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Rationale Use of Manipulation in Cervical Spine Disorders Timothy W

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Rationale Use of Manipulation in Cervical Spine Disorders Timothy W Rationale Use of Manipulation in Cervical Spine Disorders Timothy W. Flynn, PT, PhD Board Certified in Orthopaedic Physical Therapy Fellow, American Academy of Orthopaedic Manual Physical Therapists Session Description: There is always risk associated with the management of patient with head and neck disorders. Frequently injury to the vertebral artery is mentioned as a complication of cervical manipulation. Controversy continues on the magnitude of that risk and often to the exclusion of potentially more common risks such as missed diagnosis. The purpose of this session is the to review the current literature and discuss a framework of best practice risk in context when managing individuals with head and neck complaints. Lecture Slides May Change Prior to the Conference Dr. Flynn is an expert clinician and owner of Colorado Physical Therapy Specialists where he is dedicated to providing the highest quality care possible. His primary clientele is made up of individuals suffering from low back pain, chronic spinal disorders, failed back surgeries, and chronic pain disorders. He is on the executive board of Evidence in Motion Institute for Health Professions, which passionately promotes a culture of evidence-based practice within the physical therapy profession. Dr. Flynn is the immediate past President of the American Academy of Orthopaedic Manual Physical Therapists and an Associate Editor for the Journal of Orthopaedic & Sports Physical Therapy (JOSPT). He is a Distinguished Professor at Rocky Mountain University of Health Professions where he teaches professional and post-professional students in the area of musculoskeletal management, advanced manipulation skills, and evidence based practice. !"#$%"&'()*'($+(,"%-./&"#$%(-%( 0'12-3"&(4.-%'(5-*$16'1*!! 7-8$9:;(<=(>&;%%?(@7?(@:5( Board Certified in Orthopaedic Physical Therapy Fellow, American Academy of Orthopaedic Manual Physical Therapists ( 71"%*&"#%A(B2-6'%3'(-%9$(@1"3#3' 5$(%$(:"18C( "#$!%#!&'#())*! 6/4%#<9!+)B,)$! 0'12-3"&(F19'1-'*( •! +,-.!,/!0#/%)1%! •! 2)(3/,(45!6775,(48#/! •! ",-%#'9!:!&39-,(45!;14<,/48#/! –!0=!>('))/! –!?))/!