Safety and HVLA techniques

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INTRODUCTION

There are risks and benefits associated with any therapeutic intervention. High-velocity low-amplitude (HVLA) techniques are distinguished from other osteopathic techniques because the practitioner applies a rapid thrust or impulse. Thrust or impulse techniques are considered to be potentially more dangerous than non-impulse mobilization.

COMPLICATIONS Incidence

Most published literature relating to the incidence of injury resulting from manipulative techniques focuses upon serious sequelae resulting from cervical spine manipulation.

There is wide variation in estimated serious adverse reactions arising from cervical manipulation. Rivett and Milburn' estimated the incidence of severe neurovascular compromise to be within the range 1 in 50 000 to 1 in 5 million cervical spine manipulations. Other authors estimate complications for cervical spine manipulation to be 1.46 times per 1 million manipulations2 and 1 case of cerebrovascular accident in every 1.3 million cervical treatment sessions, increasing to 1 in every 0.9 million for upper cervical manipulation.3

Dvorak and Orelli4 report a ratio of 1 serious complication per 400 000 cervical manipulations, while Patijn5 found an overall ratio of 1 complication per 518 886 manipulations.

Published figures may not accurately reflect the true incidence of serious cervical spine complications.1'5-7 The frequency with which complications arise in patients receiving cervical spine manipulation can only be an estimate, as the true number of manipulations performed and the number of patients receiving cervical manipulation remain unknown." In relation to vertebral artery dissection, Haldeman et al9 indicate that a database of multiple millions of cervical manipulations are necessary to obtain accurate statistics.

Classification of complications

Serious non-reversible impairment

• Cerebrovascular accident

Spinal cord compression

• Cauda equina syndrome.

Substantive reversible impairment

• Disc herniation

• Disc prolapse

• Nerve root compression

Transient

• Local pain or discomfort

• Radiating pain or discomfort

• Paraesthesia

Less common transient reactions include early or heavy menstruation, epigastric pain, tremor, palpitation and perspiration. 10

Transient side-effects resulting from manipulative treatment may be more common than one might expect and may remain unreported by patients unless information is explicitly requested. A study of common side-effects resulting from chiropractic treatment indicated that 55% of patients reported at least one unpleasant reaction during a course of treatment.11 These side-effects generally disappear within 24 hours.

Causes of complications Incorrect patient selection

• Lack of diagnosis

• Lack of awareness of possible complications

• Inadequate palpatory assessment

• Lack of patient consent.

Poor technique

• Excessive force

• Excessive amplitude

• Excessive leverage

• Inappropriate combination of leverage

• Incorrect plane of thrust

• Poor patient positioning

• Poor operator positioning

• Lack of patient feedback.

CONTRAINDICATIONS

Whenever a practitioner applies a therapeutic intervention, due consideration must be given to the risk:benefit ratio — the benefit to the patient must outweigh any potential risk associated with the intervention. Traditionally, risks have been classified as absolute and relative. The distinction behveen absolute and relative contraindications is influenced by factors such as the skill, experience and training of the practitioner, the type of technique selected, the amount of leverage and force used, and the age, general health and physique of the patient.

Absolute

• Bone — any pathology that has led to significant bone weakening:

— tumour, e.g. metastatic deposits

— infection, e.g. tuberculosis

— metabolic, e.g. osteomalacia

— congenital, e.g. dysplasias

— iatrogenic, e.g. long-term corticosteroid medication

— inflammatory, e.g. severe rheumatoid arthritis

• Neurological

— cervical myelopathy

— cord compression

— cauda equina compression

— nerve root compression with increasing neurological deficit.

— diagnosed vertebrobasilar insufficiency

— aortic aneurysm

— bleeding diatheses, e.g. severe haemophilia.

• Lack of patient consent

• Patient positioning cannot be achieved because of pain or resistance.

