Some Thunder in OK from Down Under

  Several of us in the EIM community on the invitation of Dave Johnson, PT, PhD, OCS, FAAOMPT had the privilege to visit the Tulsa campus of the University of Oklahoma Health Sciences Center to spend several days with two master manipulators.  Peter Gibbons and Philip Tehan are 1975 graduates of the British School of Osteopathy, which is known for thrust manipulation techniques of exceptional precision.  Peter is also a medical doctor, Phillip is also a physiotherapist, and both are in the practice of manual medicine in Melbourne Australia and teach into Victoria University.

Both are fantastic (and perhaps even a bit fanatic) using their "instructional videos" to  


manipulation techniques with great use of hand skills.

The general audience was Fellows and Fellowship students from all over the US and even the UK.  This created an environment of critical thinking and critique of technical application of each other along with MANY MANY side conversations regarding evidence and its implications to practice.

Bill Kinsiinger, MD gave a lunchtime presentation that was a highlite.  Many of you know Bill from his Neck 911 Network and his large influence on closing the window on Florida State's Chiropractic school.  If you haven't seen his website, you are missing out.

Thanks to Vince Lepak and Dave Johnson for making this such an exemplary opportunity.  Look for more great things from this annual offering!

ab

Comments

[Bart Bishop]

Andrew,

Thanks for your post, and I am sure that your class was great, but I can't believe that you would endorse such a worthless site like neck911usa.com. Spending 5 minutes at a site like this shows you the level of bias and blatant misstatements on their site. For example, the front page has a really big area that says "Neck Manipulation can cause Injury or DEATH!" It takes time to discover that he is only talking about C0-C1 or C1-C2 manipulations, and being a PT who performs manipulations from C3 down, I don't want this kind of site scaring my patients; and that is what it is designed to do . . . scare patients away from manipulation. The site does say the highest part of the neck is the dangerous part, but do you really think that patients understand that phraseology? Half of them think that their hips are their gluteal and sacroiliac regions - there is no chance that they know the "highest part of the neck" from the mid-cervical region.

Don’t forget that there is a part that talks about whether chiropractors are “doctors.” “Chiropractors have been successful in convincing politicians in North America that they are "doctors". Laurie and others have been misled because of this classification of chiropractors as doctors.” How is their education substantially different from ours? We are training ourselves as doctors of physical therapy and most of our education following PT school is in the form of “weekend seminars”. We are taught things from the physical therapy viewpoint; we treat patients in campus clinics as a learning experience; we don’t have a well established and mandatory 4-5 residency program.

As PTs (and I know that there are some DCs in this community), I feel that we should be denouncing sites such as this. They don’t provide any help for changing quackery in chiropractic and they just propagate unreasonable fears in un or undereducated patients.

Bart

[Todd]

In all sincerity, I don’t understand how you can hold a weekend seminar on spinal manipulation then turn around and have the neck-911 guy address your group. Does anybody else see the problem here?

Todd

[Andrew Bennett]

Bart, Todd, and others:
I can't speak as to what Bill's beliefs are personally, only what was communicated to us during his presentation and interaction afterwards. It was VERY clear that Bill's target is the chiros who are promoting themselves as primary care providers who hold the single key to cause of all diseases (subluxation). Bill's used an alias and presented as a patient with acute appendicitis or active MI and the chiro under scrutiny felt he/she could cure the pain with manip and totally missed the classic signs.

Additionally Bill is VERY pro-PT. I have been told that it was from this particular course through Dave Johnson's group and the EIM cadre that Bill has actually been given some more data regarding the actual risk with cervical manipulation and his presentation has changed quite a bit...even allowing Prof Tehen to manip his upper cervical spine. But you're right, his message via Neck911 to the public is quite loud and doesn't discriminate as well as we'd like PT/DOs from other groups that utilize manip as their panacea. Perhaps Bill would be open to a few changes?

ab

By the way Bart, what evidence or reasoning do you use to withhold upper cervical manipulation from your patients?

[Todd]

Thanks for your reply Andrew.

