Manipulation Safety in Physical Therapy

Manipulation Safety

• The presentation focuses on the safety of manipulation techniques, specifically in physical therapy.
• Research suggests concerns regarding damage to vertebral and internal carotid arteries, fractures, and soft tissue damage.
• Questions regarding the safety of manipulation include: what are the risks, experiences with past manipulations, and whether the risks outweigh the benefits.
• A review of artery safety is included, highlighting anatomical structures relevant to manipulation, such as the vertebral and internal carotid arteries.

Research on Manipulation Safety

• Symons et al. (2002) studied cadavers to analyze strain on the vertebral artery during cervical range of motion (ROM) and high-velocity, low-amplitude thrust (HVLAT).

• ROM increased strain by 1.2% to 12.5%.

• HVLAT increased strain by 6.2%.

• Mechanical failure of the artery didn't occur until strains of 139-162% higher than at rest.

• The study concluded that HVLAT is unlikely to cause disruption to a normal vertebral artery.

• Cassidy et al. (2009) analyzed 818 cases of vertebrobasilar artery (VBA) strokes and 4 matched controls in each case.

• 4% of stroke cases and controls saw a chiropractor within 30 days of the stroke.

• 53% of cases and 30% of controls saw a PCP within 30 days of the stroke.

• Increased association seen between chiropractic care and stroke in those under 45 years.

• Increased association between PCP care and stroke in all ages.

• Patients with head and neck pain (due to vertebral artery dissection) seek care for those symptoms, preceding strokes in over 80% of cases.

• Similar conclusions were found in studies from Whedon et al. (2015) and Kosloff et al. (2015) with Medicare-age populations and US commercial/Medicare Advantage populations.

Screening for Manipulation Risks

• A thorough history is vital for identifying potential spinal manipulation risks
• Thomas et al (2015) found that 71% of cervical arterial dissection (CAD) cases and 57% of internal carotid artery (ICA) cases reported minor mechanical trauma to the head or neck in the last month.
• Individuals with CAD were approximately 60 times more likely to have reported prior trauma compared to controls.
• Understanding the typical pain patterns in CAD is crucial. Red flags in CAD require careful evaluation.

Red Flags

• A table detailing classic signs and symptoms of vertebrobasilar insufficiency (VBI) and associated neuroanatomy is included (Table 1)
• Related symptoms such as dizziness (including vertigo, giddiness, and lightheadedness), drop attacks, diplopia, dysarthria, dysphagia, ataxia, nausea, numbness, and nystagmus are listed as potential indicators.

Vertebral Artery Dissection (VAD)

• Table 2 details the presentations of vertebral artery dissection, noting that non-ischemic symptoms can precede ischemic events by days to weeks.
• Non-ischemic symptoms include ipsilateral posterior neck pain/occipital headache and C5/6 cervical root impairment (rare).
• Ischemic symptoms include hind-brain TIA (dizziness, diplopia, dysarthria related to swallowing difficulties, drop attacks, nausea, nystagmus, and facial numbness), ataxia, headache, vomiting.

Internal Carotid Artery Dissection

• Table 3 details clinical features of internal carotid artery (ICA) dissection.
• Non-ischemic symptoms include Horner's syndrome, pulsatile tinnitus, and cranial nerve palsies (most commonly CN IX to XII).
• Ischemic symptoms include TIA, ischemic stroke (usually middle cerebral artery territory), retinal infarction, and amaurosis fugax.

Other Safety Considerations

• Data on fracture risk with manipulation is limited, primarily based on case studies/case series.
• Osteoporosis/osteopenia is a contraindication for manipulation due to higher fracture risk in certain areas (i.e., C-spine is less force than T-spine or L-spine).
• Different techniques and forces are associated with risk.
• Soft tissue injury is a common adverse effect of manipulation.
• Cleland et al (2009) reported that approximately 25% of patients experienced adverse effects (aggravation of symptoms, spasm, stiffness) within 4 hours of lumbar spine manipulation that resolved within 48 hours.

Summary Questions about Manipulation

• The presentation concludes with questions about the value of manipulation, whether the risks outweigh the benefits.