Re: Manipulation and stroke

[Guest guest]

Yikes! Never did I think I'd be trying to pitch the same type of argument as

the tobacco companies. Surely, my ethical bearings have taken a slide while I

wasn't looking.

But seriously, it was difficult for the anti-tobacco people to establish a

relationship between smoking and disease. That link is now well accepted. The

anti-tobacco people had the benefit of comparing some absolutes. Someone is

either a smoker, or not, and the amount and time they smoked is acertainable.

Now consider cervical adjusting. Various posters on this subject discuss

techniques as if all treatment to the neck by everyone using & *%# technique is

identical, like all Camel straights are equivalent. We all know that is not

true. Just take what we call diversified cervical adjusting. The gamut runs

from incompetent chiropractors who are unskilled at determining direction and

level of lesion, who grab the patient's head and twist to the limit one

direction and then the other loosing a cascade of audible reports from the

neck, as compared to the doctor of more refined skills who determines a precise

level and direction of lesion, rotates the neck while maintaining contact at

the level of lesion, then maintains pressure at that level as he backs off the

rotation of the neck as a whole and at that point gives a high speed/low

amplitude impulse of force nearly invisible to an observer that allows that one

segment to release without traumatizing the neck. Both situations would be

logged in our data as diversified technique adjustments; but anyone who has

been adjusted by a hundred or so colleagues while going through chiropractic

college knows the difference. It would take only the tiniest fraction of

incompetent practitioners to skew the stats, so rare is the incidence of stroke

following manipulation. So, it seems to me that when we look at these

statistics we really need to question what these numbers represent. I doubt

seriously that we have data of sufficient quality to make the kind of

judgements about chiropractic methodology that I feel some of us would like to

rush to make. I do appreciate the appeal of being able to say the dangers of

chiropractic come from this one style of treatment and the rest is OK; but I am

skeptical of the data that suggests this, as I am skeptical of the data that

relates cervical manipulation to stroke.

If the real world risk of death is greater from OTC drugs, or virtually any of

the prescription pharmaceuticals; I have to wonder why chiropractic gets

singled out for scrutiny. 60 Minutes spends months hunting down the only

35year old woman in the country who is paraplegic following cervical

manipulation and features her in a segment on chiropractic. Meanwhile over

twice as many Americans a year die from " properly prescribed " drugs as died in

the Vietnam war, or all the yearly traffic deaths on our highways. Are we held

to a different standard than the medical community in the mayhem department?

It is common for MD's to caution patients about the terrific dangers of seeing

a chiropractor for treatment of the neck; yet plenty of data shows that the

least dangerous medical treatment is many times as dangerous as the most

dangerous chiropractic treatment.

Let's continue to make chiropractic safer and more effective. In the mean

time, let's make sure about these claims of a causal relationship between

chiropractic manipulation and stroke before we buy into such claims. I suspect

that if complete enough data were available they would show what Dr. Lubcke

alluded to in the article he mentioned, that there may well be less risk of

stroke in the population of people who have normal movement in the neck

preserved and restored by chiropractic than exists in the population that is

untreated. At this point I don't think we know.

S. Feinberg, D.C.

[Guest guest]

Les, yet another excellent commentary!

Along those lines last year published in Spine Haldeman and co-workers

published the most comprehensive retrospective review of all the english

literature on the subject (Spine 24(8):785-794, 1999). Their conclusions;

1. No neck position or movement has been shown to increase risk.

2. no form of cervical manipulation has been shown to increase risk.

3. There is no valid predictive pre-adjustment tresting.

4. Underlying pre-existing arteriopathy is suspected.

5. These should be considered random, unpredictable complications associated

with head and neck movements.

Authors of a 1985 study clearly indicated that the normal vessels of the

head and neck are quite resistent to trauma. Individuals whom had been

involved in tremendous traumatic injury (fractured necks/skulls) resulting

in their death on autopsy revealed the vertebral, carotid, etc. vessels were

apparently intake. (Stroke 16:1030-1038, 1985)

Because of the rarity of these events Triano was quoted as stating that

" We would have to study manipulation over generations before we had a large

enough sample size of incidents to use scentifically. " (JACA 36(9):6-15,

1999)

As per a comparison of medical morbidity and mortality, hows about this;

Mortality from medications is estimated at between 79,000 to 179,000 each

year ( JA..Archives of Internal Medicine)

Medical errors in and out of the hospital? >7 million per year and exceeds

workplace injuries (National Academy of Sciences Institute of Medicine Nov.

29, 1999)

The NIH study indicated that betweenn 44,000 and 98,000 people die each year

because of medical mistakes. Consequently medical error is the 4th leading

cause of death in the US!

NSAIDs result in 103,000 hospitalizations each year and result in 16,500

deaths per year in this country (Wolf MM, New Eng J Med 340(24):1888-99,

1999)

The mortality rate for patients taking NSAIDs for at least 2 months is

1:1,200, (Trammer, Pain 85(1-2):169-82, 2000)

If deaths from GI toxic effects of NSAIDs were tabulated separately, these

effects would constiutute the 15th most common cause of death in the US!

Adverse drug reation mortality, these are NOT deaths due to medical error

these are deaths secondary to the right drug being prescribed and taken

properly by the patient whom subsequently have a serious reaction to the

drug and " pop-off, " 106,000 per year!

The annual costs of drug-related morbidity was estimated at some $76.6

billion back in 1995 (Archieves of Internal Medicine 155:1949-1956, 1995)

Anyone wana bet its closer to $100 billion now!

Hospital acquired infections have increased recently some 36%, about 2

million each year and these infections acquired at the hospital result in

some 90,000 deaths each year, and cost some $4.5 billion dollars a year in

health care costs (Manning, A. USA Today March 15, 1998)

60% to 90% of ALL spinal surgeries may be unnecessary (Spine 8:131-140,

1983, Spine 17:1205, 1992).

Currently as you know everyone and their brother is performing various forms

of spinal fusion surgery for back pain! Not just disc herniation and the

concomitant radiculopathy, but for supposed " discogenic " back pain alone!

