Dr. Hussein Elsangak. Precautions / Contraindications in Chiropractic Management

Transcription

1 Dr. Hussein Elsangak Precautions / Contraindications in Chiropractic Management " Instability syndromes " Fractures " Infection of the spine " Malignancy " Abdominal aortic aneurysm " Progressive neurological deficit " UMNL Instability Syndromes Definition: Loss of ability of the spine, under physiological loads, to maintain relationship between vertebrae in such a way that it may irritate the cord or cause neurological compromise. Have the potential, and are likely, to cause neurological damage. Common Conditions Rheumatoid arthritis: due to erosion of the transverse ligament Down Syndrome: 20% absence of the transverse ligament Trauma - Facet dislocation Grade III spondylo Unstable fractures Hypermobility syndromes Down s Syndrome Atlanto - axial instability due to absence of transverse ligament in 20% of the cases 1

2 Rheumatoid Instability of upper cervical area due to erosion of the transverse ligament. Unstable Fractures Jefferson s Hangman Compression fracture Neural arch fracture Trauma Stable Fractures Spinous fracture Fractured TP Clay shoveler s Hyper mobility Syndromes Diagnosed by exclusion Excessive joint pain with absence of laboratory findings is the prevailing complaint Marfan s Syndrome and Ehlers- Danlos Syndrome Benign Hyper mobility Syndromes Recommendations: Splints, braces, or taping to protect the vulnerable joints Movement of the joint at end range should be discouraged Stretching the muscles rather than joints Strengthening exercises 2

3 Malignancy (spinal) 0.7% of causes of LBP Most common: Spinal metastasis Most common site are breast, lung, prostate Multiple myeloma Primary tumor of the spine Symptomatology: Previous history of cancer, unexplained weight loss, failure to improve Long duration of pain < one month Characterized by pain at night; not relieved by rest Progressive Neurological Deficit UMNL Cervical Myelopathy Cauda Equina Syndrome Patient s neurological presentation is progressively getting worse Cervical Myelopathy Is a common disorder that is associated with cervical spondylosis and DJD,characterized by cervical cord compression The onset is usually insidious with little or no pain in the neck There may be a picture of LMNL in the upper extremities at the level of compression and signs of UMNL in the lower extremities with difficulty walking Positive pathological reflexes, and exaggerated deep tendon reflexes below the level of the encroachment Difficulty walking ( heaviness of the lower extremities) 3

4 Decreased active and passive cervical ROM, crepitations may be present X ray is characteristic with the presence of lipping and spurring of the cervical vertebrae posteriorly Positive L hermitee s sign (electric shock type pain shooting down the spine due to cord irritation) Cauda Equina Syndrome The most consistent symptom is urinary retention. Unilateral or bilateral sciatica, sensory and motor deficits Sensory deficits over the buttocks, thighs, and perineal region ( saddle anesthesia ) Reduced anal sphincter tone occur in about 75% of patients Bell s Palsy Bell s palsy is an idiopathic facial paresis of lower motor neuron type that has been attributed to an inflammatory reaction involving the facial nerve. Comes on abruptly, but may worsen over the following day or so. The face itself feels stiff and pulled to one side. There may be difficulty with eating with accumulation of food and saliva on the involved side. 70% of cases recover completely with treatment 10% of all patients are seriously dissatisfied with the final outcome because of permanent disfigurement. Corneal protection is key Abdominal Aortic Aneurysm May be asymptomaticor may present with low back pain Causes: Atherosclerosis If less than two inches wide the surgeon may recommend to leave it, since the incidence of rupture is very low; however if 2 1/2 inches, surgery is recommended Death rate from ruptured aneurysm is 50% 4

5 Death rate from untreated ruptured aneurysm is 100% Complications: death rate from surgery is 2% Infection of the Spine Incidence 0.01 % of LBP Infectious discitis (spinal osteomyelitis) Usually acquired hematogenously from other sites such as: - Intravenous drug abuse - Urinary tract infection - Skin infection - Immunodeficiency syndromes Low Back Risk Management The major diagnostic task is to distinguish between The 95% of patients with: From The 5% with: Biomechanical pain Serious underlying diseases or neurological impairments 5

