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Joint Mobilizations and Manipulations: Risk of Adverse Events Audio

Safety and efficacy of joint mobilizations and manipulations (adjustments) for the cervical, lumbar, thoracic spine, and sacroiliac joints. Are manipulations and mobilizations risky? The likelihood of a cerebrovascular incident/accident, lumbar disk herniation/rupture, fracture, or hematoma with joint manips. 

Joint Mobilizations and Manipulations: Risk of Adverse Events

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 The risks associated with manipulations and mobilizations, especially cervical manipulations, have been dramatically overstated in several publications. This has led to unsupportable and irrational recommendations including the elimination of manipulations from practice, mandating unreliable and insensitive special tests, and/or asserting that medical professionals should be held legally accountable for unforeseeable, exceedingly rare events. These assertions may be some of the most poignant examples of unscientific thinking in our field. This course reviews all of the available research, published survey data, and case reports that could be located at the time of publication. A thorough review highlights various aspects of analysis and treatment that have been "conveniently forgotten" in several previous publications (e.g. relative risk, rate of occurrence, correlation or causation etc.).

 A review by Dabbs et al. demonstrated that current best evidence indicates that NSAIDs are likely several 100 times more dangerous than cervical manipulations (based on the rate of occurrence of adverse events). Further, several studies have demonstrated that cervical manipulations alone are more effective than physician care alone (including pharmacological intervention). This counter-intuitive finding suggests that receiving a cervical manipulation for neck pain is more likely to improve symptoms, and less likely to cause injury, than seeing a physician and taking an over-the-counter anti-inflammatory. 

Note, the Brookbush Institute recommends an integrated approach to treatment and is not recommending that NSAIDS, manipulations, or physician care should be reduced or omitted for the treatment of cervical pain.

Dabbs, V., &amp; Lauretti, W. J. (1995). A risk assessment of cervical manipulation vs.
NSAIDs for the treatment of neck pain. Journal of Manipulative and Physiological
Therapeutics, 18(8), 530-536.

There is no evidence to suggest that manipulations/mobilizations are at higher risk than any other physical or pharmaceutical intervention commonly used to address orthopedic pain. In fact, there is evidence to suggest that manipulations and mobilizations are more effective, with less risk of adverse events than physician intervention for several orthopedic conditions. Serious adverse events do occur, but these exceedingly rare events are likely no more common than severe allergic reactions to aspirin or NSAIDs, the occurrence of cardiac episodes during vigorous exercise, and/or unforeseeable deaths during routine surgery. Last, there is currently no reliable and/or accurate method for identifying patients who may be at risk of a serious adverse event during manipulations/mobilizations.

Conservative Risk Estimations based on Current Research:

Severe (risk of life or motor function loss) adverse events: 1/5,000,000+

Non-life-threatening serious transient side-effects: 1/15,000+

Radicular complaints and/or worsening symptoms: 1/1000+

Post-treatment discomfort (lasting less than 24 hours): 1/10 - 1/100

Note, removing manipulations from treatment may not reduce the rate of post-treatment discomfort.

Structural Damage Pre and Post Manipulation

Cervical Manipulations Use Less Than Available Active ROM

Correlation, Relative Risk, and Screening

Joint Mobilization and Manipulation: Introduction

Effects of Joint Mobilizations and Manipulations

Joint Mobilizations and Manipulations: Evidenced-based Teaching and Learning

Course Description: Risk of Adverse Events following Joint Mobilization and Joint Manipulation

Course Webinar: Are Manipulations Risky

There is no evidence to suggest that manipulations/mobilizations are at higher risk than any other physical or pharmaceutical intervention commonly used to address orthopedic pain. In fact, there is evidence to suggest that manipulations and mobilizations are more effective, with less risk of adverse events than physician intervention, for several orthopedic conditions. Serious adverse events do occur, but these exceedingly rare events are likely no more common than severe allergic reactions to aspirin or NSAIDs, the occurrence of cardiac episodes during vigorous exercise, and/or unforeseeable deaths during routine surgery. Last, there is currently no reliable and/or accurate method for identifying patients who may be at risk of a serious adverse event during manipulations/mobilizations.

