Neck Manipulation Safety

[Pansit]

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So I was a bit bored and I watch this Scientific America piece on PBS about Joint manipulation. In one part it talks about the dangers of neck manipulation...the piece is about chiropractors but the techniques they show for neck manipulation is pretty much what we do and according to research there is a correlation between neck manipulation and strokes. Apparently when your doing the techniques you putting strain on the vertebral arteries which can result in a small tears leading to a clot, which can dislodge and enter the brain! I did some more googling and there are other articles on this. The reason why i am writing this post is that they dont tell us any of this stuff!!...I had classmates wrangling around my neck and who knows what they are doing. The professors only tell me it's safe and that is it. This really has me questioning this stuff...I mean I am going off on the word of professors who really have no scientific data to back up what they are saying...what do you guys think? Do you feel safe that when they tell you it's safe, it actually is. My g/f would never let me do the neck manipulation and I would just roll my eyes but now I think she could be right. This is borderline crazy if this stuff is true and should be banned immediately. What do you guys think? I think they should at least tell us there is this potential risk!!!

Video: (PBS Scientific America) http://vvi.onstreammedia.com/cgi-bi...tart=1298098&ccend=2231231&videoID=pbssaf1210

Random Article: http://www.chirobase.org/15News/neurol.html

 

[bkpa2med]

So I was a bit bored and I watch this Scientific America piece on PBS about Joint manipulation. In one part it talks about the dangers of neck manipulation...the piece is about chiropractors but the techniques they show for neck manipulation is pretty much what we do and according to research there is a correlation between neck manipulation and strokes. Apparently when your doing the techniques you putting strain on the vertebral arteries which can result in a small tears leading to a clot, which can dislodge and enter the brain! I did some more googling and there are other articles on this. The reason why i am writing this post is that they dont tell us any of this stuff!!...I had classmates wrangling around my neck and who knows what they are doing. The professors only tell me it's safe and that is it. This really has me questioning this stuff...I mean I am going off on the word of professors who really have no scientific data to back up what they are saying...what do you guys think? Do you feel safe that when they tell you it's safe, it actually is. My g/f would never let me do the neck manipulation and I would just roll my eyes but now I think she could be right. This is borderline crazy if this stuff is true and should be banned immediately. What do you guys think? I think they should at least tell us there is this potential risk!!!

Video: (PBS Scientific America) http://vvi.onstreammedia.com/cgi-bi...tart=1298098&ccend=2231231&videoID=pbssaf1210

Random Article: http://www.chirobase.org/15News/neurol.html

I don't really trust many of my classmates because I feel they pass the barrier by 500 miles

Although some docs in OMM lab can do a correction without making me seem like the exorcist -- just with a true high velocity LOW AMPLITUDE. There are some who do it chiro style because they are dieing to hear the popping HVHA.

Now that I've been back home for a few weeks I've corrected some lower backs with HVLA and thoracics. I don't really feel all that comfortable with neck HVLA so I use muscle energy.

And yes you can get strokes. Imagine not checking any bruits in the carotids and manipulating. Perfect scenario for a lawsuit.

 

[JonnyG]

Cervical really needs to be done by people who are comfortable with it. We have a pathologist who rales on chiros for this saying they are doing a different technique, don't check wallenbergs and other stuff. The whole point of Facillitated Position release is to replace cervical HVLA.

I also loved the fact that the professor teaching us cervical said half way through it that he didn't feel comfortable doing cervical for a couple years into residency.........................................and hes an expert.

 

[Pansit]

Cervical really needs to be done by people who are comfortable with it. We have a pathologist who rales on chiros for this saying they are doing a different technique, don't check spurling's and other stuff. The whole point of Facillitated Position release is to replace cervical HVLA.

I also loved the fact that the professor teaching us cervical said half way through it that he didn't feel comfortable doing cervical for a couple years into residency.........................................and hes an expert.

My question is that why dont they tell students the risks? At the least wouldnt it be important for students to know it anyway because they will be the ones performng this stuff in the futre. I didnt know that I can get a stroke from being manipulated in the neck! If I knew that maybe I might be more hesistant to do it...I mean, if something were to happen than they are screwed. It seems like they are just relying on the fact that it hasnt happened before (for all we know) and are just telling us it's safe without really explaining anything. That pretty much goes for all the treatments...its assumed it's safe. That doesnt seem right to me. Specially since it's well documented that it should be something that is told.

 

[bkpa2med]

My question is that why dont they tell students the risks? At the least wouldnt it be important for students to know it anyway because they will be the ones performng this stuff in the futre. I didnt know that I can get a stroke from being manipulated in the neck! If I knew that maybe I might be more hesistant to do it...I mean, if something were to happen than they are screwed. It seems like they are just relying on the fact that it hasnt happened before (for all we know) and are just telling us it's safe without really explaining anything. That pretty much goes for all the treatments...its assumed it's safe. That doesnt seem right to me. Specially since it's well documented that it should be something that is told.