6 (Precaution in Chiropractic Practice) Condition That May Warrant Alteration/ Modification of Technique Osteoporosis/osteopenia Hypertension/diabetes Oral contraceptive pills Blood thinners (anticoagulant therapy) Smoking Overweight Bleeding disorders, Purpura ( hemoarthrosis) Metabolic syndrome ( Syndrome X) Types of Stroke Embolic /Ischemic 80% Due to blocked blood flow to part of the brain Ruptured plaque Just like a heart attack Hemorrhagic 20% Mini Stroke/ TIA (Transient Ischemic Attack) Temporary blockage of blood flow, which dissolves on its own Blood flow returns to normal Lasts for few minutes Essentially normal brain studies Considered to be a prelude to a stroke Risk Factors Same as cardiac risk factors Hypertension (#1risk factor) WHO Smoking 6

7 VBAI Incidence Vertebral artery syndrome attributed to cervical manipulation occurs in younger patients, the average age is under 40, and it occurs more often in women than men. In 1980 Jaskoviak estimated that five million treatments had been given at the National College of Chiropractic Clinics over a fifteen-year period, without a single case of vertebral artery syndrome associated with manipulation. While it is understood that the actual incidents of cerebral vascular injury would probably be higher than the reported incidents, estimates from recognized authorities in the research of this area have varied from as little as one fatality from several tens of millions of manipulations, to one in one million, and one in ten million, to the slightly more significant, one important complication in 400,000 cervical manipulations. Serious complications are very rare and it would seem unlikely that the adverse occurrences have been solely attributable to the therapeutic intervention. Risk of Vertebrobasilar Stroke and Chiropractic Care Results of a Population-Based, Case-Control and Case-Crossover Study Abstracted from Spine January 2008 J. David Cassidy, DC, PhD, DrMedSc; Eleanor Boyle, PhD; Pierre Côté, DC, PhD, Helen He, MD, PhD; Sheilah Hogg- Johnson, PhD; Frank L. Silver, MD, FRCPC; Susan J. Bondy, PhD Conclusions: VBA stroke is a very rare event in the population. The risk of VBA stroke associated with a visit to a chiropractor s office appears to be no different from the risk of VBA stroke following a visit to an MD s office. The incidence of VBA stroke associated with chiropractic and primary care physician visits is likely due to patients with headache and neck pain from VBA dissection seeking care before their stroke. The study found no evidence of excess risk of VBA stroke associated with chiropractic care compared to primary physician care. Statistics 7

8 Risk of VBAI in chiropractic practice is about one in 25 chiropractors practicing full time for 40 years. "The ratio of vertebrobasilar injuries to adjustments performed would be 100 injuries per 100 million adjustments... about one in one million.'' Hosek et al. NCMIC Insurance Company Risk Factors Transient Ischemic Attacks Sudden Severe Head and/or Neck Pain Dizziness Oral Contraceptives Cigarette Smoking Osteoarthritis Postpartum Migraine Headaches Alcohol Consumption The most detrimental motion for cervical spine is cervical rotation Management Of a Patient With VBAI Syndrome Symptomatology similar to VBAI may develop after cervical adjustment, most of it will disappear spontaneously. The Major Signs And Symptoms Of VBI Are the 5 D s and 3 N s: Dizziness vertigo/giddiness/light headedness Drop attacks loss of consciousness Diplopia or other visual problems Dysarthria speech difficulties Dysphagia difficulty swallowing 8

9 Ataxia of gait walking difficulties/incoordination of The extremities/ataxia/falling to one side 3 N s Nausea (with possible vomiting) Numbness on one side of the face and/or body Nystagmus The best steps are: Do not administer another cervical adjustment in an attempt to undo the first Keep the patient comfortable and note all physical and vital signs (pallor, sweating, vomiting, heart and respiratory rate, blood pressure, body temperature, etc.) Perform complete neurological examination (motor, sensory, cranial nerves, cerebellar evaluation and reflexes) Immobilize the neck The practitioner s assistance in describing what happened may be helpful in getting the correct therapy instituted quickly. The risk of complications following tooth extraction are much more common among members of the dental profession than any other profession. Dentists pull more teeth than any other profession. Similarly, because Chiropractors perform most cervical SMT (94 % in the USA), it would be expected that most reports of complications would be ascribed to Chiropractors. End 9