I happen to be a chiropractor. When I read what you wrote about Bill presenting to an office with a fake MI or appendicitis, I put myself into my shoes wondering if I could pass the test of a doctor malingering as a patient---but with an ulterior motive. I don’t think I could. Further, I don’t think the average medical doctor could either. If I pressed into his right lower quadrant, would Bill wince properly? I don’t think he would. I don’t know I he could properly present himself as a patient with those particular circumstances. If a patient is sweating bullets from the pain or the autonomic response, then maybe I would nail the diagnosis.

Further, I hear all the time about DCs who sell the holy subluxation theory for a cause off all disease. I’ll be the first to tell you that they are indeed out there, but they are extremely rare, and they are probably so old school that they are getting ready to retire. Most DCs that I know and have worked with are very thorough with history/exams/treatment that it’s hard for me to imagine where some of these internet rumors come from.

Third point. Chiropractors are very aware of the risks involved with rotary upper-cervical manipulation. We don’t need neck-911 or quackwatch to tell us, but I guess the public has a right to know in a, ahem, balanced manner. We try to minimize rotation as much as we can. We do it on people every day. There are various ways to do it; we try the safest ways first. Even though there are the risks of intimal tears, it is a very powerful treatment for headache cases, etc. when indicated. The risk is very much worth the reward. Personally for me, keeping my upper cervical complex in good function carries over to good occulomotor function. I notice the difference, and I’m glad we have that tool to work with.

Todd.

[Todd]

By the way, should there be a link to the instructional videos?

[Dave]

I am the person who developed and coordinates the annual “Spinal Manipulation Update” programs in Oklahoma, and who welcomed Bill Kinsinger, MD to the course faculty. Though I can't speak for him, I have heard him speak several times and have a pretty good idea of his views, which I would like to summarize here and add some thoughts of my own.

Bill is in full support of the Orthopractic Guidelines, posted at:

http://orthopractic.org/guidelines.html

He also has stated that he believes manipulation of the neck may have some benefit for people who have cervical joint dysfunction, but is strongly opposed to neck manipulation for dysfunctions / injuries affecting other body regions. Worst case in point: he knows the family of a young woman who had fallen onto her backside and sustained an injury to her coccyx, and who then died at the hands of a chiropractor who treated her coccyx problem by manipulating her upper cervical region, and only her upper cervical region.

Some of my own views of current best practice:

1. At present we do not have clinically-useful screening tests to identify persons at risk for vertebrobasilar or carotid artery insufficiency / dissection.

2. We do not have data to inform us if the risk of manipulation of the neck varies with spinal level (i.e., is manipulation of the upper cervical region truly more risky, as is commonly thought, than manipulation of the mid / lower cervical regions?)

3. We do not have data to inform us whether cervical rotation manipulations are more risky, as is commonly thought, than other cervical manipulations.

4. In the absence of useful screening tests, I believe the following may reduce risk:
a. Careful patient selection on the basis of information gained from the patient interview, from examination of active cervical movements, and from evaluation of the patient's response to the pre-thrust position -- all leading to a careful decision whether to then proceed with a manipulative technique.
b. Use of cervical techniques only for some, but not all, cervical dysfunctions -- which includes not manipulating the neck to treat a disorder affecting another body region.
c. Manual treatment directed to the thoracic region achieves satisfactory relief for some patients with cervical pain -- and they do not require cervical techniques to achieve a satisfactory outcome.
d. The type of manipulative technique itself may reduce risk -- in particular, those that are performed in mid-range with minimal leverage and minimal force, with precise positioning and quickness to achieve a gentle cavitation. Gibbons & Tehan are expert practitioners and teachers of such an approach; that is why we keep bringing them back to Oklahoma to help us further refine our skills in spinal manipulation. In their teaching, they show instructional videos of their precise and gentle mid-range manipulative techniques to help course participants further refine their skills. To provide a perspective on techniques they do NOT recommend or teach, they also show videos of chiropractic manipulative techniques, which even a casual observer would note are by comparison forceful and uncontrolled, and certainly appear to apply considerable stress to the soft tissues spanning the manipulated joint(s).

