Cervical Manipulation… Is the Juice Worth the Squeeze? (Part 1)

Neck pain is a debilitating and all too common issue worldwide. According to a systematic review published by Cote et al, the annual prevalence of neck pain in Quebec City is 48%, 27% in Norway, and 34% in the UK. Subsequently, a limitation in activities of daily living was found in between 11-14% of individuals. An additionally alarming statistic is that 50% of these individuals who suffer from neck pain still have symptoms 12 months after onset. Silverstein et al looked at workers compensation claims in the state of Washington between the years of 1990 and 1998. According to their data, 40.1/10,000 full-time equivalents (FTEs) reported claims for soft-tissue neck pain. This same study found that 19.1/10,000 FTEs missed 4 or more days of work secondary to neck pain. This tells us that neck pain is anything but a ‘self limiting’ disorder, but what are we doing to treat these patients?

Treatment approaches differ between clinicians and professions, but many include various forms of exercise, pain modulation, soft-tissue mobilization, joint mobilization, and the ever controversial cervical manipulation…

Cervical manipulation is the staple of the chiropractic profession, but is also utilized by physical therapists, osteopathic physicians, and other healthcare professions. As beneficial as these manipulative techniques appear to be, they are constantly the focus of media and medical scrutiny, but is it warranted? According to Di Fabio et al, between the years of 1925 and 1997, there were 177 cases of serious injury and 32 mortalities associated with cervical spine manipulation (CSM). The most publicized and discussed adverse events come in the forms of Cervical Artery Dissection (CAD) or Vertebral Artery Dissection (VAD). Lee et al performed an epidemiological study attempting to determine the incidence and prognosis of CAD and VAD. The general incidence of VAD is only 0.97 per 100,000 and CAD was only slightly more common at 2.6 per 100,000 people. With such a low incidence, what is the general risk of causing a severe adverse event as a result of manipulation? There have been a few studies published in recent years with reported incidences of <1/5,000,000 manipulations (Jaskoviak et al), 1/50,000 (Gutmann et al), 1/383,750 (Dvorak et al), <1/518,886 (Patijn et al), 1/3,800,000 (Carey et al), and 1/200,000 (Haynes et al). In addition to these older studies, Gouveia et al conducted a systematic review of the literature from 1966 to 2007 and after review of 46 studies, they concluded the frequency of serious adverse events varied between 5 strokes/100,000 manipulations to 1.46 serious adverse events/10,000,000 manipulations and 2.68 deaths/10,000,000 manipulations. Just to clarify, these statistics do not mean that cervical manipulation CAUSED the adverse event, only that the adverse event was associated with a recent manipulation.

Common symptoms associated with VAD include headache and neck pain, so isn’t it reasonable to assume that these strokes are not caused by the aforementioned interventions, but that these patients are just more likely to seek care for their presumed musculoskeletal symptoms? Cassidy et al investigated just that hypothesis. They found that VAD in those < 45 years old was 3 times more likely when recently visiting a chiropractor OR primary care physician (PCP). In those patients > 45 years old, there was no association between a chiropractic visit and VAD, however there was an association between PCP visits and VAD. So are PCPs somehow causing their patients to have cerebrovascular events? Common sense would dictate that these associations are simply due to ‘at risk’ patients seeking help from those qualified to treat them, regardless of intervention. All this being said, could these adverse events be prevented or predicted?

In a thorough review of 134 case reports of adverse events following cervical manipulation, Puentadura et al tried to determine how many cases could have been prevented and under what circumstances the events typically occurred. Of the cases reported, chiropractors were the practitioners in 93 cases, osteopaths in 11 cases, non-clinicians in 9 cases, physical therapists in 5 cases, a naturopath in 1 case, and unknown practitioners in 15 cases. Chiropractors were involved in the vast majority of cases, but this is likely secondary to their increased utilization of CSM compared to other professions. After evaluation of each case, the investigators determined whether CSM was indicated or unnecessary and whether the event was preventable based on presence of contraindications and/or red flags. According to their data, 44.8% of cases could have been prevented had a thorough examination and history been taken. Additionally, of the 7 deaths included, 4 could have been prevented, 1 was unpreventable, and 2 were unknown (lack of adequate information within case report). At the most recent IFOMPT Conference in Quebec City, a document written by Rushton et al was created to provide a framework for pre-manipulative evaluation. The following lists are typical historical findings in those patients that should be contraindicated from manipulation or are at risk for disorders that may become worse following manipulation:

Contraindications:

– Multi-level nerve root pathology
– Worsening neurological function
– Unremitting, severe, non-mechanical pain
– Unremitting night pain (preventing patient from falling asleep)
– Relevant recent trauma
– Upper motor neuron lesions
– Spinal cord damage

Risk Factors of CAD:

– Past history of trauma to cervical spine / cervical vessels
– History of migraine-type headache
– Hypertension
– Hypercholesterolemia / hyperlipidemia
– Cardiac disease, vascular disease, previous cerebrovascular accident or transient ischaemic attack
– Diabetes mellitus
– Blood clotting disorders / alterations in blood properties (e.g. hyperhomocysteinemia)
– Anticoagulant therapy
– Long-term use of steroids
– History of smoking
– Recent infection
– Immediately post partum
– Trivial head or neck trauma
– Absence of a plausible mechanical explanation for the patient’s symptoms

Risk Factors of Upper Cervical Instability:

– History of trauma (e.g. whiplash, rugby neck injury)
– Throat infection
– Congenital collagenous compromise (e.g. syndromes: Down’s, Ehlers-Danlos, Grisel, Morquio)
– Inflammatory arthritides (e.g. rheumatoid arthritis, ankylosing spondylitis)
– Recent neck/head/dental surgery

Outside of the identification of contraindications and red flags through patient history and subjective interview, is there evidence to support the use of pre-manipulation physical evaluation in identifying or reducing the prevalence of adverse events? Carlesso et al conducted a survey of Member Groups and Registered Special Interest Groups within the IFOMPT trying to identify how often clinicians performed pre-manipulation Vertibrobasilar Insufficiency (VBI) testing. Of the surveys that were returned, 77% of respondents did perform pre-manipulative screening for VBI. Unfortunately, despite the prevalence of pre-manipulation physical examination, there may not be evidence to support its efficacy. According to Mitchell et al, the most provocative and reliable positional test for VBI is sustained end-range rotation. This test may be of benefit, however research is lacking regarding how predictive or how reliable this test actually is. This examination is meant to maximize the occlusion of the vertebral artery, but is this too intense for those ‘at risk’ patients? In my opinion, this test puts patients into a much more dangerous position than most manipulative techniques ever will. This test alone may stress the vertebral artery beyond its limit and may predispose patients to the condition we are attempting to screen for. In fact, a biomechanical study conducted by Herzog et al determined that vertebral artery strain was significantly higher during diagnostic and range of motion testing compared to high velocity, low amplitude cervical manipulation.

