Safety of Manual Therapy and Manipulation

Patients presenting with musculoskeletal symptoms might be offered manual therapy or spinal manipulation as part of a treatment plan or in isolation. The use of manual therapy and spinal manipulation is therefore frequent and the purpose of this essay is to ensure patient safety and the correct use of this specific treatment modality. Whilst manual therapy is considered patient-centred, it remains a passive form of physical therapy where the therapist applies the treatment to the patient.

Broadly, manual therapy is a method of treatment that is commonly used by musculoskeletal physicians, osteopaths, physiotherapists and chiropractors. It aims to quickly reduce pain and improve movement (1) and is clinically and cost-effective (2). Manual therapy treatment can include techniques that glide joints in a rhythmic manner (mobilisation), gap joint surfaces (manipulation) and/or use muscle contractions to restrict or loosen joints. Manual therapy rapidly reduces pain and muscle spasm and allows help with movement. Additionally, manual therapy can help exercise muscles that are not working due to pain – this can help with exercises (3).

Manual therapy is effective in treating neck and back pain and is recommended in national and international treatment guidelines (4). The majority of patients with spinal pain can expect to see a reduction in pain and improvement in function following a course of manual therapy.

The commonest adverse reaction to manual therapy is treatment soreness, which can last a day or two (5, 15). This is a normal, temporary response to having a stiff area of the spine stretched or weak muscles exercised.
Spinal manipulation techniques involve gapping joint surfaces to effectively reduce joint stiffness, muscle spasm and pain (1). There are very rare cases of patients having serious adverse events, including stroke and death, following these techniques (6). These events are associated with damage to the arteries running through the neck. The ‘average’ risk of such events is estimated to be approximately 1 in 2.5 million treatments. (12)

This essay is aimed at providing clinical guidelines for the use of manual therapy and spinal manipulation by physicians and clinicians that perform manual therapy and spinal manipulation. The purpose of which is to reduce the risks of adverse reactions and clinical complications.

Manual therapy: a general term including hands-on techniques that glide joints in a rhythmic manner (mobilisation), gap joint surfaces (manipulation) and/or use muscle contractions to restrict or loosen joints.

Joint mobilisation: movement up to, but within, normal physiological ranges of joint mobility.

Spinal manipulation: gapping joint surfaces to effectively reduce joint stiffness, muscle spasm and pain.

In practice there is often a ‘grey area’ where joint mobilisation tapers into spinal manipulation. These guidelines are not specifically directed towards spinal manipulation and they should be equally borne in mind for all joint mobilisation techniques. Therefore, these guidelines apply to all forms of manual therapy, and safety depends not just upon good manual technique but also a satisfactory history and musculoskeletal assessment before proceeding to therapeutic procedures of any kind.

It is important to clarify the use of the term “spinal manipulation” in comparison to “joint mobilisation”. Whilst both terms are often used in conjunction when describing manual therapy in general, spinal manipulation’s precise medical usage describes the facilitation of movement beyond normal physiological but within anatomical ranges. This distinction as a therapeutic modality must be clearly documented in clinical records.

Development & evidence base
The evidence base for this guideline has been described in the Introduction. As further evidence emerges for the use of manual therapy and spinal manipulation and the contraindications thereof, clinical guidelines will be updated. Ongoing research into the safety of cervical spine manipulation (13) is likely to impact upon this guideline and it will remain the author’s responsibility to inform the clinical team should any changes in practice need to occur.

All patients must have a clinical assessment of their presenting complaint prior to undertaking manual therapy/spinal manipulation, which will include a full case history and physical assessment. Should diagnostic imaging or tests be necessary, all results should be obtained prior to deciding upon the employment of manual therapy or spinal manipulation.

At the first treatment an explanation of the procedure and its possible adverse effects should be given to the patient.

Patients should be asked to give their verbal consent before the first treatment. A record that this information has been imparted and the patient has consented should be recorded in the notes.

Formal written consent is not mandatory (with the exception of persons under 16 in the UK, in which case a parent or carer should be present during the consent process and sign the consent form). This consent form should be signed by the patient and the practitioner and one copy filed in the clinical case notes.

Contraindications to treatment
Whilst spinal manipulation and mobilization remains an extremely safe form of treatment, a number of contraindications to treatment exist and must be adhered to.

Absolute contraindications to treatment
• Where it is more likely that the risks of spinal manipulation will outweigh the potential benefits: –
• Bone disease – tumours, metastases, infection, fractures, bone weakness (long term steroids/osteomalacia, severe osteoporosis), severe inflammatory types of arthritis (not osteoarthritis).
• Neurological considerations – spinal cord compression, moderate to severe nerve root compression from a disc/spondylolisthesis, myeloradiculopathy.
• Rheumatological considerations – active rheumatoid arthritis, ankylosing spondylitis and polymyalgia rheumatica are all contraindications. The last is particularly important as to use manipulation may delay the prescription of steroids and thus risk retinal artery thrombosis and blindness.
• Vascular considerations – the risk of the patient having an aortic aneurysm, severe coagulation deficiencies, severe vertebro-basilar insufficiency (see below), ischemic cervical and thoracic myelopathy must be considered and ruled out where possible. The vascular supply to the spinal cord is only just adequate. A spinal cord already ischaemic should not have manipulative techniques inflicted upon it.
• Lack of clinical hypothesis – where the exact cause of the pain is unclear and there is no obvious mechanism of injury, spinal manipulation should not be used.
• Issues of consent or co-operation – where the patient is unable to clearly understand the aims of treatment, is unable to give their informed consent or where the patient is unable to co-operate with treatment.
• Hypermobility that is severe enough to produce frank instability – lax ligament syndromes/spondylolisthesis. The rheumatoid neck must never be manipulated as life could be at risk by the posterior dislocation of the odontoid process through a weakened or ruptured transverse ligament. Grisels syndrome (1) has been demonstrated radiologically that in children with upper respiratory tract infections there may be hypermobility of the upper cervical spine.

