Article

HVLA thrust techniques: What are the risks?

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Abstract

High velocity low amplitude (HVLA) thrust techniques are amongst the most commonly used manipulative treatment techniques used by osteopaths. HVLA thrust techniques are considered potentially more dangerous when compared to non-impulse mobilisation type techniques because of the application of a rapid thrust or impulse. This has led to concerns as to the appropriateness of using HVLA thrust techniques in certain regions of the spine and in certain spinal pain presentations. Considerable research has been undertaken on both the effectiveness and potential adverse reactions arising from HVLA thrust techniques. This paper reviews the literature regarding the nature and incidence of transient and the more serious non-reversible impairments associated with the use of HVLA thrust techniques. Consideration is given to the efficacy and appropriateness of pre-manipulative vertebrobasilar artery screening protocols and suggestions are given as to ways in which practitioners may reduce perceived risk.

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... Reports of neurovascular complications associated with the use of cervical HVLA [5,6] could possibly cause hesitation among medical school faculty to teach and/or use these techniques, although the literature shows no evidence supporting or detracting from that theory. Although rare, complications have been reported to include spinal disc herniations, radiculopathies, hematomas, and diaphragmatic paralysis [2]. ...
... Although rare, complications have been reported to include spinal disc herniations, radiculopathies, hematomas, and diaphragmatic paralysis [2]. Although patients treated with cervical HVLA have been shown to experience no adverse complications [6], the potential risk of stroke is not zero [7]. An estimated one in 20,000 spinal manipulations have resulted in a vertebral artery dissection and ischemic infarction, but the exact incidence of this complication is unknown [8]. ...
... Educational and clinical behaviors might be altered if screening maneuvers could identify patients at increased risk for vertebral artery dissection and other neurovascular complications [7]. Unfortunately, current screening modalities demonstrate low sensitivity and specificity for identifying patients at risk for cerebrovascular events following spinal manipulation [6]. Patients with atherosclerotic vascular disease risk factors, such as diabetes or hypertension, do not appear to have an increased risk for stroke after spinal manipulation [13]. ...
Article
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Context Despite the documented effectiveness of high-velocity, low-amplitude (HVLA) treatment of the cervical spine, concerns about patient safety potentially limit didactic instruction and use in clinical practice. Understanding how cervical HVLA is taught and employed is of interest to osteopathic educators and clinicians. Objectives To characterize the perspectives of osteopathic manipulative medicine/osteopathic principles and practices (OMM/OPP) departments within colleges of osteopathic medicine (COMs) in the US regarding patterns of teaching and practice of HVLA treatment of the cervical spine. Methods A questionnaire was distributed on April 11, 2019 in paper format to OMM/OPP department chairs or designated faculty member attendees at the Educational Council on Osteopathic Principles biannual meeting. If the department chair was not available, the survey was provided to the faculty member designated to represent the Chair of the institution at ECOP. All respondents in this category returned the survey in paper before they left the meeting. The OMM/OPP department chairs who did not attend or send representatives to the ECOP meeting were sent the survey by email on April 11, 2019 and given three opportunities over 6 weeks at 2-week intervals to reply to this voluntary online survey. The survey was given or sent to a total of 51 OMM/OPP department chairs or representatives. Six questions elicited demographic information pertaining to status, age, gender, ethnicity, board-certified specialty, and COM affiliation. Nine questions examined perspectives related to the instruction of cervical HVLA manipulation and treatment. Results Of the 51 OMM/OPP department chairs surveyed, 38 (74.5%) responded, 32 to the paper survey at the ECOP meeting and six to the digital survey. Respondents were primarily dual Board-certified in Family Medicine and Neuromuscular Medicine (55.3%). At over 90% (35) of the COMs for which department chairs responded to the survey, cervical HVLA instruction occurs in the curriculum primarily during program years 1 and 2. Instruction in cervical HVLA to the 2nd through 7th cervical vertebral levels occurred in 97% (37), while 11% (4) of the COMs excluded the occipital-atlanto (OA) and atlanto-axial (AA) joints. A high percentage (81.6%; 31) of the OMM/OPP department chairs or representatives reported employing cervical HVLA techniques within their practice. Among the respondents, 40.5% (15) reported that 0–25% of their school’s medical school class could perform cervical HVLA competently upon graduation, whereas 27% (10) said that 51–75% of their class could perform cervical HVLA. Conclusions A majority of COMs provide education in their curricula related to cervical HVLA primarily in the first 2 years of medical education. However, instruction often excludes cervical HVLA to the upper regions of the cervical spine. At COMs where HVLA to the cervical spine is not taught, that decision is because the techniques are thought to be too difficult and the attendant medicolegal risk perceived to be too high. OMM/OPP department chairs expressed confidence in only a small proportion of their graduates having the ability to competently apply HVLA to the cervical spine immediately after completing their predoctoral medical training.
... Licciardone et al., (2005) in a systematic review and meta-analysis of randomized controlled trials of osteopathic manipulative therapy (OMT) 2 , suggest that the reduction in pain achieved from OMT can be attributable to manipulative techniques, such as HVLA, that are used. HVLA is one of the most commonly used manipulative technqiues (Gibbons & Tehan, 2006) and form of manual medicine applied (Greenman, 1996) Johnson and Kurtz (2003). Soft tissue technique is a direct technique, which usually involves lateral or linear stretching, deep pressure, traction or separation of the attachments of a muscle, which is continued until palpable change in the tissue or increased mobility in an articulation occurs (Greenman, 1996;Hartman, 2001;Ward, 2003). ...
... Die überwiegend analysierten Rotationsmanipulationen werden sowohl von der IFOMPT sowie von anderen internationalen manualtherapeutischen Standards seit Jahren nicht mehr empfohlen, da durch deren Einsatz in der Zervikalregion potentiell negative Auswirkungen auf die hirnversorgenden Blutgefäße resultieren (Cagnie, et al., 2006;Carlesso und Rivett, 2011;Ernst, 2004;Gibbons und Tehan, 2006;Guan, et al., 2019;Moser, et al., 2019;Puentedura, et al., 2012b;Rushton, et al., 2012;Schomacher, 2007). Zukünftige Studien, in denen zervikale Gelenkmanipulationen untersucht werden, sollten die diesbezüglichen Standards der IFOMPT berücksichtigen. ...
