Joint manipulation
Encyclopedia
Joint manipulation is a type of passive movement of a skeletal joint
. It is usually aimed at one or more 'target' synovial joint
s with the aim of achieving a therapeutic effect.
interventions such as joint mobilization
by its biomechanics
, both kinetics and kinematics
.
were described as consisting of three distinct phases: the preload (or prethrust) phase, the thrust phase, and the resolution phase. Evans and Breen added a fourth ‘orientation’ phase to describe the period during which the patient is oriented
into the appropriate position in preparation for the prethrust phase.
When individual peripheral synovial joints are manipulated, the distinct force-time phases that occur during spinal manipulation are not as evident. In particular, the rapid rate of change
of force that occurs during the thrust phase when spinal joints are manipulated
is not always necessary. Most studies to have measured forces used to manipulate peripheral joints, such as the metacarpophalangeal (MCP) joints, show no more than gradually increasing load
. This is probably because there are many more tissues restraining a spinal motion segment
than an independent MCP joint.
when one of its constituent spinal joints are manipulated
are much more complex than the kinematics that occur during manipulation of an independent peripheral synovial joint
. Even so, the motion that occurs between the articular surfaces of any individual synovial joint during manipulation should be very similar and is described below.
Early models
describing the kinematics of an individual target joint during the various phases of manipulation (notably Sandoz 1976) were based on studies that investigated joint cracking in MCP joints. The cracking was elicited by pulling the proximal phalanx away from the metacarpal bone (to separate, or 'gap' the articular surfaces of the MCP joint) with gradually increasing force until a sharp resistance, caused by the cohesive
properties of synovial fluid
, was met and then broken. These studies were therefore never designed to form models of therapeutic manipulation, and the models formed were erroneous in that they described the target joint as being configured at the end range
of a rotation
movement, during the orientation phase. The model then predicted that this end range position was maintained during the prethrust phase until the thrust phase where it was moved beyond the 'physiologic barrier' created by synovial fluid resistance; conveniently within the limits of anatomical integrity provided by restraining tissues such as the joint capsule and ligaments. This model still dominates the literature. However, after re-examining the original studies on which the kinematic models of joint manipulation were based, Evans and Breen argued that the optimal prethrust position is actually the equivalent of the neutral zone of the individual joint, which is the motion region of the joint where the passive osteoligamentous stability
mechanisms exert little or no influence. This new model predicted that the physiologic barrier is only confronted when the articular surfaces of the joint are separated (gapped, rather than the rolling
or sliding
that usually occurs during physiological motion), and that it is more mechanically efficient to do this when the joint is near to its neutral configuration.
occurring within the synovial fluid
of the joint. When a manipulation is performed, the applied force separates the articular surfaces of a fully encapsulated synovial joint. This deforms
the joint capsule and intra-articular tissues, which in turn creates a reduction in pressure within the joint cavity. In this low pressure environment, some of the gas
es that are dissolved in the synovial fluid
(which are naturally found in all bodily fluids) leave solution creating a bubble
or cavity
, which rapidly collapses upon itself, resulting in a 'clicking' sound. The contents of this gas bubble are thought to be mainly carbon dioxide
. The effects of this process will remain for a period of time termed the 'refractory period
', which can range from a few minutes to more than an hour, while it is slowly reabsorbed back into the synovial fluid. There is some evidence that ligament laxity
around the target joint is associated with an increased probability of cavitation.
Common side effect
s of spinal manipulative therapy (SMT) are characterized as mild to moderate and may include: local discomfort, headache, tiredness, or radiating discomfort.
Shekelle (1994) summarised the published theories for mechanism(s) of action for how joint manipulation may exert its clinical effects as the following:
and Europe, joint manipulation is most commonly performed by chiropractors, osteopathic physicians
and physical therapists. When applied to joints in the spine
, it is referred to as spinal manipulation
.
One form of manipulation is instrument-assisted mobilisation. It is based on established physiotherapy mobilising principles such as Mulligan's positional fault concept, facet joint glides and osteopathic upslope-downslope biomechanics. In the practice of physiotherapy instrument mobilisation, developed by an Australian physiotherapist, Timothy Mann, the instrument replicates mobilising and manipulative forces more accurately and reliably than other manual techniques.
; a term commonly used by physical therapists. Because of its distinct biomechanics (see section above), the term high velocity low amplitude (HVLA) is often used interchangeably with manipulation.
. Infrequent, but potentially serious side effects, include: vertebrobasilar accidents (VBA), stroke
s, spinal disc herniation
, vertebral and rib
fracture
s, and cauda equina syndrome
.
In a 1993 study, J.D. Cassidy, DC, and co-workers concluded that the treatment of lumbar intervertebral disk herniation by side posture manipulation is "both safe and effective."
s associated with manipulation of the cervical spine is uncertain, with widely differing results being published.