Cervical manipulation is an effective means to decrease pain and improve function in patients suffering from mechanical neck pain and, based on the current evidence, is a generally safe intervention. The incidence of adverse events is minimal and, through adequate screening and evaluation, most adverse events can be prevented. There is still an inherent risk, as 10.4% of adverse events were unpreventable (Puentadura et al), but as previously mentioned, these are only associations. Many of these cases may have simply been a case of individuals presenting with seemingly mechanical symptoms (neck pain and headache), but were truly demonstrated preliminary symptoms associated with CAD. The well-informed clinician will take into consideration the patient’s prior medical history, current symptomology, comorbid conditions, and physical examination findings prior to performing any intervention aimed at the cervical spine. Through the use of sound clinical reasoning and after taking adequate precautions, I do believe the juice is worth the squeeze and my next post will delve a little more into why.

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36 thoughts on “Cervical Manipulation… Is the Juice Worth the Squeeze? (Part 1)

  1. The International Federation of Orthopaedic Manipulative Physical Therapists (IFOMPT) mentioned in this blog is the largest subgroup of the World Confederation of Physical Therapists (WCPT). IFOMPT has been promoting Excellence in Orthopaedic Manipulative Therapy (OMT) for over 38 years. It is one of the few professional bodies that have an internationally agreed standards document that guides the curricula in the teaching of manual and manipulative therapy (see http://www.ifompt.org).
    The issue of both teaching and delivering high velocity thrust (HVT) techniques to the cervical spine is controversial particularly when the true risk of adverse events is unknown. Whilst the adverse events (stroke and vertebral artery dissection VAD) are significant, they are extremely rare events. The day to day issue for physical therapists who wish to use HVT in the management of cervical or any other musculoskeletal problems is based on a range of factors. IFOMPT has always promoted the philosophy that HVT is not a stand-alone treatment and is delivered within a continuum of care with ongoing monitoring and based on a sound clinical reasoning model. This point is clearly made in the reply by Kerry, et al (BMJ rapid response)[1]. A recent review of 134 case reports of adverse events from cervical manipulation has also indicated that approximately 45 % of these events could have been prevented had a more robust clinical reasoning process been applied during the patient assessment[2]. This would further support the idea that is patient selection that is important rather than the actual technique. Clinical reasoning is also strongly emphasised throughout IFOMPT standards document.
    Another aspect of delivering this treatment is the ability to provide the recipient of this technique with an informed choice based on the risks, such that they can consent (or not) to the procedure. This is a legal requirement with any health procedure. This is a challenge where the true risk of the modality is not known, but this can be overcome, firstly, with an honest appraisal of what is currently known about the risk, and secondly, by giving the recipient an idea of the relative risk.[3] This may be in the form of a comparison with other commonly used modalities to treat the condition. For example, Dabbs et al [4] in review of the literature and comparison to the use of NSAIDs for cervical pain, found a very low risk of injury with manipulation, compared to risk of adverse effects of taking NSAIDs. The likelihood of a serious gastrointestinal bleed from NSAIDs is 1 per 1000 and the death rate for NSAID associated GI problems is estimated at 0.04% per year among patients with osteoarthritis who receive NSAIDs, with 3200 deaths per year.[4] The estimated death rate from cervical spine HVT manipulations per treatment is 0.00025% or 160 times less frequent than the NSAIDs death rate. The estimated injury rate of NSAIDs induced bleeding ulcers requiring hospitalization is 400 times greater than the estimated injury rate from manipulation. It is reasonable to ask which has greater risk, traditional medical therapy or judiciously applied spinal manipulation in appropriate selected patients?
    There are many patients who seek the skills of a manual or manipulative physical therapist. These patients are looking for the most effective management of their musculoskeletal problem. Having a practitioner that has a range of skills on both thrust and non-thrust manipulative techniques provides the patient with greater choice. Delivery of manipulation in a clinically reasoned and informed way will always be the safe way forward rather than abandoning a single modality at a time where the evidence is still variable.

    The IFOMPT Executive Committee welcomes this type of debate and feels that a balanced view of the issues needs to be presented as we move forward.

    The Cervical Screen Document mentioned is availiable on the IFOMPT website at:
    IFOMPT Cervical Screen

    Erik Thoomes on behalf of the IFOMPT executive: Annalie Basson, Ken Olson, Duncan Reid, Laura Finucane, and advice and comment from Tim Flynn.

    References
    1. Kerry, R, Taylor, A, Rushton, A, McCarthy, C and Mercer,C http://www.bmj.com/content/344/bmj.e3679/rr/588701
    2. Puentedura, E., March, J.,Anders, J., Perez, A.,Landers, M., Wallman,H., and Cleland, J. Safety of cervical spine manipulation: are adverse events preventable and are manipulations being performed appropriately? Journal of Manual and Manipulative Therapy 2012, 20 (2) 66-74
    3. Culy, R., Reid, D. A., & Diesfeld, K. Cervical spine manipulation, a procedure with a rare but potentially serious adverse reaction: Exploring the ethical dimensions in the New Zealand context. New Zealand Journal of Physiotherapy, (2011). 39(3), 114-121.
    4. Dabbs, V and Lauretti, W. A risk assessment of cervical manipulation vs. NSAIDs for the treatment of neck pain. Journal of Manipulative and Physiological Therapeutics (1995), 18(8):530-6

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    1. Erik,

      Thank you for commenting on behalf of the IFOMPT Executive Team. The additional resources and statements are appreciated and complement the points that I wanted to get across in my original post. Cervical manipulation, in my opinion, has been made into something that it is not. There are inherent risks, but there are risks with almost any intervention that any healthcare provider implements. Your comparison of manipulation to NSAIDs is one that I believe more of the general public need to know and understand. Cervical manipulation is an easy target mostly because when something happens, it happens almost instantaneously and in situations like this, the blame has to be placed somewhere. However, in the case of adverse reactions to NSAIDs, the complications come on slowly and are almost never associated with one specific event.

      Skilled manual therapy is effective and generally safe when applied to the cervical spine. After sound clinical reasoning is applied and after taking into consideration all contraindications or risk factors present for VAD, cervical manipulation should be implemented by those capable if it is indicated.

      For anyone interested in manual therapy of this region, please take the time to read the Cervical Screen Document posted by Erik. It is a fantastic resource.

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      1. Yes, comparing the use and risk of manipulation vs. NSAIDs is a legitimate, useful comparison. The question then becomes is the risk benefit profile for manipulation superior to that of NSAID’s? AND, is manipulation directly more effective when compared NSAID’s? The adverse event profile for NSAID’s is broad, and at the more severe end of the spectrum lives GI bleeds, ulcers, and liver dysfunction. But, I still think the risk of a temporal association (correlated, accelerated, or directly caused) of cervical spine manipulation with stroke (and at times stroke leading to death) is still too large to claim that cervical manipulation is “safer” than NSAID use. The worst case scenario is much worse. Further, the comparison would have be done in a way were only data from individuals using NSAID’s for neck pain (or patients who would seek or received neck manipulation) was utilized.

        To justify widespread use, cervical spine manipulation would have to show robust efficacy (Efficacy vs. Effectiveness) in clinical trials when compared directly to other physical therapy interventions and to other medical interventions (NSAID’s, surgery). Further, the overall likelihood of risk and severity of adverse events would need to be low enough when compared to those other interventions to justify tolerating the risk of a arterial dissection/stroke.

