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Physiotherapy Consent Form

Physiotherapy Consent Form

Manual therapy treatment (Manipulation, mobilization or soft tissue techniques) are recommended by NICE
in the management of back pain as part of a treatment package.

Indications for a Grade 5 Manipulation include:

• Stiffness
• Reduced Range of  Movement
• Pain
• Muscle spasm

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Possible adverse effects and Contraindications

In very rare cases the following complications may occur as a result of having a grade 5 joint manipulation:-
Stroke,
– Spinal cord compression,
– Cauda Equina Syndrome
– Disc herniation
– disc prolapse
– nerve root compression
– fracture- Local pain
– headache
– dizziness
– nausea,
fainting

The likelihood of developing any serious side effect following manipulation is extremely rare; the incidence of having a stroke after cervical manipulation is 1 in 20,000 to 1 in 1 million, the incidence of cauda equina after lumbar manipulation is less than 1 in 1 million manipulations (Assendelft et al. 1996)

There are some occasions where a manipulation should not be performed. Please let your physiotherapist know if you have suffered from any of the following, either previously or currently: • If you do not consent to a manipulation • Bone tumour • Infection
There are also some circumstances where extra caution needs to be taken, although a manipulation can still be performed. Please specify if the below apply to you:
Have you ever experienced an epileptic seizure?
Manipulation Health Screening Form
Have you ever had an adverse effect to manipulation?
Do you have any heart problems?
Do you have any problems with your circulation such as Deep Vein Thrombosis, Pulmonary Embolism or a bleeding or clotting disorder?
Are you receiving anticoagulation therapy?
Do you have, or have you ever suffered from any form of cancer?
Are you pregnant or trying to conceive?
The Physiotherapist has explained the treatment process of spinal manipulation to me including the risks, benefits, material risks & alternatives. I have answered all of the above questions to the best of my knowledge. I give my consent to the use of the spinal manipulation for my treatment . I understand I can withdraw from the treatment at any time. I agree not to disturb the needles during the treatment period and will ask for assistance if I have any concern.