists used mostly low velocity mobilisation techniques," Dr Richards said.

"All the literature points to far better outcomes with the high velocity techniques employed by chiropractors."

Low velocity? Huh? Then it's not manipulation. Besides where is that literature saying high velocity techniques are better. The problem with some old school chiropractors are that they use high amplitude techniques. I can't say I'm against HVLA neck manips. The HVHA's on the other hand...

[Javier Gonzalez]

Originally Posted by matt c

javier im not sure if your serious or not, but that is an excessive amount of rotation to take the cervicals into "even with lumbar rotation" as you say, why do chiros feel the need to take manipulations into such end range or massive rotation positions?
seems unnecessary
matt (aussie osteopath)

Perhaps I haven't explain myself correctly (sorry for my English). I agree with oljoha that I am not against HVLA spinal manipulation, but I think that HVHA manips, and especially HVHA neck manipulations like the video above, really seems to be a risk for the patient.

[Javier Gonzalez]

Originally Posted by Javier Gonzalez

I have found this video of neck manipulation in children and I think is terrific, the boy rotate his lumbar spine when the man do the neck manipulation...

http://www.youtube.com/watch?v=UQfiEuWiQ9U

Excuse me matt c, sorry for my post above. I have read it again and I have seen my mistake and now I understand your answer. I wanted to say "TERRIBLE", no "terrific".
Perhaps we agree now about that video

[Diane]

Isn't English fun Javier?
I get your meaning. In English we have the word "horrific" which means the same as "terrible". But "terrific" means the same as "great" or "excellent".

[Javier Gonzalez]

Originally Posted by Diane

Isn't English fun Javier?
I get your meaning. In English we have the word "horrific" which means the same as "terrible". But "terrific" means the same as "great" or "excellent".

I know, just a mistake.
Thank you Diane

[oljoha]

Originally Posted by bernard

I do not know if it was already posted but it's terrific!

I love those leg length tests they do - and then they use the Clickr (that's my trademarked name for a Quacktivator) in the thoracic area and then measure the leg length again.

[marcel]

Did you know that in (hopefully) rare occasions cervical traction can be fatal.

A common technique done by worldwide PT's traction of the cervical spine, guess many of you have done this too. Unlike (I hope) cervical manipulation this is used widespread. (I have no numbers)

In a post grad. course we where talkinhg abou red flags ; I brought up RA (reumatoid artritis) can be one for cerv. spine treatment.
Only one person in that room knew (the "teacher") and told he was aware of a PT gave cerv. traction to a patient with acute neckpain but because it was the end of his long working day the PT just started "treatment" (not looking further

Result : patient died on PT's "bench" due to a dens fracture; also known as a hangmansfracture.

I remember this vividly from a lecture about possible fragillity of the dens and ligg. in RA from school 23 yrs back.

After that class I knew for sure (even if I where to become an MT) I'd leave the cerv. spine alone.

[marcel]

Should be (not looking further) without the smile thing!

[oljoha]

Originally Posted by marcelk

In a post grad. course we where talkinhg abou red flags ; I brought up RA (reumatoid artritis) can be one for cerv. spine treatment.
Only one person in that room knew (the "teacher") and told he was aware of a PT gave cerv. traction to a patient with acute neckpain but because it was the end of his long working day the PT just started "treatment" (not looking further

Patient comes in - PT asks leading question...
"Are you feeling better today?"
Patient nods and dies...

I don't see why traction would lead to death due to a dens fracture. Perhaps if the patient is left alone in a machine doing the tractioning.

[nari]

It was normal practice in the '80s to leave a patient on neck traction with a bell to jangle if there were any problems. The irony of that is: it's hard to ring a bell if you can't use your paralysed arm/s. As far as I know, mechanical cervical traction is not used anymore; does that apply elswhere?

Lumbar traction also is rarely used; it sometimes worked in the past because of the skin stretch, perhaps - it surely didn't do anything else.

However manual cervical traction should avoid these mishaps, but again what tissue/s are we stretching, if we want to stretch necks in the first place? Just curious...

Nari

[marcel]

Originally Posted by oljoha

Patient comes in - PT asks leading question...
"Are you feeling better today?"
Patient nods and dies...

I don't see why traction would lead to death due to a dens fracture. Perhaps if the patient is left alone in a machine doing the tractioning.

Oljoha,
Actually this is basic knowledge (things a student should know) if you can't see it I'll explain : extension loading (forced traction from starting position extended cerv. spine) can result in posterior displacement of the dens if the dens fractures in to your spinal cord
well then this wouldn't be a good thing now would it.