Thesis
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Hintergrund: Physiotherapeut*Innen verwenden die spinale Gelenkmanipulation u.a. zur Behandlung bestimmter arthrogener Dysfunktionen. Postmanipulativ verändert sich neben dem Schmerz- und Beweglichkeitsstatus häufig das Aktivierungsmuster bestimmter Muskeln. Ziele: Detektion kurzfristiger Auswirkungen spinaler Gelenkmanipulation auf die EMG-Aktivität, Schmerz und die aktive Beweglichkeit bei erwachsenen Menschen und der Unterschied zu anderen therapeutischen Maßnahmen. Design: Systematisches Review Informationsquellen: Primäre Informationsquellen (MEDLINE, EMBASE, CINAHL, PEDro), sekundäre Informationsquellen (Open Grey, Dart-Europe, Expertenbefragungen, clinicaltrials.gov, ICTRP, Referenzlisten) Auswahlkriterien: Design (RCTs, randomisierte Cross-Over-Studien), Spezies (Humanstudien), Sprachen (Deutsch, Englisch), Publikationszeitraum (01/2000 – 03/2020) Studienbewertung: Evidenzklassen nach CEBM (relative Beweiskraft), PEDro-Skala (methodologische Qualität), modifizierte CIRCLe SMT (interventionsspezifische Berichterstattung) Ergebnisse: Von insgesamt 901 Treffern wurden 13 Primärarbeiten mit akkumuliert 443 Proband*Innen zur Bearbeitung dieser systematischen Übersichtsarbeit inkludiert. Die vorliegende Arbeit konnte keine generalisierbare Aussage über die kurzfristigen Auswirkungen spinaler Gelenkmanipulation auf die EMG-Aktivität, Schmerzen und die aktive Beweglichkeit bei erwachsenen Menschen liefern, indizierte aber schwache Evidenz für jeden Ergebnisparameter. Das detektierte postmanipulative Aktivierungsverhalten der Muskulatur konnte sowohl exzitatorisch als auch inhibitorisch sein. Mittels Subgruppenanalysen wurde ein potentieller Einfluss der Krankheitsbilder auf die postmanipulative EMG-Aktivität eruiert. Es gibt moderate Evidenz dafür, dass eine lumbale Rotationsmanipulation bei Patient*Innen mit nichtspezifischen Rückenschmerzen zu einer signifikanten Reduktion der EMG-Aktivität der paravertebralen Muskulatur während des Haltens in voller Rumpfflexion und der Extensionsbewegung aus der vollen Flexion führt. Ebenso besteht moderate Evidenz dafür, dass eine lumbopelvine Rotationsmanipulation der betroffenen Seite bei Patient*Innen mit einem Patellofemoralen Schmerzsyndrom zu einem signifikanten An-stieg der EMG-Aktivität des M. gluteus medius führt. Schwache Evidenz besteht da-für, dass segmentspezifische Manipulationen im Bezug auf die EMG-Aktivität und Schmerzen keinen Benefit im Vergleich zu global ausgeführten Techniken bringen. Unklar bleibt, ob eine spinale Gelenkmanipulation kurzfristig signifikante Benefits im Vergleich zu Placebo-, Pseudoplacebo- oder anderen therapeutischen Kontrollinterventionen im Bezug auf die EMG-Aktivität, Schmerzen und die aktive Beweglichkeit bei erwachsenen Menschen bietet. Limitationen: Die methodologische Qualität über die Studien hinweg lag bei 5,77/10 Punkten und war mäßig. Das Risiko für Performance Bias über die Studien hinweg war sehr hoch. Das Risiko für Spectrum bzw. Detection Bias war moderat. Das Risiko der Verzerrungen aufgrund der interventionsspezifischen Berichterstattung über die Studien hinweg wurde als gering angesehen. Die individuellen Primär-arbeiten waren hinsichtlich der wichtigsten Studienmerkmale heterogen. Schlussfolgerungen: Die spinale Gelenkmanipulation soll allenfalls supportiv zur überwiegend aktiven Behandlung von veränderten muskulären Aktivierungsmustern, Schmerzen und Bewegungseinschränkungen eingesetzt werden. Die spinale Gelenkmanipulation eignet sich, um Patient*Innen bereits innerhalb einer Therapieeinheit die Adaptabilität des neuromuskuloskelettalen Systems bzw. die Modifikationsmöglichkeit für Symptome und Bewegung zu visualisieren. Somit kann weitere passive, assistive oder idealerweise aktive Bewegung fazilitiert werden. Registrationsnummer: PROSPERO - CRD42020160690 Stichworte: Spinale Gelenkmanipulation, EMG, Schmerz, aktive Beweglichkeit
... Whether to test for instability is therefore an important decision when suspecting CAD. The presence of instability is a clear contraindication to the use of OMT techniques (Gibbons and Tehan, 2006). ...
Chapter
In dit hoofdstuk worden de hoogcervicale wervelkolom (C0-C3) en het kaakgewricht besproken. Er is aandacht voor het screeningsproces, de risicofactoren, de verschillende behandelprofielen en de verschillende graden van nekpijn conform de KNGFAQ-richtlijn Nekpijn. Het belang van een professioneel klinisch redeneerproces voor deze regio is evident. Daarom zijn er vaker momenten van overweging tijdens de screening en het onderzoek om uiteindelijk te komen tot een ‘pluis’-gevoel, de juiste werkdiagnose en de keuze voor de juiste behandeling: preventief, curatief of palliatief. Ook het ‘pluis’-gevoel van de patiënt, het hebben van een diagnose en de instemming met de voorgestelde aanpak zijn hier van extra groot belang. Bij het bespreken van de anatomie van de hoogcervicale regio is er aandacht voor het bijzondere verloop van bloedvaten, zoals de arteria vertebralis. Speciale paragrafen zijn er over duizeligheid en hoofdpijn. Kennis over de ingenieuze hoogcervicale osteo- en artrokinematica is natuurlijk van groot belang voor de manueeltherapeut om de functiestoornissen te kunnen diagnosticeren, analyseren en ontrafelen. Het theoriegedeelte wordt afgesloten met de bouw en functie van het temporomandibulaire gewricht en de nomenclatuur van alle tanden en kiezen. Kaakbewegingen als depressie (elevatie), occlusie (detractie), protractie (protrusie), retractie (retrusie), laterotrusie en circumductie worden toegelicht en duidelijk geïllustreerd. Het hoofdstuk wordt afgesloten met de uitgebreide beschrijving van 33 technieken. Aan de hand van instructieve video’s, duidelijke foto’s en helder geformuleerde opmerkingen wordt duidelijk gemaakt hoe de manueeltherapeut klachten aan de hoogcervicale wervelkolom en het kaakgewricht kan onderzoeken en behandelen.
... Très peu d'auteurs indexent dans leurs études les événements ou effets indésirables des thérapies manuelles [14]. Néanmoins, il est admis que les manipulations ostéopathiques ou chiropratiques dans le traitement de la LNS (hors hernie discale lombaire) comportent des risques et des contraintes minimes lorsqu'elles sont réalisées par des manipulateurs bien entraînés [15,16]. En moyenne, des effets indésirables mineurs (tension locale, céphalées, asthénie, nausées etc.) s'installent dans les 4 heures et disparaissent dans les 24 heures suivant la manipulation vertébrale [17]. ...
Article
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Résumé La loi française autorise les ostéopathes et les chiropracteurs, ni médecins ni masseurs-kinésithérapeutes, à pratiquer des manipulations vertébrales sous certaines conditions. Compte-tenu du développement tous azimuts des soins manuels en France, cet article a pour but de présenter une synthèse narrative de littérature sur les manipulations vertébrales pratiquées chez l’adulte dans le traitement des lombalgies non spécifiques aiguës et chroniques. Quatorze revues systématiques dont dix avec méta-analyses ont été incluses. Les résultats de ces revues sont souvent contradictoires et décevants d’un point de vue pratique. Les manipulations vertébrales lato sensu ont une efficacité faible avec des effets très principalement à court terme sur la réduction de la douleur ou l’amélioration des indices algo-fonctionnels dans le traitement des lombalgies. L’hétérogénéité des définitions des lombalgies et des manipulations vertébrales est la première source de discordance entre auteurs. L’attention devrait être attirée dans le futur, sur une meilleure évaluation interculturelle des pratiques et plus de recherches intégrant des méthodologies rigoureuses par sous-groupes répondant à des règles de prédiction clinique.
... Whether to test for instability is therefore an important decision when suspecting CAD. The presence of instability is a clear contraindication to the use of OMT techniques (Gibbons and Tehan, 2006). ...
... Keinerlei Informationen werden zu Nebenwirkungen der Manualtherapie gegeben, obwohl der Manipulationsbehandlung ein höheres Risiko als mobilisierenden Techniken zugeschrieben wird (4,5,6). Das mag durch die Einhaltung der strikten Ausschlusskriterien bedingt sein. ...
