POLICY AND PROCEDURE

Peek Practice is a contemporary manual therapy practice. Treatment delivered at this practice is therefore in keeping with current evidence informed procedures that are effective in treating and managing common complaints of the neuromusculoskeletal system, with primary emphasis on the spine and spine related disorders.

Your practitioner has trained specifically as a chiropractor, with further postgraduate qualification in western acupuncture and dry needling techniques. Chiropractic and western acupuncture are well tested treatment methods aimed at restoring function and managing pain.

Chiropractic

Spinal manipulation is an age-old “hands on” treatment commonly utilised in manual therapy practice. Historically, chiropractors and osteopaths were the principal practitioners sought for this intervention, however this has extended into contemporary physiotherapy practice, and at times it is used in specialised orthopaedic and musculoskeletal physician practice.

 

here are a range of manual treatments that are well supported by the scientific community. More specifically the use of carefully directed manipulative techniques directed at movement deficiencies in the spine.

This technique involves a specific low force, high-speed thrust is directed at the involved joint, this movement may produce an audible “click” or popping sound. This releasing noise can be explained as a release of a gas bubble from the joint. The sensation of manipulation may well produce instant relief to the affected area.

Spinal manipulation has been shown to have a strong effect on pain fibres and acts mechanically to restore movement to areas that are deficient. Other manual treatment options can be applied in the form of slower movements called mobilisations.

 

Sustained stretch and traction type of manoeuvres may also be utilised to aid in movement restoration

*See also:

What to Expect 

Safety of Spinal Manipulative Therapy 

Safety of neck manipulation

Spinal Manipulation for Back and Neck pain 

Western Acupuncture

Acupuncture has become widely used in manual and physical therapy practices; the origins of traditional acupuncture methods originate in ancient china.
In recent times the theories underpinning this age-old treatment have been tested through more western scientific reasoning.
The effects of acupuncture are likely a combination of the following mechanisms:
  • Local effects -  the activation of certain chemicals in the tissue to stimulate a micro-inflammatory effect on injured tissues; this accelerates the healing process leading to early recovery.
  • Segmental effects - acupuncture stimulates certain nerve fibres; the activation of these fibres has a competitive effect on pain transmission, therefore suppressing the sensation of pain.
  • Central effects - recent studies have focused on the effects of needling sensations on the brain; the resulting responses in the brain stimulate release of natural pain relieving substances such as endorphins, enkephalins and pain modulatory chemicals such as serotonin and nor-adrenaline.
  • Muscle, trigger point effects - acupuncture may help to desensitise and release taught bands in muscle
Reference - White, A., Cummings, M., & Filshie, J. (2008). An Introduction to Western Medical Acupuncture, Churchill Livingstone, U.K

*See Also

What to Expect

PAANZ Informed Consent Guidelines 

Information Gathering

To fully assess the nature of your health complaint and your reason for seeking care at this clinic, we will require you to complete a form to capture the information surrounding your condition as well as further general health information. Please be as honest and accurate as you can when completing this form. This information provides an essential tool in the assessment, diagnosis and prognosis of your problem. This ultimately helps us in predicting the outcome of your treatment, but it also highlights considerations important to treatment suitability or outside referral.

 

*Note: All personal and case information in this clinic is confidentially obtained and secured

Your Role as Health Consumer

It is in your interest as the “health consumer” to give feedback to your practitioner through the treatment process to inform him/her of your progress and any new information about your condition. This feedback and communication between patient and practitioner is an essential component to balancing and modifying your treatment to improve the outcome.

If at any point in the treatment process you are uncomfortable with your progress or the delivery of treatment, you can choose to discontinue treatment, seek further information, ask for alternative options or onward referral.

It is also your right to make a complaint if the standard of care you have received is inadequate or in breach of healthcare standards.

Health and Disability Commission (ref: http://www.hdc.org.nz/)

The Practitioners Role

  • To provide you the consumer with understandable, accurate, evidence informed information regarding the nature and management of your health concern.

  • To listen to you and advise you in a non-judgemental manner, with dignity and with independence.

  • To provide safe delivery of treatment that is appropriate for your condition.

  • To refer you for further assessment and management if required.

  • To allow you to have a support person present.

  • To treat you fairly and with respect.

  • To give you a choice about your care and support. *(adapted from the Health and Disability Commissioner’s website

    http://www.hdc.org.nz/disability/the-code-and-your-rights/)

Communication

The treatment process involves an active exchange of information between patient and practitioner. Effective communication during the treatment process is extremely important, not only does it relay pertinent information relevant to your case, it also serves to allay concerns between the two parties. Numerous contemporary studies highlight how efficacious this exchange can be on the outcome of your treatment. Reassurance and the educational components of treatment are extremely powerful and relevant.