 Stroke, vertebral artery dissection, brainstem or spinal cord injury, worsening neuropathy

 Mechanical or vascular injuries to the spinal cord, pneumothorax and/or hemothorax, cerebrospinal fluid leak secondary to injury of the dural sleeve

 Cauda equina syndrome, lumbar disk herniation/rupture, fracture, hematoma or hemorrhagic cyst, neurologic compromise, vascular compromise, muscle abscess formation

 There may be utility for a subjective questionnaire with the intent of identifying a serious adverse (Red Flag) event in progress.

Vertebrobasilar Insufficiency (VBI) and Upper Cervical Instability Testing

: The reliability, sensitivity, and positive predictive values of VBI and Cervical Instability Tests are far too low to be trusted to screen the general population for individuals at-risk of exceedingly rare events. It should also be noted that there is no evidence that serious adverse events are correlated with a positive result on VBI or upper cervical instability testing, with or without the addition of manipulations.

Confounding Estimations of Risk (Author's Note)

The risks associated with manipulations and mobilizations have been dramatically overstated in various publications. These dramatized risks have resulted in unsupportable and irrational recommendations including the elimination of manipulations from practice, and/or mandating unreliable and insensitive special tests prior to manipulations, and/or asserting that medical professionals should be held legally accountable for unforeseeable, exceedingly rare events. These assertions may be some of the most poignant examples of unscientific thinking by licensed professionals in the allied health fields. The common fallacy that may be observed throughout these publications is a blatant disregard of probabilities including fallacious attempts to imply prevalence from case studies, failure to consider risk-to-benefit ratio, no consideration of the risk relative to other interventions, and a lack of consideration of confounding variables including rare anatomical abnormalities. To date, there is no evidence to suggest that manipulations are higher risk than any other physical or pharmaceutical intervention commonly used to address orthopedic pain, and the problems that arise in attempting to estimate the risks associated with manipulations and mobilizations are similar to the issues that arise when attempting to estimate risk for any medical intervention.

Based on the evidence currently available, there are several confounding factors that are likely to make estimating "risk" difficult.

 There is a high likelihood of under-reporting of serious cases due to the potential risk of professional harm. A larger movement is needed to promote and praise no-fault retrospective analysis and the publication of case studies involving serious adverse events. This is not a recommendation for protection from negligence; however, it is important that organizations with the intent to represent a profession (e.g. American Physical Therapy Association, Federation of Chiropractic Licensing Boards, Etc.) aid in preventing legislation that may imply liability, and/or these organizations should aid in developing systems and legislation that promote blameless retrospective analysis.

 A review by Haneline et al. noted the almost all published case studies failed to rule out factors such as connective tissue aberrations, underlying arteriopathy, coexistent infection, etc., prior to labeling manipulation as the cause of the severe adverse event (51). In these cases, it may be hypothesized that the manipulation was the "straw that broke the camel's back". That is, although the manipulation was the cause of the insult, the patient was uniquely susceptible and likely to have experienced a similar adverse event resulting from any vigorous force. A study discussed below by Triano et al. suggests that the forces imparted during the manipulation of the spine are similar to those experienced by airline baggage handlers (38). Could it be that a patient with a connective tissue aberration was highly likely to experience cervical vessel damage during a high-impact daily task (e.g. colliding with another pedestrian while quickly walking to work), but before that event could occur they received a cervical manipulation for neck pain?

 Several of the cases and reviews below suggest that the correlation between manipulation/mobilization and severe adverse events may be due to patients looking for care for a serious adverse event in progress. For example, a patient may visit a manual therapist first for a cervical artery dissection that results in neck pain and neurological signs consistent with cervical radiculopathy. This category of cases deserves further attention, as it may be possible to develop a reliable subjective questionnaire that aids in differentiating "normal" orthopedic symptoms from those symptoms that suggest a severe adverse event in progress, which could enhance expediency to emergency care.

Introduction: Position Stand and Summary

 These studies suggest that despite a movement to pursue evidence-based practice, many clinicians (and some courts) have beliefs that do not accurately reflect the best evidence available regarding manipulations and the risk of adverse events.

 Published studies and reviews imply that one in several million manipulations may be related to a vertebrobasilar accident or cerebrovascular accident (including cervical arterial dissection), suggesting these events should be considered exceedingly rare. Further, research has failed to correlate any specific risk factor that could be used to identify at-risk individuals prior to manipulation.