Generally the diagnostic test to confirm the need for surgery is a

provocative discogram. Discogram are know to have a high false positive

rate (Spine 18(14)2035-2038, 1993) and major complications occur at an

incidence at high as 1:8 (same reference).

The Cochrane review which is a group of international research network of

volunteers, published last year in Spine the fact there is NO VALID EVIDENCE

for spinal fusion for DJD, back pain, instability, or stenosis (Spine

24(17):1820-32, 1999) the most notable of these fusions currently is the

BAK interbody cages.

38.3% of the patient having an anterior BAK spinal fusion will have

significant complications. (Journal of Neurosurgery 91(1 Suppl):60-4, 1999)

Not only is there no valid evidence of the efficacy of these fusions but

there is no consensus among spine surgeons as per when to perform an

anterior approach, vs. a posterior approach, or when to do a 360 (which is

both)?

Oh, and the mortality rate for spinal surgery has been cited to be around

1:1,430 (JBJS 74-A:536-543, 1992). In the VA hospital system its worse

laminectomies 1:204 and spinal fusions 1:51!! (J Surg Research, 56:405-416,

1994)

Parfenchuck cited the fact that about 9,000 of the 60,000 + spinal fusions

each year fail resulting in direct costs of >$25 billion each year, and

indirect costs of >$75 billion and that was back in 1995! (Parfenchuck TA Am

J Orthop. Nov:854-858, 1995)

Ok so I'll get off my soap box! This is all stuff and more that I'm

presenting this Friday in Vancouver, BC at an International Low Back Pain

Symposium.

Vern Saboe, DC

Re: Manipulation and stroke

>Yikes! Never did I think I'd be trying to pitch the same type of argument

as

>the tobacco companies. Surely, my ethical bearings have taken a slide

while I

>wasn't looking.

>

>But seriously, it was difficult for the anti-tobacco people to establish a

>relationship between smoking and disease. That link is now well accepted.

The

>anti-tobacco people had the benefit of comparing some absolutes. Someone

is

>either a smoker, or not, and the amount and time they smoked is

acertainable.

>Now consider cervical adjusting. Various posters on this subject discuss

>techniques as if all treatment to the neck by everyone using & *%# technique

is

>identical, like all Camel straights are equivalent. We all know that is

not

>true. Just take what we call diversified cervical adjusting. The gamut

runs

>from incompetent chiropractors who are unskilled at determining direction

and

>level of lesion, who grab the patient's head and twist to the limit one

>direction and then the other loosing a cascade of audible reports from the

>neck, as compared to the doctor of more refined skills who determines a

precise

>level and direction of lesion, rotates the neck while maintaining contact

at

>the level of lesion, then maintains pressure at that level as he backs off

the

>rotation of the neck as a whole and at that point gives a high speed/low

>amplitude impulse of force nearly invisible to an observer that allows that

one

>segment to release without traumatizing the neck. Both situations would be

>logged in our data as diversified technique adjustments; but anyone who has

>been adjusted by a hundred or so colleagues while going through

chiropractic

>college knows the difference. It would take only the tiniest fraction of

>incompetent practitioners to skew the stats, so rare is the incidence of

stroke

>following manipulation. So, it seems to me that when we look at these

>statistics we really need to question what these numbers represent. I

doubt

>seriously that we have data of sufficient quality to make the kind of

>judgements about chiropractic methodology that I feel some of us would like

to

>rush to make. I do appreciate the appeal of being able to say the dangers

of

>chiropractic come from this one style of treatment and the rest is OK; but

I am

>skeptical of the data that suggests this, as I am skeptical of the data

that

>relates cervical manipulation to stroke.

>

>If the real world risk of death is greater from OTC drugs, or virtually any

of

>the prescription pharmaceuticals; I have to wonder why chiropractic gets

>singled out for scrutiny. 60 Minutes spends months hunting down the only

>35year old woman in the country who is paraplegic following cervical

>manipulation and features her in a segment on chiropractic. Meanwhile over

>twice as many Americans a year die from " properly prescribed " drugs as died

in

>the Vietnam war, or all the yearly traffic deaths on our highways. Are we

held

>to a different standard than the medical community in the mayhem

department?

>It is common for MD's to caution patients about the terrific dangers of

seeing

>a chiropractor for treatment of the neck; yet plenty of data shows that the

>least dangerous medical treatment is many times as dangerous as the most

>dangerous chiropractic treatment.

>

>Let's continue to make chiropractic safer and more effective. In the mean

>time, let's make sure about these claims of a causal relationship between

>chiropractic manipulation and stroke before we buy into such claims. I

suspect

>that if complete enough data were available they would show what Dr. Lubcke

>alluded to in the article he mentioned, that there may well be less risk of

>stroke in the population of people who have normal movement in the neck

>preserved and restored by chiropractic than exists in the population that

is

>untreated. At this point I don't think we know.

>

> S. Feinberg, D.C.

>

>

>

>

>

>

>

>

>

[Guest guest]

Verne and Les

My hat off to both of you,

I beleive is talking about which one looks worse in the publics eyes

because we both know the medical profession being in control is able to

cover up or explain away its mistakes in many cases where as once the

patient with a stroke leaves and goes to the hospital we lose all control

and in many cases it is how it is explained to the patient and their family

as to if there is litigation.

I think all three of you are right on though in that although there are

those in our profession out there just waiting to testify against you I saw

a statistic once showing the average chiropractor because stroke is such a

low incidence would have to practice for a 100 years to statistically have

one occur in their office. As Larry said that's a lot of folks you may have

saved from having a stroke in all those years not to mention all the

patients you saved from going to a MD and being injured or killed.

I use a PAR form in my office listing this as a complication of manipulation

amoungst others and I have each patient sign it and ask them if they have

any questions before they are tx'd/ Although this does not keep them from

litigation against me at least they were informed. I ave. between 30 and 50

new patients a month and have been using it for 3-4 years and have yet had

one patient to refuse neck adj. if I felt it was indicated. There have been

several through testing I have refused to tx. because of irregularities. If

anyone is interested in seeing it let me know and I will e-mail it in word

format to you so you can customize it to your office if you wish to use it.