Article
Kommentar Zur Publikation von Martinez-Segura R, Fernandez-de-la Penas C, Ruiz-Saez M et al. (2006) Immediate Effects on Neck Pain and Active Tange of Motion After a Single Cervical High-Velocity Low-Amplitude Manipulation in Subjects Presenting with Mechanical Neck Pain; A Randomized Controlled Trial. J Manipulative Physiol Ther 29: 511-517
... Many published studies have evaluated the indications, contraindications, risks, and effects of spinal manipulation [7][8][9][10][11][12]. Another focus of considerable attention has been the cracking sound heard during joint manipulation; however, most studies concerned the metacarpophalangeal joints [13], which are readily accessible and often emit cracking sounds [14]. ...
Article
Objectives: To examine beliefs about cracking sounds heard during high-velocity low-amplitude (HVLA) thrust spinal manipulation in individuals with and without personal experience of this technique. Methods: We included 100 individuals. Among them, 60 had no history of spinal manipulation, including 40 who were asymptomatic with or without a past history of spinal pain and 20 who had nonspecific spinal pain. The remaining 40 patients had a history of spinal manipulation; among them, 20 were asymptomatic and 20 had spinal pain. Participants attended a one-on-one interview during which they completed a questionnaire about their history of spinal manipulation and their beliefs regarding sounds heard during spinal manipulation. Results: Mean age was 43.5±15.4 years. The sounds were ascribed to vertebral repositioning by 49% of participants and to friction between two vertebras by 23% of participants; only 9% of participants correctly ascribed the sound to the release of gas. The sound was mistakenly considered to indicate successful spinal manipulation by 40% of participants. No differences in beliefs were found between the groups with and without a history of spinal manipulation. Conclusions: Certain beliefs have documented adverse effects. This study showed a high prevalence of unfounded beliefs regarding spinal manipulation. These beliefs deserve greater attention from healthcare providers, particularly those who practice spinal manipulation.
Article
•Spinal manipulation does help many people significantly particularly when combined with advice on exercise/active lifestyle.•The risks associated with SM appear to be small for the majority of problems presenting clinically, but for cervical spine manipulation, much more research on risk/benefit is urgently needed.•Spinal manipulation is not a panacea for all musculoskeletal pain, and the details of what type of people it helps most still requires considerable investigation.•Osteopathy must participate and take a lead in developing patient-centered evidence-based healthcare.
Article
A case of a delayed presentation of an elderly patient with cervical instability as a result of an odontoid peg fracture sustained in childhood is presented. Implications for osteopaths are discussed.
Article
Objectives The Research Council of the Australian Osteopathic Association (AOA) identified the need to gather data about the members of the Association as well as ‘who’ and ‘what’ they treat in order to guide strategic planning in research.
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Background When obtaining informed consent osteopaths should explain to patients the potential risks from treatment. However, relevant literature is lacking in this area and none relates to a teaching clinic environment.
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Despite the augmented use and dependence on manual therapy (MT), there are still calls from both within and outside the MT professions to provide robust evidence that spinal manipulative therapy (SMT) induces therapeutic effects beyond placebo. To facilitate this, placebo or ‘sham’ treatments, the development of which is notoriously difficult, must be used in rigorously controlled trials. The aim of this study was to investigate the suitability of different shams as controls in SMT trials. A repeated measures, single-blind, randomised trial was conducted on 10 asymptomatic subjects. Pain pressure thresholds (PPTs) were measured at 2 sites, local and systemic, before and after the application of either high-velocity low-amplitude thrust (HVLAT), sham functional technique (SFT), sham ultrasound (SUS) or no intervention control (NIC) to the cervico-thoracic (CT) junctional area. Treatment credibility was then assessed using a 4-point Likert Scale in response to 4 statements. Results demonstrated no significant change in PPT following any of the interventions, irrespective of site tested. The effect sizes for all interventions were considered small (d = <0.2). There were significant differences in Likert Scale responses for each statement (P < 0.001), with SUS eliciting significantly different responses as compared to SFT and NIC but not, predominantly, with HVLAT.
Article
Spinal cord injury is a rare complication of chiropractic treatment. This case report describes a 50-year-old man who developed neurological symptoms a few hours after manipulation (high velocity low amplitude [HVLA] technique) of the cervical spine. Magnetic resonance (MR) imaging of the cervical spine revealed intramedullary high signal at the C2/3 level of the right side of the cervical cord on the T2-weighted images. The potential mechanism of injury and causes of the radiological appearance are discussed.
Article
Osteopathic medicine is a profession that has existed for more than 130 years. However, the profession is poorly understood by many health care professionals. This article introduces osteopathic medicine, including similarities and differences between osteopathic physicians (DOs) and allopathic physicians (MDs). It describes osteopathic manipulative treatment (OMT), including the risks and many of the challenges faced while doing clinical research on OMT. Finally, the article reviews the research that has evaluated the effect of OMT on various medical conditions, including musculoskeletal, neurologic, respiratory, obstetric, gynecologic, and pediatric conditions.
Article
Background and objectivesCavitation sounds (‘cracks’, ‘clicks’ or ‘pops’) associated with spinal thrust manipulation are commonly observed in clinic. However, the literature is sparse regarding the location of cavitation sounds during thrust manipulation of the spine. The primary purpose of this study was to determine which side of the cervical spine cavitates during application of two different manipulative thrust techniques. A secondary purpose of the study was to compare the recorded cavitation sounds with the subjects' perceptions of the side of cavitation and their perceptions of the location of pre-thrust tension during all manipulations.
Article
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Introduction: Spinal and peripheral joint manipulation and mobilization are interventions used by many healthcare providers to manage musculoskeletal conditions. Although there are many reports of adverse events (or undesirable outcomes) following such interventions, there is no common definition for an adverse event or clarity on any severity classification. This impedes advances of patient safety initiatives and practice. This scoping review mapped the evidence of adverse event definitions and classification systems following spinal and peripheral joint manipulation and mobilization for musculoskeletal conditions in adults. Methods: An electronic search of the following databases was performed from inception to February 2021: Medline, Embase, CINHAL, Scopus, AMED, ICL, PEDro, Cochrane Library, Open Grey and Open Theses and Dissertations. Studies including adults (18 to 65 years old) with a musculoskeletal condition receiving spinal or peripheral joint manipulation or mobilization and providing an adverse event definition and/or classification were included. All study designs of peer-reviewed publications were considered. Data from included studies were charted using a standardized data extraction form and synthesized using narrative analysis. Results : From 8248 identified studies, 98 were included in the final synthesis. A direct definition for an adverse event and/or classification system was provided in 69 studies, while 29 provided an indirect definition and/or classification system. The most common descriptors to define an adverse event were causality, symptom severity, onset and duration. Twenty-three studies that provided a classification system described only the end anchors (e.g., mild/minor and/or serious) of the classification while 26 described multiple categories (e.g., moderate, severe). Conclusion: A vast array of terms, definition and classification systems were identified. There is no one common definition or classification for adverse events following spinal and peripheral joint manipulation and mobilization. Findings support the urgent need for consensus on the terms, definition and classification system for adverse events related to these interventions.
Article
Objectif Étudier l’efficacité et la sécurité de certaines méthodes alternatives à l’analgésie péridurale pour la gestion de la douleur pendant le travail. Matériel et méthodes Revue de la littérature à partir des bases de données Pubmed, Cochrane Library et Google Scholar interrogées jusqu’en mai 2012 sur les méthodes suivantes: acupuncture, acupression, ostéopathie, transcutaneous electrical nerve stimulation (TENS), méthodes de relaxation, phytothérapie et aromathérapie. Chacun de ces mots clés était associé au terme en anglais: « efficacité », « sécurité » ou « effets indésirables ». Résultats Cent vingt et un résumés ont été identifiés et 57 études ont été incluses dont sept relatives à la sécurité des méthodes étudiées. L’efficacité n’était pas encore prouvée pour l’aromathérapie, la phytothérapie, l’haptonomie et le TENS. Conclusion D’autres études semblent nécessaires pour évaluer notamment leur sécurité d’application.
