Names have been removed to protect privacy. Identifying letters are assigned in alphabetical order and bear no relationship to the person's actual name.
The Commissioner received a complaint from the consumer regarding physiotherapy treatment received in March and April 1998. The complaint is that:
- The consumer sustained mild central cord syndrome as a result of a cervical cord hyperextension/torsion injury, during physiotherapy manipulation by the physiotherapist.
The Commissioner received a complaint on 30 November 1998 and an investigation was undertaken. Information was received from:
- The Consumer
- The Provider
Relevant medical records were obtained and the Commissioner obtained advice from an independent physiotherapist.
Information Gathered During Investigation
In mid-March 1998 the consumer injured his left shoulder at work. A general practitioner at a medical centre referred the consumer to the physiotherapist from a physiotherapy clinic for treatment of this injury.
His first treatment session was in late March 1998. There is a consent form on file, which has specific questions about pre-existing medical and other conditions, as well as adverse reactions to previous treatment. These sections were left blank and the consumer signed the form. In the physiotherapist's consultation notes of the same date he noted that the consumer sprained a shoulder in 1994, although it was unclear which shoulder was sprained.
Treatment during the first and second consultations in late March 1998 initially consisted of local ultrasound, soft tissue massage, advice about avoiding movements which caused pain and shoulder strapping.
By the first consultation in early April 1998, the consumer's symptoms had changed. Both active and resisted left shoulder movements were not painful, but his first rib was very tender when palpated. The physiotherapist therefore queried whether the consumer had an underlying first rib dysfunction. The physiotherapist adjusted the treatment he provided accordingly. At this session, treatment consisted of first rib mobilisation and local ultrasound. The physiotherapist defined mobilisation as a passive movement technique applied to a joint. He stated to the Commissioner:
"The joint is moved rhythmically within its normal range and at a speed that the patient can voluntarily resist or prevent ? A grade three movement was performed i.e. a large amplitude of movement but one that does not move into stiffness or muscle spasm."
At the consumer's next consultation five days later, he informed the physiotherapist that he felt much better, but indicated numbness over his left shoulder and arm region. This was noted to be over the C 5/6 dermatome (the skin which relates to nerve fibres from this part of the spine). He had pain with active cervical rotation to the left and left lateral side bending and with accessory joint glide over the left facet joints of C3/4/5. The physiotherapist queried a cervical dysfunction and undertook sensation testing, but no other neurological tests. The treatment on that day consisted of mobilisation to the left facet joints of the fourth and fifth cervical segments and of the first rib. Grade three movements were performed according to the physiotherapist's record. Cervical traction was also applied, although the consultation notes do not record the grade of traction movement used.
The consumer described these subsequent treatments as:
"?/I>[T]raction and manipulation of my neck. During this treatment I could feel and hear a bone grating and told [the physiotherapist] who carried on with the treatment. I also asked him at this session whether I should have a x-ray to which he replied "no"? One procedure consisted of [the physiotherapist] standing behind me and pulling my neck sufficiently hard enough to move my 85kgs up the bed. The other thing he did to me I can only describe as putting me in a headlock and then pulling on my neck. At no time during any session did he ask whether there were any possible previous injuries to my neck."
The physiotherapist stated that:
"[The consumer's] description of 'bone grating' was crepitus, which most commonly indicates a roughened joint surface moving and is not cause for undue concern. I did not feel that a x-ray at that point would help clarify the clinical picture."
The physiotherapist said that he provided a full and accurate response to the consumer's questions about the crepitus in his neck and the need for an x-ray, but that he did not document this discussion. The physiotherapist also said that had the consumer communicated his dissatisfaction with the explanation given, he would have re-explained the situation.
The physiotherapist defines traction as:
"A sustained passive-movement mobilisation that produces a vertical distraction force to the spine."
When describing the cervical traction performed, the consumer said that he lay on his back and the physiotherapist stood at the head of the table. The physiotherapist's arm went over one of the consumer's shoulders and across his neck, with his hand resting on the other shoulder. He then applied pressure and pulled the consumer up the table. The physical reaction was immediate. The consumer sat up, felt dizzy and saw a bright flash of light.
The consumer described his symptoms following this treatment as follows:
"At the conclusion of this last session I felt light-headed and "saw stars" while dressing. By mid-evening I had developed a severe headache and when I woke the next morning I had pain through most of my body and numbness and weakness in all of my limbs, and I could not move."
The physiotherapist denied applying manual traction to the consumer's neck with enough force to move him up the bed.
Firstly, he is about 16kg heavier than I am and I doubt I have the strength to carry out such a vigorous procedure. Secondly, I would never professionally choose such a procedure, as it is neither indicated nor safe. Thirdly, while I did not document the grade of traction on the [second consultation in] April, traction applied on the [following day] was a grade III, which indicates the likely grade the previous day, as therapeutically it is not usual to go from a higher grade to a lower grade."