A 2008 study in the journal "Spine", JD Cassidy, E Boyle, P Cote', Y He, et al. investigated 818 VBA strokes that were hospitalized in a population of more than 100 million person-years. In those aged <45 years, cases were about three times more likely to see a chiropractor or a PCP before their stroke than controls. Results were similar in the case control and case cross over analyses. There was no increased association between chiropractic visits and VBA stroke in those older than 45 years. Positive associations were found between PCP visits and VBA stroke in all age groups. The study concluded that VBA stroke is a very rare event in the population. The increased risks of VBA stroke associated with chiropractic and PCP visits is likely due to patients with headache and neck pain from VBA dissection seeking care before their stroke. The study found no evidence of excess risk of VBA stroke associated chiropractic care compared to primary care.
A 1996 Danish chiropractic
study confirmed the risk of stroke to be low, and determined that the greatest risk is with manipulation of the first two vertebra of the cervical spine, particularly passive rotation
of the neck, known as the "master cervical" or "rotary break."
Serious complications after manipulation of the cervical spine are estimated to be 1 in 4 million manipulations or fewer. A RAND Corporation extensive review estimated "one in a million." Dvorak, in a survey of 203 practitioners of manual medicine in Switzerland, found a rate of one serious complication per 400,000 cervical manipulations, without any reported deaths, among an estimated 1.5 million cervical manipulations. Jaskoviak reported approximately 5 million cervical manipulations from 1965 to 1980 at The National College of Chiropractic Clinic in Chicago, without a single case of vertebral artery stroke or serious injury. Henderson and Cassidy performed a survey at the Canadian Memorial Chiropractic College outpatient clinic where more than a half-million treatments were given over a nine-year period, again without serious incident. Eder offered a report of 168,000 cervical manipulations over a 28 year period, again without a single significant complication. After an extensive literature review performed to formulate practice guidelines, the authors concurred that "the risk of serious neurological complications (from cervical manipulation) is extremely low, and is approximately one or two per million cervical manipulations."
In comparison, there is a 3-4% rate of complications for cervical spinal surgery
, and 4,000-10,000 deaths per million neck surgeries.
Understandably, vascular accidents are responsible for the major criticism of spinal manipulative therapy. However, it has been pointed out that "critics of manipulative therapy emphasize the possibility of serious injury, especially at the brain stem, due to arterial trauma after cervical manipulation. It has required only the very rare reporting of these accidents to malign a therapeutic procedure that, in experienced hands, gives beneficial results with few adverse side effects". In very rare instances, the manipulative adjustment to the cervical spine of a vulnerable patient becomes the final intrusive act which results in a very serious consequence.
surveyed neurologists in Britain for cases of serious neurological complications occurring within 24 hours of cervical spinal manipulation by various types of practitioners; 35 cases had been seen by the 24 neurologists who responded, but none of the cases had been reported. He concluded that underreporting was close to 100%, rendering estimates "nonsensical." He therefore suggested that "clinicians might tell their patients to adopt a cautious approach and avoid the type of spinal manipulation for which the risk seems greatest: forceful manipulation of the upper spine with a rotational element." The NHS Centre for Reviews and Dissemination stated that the survey had methodological problems with data collection. Both NHS and Ernst noted that bias is a problem with the survey method of data collection.
A 2001 study in the journal Stroke found that vertebrobasilar accidents (VBAs) were five times more likely in those aged less than 45 years who had visited a chiropractor in the preceding week, compared to controls who had not visited a chiropractor. No significant associations were found for those over 45 years. The authors concluded: "While our analysis is consistent with a positive association in young adults... The rarity of VBAs makes this association difficult to study despite high volumes of chiropractic treatment." The NHS notes that this study collected data objectively by using administrative data, involving less recall bias than survey studies, but the data were collected retrospectively and probably contained inaccuracies.
In 1996, Coulter et al. had a multidisciplinary group of 4 MDs, 4 DCs and 1 MD/DC look at 736 conditions where it was used. Their job was to evaluate the appropriateness of manipulation or mobilization of the cervical spine in those cases (including a few cases not performed by chiropractors).
"According to the report ... 57.6% of reported indications for cervical manipulation was considered inappropriate, with 31.3% uncertain. Only 11.1% could be labeled appropriate. A panel of chiropractors and medical practitioners concluded that '. . . much additional scientific data about the efficacy of cervical spine manipulation are needed.'"
