Manipulate or Not?

By Brett Windsor, PT

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In the world of manual therapy and in particular at NAIOMT, we are constantly reminded of the need to be vigilant in our screening examinations. Much of the serious pathology that can potentially compromise the stability or vascular integrity of the cervical spine presents in a manner as would any relatively simple mechanical neck pain.

I was recently reminded of this point while reading a case study in a recent issue of the Journal of the Canadian Chiropractic Association. It describes the case of a 54 year old male presenting to a chiropractor with chronic neck pain absent headache. The patient had a history of previous trauma and episodes of pain for which he had received treatment. The DC ordered up copies of previous MRI’s and radiographs. In the meantime, following examination, the patient was treated with mobilization and manipulation. No adverse effects were noted either at the time of treatment or upon the patients return a few days later.

Here’s the interesting part…when the reports showed up a few days later, having been done a few years prior, they showed the presence of an ‘Os Odontoideum’, or as specifically described in this case, a remote fracture of the dens at the base of C2. Flexion-Extension radiographs showed a decrease in the A-P width of the spinal canal at the C1-2 segment, so it is fair to say that the condition was compromising the stability of the upper cervical segments. All of this in the presence of a pretty benign examination sequence, although perhaps it could be argued that a more thorough examination could have been performed? AS discussed below, maybe there were a few clues as to what was going on? At any rate, I bet there were a few nervous moments upon reading that!!. Happy days were here again when the patient showed up showing no ill-effects from the previous manipulation.

Could a case have be made that this patient should never have never been manipulated? Perhaps…he was 54, which is neither here nor there. He did have a history of trauma, but it was two decades ago. There were no headaches. There was no discussion about the onset or behavior of the pain so it is difficult to know if there were any non-mechanical cues. There was a ‘global’ and ‘significant’ restriction of ROM, although no specific numbers were provided. Objectively, the neurological examination was unremarkable. There was no discussion of upper cervical stability tests being performed, nor was there any real discussion of specific segmental testing. Could specific segmental stress testing have identified this lesion? It is difficult to say…what is known is that these types of conditions are often completely asymptomatic and look exactly like legitimate mechanical neck pain. In short, there was just nothing obvious to suggest that there was a problem here.

One lesson here? Always keep the index of suspicion open…never drop your guard. For us at NAIOMT that means always thinking about the screening examination and being thorough with the evaluation – not being seduced into making quick, reactive decisions about care.

Should there have been more caution here? What would you have done? Did the DC miss something that could have prevented a manipulation from being performed? Interested in your thoughts…

If you’d like to read a full text copy of the article, it can be found at the link below:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4139764/

Best regards

Brett Windsor

2 thoughts on “Manipulate or Not?

  1. I once had a patient attend for another condition (calf strain) ask about my having a look at his neck since it had been shoved forward in a rugby tackle earlier the same day. Cervical range was restricted but not exceptionally and there wasn’t a huge amount of pain. Neurological tests were negative and there wasn’t any reaction to upper neck ligament testing but the muscles in the area felt unusually tight. I wasn’t happy with the way things felt overall so I sent the patient back to his GP who had an x-ray done showing an undisplaced fracture of the dens. Sometimes, even with trauma, there isn’t a huge amount to show you when there is something sinister in the background. Thanks goodness for being cautious and the old maxim I learnt from David Lamb years ago ”If in doubt, don’t”.

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    1. Hi Ross, Great story, great comments and I love the David Lamb quote as well. We so often forget that doing nothing can often do everything can’t it? Best regards. Brett

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