During the third consultation in April the consumer complained of central cervical and lumbar pain. Upon reassessment the consumer now had pain with active cervical rotation to the left, flexion and left lateral side bending. He also exhibited stiffness when joints C7/T1/T2/T3 were palpated. The physiotherapist noted that the consumer's symptoms were continuing to fluctuate and did not fit any clear clinical presentation. Treatment at this session consisted of gentle left and right active cervical rotation exercises and a trapezius stretch, as well as cervical traction and a mobilisation technique.
This time the consumer did not recall being moved up the bed during this procedure. The consumer's wife was present during this treatment and she confirmed that there was no movement. The physiotherapist explains the mobilisation technique as follows:
"This technique involves the patient seated. The patient's head is side-bent to one side and rotated to the opposite side with the therapist fixing the spinous process of T1."
The consumer returned the following day for his fourth consultation and informed the physiotherapist that he felt more comfortable after the treatment but now complained of numbness in both arms and legs, with the left being worse than the right. The physiotherapist conferred with a colleague who agreed that there was no clear clinical picture. At this point the physiotherapist referred the consumer back to his general practitioner for medical review, as he was not convinced that the problem was mechanical and therefore physiotherapy may not have been appropriate treatment.
The consumer has described ongoing and long-term problems attributable to this injury, and a diminished quality of life. He initially did not understand what was happening to him. The consumer says that he waited before consulting a doctor about his symptoms as he thought that it was a minor reaction or condition which would clear up on its own.
Six days after the consumer's consultation with the physiotherapist the consumer consulted a second general practitioner from the same medical centre about these problems. The medical centre is where the consumer accesses general practitioner services. He generally consults the doctor available at the time of need. This is why he saw the second general practitioner instead of the first general practitioner who had originally referred him for physiotherapy . The consultation notes read:
"Syndromes of Cervical Spine
Left shoulder review. After a manipulation last week he felt quite drunk for 1-2 minutes afterwards; then he felt ok; that evening he developed a headache and felt very tired ++ and has had trouble sleeping all week; quite scared; he has had stabbing pains from lower back; at some time he developed numbness on left upper torso; by day 2 he had trouble wriggling his toes; the manipulation was of upper COC1 area."
The second general practitioner referred the consumer to a neurologist. The neurologist concluded, in a letter to the second general practitioner dated late June 1998 that:
"The signs today are suggestive of a cervical cord hyperextension /torsion injury, giving rise to a mild central cord syndrome ? Certainly the connection to whatever was done on his neck is firmly locked in time, and it would seem that his symptoms definitely developed after the session of physiotherapy. As you know his physiotherapist assures us that no actual neck manipulation was done at that time."
Advice to the Commissioner
The Commissioner sought advice from an independent physiotherapist who stated the following:
1. "It is clear that cervical spine manipulation (a high velocity thrust technique) was not performed and that any procedures applied to the neck were consistent with the definition of mobilisation provided by [the physiotherapist].
2. The mobilisation procedures applied to [the consumer's] neck did not involve 'hyperextension/torsion'. The 'headlock' procedure to which [the consumer] refers involves a combination of partial rotation and partial side-flexion of the neck, and is a standard procedure regarded as normally of only moderate vigour.
3. [The consumer] complains that [the physiotherapist] did not listen to nor respect his concerns. This is a difficult issue to comment on as it essentially is a matter of communication. The very fact that this complaint was lodged suggests that there may have been inadequate communication on the part of the provider. Furthermore, the provider's notes do not demonstrate evidence of any explanation nor the gaining of informed consent, but this does not mean that such communication did not actually occur - it may be just that the notes were inadequate in that they did not provide a record of this.
4. The adverse reaction that [the consumer] experienced is highly unusual considering the treatment applied to the cervical spine. Prediction of such a reaction in the first instance would have been impossible.
5. [The physiotherapist] however did not undertake a full neurological examination of the patient on either the [second or third consultations in] April 1998. [The consumer's] complaint of numbness made such an examination necessary for both diagnostic and safety reasons, in order to determine if there was any compromise of neurological structures. It is possible that had a complete neurological examination been undertaken on either of these visits then initial signs of cervical cord pathology may have been detected earlier and treatment discontinued before further injury was sustained. On the [second consultation in] April sensation testing was performed but there is no evidence of either muscle strength (myotomal) or reflex testing having been undertaken on this occasion. No neurological testing at all appears to have been performed [during the third consultation in] April, including any reassessment of the sensation changes detected the previous day. In this regard [the physiotherapist] has failed to provide care which complied with appropriate professional standards.