 Studies demonstrate that serious adverse events from thoracic and lumbar manipulation are also exceedingly rare, thoracic manipulation likely results in the fewest adverse events and serious adverse events may be as strong, or more strongly correlated with physician visits.

 Published case series suggest that serious adverse events may occur following manipulation, they may require surgical intervention, they may progress quickly and require emergency care, and symptoms treated with manipulations may actually be the result of serious undiagnosed pathologies in progress.

 Case studies may be important for identifying exceedingly rare events that may arise in the course of a manual therapist's career, including manipulation correlated with intradural hematoma, cauda equina ischemia, hemorrhage of a thoracic schwannoma, etc.

Less serious adverse events may occur with more frequency than serious adverse events following manipulation; however, they are likely still relatively rare. Additionally, minor side effects may occur following manipulation (e.g. headache, muscle soreness, fatigue, etc.); however, considering these events do not occur with less frequency when manipulation and stretching are removed from treatment, the frequency of these effects may represent the frequency of effects following any intervention plan.

 The mean force used during manipulation and mobilization techniques is well below the minimum threshold for increased risk of tissue injury, and may be comparable to the forces experienced during demanding manual labor. However, some care may be warranted for osteoporotic patients based on a presumed increase in the risk of laminar fracture and the potential for neurologic injury.

Structural Damage Pre and Post Manipulation:

 Manipulations do not routinely result in tissue damage of facet joint capsules or disks, including damage to disks exhibiting signs of dysfunction prior to manipulation.

Cervical Manipulations Use Less Than Available Active ROM: 

Pre-manipulative and thrust ROM during manipulation is less than the participant's active ROM, refuting claims that cervical manipulations are dangerous due to excessive lengthening of at-risk tissues.

Manipulation does not result in greater strain to cervical arteries than daily activity, does not result in changes in cervical blood flow in otherwise healthy adults, and only some evidence from animal studies suggests that significant atherosclerotic disease may be a contraindication.

 Research suggests that the correlation between cervical artery dissection and manipulation/chiropractic care may be the result of patients seeking treatment for dissection in progress, and/or that manipulations/chiropractic care is no riskier than seeking care from a physician.

Manipulations are effective for improving both short-term and long-term outcomes, serious adverse effects are exceedingly rare, and current best evidence suggests chiropractic care and manipulations are likely safer than physician care or NSAIDs (for relevant orthopedic issues). Some evidence suggests that mobilizations result in slightly fewer adverse reactions than manipulations; therefore, mobilizations may be recommended for patients who exhibit signs that may increase their risk of adverse effects.

 The reliability, sensitivity, and positive predictive value of vertebrobasilar insufficiency (VBI) and upper cervical instability testing only reaches a level of "fair" when the criterion for a positive result is a relatively large change (4mm or combining multiple grades), and/or these tests are performed on a patient population with a much higher than normal prevalence of positive results. Many studies demonstrated zero or poor sensitivity/positive predictive value, even when used with high prevalence populations, suggesting that these tests cannot be trusted to screen the general population for individuals at-risk for exceedingly rare events. Last, it should also be noted that there is no evidence that serious adverse events are correlated with positive results on VBI or upper cervical instability testing, with or without the addition of manipulations.

Research Summary

Perception of Risk

Survey Data and Systematic Review

Published Case Series and Case Studies

Non-life-threatening Adverse Effects and Classification

Survey Data, Reviews and Cases

Tissue Damage

Range of Motion and Cervical Vessel Insult

Proposed Mechanisms of Injury

Correlation and Relative Risk

Pre-manipulative Screening

Correlation, Relative Risk and Screening

Puentedura, E. J., Slaughter, R., Reilly, S., Ventura, E., & Young, D. (2017). Thrust joint manipulation utilization by US physical therapists. 

Hincapié, C. A., Cassidy, J. D., Côté, P., Rampersaud, Y. R., Jadad, A. R., & Tomlinson, G. A. (2018). Chiropractic spinal manipulation and the risk for acute lumbar disc herniation: a belief elicitation study. 

Boucher, P., & Robidoux, S. (2014). Lumbar disc herniation and cauda equina syndrome following spinal manipulative therapy: a review of six court decisions in Canada. 

