Friday, August 08, 2014

APTA Challenges AHA Report on 'Association' Between CMT and Stroke

A recent American Heart Association (AHA) statement that cervical manipulation may "play a role" in stroke fails to consider how physical therapist (PT) clinical judgment can reduce this risk, and overlooks the fact that manipulation is associated with far fewer complications than drug-based and surgical interventions, according to a news release from APTA. The AHA statement (.pdf) focused on an analysis of strokes caused by cervical arterial dissections (CDs).

"Incidents of stroke associated with cervical manipulation are rare," according to the APTA statement, which cites studies from 2002 and 2010 that found "no strong evidence" connecting cervical manipulation therapy (CMT) and adverse events.

APTA's statement was issued in response to an AHA report that concludes there is a "statistical association" between CD and CMT but does not cite a definitive link. In fact, AHA describes the incidence of CD in patients who have received CMT as "not well established, and probably low," and characterizes evidence as "insufficient to establish the claim that CMT causes CD." In a news release issued by AHA, the report's lead author is quoted as saying that “A cause-and-effect relationship between [CMT] and CD has not been established." Still, he said, “Patients should be informed of this association before undergoing neck manipulation.”

In its statement, APTA emphasizes the role of the clinical judgment of the PT, supported by a 2-decade history of guidelines for CMT, and a 2012 clinical reasoning framework developed by the International Federation of Orthopaedic Manipulative Physical Therapists, an organization that works closely with the Orthopaedic Section of APTA. The framework in particular was designed "to provide guidance for the assessment of patients for the likelihood of stroke in advance of [CMT]," according to the statement.

APTA also points out that CMT has rates of risk lower than the use of pain relievers or cervical spine surgery, both of which are reported to increase likelihood of a range of adverse outcomes in addition to stroke.

"The physical therapy community is committed to educating patients and practitioners about the risks and benefits of cervical manipulation," said Timothy W. Flynn PT, PhD, OCS, immediate past president of the American Academy of Orthopaedic Manual Physical Therapists. "[PTs] understand the small risk of stroke associated with cervical manipulation, and they base decisions regarding the select use of this procedure on a detailed and ongoing evaluation and a treatment plan that is consistent with patient preferences."

Comments

Nice to see APTA speaking out about evidence taken out of context and spun to say what the reader (AHA) wanted it to say rather than analyzing what was and what was not possible to conclude. Binary thinking is a scourge that has become pandemic in the age of evidence driven medicine. tim1

Posted by Tim Fearon on 8/8/2014 5:04 PM
Thanks for doing such a wonderful job advocating for our profession. The risk is so low, compared to the benefits of cervical manipulation and the risks of treatments commonly prescribed by physicians.

Posted by Aaron LeBauer PT, DPT, LMBT on 8/8/2014 6:33 PM
As an EBP educator, it is clear that the results of this study have been misconstrued. The report suggests a "significant association", however, the strength of the association is not reported. Another example of why therapists need to return to the original study before making conclusions themselves. Our local news highlighted this study just a few days ago, however, linked the practice of cervical manipulation to DC's.

Posted by Jena Ogston on 8/9/2014 7:54 AM
This piece is poised as a reputable compilation of literature evidenced by using descriptive anatomy while attempting to inform the public of a potential correlation between “manipulation” and cerebral arterial dissection, but does not use valid and comprehensive data to support the conclusion. Two primary threats to the merit of this article: 1) As I would with any “article” claiming a cause – effect relationship exists, I quickly referred to the references. The references are purely FA, Twitter, and public speaking vignettes that would not suffice in even the most lax thesis/dissertation defenses that I have been a part of; 2) The fact that he uses “manipulation” strongly suggests that the intervention may have been provided by disciplines either in addition to, or, by chiropractors. This is supported by his choice to use “healthcare providers.” In conclusion, I greatly appreciate and respect the connection between compromised vessel integrity secondary to harmful forces and resultant adverse responses of the cervical vasculature. However, prior to a generic, all-encompassing article being disseminated to the public, the authors (MDs) owe it the public and to the integrity of their profession to RESEARCH their data through referred journals and formulate a cogent representation of the findings.

Posted by Kirk Bradley on 8/9/2014 12:29 PM
I believe there was a similar misleading statement played on the chiropractic profession years back. When truly assessed, I recall the research provided no statistically relevant support of the statement. It is unfortunate the public is exposed to such misleading and confusing information.

Posted by Gary Fischer on 8/10/2014 11:11 PM
I'm a bit stunned by my colleagues' responses here to this slanted and cherry-picked defense of cervical manipulation therapy (CMT) by APTA. Dr. Steven Novella of Science Based Medicine has provided a very succinct and well-referenced response to the recent AHA/ASA commentary and position statement based on the recent study showing a link between cervical artery dissection (CAD) and CMT: http://www.sciencebasedmedicine.org/a-statement-on-cervical-manipulation-and-dissections/ Dr. Novella rightly points out that the risk/reward of performing thrust manipulation of the neck favors avoiding performing this procedure. This is not only based on the growing body of evidence suggesting that their is a link between CAD and CMT, but also both a Cochrane review and RCT evidence that cervical manipulation is **no more effective** than non-thrust mobilization techniques. The arguments I'm seeing here comparing the risks of CMT to various medical interventions are examples of the classic "tu quoque" fallacy: just because physicians perform procedures that increase risk of harm doesn't mean that we are justified in performing a procedure that has a lower risk of harm, especially when there is another option with virtually no risk of harm that has been shown by the evidence to be just as effective. I can only conclude that in the current increasingly desperate climate of shrinking reimbursement across the board for treatment provided by Physical Therapists, that ulterior motives are driving this irrational support of cervical manipulation. APTA, AAOMPT and IFOMPT have circled the wagons in a desperate attempt to protect turf from other professions that would wrest CMT from us if we were to give them the opportunity. Who cares what the totality of the evidence suggests! By golly we're not gonna let the chiros take manipulation from us!! Who cares if one in a million or one in ten million might be rendered quadriplegic or dead! Where's the courage to stand up for the science-based principles that have gotten the profession this far? Shame on APTA for taking this cowardly position. Shame on all of us for letting it reach the point where we're willing to sell out our principles and ignore the totality of the evidence in order to protect turf. No wonder the value of our services continues to shrink in real terms. I'm saddened to sit here and watch our profession lose its soul. Jules Rothstein just rolled over in his grave.

Posted by John Ware, PT on 8/14/2014 9:57 AM
Thank you, John Ware, for hitting the head of the nail. Just because we can do something, doesn't mean we should. We need to quit trying to be chiros with another name.

Posted by John Thomas on 8/18/2014 3:02 PM

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