6. The claim by [the consumer] that he was pulled up the bed while the traction treatment was applied is somewhat at odds with the claim by [the physiotherapist] that a grade three traction technique was applied. A grade three technique is normally applied well short of the end of available joint range and would not cause body movement. If indeed the traction procedure caused movement of [the consumer's] body up the plinth, then the degree of traction force applied would seem to be overly strong (>85kg) and it would be likely that this procedure led to the adverse reaction.
7. The management of [the consumer] was otherwise appropriate and consistent with the expected and other relevant standards of care. In particular, the 'grating' noise heard by [the consumer] was likely to be joint crepitus relating to the degeneration of his neck and did not necessitate an x-ray. If an x-ray [had] been taken it would not have provided any clinically useful information."
The Code of Health and Disability Services Consumers' Rights
The following Rights are applicable:
Right to Services of an Appropriate Standard
2) Every consumer has the right to have services provided that comply with legal, professional, ethical, and other relevant standards.
4) Every consumer has the right to have services provided in a manner that minimises the potential harm to, and optimises the quality of life of, that consumer.
Right to be Fully Informed
3) Every consumer has the right to honest and accurate answers to questions relating to services, including questions about -
a) The identity and qualifications of the provider; and
b) The recommendation of the provider; and
c) How to obtain an opinion from another provider; and
d) The results of research.
Rights 4(2) and 4(4)
In my opinion, the physiotherapist breached Right 4(2) and Right 4(4) of the Code of Health and Disability Services Consumers' Rights as follows:
The consumer first complained of numbness over his left shoulder and arm during the second consultation in April 1998. I accept the advice from my physiotherapist advisor that at this point a full neurological examination was necessary for diagnostic and safety reasons. There is evidence of some testing having been done during this consultation, and a note of a possible cervical dysfunction, but no evidence for the third consultation in April. In failing to undertake neurological examinations when the need to do so was clearly indicated, the physiotherapist failed to provide treatment that complied with the professional standard and treatment was not provided in a manner that minimised the potential harm to the consumer.
I received conflicting evidence regarding the claim that the consumer was pulled up the bed while cervical traction was applied. The consumer clearly remembers being moved up the bed as a result of this procedure during the second consultation in April 1998. The consultation notes for that day did not record the degree of force used, although the physiotherapist denies applying enough force to move the consumer's body up the bed. During the third consultation in April 1998 neither the consumer nor his wife recall the consumer moving up the bed when cervical traction was applied. The consultation notes recorded that grade three traction was applied on this occasion.
While the consultation notes for the second consultation in April 1998 do not record the grade of pressure exerted during the cervical traction manoeuvre, I accept the physiotherapist's response and the advice of my independent physiotherapist that grade three traction, as occurred during the third consultation in April 1998, would not supply enough force to cause body movement. However, the physiotherapist should have recorded the grade of pressure in his consultation notes of the second consultation in April.
The consumer claimed that at no time during any session did the physiotherapist ask whether there were any possible previous neck injuries. However, there is a signed consent form on file on which the consumer left blank the sections relating to relevant pre-existing conditions. In the consultation notes of the first consultation in March 1998 the physiotherapist has noted a shoulder injury in 1994 and this note indicates there was discussion about the consumer's previous injury and history.
In my opinion the physiotherapist breached Right 6(3) of the Code of Health and Disability Services Consumers' Rights.
The consumer expressed concerns at the time of treatment that he could feel and hear a bone grating during one of the mobilisations. The consumer queried whether an x-ray was necessary to determine its cause, to which the physiotherapist responded that an x-ray was not necessary. Although the physiotherapist has stated that he did explain this fully to the consumer, this discussion was not documented.
In my opinion the physiotherapist failed to show that he provided a full and accurate response to the consumer's question, by explaining to the consumer that the problem was crepitus relating to neck degeneration which is not a cause for concern and did not require an x-ray to be taken. The physiotherapist's notes did not demonstrate evidence of any explanation to the consumer. The physiotherapist was required by Right 6(3) to fully explain what the noise actually was and why a x-ray was not needed.
I recommend that the physiotherapist takes the following actions:
- Apologises in writing to the consumer for breaching the Code of Rights. This apology is to be sent to the Commissioner, who will forward it to the consumer.
- Refunds any ACC surcharge payments that the consumer made for the second, third and fourth consultations in April 1998. The cheque is to be sent to the Commissioner, who will forward it to the consumer.
- Reviews his record keeping practice.
- Alters his consent form to ask Yes/No questions at the beginning of sections and ensures the consumer has filled in the form correctly.
A copy of this opinion will be sent to the New Zealand Physiotherapist Registration Board.
For further information, contact: HDC Communications Section (09) 373 1060.
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