Section 6: Risk versus benefit analysis

International Framework for Examination of the Cervical Region

Framework for evaluating risk

The risk associated with OMT intervention for musculoskeletal cervical spine disorders should be considered within a clinical reasoning framework. That is, the risk, likely being extremely low in general and in comparison to some other conservative treatments[1], may vary somewhat depending on the patient’s individual clinical presentation, and in particular in the presence of risk factors previously discussed (see Section 3). It is therefore the responsibility of the physical therapist to recognise and consider whether the risk for a particular patient is increased, and to do whatever is reasonable to minimise any risk associated with OMT intervention.

Risk versus benefit analysis:

Data and evidence surrounding the clinical concern of this framework are incomplete and often contradictory. It is important to appreciate that an absolute diagnosis cannot be made by the physical therapist. The physical therapist must accept that the clinical decision is made in the absence of certainty and a decision based on a balance of probabilities is the aim of assessment. Although some presentations absolutely contraindicate OMT intervention, others suggest risk factors for potential adverse events and may co-exist with treatable musculoskeletal dysfunction. It is the responsibility of the physical therapist to make the best decision regarding treatment in these situations using their clinical reasoning skills[2][3].

The following model provides a simple framework for decision-making regarding risk versus benefit but should not be considered didactic:

Decision-making framework for analysing risk versus benefit
Risk Benefit Action
High number/ severe nature of risk factors Low predicted benefit of manual therapy Avoid treatment
Moderate number / moderate nature of risk factors Moderate predicted benefit of manual therapy Avoid or delay treatment / monitor and reassess
Low number / low nature of risk factors Low / moderate / high predicted benefit of manual therapy Treat with care / continual monitoring for change/new symptoms


  1. Rivett DA (2004). Adverse effects of cervical manipulative therapy. In J.D. Boyling and G.A. Jull (eds.), Grieve’s Modern Manual Therapy of the Vertebral Column (3rd ed). Churchill Livingstone: Edinburgh 533-549.
  2. Jones MA, Rivett DA (2004). Introduction to clinical reasoning. In M.A. Jones and D.A. Rivett (eds.), Clinical Reasoning for Manual Therapists. Butterworth-Heinemann: Edinburgh 3-24.
  3. Kerry R, Taylor AJ (2009). Cervical arterial dysfunction: knowledge and reasoning for manual physical therapists. Journal of Orthopaedic and Sports Physical Therapy 39(5):378-387.