A survey of UK manual therapists' practice of and attitudes towards manipulation and its complications

A survey of UK manual therapists’practice of and attitudes towardsmanipulation and its complications

GEORGINA ADAMS Oxford, UK.JULIUS SIM Department of Physiotherapy Studies, Keele University, UK.

ABSTRACT Background and Purpose. Little is known about the practice of manipula-tion by UK physiotherapists. This study was conducted to discover current practice of, andattitudes towards, manipulation among UK manipulative therapists. Methods. A postalquestionnaire was sent to 300 UK manipulative therapists who were members of two pro-fessional associations representing differing approaches to manual therapy: the Society ofOrthopaedic Medicine (SOM) and the Manipulation Association of Chartered Physiother-apists (MACP). Results. A 50% response rate was achieved and 129 respondents identi-fied themselves as ‘users’ of manipulation. Anxiety about possible complications was aprominent reason adduced by ‘non-users’ and ‘partial users’ for their avoidance of manipu-lative procedures. The thoracic spine was the region most often manipulated, followed bythe lumbar spine. Nineteen per cent of users had encountered complications frommanipulation, which were most common in the cervical region and were predominantlynon-serious. The majority of SOM members and a minority of MACP members usedgeneralized cervical rotary manipulations — thought by some to be potentially dangerous.Attitudes to manipulation were generally positive, although overall respondents were uncer-tain as to whether its benefits outweighed its risks. Members of the SOM emerged as morefrequent users of manipulation and as less conservative in their attitudes to certain aspectsof manipulation. Conclusions. Allowing for possible under-reporting or other responsebiases, spinal manipulation emerged as a relatively safe and widely practised techniqueamong this sample.

Key words: attitudes, complications, manipulation, physical therapy.

INTRODUCTION

The art of manipulation is old, and is thought to have been first described byHippocrates in approximately 400 BC (Cyriax, 1982). Physiotherapists have been usingmanipulation for a long time (Grieve, 1978), but little is known of the manipulative

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practices of today’s physiotherapist. To address this deficit, a postal survey was con-ducted to gather information on the use of manipulation by UK physiotherapists and tomeasure their attitudes regarding the practice of manipulation and its complications.

Research has highlighted certain risks that accompany the use of manipulation(Schellhas et al., 1980; Grant, 1988; Terrett, 1988; Rivett, 1997). Although mostreports of complications have occurred after chiropractic treatment (Patijn, 1991),there are a few reports of serious complications following manipulation by a physio-therapist (Parkin et al., 1978; Fritz et al., 1984; Terrett, 1988). Recent research sug-gests that complications following manipulation by a physiotherapist may indeedconstitute an appreciable and hitherto unrecognized proportion of all manipulativecomplications (Rivett & Milburn, 1997).

In the light of concerns about the risks of manipulation, pre-manipulative proto-cols have emerged (Australian Physiotherapy Association, 1988) and there havebeen suggestions that certain manipulative techniques should no longer be used inclinical practice (Terrett, 1988; Dvorák et al., 1993; Grant, 1994). A question whichis raised, and which this survey seeks to answer, is: Are physiotherapists regularlypractising these putatively risky techniques?

Two questionnaire studies on the practice of manipulation by physiotherapists havebeen conducted previously. Michaeli (1991a, 1991b, 1992, 1993) conducted a surveyof 250 physiotherapists who had completed the South African postgraduate coursebased on the Maitland approach, and gathered information on the use of manipulationand mobilization, complications arising from their use, and the use of pre-manipulativetesting. His main findings were that 67% of his sample of 153 respondents used spinalmanipulation, that most physiotherapists who manipulated the cervical spine usedsome sort of pre-manipulative test, and that more complications were reported follow-ing cervical mobilization than following cervical manipulation, the majority of whichwere minor.

Goldby (personal communication), on behalf of the British Association ofChartered Physiotherapists in Manipulation (BACPIM), presented a questionnairein Frontline, a professional physiotherapy magazine in the UK. A total of 603physiotherapists replied within the four-month period of data collection. Some basicinformation on current practice of manual skills was ascertained from the ten ques-tions asked. Of the 421 physiotherapists who had been on a manipulative trainingcourse, 61.5% used manipulation as a form of treatment. Manipulations were per-formed on a daily basis by 20.7% in the lumbar spine and by 14.8% in the thoracicand cervical spine. This study gives us a general picture of the use of manipulationby physiotherapists in the UK. Our study endeavoured to provide a more detailedprofile of manipulative practice.

Complications of manipulation

It is worth considering some of the grounds for concern in respect of spinal manipu-lation. Estimates have been made which suggest a very low frequency of complica-tions. Hosek et al. (1981) estimate that about one in a million cervical

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manipulations will result in a serious vertebrobasilar complication, and Hurwitz etal. (1996) put the complication rate at 5–10 per 10 million cervical manipulations.Dvorák and Orelli (1985), in a survey of the Swiss Society for Manual Medicine,found one ‘important’ complication per 400 000 manipulation procedures.

Exact information on the frequency of complications is, however, hard to obtain(Michaeli, 1993). The most widely reported category has been that of vascular com-plications following cervical manipulation. This spans the whole spectrum of adversevertebrobasilar events, from minor visual disturbance to stroke and even death(Schellhas et al., 1980; Grant, 1987, 1988; Terrett, 1988). On the other hand, Dabbsand Lauretti (1995) present evidence, based on a literature review, that the risk asso-ciated with cervical spine manipulation is considerably less than that associated withtreatment with non-steroidal anti-inflammatory medication. Few complications havebeen reported following manipulation of the thoracic spine and no indication of thefrequency of such complications can be found in the literature. Complications follow-ing lumbar manipulation have been reported (Terrett & Kleynhans, 1992; Grieve,1994), but again, the frequency of such incidents is unknown. It should be borne inmind that complications are considered to be under-reported in the literature, per-haps because there is no legal obligation to report them (Grieve, 1994). Our surveysought to increase understanding of the potential risks of manipulation, by includingquestions on the frequency and types of complications encountered.

Approaches to manipulation

Manipulation does not belong to a particular professional group, and different pro-fessions tend to take different perspectives on manual therapy. Within physiother-apy, various approaches to evaluating and treating musculoskeletal disorders haveevolved, the two main schools in the UK being those based on the work of GeoffreyMaitland (1986) and James Cyriax (1982, 1984). These schools of thought embodydifferent approaches towards manipulation and it is therefore of interest to comparethe manipulative practice of a group such as the Manipulation Association of Char-tered Physiotherapists (MACP), most of whose members are trained in the system ofmanual therapy developed by Maitland, with that of the Society of OrthopaedicMedicine (SOM), which draws on the methods advocated by Cyriax. The member-ships of both groups have specialist education in manipulation. Our study addressedthe question of whether these groups differed in their practice of manipulation andin their attitudes towards its use.