Relative

Certain categories of patients have an increased potential for adverse reactions following the application of a HVLA technique. Special consideration should be given prior to the use of HVLA techniques in the following circumstances:

• Adverse reactions to previous manual therapy

• Disc herniation or prolapse

• Inflammatory arthritides

• Spondylolysis

• Spondylolisthesis

Osteoporosis

• Anticoagulant or long-term corticosteroid use

• Advanced degenerative joint disease and spondylosis

• Psychological dependence upon HVLA technique

• Ligamentous laxity

• Arterial calcification.

The above list is not intended to cover all possible clinical situations. Patients who have pathology may also have coincidental spinal pain and discomfort arising from mechanical dysfunction that may benefit from manipulative treatment.

The use of manipulation techniques under general anaesthesia for low back pain is associated with an increased risk of serious neurological damage.12 There is no evidence that this approach for the treatment of low back pain is effective.1 1

VERTEBROBASILAR INSUFFICIENCY

The vertebrobasilar system comprises the two vertebral arteries and their union to form the basilar artery (Fig. A.S.I). This system supplies approximately 20% of the intracranial blood

Basilar artery Atlas (C1)

Basilar artery Atlas (C1)

Posterior inferior cerebellar artery

Vertebral artery

Fig. A.S.1 Relationship of the cervical spine to the vertebral artery.

Posterior inferior cerebellar artery

Vertebral artery

Fig. A.S.1 Relationship of the cervical spine to the vertebral artery.

supply.'4 Blood flow in the vertebral artery may be affected by intrinsic and extrinsic factors. Intrinsic factors, such as atherosclerosis, narrow the vessel lumen, increase turbulence and reduce blood flow. Extrinsic factors compress or impinge upon the external wall of the vertebral artery.

There are three areas where the vertebral artery is vulnerable to external compression:

• at the level of the vertebral foramen of C6 by the contraction of the longus colli and/or the anterior scalene muscles

• within the foramen transversarium between C6 and C2

The ability to recognize symptoms that may indicate vertebrobasilar insufficiency (VBI) is essential for safe practice. Symptoms of VBI occur because of ischaemia in the structures

Vertebral artery

Vertebral artery

Fig. A.S.2 Upper cervical rotation stretches the vertebral artery between the atlas and the axis.

Box A.5.1 Causes of dizziness

Systemic causes of dizziness

• Medication

• Hypotension

Hypothyroidism

Central causes of dizziness

• Demyelinating diseases

• Tumours of brain or spinal cord

• Vertebrobasilar insufficiency

• Post-traumatic (concussion) vertigo

Peripheral causes of dizziness

Benign positional vertigo

• Meniere's disease

• Cervical spine dysfunction

Labyrinthitis

• Vestibulotoxic medication supplied by the vertebrobasilar system. There are a number of signs and symptoms that may be suggestive of VBI.

Signs of VBI

• Gait disturbances

Symptoms of VBI

• Dizziness/vertigo

• Dysarthria

• Occipital headaches

• Facial paraesthesia

• Tingling in the upper limbs

• Pallor and sweating

• Blurred vision

• Light-headedness

• Fainting/blackouts.

Dizziness is a common presenting complaint with multiple aetiologies that must be distinguished from dizziness arising from VBI (Box A.S.1). It has been suggested that questioning about nausea during VB! testing is as important as enquiring about dizziness. 15 Diagnosed VBI is an absolute contraindication to HVLA techniques to the cervical spine.

VBI testing protocol

Testing for VBI prior to manipulation of the cervical spine is common because of legal implications and the risk of a cerebrovascular accident following HVLA. There are many physical tests described for determining the presence or absence of VBI.'"'"21

A comprehensive testing procedure might include both active and passive movements (Box A.S.2). All positions should be end of range and maintained for 10 seconds unless symptoms or signs are provoked sooner. On returning the patient's neck to the neutral position, a period of 10 seconds should be allowed before proceeding with the next neck movement. During this time the patient should be asked whether any symptoms were

Box A.5.2 Vertebrobasilar insufficiency testing protocol

Patient sitting/active movement/cervical spine

Patient supine/passive movement/cervical spine

provoked. Reproduction of symptoms and/or signs of VBI constitutes a positive test.