This error was taken into account in a 1999 review of the scientific literature on the risks and benefits of manipulation of the cervical spine (MCS). Special care was taken, whenever possible, to correctly identify all the professions involved, as well as the type of manipulation responsible for any injuries and/or deaths. It analyzed 177 cases that were reported in 116 articles published between 1925 and 1997, and summarized:
In Figure 1 in the review, the types of injuries attributed to manipulation of the cervical spine are shown, and Figure 2 shows the type of practitioner involved in the resulting injury. For the purpose of comparison, the type of practitioner was adjusted according to the findings by Terrett.
The review concluded:
Edzard Ernst
has written:
joint manipulation can also refer to the process of bringing fragments of fractured bone or dislocated
joints into normal anatomical
alignment (otherwise known as 'reducing' the fracture or dislocation). These procedures have no relation to the HVLA thrust procedure.
Joint
A joint is the location at which two or more bones make contact. They are constructed to allow movement and provide mechanical support, and are classified structurally and functionally.-Classification:...
. It is usually aimed at one or more 'target' synovial joint
Synovial joint
A Synovial joint, also known as a diarthrosis, is the most common and most movable type of joint in the body of a mammal. As with most other joints, synovial joints achieve movement at the point of contact of the articulating bones....
s with the aim of achieving a therapeutic effect.
Biomechanics of joint manipulation
Manipulation can be distinguished from other manual therapyManual therapy
Manual therapy, manipulative therapy, or manual & manipulative therapy is a physical treatment primarily used by physiotherapists, chiropractors, osteopaths to treat musculoskeletal pain and disability; it most commonly includes massage therapy, joint mobilization and joint...
interventions such as joint mobilization
Joint mobilization
Joint mobilization is a type of passive movement of a skeletal joint. It is usually aimed at a 'target' synovial joint with the aim of achieving a therapeutic effect...
by its biomechanics
Biomechanics
Biomechanics is the application of mechanical principles to biological systems, such as humans, animals, plants, organs, and cells. Perhaps one of the best definitions was provided by Herbert Hatze in 1974: "Biomechanics is the study of the structure and function of biological systems by means of...
, both kinetics and kinematics
Kinematics
Kinematics is the branch of classical mechanics that describes the motion of bodies and systems without consideration of the forces that cause the motion....
.
Kinetics
Until recently, force-time histories measured during spinal manipulationSpinal manipulation
Spinal manipulation is a therapeutic intervention performed on spinal articulations which are synovial joints . These articulations in the spine that are amenable to spinal manipulative therapy include the z-joints, the atlanto-occipital, atlanto-axial, lumbosacral, sacroiliac, costotransverse...
were described as consisting of three distinct phases: the preload (or prethrust) phase, the thrust phase, and the resolution phase. Evans and Breen added a fourth ‘orientation’ phase to describe the period during which the patient is oriented
Orientation (geometry)
In geometry the orientation, angular position, or attitude of an object such as a line, plane or rigid body is part of the description of how it is placed in the space it is in....
into the appropriate position in preparation for the prethrust phase.
When individual peripheral synovial joints are manipulated, the distinct force-time phases that occur during spinal manipulation are not as evident. In particular, the rapid rate of change
Rate of change
Rate of change may refer to:* Derivative, rate of change in a mathematical function* Difference quotient, the difference between two output values divided by the difference between the corresponding input values...
of force that occurs during the thrust phase when spinal joints are manipulated
Spinal manipulation
Spinal manipulation is a therapeutic intervention performed on spinal articulations which are synovial joints . These articulations in the spine that are amenable to spinal manipulative therapy include the z-joints, the atlanto-occipital, atlanto-axial, lumbosacral, sacroiliac, costotransverse...
is not always necessary. Most studies to have measured forces used to manipulate peripheral joints, such as the metacarpophalangeal (MCP) joints, show no more than gradually increasing load
Structural load
Structural loads or actions are forces, deformations or accelerations applied to a structure or its components.Loads cause stresses, deformations and displacements in structures. Assessment of their effects is carried out by the methods of structural analysis...
. This is probably because there are many more tissues restraining a spinal motion segment
Functional spinal unit
A functional spinal unit is the smallest physiological motion unit of the spine to exhibit biomechanical characteristics similar to those of the entire spine....
than an independent MCP joint.
Kinematics
The kinematics of a complete spinal motion segmentFunctional spinal unit
A functional spinal unit is the smallest physiological motion unit of the spine to exhibit biomechanical characteristics similar to those of the entire spine....
when one of its constituent spinal joints are manipulated
Spinal manipulation
Spinal manipulation is a therapeutic intervention performed on spinal articulations which are synovial joints . These articulations in the spine that are amenable to spinal manipulative therapy include the z-joints, the atlanto-occipital, atlanto-axial, lumbosacral, sacroiliac, costotransverse...
are much more complex than the kinematics that occur during manipulation of an independent peripheral synovial joint
Synovial joint
A Synovial joint, also known as a diarthrosis, is the most common and most movable type of joint in the body of a mammal. As with most other joints, synovial joints achieve movement at the point of contact of the articulating bones....