Cervical Spine: Survey Data and Systematic Reviews

Magarey, M. E., Rebbeck, T., Coughlan, B., Grimmer, K., Rivett, D. A., & Refshauge, K. (2004). Pre-manipulative testing of the cervical spine review, revision and new clinical guidelines. 

Stevinson, C., Honan, W., Cooke, B., & Ernst, E. (2001). Neurological complications of cervical spine manipulation. 

Haldeman, S., Carey, P., Townsend, M., & Papadopoulos, C. (2002). Clinical perceptions of the risk of vertebral artery dissection after cervical manipulation: the effect of referral bias. 

Kranenburg, H. A., Schmitt, M. A., Puentedura, E. J., Luijckx, G. J., & Van der Schans, C. P. (2017). Adverse events associated with the use of cervical spine manipulation or mobilization and patient characteristics: a systematic review. 

Rothwell, D. M., Bondy, S. J., & Williams, J. I. (2001). Chiropractic manipulation and stroke. 

Smith, W. S., Johnston, S. C., Skalabrin, E. J., Weaver, M., Azari, P., Albers, G. W., & Gress, D. R. (2003). Spinal manipulative therapy is an independent risk factor for vertebral artery dissection. 

Haldeman, S., Kohlbeck, F. J., & McGregor, M. (2002). Unpredictability of cerebrovascular ischemia associated with cervical spine manipulation therapy: a review of sixty-four cases after cervical spine manipulation. Spine, 27(1), 49-55.

Thoracic Spine and Lumbar Spine: Survey Data and Systematic Reviews

Rydell, N., & Räf, L. (1999). Spinal manipulation--treatment associated with a high risk of complications. 

Puentedura, E. J., & O'Grady, W. H. (2015). Safety of thrust joint manipulation in the thoracic spine: a systematic review. 

Senstad, O., Leboeuf-Yde, C., & Borchgrevink, C. (1996). Predictors of side effects to spinal manipulative therapy. 

Journal of manipulative and physiological therapeutics

Hebert, J. J., Stomski, N. J., French, S. D., & Rubinstein, S. M. (2015). Serious adverse events and spinal manipulative therapy of the low back region: a systematic review of cases. 

Journal of Manipulative and Physiological therapeutics

Kim, H. S., Ha, J. W., Park, J. O., Park, H. W., Han, D. Y., & Hur, J. H. (1998). Ruptured lumbar disc in patients undergoing manipulation of the lumbar spine. 

Journal of the Korean Orthopaedic Association

Oliphant, D. (2004). Safety of spinal manipulation in the treatment of lumbar disk herniations: a systematic review and risk assessment. Journal of Manipulative and Physiological Therapeutics, 27(3), 197-210.

Hincapié, C. A., Tomlinson, G. A., Côté, P., Rampersaud, Y. R., Jadad, A. R., & Cassidy, J. D. (2018). Chiropractic care and risk for acute lumbar disc herniation: a population-based self-controlled case series study. European Spine Journal, 27(7), 1526-1537.

Di Fabio, R. P. (1999). Manipulation of the cervical spine: risks and benefits. 

Oppenheim, J. S., Spitzer, D. E., & Segal, D. H. (2005). Nonvascular complications following spinal manipulation. 

Hufnagel, A., Hammers, A., Schönle, P. W., Böhm, K. D., & Leonhardt, G. (1999). Stroke following chiropractic manipulation of the cervical spine. Journal of Neurology, 246(8), 683-688.

Haldeman, S., & Rubinstein, S. M. (1992). Cauda equina syndrome in patients undergoing manipulation of the lumbar spine. 

Ruelle, A., Datti, R., & Pisani, R. (1999). Thoracic epidural hematoma after spinal manipulation therapy. 

Hdeib, A., Goodwin, C. R., Sciubba, D., Bydon, A., Wolinsky, J. P., Witham, T., & Gokaslan, Z. L. (2016). Hemorrhagic thoracic schwannoma presenting with intradural hematoma and acute paraplegia after spinal manipulation therapy. 

Yang, Si-Dong, Qian Chen, and Wen-Yuan Ding. "Cauda Equina Syndrome Due to Vigorous Back Massage With Spinal Manipulation in a Patient With Pre-Existing Lumbar Disc Herniation: A Case Report and Literature Review." 

