Dear Peter

I am sorry if I have given you offence. I feel however I must respond to
your reply to give more detail to my comments.

The first point I was trying to make is that if we do see our patients as
routine treatments and not individual cases unfortunate incidents are more
likely to happen. I do not believe at any point in my last reply, I said
physios have the monopoly on clinical thoughfulness and I do not believe
this to be true.

I personally do not favour high thrust techniques in the cervical spine
although I use them elsewhere. I believe VBI is not a good exclusion test
and may be as provocative as the manipulation itself. If I were to perform
such a technique I would favour the upper cervical instability tests, which
are good but not infallable. I find gentle less aggressive procedures work
just as well.

I am not sure what you mean by relative across the manipulative therapies,
but there is evidence of the higher proportion of serious incidents due to
cervical manipulation by chiropractors over the other groups. Haldemanns
Chiropractic manual has an article in the back that illustrates the larger
proportion of serious incidents are at the hands of chiros. This is the main
document I made my previous statements upon, although I have seen others.

A final point and this is from a UK perspective, is that here as Chartered
Physios we must inform our patients of any potential risks of any treatment,
to allow them the choice of whether to have it or not. This is also in the
case of theoretical risk. I realise patients are not good witnesses and we
all have cases of how we have helped some people no one else can. I have
however, never had a patient tell me, who have seen manual therapists who
have manipulated their cervcial spine, of the risks of cervical
manipulation. If this is true, it is poor practice. Just as the prescribers
of the anti infammatories should warn of potential side affects, so should
we of cervical manipulation.

Thank you for the debate   Warm Regards Kevin

-----Original Message-----
From: Peter Kent <[log in to unmask]>
To: [log in to unmask] <[log in to unmask]>
Date: 06 September 1999 01:04
Subject: Re: FW: Clinical reasoning


>Dear Kevin
>
>I applaud your sentiment that: "We must also be able to choose
>from different schools, philosophies, intellectual approaches and
>techniques
>and mix as we see fit. The thing we must never do is stop thinking."
>
>I do not applaud your statements: "I am worred however about the idea of
>not thinking about
>certain situations and going on to automatic pilot.
>It is probably this rationale that gives the Chiropractors such a worrying
>safety record. ie  I can perform thousands of cervical manipulations
>before
>one goes wrong big style."
>
>The issues are the risk/benefit ratio of spinal (and particularly
>cervical spine) manipulation and the relative safety of different
>occupational groups who practice it.
>
>There is clear evidence that spinal manipulation can be beneficial in
>well chosen patients. The incidence of serious complication is
>consistently reported at around 1 in 1,000,000 manipulations (the
>incidence of serious complication for non steriodal anitinflammatories is
>frequently reported at around 1 in 10,000, and to anaesthetic as 1 in
>40,000). Screening tests for risk patients yield little useful clinical
>information (due to their high false positive and false negative rates).
>We routinely perform these more to satisfy medicolegal protocols, than to
>aid clinical precision, as patients who are positive on vertibro-basilar
>testing may not be at risk, and those who are negative on
>vertibro-basilar testing well be at risk.
>This situation crosses occupational boundaries and is a function of the
>procedure, not the professional association of the practitioner.
>
>The relative safely of different occupational groups has not been widely
>reported. It is likely that occupational groups that practice a technique
>more frequently incur higher complications. There are reported serious
>complications following spinal manipulation performed by
>physiotherapists, medical practitioners, osteopaths, chiropractors and
>lay people. In the absence of comparative data it is probable that the
>relative risk is the same across all groups.
>
>Practitioners across all disciplines need to be thoughtful regarding the
>risk/benefit ratio of interventions that they make. No profession has a
>monoply on either clinical thoughtfulness or lack of it.
>
>Regards
>Peter Kent
>
>B.App.Sc. (Chiropractic)
>B.App.Sc. (Physiotherapy)
>Grad.Dip.Manip.Physio.
>
>
>



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