Causation to Recognition – The Shift for Optimal Clinical Management

October 26, 2008 –  Banff, Alberta – 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.

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 with 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, and 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.”