        For example, someone stating cervical manipulation may prevent surgery to justify it’s use is flawed as a direct line of reasoning. It would be very hard to illustrate that manipulation in isolation directly prevents cervical spine surgery. Manipulation is a product (thank you Jason Silvernail for this distinction), whereas the delivery of skilled manual and physical therapy is a process leading (hopefully) to a successful outcome.

        Lastly, is manipulation even the most efficacious treatment intervention, process, or product based upon what we know about pain generally, and the treatment of neck pain specifically? Is there a strong logical argument for it’s use regardless of risk profile? Currently, taking into account risk profile and investigations comparing it to other interventions can we justify using at all?

        For comparative outcomes research in the global healthcare world we should focus on evaluation, treatment, and care by a physical therapist based on the best reasoning and evidence against some of these other medical interventions. Why would we want to compare ONE physical therapy intervention to a medical intervention? While we may illustrate (or not) efficacy in a clinical research environment, those investigations tells us little of the effectiveness when applied in real world clinical scenarios.

        Specifically within the physical therapy realm we should focus on which processes, interactions, and intervention strategies are most efficacious, and then move on to develop broader clinical trials of the effectiveness of physical therapist best practice.

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  2. John, this is a great article, that involves a lot of work/research, and we thank you for that. Totally supportive of most of your statements with still a question regarding your final decision to go for it . I mean, a lot to prove yet to justify not doing it, but a lot of questions and associations around it , to openly favor doing it. Stanley Paris in his C.E. classes emphasize the testing of VA prior to suboccipital manipulation , expressing that there will be no justification if an incident occurs and no testing was performed. A quick comment regarding the strain to the artery during diagnostic and range of motion testing.; strain is not always associated with lesion/injury. Couldn’t this be the case to justify straining to avoid a lesion? Conclusion: manipulation of Suboccipital region may have a place considering all risks and precautions were considered, but isn’t VA testing part of it? Just thinking loud!!

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    1. Thank you very much for your reply. At this point, VA testing definitely has a place… I just wanted to get across the fact that a negative VA test battery does not necessarily mean that they are cleared for CSM. Based on the evidence, our best indication regarding screening prior to manipulation comes from the patient’s past medical history, current comorbidities, and current symptomology. I use and will continue to use VA testing based almost solely on the reason Dr. Stanley Paris stated. Even with the rare occurrence of adverse events, more research must be done to develop more sensitive screening tests.

      And please speak out loud whenever you feel like it!

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  3. “Cervical manipulation is an effective means to decrease pain and improve function in patients suffering from mechanical neck pain and, based on the current evidence, is a generally safe intervention. The incidence of adverse events is minimal and, through adequate screening and evaluation, most adverse events can be prevented. There is still an inherent risk, as 10.4% of adverse events were unpreventable (Puentadura et al), but as previously mentioned, these are only associations.”

    I think the effectiveness and efficacy of cervical manipulation vs. other physical therapy interventions/processes is still very much in question. Info about effectiveness vs. efficacy: http://www.amhd.org/cebp/concept3.html

    Also, via Dr. Jason Silvernail, DPT, DSc, FAAOMPT recommends the following foundational studies: http://www.somasimple.com/forums/showpost.php?p=138624&postcount=66
    1. http://www.ncbi.nlm.nih.gov/pubmed/12356613
    “Cervical spine manipulation and mobilization yield comparable clinical outcomes”
    2. http://www.ncbi.nlm.nih.gov/pubmed/18923311
    –Full Text: http://www.alliance-rehabilitation.com/wp-content/themes/alliance/files/cervical/Treating%20Mechanical%20Neck%20Pain.pdf
    3. http://www.ncbi.nlm.nih.gov/pubmed/20195023
    “Clinically meaningful and statistically significant improvements in both subgroups of patients over time suggest that cervical thrust manipulation, as part of the MPT treatment plan, did not influence the results of the treatment arm of the larger RCT from which this study was drawn”
    4. http://cdn.bodyinmind.org/wp-content/uploads/Arch-Phys-Med-Rehabil-2010-Leaver.pdf
    “The median number of days to recovery of pain was 47 in the manipulation group and 43 in the mobilization group. Participants treated with neck manipulation did not experience more rapid recovery than those treated with neck mobilization.”

    With recent evidence suggesting that it is likely not the product (i.e. manipulation) that it is important, why would we risk it? A few nice RCTs illustrated that manipulation (high velocity, thrust techniques) and mobilization result in similar outcomes (http://www.ncbi.nlm.nih.gov/pubmed/1469341, http://www.ncbi.nlm.nih.gov/pubmed/12356613). Further, a recent RCT comparing kinesio tape to cervical manipulation found no significant differences between groups (http://www.ncbi.nlm.nih.gov/pubmed/22523090). Cochrane Review here: http://www.ncbi.nlm.nih.gov/pubmed/20510644.

    Sure, every intervention has risk. But, I think physical therapists are not doing an appropriate job of performing risk analysis. There are two distinct comparisons that must be made in physical therapy. The risk of an intervention (or package or approach) vs. other physical therapy interventions. This would be mobilization vs. manipulation. If one is not robustly and definitively a better option, but has an increased risk profile (manipulation) than the less risky/invasive measure should be untertaken. This is even true if the risk profile is only slightly higher. In the case of manipulation we do not know the true risk profile. And, the risk is not of slowed recovery or soreness, but potentially a dissection or stroke! We can not tolerate that type of risk in our practice without significant significant improvements in outcome or else it is not worth.

    The second comparison is of that physical therapy treatment to other medical interventions. Yes, this is a useful comparison when discussing global health policy and healthcare flow. But, without the first analysis this analysis can NOT be the basis of your decision making. Almost all PT interventions have less risk than almost any medical intervention for the same condition. Thus, we need to be very disciplined in how we assess and integrate risk analysis into our practices and professional discussions.

    Resources:
    http://www.sciencebasedmedicine.org/index.php/neck-manipulation-risk-vs-benefit/
    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2271098/
    http://www.ncbi.nlm.nih.gov/pubmed/22523090
    http://www.ncbi.nlm.nih.gov/pubmed/20510644

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  4. Obviously, performing a tightly controlled prospective study of adverse events is not only unfeasible, but not ethical.

    The question is are neck manipulations causing or correlated with dissections and strokes? Although, the correlation argument may be accurate I think that is not analyzing the situation appropriately enough.

    That being said, there are likely 3 distinct scenarios happening when a neck manipulation “correlates” with a stroke.

    1. Active or developing dissection or stroke is correlated with neck manipulation
    In this instance, a patient with neck pain, headaches, or other symptoms presents to a practitioner and receives a cervical manipulation. The manipulation did not cause nor further the dissection or stroke.

    2. Active or developing dissection or stroke is worsened, exacerbated, or accelerated with neck manipulation
    In this instance, a patient with neck pain, headaches, or other symptoms presents to a practitioner and receives a cervical manipulation. The patient is actively in the process of a developing dissection or stroke. The manipulation did not cause the dissection or stroke, but accelerates or worsens it.

    3. Dissection or stroke is caused by neck manipulation.
    Patient has neck pain, neck is manipulated. Dissection and stroke are direct result of the manipulation.