("Physicians should be aware of the possibility that even minor injury can cause dens fracture in elderly parients" from Author;NAGAI TOKIHISA(Ehimedai Ronen'igaku) IGASE MICHIYA(Ehimedai Ronen'igaku) KOHARA KATSUHIKO(Ehimedai Ronen'igaku) MIKI TETSURO(Ehimedai Ronen'igaku)
Journal Title;Japanese Journal of Geriatrics
Journal Code:Z0680A )

[oljoha]

Originally Posted by marcelk

Oljoha,
Actually this is basic knowledge (things a student should know) if you can't see it I'll explain : extension loading (forced traction from starting position extended cerv. spine) can result in posterior displacement of the dens if the dens fractures in to your spinal cord
well then this wouldn't be a good thing now would it.

It's the extension that breaks it not the tractioning... perhaps I should have written distraction.

[oljoha]

Originally Posted by nari

However manual cervical traction should avoid these mishaps, but again what tissue/s are we stretching, if we want to stretch necks in the first place? Just curious...

At least one provides movement. I don't use it much though.

[Diane]

I found this on chirotalk today:
NECK 911 RESPONSE TO SUSAN MARTINUK'S ARTICLE IN THE CALGARY HERALD re: the Sandra Nette case.

Some person named "Susan Martinuk" apparently wrote a pro-neck manip, pro-chiro, anti-Kinsinger article in the Calgary Herald, which doesn't deserve a link because her points are contained inside the response (it could easily have been a chiro copying and pasting a script retort, pretending to be a "regular" person who likes her chiro).

It's interesting to read line for line this carefully crafted refutation. Check out the Sandy Nette site to see a good example of the wonders wellness maintenance can deliver unto humanity.

[Javier Gonzalez]

I have found an article in the New York Times about this subject published on August 25th:

http://www.nytimes.com/2008/08/26/he...WJyxBUB4QIscSw

What do you think about it?

[Diane]

It's a start.
(Congratulations on getting your article published by the way, Javier.)

[Javier Gonzalez]

Originally Posted by Diane

(Congratulations on getting your article published by the way, Javier.)

Thank you Diane

[Diane]

Javier, this EIM link might interest you.

[Jon Newman]

Javier,

I thought it was a reasonable article and comparable to other work the author has done. What did you think?

[christophb]

Here is a case report I stumbled upon regarding neck manipulation and internal carotid artery dissection. Cervical Spine Manipulation: "Neck Relief and Brain Grief"

[mikept7]

In the Kaltenborn-Evjenth system of manual therapy there are no rotational manipulations to the spine. Is anyone familiar with this system?

[TexasOrtho]

No rotational manips in the IAOM either.

[kongen]

Latest from European Radiology:
http://content.karger.com/ProdukteDB...ame=180314.pdf

[John W]

I recently completely a project for an education course that I just completed. The title: "Should Physical Therapists Perform Cervical Manipulation?" It's in the form of a WebQuest, which is a web-based educational tool where you provide a lesson plan on a topic with links to various web sources to gather information and then do a project. In this case, the project is a persuasive essay taking a position on whether or not PTs should manipulate the neck.

Feel free to look it over, send the link to anyone who you think might be able to use it, or post here with your comments and critiques.

Or, you can just ignore it if you want.

I should acknowledge that it was this Soma Simple thread that provided the inspiration and much of the web-based resource material.

[Diane]

That is one very detailed teaching tool you have developed John. I very much liked how carefully you laid out the evaluation page.

Back in the day (2005) who knew that laying these threads down would produce such intellectual foment which will go on to produce more intellectual foment? I didn't.. but I think this project is great.



Good luck.

[smith]

About once a month one of my kids will ask me "what do I do for a sore neck, I saw a chiropractor last week." We'll laugh and I'll say, your feeling a lot better right? More chuckles. I'm thinking its the treatment not the practicioner. I start them of with ice and gentle chin tucks if no point tenderness.

[Diane]

This is interesting: From a thread on SBM: Risks Associated With Complementary And Alternative Medicine (CAM): A Brief Overview, in the comment section;

Dutch infant dies after “craniosacral” manipulation of neck and vertebral column

In the Dutch Medical Journal authors from the University Hospital St. Radboud in Nijmegen reported a tragic case-history of which the summary follows here:

A formerly healthy, three months old girl died after manipulation of the neck and the vertebral column by a so called “craniosacral therapist.” During continued and deep bending of the neck, the patient developed incontinence of faeces, atonia and respiratory arrest followed by asystolia. Based on findings at the physical examination of the body, an additional MRI examination and the autopsy, it is likely that the cause of death was a local neurovascular or a mechanic respiratory-induced problem. This is the second report of infant death after forceful manipulation of the neck. As long as there is no scientific evidence for the efficacy and safety of forceful manipulation of the neck and the vertebral column, we advise against this treatment for newborns and infants.

