Spinal Manipulation

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Chapter 26 Spinal Manipulation

OVERVIEW.

Spinal manipulation (also called thrust, chiropractic adjustment) involves passive mechanical movement directed at a specific spinal joint or joint segment in order to restore movement or reduce pain. It is a high-velocity, low-amplitude maneuver performed at the end of the patient’s spinal range, which the patient cannot stop or control. Theories for the pain relief following spinal adjustments include (1) mechanical/reflexive relaxation of soft tissue, (2) movement of a disc bulge away from pain-sensitive structure, or (3) proprioceptive input to the spinal cord to gate out pain.¹

SUMMARY: CONTRAINDICATIONS AND PRECAUTIONS.

Six sources cited a total of 47 concerns for spinal manipulation. Concerns ranged from eight to 31 per source, with a physical therapist citing the largest number. The largest proportion of concerns (about 40%) relate to musculoskeletal diseases. The most frequently cited concerns were vertebral artery disease and inflammatory joint disease (all six sources). Other frequently cited concerns included cauda equina syndrome, osteoporosis, metastatic cancer, and anticoagulation disorders. Two sources cited numerous ACIs.

Note: Although authorities suggest adverse events following manipulation are rare, numerous case reports of individuals sustaining vascular damage with subsequent neurologic impairment (particularly following cervical manipulation) have been published over the years in the medical literature.

The list of adverse events for spinal manipulation below is not exhaustive, nor should it suggest an incidence rate. Readers are also reminded that case reports are a weak form of evidence.

PROCEDURAL CONCERNS

ADVERSE EVENT

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10 Green D, Jaynt RJ. Vascular accidents to the brain stem associated with neck manipulation. JAMA. 1959;170:522-524.

11 Walton JN. Essentials in neurology, ed 4. Philadelphia: J.B. Lippincott, 1975.

12 Dorland’s illustrated medical dictionary. ed 24. Philadelphia: WB Saunders; 1965.

13 Shvartzman P, Abelson A. Complications of chiropractic treatment for back pain. Postgrad Med. 1988;83(7):57-58. 61

14 Fisher ED. Report of a case of ruptured intervertebral disc following chiropractic manipulation. Ky Med J. 1943;41:14.

15 Goodman CC. The cardiovascular system. In Goodman CC, Boissonnault WG, Fuller KS, editors: Pathology: implications for the physical therapist, ed 2, Philadelphia: W.B. Saunders, 2003.

16 Donzis PB, Factor JS. Visual field loss resulting from cervical chiropractic manipulation. Am J Ophthalmol. 1997;123(6):851-852.

17 Jensen FE. Cerebrovascular disease. In Loscalzo J, Creager MA, Dzau VJ, editors: Vascular medicine: A textbook of vascular biology and diseases, ed 2, Boston: Little, Brown, 1996.

18 Lyness S, Wagman AD. Neurological deficit following cervical manipulations. Surg Neurol. 1974;2:121-124.

19 Mueller S, Sahs AL. Brain stem dysfunction related to cervical manipulation: report of three cases. Neurology (Minneapolis). 1976;26:547-550.

20 Kunkle EC, Muller JC, Odom GL. Traumatic brain-stem thrombosis: report of a case and analysis of the mechanism of injury. Ann Intern Med. 1952;36:1329-1335.

21 Rinsky LA, Reynolds GG, Jameson RM, et al. A cervical spinal cord injury following chiropractic manipulation. Paraplegia. 1976;13(4):223-227.

22 Hunter T, Dubo H. Spinal fractures complicating ankylosing spondylitis. Ann Intern Med. 1978;88(4):546-549.

23 Eisenberg MG. Dictionary of rehabilitation. New York: Springer, 1995.

24 Kisner C, Colby LA. Therapeutic exercise: foundations and techniques, ed 3. Philadelphia: F.A. Davis, 1996.

25 Livingston M. Paramedics, chiropractors and health planners [case reports, letter]. Can Med Assoc J. 1978;119(12):1391-1392.

26 Blaine ES. Manipulative (chiropractic) dislocations of the atlas. JAMA. 1925;85:1356.

27 Davidson KC, Weiford EC, Dixon GD. Traumatic vertebral artery pseudoaneurysm following chiropractic manipulation. Radiology. 1975;115:651-652.

28 Johnson DW, Whiting G, Pender MP. Cervical self manipulation and stroke. Med J Aust. 1993;158(4):290.

29 Kanshepolsky J, Danielson H, Flynn RE. Vertebral artery insufficiency and cerebellar infarct due to manipulation of the neck: report of a case. Bull Los Angeles Neurol Soc. 1972;37:62-66.

30 Miller RG, Burton R. Stroke following chiropractic manipulation of the spine. JAMA. 1974;229:189-190.

31 Pratt-Thomas HR, Berger KE. Cerebellar and spinal injuries after chiropractic manipulation. JAMA. 1947;133:600-603.

32 Richard J. Disk rupture with cauda equine syndrome after chiropractic adjustment. N Y State J Med. 1967;67(18):2496-2498.

33 Rivett DA, Milburn P. Complications arising from spinal manipulative therapy in New Zealand. Physiotherapy. 1997;83(12):626-632.

34 Schwarz GA, Geiger JK, Spano AV. Posterior inferior cerebellar artery syndrome of Wallenberg after chiropractic manipulation. Arch Intern Med. 1956;97:352-354.

35 Smith RA, Estridge MN. Neurologic complications of head and neck manipulations: report of two cases. JAMA. 1962;182:528-531.

36 Zauel D, Carlow TJ. Internuclear ophthalmoplegia following cervical manipulation. Ann Neurol. 1977;1(3):308.

37 Zimmerman AW, Kumar AJ, Gadoth N, Hodges FJIII. Traumatic vertebrobasilar occlusive disease in childhood. Neurology. 1978;28(2):185-188.

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