A paradigm shift for chiropractors
On October 26, Dr. Greg Dunn, Chief Operating Officer for the Canadian Chiropractic Protective Association (CCPA), addressed attendees at the Alberta College and Association of Chiropractors (ACAC) 2008 conference. Dr. Dunn’s open and practical discussion about managing patients with unusual/unexplained neck pain, or with neurological symptoms of unknown etiology, offered current clinical insights, and an algorithm for care, to place chiropractors at the forefront of recognition and optimal patient management.
Dunn began by noting that the profession of chiropractic must shift from ruminating on causation of stroke from manipulation – a link that clinical and epidemiological studies, as well as an understanding of the development of a stroke, show to be unlikely – to sharpening skills and knowledge for recognition of salient signs and symptoms, in order to manage patients in a way that will result in the best possible outcome.
Dunn explained that careful examination of the events in recent chiropractic history, as well as work by DCs with experts in the fields of neurology, neuroradiology, neuropathology, etc, has allowed for increased depth of understanding regarding the stroke process and whether it relates to manipulation.
As a result of this work, Dunn was able to expand on the following:
- The cerebrovascular events associated temporally to chiropractic care and culminating in stroke occur in two distinct steps: arterial dissection – damage to the vessel, and subsequent formation of a thrombus – and migration of the clot, or a portion of it, to cause blockage to cerebral blood flow. (ie, stroke.)
- The first step, arterial damage, often occurs prior to the patient seeking help, medical or chiropractic, and may not manifest any neurological symptoms, at all.
- In over 80 percent of patients, damage to the vertebrobasilar artery (VBA) will result in severe headache pain, neck pain or both. A person with this pain may seek chiropractic or medical care.
- Studies have shown the incidence of these posterior brainstem strokes occur just as
- frequently in patients seeking medical care as they do in those seeking chiropractic
- care. Since medical doctors and chiropractors use different and distinct therapeutic
- interventions, it is unlikely that the cerebrovascular event is related to the treatment.
However, noted Dunn, a chiropractor who recognizes the signs and symptoms of stroke, and refers the patient for early intervention, could facilitate an improved outcome for the patient. Dunn went on to describe several simple in-office screening tests for stroke, but
pointed out the unfortunate fact that there is no screening tool available to recognize the preceding arterial dissection.
When a patient does present acute, severe head and/or neck pain of unexplained etiology it may be better to take a “wait-and-see” approach rather than treating the neck right away. In a patient demonstrating neurological signs and symptoms that may be related to a stroke, the chiropractor and office team are asked to look after the patient, while arranging the appropriate referral option – ER or family doctor – follow up with the patient and family a few hours later, or within the next day or two, and carefully document the steps taken.
The talk also addressed the issue of obtaining informed consent and the need to maintain meticulous – but also lucid and legible – records of the patient’s history and care at all times. Notes should include mention of what is examined, a diagnosis, what treatment is given, when an approach is altered, and why, as well as whether or not a patient is progressing well under the DC’s care.
The CCPA has issued a new consent form for use by chiropractors with their patients. Attendees at the ACAC meeting received a copy of the new consent form. Copies will also be sent to DCs across Canada – and will be made available on the newly constructed CCPA website – in the weeks to come.
For further information, chiropractors are invited to contact the CCPA at (416) 781-5656.
Dunn expressed confidence in the work that DCs do, regardless of paradigm of practice or manipulation techniques performed but stated, “The bottom line is that you must be vigilant and always be able to give a ‘reason to be there’ for whatever you do.” •
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