. Even so, the motion that occurs between the articular surfaces of any individual synovial joint during manipulation should be very similar and is described below.
Early models
Scientific modelling
Scientific modelling is the process of generating abstract, conceptual, graphical and/or mathematical models. Science offers a growing collection of methods, techniques and theory about all kinds of specialized scientific modelling...
describing the kinematics of an individual target joint during the various phases of manipulation (notably Sandoz 1976) were based on studies that investigated joint cracking in MCP joints. The cracking was elicited by pulling the proximal phalanx away from the metacarpal bone (to separate, or 'gap' the articular surfaces of the MCP joint) with gradually increasing force until a sharp resistance, caused by the cohesive
Cohesion (chemistry)
Cohesion or cohesive attraction or cohesive force is the action or property of like molecules sticking together, being mutually attractive...
properties of synovial fluid
Synovial fluid
Synovial fluid is a viscous, non-Newtonian fluid found in the cavities of synovial joints. With its yolk-like consistency , the principal role of synovial fluid is to reduce friction between the articular cartilage of synovial joints during movement.-Overview:The inner membrane of synovial joints...
, was met and then broken. These studies were therefore never designed to form models of therapeutic manipulation, and the models formed were erroneous in that they described the target joint as being configured at the end range
Range of motion
Range of motion , is the distance that a movable object may normally travel while properly attached to another object. It is also called range of travel, particularly when talking about mechanical devices and in mechanical engineering fields...
of a rotation
Rotation
A rotation is a circular movement of an object around a center of rotation. A three-dimensional object rotates always around an imaginary line called a rotation axis. If the axis is within the body, and passes through its center of mass the body is said to rotate upon itself, or spin. A rotation...
movement, during the orientation phase. The model then predicted that this end range position was maintained during the prethrust phase until the thrust phase where it was moved beyond the 'physiologic barrier' created by synovial fluid resistance; conveniently within the limits of anatomical integrity provided by restraining tissues such as the joint capsule and ligaments. This model still dominates the literature. However, after re-examining the original studies on which the kinematic models of joint manipulation were based, Evans and Breen argued that the optimal prethrust position is actually the equivalent of the neutral zone of the individual joint, which is the motion region of the joint where the passive osteoligamentous stability
Joint stability
Joint stability refers to the resistance offered by various musculoskeletal tissues that surround a skeletal joint. Several subsystems ensure the stability of a joint. These are the passive, active and neural subsystems. The opposite of stability is instability...
mechanisms exert little or no influence. This new model predicted that the physiologic barrier is only confronted when the articular surfaces of the joint are separated (gapped, rather than the rolling
Rolling
Rolling is a combination of rotation and translation of that object with respect to a surface , such that the two are in contact with each other without sliding. This is achieved by a rotational speed at the cylinder or circle of contact which is equal to the translational speed...
or sliding
Sliding (motion)
Sliding is a type of frictional motion between two surfaces in contact. This can be contrasted to rolling motion. Both types of motion may occur in bearings....
that usually occurs during physiological motion), and that it is more mechanically efficient to do this when the joint is near to its neutral configuration.
Cracking joints
Joint manipulation is characteristically associated with the production of an audible 'clicking' or 'popping' sound. This sound is believed to be the result of a phenomenon known as cavitationCavitation
Cavitation is the formation and then immediate implosion of cavities in a liquidi.e. small liquid-free zones that are the consequence of forces acting upon the liquid...
occurring within the synovial fluid
Synovial fluid
Synovial fluid is a viscous, non-Newtonian fluid found in the cavities of synovial joints. With its yolk-like consistency , the principal role of synovial fluid is to reduce friction between the articular cartilage of synovial joints during movement.-Overview:The inner membrane of synovial joints...
of the joint. When a manipulation is performed, the applied force separates the articular surfaces of a fully encapsulated synovial joint. This deforms
Deformation (mechanics)
Deformation in continuum mechanics is the transformation of a body from a reference configuration to a current configuration. A configuration is a set containing the positions of all particles of the body...
the joint capsule and intra-articular tissues, which in turn creates a reduction in pressure within the joint cavity. In this low pressure environment, some of the gas
Gas
Gas is one of the three classical states of matter . Near absolute zero, a substance exists as a solid. As heat is added to this substance it melts into a liquid at its melting point , boils into a gas at its boiling point, and if heated high enough would enter a plasma state in which the electrons...
es that are dissolved in the synovial fluid
Synovial fluid
Synovial fluid is a viscous, non-Newtonian fluid found in the cavities of synovial joints. With its yolk-like consistency , the principal role of synovial fluid is to reduce friction between the articular cartilage of synovial joints during movement.-Overview:The inner membrane of synovial joints...