@A-)'B48#/!:!05,/,(45!+)4-#/,/C! •! =)$!@/-)%!=)(.!0#<754,/%-! D'19'E1"&("19'1;( 1 D34%!297)!#E!>%'#.)!>3#F5*!$)!G)! 47!GHB! H#-%!D#'',)*!6A#F%I! •! Stroke is the third leading cause of death in the US •! Mississippi leads the nation in stroke prevalence at 4.3% •! Connecticut has the lowest prevalence at 1.5% 2005 Behavioral Risk Factor Surveillance System J/(,*)/()!:!#F%(#<)!#E!()'B,(45!4'%)'9! >%'#.)! *,--)(8#/K!4!7#7F548#/LA4-)*!-%F*9M!!! !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!"#$%&%'()NOOPQ!PRKSTOU! 23)!A)-%!,/(,*)/()!)-8<4%)!(#<)-!E'#<!@5<-%)4*!(#F/%9!VSUTRLNOOWXM! Y)'%)A'45!4'%)'9!*,--)(8#/!(4F-,/C!-%'#.)!! I=JK(.'1(LII?III(( 23)!#B)'455!'4%)!E#'!#((F'')/()!#E!455!-%'#.)-! (MNJ(.'1(LII?III( 4C)L!4/*!-)1L4*ZF-%)*!%#!SUUP![>!7#7F548#/L!GH0!=)F'#5M\!NOOS!! • D34%!,-!4!$"*+%,"-!)-8<4%)!#E!',-.!E'#<! ! (3,'#7'4(8(!<4/,7F548#/!4/*!-%'#.)I! There is an association between vertebrobasilar artery stroke and chiropractic visits in those under 45 years of age. 1.3 per 100,000 There is also an association between vertebrobasilar artery stroke and use of primary care physician visits in all age groups. 1 per 9,122 1 per 200,000 (Michaeli ’93) (Haynes, ’94) 2 +)5)B4/()!%#!&39-,(45!23)'479I! The increased risks of vertebrobasilar artery stroke <-9:(1'*'"13:('2-6'%3'(*/..$1#%A(-9*( associated with chiropractic and physician visits 'O3"3;(.:;*-$9:'1".-*9*(1$/#%'&;(/*'( is likely explained by patients with vertebrobasilar 3'12-3"&(8"%-./&"#$%(PQ(8$E-&-R"#$%S(-%( dissection-related neck pain and headache ."#'%9*(T-9:U( consulting both chiropractors and primary care –!V'3W(."-%( physicians before their VBA stroke. X'"6"3:'( –! YYY( –!5-RR-%'**( ;7,*)<,#5#C9!=)(.!&4,/! ]#!%3)-)!748)/%!(#<754,/%-!<4.)!F7!4!A,C! 7#'8#/!#E!#F'!*49L%#L*49!(5,/,(45!7'4(8()I! ^! &#,/%!7')B45)/()!/)(.!74,/K!U_! ^! PL<#/%3!7')B45)/()K!`a_! ^! b,E)8<)!7')B45)/()K!PP_! ^! &#,/%!7')B45)/()!(3'#/,(!/)(.!74,/!VcP!<#/%3-XK!ST_! Douglass AB, Bope ET. Evaluation and treatment of posterior neck pain in family practice. J Am Board Fam Pract 2004;17:S13-S22. Guez M, et al. Chronic neck pain of traumatic and non-traumatic origin. Acta Orthop Scand 2003;74:576-579 ;7,*)<,#5#C9!")4*4(3)! ;7,*)<,#5#C9!],dd,/)--! • 0'12-3$A'%-3!3)4*4(3)K!! ! •! ],dd,/)--!4((#F/%-!E#'!R_!#E!739-,(,4/!B,-,%-!E#'! –! OMaLNM`_!,/!%3)!C)/)'45!7#7F548#/!! 748)/%-!#B)'!%3)!4C)!#E!a`! –! S`LNO_!,/!%3#-)!