Joint Mobilizations and Manipulations: Risk of Adverse Events

Unscientific Thinking: 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.).

Example of Omitted Research: 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., & 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.

Samples from this Course

Brookbush Institute's Position Stand

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.

Topics Covered in this Course

Survey Data, Reviews, and Case Studies

• Perception of risk:
• Survey Data and Systematic Review:
  • Cervical Spine Manipulation:
  • Thoracic and Lumbar Manipulation:
• Case Series and Case Studies:
  • Case Series
  • Case studies
• Non-life Threatening Adverse Effects

Proposed Mechanisms of Injury

• Force Necessary for Tissue Failure
• Structural Damage Pre and Post Manipulation
• Cervical Manipulations Use Less Than Available Active ROM
• Vessel Dissection and Occlusion

Correlation, Relative Risk, and Screening

• Correlation or Causation
• Relative Risk
• Pre-manipulative Screening

Pre-approved credits for:

• Integrated Manual Therapist (IMT) Certification

Pre-approved for Continuing Education Credits for:

• Athletic Trainers
• Chiropractors
• Group Exercise Instructors
• Massage Therapists
• Occupational Therapists - Advanced
• Personal Trainers
• Physical Therapists
• Physical Therapy Assistants

This Course Includes:

• AI Tutor
• Webinar
• Study Guide
• Text and Illustrations
• Research Review
• Practice Exam
• Pre-approved Final Exam

Related Courses

• Joint Mobilization and Manipulation: Introduction
• Joint Stiffness Assessment by Palpation
• Effects of Joint Mobilizations and Manipulations
• Joint Mobilizations and Manipulations: Evidenced-based Teaching and Learning