In sum, the objectives of this study, as reported in this paper, were to:

• Describe and quantify manual therapists’ use of manipulation.• Measure their attitudes to the practice of manipulation and its complications.• Ascertain the reported frequency and severity of manipulative complications.• Draw comparisons, with respect to the above, between members of the SOM and

members of the MACP.

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METHOD

The respondents for this survey comprised members of the SOM and the MACP. Itwas considered that these two groups would be representative of the majority ofphysiotherapists in the UK currently practising, or likely to practise, manipulation asdefined for the purposes of this study.

In order to gather data from respondents across the UK, a postal questionnairewas drawn up. It included sections on the following:

• Respondents’ biographical details.• Their frequency of use of manipulation.• Which specific manipulative techniques they currently used.• Their current use of pre-manipulative protocols.• Complications encountered following the use of manipulation.• Attitudes to the practice of manipulation.• Attitudes to the use of pre-manipulative testing.

In this paper only the data related to the practice and complications of manipulationare reported.

Most questions were closed-ended. However, some open-ended questions wereincluded to allow respondents the opportunity to qualify or explain certainresponses. Respondents’ attitudes to aspects of manipulative therapy were tapped bymeans of a five-point Likert scale (5 = strongly agree, 4 = agree, 3 = uncertain, 2 =disagree, 1 = strongly disagree). Some modifications to the questionnaire occurredfollowing a pilot study conducted on 12 physiotherapists with experience in manualtherapy. This also revealed possible reluctance to answer some questions that mightbe seen to reflect unfavourably on respondents’ clinical practice, and it was thereforedecided to ensure that the questionnaire was anonymous. The questionnaire wasdesigned so that it could be completed within approximately 30 minutes.

The questionnaire was accompanied by a sheet of definitions of key terms, toencourage respondents to use a common frame of reference when providing informa-tion on their clinical practice. The definitions provided are shown in Appendix I.

The sampling frame for the survey consisted of the membership lists of the SOMand the MACP, current in 1995 (these were provided with the approval of theseassociations). A total of 300 therapists were randomly sampled from these lists —112 from the 210 names on the SOM list and 188 from the 355 names on theMACP list (a 53% sampling intensity in both cases). In order to preserve anonymity,no identifying questions were asked, but the return envelope had an identifyingnumber on it. Returned questionnaires were received by a third party who was notdirectly involved with the research, and once personal identifiers had been removed,the questionnaires were then forwarded to the researchers. In this way, a record waskept of which respondents had replied while maintaining the anonymity of the indi-vidual questionnaires. Questionnaires were posted in June 1996, and respondents


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were asked to return the questionnaire within three weeks. At the end of this period,non-responders were sent a reminder.

Data analysis was principally by means of descriptive statistics. Nonparametricinferential statistics were used to compare certain findings in view of the risk of Type1 error when conducting multiple comparisons, p < 0.02 (two-tailed) was taken asthe cut-off point for statistical significance. Qualitative data from the open questionswere analysed under categories that emerged from the data.

RESULTS

Sample characteristics

A total of 149 questionnaires were returned, constituting a response rate of 50%,which is 13% lower than that of a similar survey by Michaeli (1991a). Given thenumber of non-responders, the possibility of response bias should be consideredwhen interpreting the results from this study.

Six questionnaires were incomplete due to the respondents’ being retired, nolonger in clinical practice or having moved abroad. These were discarded, leaving anachieved sample of 143 (48% of original sample). The SOM response rate was lower(N = 41; 37% of original sample) than that of the MACP (N = 102; 54% of originalsample).

Of the respondents, 24 (17%) were male and 119 (83%) were female (the distrib-ution of males and females was similar for SOM and MACP members). Their year ofqualification as a physiotherapist ranged from 1957 to 1990, the median being 1980.Overall, the SOM and MACP groups were very similar in their work characteristics(number of hours of work, area of work and place of work).

Use of manipulation

A total of 129 (90%) respondents used manipulation, as defined, as a form of treat-ment (‘users’). Of those who did not use manipulation (‘non-users’), two were fromthe SOM and 12 were from the MACP (i.e. 5% of the SOM sample and 12% of theMACP sample): the difference in proportions was not statistically significant(Fisher’s exact test, p = 0.3505). All non-users were female, and none listed privatepractice as their primary area of work. The mean proportion of time spent in spinaland peripheral manipulation and mobilization was 61% for users and 48% for non-users. Table 1 shows the proportions of patients with spinal musculoskeletal disorderstreated with manipulation by the two groups of therapists. The modal range of pro-portions for both groups was 1–20% of patients.

Table 2 shows the numbers of users who indicated that they utilize manipulationat different spinal levels. The cervical spine was divided into four sub-regions as itwas anticipated that practice would vary within this region. The percentage endorse-ment is also shown for each level or range of levels. Levels T2–T12 emerged as those

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most consistently manipulated by the two groups (i.e. the range of levels manipu-lated by the highest proportion of users). Differences in practice between the groupsemerged in respect of the cervical spine, and by use of a X2 test, these were found tobe statistically significant for C1/2 (X 2 = 5.7742, df = 1; p = 0.0163) and forC2/3–C4/5 (X2 = 6.4952, df = 1; p = 0.0108). The difference for C5/6–C7/T1 justescaped significance (X2 = 5.3952, df = 1; p = 0.0202).

In order to gauge the frequency of use of manipulation at different spinal regions,respondents were asked to select a category corresponding to the mean number ofmanipulations performed per week (Table 3). In respect of the sample as a whole, acomparison across the three spinal regions was made by means of a Friedman test,which revealed that at least one median category differed from at least one othermedian category (X2 = 39.594, df = 2; p < 0.0005). On the basis of this, pairwisecomparisons were carried out by means of a sign test (the cut-off point for statistical


TABLE 1: Proportion of patients with spinal musculoskeletal disorders treated by means of manipu-lation by members of SOM and MACP*

Proportion of patients treated with manipulation (%)Group 1–20 21–40 41–60 61–80 81–100

SOM (N = 39) 24 (62) 9 (23) 4 (10) 1 (3) 1 (3)MACP (N = 90) 77 (86) 6 (7) 0 (0) 7 (8) 0 (0)Total (N = 129) 101 (78) 15 (12) 4 (3) 8 (6) 1 (1)

*The figures represent the number of therapists with percentages given in parentheses (due torounding, percentages may sum to more than 100%).SOM = Society of Orthopaedic Medicine; MACP = Manipulation Association of CharteredPhysiotherapists.