Please inform your practitioner if they are not clear in their communication. 

Informed Consent

Informed consent to treatment is the process by which you and your practitioner work through the treatment options for your specific case. This involves a discussion and a “weighing up” of the potential benefits versus the potential risks of any treatment procedure. To some degree, the efficacy of some methods may carry a slightly higher risk but also provide a more effective outcome.

Your practitioner will discuss the nature and mechanisms of your condition, they will also discuss (based on current scientific understandings) how an individual treatment may influence and ameliorate your symptoms to get you back to full function.

Information will also be discussed regarding the limitations of the treatment modality and a consideration that that treatment may not fully restore or change the pattern of your condition. In such cases, referral to another specialisation may be required.

Whilst risks of the treatment modalities used in this clinic are reported to be rare, it is important to understand that many forms of treatment come with some form of risk. These risks will be discussed, and you may be required to sign an informed consent to treatment form.

Spinal Manipulative Therapy 

In keeping with many other forms of treatment clinicians who use spinal manual therapy techniques, such as for example joint adjustment or manipulation or mobilisation, are required to inform patients that there are or may be some risks associated with such treatment. In particular: 

 

Risk

Muscle, ligament and joint strains and rib fractures, vertebral fractures and disc injuries. These are usually reversible but cause significant discomfort and distress. These are classified as rare (1 in 100 000 treatments). Research also tells us that underlying and pre-existing problems are likely present prior to the event occurring - for example, a disc injury was the reason a patient sought care.

There have been reported cases of a rare form of stroke following neck adjustment, manipulation and mobilisation. This form of complication is an extremely rare event.

What is the underlying mechanism?

Studies have linked damage to one of the main arteries in the neck to the development of a type of stroke. Some of these strokes have occurred following spinal manipulation. This type of stroke is a rare event, and this event is infrequently associated with spinal manipulation (1 in 1,000,000 to 1 in 5,000,000 million manipulations).

What the evidence tells us

Numerous studies have been conducted in large populations to assess the risk of stroke following neck manipulation. This research demonstrates a small association between spinal manipulation of the neck and stroke; however, when these researchers also compared the data to other patients who had this type of stroke they found that there was the same correlation with having recently seen a general practitioner. In other words, strokes were equally associated with chiropractic visits and general practitioner visits.

 

What does this mean?

General practitioners do not perform neck manipulation, but they do consult patients for pain. Therefore, patients will potentially consult either a GP or a manual therapist for pain. The most common symptoms of early onset of artery damage are head and neck pain i.e. the symptoms of the event lead to the patient seeking care. This explains an association, not a direct cause and effect relationship.

This was further succinctly put by a recent systematic review conducted by Church et al. (2016), these authors conclude:

 

                          “There is no convincing evidence to support a causal link between chiropractic manipulation and stroke” 

Further research on this topic has looked at the stress applied to the artery during spinal manipulation, and these authors found that stresses applied during spinal manipulation were lower than those produced during simple range of motion testing.

 

In other words, simple life events like turning to look in your rear-view mirror and getting your hair washed at the salon could also be catastrophic. One should be careful not to infer causation from a correlation. Similarly, it is important to remain open to the possibility that in some cases there may be relevant factors related to the administration of an intervention that should be carefully considered prior to delivery.
 

Treatments provided at this clinic, including spinal adjustment, manipulation and/or mobilisation, have been the subject of much research conducted over many years and have been demonstrated to be appropriate and effective treatments for many common forms of spinal pain, pain in the shoulders/arms/legs, headaches and other similar symptoms. 

Comparative Risk

 

Take non-steroidal anti-inflammatory medications (NSAIDs) as an example (Voltaren®, Diclofenac, Aspirin, Paracetamol) commonly prescribed and over the counter medications (as seen on TV). It is estimated that 1 trillion tonnes of aspirin have been consumed since it was patented. These medications have wide ranging and significant side effect profiles. Including, renal failure, heart complications, gastrointestinal bleeding and stroke and death. To be more precise the literature states that 1 in 100 patients exhibit renal functional abnormalities and superficial gastric erosions or asymptomatic ulcers occur in 5 to 20 out of 100 patients. It should also be noted that a recent systematic review found that:

 

   “NSAIDs are effective for spinal pain, but the magnitude of the difference in outcomes between the intervention and placebo groups       is not clinically important. At present, there are no simple analgesics that provide clinically important effects for spinal pain over        placebo”.