The rationale for using active movement as part of the protocol is that the vertebral artery may be vulnerable to external compression at the level of the vertebral foramen of C6 by the contraction of the longus colli and/or the anterior scalene muscles.

Fig. A.S.4 Active rotation left.

Fig. A.S.3 Active rotation right.

Fig. A.S.S Active extension.

Fig. A.S.6 Active extension and rotation right.

Fig. A.S.7 Active extension and rotation left.

Fig. A.S.8 Passive rotation right.

Fig. A.S.9 Passive rotation left.

Fig. A.S.8 Passive rotation right.

Fig. A.S.9 Passive rotation left.

Tests for VBI are based upon the premise that cervical spine positioning may reduce the lumen and blood flow in the vertebral arteries.22,23 Studies on cadaveric specimens have demonstrated reduced flow through contralateral vertebral arteries in combined extension and rotation.243 In vivo studies also support the view that cervical spine positioning may reduce vertebral artery blood fiow.26_2S A study of normal volunteers concluded that

Fig. A.S.10 Passive extension.
Fig. A.S.11 Passive extension and rotation right.

blood velocity altered significantly at 45° cervical spine rotation, and again at full-range cervical spine rotation.28

Evidence linking vertebral artery narrowing or occlusion with cervical spine extension and rotation positioning has contributed to the development and use of many pre-manipulative tests for VBI. It is postulated that a reduction in blood flow as a result of cervical spine positioning will produce detectable symptoms or signs in a patient with VBI. Positive tests are assumed to be predictors of patients at risk of cerebrovascular complications of manipulation. However, tests for VBI may have low sensitivity and specificity for predicting cerebral ischaemia prior to neck manipulation,29 and the value of these tests in determining VBI has been questioned. 2l3lJ-32

There is debate as to whether VBI testing can reliably detect patients with VBI or identify those patients at risk of a cerebrovascular accident following cervical spine manipulation. It has been suggested that the tests themselves hold certain risks and could have a morbid effect on the vertebral artery.33 There is a need for continuing research to investigate the sensitivity and specificity of VBI testing in identifying those patients at risk of complications from manipulation, and to relate this research to the ethical and legal aspects of practice.

Fig. A.S.12 Passive extension and rotation left.

UPPER CERVICAL INSTABILITY

The bony anatomy of the atlantoaxial joint favours mobility rather than stability,34 with the atlantoaxial joint being more vulnerable to subluxation than other segments of the cervical spine.35 The transverse and alar ligaments have an integral role in maintaining stability in the upper cervical spine. Instability of the upper cervical spine may compromise related vascular and neurological structures and, in these circumstances, would be a contraindication to the use of ^VLA techniques.

Instability must be differentiated from hypermobility.3'1"37 Instability is a pathological situation that exists with clinical symptoms or complaints.37 Causes of upper cervical instability may be a result of incompetence of the odontoid process or of the transverse atlantal ligament. These causes can be classified as congenital, inflammatory, neoplastic and traumatic.

Congenital

Incompetence of the odontoid process

• Free apical segment — 'ossiculum terminale'

• Agenesis of odontoid base

• Agenesis of apical segment

• Agenesis of odontoid process.

Incompetence of the transverse atlantal ligament

• Idiopathic

Inflammatory

Incompetence of the odontoid process

• Osteomyelitis.

Incompetence of the transverse atlantal ligament

• Bacterial infection

• Viral infection

• Granulomatous change

• Rheumatoid arthritis

Ankylosing spondylitis.

Neoplastic

Incompetence of the odontoid process

• Primary tumour of bone

• Metastatic tumour of bone.

Traumatic

Incompetence of the odontoid process

• Acute bony injury

• Chronic bony change.

Incompetence of the transverse atlantal ligament

• Acute ligamentous damage associated with fracture and trauma

• Chronic ligamentous change.

Symptoms and signs of upper cervical instability

Symptomatic instability of the upper cervical spine is rare. Atlantoaxial instability occurs most frequently in patients with rheumatoid arthritis and is also well documented in Down's syndrome and in patients subsequent to retropharyngeal inflammatory processes.