(which are naturally found in all bodily fluids) leave solution creating a bubble
Liquid bubble
A bubble is a globule of one substance in another, usually gas in a liquid.Due to the Marangoni effect, bubbles may remain intact when they reach the surface of the immersive substance.-Common examples:...
or cavity
Cavity
A cavity is a hole. It may refer to:*Dental cavity, damage to the structure of teeth*Body cavity, a fluid filled space in many animals where organs typically develop*Cavity wall, a wall consisting of two skins with a cavity....
, which rapidly collapses upon itself, resulting in a 'clicking' sound. The contents of this gas bubble are thought to be mainly carbon dioxide
Carbon dioxide
Carbon dioxide is a naturally occurring chemical compound composed of two oxygen atoms covalently bonded to a single carbon atom...
. The effects of this process will remain for a period of time termed the 'refractory period
Refractory period
In physiology, a refractory period is a period of time during which an organ or cell is incapable of repeating a particular action, or the amount of time it takes for an excitable membrane to be ready for a second stimulus once it returns to its resting state following an excitation...
', which can range from a few minutes to more than an hour, while it is slowly reabsorbed back into the synovial fluid. There is some evidence that ligament laxity
Ligamentous Laxity
Ligamentous laxity is a term given to describe "loose ligaments."In a 'normal' body, ligaments are naturally tight in such a way that the joints are restricted to 'normal' ranges of motion. This creates normal joint stability...
around the target joint is associated with an increased probability of cavitation.
Clinical effects and mechanisms of action
The clinical effects of joint manipulation have been shown to include:- Temporary relief of musculoskeletal pain.
- Shortened time to recover from acute backBack- People :* Adam Back, British cryptographer* Charles Back, South African winemaker* Chris Back , Australian politician* Ernst Emil Alexander Back , German physicist* Frédéric Back , Canadian animator...
sprains (Rand). - Temporary increase in passive range of motion (ROM).
- Physiological effects upon the central nervous system.
- No alteration of the position of the sacroiliac joint.
Common side effect
Adverse effect
In medicine, an adverse effect is a harmful and undesired effect resulting from a medication or other intervention such as surgery.An adverse effect may be termed a "side effect", when judged to be secondary to a main or therapeutic effect. If it results from an unsuitable or incorrect dosage or...
s of spinal manipulative therapy (SMT) are characterized as mild to moderate and may include: local discomfort, headache, tiredness, or radiating discomfort.
Shekelle (1994) summarised the published theories for mechanism(s) of action for how joint manipulation may exert its clinical effects as the following:
- Release of entrapped synovial folds or plica
- Relaxation of hypertonic muscle
- Disruption of articular or periarticular adhesions
- Unbuckling of motion segments that have undergone disproportionate displacement
Practice of manipulation
In the context of healthcare, joint manipulation is performed by several professional groups. In North AmericaNorth America
North America is a continent wholly within the Northern Hemisphere and almost wholly within the Western Hemisphere. It is also considered a northern subcontinent of the Americas...
and Europe, joint manipulation is most commonly performed by chiropractors, osteopathic physicians
Osteopathic medicine
Osteopathic medicine is a branch of the medical profession in the United States. Osteopathic physicians, known as DOs, are licensed to practice medicine and surgery in all 50 states and are recognized in forty-seven other countries, including most Canadian provinces.Frontier physician Andrew Taylor...
and physical therapists. When applied to joints in the spine
Vertebral column
In human anatomy, the vertebral column is a column usually consisting of 24 articulating vertebrae, and 9 fused vertebrae in the sacrum and the coccyx. It is situated in the dorsal aspect of the torso, separated by intervertebral discs...
, it is referred to as spinal manipulation
Spinal manipulation
Spinal manipulation is a therapeutic intervention performed on spinal articulations which are synovial joints . These articulations in the spine that are amenable to spinal manipulative therapy include the z-joints, the atlanto-occipital, atlanto-axial, lumbosacral, sacroiliac, costotransverse...
.
One form of manipulation is instrument-assisted mobilisation. It is based on established physiotherapy mobilising principles such as Mulligan's positional fault concept, facet joint glides and osteopathic upslope-downslope biomechanics. In the practice of physiotherapy instrument mobilisation, developed by an Australian physiotherapist, Timothy Mann, the instrument replicates mobilising and manipulative forces more accurately and reliably than other manual techniques.
Terminology
Manipulation is known by several other names. Chiropractors refer to manipulation of a spinal joint as an 'adjustment'. Following the labelling system developed by Geoffery Maitland, manipulation is synonymous with Grade V mobilizationJoint mobilization
Joint mobilization is a type of passive movement of a skeletal joint. It is usually aimed at a 'target' synovial joint with the aim of achieving a therapeutic effect...