$,%3!(3'#/,(!3)4*4(3)-! •! 7'%*-$%Z9;.'!3)4*4(3)K!! •! e#'!4*F5%-!#B)'!P`\!,%!,-!%3)!/F<A)'!#/)!')4-#/!%#! ! –! P`_!!<45)-!! B,-,%!4!739-,(,4/ – TO_!!E)<45)-! ! •! 677'#1,<4%)59!S`!%#!WO_!#E!7)#75)!)17)',)/(,/C! •! ,-A1"-%'!3)4*4(3)K!! *,dd,/)--!$,55!-)).!<)*,(45!4f)/8#/! –! PLT_!!<45)-!! –! S`LST_!!E)<45)-! "F,ZA')C%-!&\!Y,*45!&M!],dd,/)--!,/!#'%3#74)*,(!739-,(45!%3)'479!7'4(8()K!054--,g(48#/!4/*! D#'5*!")45%3!@'C4/,d48#/M!."*-*/0")1*/2)30""2M!NOOTM! 74%3#739-,#5#C9M!6)7*,#*&)7*,54#&*89"):0"$!NOOaQ!SNK!SUPLNSS(( "45*)<4/!>\!]4C)/4,-!>M!0)'B,(#C)/,(!3)4*4(3)-K!6!(',8(45!')B,)$M!345,")6!NOOSQSKWSLaP! 3 ;B,*)/()!b,/.,/C!H4/,7F548#/! >%#'9!2,<)! %#!>%'#.)I! hi!j6!-,<,54'!4--#(,48#/!A)%$))/!(3,'#7'4(8(! 4/*!k&!B,-,%-!,/!%3)!<#/%3!A)E#')!%3)!-%'#.)! )B)/%l!-FCC)-%-!%34%!748)/%-!$,%3!F/*,4C/#-)*! Y6!*,--)(8#/!4')!-)).,/C!(5,/,(45!(4')!E#'! 3)4*4(3)!4/*!/)(.!74,/!A)E#')!34B,/C!4!YG6! -%'#.)im! Cassidy JD, et al. Risk of vertebrobasilar stroke and chiropractic care. Spine 2008;33:S176-S183. ]#)-!eF/(8#/45!&')L>('))/,/C! 04/!$)!,*)/8E9!4%L',-.!748)/%-I! J*)/8E9!6%L+,-.!&48)/%-I!! NO! 5$'*(>/%3#$%"&(@1'Z431''%-%A( [6'%#+;(F9Z!-*W(@"#'%9*Y(( •! 23)')!,-!%$('2-6'%3'!%#!-F77#'%!%3)!(#/-%'F(%! NO! B45,*,%9!#E!EF/(8#/45!7')L-('))/,/C!%)-8/C!,/!%)'<-! #E!,%-!4A,5,%9!%#!,*)/8E9!748)/%-!$3#!4')!<#')!5,.)59! %#!34B)!-7#/%4/)#F-!*,--)(8#/!)B)/%-M!! •! eF'%3)'<#')!%3)-)!7'#7#-)*!%)-%-!4')!#/59!-7)(,g(! %#!%3)!B)'%)A'#A4-,54'!-9-%)<!4/*!F/5,.)59!%#!A)! -)/-,8B)!%#!J/%)'/45!04'#8*!A5##*!n#$!(34/C)-M! 4 Does a Thorough History Identify At-Risk Patients? ((("#$%&'(!)*+,-#'!.*/0!#1,%,23%,0!4,!,&#1,%!#13',! )%,',-+-5!6&#1!2%*-(!*%#,%&*7!)*#13735/!3%! #13',!6&#1!-3!87&-&8*7!)*#13735/!49#!6&#1!*! 1&51!-9.4,%!32!:*'897*%!%&'(!2*8#3%';!! >9<7%#<-! ",-%#'9! •! >9<7%#<-! •! H)*,(45!",-%#'9! •! H)*,(48#/-! •! >#(,45!",-%#'9!! <3-&'81,.&8!'&5-'!*-=!'/.)#3.'!.*/!)%,8,=,!8,%,4%*7>%,+-*7!&'81,.&*! 4/!*-/#1&-5!2%3.!*!2,6!=*/'!#3!',:,%*7!6,,(';( >9<7%#<-! ",-%#'9! •! >9<7%#<-! •! H)*,(45!",-%#'9L!2'4F<4oHY6! •! H)*,(48#/-L!"2=! •! >#(,45!",-%#'9L!><#.,/C!! <3-&'81,.&8!'&5-'!*-=!'/.)#3.'!.*/!)%,8,=,!8,%,4%*7>%,+-*7! &'81,.&*!4/!*-/#1&-5!2%3.!*!2,6!=*/'!#3!3:,%!*!.3-#1;( 5 5$'*("(7:$1$/A:(X-*9$1;( [6'%#+;(F9Z!-*W(@"#'%9*Y(( 5$'*("(,$1'(>$3/*'6(V'/1$2"*3/&"1( @:;*-3"&(B\"8-%"#$%([6'%#+;(( F9Z!-*W(@"#'%9*Y(( Possibly =)F'#Y4-(F54'!&39-,(45! [77)'!H#%#'!=)F'#/!