Reference:
Micha Holla, Marloes M. IJland et al. Ned Tijdschr Geneeskd, 2009; 22 April; 153:A290.

Stop doing neck counterstrain on anyone preverbal. In fact, stop treating preverbal infants with neck manipulation of any sort, period.

[Nick]

Originally Posted by John W

I recently completely a project for an education course that I just completed. The title: "Should Physical Therapists Perform Cervical Manipulation?" It's in the form of a WebQuest, which is a web-based educational tool where you provide a lesson plan on a topic with links to various web sources to gather information and then do a project. In this case, the project is a persuasive essay taking a position on whether or not PTs should manipulate the neck.

Feel free to look it over, send the link to anyone who you think might be able to use it, or post here with your comments and critiques.

Or, you can just ignore it if you want.

I should acknowledge that it was this Soma Simple thread that provided the inspiration and much of the web-based resource material.

John, that is fantastic. Thanks so much for this link.

[Barrett Dorko]

Nick,

I agree entirely. Who is willing to send this to the DPT programs promoting cervical manipulation?

[Jason Silvernail]

Originally Posted by Barrett Dorko

Nick,

I agree entirely. Who is willing to send this to the DPT programs promoting cervical manipulation?

Are there any DPT programs promoting cervical manipulation?

Every academic I've ever spoken to teaches oscillatory mobilization and MET type stuff for the cervical spine, and they are either foursquare against thrust manipulation or they look at it the way I do: rarely indicated and only used in the proper patient population. It's hard enough getting the academics to follow the evidence and teach thrust for the lumbar spine, let alone the neck.
I'm trying to remember the last time I used thrust manipulation in the neck - not sure. Must have been a while ago. And only in the lower C spine.

[Bas Asselbergs]

John, I finally got to look at your effort. What a gem! Where were you when I went to school? (oh, wait...you probably weren't born yet....) Thank you!

Jason, isn't St. Augustine doing all spinal levels in their curriculum? I do not know.

[Jason Silvernail]

Bas,
I'm not sure what St Augustine is teaching about thrust manipulation of the neck.
I've never known a physical therapist to be cavalier about this technique or to approach it with anything but caution. Though I'm sure it does happen out there somewhere.

I'm about to enter an AAOMPT-credentialed manual therapy fellowship, so I'll see what happens and what they are teaching.

[John W]

Jason's point about the rarity of teaching cervical manipulation in PT school is well-taken.

I was really just using cervical manipulation as a "selling point" to get PT students thinking more deeply about why we use manual techniques for pain. Cervical manipulation is without question an "outlier" among PTs, but I think it is used more widely in private practice among OMPT-trained PTs than some might think.

As far as who's teaching it- I think all, if not most, of the AAOMPT fellowship programs teach cervical manipulation. I'm not sure about on the DPT level. I know there's a lot of talk about performing manipulation in general in entry-level DPT programs.

I don't think it should ever be done in the upper cervical spine, and I think APTA and AAOMPT should develop an official position on it. Unfortunately, I don't think most PTs have a solid enough understanding of pain/neuroscience to even muster enough points to debate whether or not PTs should be doing thrust techniques at any level of the cervical spine. The debate is not all about catastrophic injury. That's really just the tip of the pedagogical iceberg.

This WebQuest is my small effort to bring the discussion to the classroom within the context of current pain theory. Cervical manipulation is the attention grabber. Remember, we're primarily addressing 20-something's here who've been raised in the era of "give me drama or give me death."

[kongen]

John,

What is your definition of "upper cervical spine"? Just curious.

[John W]

C0-C2.

[smith]

Diane we've must of got our lines crossed. I don't do spinal manipulation.

[nari]

smith, Diane was talking generally to anyone who would consider cervical manips to a young person or baby. Not you...

Nari

[Diane]

Nari's right smith, it was a general comment. Not to you specifically. If it had been, I would have used your name.

[smith]

Sorry, my bad, got defensive.

[estherderu]

dear everyone,
Have been away for a few days and have a question or two. Because of the Dutch article named earlier, I am in the middle of writing a small article for my Spanish colleague paediatric physio´s about the dangers of "manipulative holds". As far as I have understood, it was not the manipulation but the prolonged time that the infant was held in a very awkward position (in this case flexion) that was the probable cause for the infants death.