The anatomists at my school told us about this and some OMM instructors.

 

[strawberryfield]

My question is that why dont they tell students the risks? At the least wouldnt it be important for students to know it anyway because they will be the ones performng this stuff in the futre. I didnt know that I can get a stroke from being manipulated in the neck! If I knew that maybe I might be more hesistant to do it...I mean, if something were to happen than they are screwed. It seems like they are just relying on the fact that it hasnt happened before (for all we know) and are just telling us it's safe without really explaining anything. That pretty much goes for all the treatments...its assumed it's safe. That doesnt seem right to me. Specially since it's well documented that it should be something that is told.

we had an entire 1-2 hr lecture on the research and safety of cervical HVLA before learning it at KCOM

 

[scpod]

....The reason why i am writing this post is that they dont tell us any of this stuff!!.....

We generaly don't do cervical HVLA at my school in extension because the data indicates that almost all problems have occured that way. Obviously, there are contraindications, both absolute and relative, for any cervical HVLA. We learned all of those first, then looked at the studies as well. Most of the folks I've talked to went over this in school. If your school isn't teaching that, then there's something wrong with your school's curriculum.

 

[BobBarker]

We just got to popping with the cervical HVLA. A few weeks later we learned not to do it on patient's with RA or JRA. We have a classmate with JRA. Ooopss..

 

[facetguy]

Pansit,

I must say that I am quite surprised that you haven't been taught anything about the potential risks of cervical manipulation, including vertebrobasilar artery dissection and subsequent stroke. Such strokes are exceedingly rare, so rare that it is difficult to measure the incidence. Estimates range from 1 in 500,000 to 1 in several million, and they are essentially random. Evidence shows that it is impossible to determine beforehand who may suffer stroke following cervical manipulation, and that includes checking for bruits, using various provocative maneuvers, etc. (But, from a med-legal risk perspective, you would be in a much better position if you did these pre-treatment checks anyway.) A recent study in Spine showed that the risk of stroke was the same regardless of whether a patient with neck pain presents to a chiropractor or presents to their primary care physician. Would anyone really say that PCPs cause strokes? No, but it indicates that patients may be presenting with some vascular phenomenon already underway. It's an evolving area of research, as it should be.

There are some who do it chiro style because they are dieing to hear the popping HVHA.

As to this comment, there obviously continues to exist some type of anti-chiropractic bias (and gross misinformation) among some, which I suspect will always exist. "Chiro style"?? I'm going to guess that the person making that comment doesn't know a whole lot about what chiropractors do. Do you really believe that chiropractors don't learn muscle energy and a whole host of other non-"popping" techniques? In your mind, do chiropractors simply grab people's necks and just go crazy? Interestingly, many published cases of stroke that have been attributed to chiropractors have later been proven to be non-chiropractic in nature (but instead due to a medical practitioner, or an unqualified friend, or a karate instructor, and the like). Let's try to keep it professional.

 

[SomeDoc]

Pansit,

I must say that I am quite surprised that you haven't been taught anything about the potential risks of cervical manipulation, including vertebrobasilar artery dissection and subsequent stroke. Such strokes are exceedingly rare, so rare that it is difficult to measure the incidence. Estimates range from 1 in 500,000 to 1 in several million, and they are essentially random. Evidence shows that it is impossible to determine beforehand who may suffer stroke following cervical manipulation, and that includes checking for bruits, using various provocative maneuvers, etc.

This is true- I remember reading up on this. Any references would be appreciated.

I don't really trust many of my classmates because I feel they pass the barrier by 500 miles

There are some who do it chiro style because they are dieing to hear the popping HVHA.

Let's just say I was quite upset when a student "TA" kept doing OA HVLA on me because the joint was "so close to popping" (despite being taught that a "pop" is by no means an indication of procedure success) I politely declined any of his further attempts. Despite my preventive measures, I was sore for slightly over a week thereafter.

 

[DrWBD]

A recent study in Spine showed that the risk of stroke was the same regardless of whether a patient with neck pain presents to a chiropractor or presents to their primary care physician.

The article you refer to is an example of very sloppy science.
Here's a blogger's interesting take on the article:
http://www.sciencebasedmedicine.org/?p=170

I also avoided performing or receiving cervical manipulation except during OMT practical examinations.

 

[Pansit]

The article you refer to is an example of very sloppy science.
Here's a blogger's interesting take on the article:
http://www.sciencebasedmedicine.org/?p=170

I also avoided performing or receiving cervical manipulation except during OMT practical examinations.

