Section 9: Safe OMT Practice

Original Editor - Lucy Aird

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Range of techniques recommended as good practice[edit | edit source]

This page follows on the International Framework for Examination of the Cervical Region
and is based on Section 9 Safe OMT Practice from:

Rushton A, Rivett D, Carlesso L, Flynn T, Hing W, Kerry R. International Framework for Examination of the Cervical Region for potential of vascular pathologies of the neck prior to Orthopaedic Manual Therapy (OMT) Intervention: International IFOMPT Cervical Framework. International Federation of Orthopaedic Manipulative Physical Therapists (IFOMPT). 2020[1]

OMT practice encompasses a wide range of therapeutic manoeuvres from patient activated forces to therapist activated forces. OMT is integrated into the overall management strategy of patient care. Reports of patient harm from OMT in the cervical region have typically been in the practice of cervical manipulation.

The following are necessary considerations for the physical therapist during the selection and application of cervical manipulation[2][3]:

  • The principle of all techniques is that minimal force should be applied to any structure within the cervical spine i.e. low amplitude, short lever thrusts.
  • Patient safety and comfort form the basis of appropriate technique selection.
  • Cervical manipulation techniques should be comfortable for the patient.
  • Cervical manipulation techniques should not be performed at the end of range of cervical movement, particularly extension and rotation.
  • There is flexibility in the choice of the patient’s position using the principles that the patient needs to be comfortable, and that the physical therapist needs to be able to receive feedback. The use of the supine lying position with the patient’s head supported on a pillow is encouraged. This position allows the physical therapist to monitor facial expressions, eye features, etc.
  • Positioning the patient in the pre-manipulative test position prior to manipulation is good practice to evaluate patient comfort and to enable evaluation of their response.
  • The patient response to all cervical spine movements, including cervical manipulation interventions is continuously monitored.
  • The skills of the physical therapist may be a limitation for the selection of manipulation as a treatment technique, even though clinical reasoning may suggest manipulation is the best choice. In this situation, a risk may be introduced owing to limited clinical skills and it would therefore be a responsible decision to not use manipulation. The self-evaluative skills of the physical therapist in evaluating their ability to perform the desired technique safely and efficiently are therefore important. Referral to a colleague suitably qualified/trained in the desired manipulative technique may be appropriate.

Alternative approaches to direct cervical treatment.[edit | edit source]

Emerging pain sciences suggests that the effects of manual techniques (such as mobilisation and manipulation) on pain may be largely neurological in nature and not limited to the direct influence of a particular spinal motion segment. Furthermore, clinical trials have reported that thoracic spine manipulation results in improvements in perceived levels of cervical pain, ranges of motion, and disability in patients with mechanical neck pain[4][5][6][7][8], although the mechanism by which this occurs is not known. Given the concern regarding the risks associated with cervical spine manipulation, thoracic spine manipulation provides an alternative, or supplement to, cervical manipulation and mobilisation to maximise the patient’s outcome with an extremely low level of risk. The current evidence suggests that during the initial treatment sessions there is a large likelihood of improved patient outcomes when thoracic manipulation is coupled with cervical active range of movement exercises[4][5][6][7][8]. Subsequent sessions can then introduce more direct manual cervical treatments if warranted. This approach allows the therapist to observe the patient’s response to treatment over a longer time period and theoretically minimises the risks associated with cervical manipulation in the presence of an emerging cervical vascular disorder, such as arterial dissection.

Frequency of treatment[edit | edit source]

Frequency of treatment will vary depending on the individual and injury in question. Current evidence suggests that manual interventions should be coupled with therapeutic exercise when managing a patient’s neck pain and headache[9][10]

Minimising end-range cervical techniques[edit | edit source]

End of range movements are known to stress the cervical arteries and potentially neural structures. Thus avoidance of these positions is recommended during cervical manipulation[11]

Force minimisation[edit | edit source]

OMT techniques used to treat the cervical region should be applied in a controlled, comfortable manner in mid ranges of cervical movement in order to reduce the potential stress on vascular and neurological structures. The influence of the head and cervical spine segments not included in the manipulation can be used to direct loads to the targeted segment. Vetebral artery strains measured in cadavers during high velocity, low amplitude cervical spine manipulation are significantly smaller than those obtained with diagnostic and range of motion testing[11]

Monitor for any adverse effects[edit | edit source]

Monitoring the patient for response to treatment and any harmful incidents is a continual process throughout treatment, at the conclusion of treatment, and prior to a new treatment session. Verbal and physical examination can be carried out while performing a treatment technique through monitoring physical body behaviour, facial expression, muscle tone, and verbal communication / responsiveness. However, the ultimate standard of response should be based on the change in a patient’s reported outcome measure (e.g. Neck Disability Index, Global Rating of Change, etc).

