Pre-Manipulative Hold

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Definition

Before performing a manipulation of a joint, a pre-manipulative hold can be performed. A pre-manipulative hold, can be defined as holding a patient's joint at end range for a period of time while monitoring for any potential adverse responses. These include the 5 D's (Diplopia, Dizziness, Drop Attack, Dysarthria, & Dysphagia), 3 N's (Nausea, Numbness, & Nystagmus), peripheralization, worsening of symptoms, or symptoms of Cervical Arterial Dysfunction (CAD).

Purpose

There are two purposes for performing a pre-manipulative hold prior to a spinal manipulation. The first is to assess the patient's symptoms when taken to the end range of the joint. When the joint is taken to end range and held, assess the patient's symptoms. If they are experiencing an improvement or if the symptoms are not worsening, then a manipulation may be warranted. The second, and most well known reason, is to ensure the safety of the manipulation that will be performed. There is conflicting information on the validity of testing prior to a manipulation in predicting an adverse event, however, it is often recommended for liability documentation. Additionally, it also can be used to inform the patient of what position will take place with a manipulation so they may provide consent.

Research

Most of the research involves the cervical spine which includes the International Framework for Examination of the Cervical Region, which has the overall goal of educating providers in proper assessment of vascular disorders in the cervical spine. The use of the Vertebral Artery Test (VAT), (also known as the VBI test), is the most commonly known pre-manipulative test. It is done to test the blood flow through the vertebral artery in the neck by putting the neck into an end range position. If a patient experiences any adverse responses with this position (the 5D's or 3N's), then manual therapy may not be warranted to the patient's cervical spine.

There is evidence that the VAT or VBI test is not a valid prediction tool for adverse effects. It has been found to inaccurately produce false positives in patients who do not have vascular conditions and produce a negative test in people who do have a vascular condition. The Australian Physiotherapy Association (APA) does have a vertebral artery protocol. It includes a detailed history of the patient (including any history of the 5D's and 3N's along with the past medical history), it also includes tests of movement of the cervical spine, assessment of the cranial nerves, pupils and pre-manipulative holds.

Bottom line, if you suspect any possibility of an adverse vascular event based upon the patient's past medical history or response with a pre-manipulative hold, trust your judgment in proceeding with a manipulation.