; a term commonly used by physical therapists. Because of its distinct biomechanics (see section above), the term high velocity low amplitude (HVLA) is often used interchangeably with manipulation.
Safety issues
As with all interventions, there are risks associated with joint manipulation, especially manipulation of spinal jointsSpinal manipulation
Spinal manipulation is a therapeutic intervention performed on spinal articulations which are synovial joints . These articulations in the spine that are amenable to spinal manipulative therapy include the z-joints, the atlanto-occipital, atlanto-axial, lumbosacral, sacroiliac, costotransverse...
. Infrequent, but potentially serious side effects, include: vertebrobasilar accidents (VBA), stroke
Stroke
A stroke, previously known medically as a cerebrovascular accident , is the rapidly developing loss of brain function due to disturbance in the blood supply to the brain. This can be due to ischemia caused by blockage , or a hemorrhage...
s, spinal disc herniation
Spinal disc herniation
A spinal disc herniation , informally and misleadingly called a "slipped disc", is a medical condition affecting the spine due to trauma, lifting injuries, or idiopathic, in which a tear in the outer, fibrous ring of an intervertebral disc allows the soft, central portion A spinal disc herniation...
, vertebral and rib
Rib
In vertebrate anatomy, ribs are the long curved bones which form the rib cage. In most vertebrates, ribs surround the chest, enabling the lungs to expand and thus facilitate breathing by expanding the chest cavity. They serve to protect the lungs, heart, and other internal organs of the thorax...
fracture
Bone fracture
A bone fracture is a medical condition in which there is a break in the continuity of the bone...
s, and cauda equina syndrome
Cauda equina syndrome
Cauda equina syndrome ' is a serious neurologic condition in which there is acute loss of function of the lumbar plexus, neurologic elements of the spinal canal below the termination of the spinal cord.-Causes:...
.
In a 1993 study, J.D. Cassidy, DC, and co-workers concluded that the treatment of lumbar intervertebral disk herniation by side posture manipulation is "both safe and effective."
Risks of upper cervical manipulation
The degree of serious riskRisk
Risk is the potential that a chosen action or activity will lead to a loss . The notion implies that a choice having an influence on the outcome exists . Potential losses themselves may also be called "risks"...
s associated with manipulation of the cervical spine is uncertain, with widely differing results being published.
A 2008 study in the journal "Spine", JD Cassidy, E Boyle, P Cote', Y He, et al. investigated 818 VBA strokes that were hospitalized in a population of more than 100 million person-years. In those aged <45 years, cases were about three times more likely to see a chiropractor or a PCP before their stroke than controls. Results were similar in the case control and case cross over analyses. There was no increased association between chiropractic visits and VBA stroke in those older than 45 years. Positive associations were found between PCP visits and VBA stroke in all age groups. The study concluded that VBA stroke is a very rare event in the population. The increased risks of VBA stroke associated with chiropractic and PCP visits is likely due to patients with headache and neck pain from VBA dissection seeking care before their stroke. The study found no evidence of excess risk of VBA stroke associated chiropractic care compared to primary care.
A 1996 Danish chiropractic
Chiropractic
Chiropractic is a health care profession concerned with the diagnosis, treatment and prevention of disorders of the neuromusculoskeletal system and the effects of these disorders on general health. It is generally categorized as complementary and alternative medicine...
study confirmed the risk of stroke to be low, and determined that the greatest risk is with manipulation of the first two vertebra of the cervical spine, particularly passive rotation
Rotation
A rotation is a circular movement of an object around a center of rotation. A three-dimensional object rotates always around an imaginary line called a rotation axis. If the axis is within the body, and passes through its center of mass the body is said to rotate upon itself, or spin. A rotation...
of the neck, known as the "master cervical" or "rotary break."
Serious complications after manipulation of the cervical spine are estimated to be 1 in 4 million manipulations or fewer. A RAND Corporation extensive review estimated "one in a million." Dvorak, in a survey of 203 practitioners of manual medicine in Switzerland, found a rate of one serious complication per 400,000 cervical manipulations, without any reported deaths, among an estimated 1.5 million cervical manipulations. Jaskoviak reported approximately 5 million cervical manipulations from 1965 to 1980 at The National College of Chiropractic Clinic in Chicago, without a single case of vertebral artery stroke or serious injury. Henderson and Cassidy performed a survey at the Canadian Memorial Chiropractic College outpatient clinic where more than a half-million treatments were given over a nine-year period, again without serious incident. Eder offered a report of 168,000 cervical manipulations over a 28 year period, again without a single significant complication. After an extensive literature review performed to formulate practice guidelines, the authors concurred that "the risk of serious neurological complications (from cervical manipulation) is extremely low, and is approximately one or two per million cervical manipulations."