TABLE 2: Utilization of manipulation at various spinal levels *

Spinal levelsGroup CO/1 C1/2 C2/3–C4/5 C5/6–C7/T1 T1/T2–T12 L1–L5

SOM (N=39) 10 (26) 14 (36) 32 (82) 36 (92) 37 (95) 38 (97)MACP (N=90) 21 (23) 15 (17) 53 (59) 67 (74) 88 (98) 81 (90)Total (N=129) 31 (24) 29 (22) 65 (66) 103 (80) 125 (97) 119 (92)

*The figures represent the number of users who employ manipulation at the level, or range of levels,in question. Respondents were asked to endorse all categories applicable. The figures in parenthesesrepresent the percentage endorsement (i.e. the number of responses in each cell as a percentage ofthe corresponding number of respondents).SOM = Society of Orthopaedic Medicine; MACP = Manipulation Association of CharteredPhysiotherapists.

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significance was adjusted to p < 0.007 for this purpose). The median category for thecervical spine was found to be lower than that of the thoracic spine (z = –5.340, N = 123; p < 0.0005) and that of the lumbar spine (z = –4.783, N = 123;p < 0.0005), but no difference existed between the thoracic and lumbar spines(z = –1.750, N = 125; p = 0.080). Hence, the cervical region is manipulated less fre-quently than either the thoracic or lumbar regions.

In terms of between-group comparisons, the median categories for the cervicaland lumbar spines were higher for the SOM than for the MACP, and a Mann–Whitney test revealed these differences to be statistically significant (U = 1093, n1 = 39 n2 = 87; p = 0.0003 for the cervical spine; U = 1231.5, n1 = 38 n2 = 89; p =0.0089 for the lumbar spine).

Table 4 shows responses to questions on the use of repeated manipulations at thesame spinal level at one treatment session. With regard to the figures for the samespinal level, those for the SOM were consistently higher. These differences weretested by means of a Mann–Whitney test and were found to be statistically signifi-cant in each case (U = 867, n1 = 36 n2 =64; p = 0.009 for the cervical spine; U =944, n1 = 35 n2 = 82; p = 0.001 for the thoracic spine; U = 925.5, n1 = 36 n2 = 78;p = 0.001 for the lumbar spine). In addition, the ranges indicate that the number ofmanipulations performed was more variable in respect of the SOM group in eachspinal region.

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TABLE 3: Mean number of manipulations performed per week in the cervical, thoracic and lumbarspines*

Mean number of manipulations per week<1 1–5 6–10 11–15 16–20 21–25 26+

CervicalSOM (N = 39) 13 (33) 18 (46) 5 (13) 3 (8) 0 (0) 0 (0) 0 (0)MACP (N = 87) 59 (68) 22 (25) 1 (1) 2 (2) 2 (2) 0 (0) 1 (1)Total (N = 126) 72 (57) 30 (32) 6 (5) 5 (4) 2 (2) 0 (0) 1 (1)

ThoracicSOM (N = 38) 11 (29) 16 (42) 7 (18) 4 (11) 0 (0) 0 (0) 0 (0)MACP (N = 89) 30 (34) 41 (46) 9 (10) 6 (7) 1 (1) 0 (0) 2 (2)Total (N = 127) 41 (32) 57 (45) 16 (13) 10 (8) 1 (1) 0 (0) 2 (2)

LumbarSOM (N = 38) 12 (32) 13 (34) 8 (21) 3 (8) 1 (3) 0 (0) 1 (3)MACP (N = 89) 46 (52) 33 (37) 3 (3) 0 (0) 3 (3) 3 (3) 1 (1)Total (N = 127) 58 (46) 46 (36) 11 (9) 3 (2) 4 (3) 3 (2) 2 (2)

*The figures represent the number of responses under each category, with percentages in parenthe-ses (which may sum to more than 100 owing to rounding errors). The category corresponding to themedian score within each row has been shown in bold type. Missing values have been excluded.SOM = Society of Orthopaedic Medicine; MACP = Manipulation Association of CharteredPhysiotherapists.

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Use of specific techniques

Respondents were asked to indicate their use of localized manipulations (i.e. thosedirected at a single intervertebral level) as opposed to generalized manipulations (i.e.those capable of affecting more than one intervertebral level). Members of the SOMindicated that the mean frequency with which they use such techniques is 7.9 timesper week (range 0–40), compared with a mean of 2.2 times per week (range 0–80)for MACP members; 72% of MACP members never use such techniques, comparedwith 15% of SOM members. The difference in frequency between groups was statis-tically significant (Mann–Whitney test) (U = 351, n1 = 26 n2 = 74; p < 0.00005).

Respondents were also asked to indicate which manipulative techniques they hadused in the last 12 months, and were provided with region-specific lists of proceduresthat satisfy the definition of manipulation. Responses are shown in tables 5–7. Themost consistently used techniques in each region were, respectively:

• Localized lateral flexion of the C2–C7 intervertebral (IV) joints (63%endorsement).

• Postero-anterior thrust to T3–T10 IV joints (73% endorsement).• Localized rotation to T10–S1 IV joints (61% endorsement).

In contrast, the techniques with the lowest reported use in each region were,respectively:

• Atlanto-axial joint rotation (9% endorsement).• Nelson’s manipulation (i.e. postero-anterior thrust with longitudinal traction)

and longitudinal manipulation to IV joints T3–T10 (20% endorsement each).• Lumbar extension with leverage (9% endorsement).


TABLE 4: Maximum number of manipulations performed at the same level in the cervical, thoracicand lumbar spines*

Maximum at same spinal level (range)Group Cervical Thoracic Lumbar

SOM 1 (1–5) 2 (1–5) 2 (1–5)MACP 1 (1–2) 1 (1–3) 1 (1–3)Total 1 (1–5) 1 (1–5) 1 (1–5)N (out of 143) 100 117 114

*Figures are medians, with ranges in parentheses. Despite the equivalent median values for thecervical spine, there was a statistically significant difference between groups.SOM = Society of Orthopaedic Medicine; MACP = Manipulation Association of CharteredPhysiotherapists.

