HVLA thrust techniques: What are the risks?

Definition and classification for adverse events following spinal and peripheral joint manipulation and mobilization: A scoping review

Introduction

Spinal and peripheral joint manipulation and mobilization are interventions used by many healthcare providers to manage musculoskeletal conditions. Although there are many reports of adverse events (or undesirable outcomes) following such interventions, there is no common definition for an adverse event or clarity on any severity classification. This impedes advances of patient safety initiatives and practice. This scoping review mapped the evidence of adverse event definitions and classification systems following spinal and peripheral joint manipulation and mobilization for musculoskeletal conditions in adults.

Methods

An electronic search of the following databases was performed from inception to February 2021: MEDLINE, EMBASE, CINAHL, Scopus, AMED, ICL, PEDro, Cochrane Library, Open Grey and Open Theses and Dissertations. Studies including adults (18 to 65 years old) with a musculoskeletal condition receiving spinal or peripheral joint manipulation or mobilization and providing an adverse event definition and/or classification were included. All study designs of peer-reviewed publications were considered. Data from included studies were charted using a standardized data extraction form and synthesised using narrative analysis.

Results

From 8248 identified studies, 98 were included in the final synthesis. A direct definition for an adverse event and/or classification system was provided in 69 studies, while 29 provided an indirect definition and/or classification system. The most common descriptors to define an adverse event were causality, symptom severity, onset and duration. Twenty-three studies that provided a classification system described only the end anchors (e.g., mild/minor and/or serious) of the classification while 26 described multiple categories (e.g., moderate, severe).

Conclusion

A vast array of terms, definition and classification systems were identified. There is no one common definition or classification for adverse events following spinal and peripheral joint manipulation and mobilization. Findings support the urgent need for consensus on the terms, definition and classification system for adverse events related to these interventions.

Teaching and use of cervical high-velocity, low-amplitude manipulation at colleges of osteopathic medicine

Context

Despite the documented effectiveness of high-velocity, low-amplitude (HVLA) treatment of the cervical spine, concerns about patient safety potentially limit didactic instruction and use in clinical practice. Understanding how cervical HVLA is taught and employed is of interest to osteopathic educators and clinicians.

Objectives

To characterize the perspectives of osteopathic manipulative medicine/osteopathic principles and practices (OMM/OPP) departments within colleges of osteopathic medicine (COMs) in the US regarding patterns of teaching and practice of HVLA treatment of the cervical spine.

Methods

A questionnaire was distributed on April 11, 2019 in paper format to OMM/OPP department chairs or designated faculty member attendees at the Educational Council on Osteopathic Principles biannual meeting. If the department chair was not available, the survey was provided to the faculty member designated to represent the Chair of the institution at ECOP. All respondents in this category returned the survey in paper before they left the meeting. The OMM/OPP department chairs who did not attend or send representatives to the ECOP meeting were sent the survey by email on April 11, 2019 and given three opportunities over 6 weeks at 2-week intervals to reply to this voluntary online survey. The survey was given or sent to a total of 51 OMM/OPP department chairs or representatives. Six questions elicited demographic information pertaining to status, age, gender, ethnicity, board-certified specialty, and COM affiliation. Nine questions examined perspectives related to the instruction of cervical HVLA manipulation and treatment.

Results

Of the 51 OMM/OPP department chairs surveyed, 38 (74.5%) responded, 32 to the paper survey at the ECOP meeting and six to the digital survey. Respondents were primarily dual Board-certified in Family Medicine and Neuromuscular Medicine (55.3%). At over 90% (35) of the COMs for which department chairs responded to the survey, cervical HVLA instruction occurs in the curriculum primarily during program years 1 and 2. Instruction in cervical HVLA to the 2nd through 7th cervical vertebral levels occurred in 97% (37), while 11% (4) of the COMs excluded the occipital-atlanto (OA) and atlanto-axial (AA) joints. A high percentage (81.6%; 31) of the OMM/OPP department chairs or representatives reported employing cervical HVLA techniques within their practice. Among the respondents, 40.5% (15) reported that 0-25% of their school's medical school class could perform cervical HVLA competently upon graduation, whereas 27% (10) said that 51-75% of their class could perform cervical HVLA.

Conclusions

A majority of COMs provide education in their curricula related to cervical HVLA primarily in the first 2 years of medical education. However, instruction often excludes cervical HVLA to the upper regions of the cervical spine. At COMs where HVLA to the cervical spine is not taught, that decision is because the techniques are thought to be too difficult and the attendant medicolegal risk perceived to be too high. OMM/OPP department chairs expressed confidence in only a small proportion of their graduates having the ability to competently apply HVLA to the cervical spine immediately after completing their predoctoral medical training.