Take care and appreciate the information

Steve Kinne

Re: Manipulation and stroke

>

>

>>Yikes! Never did I think I'd be trying to pitch the same type of argument

>as

>>the tobacco companies. Surely, my ethical bearings have taken a slide

>while I

>>wasn't looking.

>>

>>But seriously, it was difficult for the anti-tobacco people to establish a

>>relationship between smoking and disease. That link is now well accepted.

>The

>>anti-tobacco people had the benefit of comparing some absolutes. Someone

>is

>>either a smoker, or not, and the amount and time they smoked is

>acertainable.

>>Now consider cervical adjusting. Various posters on this subject discuss

>>techniques as if all treatment to the neck by everyone using & *%#

technique

>is

>>identical, like all Camel straights are equivalent. We all know that is

>not

>>true. Just take what we call diversified cervical adjusting. The gamut

>runs

>>from incompetent chiropractors who are unskilled at determining direction

>and

>>level of lesion, who grab the patient's head and twist to the limit one

>>direction and then the other loosing a cascade of audible reports from the

>>neck, as compared to the doctor of more refined skills who determines a

>precise

>>level and direction of lesion, rotates the neck while maintaining contact

>at

>>the level of lesion, then maintains pressure at that level as he backs off

>the

>>rotation of the neck as a whole and at that point gives a high speed/low

>>amplitude impulse of force nearly invisible to an observer that allows

that

>one

>>segment to release without traumatizing the neck. Both situations would

be

>>logged in our data as diversified technique adjustments; but anyone who

has

>>been adjusted by a hundred or so colleagues while going through

>chiropractic

>>college knows the difference. It would take only the tiniest fraction of

>>incompetent practitioners to skew the stats, so rare is the incidence of

>stroke

>>following manipulation. So, it seems to me that when we look at these

>>statistics we really need to question what these numbers represent. I

>doubt

>>seriously that we have data of sufficient quality to make the kind of

>>judgements about chiropractic methodology that I feel some of us would

like

>to

>>rush to make. I do appreciate the appeal of being able to say the dangers

>of

>>chiropractic come from this one style of treatment and the rest is OK; but

>I am

>>skeptical of the data that suggests this, as I am skeptical of the data

>that

>>relates cervical manipulation to stroke.

>>

>>If the real world risk of death is greater from OTC drugs, or virtually

any

>of

>>the prescription pharmaceuticals; I have to wonder why chiropractic gets

>>singled out for scrutiny. 60 Minutes spends months hunting down the only

>>35year old woman in the country who is paraplegic following cervical

>>manipulation and features her in a segment on chiropractic. Meanwhile

over

>>twice as many Americans a year die from " properly prescribed " drugs as

died

>in

>>the Vietnam war, or all the yearly traffic deaths on our highways. Are we

>held

>>to a different standard than the medical community in the mayhem

>department?

>>It is common for MD's to caution patients about the terrific dangers of

>seeing

>>a chiropractor for treatment of the neck; yet plenty of data shows that

the

>>least dangerous medical treatment is many times as dangerous as the most

>>dangerous chiropractic treatment.

>>

>>Let's continue to make chiropractic safer and more effective. In the mean

>>time, let's make sure about these claims of a causal relationship between

>>chiropractic manipulation and stroke before we buy into such claims. I

>suspect

>>that if complete enough data were available they would show what Dr.

Lubcke

>>alluded to in the article he mentioned, that there may well be less risk

of

>>stroke in the population of people who have normal movement in the neck

>>preserved and restored by chiropractic than exists in the population that

>is

>>untreated. At this point I don't think we know.

>>

>> S. Feinberg, D.C.

>>

>>

>>

>>

>>

>>

>>

>>

>>

>

>

>

>

>

>

[Guest guest]

Steve, a written informed constent form signed by the patient is not legally

needed, simply a note in the chart indicating a PARQ conference was given is

enough. However with that said, I to have a written informed consent form

which deep in the bowels of the form lists stroke as a extremly rare

event,etc., the patient signs this form as do I and we both dated it.

However I also have a paragraph describing this process and that I and the

patient had a conversation (PARQ conference) regarding my treatment/exam

procedures etc. which is pulled into my chart note (of course using the

Saboe Chart Note System ha!). At trial the patient's will say yes I signed

" that form " but I really did not read it! Every juror can relate to that,

but if you back it up with a note in the chart the deal is sealed!

Vern Saboe

Re: Manipulation and stroke

>>

>>

>>>Yikes! Never did I think I'd be trying to pitch the same type of

argument

>>as

>>>the tobacco companies. Surely, my ethical bearings have taken a slide

>>while I

>>>wasn't looking.

>>>

>>>But seriously, it was difficult for the anti-tobacco people to establish

a

>>>relationship between smoking and disease. That link is now well

accepted.

>>The

>>>anti-tobacco people had the benefit of comparing some absolutes. Someone

>>is

>>>either a smoker, or not, and the amount and time they smoked is

>>acertainable.

>>>Now consider cervical adjusting. Various posters on this subject discuss

>>>techniques as if all treatment to the neck by everyone using & *%#

>technique

>>is

>>>identical, like all Camel straights are equivalent. We all know that is

>>not

>>>true. Just take what we call diversified cervical adjusting. The gamut

>>runs

>>>from incompetent chiropractors who are unskilled at determining direction

>>and

>>>level of lesion, who grab the patient's head and twist to the limit one

>>>direction and then the other loosing a cascade of audible reports from

the

>>>neck, as compared to the doctor of more refined skills who determines a

>>precise

>>>level and direction of lesion, rotates the neck while maintaining contact

>>at

>>>the level of lesion, then maintains pressure at that level as he backs

off

>>the

>>>rotation of the neck as a whole and at that point gives a high speed/low

>>>amplitude impulse of force nearly invisible to an observer that allows

>that

>>one

>>>segment to release without traumatizing the neck. Both situations would

>be

>>>logged in our data as diversified technique adjustments; but anyone who

>has

>>>been adjusted by a hundred or so colleagues while going through

>>chiropractic

>>>college knows the difference. It would take only the tiniest fraction

of

>>>incompetent practitioners to skew the stats, so rare is the incidence of

>>stroke

>>>following manipulation. So, it seems to me that when we look at these

>>>statistics we really need to question what these numbers represent. I

>>doubt

>>>seriously that we have data of sufficient quality to make the kind of

>>>judgements about chiropractic methodology that I feel some of us would

>like

>>to

>>>rush to make. I do appreciate the appeal of being able to say the

dangers

>>of

>>>chiropractic come from this one style of treatment and the rest is OK;

but

>>I am

>>>skeptical of the data that suggests this, as I am skeptical of the data

>>that

>>>relates cervical manipulation to stroke.