Relative contraindications
• Where it is less clear whether the risks of spinal manipulation will outweigh the potential benefits.
• Adverse reactions to similar treatments in the past.
• Intervertebral disc prolapse – where there has been shown to be a prolapse that is large enough to be causing frank neurological compression.
• Pregnancy – Spinal manipulation and its risks need to be discussed in relation to precipitating a miscarriage (in the first trimester) or premature labour (in the last trimester). The overall risks are low during the second trimester where gentle techniques are advised. (14)
• Osteopenia, osteoporosis, metabolic bone disease
• Hypermobility syndromes with ligamentous laxity. If all movements on pre-manipulative positioning of the patient are painful, manipulation should not be attempted
• Psychological dependence upon manipulative treatment.

Vertebro-Basilar Arterial insufficiency
Episodes of vertebro-basilar arterial insufficiency have been reported to be provoked by manipulation of the cervical spine. The anatomy of the vertebral artery is such that rotation of the upper cervical spine of 30 degrees or more might cause a diminution and even an interruption of the blood flow of the vertebro-basilar artery opposite to the direction of the rotation which may lead to a fatality, although recent evidence suggests the contrary. (16)

The key to the prevention of these problems is in the taking of a careful clinical history. Any symptom such as vertigo, giddiness on turning suddenly or standing up, of loss of consciousness or transient hemiparesis must be carefully elicited and all further neck rotation avoided, (12, 13).

Given a normal history it is reasonable to proceed with the examination having warned the patient to report any giddiness or other relevant symptom and to desist immediately if this happens.

Post treatment management
Risk of minor and moderate adverse events to manual therapy/spinal manipulation is high (circa 50%) but the effects are mild and short lived (15). Patients should be encouraged to contact their clinician should any adverse event last longer than 72 hours. Post treatment, patients may feel sleepy, light-headed, or experience some aching in the areas in which treatment has been directed. Should symptoms progress acutely, medical attention should be sought immediately.

Management of musculoskeletal ‘red flags’
Patients presenting with symptoms suggestive of cauda equina symptoms, muscle weakness or any conditions referred to in 9.1 should not be treated using manual therapy or spinal manipulation and must be managed in a clinically relevant way.

1. Herzog W. (2010) The Biomechanics of Spinal Manipulation. Journal of Bodyworks and
Movement Therapies. 14:280-286.

2. Michaleff A.Z., Lin C.-W.C.,Maher C.G., van Tulder M.W. (2012) Spinal Manipulation
Epidemiology: Systematic Review of Cost-Effectiveness Studies. Journal of Electromyography and Kinesiology. 22:655-662.

3. Haavik H., Murphy B. (2012) The role of spinal manipulation in addressing disordered sensorimotor integration and altered motor control. Journal of Electromyography and Kinesiology. 22:768-77.

4. Carragee E.J, van der Velde, et al., Carroll L.J. et al., (2009) Treatment Of Neck Pain: Noninvasive Interventions. Results of the Bone and Joint Decade 2000–2010 Task Force on Neck Pain and Its Associated Disorders. Journal of Manipulative and Physiological Therapeutics. 32:S141-S175.

5. Carnes D., Thomas S, Mars T.S., Mullinger B., Froud R, Underwood M. (2010) Adverse events and manual therapy: A systematic review. Manual Therapy.15: 355–363.

6. Miley M.L., Wellik K.E., Wingerchuk D.M., Demaerschalk B.M. (2008) Does Cervical Manipulative Therapy Cause Vertebral Artery Dissection and Stroke? The Neurologist. 14:1, 66-73.

7. Cassidy J.D., Boyle E., Côté P., He Y., Hogg-Johnson S., Silver F.L., Bondy S.L.(2008) Risk of Vertebrobasilar Stroke and Chiropractic Care. Results of a Population-Based Case-Control and Case-Crossover Study. Spine. 33:4S. S176-S183.

8. Kerry R., Taylor A.J., Mitchell J., McCarthy C., Brew, J. (2008) Manual Therapy and Cervical Arterial Dysfunction, Directions for the Future.

9. Grisel (1930) Enucleation de l’atlas et torticollis nasopharyngien. Presse Med 38,50.

10. Cyriax (1982) Textbook of Orthopaedic Medicine.

11. Ernst and Cantor (2006) A Systematic Review of Spinal Manipulation. JR Soc. Med. 99:279-280

12. Ernst E. (2010) Vascular accidents after neck manipulation: cause or coincidence? Int J Clin Pract;64:673-7

13. Taylor, Alan J. et al. (2010)
A ‘system based’ approach to risk assessment of the cervical spine prior to manual therapy
International Journal of Osteopathic Medicine , Volume 13 , Issue 3 , 85 – 93

14. Stuber, Kent Jason et al (2012)
Adverse events from spinal manipulation in the pregnant and postpartum periods: a critical review of the literature
Chiropr Man Therap. 2012; 20: 8.

15. Carnes, Dawn et al (2009)
Adverse events in manual therapy: a systematic review
National Council for Osteopathic Research

16. Erhardt, Jonathan et al (2015)
The immediate effect of atlanto-axial high velocity thrust techniques on blood flow in the vertebral artery: A randomized controlled trial
Manual Therapy Vol. 20 Iss. 1, February 2015

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