Article
Introduction The aim of this study was to explore the information needs of osteopathic patients and practitioners with respect to understanding of risk and shared decision-making about care. Methods The study comprised two stages, (i) design of an evidence-based patient information leaflet on the risks and benefits of osteopathic treatment and (ii) pilot focus groups with patients and practitioners to test the leaflet and explore user perceptions. Thematic analysis was used to analyse the transcript of the discussions. Results Five main themes emerged from the thematic analysis of the discussions. Both patients and practitioners saw the need for change (Theme 1) but perceived a tension between providing more information on risk and benefit, versus allowing adequate time for hands-on treatment within the consultation. This conflict may be exacerbated by complex attitudes to risk (Theme 2), a need for more patient education about osteopathy (Theme 4) and the diverse information preferences of patients (Theme 5). Patients currently exercise choices about their care; they were more positive than practitioners about being provided with choice of treatment (Theme 3). Conclusions This pilot study provides a valuable basis for the design of further research in order to enhance shared decision making in osteopathic practice. Further research, development and evaluation of the leaflet are required.
Article
To systematically review cervical artery blood flow behaviour by duplex Doppler ultrasonography with different cervical movements often used during vascular premanipulative testing.MethodsPRISMA guidelines were followed to conduct this systematic review. Electronic search was carried out using the following databases: Pubmed, Web of Science, ScienceDirect, Scopus, IME, Dialnet, Lilacs, ENFISPO and AMED. Observational studies focussing on the duplex Doppler ultrasound measurements of cervical artery flow (VA or ICA) in different cervical positions were included. Studies selection was conducted by two reviewers who screened firstly for titles, then for abstracts and finally for full articles. The following data were extracted from the studies: author, year, sample, measurements and instruments, cervical movement and results.Results379 records were identified. Seven articles met the inclusion criteria and were considered for this systematic review. Five studies tested only vertebral artery flow, one study assessed internal carotid artery flow and the remaining study examined both. There is a lack of homogeneity concerning the samples included in the studies (age, sex and presence or absence of symptoms) and the methodology used for measuring blood flow. Four out of the seven studies did not obtain any significant decrease of cervical arteries blood flow in different neck positions, while the remaining three studies found a significant decrease of the contralateral vertebral artery blood flow.Conclusions Results of the studies included in this systematic review show no consensus. Further research and better methodological designs are required to analyze cervical artery blood flow behaviour with different neck movements and elucidate the role of vascular premanipulative testing.
Article
Objective: To assess the efficacy and safety of alternative therapies to epidural for pain management during labour. Materials and methods: A review was carried out by searching Pubmed, Cochrane Library databases and Google Scholar until May 2012. Search terms included acupuncture, acupressure, osteopathy, transcutaneous electrical nerve stimulation (TENS), relaxation, phytotherapy and aromatherapy. Each of these terms was associated with the keywords "efficacy", "safety" or "adverse event". Results: One hundred and twenty-one abstracts were identified and 57 studies were included. Among these studies, seven were related to alternative therapy safety. The efficacy was not proven for aromatherapy, phytotherapy, haptonomy and TENS. Conclusion: Further studies should be realized to particularly evaluate the safety of alternative therapies.
Article
Although national didactic criteria have been set for predoctoral education and assessment in osteopathic manipulative treatment, there is no criterion standard for teaching methods and assessments of osteopathic manipulative treatment competence in colleges of osteopathic medicine. This issue is more pressing with the creation of the single graduate medical education accreditation system by the American Osteopathic Association and Accreditation Council for Graduate Medical Education, which introduced the creation of "osteopathic recognition" for residencies that want to incorporate osteopathic principles and practice into their programs. Residencies with osteopathic recognition may include both osteopathic and allopathic graduates. Increased standardization at the predoctoral level, however, is recommended as osteopathic principles and practice training applications are expanded. The objectives of this article are to review the standards for teaching osteopathic medical students high-velocity, low-amplitude (HVLA) techniques for the spine; to review and discuss the methods used to assess medical students' proficiency in using HVLA; and to propose baseline standards for teaching and assessing HVLA techniques among medical students.
Article
Résumé Objectifs Examiner les représentations de la population vis-à-vis du craquement associé aux manipulations vertébrales (MV) de haute vélocité et basse amplitude (« thrust ») et comparer les croyances des sujets avec ou sans antécédents de MV. Méthodes Cent participants ont été inclus dans cette étude : 60 (groupe « no-MV ») sans antécédent de MV (40 sujets asymptomatiques avec ou sans antécédents de douleurs rachidiennes et 20 patients souffrant de douleurs rachidiennes non spécifiques) et 40 (groupe « MV ») avec antécédent de MV (20 sujets asymptomatiques et 20 patients). Tous les participants ont été conviés à une séance individuelle au cours de laquelle ils ont été soumis à un questionnaire au sujet de leurs antécédents de MV et de leurs croyances concernant le bruit associé aux MV. Résultats La population était âgée en moyenne de 43,5 ± 15,4 ans. La question relative à l’origine du bruit a indiqué que 49 % des participants pensent que le bruit résulte de la « remise en place d’une vertèbre » ou du « frottement entre deux vertèbres » (23 %) ; seuls 9 % des participants ont évoqué, à juste titre, la formation d’une bulle de gaz. Quarante pour cent des sujets ont expliqué à tort que le bruit signifiait qu’une manipulation était réussie. Aucune différence en termes de croyances n’a été mise en évidence entre les groupes « MV » et « no-MV ». Conclusions Compte tenu des effets délétères démontrés de certaines croyances, celles-ci, très présentes en ce qui concerne les MV comme en témoigne la présente étude, devraient être davantage prises en considération par les thérapeutes et plus particulièrement par ceux effectuant des MV.
Article
The National Council for Osteopathic Research (NCOR) welcomes Professor Ernst's interesting paper1 concerning safety and spinal manipulation (JRSM 2007;100:330-338). This is a topic taken very seriously by all osteopaths.
Article
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To determine the validity of the neck extension-rotation test as a clinical screening procedure to detect decreased vertebrobasilar blood flow that might be associated with dizziness. Secondary analysis of a clinical screening test. Twelve subjects with dizziness reproduced by the extension-rotation test and 30 healthy control subjects had Doppler ultrasonography examination of their vertebral arteries with the neck extended and rotated. Vascular impedance to blood flow was measured and the presence of signs and symptoms of vertebrobasilar ischemia was recorded. Cut-off points for validity estimates were derived through the percentile and Gaussian methods using impedance to blood flow as the standard. The sensitivity of the extension-rotation test for increased impedance to blood flow was 0%, regardless of the selected cut-off point. The specificity rates for the left vertebral artery were 71% and 67% for the percentile and Gaussian methods, respectively. The extension-rotation test was more specific on the right side, with a rate varying from 90% with the percentile method to 86% with the Gaussian technique. The positive predictive value of the test was 0% and its negative predictive value ranged from 63% to 97%. We were unable to demonstrate that the extension-rotation test is a valid clinical screening procedure to detect decreased blood flow in the vertebral artery. The value of this test for screening patients at risk of stroke after cervical manipulation is questionable.