The ability to recognize symptoms and signs that may indicate upper cervical instability is essential for safe practice. There are four cardinal symptoms and signs that may indicate presence of upper cervical instability:3"

• Overt loss of balance in relation to head movements

• Facial lip paraesthesia, reproduced by active or passive neck movements

• Bilateral or quadrilateral limb paraesthesia, either constant or reproduced by neck movements

• Nystagmus produced by active or passive neck movements.

In addition to the cardinal features of instability, there are other symptoms which may also indicate the presence of instability, including: 7

• Limitation of neck movements

• Torticollis

• Neurological symptoms —headache

• Neurological signs

— hyperreflexia

— gait disturbances

— spasticity

The above symptoms and signs might also indicate the presence of VBI or spinal cord compression unrelated to upper cervical instability. Thus, it is necessary to establish whether the symptoms or signs are related to instability of the upper cervical spine or to other causes.

Currently, the most reliable method for detecting increased movement in the upper cervical . spine is by the use of imaging techniques. The atlantodental interval is the distance between the most anterior point of the dens of the axis and the back of the anterior arch of the atlas. This is measured on lateral radiographs of the cervical spine in flexion, neutral and extension positions. An atlantodental interval greater than 2.5-3 mm in adults and greater than 4.5-5 mm in children indicates atlantoaxial instability.1" Computerized tomography may have some advantages over plane radiographs40 with magnetic resonance imaging also offering benefits because of the ability to provide direct sagittal projection.37

A number of physical tests have been described for the examination of instability of the upper cervical region.58'4^'2 A comprehensive testing procedure should include movements and positions that stress both the transverse atlantal and alar ligaments.

Transverse atlantal ligament stress test

The Sharp-Purser test was designed to demonstrate anterior instability at the atlantoaxial segment in patients with rheumatoid arthritis and ankylosing spondylitis.42'43 A modified Sharp-Purser test analyses the onset of symptoms and signs following head and neck flexion, and the reduction of signs and symptoms accompanying posterior translation of the occiput and atlas on the axis.

Patient position. Sitting with the head and neck relaxed in a semi-flexed position.

Operator position. Standing to the right of the patient with your right arm cradling the patient's forehead. The spinous process and vertebral arch of the axis are stabilized with the thumb and index finger of your left hand (Fig. A.5.13).

Stress applied. The occiput and atlas are translated posteriorly by applying pressure on the forehead with your right arm (Fig. A.5.14). Positive test. A positive test occurs when:

• there is onset of symptoms and signs with head and neck flexion

Fig. A.S.13 i* Stabilization
Fig. A.S.14 f Stabilization

» Plane of force (operator)

• there is a reduction of symptoms and signs with posterior translation of the occiput and atlas on the axis

• there is palpable hypermobility of anterior/posterior translation.

Alar ligament stress tests

There are many tests that purport to stress the alar ligaments and identify alar ligament instability. A comprehensive testing regimen might include the following three tests:

Patient sitting with the neck in a neutral position. Ensure that there is no sidebending of the head and neck. Stabilize the spinous process and vertebral arch of the axis with the thumb and index finger. Passively rotate the occiput and atlas to the right (Fig. A.5.1S). There should be no more than 20-30° rotation. Repeat the procedure to the left.

A positive test is characterized by the onset of symptoms or signs and/or a range of passive rotation greater than 30° at the upper cervical segments.

Patient sitting with the neck in a neutral position. Ensure the head is straight and there is no rotation of the neck. Stabilize the spinous process and vertebral arch of the axis with the thumb and index finger while placing the other hand on the patient's vertex (Fig. A.5.16). Attempt to passively sidebend the head to the left and then to the right (Fig. A.S.17). There should be minimal movement in either direction. This test must be repeated with the neck in flexion (Fig. A.S.18) and extension (Fig. A.5.19).

