Manipulation Methods, Indications, and Contraindications

Author: J Michael Wieting, DO, MEd; Chief Editor: Consuelo T Lorenzo, MD

The availability of manipulation care varies significantly, depending upon geographic location and regional practice patterns. Physiatrists who wish to use manipulation but who do not wish to provide it themselves generally refer patients either to a physician or to a licensed nonphysician practitioner. Referral to another physician practitioner often works well, but potential problems exist, especially regarding patient referral. This issue may be addressed through a specific referral that states the exact nature and scope of the evaluation and treatment requested, that encourages discussion with the referring physician, and that makes clear the intention of the physiatrist to resume the remainder of the patient's care. If the referral is to a licensed nonphysician practitioner, first diagnose the appropriate problem and write a specific prescription for manipulation.

Manipulative care can be provided as part of a comprehensive therapy program; however, the physiatrist should write a detailed prescription for the specific area to be treated and identify the diminished motion to be restored, as well as the frequency and length of treatment. This enables the physiatrist to monitor patient progress objectively and determine the end point and benefit of manipulative treatment.

The 3 main obstacles for the physiatrist interested in performing manipulation are acquisition of skills, maintenance of skills, and economic considerations. Manipulative techniques are learned best on colleagues and fellow learners under close supervision. Studies suggest that the minimum learning time required might vary from 3-12 months, depending upon the modality being learned. This extended period of time has significant ramifications for the practitioner. Because of enhanced safety and the small potential for harm, sufficient skill can be acquired by most practitioners in 1-2 weeks of formal training in each of the types of manipulation, including isometric/muscle energy, counterstrain, myofascial release, and articulatory techniques. Training time for these approaches is shorter, because inappropriate or nonindicated indirect technique, unless repeated frequently or over a prolonged period of time, rarely causes detrimental effects.

Postdoctoral training programs, such as those approved or offered by the American Academy of Physical Medicine and Rehabilitation, the American Association of Colleges of Osteopathic Medicine, and other organizations, may provide a means by which the physiatrist can become acquainted with the skills necessary to begin manipulative care. Interest among physiatric residents in acquiring manipulative skills is high, and this fact has expanded training opportunities for physicians. Many residency programs now include required and/or optional training in manipulative skills.

Maintenance of manipulative skills is fairly easy for a full-time practitioner; however, it may be more difficult for the physiatrist whose practice does not feature a high volume of manipulative care. Infrequent use of manipulative skills results in decreased competence, but the actual minimum frequency of use needed to maintain competence or excellence varies considerably among practitioners. Manipulation, if performed appropriately, can be time efficient and financially viable.

Indications for manipulation

Manipulation is appropriate for a variety of musculoskeletal problems, especially those of the thorax, rib cage, upper and lower extremities, back, pelvis, and neck. It is also useful when loss of motion or function is encountered or when localized tenderness or pain is noted on induced motion. Some clinical situations (eg, acute fractures, disk herniations with neurologic signs, tumors, acute inflammation, joint disease) may not respond to manipulative care because of local conditions that may constitute contraindications or hypermobility. Remember also to exclude systemic or visceral pathologic conditions, or at least to put them under concurrent care of the practitioner. Some physicians use manipulation for treatment, while others provide it in a more prophylactic manner.

Side effects of manipulation

The most commonly reported side effect of manipulation is a transient increase in discomfort lasting approximately 6-72 hours. Minor, temporary autonomic effects (eg, early or increased menses, increased perspiration, vasomotor changes) have been reported.

Duration of manipulative care

Direct techniques (such as high-velocity, low-amplitude thrust) usually have immediate effect, and improvement is seen within a week. Indirect techniques may take longer for the effect to be seen. Caution must be used to avoid unnecessary continuation of treatment when pain relief does not correlate with biomechanical improvement. If the patient's condition does not improve objectively within 2-4 weeks, reevaluation of the structural diagnosis, manipulative approach, or other therapeutic plan is indicated. Determine the duration of each course of therapy on a case-by-case basis.

Contraindications for manipulation

Different manipulative approaches vary as to the degree of invasiveness. Because of higher forces involved, direct techniques are the most invasive and, therefore, are more likely to be contraindicated.

Absolute contraindications for manipulative care, especially indirect techniques, are very rare. Few relative contraindications exist. Manipulative care should be performed only for hypomobile vertebral segments or other structural dysfunctions deemed amenable to manipulation. Accurate structural diagnosis is critical. Inadequate practitioner skill is a major contraindication for all types of manipulative care.

Articulatory techniques are contraindicated for patients with vertebral malignancy, infection or inflammation, myelopathy, multiple adjacent radiculopathies, cauda equina syndrome, vertebral bone disease, bony joint instability, and cervical rheumatoid disease. Direct manipulation (eg, high-velocity/low-amplitude) is contraindicated in those cases and, additionally, in the presence of (1) spinal deformity, (2) systemic anticoagulation treatment, (3) severe diabetes or atherosclerotic disease, (4) degenerative joint disease, (5) vertebral basilar diseaseor insufficiency, (6) spondyloarthropathies, (7) ligamentous joint instability or congenital joint laxity, (8) aseptic necrosis, (9) local aneurysm, (10) osteoporosis, (11) acute disk herniation, and (12) osteomalacia.