???...So you are fine with a school teaching health care providers a treatment that you dont even feel safe enough that you would have it perfomed on to you. What does that say? Shouldn't the profession advocate some kind of reform on this stuff. It's like an attack on a specific part of OMM is seen as an attack on the entire profession.

 

[DrWBD]

???...So you are fine with a school teaching health care providers a treatment that you dont even feel safe enough that you would have it perfomed on to you. What does that say?

I never said I was fine with it, although I suppose you're implying that because I graduated from a school of osteopathic medicine that I implicitly endorse everything taught there. To be honest, you'd actually have a valid point. I simply didn't care enough to challenge the status quo as a student. I had too much time and money invested to fight a losing battle. I knew I would use OMT minimally, if at all, in my career as a physician. Getting through OMT is the penance for not doing better in college organic chemistry, I guess. 😀

???...Shouldn't the profession advocate some kind of reform on this stuff. It's like an attack on a specific part of OMM is seen as an attack on the entire profession.

The osteopathic profession, in case you haven't figured it out by now, is controlled by the very vocal minority of zealots who do not give a crap about your opinion or the opinion of students in general. To them, any attack on OMT is preceived as an attack on the profession.

 

[Old_Mil]

I simply didn't care enough to challenge the status quo as a student. I had too much time and money invested to fight a losing battle. I knew I would use OMT minimally, if at all, in my career as a physician. Getting through OMT is the penance for not doing better in college organic chemistry, I guess. 😀

It's guerilla warfare your first couple of years. Once you get a few USMLES under your belt and match ACGME, the game changes.

The osteopathic profession, in case you haven't figured it out by now, is controlled by the very vocal minority of zealots who do not give a crap about your opinion or the opinion of students in general. To them, any attack on OMT is preceived as an attack on the profession.

Unfortunately, and they're singularly good at biting the hand that feeds (people who go to DO schools to practice allopathic medicine, that is, the majority of applicants).

 

[laboholic]

I agree with facetguy. It is very rare to have a stroke or other problems after cervical manipulation. If you take a good history, you can exclude patients with risk factors such as rheumatoid arthritis, Down syndrome, previous stroke and those who get dizzy when they turn their head to the side. Otherwise, I think the risk of negative side effects with cervical manip are less then the the risks for something like aspirin or birth control pills. However, people still seem to focus on the negatives of "alternative medicine" when things that are prescribed every day have a much higher chance of killing or hurting you.

 

[DrWBD]

I agree with facetguy. It is very rare to have a stroke or other problems after cervical manipulation. If you take a good history, you can exclude patients with risk factors such as rheumatoid arthritis, Down syndrome, previous stroke and those who get dizzy when they turn their head to the side. Otherwise, I think the risk of negative side effects with cervical manip are less then the the risks for something like aspirin or birth control pills. However, people still seem to focus on the negatives of "alternative medicine" when things that are prescribed every day have a much higher chance of killing or hurting you.

I don't think you understand the concept of risk/benefit ratio.
Justifying the use of cervical manipulation because it is supposedly less "risky" than an aspirin is illogical. Where is the evidence that cervical manipulation, especially high velocity manipulation, is actually beneficial? No well-designed study, to my knowledge, has shown this to be true. The same is not true of the analgesic properties of aspirin and NSAIDs, which have well-studied therapeutic effects in addition to a known side effect profile.

If you read the link in my earlier post, the idea that chiropractic cervical manipulation is "safe" is questionable. While I'm not sure that this can be extrapolated to OMT of the c-spine, it should be considered, despite what your OMT instructors tell you.

 

[laboholic]

Did you even read the OP's question or my post? The question was not whether or not cervical manipulation is beneficial, it was whether or not cervical manipulation is safe. I stated that current mainstream medications may have a worse safety profile than cervical manipulation. Im sure you would love to argue about this all day long, however, there is really no point since there are no good studies backing either of our arguements.
Also, some patients feel that "getting their neck cracked" helps more than taking something like aspirin for pain. So, even though it has not been proven effective, I wouldnt count it out as not being efficacious. All that may be lacking is a well designed study. So, in the mean time, why not provide patients with a service that makes them feel better?

I don't think you understand the concept of risk/benefit ratio.
Justifying the use of cervical manipulation because it is supposedly less "risky" than an aspirin is illogical. Where is the evidence that cervical manipulation, especially high velocity manipulation, is actually beneficial? No well-designed study, to my knowledge, has shown this to be true. The same is not true of the analgesic properties of aspirin and NSAIDs, which have well-studied therapeutic effects in addition to a known side effect profile.

If you read the link in my earlier post, the idea that chiropractic cervical manipulation is "safe" is questionable. While I'm not sure that this can be extrapolated to OMT of the c-spine, it should be considered, despite what your OMT instructors tell you.