    Hypothethical > In my opinion, even if scenario 1 and 2 were the only possibilities AND we knew for sure that cervical manipulation never caused a dissection or CVA, the risk of accelerating or worsening a dissection is too high in comparison to it’s effectiveness to justify the intervention. I think this stance can be supported by Cleland et al’s paper investigating adverse events with c-spine manip and the fact that even with proper screening you can’t eliminate all risk. Further, the trials comparing it directly to other interventions raises the question “Why risk it? EVER?” when we know other “interventions” including generic KT taping are likely equally efficacious?

    Lastly, it seems our profession has misunderstood risk vs. benefit analysis. Sure, comparing cervical manipulation adverse event types and adverse event rates in relation to other MEDICAL interventions is tempting. And, sure, it does hold some value for comparing intervention risks, benefits, and efficacy within the spectrum of care and the overall medical field (NSAIDs, opiates, surgery, conservative measures, etc). But, within our profession we should be comparing the risk, invasiveness, and benefit of our interventions to other interventions we use (both generally and for that specific condition/complaint). On the grounds of efficacy, risk, and reward when compared to our other interventions specifically for neck pain, I can’t understand an argument for cervical manipulation. Further, when taking into account the training cost and time it takes for most to become competent and comfortable, it does not make sense to advocate for this intervention.

    Kyle Ridgeway, DPT
    @Dr_Ridge_DPT
    PTthinkTank.com

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  5. Also, just for reference so we are all meaning the same things when using words:
    Effectiveness vs. Efficacy: http://www.amhd.org/cebp/concept3.html
    The role of efficacy and effectiveness trials: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2645005/
    Efficacy via Wikipedia: http://en.wikipedia.org/wiki/Efficacy

    In short efficacy illustrates benefit in a very tightly controlled study design that answers the question (generally): does this intervention work? (compared to placebo or other interventions). This is performed in the best of conditions. It is meant to have high internal validity and control.

    Effectiveness answer the question (generally): does this intervention work in real world, clinical scenarios (vs placebo or other interventions)?

    Drug trials are an easy example. Two separate drugs for hypertension. Drug X you take 3 times a day, Drug Z you take one a day. Drug X may be more efficacious. In other words, in a tightly controlled trial when people actually take it, it works best. But, in a real world clinical trial Drug Z is more effective. The reasons that an intervention may be efficacious, but than lack effectiveness are complex.

    In the case of cervical manipulation the effectiveness trials continue to illustrate that it provides no additional benefit over other far less risky, and even completely different interventions (KT tape).

    So my question is: Why do we still view it as effective, regardless of risk?

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  6. Hi John

    good work and thanks for sharing. As has so eloquently been outlined by the commenters the questions is really “what therapeutic benefits does manipulation have over other techniques without the risk profile.”?
    I can still remember the joy of learning and delivering “thrust techniques” almost 25 years ago now. However, is silll remember the distinct lack of clarity in when to select their use and I confess I rarely use them in clinic now..

    On a second note – as I have always understood anyway – the principal of VA Testing is based on the premis of circulatory occlusion (which has been verified in at least some doppler blood flow studies) as a result of external (osteophytic impingement / narrowing).

    Whilst this is one possible mechanism if we consider the pathology of vertebral artery disection this is primarily an internal event within the deepest arterial layers. This raises the question of whether external compression is the underlying mechanism or a whole myriad of other possibilities not tested with the current VA protocols.

    Here is a link to a lecture on this topic http://www.physiodigest.com/lec/VA/player.html

    David

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  7. Thank you everyone for your comments and resources. I apologize for my delayed response… I have been a little preoccupied studying for my pharmacology mid-term (not sure how anyone can stay awake long enough to get their pharmD).

    Cervical manipulation is a topic that many are very passionately supportive or critical of, and understandably so. However, I think the topic needs to be further researched and conceptionalized before a solid stance can be taken.

    Spinal manipulation, in general, is not a stand alone intervention and is not appropriate for every patient with a given diagnosis. The management of LBP has evolved to a point that specific sub-grouping has begun to emerge. With this sub-grouping, therapists are better able to select patients that will benefit from specific therapeutic techniques. This is something that is lacking in the cervical spine.

    Most of these references that discredit cervical manipulation apply the technique to any patient presenting with neck pain. Obviously, there are some that will respond and there are some that will not. Puentedura et al (http://www.ncbi.nlm.nih.gov/pubmed/22585595), recently began the development of a CPR to identify patients who will respond favorably to manipulation… I believe this is a huge step in the right direction. When this is coupled with the CPR developed for thoracic spine manipulation (http://www.ncbi.nlm.nih.gov/pubmed/21335931) and the preliminary Treatment-Based Classification (http://www.ncbi.nlm.nih.gov/pubmed/17142640), it further increases our odds of selecting the appropriate interventions on a patient by patient basis. The key to improvement of clinical outcomes with regards to neck pain is the continued progression of these classification systems. This is all part of the clinical reasoning process and to eliminate a intervention that is appropriate for your patient may be counterproductive.

    While mobilization and manipulation have provided similar results in a few well-done studies, I still believe there is a place for manipulation… It is not and never should be an all or none approach. Generally speaking, when treating the cervical spine for a patient who demonstrates the need for manual therapy, the therapist should take the path of least resistance. Application of thoracic manipulation precedes mobilization to the cervical spine, which precedes manipulation of the cervical spine. There is no place for mindless manipulation or ‘maintenance’, however I believe there are still patients that benefit from HVLA v. joint mobilization. The application of the appropriate CPRs, interpretation of physical examination and historical findings, and understanding of patient expectations/beliefs should help you guide your treatment approach.

    For those that have eliminated HVLA techniques at the cervical spine, what was the ‘tipping point’ that led to this decision?

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    1. For cervical spine..

      1 Lack of demonstratable improvement over othe techiques.
      2.Unpredictability of patients response (emotional rather than mechanical.
      3.Potential risk

      With the exception of patients who ask for thrust techniques (for a hole myriad of reasons) I will oblige.

      The predominance of my caseload is chronic spinal pain (meaning recurrent , episodic , mechanically mediated rather than “chronic pain syndrome” and which I don’t this is adequately distinguished in the literature. A significant proportion of the cervical element of this group report initial positive response to Chiropractic manupulation in the early evolution of their condition with a gradual progression of increasing treatment frequency, reduced effect to eventually provocation and adandonment.

      This observation has propably clouded my judgement.?

      I have yetto see a convincing list of selection criteria that differ in any menaingful way from indications for mobilisation.

      I won’t detract from your studies any furthur John – pharmacology will demand all powers of concentration!

      David

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    2. John,
      I pretty much agree with David, but I would add one key element with a reference to one of the largest clinical trials to date on neck pain. The M.I.N.T. study out of Australia (see Williamson E. et al) found that the best predictor a poor outcome following a whiplash injury was the lack of confidence that the condition would be better in 6 months. Physical findings, e.g. ROM, initial pain level or even fear-avoidance beliefs were good predictors of a poor outcome. The “moral of that story”, in my view, is that self-efficacy plays a key role in recovery from persistent mechanical pain problems.

      The nature of spinal manipulation seems to be diametrically opposed to building a patient’s self-confidence and internal locus of control. Sure, adding other interventions like education and exercise can help to build patient confidence, but I don’t think that should provide an excuse for doing another intervention, in this case HVLA technique, that detracts from internal locus. It just doesn’t make any sense to me. Spinal manipulation techniques are fraught with pitfalls that can feed into a patients erroneous ideas of what happens when they are manipulated, no matter how you try to mitigate that with education.