>>>

>>>If the real world risk of death is greater from OTC drugs, or virtually

>any

>>of

>>>the prescription pharmaceuticals; I have to wonder why chiropractic gets

>>>singled out for scrutiny. 60 Minutes spends months hunting down the only

>>>35year old woman in the country who is paraplegic following cervical

>>>manipulation and features her in a segment on chiropractic. Meanwhile

>over

>>>twice as many Americans a year die from " properly prescribed " drugs as

>died

>>in

>>>the Vietnam war, or all the yearly traffic deaths on our highways. Are

we

>>held

>>>to a different standard than the medical community in the mayhem

>>department?

>>>It is common for MD's to caution patients about the terrific dangers of

>>seeing

>>>a chiropractor for treatment of the neck; yet plenty of data shows that

>the

>>>least dangerous medical treatment is many times as dangerous as the most

>>>dangerous chiropractic treatment.

>>>

>>>Let's continue to make chiropractic safer and more effective. In the

mean

>>>time, let's make sure about these claims of a causal relationship between

>>>chiropractic manipulation and stroke before we buy into such claims. I

>>suspect

>>>that if complete enough data were available they would show what Dr.

>Lubcke

>>>alluded to in the article he mentioned, that there may well be less risk

>of

>>>stroke in the population of people who have normal movement in the neck

>>>preserved and restored by chiropractic than exists in the population that

>>is

>>>untreated. At this point I don't think we know.

>>>

>>> S. Feinberg, D.C.

>>>

>>>

>>>

>>>

>>>

>>>

>>>

>>>

>>>

>>

>>

>>

>>

>>

>>

>

>

>

>

>

>

[Guest guest]

I just gotta put my own two bits in. Les, I have two chiropractic buddies

in so. oregon who have had patients have strokes after manipulation. I had

the opportunity to treat one of these patients, several months after her

manipulation caused stroke. It was a devastating experience for her, and

did have a dramatically negative effect on her life. She was unable to

drive, couldn't quite think straight, her vision was altered. None of these

conditions really improved much over time. I could go on. Anyway, lets not

be in denial, bad things can happen.

We cannot ignore the paradigm, yes, the media beats this into the ground,

and of course medicine is more dangerous, but cervical adjusting is not

risk-free. Thus we need to weight risk-benefit, and learn lower risk

techniques. Try them first, if they are not working, after a couple of

visits, switch to a more forceful or rotary method.

I happen to agree with those who feel that rotary adjustments are not the

first choice for upper cervical adjusting, although I don't use the

activator, its too canned and two dimensional for me. the upper cervical

area is so important, we need to know how to effectively work here with

softer techniques.

We as a profession are so stuck on the osseous release. In the case I

mentioned above, the DC tried to adjust the neck, it didn't go, meaning he

didn't get an osseous release, so he adjusted again, causing a stroke.

First off, by being so focused on the osseous release, we end up ignoring

all kinds of areas that need manipulation, but do not lend themselves to an

osseous release, such as the sterno-costal junctions, and the whole of the

extremities, as well as a-p restriction of the cervical spine. We need to

evolve as a profession, and learn good low force adjusting methods. I can

suggest a whole list of teachers in the northwest, write me if you want the

list.

I could go on and on, but I'll stop here.

Take care,

Marc Heller

Re: Manipulation and stroke

>>

>>

>>>Yikes! Never did I think I'd be trying to pitch the same type of

argument

>>as

>>>the tobacco companies. Surely, my ethical bearings have taken a slide

>>while I

>>>wasn't looking.

>>>

>>>But seriously, it was difficult for the anti-tobacco people to establish

a

>>>relationship between smoking and disease. That link is now well

accepted.

>>The

>>>anti-tobacco people had the benefit of comparing some absolutes. Someone

>>is

>>>either a smoker, or not, and the amount and time they smoked is

>>acertainable.

>>>Now consider cervical adjusting. Various posters on this subject discuss

>>>techniques as if all treatment to the neck by everyone using & *%#

>technique

>>is

>>>identical, like all Camel straights are equivalent. We all know that is

>>not

>>>true. Just take what we call diversified cervical adjusting. The gamut

>>runs

>>>from incompetent chiropractors who are unskilled at determining direction

>>and

>>>level of lesion, who grab the patient's head and twist to the limit one

>>>direction and then the other loosing a cascade of audible reports from

the

>>>neck, as compared to the doctor of more refined skills who determines a

>>precise

>>>level and direction of lesion, rotates the neck while maintaining contact

>>at

>>>the level of lesion, then maintains pressure at that level as he backs

off

>>the

>>>rotation of the neck as a whole and at that point gives a high speed/low

>>>amplitude impulse of force nearly invisible to an observer that allows

>that

>>one

>>>segment to release without traumatizing the neck. Both situations would

>be

>>>logged in our data as diversified technique adjustments; but anyone who

>has

>>>been adjusted by a hundred or so colleagues while going through

>>chiropractic

>>>college knows the difference. It would take only the tiniest fraction

of

>>>incompetent practitioners to skew the stats, so rare is the incidence of

>>stroke

>>>following manipulation. So, it seems to me that when we look at these

>>>statistics we really need to question what these numbers represent. I

>>doubt

>>>seriously that we have data of sufficient quality to make the kind of

>>>judgements about chiropractic methodology that I feel some of us would

>like

>>to

>>>rush to make. I do appreciate the appeal of being able to say the

dangers

>>of

>>>chiropractic come from this one style of treatment and the rest is OK;

but

>>I am

>>>skeptical of the data that suggests this, as I am skeptical of the data

>>that

>>>relates cervical manipulation to stroke.

