Informed Consent and Cervical
Provocation Tests
In an attempt to clarify my thoughts and provide an overview.
by Cliff Morris, D.C.
I. Informed consent
Proving SMT safe. A possible measure may be the Safety Uncertainty Ratio. Nothing is 100% safe, but if something were 100% safe it would have an UCR of 0. If something (an exercise) is 100% un-safe it would have an UCR of1.00.
Ex: an exercise that is unsafe half of the time would have an UCR of ½, or .50. An exercise (SMT) that yields an unsafe event of 1/7,000,000 would have a UCR of 0.0000001,very close to 0..
Obviously the SMT UCR is extremely low, meaning SMT is extremely safe.
At some point an UCR should indicate that an exercise can be accepted as safe. When this level is accepted then all exercises (medical procedures, SMT, etc.) having the same UCR should be treated the same. If it should be determined that chiropractic with an UCR of 0.0000001 be subjected to Informed Consent, then any and all other healthcare exercises with that UCR or higher (less safe, more uncertainty) should also be subjected to Informed Consent. Otherwise it would be undisguised discrimination.
It may be reasonably assumed that the incredibly low UCR for SMT should qualify it as being safe. And if it is so safe, why introduce Informed Consent.
Informed Consent:
Cannot improve the UCR (cannot improve safety) of the exercise.
Necessarily introduces an element of uncertainty regarding the treatment, to the patient’s understanding, to the trust of the healthcare provider, to the patient’s acceptance of the therapy and to the credibility of the profession itself.
Provides so much information on the form that any new patient cannot be expected to understand it, especially when the patient may be in pain, mistrustful, and almost certainly in confusion, raising concerns as to the validity of any information offered.
If an exercise (SMT) is safe, why introduce an extraneous, non-productive (even counterproductive) complication?
II. Cervical Provocation Tests
CPTs are controversial , and have been discontinued by many if not all chiropractic colleges. They do not provide specific diagnoses, often yield false results, are hard to interpret, and above all may be dangerous, in fact creating the dangerous effects that they were designed to diagnose and guard against.
A proper (safe) cervical SMT maneuver will be performed with the head in slight flexion and without excessive rotation. In other words without subjecting the neck to dangerous ranges of motion.
A CPT on the other hand is designed to test the neck in these dangerous ranges of motion: extreme extension and rotation, something SMT is designed to avoid. If ever there is a chance of a CVA it would occur during a CPT, when it would not have happened during a proper cervical adjustment.
6/21/2018
Some relevant cites:
https://www.ncbi.nlm.nih.gov/pubmed/12497733
J Law Med.2002 Nov;10(2):174-86.
Cervical manipulation--how might informed consent be obtained before treatment?
Delany C1.
Abstract
This article discusses methods and mediums of obtaining informed consent in physiotherapy clinical practice, specifically in relation to cervical manipulation. Whilst cervical manipulation is a useful method of treatment for spinal joint pain and dysfunction, it has also been shown to be ineffective or even positively harmful. Legal precedents have set boundaries for informing patients of such adverse consequences. However, a degree of uncertainty exists in the physiotherapy profession, as in other health care professions, as to how to obtain informed consent in a busy clinical setting in order to discharge the legal duties owed. Obtaining meaningful informed consent in clinical practice raises issues of patient comprehension, memory and decision-making capacity. A large quantity of research directed at enhancing patient understanding has been undertaken in recent years. The important findings are that a variety of communication methods and mediums need to be employed in both providing information and assessing patient understanding. A combination of verbal, written and audiovisual information provides patients with maximum opportunity to be involved in treatment decision
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https://www.ncbi.nlm.nih.gov/pubmed/23787298
J Manipulative Physiol Ther.2015 Nov-Dec;38(9):677-91. doi: 10.1016/j.jmpt.2013.05.009. Epub 2013 Jun 17.
Serious Adverse Events and Spinal Manipulative Therapy of the Low Back Region: A Systematic Review of Cases.
==admin edit==
This systematic review describes case details from published articles that describe serious adverse events that have been reported to occur following SMT of the lumbopelvic region. The anecdotal nature of these cases does not allow for causal inferences between SMT and the events identified in this review. Recommendations regarding future case reporting and research aimed at furthering the understanding of the safety profile of SMT are discussed. [emphasis added -ed.]
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Hebert JJ1, Stomski NJ2, French SD3, Rubinstein SM4.
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https://www.ncbi.nlm.nih.gov/pubmed/17906581
Spine (Phila Pa 1976).2007 Oct 1;32(21):2375-8; discussion 2379.
Safety of chiropractic manipulation of the cervical spine: a prospective national survey.
Thiel HW1, Bolton JE, Docherty S, Portlock JC.
SUMMARY OF BACKGROUND DATA:
The risk of a serious adverse event following chiropractic manipulation of the cervical spine is largely unknown. Estimates range from 1 in 200,000 to 1 in several million cervical spine manipulations.
Manual Therapy 10 (2005) 154–158
Professional issue
Is it time to stop functional pre-manipulation testing of the cervical spine?
Haymo Thiel
, George Rix
