THE CERVICAL SPINE: WHAT GUIDES CURRENT 'BEST PRACTICE' IN OSTEOPATHY?
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1 THE CERVICAL SPINE: WHAT GUIDES CURRENT 'BEST PRACTICE' IN OSTEOPATHY? LOS 20th May 2008 Laurence Butler BA(hons); DO(hons); MSc/D.Ost
2 My thanks go to: Barry Jacobs (slides on cervical rotation) Steve Vogel (examples up to date references) Janet Suckley (general moral support) David Tatton (liaison with LOS) Martin Pendry (IT support and smiles)
3 OVERVIEW Vascular structures e.g. vertebrobasilar tree Neural structures e.g. spinal cord
4 OVERVIEW Vascular structures e.g. vertebrobasilar tree Neural structures e.g. spinal cord
5 OVERVIEW In summary, we have found the burden of evidence to support (a weak to moderately strong) cause-and-effect relationship between cervical manipulation with vertebral arterial dissection and subsequent stroke. Miley, Wellik et al (2008) The Neurologist 14 (1): 66-73
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12 Arterial structure
13 Ernst E (2007) J R Soc Med 100: Adverse effects of spinal manipulation: a systematic review Finds majority of cases associated with chiropractic Osteopathy comes out relatively well (Force-related? related? Tissue warm up?)
14 Osteopathic philosophy guides us Vascular symptoms and signs are caused by altered vessel/blood function governed by altered vessel/blood structure
15 NECK VESSELS Are pain sensitive Can be intimally traumatised (especially in young) Vulnerability is hard to predict at present Supply vital structures Supply important structures Supply structures that can cause signs and symptoms
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17 NECK VESSELS Dittrich R, Rohsbach D et al (2007) Cerebrovascular Diseases 23: They found no association between any single risk factor (in isolation) and cervical artery dissection. Cervical manipulation and infections were more common In people with vascular damage, but failed to reach significance. Mild mechanical stress, including cervical manipulation, plays a role as possible trigger factor in the pathogenesis of cervical artery dissection.
18 There is, as yet, NO credible research base for the use of pre-manipulation positioning tests in relation to neck vessels
19 SO,, the history comes to the fore Consider factors that lead to a suspicion of neck injured vessels. Such as recent and previous trauma, connective tissue disorders, generalised vascular degeneration, previous poor response to treatment
20 The Society for Orthopaedic Medicine Moving Musculoskeletal Medicine Forward Risk factors associated with cervical vascular dysfunction/trauma etc drop attacks, black outs, loss of consciousness nausea, vomiting and general unwell feelings dizziness or vertigo, particularly if associated with head positioning disturbances of vision (e.g. decreased, blurred, diplopia) unsteadiness in the gait (ataxia) and general feelings of weakness tingling or numbness (especially, dysaethesia i.e. tingling around the lips, hemianaesthesia or any alteration in facial sensation) difficulty in speaking (dysarthria) or swallowing hearing disturbances (e.g. tinnitus, deafness) headache past history of trauma cardiac disease, vascular disease, altered blood pressure, previous cerebrovascular accident or transient ischaemic attacks blood clotting disorders/anticoagulant therapy oral contraceptives long term oral steroids a history of smoking immediately post partum (Kleynhans & Terrett, 1985; Grant, 1988; Hutchinson, 1989; Chapman-Smith, 1994; Kunnasmaa & Thiel, 1994; Rivett, 1994; Carey, 1995; Rivett,1995; Grant,1994; Kuether et al, 1997; Rivett, 1997; Kesson & Atkins, 1998; Di Fabio, 1999).
21 Is there Vascular (Arterial)( Damage in this Neck? There follows a potential mnemonic of important clinical features NB how useful is it? -Your feedback is welcome-
22 V A D N Vessel pain Vertigo V / VII CNS Ataxia (clumsy) Anhydrosis Drop attacks Diplopia Dysarthria Numbness (face/body) Nausea Vision change Aphasia Dysphagia Nystagmus Vomiting
23 V A D N Vessel pain Vertigo V / VII CNS Ataxia (clumsy) Anhydrosis Drop attacks Diplopia Dysarthria Numbness (face/body) Nausea Vision change Aphasia Dysphagia Nystagmus Vomiting
24 V A D N Vessel pain Vertigo V / VII CNS Ataxia (clumsy) Anhydrosis Drop attacks Diplopia Dysarthria Numbness (face/body) Nausea Vision change Aphasia Dysphagia Nystagmus Vomiting
25 V A D N Vessel pain Vertigo V / VII CNS Ataxia (clumsy) Anhydrosis Drop attacks Diplopia Dysarthria Numbness (face/body) Nausea Vision change Aphasia Dysphagia Nystagmus Vomiting
26 V A D N Vessel pain Vertigo V / VII CNS Ataxia (clumsy) Anhydrosis Drop attacks Diplopia Dysarthria Numbness (face/body) Nausea Vision change Aphasia Dysphagia Nystagmus Vomiting
27 Reciprocal holism
28 PERIPHERAL CIRCULATION Are there any indicators of aterial vessel susceptibility elsewhere too?
29 OVERVIEW Vascular structures e.g. vertebrobasilar tree Neural structures e.g. spinal cord
30 OVERVIEW Vascular structures e.g. vertebrobasilar tree Neural structures e.g. spinal cord
31 Antero-listhesis at C4-C5 with C5-C6 block vertebra
32 Is there Spinal Cord Damage in this Neck?
33 MRI: cervical cord compression
34 Osteopathic philosophy guides us Neurological symptoms + signs are caused by altered spinal cord function governed by altered spinal cord structure
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36 Is this cord intact? What is a good way to decide whether a patient has damage to the spinal cord? Examine the functions of its sub- structures UMN (cortico( cortico- and reticulo-spinal tracts) Spinothalamic tract Dorsal Columns Is it susceptible to provocation?
37 Likely cord-related related symptoms Lhermitte s/barber s/barber s chair Loss of fine motor control Heaviness in limbs Loss of temperature/pain sensitivity Problems after dark!
38 Treatment implications
39 0 o 60 o
40
41 0 o 60 o
42 0 o 60 o
43 Vascular arterial damage - or not?
44 Which elements of a thrust are most damaging? NB PhD material!
45 CONCLUSIONS
46 A few of the points discussed: Provocative tests are just that - potentially dangerous They have no proven utility - they do not predict who will go wrong This makes sense - only a thrust can mimic a thrust If thrusts have some danger associated with them, why is osteopathy s s record relatively good? British osteopaths appear to contribute to vascular accidents on a relatively small scale and at a relatively low level of morbidity/mortality Patients affected by injury - esp vascular - appear mainly relatively young (often below 45 years of age) Is this an artefact of statistical sampling, stats, self-referral? OR is it because of their intrinsic nature (e.g. connective tissue)? OR is it because they tend to suffer more trauma? OR is it because of practitioner complacency in the face of an apparently a youngish and healthy-ish patient? THEN is too little warm up ttt followed by a single-leverage leverage thrust (usu. rotational) with excessive angular momentum?
47
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