Fig. A.S.16 Stabilization

Fig. A.5.18 Stabilization

Fig. A.5.19 Stabilization

A positive test is characterized by the onset of symptoms or signs and/or an increased range of passive sidebending in all positions of neutral, flexion and extension.

Patient supine with the head and neck beyond the end of the couch and in a neutral position. Ensure the head is straight and there is no rotation of the neck. Stabilize the spinous process and vertebral arch of the axis with the thumb and index finger while placing the other hand on the patient's vertex (Fig. A.S.20). Both hands support the weight of the patient's head. Attempt to passively sidebend the head to the left and then to the right. There should be minimal movement in either direction. This test must be repeated with the neck in flexion (Fig. A.S.21) and extension (Fig. A.S.22).

A positive test is characterized by the onset of symptoms or signs and/or an increased range of passive sidebending in all positions of neutral, flexion and extension.

REFERENCES

Transverse atlantal and alar ligament stress tests have been developed on the premise that patients at risk from manipulation to the upper cervical spine may be identified using physical examination techniques. There is a need for continuing research to investigate the reliability and validity of upper cervical instability tests in identifying those patients at risk.

CONCLUSION

It is often stated that manipulation of the spine is a therapeutic technique associated with a high level of risk. The potential benefits"^ for the patient must be weighed against the risks associated with manipulation of the cervical spine. While there is a potential for serious sequelae, the risk is extremely low.

The evidence review accompanying the national clinical guidelines on acute and recurrent low back pain indicates that the risks of manipulation for low back pain are very low provided patients are assessed and selected for treatment by trained practitioners.4647

An extensive review of the literature between 1925 to 1993 indicates that the key to safety is dependent upon appropriate training, a thorough patient history and physical assessment prior to the application of any manipulative procedure."8

) Rivett D A, Milburn P A 1996 A prospective study of cervical spine manipulation. Journal of Manual Medicine 4 : 166-170

2 Coulter I D, Hurwitz E L, Adams A H et al 1996 The appropriateness of manipulation and mobilization of the cervical spine. RAND, Santa Monica, CA

3 KJougart N, Leboeuf-Yde C, Rasmussen L R 1996 Safety in chiropractic practice, part 1: the occurrence of cerebrovascular accidents after manipulation to the neck in Denmark from 1978-1988. Journal of Manipulative and Physiological Therapeutics 19: 371-377

4 Dvorak J, Orelli F 1985 How dangerous is manipulation to the cervical spine? Journal of Manual Medicine 2: 1-4

5 Patijn J 1991 Complications in manual medicine: a review of the literature. Journal of Manual Medicine 6: 89-92

6 Lee K P, Ca rlini W G, McCormick G F, Albers G W 1995 Neurologic complications following chiropractic manipulation: a survey of California neurologists Neurology 45: 1213-1215

7 Powell F C, Hanigan W C, Olivero W C 1993 A risk/benefit analysis of spinal manipulation therapy for relief of lumbar or cervical pain. Neurosurgery 33: 73-79

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9 Haldeman S, Kohlbeck F, McGregor M 1999 Risk factors and precipitating neck movements causing vertebrobasilar artery dissection after cervical trauma and spinal manipulation. Spine 24(8): 785-794

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11 Senstad 0, Leboeuf-Yde C, Borchgrevink C 1997 Frequency and characteristics of side effects of spinal manipulative therapy. Spine 22(4): 435-440

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26 Schmitt H 1991 Anatomical structure of the cervical spine with reference to pathology of manipulation complications. Journal of Manual Medicine 6: 93-101

27 Stevens A 1991 Functional Doppler sonography of the vertebral artery and some considerations about manual techniques. Journal of Manual Medicine 6: 102-105

28 Refshauge K 1994 Rotation: a valid premanipulative dizziness test? Does it predict safe manipulation? Journal of Manipulative and Physiological Therapeutics 17(1): 15-19

29 Bolton P, Stick P, Lord R 1989 Failure of clinical tests to predict cerebral ischaemia before neck manipulation. Journal of Manipulative and Physiological Therapeutics 12 304-307

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