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Respondents who had classified themselves as non-users of manipulation wereasked to indicate the relevance to their decision of various possible reasons for notusing manipulative techniques. Respondents were also asked to complete this sec-tion of the questionnaire if they avoided manipulating one or more specific areas ofthe spine (‘partial users’ of manipulation). For each factor, five response categorieswere provided: 5 = Very relevant, 4 = Relevant, 3 = Uncertain, 2 = Irrelevant, 1 =

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TABLE 5: Reported use in the last 12 months of techniques for the cervical region that satisfy thedefinition of a manipulative procedure*

Technique SOM MACP Total(N = 38) (N = 70) (N = 108)

Generalized cervical rotation 27 (71) 18 (26) 45 (42)Occipito-atlantal joint rotation 5 (13) 6 (9) 11 (10)Occipito-atlantal joint unilateral postero-anterior pressure 8 (21) 14 (20) 22 (20)Occipito-atlantal joint longitudinal 3 (8) 16 (23) 19 (18)Transverse thrust 0/1, 1/2. 2/3 6 (16) 16 (23) 22 (20)Atlanto-axial joint rotation 4 (11) 6 (9) 10 (9)IV joints C2–7 rotation 20 (53) 44 (63) 64 (59)IV joints C2–7 lateral flexion 17 (45) 51 (73) 68 (63)IV joints C2–7 transverse thrust 10 (26) 42 (60) 52 (48)Non-specific rotation under traction 29 (76) 6 (9) 35 (32)Non-specific side flexion under traction 17 (45) 4 (6) 21 (19)Cervical extension with leverage 9 (24) 2 (3) 11 (10)

*Figures in parentheses are percentages.IV = intervertebral.

TABLE 6: Reported use in the last 12 months of techniques for the thoracic region that satisfy the definition of a manipulative procedure*


Nelson’s posterior-anterior manipulation 10 (26) 15 (17) 25 (20)IV joints C7–T3 lateral flexion 6 (15) 21 (24) 27 (21)IV joints T3–T10 postero-anterior pressure 24 (62) 69 (78) 93 (73)IV joints T3–T10 longitudinal 2 (5) 23 (26) 25 (20)IV joints T3–T10 rotation 16 (41) 41 (47) 57 (45)IV joints T3–T10 rotary postero-anterior thrust 13 (33) 65 (74) 78 (61)Straight extension thrust 24 (62) 26 (30) 50 (39)Localized butterfly extension/rotation 33 (85) 18 (20) 51 (40)Sitting lateral flexion/rotation technique 16 (41) 26 (30) 42 (33)

*Figures in parentheses are percentages.IV = intervertebral

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Very irrelevant. Table 8 shows the median response for each of the factors proposedto respondents.

Of the users of manipulation, 81 (63%) stated that they had changed the way inwhich they practised manipulation since beginning to use manipulative techniques.Of these, 52 stated that they used it less often than previously. The main reasonsgiven for this were:


TABLE 7: Reported use in the last 12 months of techniques for the lumbar region that satisfy thedefinition of a manipulative procedure*


Generalized lumbar rotation 30 (79) 34 (40) 64 (52)IV joints T10–S1 rotation 15 (39) 61 (71) 76 (61)Postero-anterior central vertebral pressure 24 (63) 34 (40) 58 (47)Postero-anterior unilateral vertebral pressure 21 (55) 13 (15) 34 (27)Transverse vertebral pressure 6 (16) 10 (12) 16 (13)Distraction technique 13 (34) 7 (8) 20 (16)Short lever rotation 27 (71) 24 (28) 51 (41)Central thrust 13 (34) 7 (8) 20 (16)Unilateral extension thrust 10 (26) 6 (7) 16 (13)Long lever rotation 22 (58) 11 (13) 33 (27)Extension with leverage 6 (16) 5 (6) 11 (9)

*Figures in parentheses are percentages.IV = intervertebral.

TABLE 8: Reasons indicated by non-users and partial users of manipulation for avoiding the use ofmanipulation

Factor Median responseNon-users Partial users(N = 14) (N = 89)

Anxiety about possible complications 4 5Lack of skill 4 4Lack of suitable patients 4 4Lack of practice after manipulation course 4 4Better results after mobilization 3.5 4Better results from other modalities 3.5 4Have found manipulation techniques ineffective 3 2Unable to obtain click 2 1Uncomfortable about close contact necessary 2 1Aware of previous inadequate teaching 2 2

Scale for responses: 5 = Very relevant; 4 = Relevant; 3 = Uncertain; 2 = Irrelevant; 1 = Very irrelevant.

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• Better results from less vigorous techniques, especially NAGS and SNAGS(Mulligan, 1995) and combined movements (Edwards, 1994), and without theside effects of manipulation.

• The risk of serious complications and fear of litigation.• More selective use due to increased palpatory skill.• Lack of suitable patients.• Adoption of a more integrated approach; no longer purely ‘joint based’.

Sixteen therapists had stopped manipulating the cervical spine, or did so onlyvery occasionally; the main reason given was because of the risk of stroke or deathand the fear of subsequent litigation. Twelve respondents stated that they hadchanged from using generalized techniques to more localized techniques. This wasattributed to two main factors: research which questioned the safety of generalizedtechniques, and respondents’ perception that their skill had increased such that theywere able to be more precise and safe with their techniques without undue stressbeing placed on other spinal levels. Eight therapists felt that their techniques hadimproved, being more precise and selective, and they felt this was due to an increasein their knowledge base, derived from cumulative experience. Two therapists statedthat they now used manipulation to mobilize hypomobile segments that may not bea source of direct symptoms, but are a predisposing factor. Five therapists hadincreased their use of manipulation due to increased confidence and from havinggained good clinical results.

Experience of complications

Users of manipulation had experienced a total of 46 post-manipulation complica-tions. These complications were reported by only 25 (19%) of the users — this pro-portion was the same for both the SOM and the MACP groups. Respondents weregiven a list of possible complications (Appendix II) for each spinal region and askedto indicate whether they had encountered each complication; they were also invitedto specify any other complications experienced that had not been listed. Table 9shows the specific complications reported and Table 10 indicates the procedures towhich respondents attributed the complications. Only one therapist who had experi-enced complications following the use of manipulation chose not to give furtherdetails. Of the 21 patients who had experienced complications following manipula-tion of the cervical spine, 13 (62%) were reported to have undergone pre-manipula-tive testing. The duration was given for 43 reported complications; 28 (65%) lastedfor less than a week, and 15 (35%) lasted for a week or longer (six months in onecase of first thoracic dermatome hypersensitivity).