>>>

>>>If the real world risk of death is greater from OTC drugs, or virtually

>any

>>of

>>>the prescription pharmaceuticals; I have to wonder why chiropractic gets

>>>singled out for scrutiny. 60 Minutes spends months hunting down the only

>>>35year old woman in the country who is paraplegic following cervical

>>>manipulation and features her in a segment on chiropractic. Meanwhile

>over

>>>twice as many Americans a year die from " properly prescribed " drugs as

>died

>>in

>>>the Vietnam war, or all the yearly traffic deaths on our highways. Are

we

>>held

>>>to a different standard than the medical community in the mayhem

>>department?

>>>It is common for MD's to caution patients about the terrific dangers of

>>seeing

>>>a chiropractor for treatment of the neck; yet plenty of data shows that

>the

>>>least dangerous medical treatment is many times as dangerous as the most

>>>dangerous chiropractic treatment.

>>>

>>>Let's continue to make chiropractic safer and more effective. In the

mean

>>>time, let's make sure about these claims of a causal relationship between

>>>chiropractic manipulation and stroke before we buy into such claims. I

>>suspect

>>>that if complete enough data were available they would show what Dr.

>Lubcke

>>>alluded to in the article he mentioned, that there may well be less risk

>of

>>>stroke in the population of people who have normal movement in the neck

>>>preserved and restored by chiropractic than exists in the population that

>>is

>>>untreated. At this point I don't think we know.

>>>

>>> S. Feinberg, D.C.

>>>

>>>

>>>

>>>

>>>

>>>

>>>

>>>

>>>

>>

>>

>>

>>

>>

>>

>

>

>

>

>

>

[Guest guest]

Mark,

I would have to ague your statement that the extremities do not lend

themselves to osseous release. As synovial joints

the extremities respond nicely to osseous adjusting, and stroke is not an

excuse to avoid adjusting these regions.

Ted Forcum, DC, DACBSP

On Tue, 14 Nov 2000 20:25:26 -0800 " Marc Heller "

<mheller@...> writes:

> I just gotta put my own two bits in. Les, I have two chiropractic

> buddies

> in so. oregon who have had patients have strokes after manipulation.

> I had

> the opportunity to treat one of these patients, several months after

> her

> manipulation caused stroke. It was a devastating experience for

> her, and

> did have a dramatically negative effect on her life. She was unable

> to

> drive, couldn't quite think straight, her vision was altered. None

> of these

> conditions really improved much over time. I could go on. Anyway,

> lets not

> be in denial, bad things can happen.

>

> We cannot ignore the paradigm, yes, the media beats this into the

> ground,

> and of course medicine is more dangerous, but cervical adjusting is

> not

> risk-free. Thus we need to weight risk-benefit, and learn lower

> risk

> techniques. Try them first, if they are not working, after a couple

> of

> visits, switch to a more forceful or rotary method.

>

> I happen to agree with those who feel that rotary adjustments are

> not the

> first choice for upper cervical adjusting, although I don't use the

> activator, its too canned and two dimensional for me. the upper

> cervical

> area is so important, we need to know how to effectively work here

> with

> softer techniques.

>

> We as a profession are so stuck on the osseous release. In the case

> I

> mentioned above, the DC tried to adjust the neck, it didn't go,

> meaning he

> didn't get an osseous release, so he adjusted again, causing a

> stroke.

>

> First off, by being so focused on the osseous release, we end up

> ignoring

> all kinds of areas that need manipulation, but do not lend

> themselves to an

> osseous release, such as the sterno-costal junctions, and the whole

> of the

> extremities, as well as a-p restriction of the cervical spine. We

> need to

> evolve as a profession, and learn good low force adjusting methods.

> I can

> suggest a whole list of teachers in the northwest, write me if you

> want the

> list.

>

> I could go on and on, but I'll stop here.

>

> Take care,

>

> Marc Heller

>

> Re: Manipulation and stroke

> >>

> >>

> >>>Yikes! Never did I think I'd be trying to pitch the same type of

> argument

> >>as

> >>>the tobacco companies. Surely, my ethical bearings have taken a

> slide

> >>while I

> >>>wasn't looking.

> >>>

> >>>But seriously, it was difficult for the anti-tobacco people to

> establish

> a

> >>>relationship between smoking and disease. That link is now well

> accepted.

> >>The

> >>>anti-tobacco people had the benefit of comparing some absolutes.

> Someone

> >>is

> >>>either a smoker, or not, and the amount and time they smoked is

> >>acertainable.

> >>>Now consider cervical adjusting. Various posters on this subject

> discuss

> >>>techniques as if all treatment to the neck by everyone using & *%#

> >technique

> >>is

> >>>identical, like all Camel straights are equivalent. We all know

> that is

> >>not

> >>>true. Just take what we call diversified cervical adjusting.