      Why even go there, particularly given that you can’t effectively screen for a potentially- albeit rare- catastrophic event?

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  8. John,
    This has been a great discussion, with some excellent input from a lot of very well read individuals. Thank you for spearheading this discussion, and touching on one of the more virulent topics in our profession. So many major points have already been made, so hopefully i’m not too repetitive in my points.

    Truly, this discussion always bothered me while I was in school learning about manipulation, and learning how to perform manipulation. I’m now currently involved in teaching manipulation to the next generation of DPT’s, and I find myself challenged to answer the famous question in class : do you use cervical manipulation in your own practice?

    1) Yes. Sparingly. After very thorough subjective screening which excludes ALL potential risk factors, full physical examination, and negative pre-manipulative testing.

    Why not mobilize first? or as stated above, why manipulate at all?

    This skill inherent in delivering manipulation has some to do with motor skills of the therapist, their positioning of the patient, and thorough understanding of the anatomy they are trying to effect. (Therefore, if you didn’t learn manipulation in school, continuing education until you feel confident is a must.)

    However, I truly believe the “Skill” that we offer as manipulative therapists is knowing WHEN to manipulate. This comes purely from reasoning.

    This requires having a firm understanding in all of the potential risk factors (not just being able to identify them, but also hypothesize on why they might occur). It also requires a very firm understanding in what the literature on this subject is currently saying, or not saying.

    As was outlined above in Kyle Ridgeway’s posts, the inherent risk of manipulation has not yet been adequately established.

    There are those that would argue the incidence is currently under reported- that the numbers we have barely represent the actual incidence. I would argue that based on the current literature out there, there have not been enough studies performed with good enough metrics to represent any numbers that we can use. There have been numbers published ranging anywhere from 1:100,000, to 3: 1mil. That’s a huge range. And one must remember that these numbers are representing a population the study is projected to represent. Most of the studies that have tried to report incidence are reporting in other countries-which have any number of techniques represented by “manipulation”, over smaller population bases vs. our country. This alone disqualifies my trust in the use of incidence numbers as an indication that CAD adverse events with manipulation is common.

    This does not mean I dismiss the potential that the incidence could be more than what we are currently estimate; it simply makes me aware that there could also be the potential that it is less frequent than we are currently reporting. In essence, we are going on theory, and overly protective common sense: if there is the potential for injury, don’t do it. All we know right now is there is some potential. We don’t know how MUCH potential. The point has not yet been clearly proven for it to dismiss my use of the technique.

    There are also those that would state the people who have an adverse event, already had some sinister process underway, that was then made worse by the manipulation.
    The studies that I have come across have mentioned a long list of medical risk factors that can help you identify patient’s more likely to have an adverse response. This is still theory, because there is no safe way to study the effectiveness of identifying these factors as “saving you” from an adverse reaction. As Kyle pointed out, it would be unethical to try to study this: one person identified as high risk, no manip. Other person identified as high, manip. No one would think to do that, so with out being able to put the question through the thorough process of scientific inquiry like we want to, we have to rely on sound reasoning.
    In my mind, this equates to “since we can’t prove that these people with risk indicators won’t have an adverse event, we should consider mobilization first.” And so the pendulum swings the other way.

    Someone above had offered up CAD being an issue of occlusion detectable with doppler US, however the use of doppler ultrasound has not yet been validated for screening these patients prior to manipulation. The tool has not been found to be specific or sensitive enough to detect blood flow changes; however there are a lot of things that could be done in the research world to improve understanding of Doppler, starting with performing it on patients with known occlusions. Performing a test on healthy subjects is hardly representing the population that you hope to target when using the tool clinically.
    Here in lies the issue: if we can’t effectively find out who DOES have an occlusion without the use of the gold standard MRA, and the incidence of preexisting CAD is low, how do we recruit for this study. Then, lets just pretend we gather up enough of these people for a properly powered study, how do we ethically justify testing a pre-manipulative position to check a change in blood flow when the hypothesis is such that this may cause an adverse event by causing occlusion?

    So again, the point is: the risk and efficacy of manipulation has not been accurately identified. Due to the challenges posed to researchers in this field and the limited amount of good quality studies available currently, we need another generation of inquisitive minds to pursue this issue further. In the mean time, we are left to our clinical reasoning skills, our experience, and our base understanding of the current literature, and foundational knowledge to make a decision for our patient.

    Is the juice worth the squeeze?

    Famous words of PT instructors everywhere: It depends.

    I think it is too soon to dismiss the use of a potentially effective tool until more has been published on this topic across the board.

    I’ve included all resources below that support my current line of thought on this issue, but of course welcome any input that this discussion group would add to improve everyone’s understanding of this complex issue, including my own.

    Sarah H. Stuhr, PT, DPT

    Rivett DA. The vertebral artery and vertebrobasilar insufficiency. In: Boyling J, Jull G, eds.Grieve’s Modern Manual Therapy. 3rd ed. Edinburgh, EK. Churchill Livingstone, 2005.

    Kerry R, Taylor A, Mitchell J, McCarthy C, Brew J. Manual therapy and cervical arterial dysfunction, directions for the future: A clinical perspective. The Journal of Manual & Manipulative Therapy. 2008:16(1);39-48.

    Rivett DA, Shirley D, Magarey M, Refshauge K. Clinical guidelines for assessing vertebrobasilar insufficiency in the management of cervical spine disorders. Australian Physiotherapy Association. 2006.

    Cagnie B, Barbaix E, Vinck E, D’Herde K, Cambier D. Arherosclerosis in the vertebral artery: an intrinsic risk factor in the use of spinal manipulation?. Surg Radiol Anat. 2006;28:129-134.

    Asavasopon S, Jankoski J, Godges J. Clinical diagnosis of vertebrobasilar insufficiency: Resident’s case problem.J Orthop Sports Phys Ther.2005;35:645-650.

    Hutting N, Verhagen AP, Vijverman V, Keesenberg MDM, Dixon G, Scholten-Peeters GGM. Diagnostic accuracy of premanipulative vertebrobasilar insufficiency tests: A systematic review. Manual Therapy.2012;1-6.

    Childs JD, Flynn TW, Fritz JM, Piva SR, Whitman JM, Wainner RS, Greenman PE. Screening for vertebrobasilar insufficiency in patients with neck pain: Manual therapy decision-making in the presence of uncertainty.J Orthop Sports Phys Ther. 2005;35:300-306.

    Carlesso L, Rivett D. Manipulative practice in the cervical spine: a survey of IFOMPT member countries.Journal of Manual and Manipulative Therapy. 2011;19(2):66-70.

    Arnold C, Bourassa R, Langer T. Stoneham G. Doppler studies evaluating the effect of a physical therapy screening protocol on vertebral artery blood flow.Manual Therapy. 2004; 9:1-21.

    Caplan, LR. Dissections of brain-supplying arteries.Nature Clinical Practice Neurology.2008;4:34-42.

    Taylor AJ, Kerry R. A ‘system base’ approach to risk assessment of the cervical spine prior to manual therapy. International Journal of Osteopathic Medicine. 2010;13:85-93.