In answer to a question on ways in which the reported complications might havebeen prevented, the predominant factor to emerge related to more appropriate selec-tion of patients for manipulative procedures. However, the majority of respondentsfor each region felt that prevention had not been possible.

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Respondents were asked to respond to a number of Likert items tapping their atti-tudes to manipulation. These results are shown in Table 11 for the sample as a whole,for the SOM and MACP groups, and for users and non-users. There was overall agree-ment that more physiotherapists should practise manipulation, and SOM memberswere in significantly greater agreement with this statement that MACP members (U =1540.5, n1 = 41 n2 = 101; p = 0.0120). The median score on this item was also higher forusers than for non-users, but this was not tested statistically owing to the gross disparityin group sizes. There was also an overall rejection of the statement that manipulationcannot be considered a safe technique. Respondents agreed overall that manipulationhas an inherent unpredictability and that poor training is the principal cause of manip-ulative complications, but disagreed with the statement that it is an effective means ofinhibiting spasm. The view of the sample as a whole on the statement that manipula-tion should only be used as a progression from mobilization was marginally on the sideof disagreement. Although MACP members seemed to show greater agreement withthis item than SOM members, the null hypothesis of the difference was retained (U =1961.5, n1 = 41, n2 = 101; p = 0.6038). The sample as a whole was uncertain as towhether benefits of manipulation of the cervical spine outweigh its risks.

TABLE 9: Complications of manipulation reported by 25 respondents

Complication Frequency

Cervical (21 patients)Increased pain lasting for more than one day 7Dizziness 3Paraesthesia 3Headache 2Hearing loss 1Vomiting 1Petit mal fit 1Marked oedema of arm 1Patient angry and upset 1Hypersensivity 1Other (unspecified) 2Total 23

Thoracic (9 patients)Increased pain lasting more than one day 8Paraesthesia 1Rib fracture 1Loss/decreased muscle power 1Autonomic problems 1Total 12

Lumbar (7 patients)Increased pain lasting more than one day 5Referred pain 4Loss/decreased muscle power 1Loss/decreased sensation 1Total 11

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TABLE 11: Median responses to five-point Likert items measuring attitudes to manipulation*

Statement Median ratingOverall Users Non-users SOM MACP

(N = 143) (N = 129) (N = 14) (N = 41) (N = 102)

Manipulation has an inherent element of unpredictability 4 4 4 4 4Manipulation is an effective way to inhibit muscle spasm 2 2 3 2 2More physiotherapists who treatmusculoskeletal conditions shouldpractise manipulation 5 5 2.5 4 3Manipulation cannot be considereda safe technique 2 2 2.5 2 2Manipulation should only be used asa progression from mobilization 2.5 2 4 2 3It is the thrust that is the dangerouscomponent of manipulation 2 2 3 2.5 2Poor training is the cause of mostcomplications of manipulation 4 4 4 4 4The benefits of manipulation of thecervical spine outweigh the risks 3 3 3 3 3

*Scores ranged from 5 (strongly agree) to 1 (strongly disagree); responses for each item are based on at least 138(97%) of the total sample of respondents.SOM = Society of Orthopaedic Medicine; MACP = Manipulation Association of Chartered Physiotherapists.

TABLE 10: Specific techniques to which respondents attributed reported complications

Region Technique N

Cervical Non-specific rotation under traction 5Localized rotation 4Localized transverse manipulation 4Manipulations to C0/1 or C2/3 4Generalized rotation 3Localized longitudinal manipulation 2Unilateral postero-anterior manipulation 1

Thoracic Thrust to 1st rib 3Thrust to rib angle 2C7–T1 lateral flexion in prone 2Lift in extension 1Antero-posterior thrust 1Knee on the vertebra 1

Lumbar Generalized long lever rotation 5Localized rotation 4Unspecified rotary manipulation 2

Despite the equivalent median rating on this item for both groups, a comparisonof the interquartile range for the SOM (3, 4) with that of the MACP (2, 3)

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suggested that there was a greater degree of agreement with this statement amongSOM members than among MACP members. This difference was found to be statis-tically significant (U = 1471.5, n1 = 41 n2 = 101; p = 0.0053).

DISCUSSION

The use of manipulation

In this study the majority (90%) of respondents trained in the use of manipulationuse it as a form of treatment in physiotherapy. However, it was used somewhat infre-quently; 78% of users of manipulation employ it on 1–20% of patients they treat withspinal musculoskeletal disorders, and only 6% of users make use of it on more than60% of such patients. This accords with views expressed in the literature on the indi-cations for manipulation. Maitland (1986) suggests that some 15% of patients treatedwill require manipulation, and Grieve (1978) implies that some 20% of patientswould require this form of treatment. Similar findings emerged from a survey in SouthAfrica, where the majority of respondents used manipulation on less than 13.5% oftheir patients (Michaeli, 1991a). In contrast, figures reported by Dvorák and Orelli(1985) on Swiss medical practitioners and by Hosek et al. (1981) on North Americanchiropractors imply a more frequent use of manipulation by these professional groups,and suggest a difference in attitude towards manipulative therapy.

Areas of the spine manipulated

This survey revealed that not all areas of the spine were manipulated by those whodefined themselves as users of manipulation, and between-group differences emergedin terms of whether or not certain levels or regions are manipulated and the fre-quency with which manipulation is carried out (tables 2 and 3).

The cervical spine was manipulated less frequently than either the thoracic orthe lumbar spine. The extent to which users of manipulation treat the cervical spinewith manipulative techniques varied at different levels, and was greater in the lowercervical spine. The upper segments (C0/1, C1/2) were the levels manipulated by thefewest, and the most frequent reason given for not using manipulation at these levelswas concern at the risk of vertebral artery complications. Research indicates that theupper cervical spine — especially C1/2 — is where post-manipulation complicationsmost frequently occur (Schellhas et al., 1980; Sherman et al., 1987; Fast et al., 1987;Grant, 1988), and physiotherapists’ practice seems to reflect this risk. The frequencyof use of cervical manipulation would seem to be low overall, with more than half ofusers employing it less than once a week. However, members of the SOM emerged asmore frequent users.