Could you, the interested, have a look and see if I have missed something important? Is my reference (6)regarding the nerve reactions to pressure the best, or could you suggest something better?
Thanks in advance. please feel free to critize and add information.
I am waiting for permission to use the figures. When complete, I will have it translated.

Esther

oh dear I cannot attach for some reason..... will have to past the whole thing here----- sorry for this


Dear colleagues,
Last month an article was published in the Dutch Journal of Medicine[1] about the adverse effects of a cranial-sacral manipulation on a young baby. This is the second child who has died because of a cervical spinal “manipulation”. One child died after being held in a Vojta position in rotation, the other after having been held in a cranial-sacral flexion position.
Articles can be downloaded (they are in Dutch and German) http://www.ewmm.net/downloads/Vojta.pdf
http://www.ntvg.nl/publicatie/overleden-zuigeling-na-ocraniosacraleo-/volledig

I have summarized the most important conclusions from both articles and will discuss what we can learn from this.

1. Forced rotation and forced deep cervical flexion can lead to an infant’s death.
2. Forced manipulations of the spine in young infants can result in very dangerous complications such as; lowered hart frequency and apnoea[2] . The vertebral arteries can also be irritated or trapped and can cause high spinal cord lesion
3. There is no scientific proof of a positive effect of the manipulation as applied in craniosacral therapy or Vojta therapy
4. In the case of the infant being treated with Vojta, the therapist and mother (after instruction) had held the child in the forced rotational position several times during the therapy session and the child had cried and sweated a lot during treatment.[3] In the case of the cranial-sacral therapy, the flexion position (Fig 1.) was held for several minutes until the (crying) child started to decompensate, losing faeces and having breathing problems (child´s lips had turned blue in 10 minutes).
The authors [1] strongly suggest not using manipulations in treating children as long as the evidence is insufficient. Evidence that manipulations are not without risk for adults was published in 2005.[4]


What can we learn from this?
1. Never put babies in positions and hold them firmly if the child protests.
2. Babies that cry, start sweating or flushing are telling us we are doing something that is not good for them. Blue lips are a sign of respiratory distress.
3. Extra care should be taken with infants younger than 3 months.
4. Be very aware that you can obstruct the respiratory system easily because the child skeleton consists of cartilage for the most part. The myelin can be irritated or trapped and can lead to a neurological brachytachycardia with apnoea. Forced flexion can cause obstruction of the upper airways which are relatively narrow (children have a relatively large tongue and the larynx in anterior position). [5]
5. Always look for alternative and milder treatment options and do not manipulate babies and children.
6. If you wish to hold a child in a position, do so for a very short time.
7. Remember that nerve tissue does not respond well to prolonged stretch.

We know that prolonged stretching can have a negative effect on the nervous system. If the nerve is stretched only slightly beyond the protective limits, and for a brief period, nerve function is likely to return rapidly to normal (Lundborg et at 1982).
However, if the strain in the nerve is particularly severe or the pressure stays on for a long period of time, the alterations in nerve function will be permanent. Excessive mechanical stress may cause anoxia and nerve damage, leading to heightened mechanosensitivity and pain. [6]

In her book The aware baby, the developmental psychologist, Aletha J Solter [7]suggests that babies know what is good for them and can tell you, if you learn to read the signs. Crying is their way of communicating, asking for attention, showing frustration, showing their needs and their pains. Be very aware of this and act appropriately in my opinion.
The book is primarily written for parents but I can recommend it to both parents and health professionals.


[1]Ned Tijdschr Geneeskd. 2009;153:A290 Overleden zuigeling na ‘craniosacrale’ manipulatie van hals en wervelkolom Micha Holla, Marloes M. IJland, A.M. (Ton) van der Vliet, Michael Edwards en Carin W.M. Verlaat
[2] Koch LE, Koch H, Graumann-Brunnt S, Stolle D, Ramirez JM, Saternus KS. Heart rate changes in response to mild mechanical irritation of the high cervical spinal cord region. Forensic Sci Int. 2002;128:168-76.
[3] Jacobi G, Riepert Th, Kieslich M, Bohl J. Über einen Todesfall während der Physiotherapie nach Vojta bei einem drei Monate alten Säugling. Klin Padiatr. 2001;213:76-8.
[4]Ernst E. Adverse effects of spinal manipulation: a systematic review. J R Soc Med. 2007;100:330-8.
[5] Turner NM, van Vught AJ. Advanced paediatric life support. 2e dr. Maarssen: Elsevier Gezondheidszorg; 2006.
[6] Schacklock M. Moving in on pain. isbn 978-0-7506-8926-7
[7] The aware baby- a new approach to parenting isbn 90 6020 649 5