In comparison, there is a 3-4% rate of complications for cervical spinal surgery
Surgery
Surgery is an ancient medical specialty that uses operative manual and instrumental techniques on a patient to investigate and/or treat a pathological condition such as disease or injury, or to help improve bodily function or appearance.An act of performing surgery may be called a surgical...
, and 4,000-10,000 deaths per million neck surgeries.
Understandably, vascular accidents are responsible for the major criticism of spinal manipulative therapy. However, it has been pointed out that "critics of manipulative therapy emphasize the possibility of serious injury, especially at the brain stem, due to arterial trauma after cervical manipulation. It has required only the very rare reporting of these accidents to malign a therapeutic procedure that, in experienced hands, gives beneficial results with few adverse side effects". In very rare instances, the manipulative adjustment to the cervical spine of a vulnerable patient becomes the final intrusive act which results in a very serious consequence.
Potential for incident underreporting
Statistics on the reliability of incident reporting for injuries related to manipulation of the cervical spine vary. The RAND study assumed that only 1 in 10 cases would have been reported. However, Prof ErnstEdzard Ernst
Edzard Ernst is the first Professor of Complementary Medicine in the world, at the University of Exeter, England....
surveyed neurologists in Britain for cases of serious neurological complications occurring within 24 hours of cervical spinal manipulation by various types of practitioners; 35 cases had been seen by the 24 neurologists who responded, but none of the cases had been reported. He concluded that underreporting was close to 100%, rendering estimates "nonsensical." He therefore suggested that "clinicians might tell their patients to adopt a cautious approach and avoid the type of spinal manipulation for which the risk seems greatest: forceful manipulation of the upper spine with a rotational element." The NHS Centre for Reviews and Dissemination stated that the survey had methodological problems with data collection. Both NHS and Ernst noted that bias is a problem with the survey method of data collection.
A 2001 study in the journal Stroke found that vertebrobasilar accidents (VBAs) were five times more likely in those aged less than 45 years who had visited a chiropractor in the preceding week, compared to controls who had not visited a chiropractor. No significant associations were found for those over 45 years. The authors concluded: "While our analysis is consistent with a positive association in young adults... The rarity of VBAs makes this association difficult to study despite high volumes of chiropractic treatment." The NHS notes that this study collected data objectively by using administrative data, involving less recall bias than survey studies, but the data were collected retrospectively and probably contained inaccuracies.
In 1996, Coulter et al. had a multidisciplinary group of 4 MDs, 4 DCs and 1 MD/DC look at 736 conditions where it was used. Their job was to evaluate the appropriateness of manipulation or mobilization of the cervical spine in those cases (including a few cases not performed by chiropractors).
"According to the report ... 57.6% of reported indications for cervical manipulation was considered inappropriate, with 31.3% uncertain. Only 11.1% could be labeled appropriate. A panel of chiropractors and medical practitioners concluded that '. . . much additional scientific data about the efficacy of cervical spine manipulation are needed.'"
Misattribution problems
Studies of stroke and manipulation do not always clearly identify what professional has performed the manipulation. In some cases this has led to confusion and improper placement of blame. In a 1995 study, chiropractic researcher Allan Terrett, DC, pointed to this problem:- "The words chiropracticChiropracticChiropractic is a health care profession concerned with the diagnosis, treatment and prevention of disorders of the neuromusculoskeletal system and the effects of these disorders on general health. It is generally categorized as complementary and alternative medicine...
and chiropractor have been incorrectly used in numerous publications dealing with SMT injury by medical authors, respected medical journals and medical organizations. In many cases, this is not accidental; the authors had access to original reports that identified the practitioner involved as a nonchiropractor. The true incidence of such reporting cannot be determined. Such reporting adversely affects the reader's opinion of chiropractic and chiropractors."
This error was taken into account in a 1999 review of the scientific literature on the risks and benefits of manipulation of the cervical spine (MCS). Special care was taken, whenever possible, to correctly identify all the professions involved, as well as the type of manipulation responsible for any injuries and/or deaths. It analyzed 177 cases that were reported in 116 articles published between 1925 and 1997, and summarized:
- "The most frequently reported injuries involved arterial dissection or spasm, and lesions of the brain stem. Death occurred in 32 (18%) of the cases. Physical therapists were involved in less than 2% of the cases, and no deaths have been attributed to MCS provided by physical therapists. Although the risk of injury associated with MCS appears to be small, this type of therapy has the potential to expose patients to vertebral artery damage that can be avoided with the use of mobilization (nonthrust passive movements)."