Article
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To characterize the informed consent process in routine, primary care office practice. Cross-sectional, descriptive evaluation of audiotaped encounters. Offices of primary care physicians in Portland, Oregon. Internists (54%) and family physicians (46%), and their patients. Audiotapes of primary care office visits from a previous study of doctor-patient communication were coded for the number and type of clinical decisions made. The discussion between doctor and patient was scored according to six criteria for informed decision making: description of the nature of the decision, discussion of alternatives, discussion of risks and benefits, discussion of related uncertainties, assessment of the patient's understanding and elicitation of the patient's preference. Discussions leading to decisions included fewer than two of the six described elements of informed decision making (mean 1.23, median 1.0), most frequent of these was description of the nature of the decision (83% of discussion). Discussion of risks and benefits was less frequent (9%), and assessment of understanding was rare (2%). Discussions of management decisions were generally more substantive than discussions of diagnostic decisions (p = .05). Discussions leading to clinical decisions in these primary care settings did not fulfill the criteria considered integral to informed decision making. Physicians frequently described the nature of the decision, less frequently discussed risks and benefits, and rarely assessed the patient's understanding of the decision.
Article
We report on a 35-yr-old woman who became tetraplegic after manipulation of her neck, probably caused by ischemia of the brain stem due to mechanical compression of the vertebral artery or to a reflex spasm following forced rotation and reclination of the head. An inquiry among the members of the Swiss medical group for manual medicine furnished some data on morbidity due to manipulation (SAMM) of the neck in the last couple of years. In 1 of 40,000 cases, slight neurological complications were observed, and one important complication was observed in 1 of 400,000 manipulations.
Article
This review gives a survey of the risks and complications of cervical spine manipulation with special emphasis on vascular lesions. These center mainly on the vertebrobasilar system. Biomechanical aspects of the complications in relation to the therapy-induced movements (thrusts) of the cervical spine and the atlanto-occipital joints are summarized and discussed. It seems to emerge that major risks occur from forceful and vigorous movements resulting in extreme positions of the head, such as rotation and hyperextension. The most dangerous are twisting movements (rotation + extension + traction). Manipulation strategies should exclude thrusts of this kind to minimize the risk of complications.
Article
We report on a 35 year old woman who became paraplegic after manipulation to her neck, probably the result of ischemia of the brainstem due to mechanical compression of the vertebral artery or to a reflex spasm following forced rotation and reclination of the head. A survey among the members of the Swiss Society for Manual Medicine (SAMM) provided some data on morbidity resulting from manipulation to the neck within the past few years. In one out of 40,000 cases, slight neurological complications were observed, and one important complication was found in one out of 400,000 manipulative procedures.
Article
Complications during manipulative therapy are rare. A review of the literature indicates a relation between the nature of the manipulative therapy and severe complications. In 67% of the cases reviewed a chriopractor was involved. Proper diagnostic procedures could have prevented serious sequelae in the vast majority of the cases described.
Article
The vertebral artery may be injured by high stresses and strains in the segment C1-2 at which the elasticity of the vessel may be exceeded. For qualitative estimation of the elasticity and of changes in diameter of the lumen, the variation in the relative flow velocity per heart beat is evaluated by means of Doppler ultrasound at the C1-2 level as a function of the rotation of the head. In 62% of the disturbed flow patterns (n = 250) a decrease in the flow velocity profile is observed as a function of rotation of the neck. In 20% the flow velocity is increased. In both cases the lumen of the vertebral artery is narrowed to a different degree. In 18% of the disturbed flow patterns the flow velocity at the level C1-2 decreased on extension of the neck in the complex C2-7. This is due to the occlusion of the vessel in the segments C2-7. The relationship between the transmural pressure, the cross-sectional area and the elasticity is discussed and also the risky treatment techniques.
Article
In cases of cerebral vascular insufficiency there is a group in which insufficiency of the vertebral arteries can be recognized. The patient with this condition is usually over fifty years of age and complains of a variety of symptoms including dizziness or vertigo, diplopia and visual changes, transient weakness of the extremities, and sometimes a brief loss of consciousness. The clinical condition is readily explained by transient ischemia of the brain stem. Sometimes the symptoms can be provoked or aggravated by certain positions of the head on the neck. These include such mundane movements as are employed in watching an aircraft, hanging out the washing, and sitting in the barber's chair. In a few instances, the ischemic attack may be so consistently induced that the movement is recognized and avoided. It would appear that the position of the head on the neck in these patients might influence the vertebral arterial flow. Following a report of 3 cases, in 1 of which postmortem vertebral arteriography (...
Article
We applaud Musculoskeletal Physiotherapy Australia for the formulation of the new Pre-Manipulative guidelines. The new guidelines are a step forward from the previous protocol because they allow individual practitioners choice when making clinical decisions. The previous protocol proved to be legally challenging and further increased practitioners' fear of manipulating.
Article
Patients with clinical evidence of cerebral vascular insufficiency frequently relate that a particular head position may precipitate their symptoms. Usually, extension of the head, as in looking upward, or lateral rotation, as in looking over the shoulder, is mentioned. In a previous study1 we found that many such patients tolerated compression of a carotid artery when their heads were face forward but quickly developed signs and symptoms of insufficiency when carotid compression was repeated after the head had been turned to one side. In the past, those2,3 who have recognized this influence which head position can have upon response to carotid compression have usually attributed it to stimulation of a carotid sinus reflex mechanism or to local anatomical factors which permit more effective compression of the sinus when the head is rotated. In this paper we suggest that a more important factor may be change in blood flow
Article
This issue of the Journal includes a new feature: the 'AJP Forum'. The Editorial Board envisages that this feature will be used from time to time to provide a venue for expert comment on issues of importance for physiotherapy practice. The first Forum examines issues related to premanipulative testing of the cervical spine. It follows the Australian Physiotherapy Association's recent release of Clinical Guidelines for Pre-Manipulative Procedures for the Cervical Spine (Magarey et al 2000). The 2000 guidelines replace the protocol published in 1988.
Article
Study Design. Cervical spine manipulation and mobilization were reviewed in an analysis of the literature from 1966 to the present. Objectives. To assess the evidence for the efficacy and complications of cervical spine manipulation and mobilization for the treatment of neck pain and headache. Summary of Background Data. Although recent research has demonstrated the efficacy of spinal manipulation for some patients with low back pain, little is known about its efficacy for neck pain and headache. Methods. A structured search of four computerized bibliographic data bases was performed to identify articles on the efficacy and complications of cervical spine manual therapy. Data were summarized, and randomized controlled trials were critically appraised for study quality. The confidence profile method of meta-analysis was used to estimate the effect of spine manipulation on patients' pain status. Results. Two of three randomized controlled trials showed a short-term benefit for cervical mobilization for acute neck pain. The combination of three of the randomized controlled trials comparing spinal manipulation with other therapies for patients with subacute or chronic neck pain showed an improvement on a 100-mm visual analogue scale of pain at 3 weeks of 12.6 mm (95% confidence interval, -0.15, 25.5) for manipulation compared with muscle relaxants or usual medical care. The highest quality randomized controlled trial demonstrated that spinal manipulation provided short-term relief for patients with tension-type headache. The complication rate for cervical spine manipulation is estimated to be between 5 and 10 per 10 million manipulations. Conclusions. Cervical spine manipulation and mobilization probably provide at least short-term benefits for some patients with neck pain and headaches. Although the complication rate of manipulation is small, the potential for adverse outcomes must be considered because of the possibility of permanent impairment or death.
Article
The purpose of this study was to assess blood flow velocity in the vertebral arteries with duplex Doppler ultrasound during various positions of the head and neck. Vertebral artery morphology and blood flow velocity were assessed in a control group and in a group of subjects who displayed clinical signs and symptoms of vertebrobasilar insufficiency. The two groups did not differ in vertebral artery gross morphology as assessed by ultrasound. The arteries were examined for vascular impedance by calculating the ratio of peak systolic velocity to end diastolic velocity (systolic/diastolic ratio). In the context of this study, a lower velocity ratio implied less resistance to vascular flow. These velocity ratios were established during several positions of the head and neck, including a widely used provocational test manoeuvre for vertebrobasilar insufficiency. No meaningful significant differences in mean velocity ratios were found between the two groups. None of the subjects had abnormal spectral flow patterns during the different testing positions.