    Borgman CJ. Horner syndrome secondary to internal carotid artery dissection after a short-distance endurance run: A case study and review. J Optom.2012;(5) 4:209-216.

    Kerry R, Pope D. PE #013 Cervical Spine Arter and VBI testing with Roger Kerry. Multimedia podcast accessed at: .n Accessed: January 8, 2013.

    Rushton A, Rivett D, Carlesso L, Flynn T, Hing W, Kerry R. International framework for examination of the cervical region for potential of cervical arterial dysfunction prior to orthopaedic manual therapy intervention. IFOMPT. 2012. Accessed online at :http://www.ifompt.com&gt; searched under Research/Docs.

    Culy R, Reid DA, Diesfeld K (2011): Cervical spine manipulation, a procedure with a rare but potentially serious adverse reaction: Exploring the ethical dimensions in the New Zealand context. New Zealand Journal of Physiotherapy.2011;39(3):116-123

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  9. Sarah,
    I think you’re missing Kyle’s point about risk associated with manipulation by referring to his acknowledgment of the inability to ethically study this in clinical trials. The fact of the matter is that catastrophic events are, in certain if not most instances, unpredictable. So the issue is not how often an adverse event occurs- we know that they occur- the issue is we can’t predict a potentially catastrophic adverse consequence from performing this intervention on a patient, who came to us for treatment of their neck pain.

    Take a look at some of the epidemiological research on incidence of hypoplastic vertebral arteries and their relationship to posterior circulation strokes (e.g. Park et al 2007). This knowledge alone should have any clinician asking himself, “Why should I manipulate the neck at all given that the only way to identify one of these (other than post-mortem autopsy) is via arteriogram?” Who’s routinely doing arteriograms on patients prior to manipulation? Even if we could, would it be cost-effective? Probably not.

    So, I think we’re asking the wrong question. We should be asking “Why manipulate at all?” not “Are the risks minimal with this particular patient?” We already know the risks are minimal- it’s the magnitude of the unpredictable potentially catastrophic outcome that should sway us from doing this intervention on anyone, in my opinion.

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    1. I agree John. I think the clinical reality is that physiotherapists feel vindicated when they have followed the protocol – and whilst it may be enough to protect us of negligance (at least in this durisdiction) is scant consellation for the patient!
      I think the lack of reliability of the test (if that’s the right statistical phrase)superseeds any “well meaning” motives of the healthcare professional tyring to help.
      I would confess to not normally taking too radical a view on technique abandonement on the basis of literature alone but I think this is one situation where “winging it” is not ethically or professionally justified.

      Unfortunately, I have had to ajudicate on these issues several times in my career as an expert witness (not caused by my own hand!!!) and have dealt with the “modest aftermath” of adverse manipulative advents – dizziness, nausea, tinnitus, blurred vision lasting several weeks and that’s not something I rush to repeat.

      Lastly, and I would urge students to ponder this again, “is there even a theoretical model describing Indications for Cervical Thrust Techniques” that differs in any meaningful way from other manual techniques?

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  10. Cervical manipulation has inherent risks, regardless of the probability, I believe this is something we can all agree on. However, almost any intervention that a physical therapist, chiropractor, or physician utilizes will have similar risks. Some interventions may be ‘safer’ than others, but there is always risk and identifying these patients demands the use of biologically plausible tests/measures and sound clinical reasoning. For example, while physical activity and many times aerobic exercise is included in our plan of care without worry, there are still risks (albeit very low). Whang et al determined the likelihood of exertion-related and sudden cardiac death to be 1/1,510,000 in men and 1/36,000,000 in women. Take into consideration that these proportions are only taking into consideration SUDDEN DEATH and not necessarily ‘adverse events’. Should we eliminate aerobic training with our clients/patients based on these risks? I am hoping you will agree this would be a little absurd. No matter how benign or safe an intervention appears, there will always be risk, but this should not prevent us from utilizing said intervention. Yes, the adverse events associated with cervical manipulation are typically debilitating for the affected patients, but as I have continued to preach, solid clinical reasoning, use of potentially sensitive tests, and a thorough subjective interview/medical history coupled with continual reassessment should all but eliminate any likelihood of an adverse event (regardless of intervention). Based on the uncertainty that may go along with cervical manipulation, I can completely understand clinicians who abandon these techniques in favor of less ‘invasive’ techniques, but I am not ready to write it off this early in my career.

    I agree that joint mobilization should be used as your primary means of manually treating neck pain. Several recent studies have shown similar outcomes when manipulation and mobilization were compared and this should put mobilization at the top of the list for most clinicians. However, what about those patients that do not respond to other interventions? There are those patients that need to be manipulated, whether it be due to some underlying neurophysiological mechanism or simply that they achieve a superior psychological response following manipulation. If you look at Puentedura’s CPR, the most sensitive variable associated with improved outcomes was “Positive expectation that manipulation will help”. I do not think that was a coincidence.

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  11. I see where your comming from John. Your parting words are central to every clinicians dilemma (and probably worthy of a separate discussion. Conforming / complying with patient’s expectations is a continual challenge which frequently presents a barrier to implementation of EVP. Contrary to the perpetual clamour about changing beliefs / attitudes and all the other psychosocial variables we have become famaliar with it is dependant on a collaboative dynamic.
    As in so many facets of human interaction this can be a laborious dwarn out affair with an uncertain outcome – even if well intentioned!
    David

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  12. John,
    I think you’re making a straw man argument with the comparison to aerobic training. The understanding of the mechanisms involved, the explanatory model and the overwhelming evidence of benefit from aerobic training all far exceed the paltry evidence supporting cervical manipulation.

    Your statement about being able to “all but eliminate any likelihood of an adverse event” simply isn’t borne out by the evidence. Kyle cited the study which found that 45% of adverse events were preventable, but that means 55% weren’t! So, an ability to reduce adverse events by about half is equivalent to “all but eliminate”? I disagree with your math.

    Current evidence supports mobilization as being at least as effective as manipulation, AND there is virtually no risk of a catastrophic event from cervical mobilization. When this is considered along with the lack of understanding of the underlying mechanisms of manipulation, I can’t see how any science-based clinician can justify performing this procedure on any patient ever.

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    1. John, I am not remotely interested in dialectics. The evidence and common practice do not justify a “all thrust manipulation to the cervical spine is dangerous” belief, therefore completely eliminating it from my treatment options is unfounded, especially if there is a yet to be discovered subgroup. Furthermore, there is a sound body of knowledge indicating the majority of a thrust manipulation’s effect comes from a neurophysiological mechanism. As such, the need to “lock down” the joint in near end-range positions prior to thrust manipulation is questionable. I have personally used thrust manipulations near R1 allowing for both decreased pain and subsequent corrective exercise. I will use test-retest, patient values and my own interpretation of the evidence to guide my practice. Your opinions are welcome but your “holier than thou” judgements are not.

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      1. “Holier than thou judgments”? Where are those?

        A “neurophysiological mechanism” does not constitute a deep explanatory model, in my opinion. If there’s no deep model/developed theory, then the prior plausibility to justify the intervention is lacking- that is, if you are using science to guide your clinical reasoning. Outcomes evidence is important- and very seductive, but it does not encompass all of scientific discovery, in fact it covers a very small bit of it.