Haldeman and colleagues performed a retrospective review of patients in whom the occurrence of stroke was temporally associated with cervical spine manipulation.^[25]It was concluded that no known mechanism exists to predict who is at risk for such an event and that stroke is an inherent and idiosyncratic risk associated with this type of treatment, as well as an exceedingly rare complication.

Patients with a tendency toward somatoform fixation in painful anatomic areas, as well as those with obsessional neurosis, are poor candidates for direct manipulative techniques. Pregnancy and known threat of miscarriage are absolute contraindications only for direct manipulative techniques. Conservative indirect techniques are considered safe (as long as they are performed by a competent practitioner) into the latter stages of pregnancy.

Objective radicular signs are a contraindication for direct-thrust techniques of all kinds. Active myositis or infection may constitute a contraindication for isometric care because of the need to provide active muscular contractions. Functional techniques, counterstrain, or other indirect approaches may be applied safely in these conditions. No contraindications have been documented for functional or counterstrain techniques.

Complications of manipulation

Complications of manipulation generally arise because of poorly skilled/trained practitioners or due to the performance of contraindicated procedures. No documented or anecdotal reports of complications resulting from articular, isometric, counterstrain, functional, soft-tissue, or myofascial release exist. Most reported complications involve direct (eg, high-velocity/low-amplitude) thrusting techniques that generally have been done in the cervical region and, in almost all cases, the neck was extended inappropriately during the procedure. Extremely serious consequences may occur with very low frequency, estimated to be approximately 1 case in 1-1.5 million manipulations. The Back Letter states that, "As to whether or not healthy patients should be concerned with the risk of cervical manipulation, the risk appears to be quite small."^[26]

Risk to the patient is minimized by proper positioning of the individual, with avoidance of extreme positions of flexion, extension, side bending, and rotation. Careful evaluation and treatment of patients with known or suspected osteoporosis or spinal disease also is important.

Manipulation, specifically its application to the cervical spine, has been mentioned in the lay press. Associations have been made between cervical, high-velocity thrust techniques and vertebrobasilar artery strokes and strokelike symptoms. Given the number of such manipulative treatments performed in the US and Canada alone on an annual basis (estimated conservatively in the tens of millions) and the number of reported cases of such events per year (estimated to be in the single digits), cervical spinal manipulation is a relatively safe procedure.

However, a thorough physical examination, including a neurologic examination and an assessment of the patient’s comorbid conditions and risk factors, needs to be conducted before such manipulation is performed. If a thrusting technique is chosen, the force used should be the minimal necessary to achieve the correction and should be localized as precisely as possible to the restricted segment. Extremes of motion in any direction, but especially cervical extension, should be avoided, because these end ranges have been shown to be the ones most often associated with poor treatment outcomes.

A study by Cassidy and colleagues that specifically investigated the possible link between the risk of vertebrobasilar artery stroke and chiropractic manipulation did not rule out a potential connection between these "rare events" and cervical manipulation; the authors found such an association in study patients under age 45 years.^[27] The results, according to the report, "suggest that the association between chiropractic care and [vertebrobasilar] stroke found in previous studies is likely explained by presenting symptoms attributable to vertebral artery dissection. It might also be possible that chiropractic manipulation, or even simple range-of-motion examination by any practitioner, could result in a thromboembolic event in a patient with a preexisting vertebral dissection." It should also be remembered that this reference does not apply to manipulation performed by a fully trained and licensed physician, nor does it apply to anytypeofmanipulation other than high-velocity, low-amplitude thrust in the cervical spine.

Manipulation may be used to treat infants and children, as well as adults. Particular care must be taken in the application of manipulative treatments to children, especially with regard to thrust techniques. Some of the serious adverse events in this population that have been documented include death, subarachnoid hemorrhage and tetraplegia.

A systematic review study of manipulation-associated adverse events in children, which included information culled from many case reports, found that all such events involved children under age 13 years and that these events were associated with diagnoses that did not appear to be those commonly addressed by manipulation.^[28] The authors of this review performed literature searches using multiple electronic databases for articles published from 1900-2005. Given the large number of patients who were treated with spinal manipulation during this time period, they felt that it was reasonable to conclude that "adverse events resulting from spinal manipulation are either remarkably rare or underreported."

According to the report, a number of risk factors may predispose a child to an adverse event as a result of spinal manipulative procedures, including "immaturity of the spine, rotational manipulation of the cervical spine, and high-velocity thrust techniques." Five of the serious adverse-event reports in this study did not specify the type of spinal manipulation used. Two of the 4 that reported such events specified that the practitioner used "rapid and/or strong rotational maneuvers."

It can be inferred from reviews such as this that rotational manipulation of the cervical spine should be used with extreme caution in the pediatric population, and that young patient age may be a relative contraindication for thrusting, especially rotational, maneuvers. Additional attention to accurate diagnosis and a thorough history and physical examination may prevent such catastrophic outcomes in the pediatric population.