> The gamut

> >>runs

> >>>from incompetent chiropractors who are unskilled at determining

> direction

> >>and

> >>>level of lesion, who grab the patient's head and twist to the

> limit one

> >>>direction and then the other loosing a cascade of audible reports

> from

> the

> >>>neck, as compared to the doctor of more refined skills who

> determines a

> >>precise

> >>>level and direction of lesion, rotates the neck while maintaining

> contact

> >>at

> >>>the level of lesion, then maintains pressure at that level as he

> backs

> off

> >>the

> >>>rotation of the neck as a whole and at that point gives a high

> speed/low

> >>>amplitude impulse of force nearly invisible to an observer that

> allows

> >that

> >>one

> >>>segment to release without traumatizing the neck. Both

> situations would

> >be

> >>>logged in our data as diversified technique adjustments; but

> anyone who

> >has

> >>>been adjusted by a hundred or so colleagues while going through

> >>chiropractic

> >>>college knows the difference. It would take only the tiniest

> fraction

> of

> >>>incompetent practitioners to skew the stats, so rare is the

> incidence of

> >>stroke

> >>>following manipulation. So, it seems to me that when we look at

> these

> >>>statistics we really need to question what these numbers

> represent. I

> >>doubt

> >>>seriously that we have data of sufficient quality to make the

> kind of

> >>>judgements about chiropractic methodology that I feel some of us

> would

> >like

> >>to

> >>>rush to make. I do appreciate the appeal of being able to say

> the

> dangers

> >>of

> >>>chiropractic come from this one style of treatment and the rest

> is OK;

> but

> >>I am

> >>>skeptical of the data that suggests this, as I am skeptical of

> the data

> >>that

> >>>relates cervical manipulation to stroke.

> >>>

> >>>If the real world risk of death is greater from OTC drugs, or

> virtually

> >any

> >>of

> >>>the prescription pharmaceuticals; I have to wonder why

> chiropractic gets

> >>>singled out for scrutiny. 60 Minutes spends months hunting down

> the only

> >>>35year old woman in the country who is paraplegic following

> cervical

> >>>manipulation and features her in a segment on chiropractic.

> Meanwhile

> >over

> >>>twice as many Americans a year die from " properly prescribed "

> drugs as

> >died

> >>in

> >>>the Vietnam war, or all the yearly traffic deaths on our

> highways. Are

> we

> >>held

> >>>to a different standard than the medical community in the mayhem

> >>department?

> >>>It is common for MD's to caution patients about the terrific

> dangers of

> >>seeing

> >>>a chiropractor for treatment of the neck; yet plenty of data

> shows that

> >the

> >>>least dangerous medical treatment is many times as dangerous as

> the most

> >>>dangerous chiropractic treatment.

> >>>

> >>>Let's continue to make chiropractic safer and more effective. In

> the

> mean

> >>>time, let's make sure about these claims of a causal relationship

> between

> >>>chiropractic manipulation and stroke before we buy into such

> claims. I

> >>suspect

> >>>that if complete enough data were available they would show what

> Dr.

> >Lubcke

> >>>alluded to in the article he mentioned, that there may well be

> less risk

> >of

> >>>stroke in the population of people who have normal movement in

> the neck

> >>>preserved and restored by chiropractic than exists in the

> population that

> >>is

> >>>untreated. At this point I don't think we know.

> >>>

> >>> S. Feinberg, D.C.

> >>>

> >>>

> >>>

> >>>

> >>>

> >>>

> >>>

> >>>

> >>>

> >>

> >>

> >>

> >>

> >>

> >>

> >

> >

> >

> >

> >

> >

>

>

>

>

>

>

>

> -------------------------- eGroups Sponsor

>

>

>

[Guest guest]

Hi, Ted,

Perhaps a didn't say it well. Yes, high velocity adjusting works just fine

on most extremity joints. I find, and others have agreed with me, that one

does not necessarily get an osseous release, the " pop, " when adjusting the

foot or knee, etc. My problem is not so much with osseous adjusting, as

with the holy grail of the osseous release sound, and the lack of interest

in the other ways of moving joints such as sustained contacts, myofascial

relase applied to joints, and muscle energy (contract relax).

Obviously, in talking about the extremities the worry is not about stroke or

other damage to the arteries. But, low force techniques are safe in a

swollen knee with possible meniscus damage, where HVLA might be relatively

contra-indicated.

I so often feel like I'm talking to people who cannot hear or see, when I

talk to DCs about low force technique. Most DCs think activator. There is

such a wonderful world of low force methods available, which have been used

and tested clinically.

Marc

Re: Manipulation and stroke

> >>

> >>

> >>>Yikes! Never did I think I'd be trying to pitch the same type of

> argument

> >>as

> >>>the tobacco companies. Surely, my ethical bearings have taken a

> slide

> >>while I

> >>>wasn't looking.

> >>>

> >>>But seriously, it was difficult for the anti-tobacco people to

> establish

> a

> >>>relationship between smoking and disease. That link is now well

> accepted.

> >>The

> >>>anti-tobacco people had the benefit of comparing some absolutes.

> Someone

> >>is

> >>>either a smoker, or not, and the amount and time they smoked is

> >>acertainable.

> >>>Now consider cervical adjusting. Various posters on this subject

> discuss

> >>>techniques as if all treatment to the neck by everyone using & *%#

> >technique

> >>is

> >>>identical, like all Camel straights are equivalent. We all know

> that is

> >>not

> >>>true. Just take what we call diversified cervical adjusting.

> The gamut

> >>runs

> >>>from incompetent chiropractors who are unskilled at determining

> direction

> >>and

> >>>level of lesion, who grab the patient's head and twist to the

> limit one

> >>>direction and then the other loosing a cascade of audible reports

> from

> the

> >>>neck, as compared to the doctor of more refined skills who

> determines a

> >>precise

> >>>level and direction of lesion, rotates the neck while maintaining

> contact

> >>at

> >>>the level of lesion, then maintains pressure at that level as he

> backs

> off

> >>the

> >>>rotation of the neck as a whole and at that point gives a high

> speed/low

> >>>amplitude impulse of force nearly invisible to an observer that

> allows

> >that

> >>one

> >>>segment to release without traumatizing the neck. Both

> situations would

> >be

> >>>logged in our data as diversified technique adjustments; but

> anyone who

> >has

> >>>been adjusted by a hundred or so colleagues while going through

> >>chiropractic

> >>>college knows the difference. It would take only the tiniest

> fraction

> of

> >>>incompetent practitioners to skew the stats, so rare is the

> incidence of

> >>stroke

> >>>following manipulation. So, it seems to me that when we look at

> these

> >>>statistics we really need to question what these numbers

> represent. I

> >>doubt

> >>>seriously that we have data of sufficient quality to make the

> kind of

> >>>judgements about chiropractic methodology that I feel some of us

> would

> >like

> >>to

> >>>rush to make. I do appreciate the appeal of being able to say

> the

> dangers

> >>of

> >>>chiropractic come from this one style of treatment and the rest

> is OK;

> but

> >>I am

> >>>skeptical of the data that suggests this, as I am skeptical of

> the data

> >>that

> >>>relates cervical manipulation to stroke.