>('))/! ;14<,/48#/! •! Blood Pressure •! Body Mass Index •! Pulse Check •! Neurological Examination •! Functional Positional Tests •! Ligamentous Tests (Upper Cervical) •! Eye Examination 0'4/,45!=)'B)!>('))/! ;14<,/48#/! 6 Does a More Focused Neurovascular H#*)5!E#'!YGJ!>('))/,/C!,/! Physical Examination Identify At- %3)!H#A,5,%9!2)-8/C!7#'8#/! Risk Patients? #E!%3)!&39-,(45!;14<,/48#/!! •! 6775,(48#/!#E!,/(')<)/%4559!C')4%)'!<#B)<)/%-!4/*!5#4*-! •! 23)!CF,*,/C!4--F<78#/i! –! ]#!/#%!(3455)/C)!%3)!()'B,(45!-7,/)!A)9#/*!$34%!,%!$#F5*! )/(#F/%)'!*F',/C!)14<,/48#/!4/*!%')4%<)/%! •! J/!%3)!4A-)/()!#E!-,C/-!#'!-9<7%#<-!#E!()'B,(45!4'%)'9!*9-EF/(8#/! ,*)/8g)*!*F',/C!%3)!3,-%#'9!#'!/)F'#5#C,(!-('))/,/Ci! –! &'#())*!$,%3!6+@H!%)-8/C! –! 0#<A,/)*!<#B)<)/%!#E!)1%)/-,#/!$,%3!'#%48#/! Possibly J-!%3)')!4!h-4E)m!! Are particular manual therapy %)(3/,pF)!E#'!()'B,(45!! techniques better suited to -7,/)!%3'F-%!<4/,7F548#/I! decrease the risk? =)(.!H4/,7F548#/!>3#F5*!=#%! +)-)<A5)!H4'845!6'%-! J-!%3)')!4!*,q)')/()!A)%$))/!(3,'#7'4(8(!4*ZF-%<)/%!\!()'B,(45! <4/,7F548#/!4/*!<4/F45!739-,(45!%3)'479!7'#()*F')-I! 7 =)(.!H4/,7F548#/!>3#F5*!/#%! b##.!b,.)!H4'845!6'%-! >#!-3#F5*!&2-!E))5!E4%!:!34779I! Primal Software Chiropractic Techniques &')L<4/,7F548B)!"#5*! ;14<75)-!#E!0)'B,(45!23'F-%! r#,/%!H4/,7F548#/! Spinal & Extremity Manipulation: The Basic Skill Set for Physical Therapists. - Wainner, Flynn, and Whitman. ISBN 0-9714792-1-6, 2001. ;14<75)-!#E!0)'B,(45!23'F-%!r#,/%! Are certain techniques better H4/,7F548#/! able to decrease the risk? Possibly Spinal & Extremity Manipulation: The Basic Skill Set for Physical Therapists. - Wainner, Flynn, and Whitman. ISBN 0-9714792-1-6, 2001. 8 D34%!,-!%3)!+,-.!E'#<!! +,-.!9"$+#+!G)/)g%! 0#<7)8/C!23)'47,)-!! =>6J]-o295)/#5! •! L](9$(^](9:$/A:9(9$(6'2'&$.(_[(E&''6-%A("*("(3$%*'`/'%3'=L( •! 49"%6"16(V4F[5*U(_[(E&''6(-%(L(a(L?III(-+(/*'6(b(c(TW*=M(( •! K?NII(6'"9:*("%6(KN?III(:$*.-9"&-R"#$%*("%%/"&&;(-%()=4=(8";(E'("d1-E/9"E&'( 9$(V4F[5*=^(( •! 0GeZM(-%:-E-9$1*(Z(%$('*9"E&-*:'6(3&-%-3"&&;(8'"%-%A+/&(*"+'9;("62"%9"A'($2'1( *9"%6"16(V4F[5*=c( •! F3'9"8-%$.:'%(P7;&'%$&S($2'16$*'(1'*/&9'6(-%("%('*#8"9'6(fN?III('8'1A'%3;( 1$$8(2-*-9*("%6(cfg(6'"9:*($2'1("%('-A:9Z;'"1(.'1-$6=(>5F("62-*$1;(."%'&(2$9'6( 9$(1'3$88'%6(&$T'1-%A(9:'(8"\-8/8(6"-&;(6$*"A'($+("3'9"8-%$.:'%=5( 1 Tannenebaum et al.
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