Emergency management of an adverse situation[edit | edit source]

As a health professional, the physical therapist is expected to act swiftly and judiciously when confronted with an emergency situation. A plan of action should be devised, available, and operational for effective management of a safety incident or adverse reaction. In the unlikely event that a patient becomes unresponsive during any aspect of physical therapy care, the physical therapist should immediately implement an emergency action plan for cardiopulmonary resuscitation. A local accepted procedure for an emergency should be initiated, such as calling an ambulance. Training in cardiopulmonary resuscitation should be completed on a regular basis.

References[edit | edit source]

  1. Rushton A, Rivett D, Carlesso L, Flynn T, Hing W, Kerry R. International Framework for Examination of the Cervical Region for potential of vascular pathologies of the neck prior to Orthopaedic Manual Therapy (OMT) Intervention: International IFOMPT Cervical Framework. International Federation of Orthopaedic Manipulative Physical Therapists (IFOMPT). 2020
  2. 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.
  3. Childs JD, Flynn TW, Fritz JM, et al (2005). Screening for vertebrobasilar insufficiency in patients with neck pain: manual therapy decision-making in the presence of uncertainty. J Orthop Sports Phys Ther 35(5):300-306.
  4. 4.0 4.1 Cleland JA, Childs JD, McRae M, et al (2005). Immediate effects of thoracic manipulation in patients with neck pain: a randomized clinical trial. Manual Therapy 10:127-135.
  5. 5.0 5.1 Cleland JA, Childs JD, Fritz JM, et al (2007a). Development of a clinical prediction rule for guiding treatment of a subgroup of patients with neck pain: use of thoracic spine manipulation, exercise, and patient education. Physical Therapy 87:9-23.
  6. 6.0 6.1 Cleland JA, Glynn P, Whitman JM, et al (2007b). Short-term effects of thrust versus nonthrust mobilization/manipulation directed at the thoracic spine in patients with neck pain: a randomized clinical trial. Physical Therapy 87:431-440.
  7. 7.0 7.1 Krauss J, Creighton D, Ely JD, et al (2008). The immediate effects of upper thoracic translatoric spinal manipulation on cervical pain and range of motion: a randomized clinical trial. J Man Manip Ther 16(2):93-99.
  8. 8.0 8.1 Gonzalez-Iglesias J, Fernandez-de-las-Penas C, Cleland JA, et al (2009). Thoracic spine manipulation on the management of patients with neck pain: A randomized clinical trial. Journal of Orthopaedic and Sports Physical Therapy 39(1):20-27.
  9. Bussières, A.E., Stewart, G., Al-Zoubi, F., Decina, P., Descarreaux, M., Hayden, J., Hendrickson, B., Hincapié, D.C., Pagé, I., Passmore, S., Srbely, J., Stupar, M., Weisberg, J., Ornelas, J. (2016). The treatment of neck pain-associated disorders and whiplash-associated disorders: A clinical practice guideline. Journal of Manipulative and Physiological Therapeutics, 39(8), 523–564.
  10. Blanpied, P.R., Gross, A.R., Elliott, J.M., Devaney, L.L., Clewley, D., Walton, D.M., Sparks, C., Robertson, E.K. (2017). Neck pain: Revision 2017. Journal of Orthopaedic & Sports Physical Therapy, 47(7), A1-A83.
  11. 11.0 11.1 Herzog, W., Leonard, T.R., Symons, B., Tang, C., Wuest, S. (2012). Vertebral artery strains during high- speed, low amplitude cervical spinal manipulation. Journal of Electromyography and Kinesiology, 22(5), 740-746.