We learned in school 5 criterias for spinal manipulation when it comes to clinical prediction rules: <16 days for the duration of the current episode of low back pain, no symptoms distal to knee, < 19 on FABQ, > 1 hypomoile segment in the lumbar spine, > 1 hip with > 35 degrees of internal rotation (1). We also know contraindications such as: VBI, RA, fracture, osteomyelitis, bone tumors; however, osteoporosis is not a contraindication. I researched “thrust manipulation osteopenia”, “thrust manipulation osteoporosis “ , “HVLA with osteopenia”, “HVLA with osteoporosis” and found 0 hits on pub med. I think that would be an interesting study, but honestly how many sweet old ladies who have osteoporosis would be thrilled to join this study? I’m already speculating a small pull of patients.
I ran into a narrative review done by the American College of Physicians in 2014 and they concluded that if all contraindications and red flags were ruled out then clinicians can prevent up to 44.8% of adverse effects. An adverse effect was defined as “the sequelae following a CSM that are medium to long term in duration, with moderate to severe symptoms, and of a nature that was serious, distressing, and unacceptable to the patient and required further treatment” (2) Absolute contraindications were found to be: acute fracture, Acute soft tissue injury, Dislocation , Osteoporosis, Ligamentous rupture, Ankylosing spondylitis, Instability, Rheumatoid arthritis, Tumor Vascular disease, Infection, Vertebral artery abnormalities, Acute myelopathy, Connective tissue disease, Recent surgery, Anticoagulant therapy. These were found by Dr. Kathryn Refshauge, dean faculty of Health Sciences and Professor of Physiotherapy at the University of Sydney, who quotes “with subsequent research, manipulation may ultimately prove to be effective in the hands of particularly skilled practitioners for a sub-group of patients” (3) Of those 44.8% of AE cases were not screened for contraindicated signs. A thorough examination needs to be done to rule out contraindications and red flags. I would say as a novice therapist, it’s important to abide strictly to these contraindications. I do know a few experienced physical therapist who have done thoracic HVLA on patients with osteoporosis and have received great results.
Mark Jones brought up a great discussion when he compared novice to experts. When do you think it is appropriate to go off of clinical judgement and use HVLA even if a patient has osteoporosis/ penia? If you can’t use a thrust technique what’s another technique to consider? Dunning et al reports non thrust techniques have a statistical significance of improvement (thank you Nick). What other techniques compared to thrust manipulation could we use to help decrease neck pain?
Reference:
1. Childs JD, Fritz JM, Flynn TW, Irrgang JJ, Johnson KK, Majkowski GR, et al. A Clinical Prediction Rule To Identify Patients with Low Back Pain Most Likely To Benefit from Spinal Manipulation: A Validation Study. Ann Intern Med. 2004;141:920-928. doi:10.7326/0003-4819-141-12-200412210-00008
2. Puentedura EJ1, March J, Anders J, Perez A, Landers MR, Wallmann HW, Cleland JA:Safety of cervical spine manipulation: are adverse events preventable and are manipulations being performed appropriately? A review of 134 case reports. J Man Manip Ther. 2012 May;20(2):66-74. doi: 10.1179/2042618611Y.0000000022.
3. Refshauge KM, Parry S, Shirley D, Larsen D, Rivett DA, Boland R. Professional responsibility in relation to cervical spine manipulation. Aust J Physiother. 2002;48:171–9