Article
Une enquête a été entreprise auprès de tous les membres de la Société Médicale Suisse de Médecine Manuelle au cours de l'année 1989. 425 correspondants ont apporté des données instructives sur la fréquence des complications rachidiennes imputables aux manipulations vertébrales. Le nombre total des manipulations au cours de l'année 1989 (225 jours ouvrables), s'élevait pour chuque correspondant à 805 manipulations thoracolombaires et 354 manipulations cervicales. Par conséquent le nombre total de manipulations thoraco-lombaires s'élevait à 342 125 et celui des manipulations cervicales à 150 450. La fréquence globale des effects secondaires ou des complications transitoires dues aux manipulations du rachis cervical tels qu'une altération de la conscience ou l'installation de signes radiculaires a été de 1:16716. 17 patients (1:20 125) ont présenté après une manipulation du rachis lombaire, en plus de l'accentuation de l'intensité douloureuse, un déficit sensitivomoteur de topographie radiculaire précise. Neuf parmi ces 17 patients (1:38013) ont développé un syndrome radiculaire progressif avec un déficit sensitivo-moteur et une hernie discale mise en évidence par l'imagerie, nécessitant une intervention chirurgicale. Les effets secondaires et les comlications des manipulations cervicales et lombaires sont rares. Si l'on prend en compte le nombre annuel de manipulations effectuées en Suisse par un seul médecin et le taux de complications, on peut calculer qu'un médecin pratiquant la médecine manuelle, verra une complication due à une manipulation du rachis cervical en 47 années d'exercice individuel et une complication due à une manipulation du rachis lombaire en 38 années d'exercice. Cependant, il est important d'effectuer une évaluation clinique soigneuse afin d'éviter les complications dues à des indications inappropriées. Aussi la décision de la technique à mettre en œuvre dans un trouble fonctionnel donné du rachis, doit être prise sur des critères rationnels basés sur la connaissance de la biomécanique clinique, de l'anatomie fonctionnelle et de la neurophysiologie. Les auteurs recommandent une étude prospective de la morbidité, entreprise chez les médecins, chiropractors, ostéopathes et kinésithérapeutes, et prenant en compte les différentes indications et techniques thérapeutiques rapportées à leurs complications.
Article
This guidance has been a joint venture by the Manipulation Association of Chartered Physiotherapists and the Society of Orthopaedic Medicine to provide an evidence-based approach to vertebrobasilar insufficiency testing before manipulation. The guidance highlights signs and symptoms that should be considered in the light of present research. Evidence to support this guidance is provided. A flowchart to represent the process is included.
Article
Despite the many published randomized clinical trials (RCTs), a substantial number of reviews and several national clinical guidelines, much controversy still remains regarding the evidence for or against efficacy of spinal manipulation for low back pain and neck pain.
Article
Objectives: To review the scientific evidence for both manipulation and mobilization therapies for the cervical spine. This report presents the results from a review of the medical, chiropractic, osteopathic, physical therapy, and dental literature on the efficacy, complications, and indications for manipulation and mobilization of the cervical spine, and the appropriateness ratings of indications for manipulation and mobilization. Methods: Articles were identified through searches of computerized databases [MEDLINE [Index Medicus], CHIROLARS [Chiropractic Literature Analysis and Retrieval System] etc.], review of article's bibliographies, and advice from experts. This yielded 362 primary articles on cervical spine manual therapy and 145 articles on complications. Priority was given to research that used randomized, controlled trial [RCT] designs. Second priority was given to non-experimental studies including cohort, case-control, and cross sectional studies. Case series and case reports were given lowes...
Book
This book covers the major applications of vascular ultrasonography, including cerebral, extremity, and abdominal vascular diagnosis. Hemodynamics, physics, instrumentation, the cerebrovascular system, the extremity vasculature, the abdominal vasculature, and postoperative vascular examination are all covered. The rational for examination, the technique for examination, and both normal and abnormal findings are discussed for each major application. Illustrative case examples are provided in the chapters that deal with cerebrovascular and extremity diagnostic problems.
Article
Understanding the risks and benefits of manipulation of the cervical spine is essential in developing effective and safe intervention strategies for patients with cervical spine pain. A review of the literature was performed to assess the effectiveness, benefits, and risks as well as the prudence of performing manipulation to the cervical spine as it relates to vertebral artery injury.
Article
Complications or adverse responses to cervical spine manipulation, particularly neurovascular compromise, are well documented in the literature. However, the rate of incidence of such adverse responses in manipulative physiotherapy has not been documented, indicating a need for well-designed prospective studies to accurately determine the associated risk of these procedures. To this end, a pilot study trialling a prospective adverse response reporting system was undertaken over a three month period in New Zealand. Twenty manipulative physiotherapists were approached to participate by reporting and describing any adverse responses to cervical spine manipulation they experienced over this time. Nine manipulative physiotherapists were able to participate and reported only one minor incident, a temporary, mild exacerbation of neck pain. It was calculated that the incidence rate for this study was 0.21% per manipulation and 0.42% per patient. The sole notable problem encountered with the methodology was the moderate response rate.
Article
Complications of cervical spine manipulation (CSM) have been documented in the literature for over half a century. Most incidents involve neurovascular compromise resulting from trauma of the vertebral artery or less frequently the internal carotid artery. The determination of the incidence rate or degree of risk of this complication is of crucial importance in clinical decision making regarding CSM. To this end a critical review of published case reports and studies investigating the event rate of stroke associated with CSM is undertaken. It is concluded that the case reports in the literature are not representative of the frequency of neurovascular complications. Methodological limitations of past research on this topic are discussed, as is the need for a prospective study. Despite these considerations it is found that marked neurological sequelae to CSM are an uncommon event for which the level of risk may be further reduced by prudent practice.
Article
Biomechanics is the science that deals with the external and internal forces acting on biological systems and the effects produced by these forces. Here, we describe the forces exerted by chiropractors on patients during high-speed, low-amplitude manipulations of the spine and the physiological responses produced by the treatments. The external forces were found to vary greatly among clinicians and locations of treatment on the spine. Spinal manipulative treatments produced reflex responses far from the treatment site, caused movements of vertebral bodies in the "para-physiological" zone, and were associated with cavitation of facet joints. Stresses and strains on the vertebral artery during chiropractic spinal manipulation of the neck were always much smaller than those produced during passive range of motion testing and diagnostic procedures.
Article
A survey of all members of the Swiss Medical Association of Manual Medicine was undertaken for the year 1989. Informative data were given by 425 respondents on the frequency of complications of manipulation as related to the spine. The number of thoraco-lumbar manipulations during 1989 (225 working days) was 805 for each respondent, and the number manipulations of the cervical spine 354. Thus, the total number of thoraco-lumbar manipulations was 342125, and the total number of cervical manipulations was 150450. The overall incidence of side-effects of transient complications due to cervical spine manipulation such as disturbance of consciousness or radicular signs was 1:16716. Seventeen patients (ratio 1:20125) after manipulation of the lumbar spine presented, in addition to increased pain, a transient sensorimotor deficit with precise radicular distribution. Nine of the 17 patients (ratio 1:38013) developed a progressive radicular syndrome with sensorimotor defict and radiologically verified disc herniation and had to be referred for surgery. Side effects and com- plications of cervical and lumbar spine manipulation are rare. Taking in to account the yearly number of manipulations performed by a single physician in Switzerland and the rate of complications, it can be calculated that a physician practicing manual medicine will encoutner one complication due to manipulation of the cervical spine in 47 years and one complication due to lumbar spine manipulation in 38 years of practice. However, it is important that a careful clinical assessment is carried out to avoid complications due to manipulation carried out on the basis of inappropriate indications. Furthermore, the decision as to which technique is indicated for any particular functional disorder of the spine should be made on the basis of rational criteria resting on a knowledge of clinical biomechanics, functional anatomy and neurophysiology. The authors recommend a prospective morbidity study to be carried out among physicians, chiropractors, osteopaths and physiotherapists, taking into account the different indications and therapeutic techniques in relation to complications.
