Manual Therapy - Adverse Effects

PHT 5321C Manual Therapy - Adverse Effects

• Overview of Presentation

  • Discussion on adverse effects associated with spinal manipulation interventions.

  • Focus on high velocity, low amplitude techniques directed at lumbar, thoracic, and cervical regions of the spine.

  • Concluding remarks on absolute and relative contraindications to joint-specific manipulation techniques.

  • Emphasis on the fact that many conditions discussed can arise independently of treatment.

• Purpose of Interventions

  • Interventions aim to address specific impairments in body structure/function.

  • Enhance participation in daily activities while considering personal and environmental factors.

  • Collaboration with patient and other stakeholders through shared decision-making for patient benefit.

• Patient Safety Considerations

  • Recognition that no intervention is without risk.

  • Definition of adverse effects:

  • Consequences that are medium to severe and/or distressing or unacceptable to the patient, necessitating additional treatment.

  • Safety must be prioritized in the design and execution of care plans.

  • Ensuring patient safety includes:

  • Properly performed techniques.

  • Conducting a pre-manipulation screen.

  • Addressing precautions and contraindications prior to manual therapy.

• Pre-Manipulation Screen

  • Therapist positions the patient in the end position anticipated post-intervention.

  • Inquiry made regarding patient comfort and changes in symptoms.

  • Need for modifications or alternative interventions if the patient cannot achieve final position for any reason.

• Adverse Effects of Manipulation Techniques

  • Overall incidence of reported adverse effects is low, though consequences can be severe or fatal.

  • Importance for practitioners to recognize signs/symptoms for immediate medical attention.

Adverse Effects Specific to Lumbar Spine

• Serious risks include:

  • Onset of cauda equina syndrome

  • Estimated risk: less than 1 in 100,000,000 lumbar manipulations.

  • Risk of adverse effects considered on par with other traditional low back pain treatments.

  • Potential for generalized neurological signs, such as:

  • Changes in sensation manifesting in dermatomal or multi-segmental patterns.

  • Gait abnormalities.

  • Minor adverse effects commonly reported:

  • Increased local or radiating discomfort.

  • Headaches.

  • Fatigue.

  • Minor effects usually resolve within 48 hours.

Adverse Effects of Thoracic Spine Manipulations

• Limited research on safety of thrust joint manipulations.

• Systematic review of case reports (1950-2015) revealed:

  • Only 10 reported adverse cases due to thoracic manipulation techniques.

  • 7 cases involving spinal cord injuries (mechanical injury/vascular compromise).

  • 2 cases of hemothorax and pneumothorax.

  • 1 case of spinal fluid leak due to dural sleeve injury.

• Considerations:

  • Over 65 years of thoracic manipulations yielded only 10 documented adverse events, indicating a very low incidence rate.

  • Acknowledgement of unreported adverse effects; tendency to highlight successful outcomes over failures.

  • Continued monitoring essential as significant correlation likely to have been identified over the years.

Adverse Effects of Cervical Spine Manipulations

• Increased risk of complications due to proximity of internal carotid and vertebral arteries towards the brain.

• Common indicators of arterial dissection include:

  • Increased headache.

  • Neck pain.

  • Visual disturbances.

  • Paresthesias in upper/lower extremities.

  • Dizziness.

• For vertebral basilar insufficiency (VBI), clinicians should monitor for the five D’s:

  • Dizziness.

  • Diplopia (double vision).

  • Dysphagia (difficulty swallowing).

  • Dysarthria (difficulty speaking).

  • Drop attacks/syncope (episodes of fainting).

  • The presence of two or more symptoms alongside a history of acute neck injury escalates suspicion of VBI.

• Minor side effects post-cervical manipulation may include:

  • Headache.

  • Localized/radiating stiffness or discomfort.

  • Fatigue.

  • Generally resolve within 24 hours.

Contraindications to Joint-Specific Manipulation Techniques

• Absolute Contraindications

  • No sound indication for performing the intervention.

  • Lack of patient consent to treatment.

  • Areas needing to avoid manual therapy:

  • Poor ligamentous/bony integrity (unstable fractures, upper cervical instability, bone tumors, osteomyelitis, infections).

  • Proximity to spinal cord damage.

  • Patients with red flag signs (e.g., unremitting night pain, unexplained weight loss, changes to bowel and bladder function) should be referred to other health care practitioners.

• Relative Contraindications

  • Techniques may necessitate modifications to avoid risk.

  • Novice clinicians should gain advanced training before attempting joint-specific manipulations for patients with these contraindications.

Summary and Conclusion

• Overview of adverse effects from manipulation techniques across the cervical, thoracic, and lumbar spine.

• General incidence of serious adverse effects is small, with more common minor effects resolving within 24 to 48 hours.

• Importance for clinicians to be knowledgeable about absolute and relative contraindications to ensure patient safety in rehabilitation programs.