Manipulation Safety in Physical Therapy

Manipulation Safety

• The presentation is on the safety of manipulation techniques in physical therapy.
• The presenter is Adam Squires, a board-certified specialist in orthopedic physical therapy.
• The presentation covers objectives, safety concerns, evidence, screening methods, and other considerations.

Objectives

• The objective is to understand the research on manipulation safety.

Is Manipulation Safe?

• Questions to consider regarding manipulation safety include: What are the potential risks? Has the patient experienced manipulation before? What was the experience like? Do the risks outweigh the benefits?

Safety

• The primary concerns regarding manipulation center on potential damage to the vertebral and internal carotid arteries, fractures, and soft tissue damage.

Artery Safety

• The presentation highlights artery safety as a critical aspect of manipulation.
• Images or diagrams may visually represent vertebral and carotid arteries in the neck region.

Anatomy Review

• An anatomical review of the neck area is presented, showing the location of critical arteries and vertebral structures.
• Visual aids such as anatomical models are likely included for better understanding.

Evidence

• Symons et al (2002) studied strain on vertebral arteries during cervical manipulation and high-velocity, low-amplitude techniques (HVLAT).

• Their findings indicated that routine cervical range-of-motion (ROM) increased strain by 1.2-12.5%. HVLAT increased strain by 6.2%.

• Mechanical failure of the artery didn't occur unless strains exceeded 139%-162% that at rest.

• The study concluded HVLAT is unlikely to damage a healthy vertebral artery.

• Cassidy et al (2009) used databases to evaluate 818 cases of vertebrobasilar artery (VBA) strokes.

• They identified matched controls and compared historical chiropractic or physician visits to the strokes.

• Rates of visits within 30 days of stroke were similarly low for both patients and controls.

• Increased association between chiropractic visits within 30 days were seen in patients under 45 years old, with similar patterns for PCP office visits.

• Pain may lead patients to seek chiropractic assistance, which may increase this association.

• Whedon et al (2015) and Kosloff et al (2015) supported the prior studies.

• Results were comparable using US commercial and Medicare Advantage populations and Medicare-aged populations.

Screening

• A thorough patient history is crucial for effective screening.
• Thomas et al(2015) reported that 71% of cervical arterial dissection (CAD) cases had minor mechanical trauma to the head or neck within one month.
• Understand the common pain patterns in CAD.
• Screen for specific red flags associated with cervical artery dissection.

Red Flags – Ns and Ds

• (Refer to table for classic signs/symptoms of vertebrobasilar insufficiency [VBI])
• Possible associated neuroanatomy is present relating to the signs and symptoms.

VAD

• Non-ischemic symptoms may precede ischemic events related to vertebral artery dissection (VAD)
• Symptoms may occur from days to weeks prior to ischemic event.
• Ischemic and non-ischemic signs/symptoms are presented in table(refer to table)

Internal Carotid Artery Dissection

• (Refer to table for non-ischemic and ischemic symptoms)
• Common signs/symptoms in internal carotid artery dissection are presented in a table.

Other Safety Considerations

• Fracture data in relation to manipulation is limited and largely presented as case studies or case series.
• Osteoporosis/osteopenia is considered a contraindication for manipulation due to increased fracture risk in certain areas (like the C-spine).
• Different manipulation techniques may exert different levels of force, impacting the risk of injury in various areas of the spine.

Soft Tissue Injury

• Soft tissue injury is the most common adverse effect of manipulation.
• Cleland et al (2009) found that 25% of patients reported adverse effects 4 hours after lumbar spine manipulation, but these resolved within 48 hours.
• Literature on this topic is limited.

Is Manipulation Safe?

• The question concerning whether risks outweigh the benefits remains an open topic.