Monday, June 25, 2007

Is cervical spine manipulation dangerous ?

Yes Cspine manipulation is dangerous, but not that dangerous...

The risk is about 1/1.5million. It seems quite a lot but in fact you have more chances to die being struck by lightning !

Taking pills (NSAID) may seem safer, but in fact 16000 deaths a year in the US alone are attributed to the use of these painkillers. This gives a ratio of 500/1m people dying from gastric bleeding from taking anti-inflammatories. I won't even start to talk about liver intoxication associated with paracetamol.

So what is dangerous about it ?
in fact the danger comes from the rupture of the cervical artery or from a migration of atherothrombosis during the cervical manipulation which leads to a CVA or death.
Caution must be taken with :

  • patients suffering from High Blood Pressure (walls of arteries are more rigid and/or presence of cholesterol)
  • patients suffering from high cholesterol
  • patients suffering from hyperlaxity or connective tissue disorder (eg: Marfan syndrome)
  • patients suffering from vertebral atery occlusion syndrome
At a more practical level the aim is to reduce the number of cervical manipulation. And believe me a painful neck is not necessarly a neck to be manipulated !!! I've been horrified to hear patients telling me that they were seeing their therapist up to 3 times a week to have their neck manipulated.

The cause of your neck pain may not come from your neck !
This little test can be performed on yourself or on your patient. The patient sits on the table and you ask him to look over the right and left shoulder, check the rotation and ask the patients to notice when they feel the pain. Now, place your hands underneath the diaphragm and gently lift it up (liver, stomach...) and ask your patient to rotate his head again. Any change in the rotation or in the pain indicate that there is probably no need to manipulate the Cspine, the problem is coming from somewhere else. Yes this may sound odd but a gastritis, an anterior tilt of the liver, a Csection scar... can create neck pain.

Is it a problem if I "crack" my neck myself ?
It is not such a problem if you manage to do it at the right spot ! Often we tend to manipulate the part which is painful and this is not necessarly the right vertebrae or part of the body to manipulate. By moving the vertebral joint you will make it looser, if you manipulate it too often this joint will become hypermobile. To stabilize it, muscles will contract, this is painful and you feel the urge to crack it again... a splendid vicious circle. In other words, if you keep "cracking" the same vertebrae I seriously doubt that this is the right one to move and this will cause you other problem on the long run.


Sunday, June 24, 2007

Physiotherapy, Chiropractic, Osteopathy: What to choose ?

The patient is often confused between these three therapies and doesn't know what to expect from these different approaches.

Physiotherapy : the physiotherapist is a specialist in rehabilitation. After an injury (fracture, surgery, CVA...) the physio will rehabilitate the patient with massages, mobilisations, ultra-sound, exercises or even teach a patient to use crunches. His approach is generally symptomatic and his recommendations are often statisticly based (eg : in chronic low back pain a series of 3 push ups, 5 sit ups and 7 pulls of the right ear lobe improve the symptom by 47% over a period of 7 weeks. Please don't try this at home, this is just an illustrative example !!!).

Why is this ? I believe that physiotherapists are the right hand of the medical field and have been formed to fit the medical way of thinking. Therefore anything they do must be proven effective and safe, even merely effective is fine as long as it is safe.

The problem is that proving something is hardwork, time consuming, money consuming, and often another study will few months later proves the opposite to be true. A study is often too specific or too global to be constructive.

This approach avoid to talk about the "Unicity" of the patient. It does mean that if two patients complain from the "same" areas or symptoms they will be given the same treatment regardless the root of the problem which is not necessarly the same. The outcome of the treatment is therefore not as effective as it could be : it does not address the root of the problem but the treatment is as safe as it can be.

Chiropractic : Here is a joke for you ... what is the difference between a chiropractor and an osteopath ? 60 000 $ a year.

Chiropractic has been developed in the US at the end of the 19th century by Dr Palmer. Chiropractors claims that the source of our problems comes from the nervous system. Therefore corrections of "subluxed" vertebrae tend to lead us towards balance and recovery. Chiropractors will use spinal manipulations, ultra-sounds, massages, TENS, or other "high-tech" equipments. Often the massage, US, TENS(...) is given by a PA (physician assistant), then here comes the Chiropractor who will manipulate the spine. The chiropractor may need to see you up to 3 times the first week then will decrease the frequency of the treatments.

Personnally I am far from convinced that a back pain necessarly comes from a "subluxed" vertebrae but if you believe that the key of your problem comes from your spine, well then go for it. If you are not getting any better then make your next stop the Osteopath ;)

Osteopathy : Any traumas, injuries, sugeries, infections you had in the past are affecting your body in some way today by creating some restrictions and series of compensations. After a while your body cannot compensate any more, you bend forward to pick up a pen and "click", a vertebrae moved a bit too much and you just suffer from an acute facet lock. Now, is it just a vertebrae or a whole pattern of compensations, interactions, fascial connections, visceral dysfunctions, nutritions(...) that is responsible for your agony ? I would like to believe that we just need to correct a vertebrae, as it would make the work a bit easier, but the human is a little bit more complicated.

Generally an Osteopath will spend between 30 and 40 min with you and only you. During that time at least 40% of the treatment is spent in diagnosis in order to understand where the problem is coming from, this allows a more accurate treatment.

Osteopaths only use their hands, as machines tend to be imprecise and often scare the patient.

Personally I will never see a patient more than once a week and rarely more than 3 times the first month. Some Osteopaths are even reluctant to do more than one treatment every other week. (for some more details about the treatment content please check the other posts !)

What ever therapist you see do no hesitate to try different ones and stick with the one you feel the most appropriate. If you do not feel any improvement after 2-3 sessions, look for another approach or opinion.