There is a common fear in treating the cervical spine (especially the upper portion) manually due to risk of injury. With the potential for damaging the vertebrobasilar artery system in the cervical spine, many people stray away from performing cervical manipulations. There have been a few situations where patients have died of ischemia following a cervical manipulation. The fatal reaction (and associated risk for lawsuit) to something that we can do as health care practitioners may discourage some from learning how to effectively apply manual therapy to the region. Is there really that much risk to injury? And what can we do to assess it?
As with any fatalities in the health care system, media (and other professional disciplines) will try to make the public aware of the risk for injury following a treatment. The same case applies to cervical manipulations. Some people have a somewhat irrational fear of this technique following media coverage and word of mouth. But how much risk is there really? NSAIDS have a .0004% annual mortality rate (Vizniak 2015). There is a .00005% chance of dying from a lightning strike each year. With cervical manipulations, there is a .00002% risk of death. This means you are more likely to die from taking NSAIDS or being struck by lightning than a cervical manipulation.
That being said, it is essential that proper patient selection is done before even considering this type of treatment technique. Start with patient history. Any patient with ligament laxity, rheumatoid arthritis, long-term corticosteroid use, osteoporosis/-penia, Down's Syndrome, osteoarthritis, and VBI be excluded. Naturally, we should perform our structural integrity tests and blood flow tests. We recently completed a review of the upper cervical spine that may prove beneficial reading as well. The structural integrity tests should at least include Transverse Ligament Test (and/or Sharp Purser Test), Alar Ligament Test, and a test for a Jefferson's Fracture. This last test is completed by compressing the transverse processes of the Atlas to assess for integrity. A positive test will occur with lack of stability or reproduction of neural symptoms. The artery test that is commonly performed is for Vertebrobasilar Insufficiency (VBI). While the test we show displays combined end-range motions, some say this is not necessary. With the manipulation techniques staying closer to mid-ranges, some suggest just performing complete rotation when assessing. In theory, combined rotation and extension significantly closes off the vertebral arteries greater than rotation alone.
Now, the real question is: should we perform the Vertebral Artery Test? A compilation of studies revealed that there is a 0% sensitivity and .67-.90% specificity for the test (Cope et al, 1996). What this tells us is that a negative test means absolutely nothing and a positive test means a patient may have VBI. The testing we perform cannot rule out or rule in VBI. Vertebrobasilar Insufficiency is essential to consider as many of the symptoms mimic other orthopaedic cervical spine conditions: headache, neck pain, etc. (along with more traditional VBI symptoms - see link for symptoms). Even though there is poor diagnostic accuracy associated with the Vertebral Artery Test, it is recommended that the test be performed. There is a traditional thought that the vertebrobasilar artery system be tested prior to any manual therapy, no matter how poor the test is. Due to the media's perception that cervical manipulations risk VBI, any sign of "negligence" by not performing the test would likely place blame on the practitioner. As with any treatment technique, evaluate each patient individually for the potential benefit and associated risk factors prior to performing. In addition to performing the VBI test, Jim and I agree that the therapist should perform a pre-manipulative hold prior to any thrust procedure. The pre-manipulative hold allows the therapist to see how the patient will respond to the manipulative position prior to performing the thrust technique. Finally, we recommend following that process up with a "gut check" as well. Is the risk of the technique worth the reward/ benefit the patient will experience? Not everyone needs or should have a manipulation, but there are some instances where it has been shown to be highly beneficial.
Cote P et al. J Manipulative Physiol Ther. 1996.
Vizniak, Nikita. Spinal Manual. Canada: Professional Health Systems, Inc, 2015. 156-157. Print.
James Heafner PT, DPT, OCS:
Owner and lead physical therapist at Heafner Health, cash-based physical therapy in Boulder, CO. Areas of expertise include orthopedic and manual therapy, functional movement, pain science, and movement science.
In May 2013, I earned my Doctorate in Physical Therapy from Saint Louis University. After graduating from the Harris Health Systems Orthopedic Residency in October 2014, I moved to Boulder, CO. Since living in Boulder, I have started my own cash-based PT practice, earned my OCS certification, and teach for the OPTIM Fellowship and COMT program in Houston TX and Scottsdale, AZ.
Chris Fox PT, DPT, OCS: Physical therapist at Foothills Sports Medicine & Physical Therapy in Scottsdale, AZ and regularly lectures at the Phoenix Campus for NAU's DPT program and for Optim Manual Therapy's COMT program. Completed multiple advanced manual therapy courses implementing aspects of biomechanical analysis. He received his DPT from Saint Louis University in 2013. Completed Scottsdale Healthcare's Orthopaedic Residency (now Honor Health) in July 2014. He became a Board Certified Orthopaedic Specialist in 2015. Level I Expert in FMS and SFMA , Kinetacore FDN Level 1 certification, and IASTM Technique course completion. He would like to pursue further education in McKenzie Technique, Dry Needling, Strength & Conditioning, Orthopaedic and Manual Therapy.
Brian Schwabe PT, DPT, SCS, CSCS:
- Board Certified Sports Physical Therapist (SCS) at Elite OrthoSport in Santa Monica, CA which specializes in treating collegiate/professional athletes and clientele from the Beverly Hills, Hollywood, and Santa Monica areas.
- USC Sports Residency Trained Physical Therapist (<1% of all PT's residency trained)
- DPT from Saint Louis University
- Future plans/interest include:
1. USAW, SFMA & Catapult Systems technology for NBA teams
2. Pursuing a position as a sports physical therapist &/or Strength coach for a Division 1 athletic medicine department or professional sport team.
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