        There is no deep explanatory model to guide the clinical decision to use spinal manipulation. There just isn’t. Therefore, if another intervention has been shown to be as effective in well-designed outcomes studies AND it poses less risk of harm (not to mention the possibility of catastrophic harm with cervical SMT), then it should be the preferred intervention.

        That is my judgment of the evidence, not of you or John personally.

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    2. John,

      My comment regarding holier than thou was directed at the following “Current evidence supports mobilization as being at least as effective as manipulation, AND there is virtually no risk of a catastrophic event from cervical mobilization. When this is considered along with the lack of understanding of the underlying mechanisms of manipulation, I can’t see how any science-based clinician can justify performing this procedure on any patient ever.” I have read every article I know of pertaining to this topic and teach on the subject. In addition to MWM, MET and mobilization, I use these techniques. Based on your comment, you atack the basis of my scientific understanding and therefore implementation of the literature. I think open discussion of the known and extremely weak evidence (and research methodology) behind any statement made on the topics of manipulation and arterial dissection should be had prior to declaring others’ competing interpretations unjustified and lacking of scientific understanding.

      I am not entirely sure which well designed outcomes studies you are referring to, but if they are Leaver et al and Hurwitz et al I would suggest another look. There is a higher percentage of males in the manipulation group in the Leaver study (poor randomization), and, while containing a sizable sample, the Hurwitz study includes a wide amount of variation in pretty much every demographic measure. While the variation is overly equal between groups, this negates any measure of a possible effect of/on a subgroup due to the inherent heterogeneity of the entire sample. As such, I cannot call either of these studies well designed based on the increasing efficacy of sub-classification. Further work in subgrouping/sub-classification is needed to decrease heterogeneity in these studies before we can difinitively state all is equal or not. In my opinion, the jury is still out.

      Regarding risk, at present the is strongest evidence is for a temporal relationship to manipulation and dissection. There is no evidence for a cause and effect relationship. This is best defended by the work of Cassidy and the known prevalence of headache and neck pain in this population. A very real question is whether or not the patient is already suffering from a dissection prior to seeking manipulative intervention. Of note, I am unaware of any manual therapy study comparing manipulation and mobilization with a recorded vertebral artery dissection event (let alone one that assesses for the presence of dissection prior to initiation of the experimental interventions). This all demonstrates a very weak argument for the complete dismissal of an intervention that has extremely small risk on serious adverse event to begin with.

      With regards to a deep explanatory model, there is not a single treatment in physical therapy that is supported by such. The problem that arises is that the outcome of any treatment has minute physiological and undetermined psychological mechanisms (as pertaining only to our input on the patient’s psyche) and that the consciousness/expectation/values of the patient determine the resultant effect. I am of the belief that we are in agreement on this latter topic, but am unsure of your stance on the former.

      Speaking to outcomes evidence, this is the only subject to which patients are interested in. I am just as interested in finding out the “why” behind our interventions as anyone else within our profession, but the patients are interested in the “how”. Given I would not have a profession without patients, I am forced to focus on the “how” in the present while striving to understand the “why” in the future.

      John, I am completely comfortable with agreeing to disagree on this subject and hope you have not interpreted any of my comments as anything other than healthy debate.

      1. Leaver AM, Maher CG, Herbert RD, et al. A randomized controlled trial comparing manipulation with mobilization for recent onset neck pain. Archives of Physical Medicine and Rehabilitation. 2010;91(9):1313–1318.
      2. Hurwitz EL, Morgenstern H, Harber P, Kominski GF, Yu F, Adams AH. A randomized trial of chiropractic manipulation and mobilization for patients with neck pain: clinical outcomes from the UCLA neck-pain study. Am J Public Health. 2002;92(10):1634–1641.
      3. Cassidy JD, Boyle E, Côté P, et al. Risk of vertebrobasilar stroke and chiropractic care: results of a population-based case-control and case-crossover study. Journal of Manipulative and Physiological Therapeutics. 2009;32(2 Suppl):S201–8.

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      1. Kevin,
        You neglected to cite Walker et al and then the secondary analysis from that study by Boyles et al, which Kyle cited in his earlier post in this thread. Taken with the studies that you cited above, we have strong outcomes evidence that cervical mobilization is as effective as thrust techniques. Given that, do you still maintain that the evidence demonstrating that these interventions yeild comparable results is insufficient, flawed or weak? That’s four RCTs published in peer-reviewed journals.

        Regarding sub-grouping with respect to musculoskeletal pain problems- I suggest that that evidence is weak on a theoretical level because the sub-grouping literature assumes causal, biomechanical mechanisms for persistent pain in at least certain categories, i.e. lack of joint motion (mobilization category), exessive joint motion/lack of motor control (stabilization category),(I won’t even mention the “traction” category because that has been all but jettisoned). The directional preference category is the only one that does not at least imply causality; although, there are some advocates of MacKenzie’s old disc model that still use this concept to justify directional preference. I don’t want to get too far afield here, but I highly recommend you take a look at the Wand and McConnell article published in BMC in 2008: http://www.biomedcentral.com/1471-2474/9/11

        Regarding what patients care about: I disagree that most patients- or really any patients other than maybe a few with a personal curiosity- care about outcomes studies. They care about feeling better, not about studies, theories or even how you go about helping them feel better. As professionals, we have a duty to the patient and to society to minimize risk and apply interventions that make the most sense. As science-based professionals, we use science as the standard to achieve both of these goals.

        Finally, I disagree with your statement that we don’t have a deep model for anything that we do as PTs. We have the neuromatrix model of pain, which is a very well-described model that accounts for the effects of movement, and to some degree, manual interventions to treat pain. We also have a very well-developed deep model that explains the benefits of aerobic exercise. We use the latter effectively in practice, the former not so much.

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      2. John,

        Walker was an assessment of manual therapy for neck pain without distinction between manip and mobilization and Boyles was the post hoc analysis of Walker’s data to which I alluded to earlier. Post hoc analysis is a lower level of evidence given study design and bias is easier to introduce. So in essence, we are still talking of only 2 intentional RCTs comparing manip to mobilization. Please supply your references if you are referring to another group of studies so I can confirm I am not mistaken (this would not be a first given the breadth of research out there).

        I never said patients care about outcomes studies. I indicated they care about outcomes, i.e. alleviate my pain. Hence my need to look predominately at outcomes studies. While the neuromatrix model is truly tought provoking and revolutionary (relating to pain science), it does not account for the patients that don’t respond to intervention based on it. There is still the conscioussness component that will require far more research (and dare I say intelligence) to explain let alone intervene on with physical therapy-based treatment.

        Regarding the sub-groupings, we all note patterns in how groups of patients respond to specific interventions (i.e. clinical patterns). These clinical observations have driven the majority of the subclassification development with the remainder mostly coming from regression analyses or specific interventional research. The theories regarding the mechanism have unfortunately followed, yet I question these every day. I do not question the improved outcomes that can follow. Subclassification is in its infancy, further research that encorporates psychological components and pain science will likely be added to future variants.

        As for the aerobic exercise discussion, I am referring to the inherent risks of placing individuals with unknown cardiac issues (including undiagnosed malformations) and the risk of falling off of the machine. My example has
        nothing to do with aerobic training or physiological benefit, so I am not certain why you bring this up.