1. Puentedura, E. J., Slaughter, R., Reilly, S., Ventura, E., & Young, D. (2017). Thrust joint manipulation utilization by US physical therapists. Journal of Manual & Manipulative Therapy, 25(2), 74-82.
2. 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. European Spine Journal, 27(7), 1517-1525.
3. Boucher, P., & Robidoux, S. (2014). Lumbar disc herniation and cauda equina syndrome following spinal manipulative therapy: a review of six court decisions in Canada. Journal of forensic and legal medicine, 22, 159-169.
   • Cervical Spine: Survey Data and Systematic Reviews
4. 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. Manual Therapy, 9(2), 95-108.
5. Stevinson, C., Honan, W., Cooke, B., & Ernst, E. (2001). Neurological complications of cervical spine manipulation. Journal of the Royal Society of Medicine, 94(3), 107-110.
6. 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. The Spine Journal, 2(5), 334-342.
7. 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. Musculoskeletal science and practice, 28, 32-38.
8. Rothwell, D. M., Bondy, S. J., & Williams, J. I. (2001). Chiropractic manipulation and stroke. Stroke, 32(5), 1054-1063.
9. 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. Neurology, 60(9), 1424-1428.
10. 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.
    1. Thoracic Spine and Lumbar Spine: Survey Data and Systematic Reviews
11. Rydell, N., & Räf, L. (1999). Spinal manipulation--treatment associated with a high risk of complications. Lakartidningen, 96(34), 3536-3540.
12. Puentedura, E. J., & O'Grady, W. H. (2015). Safety of thrust joint manipulation in the thoracic spine: a systematic review. Journal of Manual & Manipulative Therapy, 23(3), 154-161.
13. Senstad, O., Leboeuf-Yde, C., & Borchgrevink, C. (1996). Predictors of side effects to spinal manipulative therapy. Journal of manipulative and physiological therapeutics, 19(7), 441-445.
14. 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, 38(9), 677-691.
15. 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, 33(5), 1326-1333.
16. 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.
17. 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.
    • Published Case Series
18. Di Fabio, R. P. (1999). Manipulation of the cervical spine: risks and benefits. Physical Therapy, 79(1), 50-65
19. Oppenheim, J. S., Spitzer, D. E., & Segal, D. H. (2005). Nonvascular complications following spinal manipulation. The Spine Journal, 5(6), 660-666.
20. 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.
21. Haldeman, S., & Rubinstein, S. M. (1992). Cauda equina syndrome in patients undergoing manipulation of the lumbar spine. Spine, 17(12), 1469-1473.
    • Published Case Studies
22. Ruelle, A., Datti, R., & Pisani, R. (1999). Thoracic epidural hematoma after spinal manipulation therapy. Journal of spinal disorders, 12(6), 534-536.
23. 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. International journal of spine surgery, 10, 42.
24. 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 97.4 (2018): e23-e26.
25. Solheim, O., Jorgensen, J. V., & Nygaard, O. P. (2007). Lumbar epidural hematoma after chiropractic manipulation for lower-back pain: case report. Neurosurgery, 61(1), E170-E171.
26. 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. Surgical Neurology International, 5.
27. Morandi, X., Riffaud, L., Houedakor, J., Amlashi, S. F., Brassier, G., & Gallien, P. (2004). Caudal spinal cord ischemia after lumbar vertebral manipulation. Joint Bone Spine, 71(4), 334-337
28. Kornberg, E. (1988). Lumbar artery aneurysm with acute aortic occlusion resulting from chiropractic manipulation: a case report. Surgery, 103(1), 122-124.
    • Non-life-threatening Adverse Effects
29. Dvořák, J., Loustalot, D., Baumgartner, H., & Antinnes, J. A. (1993). Frequency of complications of manipulation of the spine. European Spine Journal, 2(3), 136-139.
30. Thiel, H. W., Bolton, J. E., Docherty, S., & Portlock, J. C. (2007). Safety of chiropractic manipulation of the cervical spine: a prospective national survey. Spine, 32(21), 2375-2378.
31. Rothwell, D. M., Bondy, S. J., & Williams, J. I. (2001). Chiropractic manipulation and stroke. Stroke, 32(5), 1054-1063.
32. Cagnie, B., Vinck, E., Beernaert, A., & Cambier, D. (2004). How common are side effects of spinal manipulation and can these side effects be predicted?. Manual therapy, 9(3), 151-156.
33. 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. BMC musculoskeletal disorders, 15(1), 77.
    • Professional Consensus to Classify Adverse Events
34. 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. Journal of Manual & Manipulative Therapy, 25(5), 279-287.
35. Carnes, D., Mullinger, B., & Underwood, M. (2010). Defining adverse events in manual therapies: a modified Delphi consensus study. Manual therapy, 15(1), 2-6
    • Force Necessary for Tissue Failure
36. 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. Spine, 29(21), 2382-2388.
37. 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. Journal of manipulative and physiological therapeutics, 34(5), 290-296.
38. Triano, J., & Schultz, A. B. (1997). Loads transmitted during lumbosacral spinal manipulative therapy. Spine, 22(17), 1955-1964.
39. 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) (pp. 1-4). IEEE.
    • Structural Damage Pre and Post Manipulation
40. 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. The Spine Journal, 5(3), 277-290.
41. Chrisman, O. D., Mittnacht, A., & Snook, G. A. (1964). A study of the results following rotatory manipulation in the lumbar intervertebral-disc syndrome. JBJS, 46(3), 517-524.
    • Cervical Manipulations Use Less Than Available Active ROM
42. 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. Musculoskeletal Science and Practice, 28, 18-24.
43. 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, 2017.
44. 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.
45. Salem, W., & Klein, P. (2013). In vivo 3D kinematics of the cervical spine segments during pre-manipulative positioning at the C4/C5 level. Manual therapy, 18(4), 321-326.
    • Vessel Dissection and Occlusion
46. Herzog, W., Tang, C., & Leonard, T. (2015). Internal carotid artery strains during high-speed, low-amplitude spinal manipulations of the neck. Journal of manipulative and physiological therapeutics, 38(9), 664-671.
47. 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. Journal of manipulative and physiological therapeutics, 37(1), 22-31.
48. Licht, P. B., Christensen, H. W., Højgaard, P., & Marving, J. (1998). Vertebral artery flow and spinal manipulation: a randomized, controlled and observer-blinded study. Journal of manipulative and physiological therapeutics, 21(3), 141-144.
49. 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. BioMed research international, 2019.
50. 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, 25, 2344.
    • Correlation or Causation:
51. Haneline, M. T., Croft, A. C., & Frishberg, B. M. (2003). Association of internal carotid artery dissection and chiropractic manipulation. The Neurologist, 9(1), 35-44.
52. 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, 32(2), S201-S208.
53. Haldeman, S., Kohlbeck, F. J., & McGregor, M. (2002). Stroke, cerebral artery dissection, and cervical spine manipulation therapy. Journal of neurology, 249(8), 1098-1104.
    • Relative Risk
54. 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, 27(1), 16-25.
55. 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. Journal of Manipulative and Physiological Therapeutics, 30(6), 408-418.
56. 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. Spine, 40(4), 264.
57. Dabbs, V., & 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.
    • Pre-manipulative Screening
58. Barker, S., Kesson, M., Ashmore, J., Turner, G., Conway, J., & Stevens, D. (2001). Guidance for pre-manipulative testing of the cervical spine. Physiotherapy, 87(6), 318-321.
59. Chaibi, A., & Russell, M. B. (2019). A risk–benefit assessment strategy to exclude cervical artery dissection in spinal manual-therapy: a comprehensive review. Annals of medicine, 51(2), 118-127.
60. 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. Physical therapy, 93(12), 1686-1695.
61. Mathews, J. A. (1969). Atlanto-axial subluxation in rheumatoid arthritis. Annals of the Rheumatic Diseases, 28(3), 260.
62. Uitvlugt, G., & Indenbaum, S. (1988). Clinical assessment of atlantoaxial instability using the sharp‐purser test. Arthritis & Rheumatism: Official Journal of the American College of Rheumatology, 31(7), 918-922.
63. Forrester, G. A., & Barlas, P. (1999). Reliability and Validity of the Sharp-Purser Test in the Assessment of Atlanto-axial Instability in Patients with Rheumatoid Arthritis. Physiotherapy, 85(7), 376.
64. Cattrysse, E., Swinkels, R. A. H. M., Oostendorp, R. A. B., & Duquet, W. (1997). Upper cervical instability: are clinical tests reliable?. Manual Therapy, 2(2), 91-97.
65. Kaale, B. R., Krakenes, J., Albrektsen, G., & Wester, K. (2008). Clinical assessment techniques for detecting ligament and membrane injuries in the upper cervical spine region—a comparison with MRI results. Manual therapy, 13(5), 397-403.
66. Cote, P., Kreitz, B. G., Cassidy, J. D., & Thiel, H. (1996). The validity of the extension-rotation test as a clinical screening procedure before neck manipulation: a secondary analysis. Journal of Manipulative and Physiological Therapeutics, 19(3), 159-164.