The thoracic spine (T2–T12) was the area of the spine that was manipulated bythe greatest proportion of users (97%), and was manipulated significantly more fre-quently than the cervical spine. This may reflect the fact that few complications ofthoracic manipulation have been reported in the literature, and may also simply


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relate to the large number of IV joints in this region.Almost as high a proportion of respondents manipulated the lumbar spine, and

SOM members did so more frequently than MACP members. However, in bothgroups the majority of respondents performed lumbar manipulations less than sixtimes per week. This finding is not dissimilar to that of the BACPIM survey byGoldby (personal communication), in which just under 21% of respondents usedlumbar manipulations on a daily basis. The higher frequency of use among SOMmembers may reflect the view of Cyriax (1982) that about half of all cases of lum-bago get better in one treatment of manipulation, and his recommendation thatmanipulation should be used on all patients presenting with recent lumbago unlessotherwise contraindicated.

Although the study conducted by Goldby (personal communication) suggeststhat the thoracic spine is manipulated less frequently than the lumbar spine, no suchdifference emerged in our study.

Extent of use of manipulation at a spinal level

The maximum number of manipulations at the same spinal joint performed on onepatient at the same treatment session varied between groups, with members of theSOM group tending to perform more manipulations (though the differences weresmall at each spinal region). This suggests that the MACP group is slightly morereluctant to perform multiple manipulations at one level, at one treatment. One ofthe features highlighted by Grant (1987, 1988) and Terrett (1988) in their reviewsof complications following cervical manipulation was that the patient had oftenundergone more than one manipulation at the treatment session concerned. Itwould seem that physiotherapeutic practice has identified this as a risk factor. How-ever, practice is varied, especially within the SOM group.

Manipulation techniques

The SOM group used significantly more generalized techniques than the MACPgroup. This might be expected, as it reflects the different types of techniques likelyto have been taught to each group of therapists. With regard to specific localizedmanipulation procedures, their frequency of use differed in respect of individualtechniques and between the two groups of therapists. Most of the between-group dif-ferences are explicable in terms of the differing approaches advocated in the Mait-land and Cyriax schools of manual therapy.

The most popular cervical technique for the SOM group was non-specific rota-tion under traction, followed by generalized cervical rotation; these techniques werealso used by smaller numbers of MACP respondents. This sort of generalized rotarytechnique has been identified as a risk factor for damage to the vertebral artery(Grant, 1987, 1988; Terrett, 1988), and it is considered by some that the addition oftraction only increases this risk (Grant, 1994). It is perhaps a matter of concern thatthese procedures remain part of the practice of manipulation by UK physiothera-

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pists. In contrast, the low endorsement accorded to atlanto-axial rotation mayreflect concern among practitioners about possible damage to the vertebral artery.

Reasons given for not using manipulation

Given that entry to the SOM and the MACP has for a long time been based on suc-cessful completion of formalized training, it may be surprising to find that lack of skillis one of the main reasons given for not using manipulation. However, in the light ofthe other most relevant reason given by respondents for not using manipulation —that of anxiety about possible complications — it may be that an understanding ofthe risk of complications from these techniques might make some respondents feelthat they do not have the skill to perform them safely. One of the other main reasonsfor not using manipulation — lack of practice after manipulation training — wouldseem to suggest that it is possible for therapists to lose their skill of manipulation ifsuitable practice is not continued. The other main reason given — that of lack ofsuitable patients — will only compound the lack of practice and so the loss of skill.

The 89 partial users of manipulation were those who use manipulation as a formof treatment but have identified at least one level or area of the spine that they con-sistently avoid manipulating. In addition to anxiety about possible complications, aconviction that better results may result from mobilization techniques emerged fromthis subgroup. Partial users may thus feel that they achieve equivalent or betterresults while also avoiding some risk of complications by using mobilization at cer-tain levels rather than manipulation. However, it should be noted that Michaeli(1993) reported 129 complications following cervical mobilization, including radicu-lar symptoms with neurological deficit and a cerebrovascular accident.

Complications following manipulation

No prior data could be found in the literature on complications following the use ofmanipulation by physiotherapists in the UK.

Serious complications following cervical manipulation usually involve vascularinsult resulting in stroke, which has resulted in fatalities (Schellhas et al., 1980;Sherman et al., 1987; Grant, 1988). None of the complications reported by respon-dents fell into this category. Both Michaeli (1993) and Dvorák et al. (1993) foundthat the most common side effect from cervical spine manipulation was transientdizziness. This differs from the present survey, where only three cases of dizzinesswere reported. The aetiology of the complications is uncertain. Some complications(dizziness, hearing loss, headache, vomiting, paraesthesia and possibly patient angerand upset and petit mal) could be considered indicators of vertebrobasilar insuffi-ciency, whereas others (increased pain, hypersensitivity, paraesthesia, headache,marked oedema of arm) could be indicators of trauma to the soft tissues of the neck,which may of course include the vertebral artery.

In this survey it was found that 83% of respondents always used a pre-manipulativeprotocol (data yet to be published), whereas only 62% of patients who experienced


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cervical complications had been so tested before manipulation. Although these compli-cations may have occurred prior to widespread use of pre-manipulative testing byphysiotherapists, it may be that some of these complications could have been preventedhad a pre-manipulative test been performed. Two respondents volunteered this view.

Just over half of the cervical complications were attributed to rotary techniques.These results seem to support claims in the literature that rotation is the directionmost frequently involved in complications in the cervical spine, involving cases ofboth serious (Krueger & Okazaki, 1980; Grant, 1988) and less serious (Michaeli,1993) complications.

The debate on the use of manipulation on the cervical spine continues in allprofessional groups involved in manual therapy. The results of this survey suggestthat complications are relatively rare, a view which is echoed elsewhere in the litera-ture (Hosek et al., 1981; Dvorák et al., 1993; Hurwitz et al., 1996). Michaeli (1993)considers spinal manipulation as practised by manipulative physiotherapists a ‘rela-tively safe procedure’. However, when complications do occur, rotary techniques arefrequently implicated, and thought should therefore be given to the advisability ofthe use of such procedures. The fact that most reported complications were in theregion which respondents manipulated the least may reflect an avoidance of an areaperceived to be complication-prone. In any event, this finding suggests the need forcare in the treatment of this area of the spine.

In contrast to the findings relating to the cervical spine, there was no obvious pat-tern as regards type of technique used and frequency of complications in the thoracicspine. There is, moreover, little research available on manipulative complications in thisregion. Considering that this is the region of the spine most consistently manipulated byrespondents, the reported incidence of complications would seem to be very low.

