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RESEARCH COMMENTARY
Ejona (Ona) Jeblonski, DPT, COMT
Fellow in Training, MAPS Accredited Fellowship in Orthopedic Therapy

Chris R. Showalter, PT, COMT, OCS, FAAOMPT
MAPS Fellowship Program Director

Mobilization Increases Dorsiflexion in Chronic Ankle Instability (CAI) Patients


 
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Cervical Spine Thrust Manipulation: What are the risks?

September 17, 2013

RESEARCH COMMENTARY

Chris Showalter PT, OCS, COMT, FAAOMPT

MAPS Clinical Director

Cervical Spine Thrust Manipulation:

What are the risks?

Significant controversy and heated debate continues regarding the risks associated with cervical spine thrust manipulation and the potential for resulting serious injury, stroke or even death.  Cervical spine thrust manipulation is routinely performed by numerous professionals, including: Physical Therapists, Osteopaths, Chiropractors, and others.

Clinicians from various professions use different terminology to describe their “thrustâ€? and “non-thrustâ€? interventions.  The actual interventions utilized also vary and include both long-lever and short-lever techniques.  The techniques can be gross or localized. The conditions being treated by cervical thrust are also quite variable, based upon variable clinical intent.  All these variations confound incidence rate studies, making it difficult to determine the risk associated with performing manipulation.

There is yet another other factor that likely contributes to variation in “reportedâ€? incidence rates.  This “800 pound gorilla in the roomâ€? is the issue of underreporting of adverse events.  The significance of this issue cannot be overstated.  For a multitude of reasons, it has been poorly studied, and as such may be a very important missing factor in our understanding of the risk.

Common sense and an understanding of modern society suggest that underreporting may be an enormous factor.   Any clinician who reports an adverse event in their patient following cervical thrust manipulation is subject to significant and perhaps life changing problems.  These consequences potentially include: ridicule, malpractice lawsuits, License suspension or revocation, loss of employment, and loss of insurance provider contracts.  The outcome could be even more devastating to the clinician than the guilt they already feel for the patient’s intervention-induced condition. 

These variations are all significant factors resulting in the literature exhibiting enormous variance in incidence rates of complication following cervical thrust, as shown below: 

  • Rivett 1996 reported incidence of severe neurovascular compromise was estimated to be within a range of 1 in 50,000 to 1 in 5 Million cervical thrusts
  •  Coulter 1996 examined a community-based study of chiropractic treatments and estimated complications at 1.46 per 1 Million, serious complications at 6.39 per 10 Million and death at 2.68 per 10 Million. The incidence increased to 1 in 900,000 for the Upper Cervical Spine. Techniques using rotational thrust were overrepresented in the frequency of injury. 
  • Klougart 1996 surveyed Danish Chiropractors and estimated the incidence of cerebrovascular accident at 1 in 1.3 Million.
  • Haynes 1994 reported an incidence rate of 1 in 200,000 for Chiropractic
  • Carey 1993 reported an incidence rate of 1 in 3 Million for Chiropractic
  • Hurwitz 1996 estimated the risk of serious complications at 6 per 10 Million and risk of death at 3 in 10 Million (the authors adjusted risks based upon the assumption that only 1 in 10 events are reported in the literature). As discussed above, this assumption may be inaccurate.
  •  In 1999 Di Fabio examined 177 published cases (in 116 articles) of injury following cervical thrust from the period 1925 to 1997. The most frequently reported injuries involved arterial dissection or spasm, and lesions of the brainstem. 32 cases (18%) resulted in death. Physical Therapists were involved in less than 2% of the cases and did not result in any deaths.       
  • Haldeman 1999 examined 367 cases of arterial dissection or occlusion reported in the literature between 1966 and 1993. Multiple mechanisms of injury were found but notably 115 cases (31%) were the result of cervical manipulation.
  • Haldeman 2001 reported that there were 43 cases of neurological symptoms (reported by neurologists seeing the patient after the adverse event) following chiropractic cervical manipulation over the 10-year period (1988 to 1997) in the Province of Ontario, Canada, which at the time had a population of 4500 Chiropractors. Stated another way, over a 10 year period, 1 in 104.7 chiropractors had a patient who experienced neurological symptoms following cervical thrust manipulation.

Recently, an excellent paper in this area from Puentedura 2102 asked the question “Are adverse events preventable and are manipulations being performed appropriately?â€?  This paper reviewed 134 case reports of adverse events (in 93 articles) between 1950 and 2010.   The authors of the study concluded that:

  1. Arterial dissection was the most common adverse event representing 37.3% of the reported cases.
  2. Seven cases (5.2%) of the reported cases of adverse events resulted in death, 5 by arterial dissection, 2 by CVA (Stroke).
  3. Four of the deaths (57.1%) were determined to be preventable.
  4. Two of the deaths were categorized by the authors as preventable, because the practitioner continued to perform cervical thrust despite worsening symptoms.
  5. Two of the deaths were categorized as preventable because the practitioner continued to perform excessive numbers (>5) of cervical thrusts with no change in the symptoms following treatment. 
  6. 19.4% of cervical thrusts were performed for inappropriate conditions (conditions unlikely to benefit from thrust) and thus, these patients were placed at risk unnecessarily, because they were unlikely to benefit from the technique. 
  7. 10.5% of the 7 reported deaths in this paper were determined to be unpreventable, suggesting the inherent risk of performing manipulations, even after a thorough examination and proper clinical reasoning.
  8. 44.8% of adverse events were determined by the authors to be potentially preventable, when clinicians ruled out all contraindications and red flags.