> >>>

> >>>If the real world risk of death is greater from OTC drugs, or

> virtually

> >any

> >>of

> >>>the prescription pharmaceuticals; I have to wonder why

> chiropractic gets

> >>>singled out for scrutiny. 60 Minutes spends months hunting down

> the only

> >>>35year old woman in the country who is paraplegic following

> cervical

> >>>manipulation and features her in a segment on chiropractic.

> Meanwhile

> >over

> >>>twice as many Americans a year die from " properly prescribed "

> drugs as

> >died

> >>in

> >>>the Vietnam war, or all the yearly traffic deaths on our

> highways. Are

> we

> >>held

> >>>to a different standard than the medical community in the mayhem

> >>department?

> >>>It is common for MD's to caution patients about the terrific

> dangers of

> >>seeing

> >>>a chiropractor for treatment of the neck; yet plenty of data

> shows that

> >the

> >>>least dangerous medical treatment is many times as dangerous as

> the most

> >>>dangerous chiropractic treatment.

> >>>

> >>>Let's continue to make chiropractic safer and more effective. In

> the

> mean

> >>>time, let's make sure about these claims of a causal relationship

> between

> >>>chiropractic manipulation and stroke before we buy into such

> claims. I

> >>suspect

> >>>that if complete enough data were available they would show what

> Dr.

> >Lubcke

> >>>alluded to in the article he mentioned, that there may well be

> less risk

> >of

> >>>stroke in the population of people who have normal movement in

> the neck

> >>>preserved and restored by chiropractic than exists in the

> population that

> >>is

> >>>untreated. At this point I don't think we know.

> >>>

> >>> S. Feinberg, D.C.

> >>>

> >>>

> >>>

> >>>

> >>>

> >>>

> >>>

> >>>

> >>>

> >>

> >>

> >>

> >>

> >>

> >>

> >

> >

> >

> >

> >

> >

>

>

>

>

>

>

>

> -------------------------- eGroups Sponsor

>

>

>

[Guest guest]

Well said Vern. This topic will be addressed in the Patient Safety chapter

of the OBCE guidelines. I would appreciate anyone with evidence related to

this topic sending the information along to Dave McTeague at the OBCE

office. Before you can assume that an activator procedure is safer than a

manual thrust procedure you must be sure that there are no reported strokes

following activator treatment. It also cannot be assumed at this time that

the activator procedure is a substitute for manipulation unless the two

have been adequately compared in clinical trials for the same conditions.

The Haldeman study is the most thorough to date. If you have other evidence

please pass it on. This topic is most appropriate for this forum. I would

appreciate those of you interested in discussing state and national

politics forming another group. That would be a more appropriate than

using this forum. Meridel I Gatterman

----------

> From: LaVerne Saboe <las@...>

> A. DeShaw, D.C., P.C. <northwood@...>; S.

Feinberg <feinberg@...>

> Cc: 'Dr. D. Freeman' <drmfreeman@...>; Oregon DCs

<egroups>

> Subject: Re: Manipulation and stroke

> Date: Tuesday, November 14, 2000 3:36 PM

>

> Les, yet another excellent commentary!

>

> Along those lines last year published in Spine Haldeman and co-workers

> published the most comprehensive retrospective review of all the english

> literature on the subject (Spine 24(8):785-794, 1999). Their

conclusions;

>

> 1. No neck position or movement has been shown to increase risk.

> 2. no form of cervical manipulation has been shown to increase risk.

> 3. There is no valid predictive pre-adjustment tresting.

> 4. Underlying pre-existing arteriopathy is suspected.

> 5. These should be considered random, unpredictable complications

associated

> with head and neck movements.

>

> Authors of a 1985 study clearly indicated that the normal vessels of the

> head and neck are quite resistent to trauma. Individuals whom had been

> involved in tremendous traumatic injury (fractured necks/skulls)

resulting

> in their death on autopsy revealed the vertebral, carotid, etc. vessels

were

> apparently intake. (Stroke 16:1030-1038, 1985)

>

> Because of the rarity of these events Triano was quoted as stating

that

> " We would have to study manipulation over generations before we had a

large

> enough sample size of incidents to use scentifically. " (JACA 36(9):6-15,

> 1999)

>

> As per a comparison of medical morbidity and mortality, hows about this;

>

> Mortality from medications is estimated at between 79,000 to 179,000 each

> year ( JA..Archives of Internal Medicine)

>

> Medical errors in and out of the hospital? >7 million per year and

exceeds

> workplace injuries (National Academy of Sciences Institute of Medicine

Nov.

> 29, 1999)

>

> The NIH study indicated that betweenn 44,000 and 98,000 people die each

year

> because of medical mistakes. Consequently medical error is the 4th

leading

> cause of death in the US!

>

> NSAIDs result in 103,000 hospitalizations each year and result in 16,500

> deaths per year in this country (Wolf MM, New Eng J Med 340(24):1888-99,

> 1999)

>

> The mortality rate for patients taking NSAIDs for at least 2 months is

> 1:1,200, (Trammer, Pain 85(1-2):169-82, 2000)

>

> If deaths from GI toxic effects of NSAIDs were tabulated separately,

these

> effects would constiutute the 15th most common cause of death in the US!

>

> Adverse drug reation mortality, these are NOT deaths due to medical error

> these are deaths secondary to the right drug being prescribed and taken

> properly by the patient whom subsequently have a serious reaction to the

> drug and " pop-off, " 106,000 per year!

>

> The annual costs of drug-related morbidity was estimated at some $76.6

> billion back in 1995 (Archieves of Internal Medicine 155:1949-1956, 1995)

> Anyone wana bet its closer to $100 billion now!

