Informed Consent Form

You need to let us know:

The risk related to some treatments can increase if the physiotherapist is not aware of certain facts

Risk Related To Treatment:

Typical physiotherapy carries a remote possibility of injury to structures such as but not limited to, nerves, bones, muscles, ligaments, discs, or arteries. Manual therapy (including dry needling, exercise therapy and postural retraining) can occasionally cause local swelling, bruising, bleeding, infection or transient increase in pain, or other symptoms. Electro-physical agents such as ultrasound or interferential therapy or TENS machine or shockwave therapy or heat or cryotherapy (ice) have been linked to minor burns and abnormal skin reactions. Allergic skin reactions to creams, oils, tape, or needles are a possibility. Skin deformation that occurs when sports taping is applied may also irritate the skin in some individuals. If any discomfort, redness or itching is experienced remove the tape immediately.

Tape Removal:

Sports taping should be removed carefully by soaking the tape in nail polish remover, baby oil or a commercial tape removal product. The skin should be supported by one hand and gentle counter traction provided against the direction the tape is being pulled. The skin should be thoroughly washed and moisturised following removal. Stretchy "K" style tapes or dynamic tapes are best removed by soaking or showering or soaking in warm water until tape and all residues have been removed.

Dry Needling:

is a broad term referring to the use fine needles to stimulate the tissue and nervous system to address musculoskeletal conditions. Dry Needling, was pioneered at the clinic and has been taught around the world since the early 1990's. Most of the insertions involve no sensation at all. Occasionally a sharp insertion sensation occurs due to skin stretch at the insertion site. This is like what occurs when pulling a hair and occurs in 1 out of every 30 insertions. We recommend this modality in most treatments to address tissue and nervous system sensitivity (often perceived as tightness), inflammation, neurological muscle inhibition (often perceived as weakness) and to stimulate remodelling of maladapted connective tissue structure.

Potential Risks And Side Effects Of Dry Needling:

Pneumothorax (Puncture/Collapsed Lung):

This is extremely rare with a possibility less than 1 in 70,000 - 1.27 million treatments and most of these instances are preventable with correct risk factor screening and technique application. All of the practitioners at Physio Cure have extensive training in the dry needling techniques they use and the identification of any risk factors and prevention measures to further minimise this occurring. If you experience increasing shortness of breath, that may or may not be accompanied by pain, following dry needling over the posterior shoulders or upper trunk, please contact Physio Cure by text and email or attend to the nearest hospital emergency department for an assessment.

Infections:

are possibility but are extremely rare when single use disposable needles are used. Physio Cure uses only single use, disposable needles. Some people have been reported to experience minor skin irritation in response to the metals used in the needles. These rare adverse effects combined occur in less than 1 in 10,000 treatments.

Fatigue and Drowsiness:

Following treatment and before driving or cycling, ensure you are not feeling drowsy or fatigued. If you do experience this, consult your practitioner for advice and possibly assistance with alternative travel arrangements. Have a snack or drink and rest until you feel that you have recovered. If you have previously experienced extreme fatigue or drowsiness after acupuncture or dry needling, please inform your practitioner prior to treatment and arrange for someone else to drive you to and from the appointment.

Discomfort following treatment:

It is very rare for people to experience any discomfort as a result of the dry needling techniques used at Physio Cure. Some new soreness may be experienced as a result of changes in the mechanical and neurological loading of nerve and tissue structures as a result of altered ranges of motion following treatment. This will usually resolve within hours and a few days.

Apparent minor bruising:

Approximately one in thirty needle sites will expel 1-2 drops of blood following needle removal. A further one in thirty will result in a small bump (subdermal haematoma) under the skin that may then resolve leaving what appears to be a bruise. These are not associated with impact or tissue damage and will be absorbed within 1-3 days in a healthy individual.

Grade 5 Manipulation Consent Form:

Grade 5 manipulations are a treatment technique in which a fast, small amplitude, passive manual mobilization of a joint (commonly known as cracking or adjusting) is used to gap one or more synovial joints with the aim of improving joint mobility and reducing pain.

Manual Therapy Treatment (Manipulation, Mobilization Or Soft Tissue Techniques):

Is recommended by National Institute for Health and Care Excellence (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.

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:

The circumstances where extra caution needs to be taken, although a manipulation can still be performed: (Previous adverse reaction / Disc prolapse / Pregnant / Under 16’s / Spondylolisthesis / Vertigo / Hypermobility).

Patient Consent: 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.

Cervical Arterial Dysfunction (CAD) and Vertebral Basilar Artery (VBI) Signs and Symptoms: 

• The 3 N’s: Nystagmus, Nausea, Numbness
• Gait disturbances
• The 5 D’s: Dizziness, diplopia, dysphagia, drop attacks, dysarthria
• Tinnitus
• Occipital headaches
• Tingling in the upper arms
• Pallor
• Blurred vision / Fainting.

Major Risk Factors for CAD: 

• Hypertension
• Hypercholesterolemia
• Diabetes
• Hypothyroidism
• Tumour
• Vertigo
• Menieres
• Cervical Dysfunction

Labyrinthitis Protocols for CAD:

After subjective identification of any potential CAD symptoms, further questioning must reveal the type, duration, frequency, degree and status of symptoms.

- Check for any aggravation of symptoms with head movements

- Check the nature and type of any associated symptoms, especially headaches

- Check for any previous medical history of migraines, epilepsy, cardiovascular history, head injuries, stroke, and vestibular problems.

Specific CAD tests have been found to hold little predictive value in the incidence of onset with manipulation. Therefore, judgement on when to use manual techniques should be based on information gained during a thorough subjective examination, with considered weighing up the presence of risk factors (Kerry et al 2008).