Puentedura 2012 and colleagues concluded that 44.8% of the 134 adverse events were preventable when clinicians:

1) ruled out contraindications and red flags

2) performed a thorough examination, and

3) used sound clinical reasoning.         

Summarizing the Evidence

Despite the large variation in evidence regarding potential adverse events from manipulation, practitioners who perform manipulation, need to be aware of the risks and act accordingly in the best interest of the patient. 

  • Estimated incidence of injury ranges from 1 in 50,000 to 6 in 10 Million, showing enormous variation and thus, resulting in little consensus.
  • Underreporting of adverse events may be commonplace.  We just don’t know.
  • The most frequently reported severe injuries (31.0% - 37.3%) involved arterial dissection.
  • The risk of death in the case of an adverse event is between 18% (Di Fabio 1999) and 5.2% (Puentedura 2012).
  • 44.8% of adverse events are potentially preventable, by ruling out contraindications and red flags and using sound clinical reasoning.
  • 10.5% of deaths were unpreventable, suggesting inherent risk even after thorough examination and the use of proper clinical reasoning.

 

What can you do to minimize the risk to your patients?

1. Recognize that the risk is real, despite lack of consensus on incidence rates.

2. Consider all the evidence and remember:  “Adverse events may be rare, but when they do occur, they can be catastrophic and potentially deadly.â€?

3. Use every available clinical tool at your disposal to ensure your patient’s safety.

  • Rule out ALL Contraindications and Red Flags.
  • Perform an accurate and detailed examination.
  • Utilize special testing (like VBI Screening) when applicable.
  • Discriminate wisely the use of manipulations such that you:

            --Use thrust on clinical conditions likely to respond to thrust.

            --AND, use thrust techniques considered to carry less risk

                       (e.g., short lever, small amplitude) whenever possible.

4. If there is ANY doubt regarding the use of thrust, consider using a trial of non-thrust, localized graded mobilization.

  • Begin short of resistance.
  • Assess the effect your technique has upon the patient’s symptoms.
  • Based upon clinical reasoning, start mobilizing into resistance as needed

                 --You can add force to your techniques when you know the effect more

                    gentle techniques have had on your patient.

 

Future Directions—A Call to Action

Clinicians, Researchers and Professional Organizations should recognize there are risks associated with cervical thrust, and consider supporting the following initiatives:

--Develop an accepted standardized methodology for analyzing risk

--Develop a methodology or mechanism for reporting adverse events

--Use standardized terminology

--Remember “Above all, do no harm� from the Hippocratic Oath

 

Cheers and Enjoy,

Chris R. Showalter PT, OCS, COMT, FAAOMPT 

 

© 2013 Chris R. Showalter and Maitland Australian Physiotherapy Seminars

Not to be reproduced, copied or retransmitted in any manner without author’s express written permission

Directing others to the MAPS website (www.ozpt.com) is permissible.

 

Where to find the Articles  

1. A prospective study of complications of cervical spine manipulation

Rivett DA and Millburn P, Journal of Man. Manip. Therapy 1996;4:166-170

 

2. The appropriateness of manipulation and mobilization of the cervical spine

Coulter ID, Hurwitz EL, Adams AH et al, 1996 RAND, Santa Monica, CA

3. http://www.ncbi.nlm.nih.gov/pubmed/8864967

Safety in chiropractic practice, Part I; The occurrence of cerebrovascular accidents after manipulation to the neck in Denmark from 1978-1988.

Klougart N, Leboeuf-Yde C, Rasmussen LR. J Manip Physiol Ther 1996;19:371-377

 

4. http://www.ncbi.nlm.nih.gov/pubmed/8976474

Safety in chiropractic practice. Part II: Treatment to the upper neck and the rate of cerebrovascular incidents.

Klougart N, Leboeuf-Yde C, Rasmussen LR

 

5. Stroke following cervical manipulations in Perth.

Haynes MJ. Chiropractic Journal of Australia 1994;24(2);42-46

 

6. A report on the occurrence of cerebral vascular accidents in chiropractic practice.

Carey PF. Journal of Canadian Chiropractic Assoc. 1993;37:104-106

 

7. http://www.ncbi.nlm.nih.gov/pubmed/8855459

Manipulation and mobilization of the cervical spine. A systematic review of the literature.

Hurwitz EL, Aker PD, Adams AH, Meeker WC, Shekelle PG. Spine (Phila Pa 1976). 1996 Aug 1;21(15):1746-59; discussion 1759-60.

 

8. http://www.ncbi.nlm.nih.gov/pubmed/9920191

Manipulation of the cervical spine: risks and benefits.

Di Fabio RP. Phys Ther. 1999 Jan;79(1):50-65

 

9. http://www.ncbi.nlm.nih.gov/pubmed/10222530

Risk factors and precipitating neck movements causing vertebrobasilar artery dissection after cervical trauma and spinal manipulation.

Haldeman S, Kohlbeck FJ, McGregor M. Spine (Phila Pa 1976). 1999 Apr 15;24(8):785-94

 

10. http://www.ncbi.nlm.nih.gov/pubmed/11599329

Arterial dissections following cervical manipulation: the chiropractic experience.

Haldeman S, Carey P, Townsend M, Papadopoulos C. CMAJ. 2001 Oct 2;165(7):905-6.

 

11. http://www.ingentaconnect.com/content/maney/jmt/2012/00000020/00000002/art0003

Safety of cervical spine manipulation: are adverse events preventable and are manipulations being performed appropriately? A review of 134 case reports

Puentedura, EJ; March, J; Anders, J; Perez, A; Landers, M; Wallmann, H; Cleland, J. J of Manual and Manip Therapy 2012;20(2):66-74


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