Article
Cauda equina syndrome has been implicated as a potential complication of spinal manipulation. A review of the literature from 1911 to 1989 revealed ten reported cases of cauda equina syndrome in patients undergoing manipulation without anesthesia. This article presents three new cases where a temporal association was found between the onset of cauda equina symptoms and lumbar manipulation. The type of manipulation administered and the relationship between the treatment and symptoms is reviewed. In each of these cases both the chiropractic practitioner and the emergency room physician failed to comprehend the nature of the problem and take appropriate action. As a consequence, the patients went untreated for several days. This may have led to residual symptomatology. It is concluded that patients who present with bowel or bladder disturbances, leg weakness, or rectal and genital sensory changes after manipulation, be recognized as experiencing a cauda equina syndrome.
Article
A case report is presented of a patient with vertebral artery occlusion, demonstrated by digital subtraction angiography, in whom clinical tests designed to test for potential vertebrobasilar insufficiency were negative. The clinical tests used to examine our patient included the vertebrobasilar artery functional maneuver, the Smith and Estridge, Maigne's, Hautand's and Underberge's tests. This case report highlights the limited diagnostic value of these tests.
Article
Despite the recent dramatic increase in the use of video for patient education, there has been no critical assessment of this medium. In this paper, the author reviews 25 methodologically-sound studies in order to define the efficacy and limitations of video. Video is as good as and often more effective than traditional methods of patient education in increasing short-term knowledge. It offers no advantage, however, in improving long-term retention of knowledge or in promoting compliance with medical regimens. A strength of video is role-modeling. When applied to well-defined, self-limited stressful situations, role-modeling in video decreases patients' anxiety, pain, and sympathetic arousal while increasing knowledge, cooperation, and coping ability. These effects may carry over for patients to less structured but similarly stressful situations.
Article
We studied the characteristics of headaches in 161 consecutive symptomatic patients with spontaneous dissections of the internal carotid artery (n = 135) or the vertebral artery (n = 26). For patients with internal carotid artery dissection (ICAD), the mean age was 47 years and for those with vertebral artery dissection (VAD), 40.7 years. A history of migraine was present in 18% of the ICAD group and in 23% of the VAD group. Headache was reported by 68% of the patients with ICAD and by 69% of those with VAD, and, when present, it was the initial manifestation in 47% of those with ICAD and in 33% of those with VAD. Ten percent of patients with ICAD had eye, facial, or ear pain without headache. The median interval from onset of headache to development of other neurologic manifestations was 4 days for the ICAD group and 14.5 hours for the VAD group. For all dissections, headaches typically were ipsilateral to the side of dissection. In the ICAD group, headaches were limited to the anterior head in 60% of patients and were steady in 73% and pulsating in 25%. In the VAD group, headaches were distributed posteriorly in 83% of patients and were steady in 56% and pulsating in 44%. Neck pain was present in 26% of patients with ICAD (anterolateral) and in 46% of those with VAD (posterior). The median duration of the headache in patients with VAD and ICAD was 72 hours, but headaches became prolonged, persisting for months to years, in four patients with ICAD.
Article
To obtain an estimate of how often practicing neurologists in California encounter unexpected strokes, myelopathies, or radiculopathies following chiropractic manipulation, we surveyed each member of the American Academy of Neurology in California and inquired about the number of patients evaluated over the preceding 2 years who suffered a neurologic complication within 24 hours of chiropractic manipulation. Four hundred eighty-six neurologists were surveyed, 177 responded; 55 strokes, 16 myelopathies, and 30 radiculopathies were reported. Patients were between the ages of 21 and 60, and the majority experienced complications following cervical manipulation. Most of the patients continued to have persistent neurologic deficits 3 months after the onset, and about one-half had marked or severe deficits. Nearly all of the strokes involved the posterior circulation and almost one-half were angiographically proven. Patients, physicians, and chiropractors should be aware of the risk of neurologic complications associated with chiropractic manipulation.
Article
The purpose of this study was to investigate the validity of cervical spine rotation as a test of patency of the vertebral arteries (VAs) and the internal carotid arteries (ICAs). A descriptive study was undertaken. Testing was carried out in a private clinical vascular unit attached to a large Sydney public hospital. Twenty healthy volunteers, both male and female, who were free of risk factors commonly associated with vascular disease, participated in the study. An AutoSector 5 Duplex Doppler ultrasound instrument was used to record mean and peak frequency of blood flow (a measure of blood velocity) in the right and left VAs and ICAs in the cervical spine positions of neutral, 45 degrees contralateral rotation and full range contralateral rotation. To determine general hemodynamic stability, blood pressure and heart rate were recorded pre- and posttest, as well as in all tested positions. There was a significant trend for blood velocity to increase in 45 degrees contralateral rotation and to decrease in full rotation (p < .01). This trend was not consistent across vessels. Blood velocity decreased with rotation from neutral head position in the right VA, and continued to increase throughout rotation in the right ICA. It appears that sustained rotation influences blood velocity in the extracranial vessels. This may have relevance in patients with abnormal blood flow who are candidates for cervical manipulation.
Article
Approximately 12 million Americans undergo spinal manipulation therapy (SMT) every year. Renewed interest in this method requires an analysis of its reported risks and possible benefits. This review describes two patients with spinal cord injuries associated with SMT and establishes the risk/benefit ratios for patients with lumbar or cervical pain. The first case is a man who underwent SMT for recurrent sciatica 4 years after chemonucleolysis. During therapy, he developed bilateral sciatica with urinary hesitancy. After self-referral, myelography demonstrated a total block; he underwent urgent discectomy with an excellent result 3 months after surgery. The second patient with an indwelling Broviac catheter and a history of lumbar osteomyelitis underwent SMT for neck pain. Therapy continued for 3 weeks despite the development of severe quadriparesis. After self-referral, he underwent an urgent anterior cervical decompression and removal of necrotic bone and an epidural abscess with partial neurological recovery. An analysis of these cases and 138 cases reported in the literature demonstrates six risk factors associated with complications of SMT. These include misdiagnosis, failure to recognize the onset or progression of neurological signs or symptoms, improper technique, SMT performed in the presence of a coagulation disorder or herniated nucleus pulposus, and manipulation of the cervical spine. Clinical trials of SMT have been summarized in several recent articles.(ABSTRACT TRUNCATED AT 250 WORDS)
Article
We reviewed the literature to evaluate the risk of serious injury or death resulting from cervical manipulation and to assess the evidence that cervical manipulation is an effective treatment for mechanical neck pain. We also reviewed the literature to assess the risks and effectiveness of nonsteroidal anti-inflammatory drugs (NSAIDs), which are often used as the "conventional" first-line treatment for similar musculoskeletal conditions. A series of Medicine literature searches were performed, and materials were reviewed from 1966-1994. Key words included: Chiropractic or Orthopedic Manipulation; Non-Steroidal Anti-Inflammatory Agents; Neck or Back Pain; Randomized Controlled Trials; Adverse Effects. Studies and literature reviews that provided a numerical estimate of the risk of serious adverse effects or death from cervical manipulation or NSAID use were selected. Also, randomized, controlled studies that evaluated the effectiveness of manipulation or NSAID use for neck pain were included. Although there are a small number of well-performed trials of cervical manipulation for neck pain, we were unable to locate even a single randomized, controlled trial examining NSAID use specifically for neck pain. As for comparative safety, the best available evidence indicates that NSAID use poses a significantly greater risk of serious complications and death than the use of cervical manipulation for comparable conditions. The best evidence indicates that cervical manipulation for neck pain is much safer than the use of NSAIDs, by as much as a factor of several hundred times. There is no evidence tha indicates NSAID use is any more effective than cervical manipulation for neck pain.