 

So, to summarise this, a clinically inert substance with no side effect profile is as effective as an anti-inflammatory medication for the treatment of spinal pain? 

To summarise, it is important to note that many forms of treatment have both benefits and risks, it is important to communicate this information to the patient in an honest of forthright manner so they can make an informed choice as to whether to proceed with treatment. 

Treatment provided at this clinic may also contribute to your overall well-being. The risk of injury or complication from manual treatment is substantially lower than the risk associated with many medications, other treatments and procedures frequently given as alternative treatments for the same forms of musculoskeletal pain and other associated syndromes. 

 

Your clinician will evaluate your individual case; provide an explanation of care and a suggested treatment plan, or alternatively a referral for consultation and/or further evaluation if deemed necessary. 

Physiotherapy Acupuncture Association of New Zealand Informed Consent Guidelines (Adapted)
 

*In accordance with updated acupuncture guidelines, the following consent guidelines will be discussed and given to patients prior to receiving acupuncture at Peek Practice. 

Acupuncture enhances the body’s natural healing capabilities using slim sterile disposable needles. It is commonly used by practitioners following post graduate training.

 

Before you decide to have acupuncture, you should be aware of the risks as well as the benefits.  Your practitioner has access to the latest safety guidelines and ongoing postgraduate education and support. 

 

Although acupuncture is very safe (less than 1 serious reaction per 10,000 treatments) compared to some drugs there are still adverse reactions that you should be aware of.  

You need to be aware that:

  • the most commonly recognised reaction to acupuncture is fainting.  Just like with injections and blood tests some people may faint when they see or experience a needle insertion.  Let your physiotherapist know if you feel dizzy, nauseous or hot and sweaty straight away and they will take the needle out

  • drowsiness may occur after treatment in a small number of patients, and, if affected, you are advised not to drive straight after treatment

  • minor bleeding or bruising occurs after acupuncture in about 3% of treatments 

  • pain during treatment occurs in about 1% of treatments

  • tell your physiotherapist if the needle hurts/stings and they will remove it straight away

  • existing symptoms can temporarily flare after treatment (in less than 3% of patients). You should tell your practitioner about this, but it is usually a good sign that you will respond to acupuncture.  It tends to settle spontaneously within 24 hours and then you feel better than before treatment
     

Is there anything your practitioner needs to know?

Apart from the usual medical details, it is important that you let your practitioner know:

  • if you have ever experienced a fit, faint or funny turn

  • if you have a pacemaker or any other metal or electrical implants 

  • if you have a bleeding disorder or are on “blood thinning” medication

  • if you are taking anti-coagulants or any other medication

  • if you have damaged heart valves or have any other particular risk of infection (i.e. if you have to have antibiotics to go to the dentist)

  • if you have HIV, hepatitis, MRSA or AIDS

  • if you are pregnant

  • if you have a poor immune system (due to illness or medication such as steroids)

  • if you have an inflammatory arthritis, e.g. Rheumatoid Arthritis 

  • if you have had treatment for cancer or lymphoedema (swelling of tissues)
     

These conditions will change the way your practitioner will apply your acupuncture treatment.  If there are particular risks that apply in your case your physiotherapist will discuss these with you before you consent to treatment.

Possible adverse reactions:

Your practitioner will also ask for additional consent to needle over your chest or rib cage.  Within the rib cage is the heart and lungs which are vulnerable if the acupuncture needle penetrates too deeply - resulting in the worst-case scenario a punctured lung (pneumothorax) or heart muscle (cardiac tamponade).  If you are having acupuncture over the lungs it is important that you do not move or cough while the needles are in and shift them. Also if you suffer chest pain, a dry cough or difficulty breathing within 48 hours of acupuncture over your ribcage please contact your physiotherapist and directly seek medical treatment.

Your practitioner will also ask for additional consent to needle you if you are pregnant. Miscarriage in the first trimester is possible regardless of acupuncture, so your physiotherapist will usually ask for your midwife, GP, or obstetrician’s approval first.  In later trimesters acupuncture can promote Braxton-Hicks type contractions so certain acupuncture points may be avoided till nearer your due date.  

If you are having trigger point needling (a style of acupuncture targeting muscle spasm where the needle is left in a very short time) it is normal to experience a strong twitch during treatment.  Afterwards the muscle can feel heavy and tired, like it has had a gym work out.  This usually only lasts overnight, and the muscle usually feels better for it the next day.  If you find this sensation unpleasant you can use a wheat bag or some form of heat to take away the treatment soreness.