American journal of physical medicine & rehabilitation

Solheim, O., Jorgensen, J. V., & Nygaard, O. P. (2007). Lumbar epidural hematoma after chiropractic manipulation for lower-back pain: case report. 

Cheng, Y. P., Lee, K. W., Lin, P. Y., Huang, A. P. H., Cheng, C. Y., Ma, H. I., … & Hueng, D. Y. (2014). Full-endoscopic interlaminar removal of chronic lumbar epidural hematoma after spinal manipulation. 

Morandi, X., Riffaud, L., Houedakor, J., Amlashi, S. F., Brassier, G., & Gallien, P. (2004). Caudal spinal cord ischemia after lumbar vertebral manipulation. 

Kornberg, E. (1988). Lumbar artery aneurysm with acute aortic occlusion resulting from chiropractic manipulation: a case report. 

Dvořák, J., Loustalot, D., Baumgartner, H., & Antinnes, J. A. (1993). Frequency of complications of manipulation of the spine. 

Thiel, H. W., Bolton, J. E., Docherty, S., & Portlock, J. C. (2007). Safety of chiropractic manipulation of the cervical spine: a prospective national survey. 

Cagnie, B., Vinck, E., Beernaert, A., & Cambier, D. (2004). How common are side effects of spinal manipulation and can these side effects be predicted?. 

Paanalahti, K., Holm, L. W., Nordin, M., Asker, M., Lyander, J., & Skillgate, E. (2014). Adverse events after manual therapy among patients seeking care for neck and/or back pain: a randomized controlled trial. 

Professional Consensus to Classify Adverse Events

Kranenburg, H. A., Lakke, S. E., Schmitt, M. A., & Van der Schans, C. P. (2017). Adverse events following cervical manipulative therapy: consensus on classification among Dutch medical specialists, manual therapists, and patients. 

Carnes, D., Mullinger, B., & Underwood, M. (2010). Defining adverse events in manual therapies: a modified Delphi consensus study. 

Sran, M. M., Khan, K. M., Zhu, Q., McKay, H. A., & Oxland, T. R. (2004). Failure characteristics of the thoracic spine with a posteroanterior load: investigating the safety of spinal mobilization. 

Stemper, B. D., Hallman, J. J., & Peterson, B. M. (2011). An experimental study of chest compression during chiropractic manipulation of the thoracic spine using an anthropomorphic test device. 

Triano, J., & Schultz, A. B. (1997). Loads transmitted during lumbosacral spinal manipulative therapy. 

Boonyoung, C., Kwanyuang, A., & Chatpun, S. (2018, November). A finite element study of posteroanterior lumbar mobilization on elderly vertebra geometry. In 

2018 11th Biomedical Engineering International Conference (BMEiCON)

Ianuzzi, A., & Khalsa, P. S. (2005). Comparison of human lumbar facet joint capsule strains during simulated high-velocity, low-amplitude spinal manipulation versus physiological motions. 

Chrisman, O. D., Mittnacht, A., & Snook, G. A. (1964). A study of the results following rotatory manipulation in the lumbar intervertebral-disc syndrome. 

Van Geyt, B., Dugailly, P. M., Klein, P., Lepers, Y., Beyer, B., & Feipel, V. (2017). Assessment of in vivo 3D kinematics of cervical spine manipulation: Influence of practitioner experience and occurrence of cavitation noise. 

Liguo, Z., Minshan, F., Xunlu, Y., Shangquan, W., & Jie, Y. (2017). Kinematics Analysis of Cervical Rotation-Traction Manipulation Measured by a Motion Capture System. 

Evidence-Based Complementary and Alternative Medicine

Klein, P., Broers, C., Feipel, V., Salvia, P., Van Geyt, B., Dugailly, P. M., & Rooze, M. (2003). Global 3D head–trunk kinematics during cervical spine manipulation at different levels. Clinical Biomechanics, 18(9), 827-831.

Salem, W., & Klein, P. (2013). In vivo 3D kinematics of the cervical spine segments during pre-manipulative positioning at the C4/C5 level. 

Herzog, W., Tang, C., & Leonard, T. (2015). Internal carotid artery strains during high-speed, low-amplitude spinal manipulations of the neck. 

Quesnele, J. J., Triano, J. J., Noseworthy, M. D., & Wells, G. D. (2014). Changes in vertebral artery blood flow following various head positions and cervical spine manipulation. 