Incidents and accidents of the lumbar spine are considered to occur rarely(Terrett & Kleynhans, 1992). Most reports are, however, of serious complications.Those reported in this survey would be regarded as non-serious, with no cases ofmajor complications such as cauda equina syndrome (Terrett & Kleynhans, 1992).All lumbar complications reported in this survey occurred after a rotary manipula-tion (generalized and localized). However, this probably reflects the predominanceof this sort of manoeuvre among those identified by respondents as part of their usualpractice. The complications identified in this survey are similar to those that werefound by a larger survey of Swiss physicians (Dvorák et al., 1993).

These findings regarding lumbar complications should be set against recent evi-dence of the efficacy of lumbar manipulation in some cases of low back pain (Clini-cal Standards Advisory Group, 1994). The acceptability of a given risk ofmanipulative complications must be evaluated against the likely benefits of manipu-lative therapy within some form of cost–benefit analysis.

Attitudes

There is no known research in the UK with which to compare these results. For thesample of respondents as a whole, there is evidence of a generally positive attitude to

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the practice of manipulation; respondents disagreed that manipulation is an unsafeprocedure and endorsed the view that more physiotherapists should practise it. Thefact that there was general agreement that complications arise from poor trainingsuggests that respondents regard manipulation per se as safe, provided that it is per-formed in competent and experienced hands.

However, despite these indications of a positive attitude, the sample as a wholewere unable to commit themselves on the question of whether the benefits of cervi-cal manipulation outweigh the risks. They also acknowledged the unpredictabilityassociated with manipulation. This is also reflected in the finding that in most casesof complications following manipulation, respondents did not feel these were pre-ventable. Similarly, anxiety about possible complications was prominent among thereasons given by non-users and partial users of manipulation for their avoidance ofsome or all manipulative techniques.

The disparity in subgroup sizes did not permit reliable judgments as to differencesin attitude between users and non-users. Significant differences did emerge, how-ever, between the SOM and MACP groups on certain items. The fact that the SOMgroup was more convinced that a greater number of physiotherapists should practisemanipulation and its agreement that the benefits of manipulation outweigh the riskssuggest that, in certain respects at least, this group has a somewhat less conservativeattitude to manipulation than members of the MACP.

Limitations of the study

In common with much survey research, this study achieved a relatively low responserate. The practice of half of the membership of the two participating groups there-fore remains unknown, and the possibility exists that this differs systematically fromthat of the responders. It may be, for example, that users of manipulation were moremotivated to respond to the survey, and were therefore over-represented in theachieved sample. Moreover, the fact that data were collected on respondents’ prac-tice retrospectively leaves open the possibility of biased or incomplete recall.

It should also be borne in mind that the topic of the survey was a potentially sen-sitive one, bearing upon issues of professional competence and safety. Althoughresponses were anonymous, there may have been an understandable tendency forrespondents to portray themselves in a favourable light. Indeed, some respondentsfelt it necessary to write explanations justifying their answers when detailing theirpractice of manipulation. However, the fact that only one physiotherapist who hadexperienced complications following the use of manipulation chose not to give fur-ther details suggests a reasonable level of frankness in the information given byrespondents.

The use of a postal questionnaire did not permit a detailed insight into the deci-sion-making processes underlying respondents’ use of manipulative procedures. Thecollection of fuller, qualitative data on this topic would shed more light on this issueand there is scope for further research along such lines. Equally, research to establishthe extent of use of spinal manipulation and the incidence of complications among


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the population of physiotherapists working in musculoskeletal physiotherapy as awhole would be valuable.

Finally, it must be stressed that this study only provides self-reports of the inci-dence and severity of manipulative complications. There is a need for well-designedprospective studies, of an experimental or quasi-experimental nature, that will estab-lish more objectively the incidence of such adverse effects, and determine whetherthese are in fact attributable to the manipulative procedures performed.

CONCLUSION

This study has revealed a number of interesting facts about the use of manipulationby manipulative physiotherapists. A large proportion of those trained in manipula-tive techniques employ them in their clinical practice, but do so relatively infre-quently. The thoracic spine emerged as the region manipulated by the largestproportion of users of manipulation, followed by the lumbar spine; each of the foursub-regions of the cervical spine were manipulated by smaller proportions of users.The thoracic and lumbar regions were also manipulated more frequently than thecervical spine.

Allowing for the possibility of underreporting, the low incidence of complica-tions in general, and of serious complications in particular, is reassuring, thoughthere may be concern that generalized rotation and non-specific rotation under trac-tion remain part of the practice of manipulation by UK physiotherapists.

The practice of, and attitudes towards, manipulation of the SOM group emergedas significantly different in certain respects from those of the MACP. The formergroup were more likely to manipulate the cervical spine, used manipulation morefrequently in the cervical and lumbar spines, used more manipulations at one treat-ment, made more use of generalized techniques, and displayed a less conservativeattitude to certain aspects of manipulation.

ACKNOWLEDGEMENT

The authors would like to thank the Society of Orthopaedic Medicine and the ManipulationAssociation of Chartered Physiotherapists for their assistance in this survey, and Arie Michaeli foradvice during the initial stages of this study.

APPENDIX I

Definitions provided to respondents

Mobilization is understood to mean passive physiological and/or accessory move-ments performed in a oscillatory or sustained manner within the available physiolog-ical range (Maitland, 1986).

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Manipulation is understood to mean a small amplitude high velocity thrust tech-nique performed at the end of range, completed before the patient is able to stop it(Maitland, 1986).

Manual therapy is considered to be concerned with ‘the prevention and treatmentof musculoskeletal pain and dysfunction problems by the application of primaryphysical modalities incorporating exercise, passive joint movement (including mobi-lization and manipulation), traction and massage’ (Twomey, 1992).

Treatment soreness is understood to mean any pain or soreness experienced by apatient within a 24-hour period immediately following physiotherapy treatment,thought to be a result of the treatment, rather than a reflection of the underlyingpathology or dysfunction.