Having had Bill on the faculty for the last 3 Spinal Manipulation Update programs, I greatly value his contribution to our program and to the larger issues of patient safety, responsible practice, and scientific practice.

Not all of the faculty and participants in the Update courses agree completely on every point, so the ensuing discussions are lively and extremely valuable, and may result in one person's perspective influencing that of another.

Bill is a valued member of our faculty team, and beyond that, is a national resource and advocate for patients, survivors, victims, and their families.

[Bart Bishop]

Thanks for the clarifications, and while I agree with a great deal of it, there is still the blatant scare tactics that he and his site use. I still can't believe that you, Andrew, or you, Dave would have a manipulation course and have a guy there that is purposefully scaring patients away from that which you are trying to learn to help improve patient outcomes.

As to my treatment, I misstated. I should have said regularly for my manipulations from C3 down. I do perform upper cervical manipulations, but only rarely as headache patients are not a large part of my practice. I have found that most cervical spine and cervical radiculopathy respond best to manipulations of a lower level as that is the location of their joint dysfunction.

Dave, as the coordinator of that class in Oklahoma, I strongly urge you to reconsider your affiliation with Bill. I understand that he is a patient, victim, and family advocate, but their are better ways to do it. Insurance companies are about as much of a patient advocate as Bill is.

[Dave]

In response to Bart, who did not attend the Spinal Manipulation Update courses, I reviewed the 29 course evaluations for the program in which Bill Kinsinger spoke and presented some of his videos, and noted the following:

No course participant had anything at all negative to say about the content of Bill’s presentation or the style in which he gave it. 26 people rated the course content and presentation Excellent, the maximum rating. The remaining 3 people rated the course content and presentation as Very Good, the next highest rating. At the conclusion of Bill’s presentation, he received a warmly-enthusiastic round of applause.

Bill has been an invited speaker at several state and national physical therapy meetings. I’ve heard him speak on several occasions, and each time the response is the same: a warmly-enthusiastic round of applause. He keeps getting invited back to speak, which says a lot in itself.

Thus, Bart, you are the only physical therapist I know who doesn't like what Bill Kinsinger has to say. I googled you and found a Barton Bishop, PT, DPT, CSCS who directs a Rockville, Maryland clinic owned by chiropractors.

See the webpage at: http://www.sportandspinerehab.com/clinicstaff.php

Is that really you?? If so, I have a couple of questions for you: Is it possible that your employment status has biased your opinions expressed here? Do you think you have retained any credibility?

Dave

[Jim Cenova, PT, OCS, Cert. MDT]

I have to say we had Bill speak at a PAC fundraiser here in Oregon (for which he refuses to accept as compensation anything other than airfare and hotel) this past Fall. He is very knowledgeable, very professional and very passionate.

He knows a lot and has done a lot of research in this matter. He has no "horse in this race" so to speak, so for him to speak out says a lot about his findings.

Bill received a very warm, enthusiastic round of applause following his talk here as well.

And as for patient advocates, Bill's a pretty darn good one. He wants appropriate interventions to be done on the appropriate person. That's all. His research into the paucity of supportive data for upper Cervical manipulation is his concern. His take is basically "if there's no research to do this potentially injurious maneuver, why do it?"

I haven't heard that question answered cogently.

[Ben Hando]

Sincere thanks to Dave for shedding some much needed light on this discussion. After perusing the Sports and Spine rehab site, I'm left with several questions, chief among them is what exactly are "Physical Therapy Privileges" for a chiropractor? And is the Maryland chapter taking any action to stop chiro's use of language such as this? Very disturbing...

Ben

[Jason Silvernail]

I'm with Ben.

The Maryland Chapter has worked hard on this "Physical Therapy Privileges" issue and it comes down to a chiro being allowed to use modalities in that state, as I understand it. Part of the continual chiropractic attempts to pigeonhole the term "physical therapy" into a set of procedural interventions rather than a separate and autonomous profession.