Licht, P. B., Christensen, H. W., Højgaard, P., & Marving, J. (1998). Vertebral artery flow and spinal manipulation: a randomized, controlled and observer-blinded study. 

Qi, J., Ping, R., Zhang, S., Xu, Y., Wu, K., & Li, Y. (2019). Effects of Cervical Rotatory Manipulation (CRM) on Carotid Atherosclerosis Plaque in Vulnerability: A Histological and Immunohistochemical Study Using Animal Model. 

Guan, T., Zeng, Y., Qi, J., Qin, B., Fu, S., Wang, G., & Zhang, L. (2019). Effects of Cervical Rotatory Manipulation on Internal Carotid Artery in Hemodynamics Using an Animal Model of Carotid Atherosclerosis: A Safety Study. 

Medical science monitor: international medical journal of experimental and clinical research

Haneline, M. T., Croft, A. C., & Frishberg, B. M. (2003). Association of internal carotid artery dissection and chiropractic manipulation. 

Cassidy, J. D., Boyle, E., Côté, P., He, Y., Hogg-Johnson, S., Silver, F. L., & Bondy, S. J. (2009). Risk of vertebrobasilar stroke and chiropractic care: results of a population-based case-control and case-crossover study. 

Journal of Manipulative and Physiological Therapeutics

Haldeman, S., Kohlbeck, F. J., & McGregor, M. (2002). Stroke, cerebral artery dissection, and cervical spine manipulation therapy. 

Hurwitz, E. L., Morgenstern, H., Vassilaki, M., & Chiang, L. M. (2004). Adverse reactions to chiropractic treatment and their effects on satisfaction and clinical outcomes among patients enrolled in the UCLA Neck Pain Study. 

Journal of Manipulative and physiological Therapeutics

Rubinstein, S. M., Leboeuf-Yde, C., Knol, D. L., de Koekkoek, T. E., Pfeifle, C. E., & van Tulder, M. W. (2007). The benefits outweigh the risks for patients undergoing chiropractic care for neck pain: a prospective, multicenter, cohort study. 

Whedon, J. M., Mackenzie, T. A., Phillips, R. B., & Lurie, J. D. (2015). Risk of traumatic injury associated with chiropractic spinal manipulation in Medicare Part B beneficiaries aged 66–99. 

Dabbs, V., & Lauretti, W. J. (1995). A risk assessment of cervical manipulation vs. NSAIDs for the treatment of neck pain. 

Barker, S., Kesson, M., Ashmore, J., Turner, G., Conway, J., & Stevens, D. (2001). Guidance for pre-manipulative testing of the cervical spine. 

Chaibi, A., & Russell, M. B. (2019). A risk–benefit assessment strategy to exclude cervical artery dissection in spinal manual-therapy: a comprehensive review. 

Hutting, N., Scholten-Peeters, G. G., Vijverman, V., Keesenberg, M. D., & Verhagen, A. P. (2013). Diagnostic accuracy of upper cervical spine instability tests: a systematic review. 

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Bibliography

Questions, comments, and criticisms are welcomed and encouraged

Joint Mobilizations and Manipulations: Risk of Adverse Events

Related Courses:

Course Description: Risk of Adverse Events following Joint Mobilization and Joint Manipulation

Course Webinar: Are Manipulations Risky

Introduction: Position Stand and Summary

Research Summary

Survey Data, Reviews and Cases
4 Sub Sections

Proposed Mechanisms of Injury
2 Sub Sections

Correlation, Relative Risk and Screening
2 Sub Sections

Bibliography

Related Courses:

Comments

Guest

Joint Mobilizations and Manipulations: Risk of Adverse Events

Related Courses:

Course Description: Risk of Adverse Events following Joint Mobilization and Joint Manipulation

Course Webinar: Are Manipulations Risky

Introduction: Position Stand and Summary

Research Summary

Survey Data, Reviews and Cases4 Sub Sections

Proposed Mechanisms of Injury2 Sub Sections

Correlation, Relative Risk and Screening2 Sub Sections

Bibliography

Related Courses:

Comments

Guest

Survey Data, Reviews and Cases
4 Sub Sections

Proposed Mechanisms of Injury
2 Sub Sections

Correlation, Relative Risk and Screening
2 Sub Sections