Teaching and Assessment of High-Velocity, Low-Amplitude Techniques for the Spine in Predoctoral Medical Education

Although national didactic criteria have been set for predoctoral education and assessment in osteopathic manipulative treatment, there is no criterion standard for teaching methods and assessments of osteopathic manipulative treatment competence in colleges of osteopathic medicine. This issue is more pressing with the creation of the single graduate medical education accreditation system by the American Osteopathic Association and Accreditation Council for Graduate Medical Education, which introduced the creation of "osteopathic recognition" for residencies that want to incorporate osteopathic principles and practice into their programs. Residencies with osteopathic recognition may include both osteopathic and allopathic graduates. Increased standardization at the predoctoral level, however, is recommended as osteopathic principles and practice training applications are expanded. The objectives of this article are to review the standards for teaching osteopathic medical students high-velocity, low-amplitude (HVLA) techniques for the spine; to review and discuss the methods used to assess medical students' proficiency in using HVLA; and to propose baseline standards for teaching and assessing HVLA techniques among medical students.

Beliefs in the population about cracking sounds produced during spinal manipulation

OBJECTIVES

To examine beliefs about cracking sounds heard during high-velocity low-amplitude (HVLA) thrust spinal manipulation in individuals with and without personal experience of this technique.

METHODS

We included 100 individuals. Among them, 60 had no history of spinal manipulation, including 40 who were asymptomatic with or without a past history of spinal pain and 20 who had nonspecific spinal pain. The remaining 40 patients had a history of spinal manipulation; among them, 20 were asymptomatic and 20 had spinal pain. Participants attended a one-on-one interview during which they completed a questionnaire about their history of spinal manipulation and their beliefs regarding sounds heard during spinal manipulation.

RESULTS

Mean age was 43.5±15.4years. The sounds were ascribed to vertebral repositioning by 49% of participants and to friction between two vertebras by 23% of participants; only 9% of participants correctly ascribed the sound to the formation of a gas bubble in the joint. The sound was mistakenly considered to indicate successful spinal manipulation by 40% of participants. No differences in beliefs were found between the groups with and without a history of spinal manipulation.

CONCLUSIONS

Certain beliefs have documented adverse effects. This study showed a high prevalence of unfounded beliefs regarding spinal manipulation. These beliefs deserve greater attention from healthcare providers, particularly those who practice spinal manipulation.

The suitability of sham treatments for use as placebo controls in trials of spinal manipulative therapy: a pilot study

Despite the augmented use and dependence on manual therapy (MT), there are still calls from both within and outside the MT professions to provide robust evidence that spinal manipulative therapy (SMT) induces therapeutic effects beyond placebo. To facilitate this, placebo or 'sham' treatments, the development of which is notoriously difficult, must be used in rigorously controlled trials. The aim of this study was to investigate the suitability of different shams as controls in SMT trials. A repeated measures, single-blind, randomised trial was conducted on 10 asymptomatic subjects. Pain pressure thresholds (PPTs) were measured at 2 sites, local and systemic, before and after the application of either high-velocity low-amplitude thrust (HVLAT), sham functional technique (SFT), sham ultrasound (SUS) or no intervention control (NIC) to the cervico-thoracic (CT) junctional area. Treatment credibility was then assessed using a 4-point Likert Scale in response to 4 statements. Results demonstrated no significant change in PPT following any of the interventions, irrespective of site tested. The effect sizes for all interventions were considered small (d = <0.2). There were significant differences in Likert Scale responses for each statement (P < 0.001), with SUS eliciting significantly different responses as compared to SFT and NIC but not, predominantly, with HVLAT. SUS is implicated as being the most effective sham, having high fidelity to subjects' perceptions of a 'real' treatment, whilst being therapeutically inert i.e. results in no significant change in clinical status.

Spinal cord injury following chiropractic manipulation to the neck

Spinal cord injury is a rare complication of chiropractic treatment. This case report describes a 50-year-old man who developed neurological symptoms a few hours after manipulation (high velocity low amplitude [HVLA] technique) of the cervical spine. Magnetic resonance (MR) imaging of the cervical spine revealed intramedullary high signal at the C2/3 level of the right side of the cervical cord on the T2-weighted images. The potential mechanism of injury and causes of the radiological appearance are discussed.

An introduction to clinical research in osteopathic medicine

Osteopathic medicine is a profession that has existed for more than 130 years. However, the profession is poorly understood by many health care professionals. This article introduces osteopathic medicine, including similarities and differences between osteopathic physicians (DOs) and allopathic physicians (MDs). It describes osteopathic manipulative treatment (OMT), including the risks and many of the challenges faced while doing clinical research on OMT. Finally, the article reviews the research that has evaluated the effect of OMT on various medical conditions, including musculoskeletal, neurologic, respiratory, obstetric, gynecologic, and pediatric conditions.