HenrikWulff$Christensen$ Nordic$Instute of Chiropracc and ... 1. Lumbal diskus syndrom inkl. radikulopati

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Br cervikalcolumna manipuleres?

Henrik Wulff Christensen Nordic Ins

JA

Hvis der er indika.on

n (ud af mange) sikker og effek.v behandlingsmetode

Bivirkninger ved SMT

1.Godartede (benigne) normal reaktion! 2.Alvorlige - komplikationer

Benigne bivirkninger

Den normale reaktion hos kiropraktor patienter

Lokal mhed (19%)

Radikulrt ubehag (4%) Trthed (4%) Hovedpine (4%) Svimmelhed (2.5%) Varme fornemmelse i huden (0.25%)

Senstad et al., Scand J Prim Health Care (1996) - RETROSPEKTIVT

Benigne bivirkninger

Den normale reaktion hos kiropraktor patienter

Lokal mhed (53%)

Radikulrt ubehag (10%) Trthed (11%) Hovedpine (12%) Svimmelhed (

Benigne bivirkninger

Den normale reaktion hos patienter med nakke smerter

Nakke sm. eller mhed (27.7%) [22.3%]

Radikulrt smerte/ubehag (6.4%) [5.8%]

Trthed (12.1%) [7.9%]

Hovedpine (15.6%) [15.8%]

Svimmelhed (4.3%) [2.2%] *

Opkastning (2.1%) [1.4%] *

Slret syn (2.8%) [0.7%] *

Susen i rene (3.5%) [2.2%]

Forvirring/desorientering (1.4%) [2.5%]

Hurwitz et al, JMPT (2004)

Alvorlige bivirkninger ved SMT

1. Lumbal diskus syndrom inkl. radikulopati

og cauda equina syndrom

2. Cervical diskus syndrom inkl. radikulopati og myelopati

3. Forskellige post manipulative hndelser

4. Cerebrovasculre hndelser

Lumbal diskus syndrom

Nerverodskompression Hyppighed:

1:174.000 (radikulrt udfald)

Cauda equina Hyppighed:

1:>2.000.000

Cervical diskus syndrom

Nerverodskompression Hyppighed:

Ukendt/ Case reports

Myelopati Hyppighed:

Ukendt/ Case reports

Post manipula.ve hndelser

Comorbiditet Antikoagulations behandling (hmatom)

Spondolytisk stenose (myelopati)

Pagets sygdom (myelopati)

Tumorer (myelopati)

Post manipula.ve hndelser

Traumer Fractur (eks. costae, kompression?)

Hmatomer

Cervikal manipulativ behandling (CMB) : ca. 100.000.000 / r i USA

yderst sparsom forskning !

Spndingshovedpine / smerter i nakken forekommer meget hyppigt

10.000 nordmnd: 34% indenfor 1 r, 14% > 6 mneder

Bovim G, Schrader H, Sand T Neck pain in the general population Spine 1994; 19:1307-1309

RCT: effekt af CMB ?

Cochrane review 27 RCT , 1522 participants Cervical manipulation and mobilisation produced similar changes. Either may provide immediate- or short-term change; no long-term data are available. Optimal techniques and dose are unresolved. Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.

Manipulation or mobilisation for neck pain.Gross A, Miller J, D'Sylva J, Burnie SJ, Goldsmith CH, Graham N, Haines T, Brnfort G, Hoving JL. Cochrane Database Syst Rev. 2010 Jan 20; (1):CD004249. Epub 2010 Jan 20.

Effekt af CMB ?

Best synthesis evidence 139 articles Our best evidence synthesis suggests that therapies involving manual therapy and exercise are more effective than usual care for patients with neck pain.

Treatment of neck pain: noninvasive interventions: results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders Spine (Phila Pa 1976). 2008 Feb 15;33(4 Suppl):S123-52. doi: 10.1097/BRS.0b013e3181644b1d, Hurwitz et al,

The task force concluded: Manipulation as one of several firstline treatments for neck pain, whiplash, and related headaches (RCT + adverse effects) (Hurwitz Spine 2008) Decision analysis model examining drugs, exercise, mobilisation, and manipulation for neck pain incl benefits and harms and incorporating patient preferences NO CLEAR WINNER when the objective was to maximise quality adjusted life (Hurwitz Spine 2008)

Shekelle PG. What role for chiropractic in health care? N Engl J Med 1998;339:1074-5

cervical manipulation arouses far more concern about safety than the use of

lumbar manipulation

discourage the use of cervical manipulation .

because of an unacceptably high risk/benefit ratio

Powell FC et al. A risk/benefit analysis of spinal manipulation therapy for relief of lumbar or cervical pain. Neurosurgery 1993;33(1):73-8

Frygt for vertebrobasilar arterie (VBA)

hjernebldning (stroke)