 

[homeboy]

Interesting question.
IMHO, neck manipulation offers no more good than narcotics, arguably much less, and there's no head-to-head trials evaluating neck 'manipulation' vs 'neck massage' or soft tissue to prove it's the manipulation vs simply the 'touch' aspect. And even if someone 'proved' a difference with the usual N=5 pseudoscience a la the JAOA, no one would care because it wouldn't create any sweeping acceptance of neck manipulation...it's always going to be viewed as chiropracticesque-quackery.


Things always seem more important when you're first exposed to them, especially when you are emphatically taught something by physicians who have a vested interest in you accepting it.

IE: out in the real world, outside the confines of osteopathic education (which I'll remind you makes up a fraction of national medical education, with DOs only comprising ~7% of physicians), manipulation--ESPECIALLY spinal manipulation--holds about as much water as the diplomas of those who purport its omnipotence.

 

[ShyRem]

UNE gives a lecture on HVLA safety, including whole lists of absolute contraindications and relative contraindications before we learn any HVLA. There are a few of us in class who fell into one of those categories, and the TAs were very clear to our partners that "you do NOT do this technique on him/her - find someone else to practice on" when we got into lab.

 

[facetguy]

...manipulation--ESPECIALLY spinal manipulation--holds about as much water as the diplomas of those who purport its omnipotence.

Those purporting this omnipotence are quite rare. Keep that in mind.

 

[DaveinDallas]

Hey pancit----kumusta ka? Sucked down any cold San Miguel lately? Remember, Republika ng Pilipinas.....

Statistically speaking, you stand a better chance of dying driving to the chiro than you do dying or stroking out from a cervical manipulation. That being said, I refuse to let my classmates, with one or two exceptions perform any cervical manipulations on me.

We had a lecture on contraindications before being taught cervical manipulation and the prof said that you didn't need to 'get the pop' for
HVLA to work. So we boogie up to lab and the TA doing our instruction helped me isolate the lesioned segment and I 'engaged the restrictive barrier' to 'pop it like it's hot'. I did and with a gleeful look from their glassy eyes, the TA asked,'Did you get the pop?!!!'. The expression was almost one of ecstasy when asking the question which made me realize that 2nd year TAs are just that, 2nd year medical students......who's extensive clinical experience (unless they're DCs which a few of my classmates were) is limited to what they've done in lab. One believed in power over technique and almost blacked me out by mashing my neck with his thumb near the vertebral artery and then told me I had a birth defect because I shouldn't be blacking out......needless to say, I don't (been to chiropractors for a long time) and it was just his incompetence and lack of knowledge of anatomy and belief that 'more power' will compensate for bad technique mentality.......

Anyway, I only perform cervical HVLA on my wife when indicated and NEVER in extension.......

 

[SomeDoc]

One believed in power over technique and almost blacked me out by mashing my neck with his thumb near the vertebral artery and then told me I had a birth defect because I shouldn't be blacking out......

He must've missed the part in lecture where LA in HVLA stands for low amplitude.

 

[SomeDoc]

IE: out in the real world, outside the confines of osteopathic education (which I'll remind you makes up a fraction of national medical education, with DOs only comprising ~7% of physicians), manipulation--ESPECIALLY spinal manipulation--holds about as much water as the diplomas of those who purport its omnipotence.

I'm guessing you probably don't read the NEJM.

 

[West Coaster]

seriously? Most of the posts I've read in this thread are absolutely astounding.... some of you aren't taught the risks of procedures????!!! as first years, we were taught adverse reactions to any procedure we did... OMM or anything in "traditional" medicine .... 1 in a million to be specific and we were handed the data that supported it ... not to say that I researched it myself but at least we were given the value of such a procedure and any evidence that was compiled to support or discredit it ...... and as I said, as a class, we were informed of all aspects: the adverse reactions, the select few who are more prone to experience them, the contraindications, the expected results ... etc. the list goes on ......

not only that but honestly, in my opinion, your profs should have been teaching you how to correctly "pop" a neck .... even without the pop, just the movement ...... when my class learned, a prof was there to guide us to the barrier and the LOW AMPLITUDE through it .... their hands were on top of ours .... and this was after a two hour lecture on anything to do with not only HVLA, but more specifically, cervical HVLA ..... they told us not to try it unless we felt comfortable with the entire technique.... besides, half the objective is to make sure that the patient is completely willing to accept the treatment... i.e. they are relaxed and in a state where they will not "guard" against the tx .....

but in all honesty.... why learn something if you have no idea what data surrounds it and what, if any, evidence supports it .... those posters that have not had this education leading up to the experience should really advocate for surrounding material to be taught .....

not saying that my school does the best job of everything but seriously, I am awed that the previous posts went through such education without even the slightest idea of supporting material ....

just my two cents ....