You will be given information by your physiotherapist on why acupuncture may help you before your treatment and you will be asked to give your consent for acupuncture before every treatment.  You will always have the right to say “no thank you” and chose another treatment option. Or request the needles be removed at any time during treatment.

Please inform your practitioner immediately if you ever have any unexpected reaction to your acupuncture treatment so they might help

References

1. Nielsen SM, Tarp S, Christensen R, Bliddal H, Klokker L, Henriksen M. The risk associated with spinal manipulation: an overview of reviews.(Report). Systematic Reviews. 2017;6(1).

2. Swait G, Finch R. What are the risks of manual treatment of the spine? A scoping review for clinicians. Chiropractic & Manual Therapies. 2017;25(1):37.

3. Ernst E. Deaths after chiropractic: a review of published cases. International Journal of Clinical Practice. 2010;64(8):1162-5.

4. Wand BM, Heine PJ, O’connell NE. Should we abandon cervical spine manipulation for mechanical neck pain? Yes. BMJ : British Medical Journal. 2012;344(jun07 3).

5. Cassidy D, Boyle E, Cote P, Hogg-Johnson S, Bondy SJ, Haldeman S. Risk of Carotid Stroke after Chiropractic Care: A Population-Based Case-Crossover Study. J Stroke Cerebrovasc Dis. 2017;26(4):842-50.

6. Cassidy D, Boyle LE, Côté JP, He JY, Hogg-Johnson JS, Silver JF, et al. Risk of Vertebrobasilar Stroke and Chiropractic Care: Results of a Population-Based Case-Control and Case-Crossover Study. Spine. 2008;33(4S Suppl):S176-S83.

7. Church EW, Sieg EP, Zalatimo O, Hussain NS, Glantz M, Harbaugh RE. Systematic Review and Meta-analysis of Chiropractic Care and Cervical Artery Dissection: No Evidence for Causation. Cureus. 2016;8(2):e498.

8. Kosloff TM, Elton D, Tao J, Bannister WM. Chiropractic care and the risk of vertebrobasilar stroke: results of a case-control study in U.S. commercial and Medicare Advantage populations.(Report)(Case study). Chiropractic & Manual Therapies. 2015;23(1).

9. Cassidy D, Bronfort G, Hartvigsen J. Should we abandon cervical spine manipulation for mechanical neck pain? No. BMJ : British Medical Journal. 2012;344(jun07 3).

10. Symons BP, Leonard T, Herzog W. Internal forces sustained by the vertebral artery during spinal manipulative therapy. Journal of Manipulative and Physiological Therapeutics. 2002;25(8):504-10.

11. Piper SL, Howarth SJ, Triano J, Herzog W. Quantifying strain in the vertebral artery with simultaneous motion analysis of the head and neck: A preliminary investigation. Clinical Biomechanics. 2014;29(10):1099-107.

12. Herzog W, Leonard TR, Symons B, Tang C, Wuest S. Vertebral artery strains during high-speed, low amplitude cervical spinal manipulation. Journal of Electromyography and Kinesiology. 2012;22(5):740-6.

13. Hincapié C, Tomlinson G, Côté P, Rampersaud Y, Jadad A, Cassidy J. Chiropractic care and risk for acute lumbar disc herniation: a population-based self-controlled case series study. European Spine Journal. 2018;27(7):1526-37.

14. Vonkeman HE, van de Laar MA. Nonsteroidal anti-inflammatory drugs: adverse effects and their prevention. Semin Arthritis Rheum. 2010;39(4):294-312.

15.  Schmidt M, Sorensen HT, Pedersen L. Diclofenac use and cardiovascular risks: series of nationwide cohort studies. Bmj. 2018;362:k3426.

16.  Whelton A, Hamilton CW. Nonsteroidal anti-inflammatory drugs: effects on kidney function. J Clin Pharmacol. 1991;31(7):588-98.

17.  Machado GC, Maher CG, Ferreira PH, Day RO, Pinheiro MB, Ferreira ML. Non- steroidal anti- inflammatory drugs for spinal pain: a systematic review and meta-analysis. Annals of the Rheumatic Diseases. 2017;76(7):1269.

58 BROWN ST, PONSONBY, AUCKLAND. AUCKLAND SPINE CARE, BACK PAIN, NECK PAIN, HEADACHES, MASSAGE, MANUAL THERAPY, CHIROPRACTOR

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