AAOMPT Responds to American Heart Association Cervical Manipulation Paper

Physical Therapists Prepared to Identify Benefits, Risks of Neck Manipulation for Appropriate Patients

BATON ROUGE, LA, August 8, 2014 – The American Academy of Orthopaedic Manual Physical Therapists (AAOMPT) acknowledges the efforts of the American Heart Association (AHA) to bring to light the benefits and risks of cervical or neck manipulation.

The orthopaedic manual physical therapist community recognizes the rare but significant risks associated with cervical manipulation.  Physical therapists use manipulation as an intervention to address prevalent conditions such as headache and neck pain, and are committed to educating the public about the appropriateness of neck manipulation for particular patients. In fact, the AAOMPT, in collaboration with the International Federation of Orthopaedic Manual Physical Therapists (IFOMPT) has studied this issue in great detail and previously provided an international framework for mitigating risk associated with these techniques. This framework is reflective of best practice, intending to place risk in an appropriate context that is informed by the available evidence.  We believe the scientific statement released yesterday, while stating that the incidence of cervical manipulative therapy-associated carotid dissection is not well established, and probably low, is significantly limited in its scope and context and may place unnecessary fear in the public of an effective low risk treatment intervention.

Neck pain is a common occurrence with approximately 22% to 70% of the population potentially developing neck pain at some point in their lives.1 Approximately 44% of patients experiencing neck pain will develop chronic symptoms, and many of them will develop some level of disability.2

To date, many scientific studies support cervical manipulation for the treatment of head and neck pain of mechanical origin.  One systematic review in the Journal of Rheumatology3 from 2007 reviewed 88 randomized controlled trials and concluded that exercise combined with manipulation or mobilization demonstrated both pain relief and functional improvement in adults with acute, subacute, or chronic mechanical neck disorders. A study in the medical journal Spine5 concluded that manipulative therapy and exercise can reduce the symptoms of headaches of cervical origin and that the effects are long lasting.

 “Physical therapists are highly educated healthcare professionals that appreciate the serious, but rare complications of manipulation,” said Bob Rowe, PT, DPT, DMT, FAAOMPT, president of the American Academy of Orthopaedic Manual Physical Therapists, an organization that works closely with APTA and its Orthopaedic Section on issues related to manipulation and mobilization.

Guidelines for manual therapy treatment of the cervical spine have been available for the last 2 decades to assist practitioners in clinical decision making.6,7  In 2012, a clinical reasoning framework8 was developed by the International Federation of Orthopaedic Manipulative Physical Therapists to provide guidance for the assessment of patients for the likelihood of stroke in advance of cervical manipulation. Identified risk factors associated with an increased risk of stroke include history of trauma to the cervical spine, history of migraine-type headache, hypertension, cardiac or vascular disease, diabetes, blood clotting disorders, history of smoking, and recent infection.

“The Scientific Statement developed by the AHA regarding the risks of cervical and neck manipulation must be considered in context of the relative and comparative risks of manipulation.”  The risks of cervical manipulation are much lower than the use of other interventions such as the use of anti-inflammatory drugs,  injections and  surgery explained Rowe. “Many medications, particularly anti-inflammatory and surgery for the treatment of neck pain or headaches have much larger risks than manipulation.” In addition, a 2007 AHA scientific statement10 indicated that for patients with a prior history of or at high risk for heart disease, certain pain relievers known as COX-2 inhibitors could increase risk for heart attack, stroke, and high blood pressure.  Also, a 2013 study in Spine11 found that patients who had cervical spine surgery were at significant risk of cardiac and breathing problems as well as gastrointestinal, neurological, blood cell, and urinary tract complications. In addition, there was a greater risk of death after cervical spine surgery among patients older than 65 who had a history of heart problems.

Incidents of stroke associated with cervical manipulation of the spine are rare.In a 2002 review12 of 64 cases of cerebrovascular ischemia, or lack of blood flow to the brain, associated with cervical spine manipulation, researchers concluded that strokes after manipulation appear to be unpredictable and should be considered a rare complication of this treatment approach. In addition, a 2010 systematic review in the scientific journal Manual Therapy13 found no strong evidence linking the occurrence of adverse events to cervical manipulation and/or mobilization.

AAOMPT along with the  American Physical Therapy Association agrees that patient safety must come first when determinations regarding treatment options are made. “The orthopaedic manual physical therapist community is committed to educating patients and practitioners about the risks and benefits of cervical manipulation, with decisions based on a detailed and ongoing evaluation and a treatment plan that is consistent with patient preferences” added Rowe.

The American Academy of Orthopaedic Manual Physical Therapists represents more than 2,000 specialty trained physical therapists and students of physical therapy nationwide. Learn more about AAOMPT here.


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  9. FDA Drug Safety Communication: FDA requires label changes to warn of rare but serious neurologic problems after epidural corticosteroid injections for pain. 4-23-2014.
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