        Ultimately, our biases are resulting in a circular argument of which neither of us will come to agreement anytime soon. I am comfortable with this as I have no more time to dedicate here.

        I have enjoyed this discussion nonetheless. Kevin

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      3. Kevin,
        We’ll have to agree to disagree on the strength of the evidence that mobilization is as effective as manipulation. John, who is a proponent of cervical manipulation, has even concurred with that point, although he maintains that there may be a subgroup that benefits from SMT.

        I’ve been hearing the argument and reading the studies about sub-grouping for 20 years. How much longer will it be in its “infancy”? The first Treatment-Based Classification study was published by Delitto et al in 1994. Last I checked, outcomes for treatment of persistent LBP haven’t improved much and the epidemic of musculoskeletal pain problems continues to worsen (see the IOM report and Lewin Group report from 2006). I keep hearing the appeal from many of my colleagues, “But we need to identify the right sub-group, those studies were too heterogeneous. The treatment didn’t fit the condition.” I don’t know about you, but I’m tired of waiting around to find the right treatment for the right sub-group. I’d like to retire someday.

        I referenced Wand and O’Connell. Did you read that very thought-provoking review? If they’re right, then all these attempts to sub-group may be misguided. Shouldn’t we consider that possibility after nearly 20 years of research on sub-grouping/classification?

        Noting clinical “patterns” is not the same as sub-grouping and is prone to all kinds of confirmation bias. I don’t give it much credence.

        Someone else brought up aerobic training earlier, I was just noting that this is an intervention that possesses a very sound theoretical underpinning as opposed to SMT, which does not. We know that aerobic exercise is beneficial for very specific reasons (and for some reasons we’re not sure of). Therefore, if the patient will benefit from this intervention, we have a duty to the patient to apply it while weighing the risks. If you put a patient on a treadmill who has a balance impairment for which you didn’t screen adequately, then you’ve made a poor clinical decision. This doesn’t mean that aerobic conditioning is not indicated for that patient, you just chose the wrong method. For those that have undetectable malformations, you have the ability to provide with informed consent, which includes a thorough explanation of the risks and known benefits as well as how these benefits are achieved with that particular and only that particular intervention. No such depth of informed consent is possible with SMT.

        Sorry to see you go. Why don’t you go take a look at SomaSimple.com? I think you’ll find some stimulating discussion there.

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  13. Is the juice worth the squeeze? Followup question – where’s the juice?
    Several clinical trials have found thrust manipulation no better than nonthrust methods for mechanical neck pain. There is, at the very least, a question of thrust manipulation’s risk potential in the cervical spine. If two techniques are equivalent in effect and one has a higher risk profile, choosing it is a failure of clinical reasoning. Period.

    Those who want to use thrust in the neck will continue to engage in a process of self-justification so they can continue to do it, be paid to teach it, and speak at conferences about it. At the end of the day the published clinical trials don’t show a benefit for it above nonthrust methods. So if we are using it, the question is why? It’s clearly not about evidence, it’s about what we prefer to do for reasons that have nothing to do with the science or our patient. Wrong answer.

    Clinical practice isn’t about us, it’s about our patients. I’d like to see a little more of that from my colleagues who are so excited to crack necks.

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    1. Just to be devil’s advocate Jason, a treadmill comes with a significantly higher risk profile than a recumbent bike. Should we abandon the treadmill? What is the patient has a cardiac history? What if there is a underlying cardiac condition? The main point I am striving for is that we monitor risk factors for patient regarding the use of treadmills, cardiac, balance, motor moron-icity. In the case of cervical artery disection (including VA and ICA), these patients have a strong tendency to be between 40 and 50 years of age and ~ 40% have a history of minor trauma to the head and neck (reason they seek treatment per Cassidy). I think it is safe to say avoidance of thrust manipulation should be considered in this population. Of note, Fusco et al found that near 60% of disections occur in Autumn…

      When it comes to thrust manipulation, I think we need to verify there is not a sub-group that benefit from the technique before we simple “leave it in the dust”. This is especially true when most research on the technique involves poor methodology or post hoc analysis. We should also keep in mind that chiropractic has the highest coorelation of events to manipulation and they actively seek cavitation. Given research leans away from the need for cavitation and that seeking cavitation incurrs the unnecessary use of higher amplitude motions, keeping true to the definition of HVLA would be preferred. While I use cervical thrust manipulation (sparingly) and teach the technique, I am with many others that teach it in stating that were it removed from my “bag of tools”, I would be able to muster on without a hitch. This statement does not apply to lumbopelvic or thoracic manipulation…

      Cheers,
      KLM

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      1. Kevin,
        You’ve just made the same straw man argument that John made by comparing a treadmill to recumbent bike in terms of cardiac event risk from aerobic exercise.

        These arguments have me concerned about the overall level of thoughtfulness that is being employed by clinicians and promoted in our students. I mean, come on, you guys actually think the explanatory model for spinal manipulation is anywhere near as sophisticated as that for aerobic training?

        This is why we so desperately need to re-focus on the science-base of our profession and quit getting de-railed by “evidence” that is not based on a sound, plausible theory, which includes most of the outcomes evidence on SMT.

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      2. I have just found that nearly all thoracic rotation/shear lesions can be removed with a distraction to the sternum which un-loads the manubrium and ‘pops the cork’ which seems to be holding a sheared thoracic position. Traction manips rarely in use by me now. Not that they seemed dangerous, but it’s easier for me and the patients are less nervous.
        Upslips can be done with a contract-relax procedure a lot of the time. I have invented various ways to mobilize the neck by ‘walking the refrigerator’.
        I do like thrusts, though, and they make larger proprioceptive changes and really catch the brains’ attention, it seems. Some joints are just wedged in there and need it, too.
        The training to become a manipulator gave me more diagnostic ability, so any research would need to use well-trained people who are not choosing thrusts, otherwise you have nondescript mobilizations, not well chosen. I wouldn’t want to see this sort of forum be used to dissuade people from the training, which is one of the best things we do!
        BTW, i have had five people with lax transverse ligaments, two of whom were in huge danger, and the testing found it. Rigid collar. All was well. Some things about this manipulative system work just great. have faith. people who are logical have spent much time thinking of these things. So, no throwing the baby out with the bathwater yet please.

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  14. Jason, John, and David,

    I believe your arguments do have merit (especially in the cervical spine)… There is a certain level of uncertainty in terms of both effectiveness and safety concerns. Please take the time to read Part 2 where I explain how I have interpreted the evidence.

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  15. Greetings from Finland,
    An interesting and an important discussion and a very long one:) I wish to participate but unfortunately I haven’t had the time to read all the comments.
    I’m left with the impression here in Finland that the discussion related to this topic is being driven solely by the question weather to or not to manipulate cervical spine.
    Personally I think this question is wrong driver for the discussion. I’d prefer the question when to manipulate and when not to manipulate. This question would serve the clinical practice better in my opinion.
    The question of weather to or not to manipulate cx simply stimulates argumenting on scientific basis and does not really give answers to any one direction since science up to day related to topic supports both opinions.
    So back to the beginning. My question here is that is this discussion over this site being driven by “when to manipulate cx?” or “weather to or not to manipulate cx?” as seems to be the case here in Finland.

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