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Continuing Education2 Credits

Joint Mobilizations and Manipulations: Risk of Adverse Events

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.

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

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

Related Courses

Course Webinar: Are Manipulations Risky

Introduction: Position Stand and Summary

Research Summary

Survey Data, Reviews and Cases

4 sub-categories

Proposed Mechanisms of Injury

2 sub-categories

Correlation, Relative Risk and Screening

2 sub-categories


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1. Introduction: Position Stand

00:00 00:00