APPENDIX II

List of complications of manipulation provided to respondents

Cervical

a=increased pain lasting more than one day j=paraesthesiab=loss/decreased muscle power k=headachec=loss/decreased sensation l=dizzinessd=absent/decreased reflexes m=nystagmuse=blurring of vision n=diplopiaf=hearing loss o=tinnitusg=quadriplegia p=nauseah=vomiting q=CVAi=other (please specify) r=referred pain

Thoracic

a=increased pain lasting more than one day f=referred painb=loss/decreased muscle power g=paraesthesiac=loss/decreased sensation h=rib fractured=absent/decreased reflexes i=other (please specify)e=paraplegia

Lumbar

a=increased pain lasting more than one day f=referred painb=loss/decreased muscle power g=paraesthesiac=loss/decreased sensation h=paraplegiad=absent/decreased reflexes i=other (please specify)e=signs and symptoms of cauda equina lesion


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REFERENCES

Australian Physiotherapy Association. Protocol for pre-manipulative testing of the cervical spine.Australian Journal of Physiotherapy 1988; 34: 97–100.

Clinical Standards Advisory Group. Back Pain. London: HMSO, 1994.Cyriax J. Textbook of Orthopaedic Medicine. Volume One: Diagnosis of Soft Tissue Lesions (eighth

edition). London: Baillière Tindall, 1982.Cyriax J. Textbook of Orthopaedic Medicine. Volume Two: Treatment by Manipulation Massage and

Injection (eleventh edition). London: Baillière Tindall, 1984.Dabbs V, Lauretti WJ. A risk assessment of cervical manipulation vs NSAIDs for the treatment of neck

pain. Journal of Manipulative and Physiological Therapeutics 1995; 18: 530–536.Dvorák J, Orelli FV. How dangerous is manipulation to the cervical spine? Case report and results of a

survey. Manual Medicine 1985; 2: 1–4.Dvorák J, Loustalot D, Baumgartner, Antinnes JA. Frequency of complications of manipulation of the

spine — a survey among the members of the Swiss Medical Society of Manual Medicine. EuropeanSpine Journal 1993; 2: 136–139.

Edwards BC. Combined movements in the lumbar spine: their use in examination and treatment. In:Boyling JD, Palastanga N (eds) Grieve’s Modern Manual Therapy: The vertebral column (secondedition). Edinburgh: Churchill Livingstone, 1994; 745–752.

Fast A, Zinicola DF, Marin EL. Vertebral artery damage complicating cervical manipulation. Spine1987; 12: 840–842.

Fritz VU, Maloon A, Tuch P. Neck manipulation causing stroke — case reports. South AfricanMedical Journal 1984; 66: 844–846.

Grant ER. Clinical testing before cervical manipulation — can we recognise the patient at risk?Proceedings of the Tenth International Congress of the World Confederation for Physical Therapy,Sydney, 1987; 192–197.

Grant R. Dizziness testing and manipulation of the cervical spine. In: Grant R (Ed.) Physical Therapyof the Cervical and Thoracic Spine. New York: Churchill Livingstone, 1988; 111–124.

Grant R. Vertebral artery insufficiency: a clinical protocol for pre-manipulative testing of the cervicalspine. In: Boyling JD, Palastanga N (eds) Grieve’s Modern Manual Therapy. The VertebralColumn (second edition). Edinburgh: Churchill Livingstone, 1994; 371–380.

Grieve GP. Manipulation: a part of physiotherapy. Physiotherapy 1978; 64: 358–363.Grieve GP. Incidents and accidents of manipulation and allied treatments. In: Boyling JD, Palastanga

N (eds) Grieve’s Modern Manual Therapy. The Vertebral Column (second edition). Edinburgh:Churchill Livingstone, 1994; 673–692.

Hosek RS, Schram SB, Silverman H, Myers JB, Williams SE. Cervical manipulation (letter). Journal ofthe American Medical Association 1981; 245: 922.

Hurwitz EL, Aker PD, Adams AH, Meeker WC, Shekelle PG. Manipulation and mobilization of thecervical spine — a systematic review of the literature. Spine 1996; 21: 1746–1759.

Krueger BR, Okazaki H. Vertebral–basilar distribution infarction following chiropractic cervical manip-ulation. Mayo Clinic Proceedings 1980; 55: 322–332.

Maitland GD. Vertebral Manipulation (fifth edition). Oxford: Butterworth-Heinemann, 1986.Michaeli A. Manipulative physiotherapy in South Africa: results of a questionnaire. Unpublished MSc

dissertation. Johannesburg: University of the Witwatersrand, 1991a.Michaeli A. Dizziness testing of the cervical spine: can complications of manipulations be prevented?

Physiotherapy Theory and Practice 1991b; 7: 243–250.Michaeli A. Spinal manipulation by physiotherapists in South Africa. Results of a questionnaire.

Physiotherapy 1992; 78: 673–678.Michaeli A. Reported occurrence and nature of complications following manipulative physiotherapy in

South Africa. Australian Journal of Physiotherapy 1993; 39: 309–315.

Adams and Sim226

PRI 3(3) 3RD/JH 25/8/97 3:55 pm Page 226

Mulligan BR. Manual Therapy, ‘Nags’, ‘Snags’, ‘MWMS’ etc. (third edition). Wellington: HutchesonBowman & Stewart, 1995.

Parkin PJ, Wallis WE, Wilson JL. Vertebral artery occlusion following manipulation of the neck. NewZealand Medical Journal 1978; 88: 441–443.

Patijn J. Complications in manual medicine: a review of the literature. Journal of Manual Medicine1991; 6: 89–92.

Rivett DA. Preventing neurovascular complications of cervical spine manipulation. Physical TherapyReviews 1997; 2: 29–37.

Rivett DA, Milburn P. Complications arising from spinal manipulative therapy in New Zealand.Physiotherapy 1997; 83: 626–632.

Schellhas KP, Latchaw RE, Wendling LR, Gold LHA. Vertebrobasilar injuries following cervicalmanipulation. Journal of the American Medical Association 1980; 244: 1450–1453.

Sherman MR, Smialek JE, Zane WE. Pathogenesis of vertebral artery occlusion following cervical spinemanipulation. Archives of Pathology and Laboratory Medicine 1987; 111: 851–853.

Terrett AGJ. Vascular accidents from cervical spine manipulation: report on 107 cases. AustralianChiropractic Association Journal of Chiropractic 1988; 22: 63–72.

Terrett AGJ, Kleynhans AM. Complications from manipulation of the low back. Chiropractic Journalof Australia 1992; 22: 129–140.

Twomey LT. A rationale for the treatment of back pain and joint pain by manual therapy. PhysicalTherapy 1992; 72: 885–892.

Address correspondence to Professor Julius Sim, Department of Physiotherapy Studies, Keele University,Staffordshire ST5 5BG, UK.

Received 26 January 1998; accepted 20 April 1998.


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A survey of UK manual therapists' practice of and attitudes towards manipulation and its complications