by Mia Thomas, PT, DPT
When treating the cervical spine many therapists may perform small mobilizations to help improve motion and decrease pain, but often high velocity mobilizations or manipulations are not done in physical therapy offices. While manipulations are not under the scope of physical therapy practice in all 50 states, it has been found that therapists are often not performing them even in states where it is within our practice act. Why is this? It may be due to the amount of training the therapist has during their schooling, therapists attachment to the “pop” and fear of not achieving that, or it may be because of the misconceptions of how dangerous it is.
Everyone has seen an article talking about how someone suffered a fatal stroke after going to the hairdresser or seeing a chiropractor, but never is it put in context. The risk of death from a manipulation is .005-.009/10,000. Compare this to the risk of death due to non steroidal anti-inflammtories, such as ibuprofen, which is 20/10,000. However, because it is so startling to think you could have a fatal stroke after visiting the chiropractor it is spoken about much more in the media.
Therapists have the ability to screen their patients to ensure they are only manipulating patients that are at a low risk for an arterial dissection, the pathology which causes a stroke in this population. The primary test that physical therapists have been using is to ensure a manipulation is safe is the vertebral artery insufficiency test, which places the patient’s neck in an extreme position to see if signs of a stoke will become present. Other tests therapists are trained in look at the stability of the ligaments surrounding the cervical spine – the sharp pursers tests, alar ligament test, and transverse ligament test.
I don’t know about other therapists, but I would prefer to not rule out manipulations by trying to elicit symptoms of a stroke. Getting a complete medical history, taking more vital signs (blood pressure, carotid pulse), performing cranial nerve screens, neurological tests (Hoffman’s, babinski, and clonus), as well as an upper quarter screen can give us a better picture of how high of a risk our patient is at for an arterial dissection.
It is also important to know how the patient responds to manipulations in general. If you think your patient is at a low or moderate risk for a stroke you might try to manipulate a more stable part of the spine first to see if they will respond positively to any manipulation. Thoracic spine manipulations not only can give you a good picture of a patient’s response to this treatment, but they have also been shown to be effective in improving perceived levels of cervical spine pain, range of motion, and disability.
Incorporating manual therapy and therapeutic exercise into treatment sessions for patient’s with cervical spine pain has been shown to reduce their medical costs, and improve, pain, range of motion, and disability. Remember, if you take a thorough physical exam, trial manipulating other parts of the spine, and slowly bring the patient through their range of motion, particularly the range you are planning to manipulate in, you can perform a safe and effective mobilization with very low risks.