In Figure 1 in the review, the types of injuries attributed to manipulation of the cervical spine are shown, and Figure 2 shows the type of practitioner involved in the resulting injury. For the purpose of comparison, the type of practitioner was adjusted according to the findings by Terrett.
The review concluded:
- "The literature does not demonstrate that the benefits of MCS outweigh the risks. Several recommendations for future studies and for the practice of MCS are discussed."
Edzard Ernst
Edzard Ernst
Edzard Ernst is the first Professor of Complementary Medicine in the world, at the University of Exeter, England....
has written:
- "...there is little evidence to demonstrate that spinal manipulation has any specific therapeutic effects. On the other hand, there is convincing evidence to show that it is associated with frequent, mild adverse effectsAdverse effect (medicine)In medicine, an adverse effect is a harmful and undesired effect resulting from a medication or other intervention such as surgery.An adverse effect may be termed a "side effect", when judged to be secondary to a main or therapeutic effect. If it results from an unsuitable or incorrect dosage or...
as well as with serious complications of unknown incidence. Therefore, it seems debatable whether the benefits of spinal manipulation outweigh its risks. Specific risk factors for vascular accidents related to spinal manipulation have not been identified, which means that any patient may be at risk, particularly those below 45 years of age. Definitive, prospective studies that can overcome the limitations of previous investigations are now a matter of urgency. Until they are available, clinicians might tell their patients to adopt a cautious approach and avoid the type of spinal manipulation for which the risk seems greatest: forceful manipulation of the upper spine with a rotational element."
Emergency medicine
In emergency medicineEmergency medicine
Emergency medicine is a medical specialty in which physicians care for patients with acute illnesses or injuries which require immediate medical attention. While not usually providing long-term or continuing care, emergency medicine physicians diagnose a variety of illnesses and undertake acute...
joint manipulation can also refer to the process of bringing fragments of fractured bone or dislocated
Dislocation (medicine)
Joint dislocation, or luxation , occurs when bones in a joint become displaced or misaligned. It is often caused by a sudden impact to the joint. The ligaments always become damaged as a result of a dislocation...
joints into normal anatomical
Anatomy
Anatomy is a branch of biology and medicine that is the consideration of the structure of living things. It is a general term that includes human anatomy, animal anatomy , and plant anatomy...
alignment (otherwise known as 'reducing' the fracture or dislocation). These procedures have no relation to the HVLA thrust procedure.
See also
- Orthopedic medicine
- Osteopathic manipulative medicineOsteopathic Manipulative MedicineOsteopathic Manipulative Medicine is the application of the distinct osteopathic philosophy, structural diagnosis and use of Osteopathic Manipulative Technique in the diagnosis and management of the patient. OMM takes into account the physical and mental health of a patient, and how either aspect...
- Physical therapyPhysical therapyPhysical therapy , often abbreviated PT, is a health care profession. Physical therapy is concerned with identifying and maximizing quality of life and movement potential within the spheres of promotion, prevention, diagnosis, treatment/intervention,and rehabilitation...
- Small joint manipulationSmall joint manipulationSmall joint manipulation, in grappling, refers to twisting, pulling or bending fingers or toes to cause joint locks in the various joints in those appendages...
Further reading
- Cyriax, J. Textbook of Orthopaedic Medicine, Vol. I: Diagnosis of Soft Tissue Lesions 8th ed. Bailliere Tindall, London, 1982.
- Cyriax, J. Textbook of Orthopaedic Medicine, Vol. II: Treatment by Manipulation, Massage and Injection 10th ed. Bailliere Tindall, London, 1983.
- Greive Modern Manual Therapy of the Vertebral Column. Harcourt Publishers Ltd., 1994
- Maitland, G.D. Peripheral Manipulation 2nd ed. Butterworths, London, 1977.
- Maitland, G.D. Vertebral Manipulation 5th ed. Butterworths, London, 1986.
- McKenzie, R.A. The Lumbar Spine; Mechanical Diagnosis and Therapy. Spinal Publications, Waikanae, New Zealand, 1981.
- McKenzie, R.A. The Cervical and Thoracic Spine; Mechanical Diagnosis and Therapy. Spinal Publications, Waikanae, New Zealand, 1990.
- Mennel, J.M. Joint Pain; Diagnosis and Treatment Using Manipulative Techniques. Little Brown and Co., Boston, 1964.
External links
- American Academy of Orthopedic Manual Physical Therapy (AAOMPT)
- Canadian Academy of Manipulative Therapy (CAMT)
- Canadian Orthopractic Manual Therapy Association (COMTA)
- International Federation of Orthopaedic Manipulative Therapists (IFOMT)
- Journal of Manual and Manipulative Therapy (JMMT)
- European Association of Advanced Manual and Manipulative Therapy