Article
Many osteopathic medical students and physicians have an inherent fear of injuring patients when they perform osteopathic manipulative treatment (OMT). Based on the estimated several hundred million treatments performed each year in the United States as well as a review of the literature over the past six decades, only 185 reports of injury were found. However, besides good training in these techniques, the key to the safety of OMT is the taking of a thorough patient history and performing a thorough physical examination before the application of any manipulative procedure.
Article
Cervical spine manipulation and mobilization were reviewed in an analysis of the literature from 1966 to the present. To assess the evidence for the efficacy and complications of cervical spine manipulation and mobilization for the treatment of neck pain and headache. Although recent research has demonstrated the efficacy of spinal manipulation for some patients with low back pain, little is known about its efficacy for neck pain and headache. A structured search of four computerized bibliographic data bases was performed to identify articles on the efficacy and complications of cervical spine manual therapy. Data were summarized, and randomized controlled trials were critically appraised for study quality. The confidence profile method of meta-analysis was used to estimate the effect of spinal manipulation on patients' pain status. Two of three randomized controlled trials showed a short-term benefit for cervical mobilization for acute neck pain. The combination of three of the randomized controlled trials comparing spinal manipulation with other therapies for patients with subacute or chronic neck pain showed an improvement on a 100-mm visual analogue scale of pain at 3 weeks of 12.6 mm (95% confidence interval, -0.15, 25.5) for manipulation compared with muscle relaxants or usual medical care. The highest quality randomized controlled trial demonstrated that spinal manipulation provided short-term relief for patients with tension-type headache. The complication rate for cervical spine manipulation is estimated to be between 5 and 10 per 10 million manipulations. Cervical spine manipulation and mobilization probably provide at least short-term benefits for some patients with neck pain and headaches. Although the complication rate of manipulation is small, the potential for adverse outcomes must be considered because of the possibility of permanent impairment or death.
Article
To determine the effects of cervical contralateral rotation and cervical contralateral lateral flexion on vertebral artery blood flow velocity. A prospective study was performed at a private chiropractic clinic. One hundred forty-eight patients had their vertebral arteries insonated as part of the premanipulative screening procedure. The vertebral arteries were insonated using a Doppler ultrasound velocimeter in the neutral position, during cervical contralateral rotation to the end range and during contralateral lateral flexion to the end range. Persistence or loss of Doppler signals from the vertebral arteries during neck movement was recorded. Of 280 vertebral arteries able to be insonated, 5% (0 < 5% < 9% at p = .99 confidence interval) had Doppler signals that stopped during contralateral rotation. Doppler signals from all 187 vertebral arteries tested during lateral flexion persisted, whereas 6 (3.2%) of this group of arteries had signals that ceased during contralateral rotation. Vertebral artery Doppler signals from patients can be greatly reduced or extinguished during contralateral cervical rotation. However, this is an unusual finding. The same phenomenon was not observed during contralateral cervical lateral flexion, which suggests that there may be less mechanical stress placed on the vertebral artery during lateral flexion.
Article
Problems in ascertaining cases and in determining the total number of treatments have made it difficult to establish the rate of cerebrovascular accidents (CVA) after spinal manipulative therapy. To estimate the occurrence of cerebrovascular accidents after chiropractic treatment to the cervical spine. Information was sought on cases of CVA in Denmark during the period 1978-1988 inclusive, through several sources and through a survey of the Danish Chiropractors' Association. Information was sought also on proportion of consultations consisting of cervical treatment and preferred type of therapy. The incidence rate of CVA was calculated for several denominators. Targeted sample in survey 1: all 226 practicing members of the Danish Chiropractors' Association in 1989 [i.e., 99% of the chiropractors in Denmark at that time (response rate 54%)]. In survey 2, a random sample of 40 chiropractors (response rate 72.5%) was used. The number of CVAs in relation to the number of chiropractor-years, number of consultations, consultations including neck treatment, upper and lower neck treatment, and type of technique used. Five cases of CVA were identified; one resulted in death and the others in permanent neurological sequelae of varying severity. One case of CVA appeared for every estimated 1.3 million cervical treatment sessions and 1 for every 0.9 million upper cervical treatment sessions. Rotation techniques were over-represented in relation to their estimated frequency of use. Although the incidence of CVA after chiropractic SMT was confirmed to be low, there seems to be sufficient evidence to justify a firm policy statement cautioning against upper cervical rotation as a technique of first choice.
Article
To prospectively investigate the effect of chiropractic management on clinical and anatomical outcome of disc pathomorphology in previously magnetic resonance imaging (MRI)-documented disc herniation of the cervical and lumbar spine. Private practice. Twenty-seven patients with MRI-documented and symptomatic disc herniations of the cervical or lumbar spine. A prospective clinical case series. All patients were evaluated before commencement of chiropractic care by MRI scans for presence of disc herniations. Precare evaluations also included clinical examination and visual analog scores. Patients were then treated with a course of care that included traction, flexion distraction, spinal manipulative therapy, physiotherapy and rehabilitative exercises. All patients were re-evaluated by postcare follow-up MRI scans, clinical examination and visual analog scores. Percentage of disc shrinkage on repeat MRI, resolution of clinical examination findings, reduced visual analog pain scores and whether the patient returned to work were all recorded. Clinically, 80% of the patients studied had a good clinical outcome with postcare visual analog scores under 2 and resolution of abnormal clinical examination findings. Anatomically, after repeat MRI scans, 63% of the patients studied revealed a reduced size or completely resorbed disc herniation. There was a statistically significant association (p < .005) between the clinical and MRI follow-up results. Seventy-eight percent of the patients were able to return to work in their predisability occupations. This prospective case series suggests that chiropractic care may be a safe and helpful modality for the treatment of cervical and lumbar disc herniations. A random, controlled, clinical trial is called for to further substantiate the role of chiropractic care for the nonoperative clinical management of intervertebral disc herniation.
Article
A prospective clinic-based survey. To study the type, frequency, and characteristics of unpleasant side effects after spinal manipulative therapy. Spinal manipulative therapy is a commonly used treatment, but there is little knowledge of its side effects. Information regarding unpleasant reactions after spinal manipulative therapy was collected after 4712 treatments on 1058 new patients by 102 Norwegian chiropractors (response rate, 70%) through structured interviews. At least one reaction was reported by 55% of the patients some time during the course of a maximum of six treatments. Of the reported reactions, the most common were local discomfort (53%), headache (12%), tiredness (11%), or radiating discomfort (10%). Reactions were mild or moderate in 85% of patients. Sixty-four percent of reactions appeared within 4 hours of treatment, and 74% had disappeared within 24 hours. Uncommon reactions were dizziness, nausea, hot skin, or "other" complaints, each accounting for 5% or less of reactions. It was unusual that symptoms commenced later than on the day of or the day after treatment, were of long duration (not gone at the latest on the day after onset), described as severe, or that they resulted in reduced activities of daily living. There were no reports of serious complications in this study. Profiles now are described of common and uncommon reactions to spinal manipulative therapy and their latency, duration, and severity.