Much like nutrition, rehabiliation is an area many chiros like to say they are good at though they usually have no expertise or training in it. Many chiros do pursue training and education in it, and that's great, but relatively rare.

It's good to see where Bart's loyalties lie.

Hey Bart - glad to see you're a clinical instructor for students - what a great message you're sending them: be employed by another provider rather than in an autonomous partnership arrangement. These referral for profit working relationships are embarrassing for us and unethical for all involved.

[tmondale]

Bart,

Unbelievable! You actually allow these chiro's to advertise that they are qualified to deliver physical therapy services. You exist in a setting that will only serve to further link us to this shamefull cultish bunch of propagandeurs. We should not be linked to these people in any professional way, until they clearly and forcefully renounce their past beliefs, stop trying to fool the public with misleading labels and advertising, and join the established research community to fascilitate the gathering of real evidence for what we all do.

Tim

[Sean]

Wow Bart,
You've taken a week's worth of beatings with no response.
In all honesty, I do think that neck911.com might better serve the public to tone down their statement a notch. When there's limited evidence on both sides of the argument, it does more harm than good to take such a hard-line on an issue in public. On the other hand when dealing with individual patients, I would have no problem if a practitioner stated he didn't perform a particular technique due to the possibility of major side effects, including death - supposing that had been shown to occur due to manip. in actual patients in at least one, relevant, case study.

[Louie Puentedura]

Getting back to the original post, I'd like to echo the kudos to Dave Johnson and Vince Lepak for their awesome work in getting two such highly experienced and skilled manipulators from Down Under to visit and share their expertise, knowledge and skills. I was lucky enough to have attended the advanced course last year (2006) and would have loved to revisit with my fellow aussie mates this year, but prior committments made that impossible for me.
Despite the current evidence against specificity with technique and significant difference between novice and experienced manipulators, one only has to place their cervical spine in such skilled hands to appreciate there are some variables that can't be adequately quantified.

[Keith Bisesi]

Including Bill Kinsiinger with that manipulation class couldn't be a BETTER fit. The point of the class appears to be PRECISION manipulation which is the difference outlined by Kinsiinger when comparing precise PT manips with violent multisegment manipulations utilized by chiro's. A site like Kinsiinger's doesn't provide invalid fear in our manips, it further illustrates the differences in our two fields.

[Dr.David Black]

Spinal manipulation should be carried out by people trained in its use.
Chiropractors are the logical people to perform this task.

[Dr.David Black]

Scare tactics used by some people does the profession no good at all.
Every procedure carries with it some degree of danger and correct neurological tests must be carried out prior to manipulative therapy.

[Brett]

I'm shocked to read these posts from last year. Kudos to the people that took a step back from their personal opinion and put thought into what they wrote. No kudos go out to those that jumped on the thrashing of Bart as he too spoke with personal opinion. Apples to oranges is what this debate is. Terminology, educational backgrounds, and understanding/curiosity of what the other knows is lacking in this long winded fight from last year. You cannot form educated opinions without knowing every aspect of the different forms of health care. You cannot put down a health profession based on small number of cases that resulted in death or injury. Many people in this world have already thought they have become smarter than nature by coming up with ways to heal, help, and prolong the human body, but in fact they are just clever. Chiropractors with their hands on approach, Surgeons with their intervention on the inter workings of the human body, medical doctors with their prescribed drugs, eastern medicine with meditation and holistic approach. If you find yourself in any one of these categories you need to stop the idealistic thinking that you know it all and what you have learned is the best and only approach. Even within professions there is a lagging of knowledge. What one has learned today may have changed by tomorrow and will have never known. Only through communication, sharing, referrals, questioning each other and multi approach to solve common problems will we move past being clever and onto true health care.

One last thing… We are humans not sheep so lets not follow the person in front of us.

[Elcoj]

Greatings, Ugh, I liked! So clear and positively. Elcoj

[anonymous]

sweet,

give opinions on a technique you learned over the weekend, Now that's fair and just procedure. Have the guy that's against manipulation of the neck to a manipulation seminar. But it's okay, it's for PT's! so everythings okay.