>

> Hospital acquired infections have increased recently some 36%, about 2

> million each year and these infections acquired at the hospital result in

> some 90,000 deaths each year, and cost some $4.5 billion dollars a year

in

> health care costs (Manning, A. USA Today March 15, 1998)

>

> 60% to 90% of ALL spinal surgeries may be unnecessary (Spine 8:131-140,

> 1983, Spine 17:1205, 1992).

>

> Currently as you know everyone and their brother is performing various

forms

> of spinal fusion surgery for back pain! Not just disc herniation and the

> concomitant radiculopathy, but for supposed " discogenic " back pain

alone!

> Generally the diagnostic test to confirm the need for surgery is a

> provocative discogram. Discogram are know to have a high false positive

> rate (Spine 18(14)2035-2038, 1993) and major complications occur at an

> incidence at high as 1:8 (same reference).

>

> The Cochrane review which is a group of international research network of

> volunteers, published last year in Spine the fact there is NO VALID

EVIDENCE

> for spinal fusion for DJD, back pain, instability, or stenosis (Spine

> 24(17):1820-32, 1999) the most notable of these fusions currently is the

> BAK interbody cages.

>

> 38.3% of the patient having an anterior BAK spinal fusion will have

> significant complications. (Journal of Neurosurgery 91(1 Suppl):60-4,

1999)

>

> Not only is there no valid evidence of the efficacy of these fusions but

> there is no consensus among spine surgeons as per when to perform an

> anterior approach, vs. a posterior approach, or when to do a 360 (which

is

> both)?

>

> Oh, and the mortality rate for spinal surgery has been cited to be around

> 1:1,430 (JBJS 74-A:536-543, 1992). In the VA hospital system its worse

> laminectomies 1:204 and spinal fusions 1:51!! (J Surg Research,

56:405-416,

> 1994)

>

> Parfenchuck cited the fact that about 9,000 of the 60,000 + spinal

fusions

> each year fail resulting in direct costs of >$25 billion each year, and

> indirect costs of >$75 billion and that was back in 1995! (Parfenchuck TA

Am

> J Orthop. Nov:854-858, 1995)

>

> Ok so I'll get off my soap box! This is all stuff and more that I'm

> presenting this Friday in Vancouver, BC at an International Low Back Pain

> Symposium.

>

> Vern Saboe, DC

> Re: Manipulation and stroke

>

>

> >Yikes! Never did I think I'd be trying to pitch the same type of

argument

> as

> >the tobacco companies. Surely, my ethical bearings have taken a slide

> while I

> >wasn't looking.

> >

> >But seriously, it was difficult for the anti-tobacco people to establish

a

> >relationship between smoking and disease. That link is now well

accepted.

> The

> >anti-tobacco people had the benefit of comparing some absolutes.

Someone

> is

> >either a smoker, or not, and the amount and time they smoked is

> acertainable.

> >Now consider cervical adjusting. Various posters on this subject

discuss

> >techniques as if all treatment to the neck by everyone using & *%#

technique

> is

> >identical, like all Camel straights are equivalent. We all know that is

> not

> >true. Just take what we call diversified cervical adjusting. The gamut

> runs

> >from incompetent chiropractors who are unskilled at determining

direction

> and

> >level of lesion, who grab the patient's head and twist to the limit one

> >direction and then the other loosing a cascade of audible reports from

the

> >neck, as compared to the doctor of more refined skills who determines a

> precise

> >level and direction of lesion, rotates the neck while maintaining

contact

> at

> >the level of lesion, then maintains pressure at that level as he backs

off

> the

> >rotation of the neck as a whole and at that point gives a high speed/low

> >amplitude impulse of force nearly invisible to an observer that allows

that

> one

> >segment to release without traumatizing the neck. Both situations would

be

> >logged in our data as diversified technique adjustments; but anyone who

has

> >been adjusted by a hundred or so colleagues while going through

> chiropractic

> >college knows the difference. It would take only the tiniest fraction

of

> >incompetent practitioners to skew the stats, so rare is the incidence of

> stroke

> >following manipulation. So, it seems to me that when we look at these

> >statistics we really need to question what these numbers represent. I

> doubt

> >seriously that we have data of sufficient quality to make the kind of

> >judgements about chiropractic methodology that I feel some of us would

like

> to

> >rush to make. I do appreciate the appeal of being able to say the

dangers

> of

> >chiropractic come from this one style of treatment and the rest is OK;

but

> I am

> >skeptical of the data that suggests this, as I am skeptical of the data

> that

> >relates cervical manipulation to stroke.

> >

> >If the real world risk of death is greater from OTC drugs, or virtually

any

> of

> >the prescription pharmaceuticals; I have to wonder why chiropractic gets

> >singled out for scrutiny. 60 Minutes spends months hunting down the

only

> >35year old woman in the country who is paraplegic following cervical

> >manipulation and features her in a segment on chiropractic. Meanwhile

over

> >twice as many Americans a year die from " properly prescribed " drugs as

died

> in

> >the Vietnam war, or all the yearly traffic deaths on our highways. Are

we

> held

> >to a different standard than the medical community in the mayhem

> department?

> >It is common for MD's to caution patients about the terrific dangers of

> seeing

> >a chiropractor for treatment of the neck; yet plenty of data shows that

the

> >least dangerous medical treatment is many times as dangerous as the most

> >dangerous chiropractic treatment.

> >

> >Let's continue to make chiropractic safer and more effective. In the

mean

> >time, let's make sure about these claims of a causal relationship

between

> >chiropractic manipulation and stroke before we buy into such claims. I

> suspect

> >that if complete enough data were available they would show what Dr.

Lubcke

> >alluded to in the article he mentioned, that there may well be less risk

of

> >stroke in the population of people who have normal movement in the neck

> >preserved and restored by chiropractic than exists in the population

that

> is

> >untreated. At this point I don't think we know.

> >

> > S. Feinberg, D.C.

> >

> >

> >

> >

> >

> >

> >

> >

> >

>

>

>

>