Hvor ofte sker VBA efter CMB ? 1:20.000 - 1:3.000.000 Vickers A, Zollman C. The manipulative therapies; osteopaty and chiropractic. BMJ 1999; 319:1176-9 Carey PF: A report on the occurence of cerebral vascular accidents in chiropractic practice. J Can Chiropract Assoc 1993;37:104-106 Dvorak J et al.: How dangerous is manipulation of the cervical spine ? Man Med 1985;2:1-4 Dabbs V et al.: A risk assessment of cervical manipulation vs. NSAIDs for the treatment of neck pain. J Manipulative Physiol Ther 1995;18:530-536 Terrett AGJ: Vascular accidents from cervical spine manipulation: Report on 107 cases. J Aust Chiro Assoc 1987;17:15-24 Haynes MJ: Stroke following cervical manipulation in Perth. Chiro J Aust 1994;24:42-46 Gutmann G: Verletzungen der Arteria vertebralis durch manuelle Therapie. Manuelle Medizin 1983;21:2-14 Dvorak J et al.: Frequency of complications of manipulation of the spine. A survey among the Swiss Medical Society of Manual Medicine. Eur Spine J 1993;2:136-139 Klougart N et al.: Safety in chiropractic practice, Part I; The occurrence of cerebrovascular accidents after manipulation to the neck in Denmark from 1978-1988. J Manipulative Physiol Ther 1996;19:371-377 Hosek RS et al.: Cervical manipulation. JAMA 1981;245:922-922

DK VBA i kiropraktorpraksis Patientforsikringen: 10 tilflde 2004-2010 Antagelse 550 kiropraktorer i DK. 320.000 patienter / r 7 behandlinger / pt 1/560.000 2/5 cervikale behandlinger

Patient karakteristik?

Age distribution

Tidsfaktor mellem SMT og CVA

69 % umiddelbart under SMT 3 % minutter efter SMT 9 % < 1 time efter SMT

8 % 1 - 6 timer efter SMT 5 % 7 - 24 timer efter SMT 6 % > 24 timer efter SMT

Terrett, 1996

183 ptt Terrett AGJ. Vertebrobasilar Stroke following Manipulation. National Chiropractic Mutual Insurance Company, 1996

115 ptt Haldeman S et al. Risk factors and precipitating neck movements causing vertebrobasilar artery dissection after cervical trauma and spinal manipulation. Spine 1999; 24:785-794

196 ptt Smedegaard Andersen B & Thim HM CVAs and cervical manipulation a diploma study. Odense University 2001

# cases publiceret i 5-rs intervaller

Cerebrovaskulre katastrofer efter SMT

er meget sjldne:

ca. 400-500 i litteraturen

Mske hyppigere ?

Lee KP, Carlini WG, McCormick GF, Albers GW. Neurologic complications following chiropractic manipulation: a survey of California neurologists. Neurology 1995; 45:1213-1215 Robertson JT. Authors rebuttal to Neck manipulation as a cause of stroke. Stroke 1982; 13:260-261 Rivett DA, Milburn PD. Complications arising from spinal manipulative therapy in New Zealand. Physiotherapy 1997; 83:626-632

Klinik

Risikopa.enten? alder kn diabetes/rygestatus/hormonel behandling m.m. symptomer forandringer i col. cerv. vaskulre forandringer (e.g. Ehlors-Danlos) comorbiditet

Sidney Rubinstein, Thesis 2008

Cervical arterie dissec.on

Gene.sk predisposi.on a1 (ingen associa.on), bindevvssygdomme (mulig associa.on), gene muta.oner (ingen associa.on), homocystein (strk associa.on), karabnormaliteter (strk associa.on), migrne (strk associa.on)

METODEPROBLEMER; selek.on bias, lille studie, manglende mul.variat analyse, mangelen blinding af undersger, mulig confounder

Rubinstein 2008

Cervical arterie dissec.on

Miljfaktorer infek.oner (svag associa.on), p-piller (posi.v associa.on)

METODEPROBLEMER: selek.onsbias, manglende blinding, manglende stra.ficering.

Rubinstein 2008

Cervical arterie dissec.on

Traume manipula.on (strk associa.on) METODEPROBLEMER: sm studier (n=7), selek.ons og informa.ons bias.

Rubinstein 2008

Cervical arterie dissec.on

Risikofaktorer for arteriosklerose vaskulre risikofaktorer (hypertension, DM, rygning, p-piller, kolesterol) nega.v associa.on sammenlignet med andre strokes

- alder < 45 r hjere frekvens METODEPROBLEMER: ingen rapporteret.

Rubinstein 2008

Predictors of adverse events

Prospek.vt, mul.center kohorte studie 579 pa.enter 60 uabngige variable undersgt

4 faktorer var prdik.ve for adverse event i .lflde af kiroprak.sk behandling for nakkesmerter en af disse beskycende effekt

Rubinstein 2008

Predictors of adverse events

Rapporteret brug af rota.onsteknik ved behandling i nakken

Erhvervsstatus (fuld.d, del.d, arbejdsls >< sygemeldt/understcelse)

Langvarige nakkesmerter indenfor det sidste r (>60 dg)

Beskycende effekt: besg hos e.l. inden besg hos kiropraktor

Rubinstein 2008

Klinik

Manipula.onen behandlingsstyrken behandlingsfrekvensen behandlingsniveauet selve teknikken

Anbefalinger ved SMT i cervical kolumna

Strstedelen af .lflde drejer sig om skader p AV i vre del af nakken.

Rota.on af col. cerv. i srlig grad kompromicerer AV i den vre del af nakken.

Med rimelighed kan antages, at isr ro