Research Review By Dr. Michael Haneline©


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Date Posted:

February 2021

Study Title:

Beliefs, perceptions and practices of chiropractors and patients about mitigation strategies for benign adverse events after spinal manipulation therapy


Funabashi M, Pohlman K, Goldsworthy R, Lee A, Tibbles A, Mior S & Kawchuk G

Author's Affiliations:

Department of Chiropractic, Université du Québec à Trois-Rivières, Quebec, Canada; Canadian Memorial Chiropractic College, Toronto, Canada; Parker University, Dallas, USA; University of Alberta, Canada.

Publication Information:

Chiropractic & Manual Therapies 2020; 28: 46.

Background Information:

Spinal manipulative therapy (SMT) is reported to be the most common treatment modality provided by chiropractors. Worldwide, the median 12-month utilization rate for chiropractic services is 9.1% and the use of chiropractic services between 1980 and 2015 has grown from 10.0 to 11.7% in Canada and from 7.2 to 10.7% in the United States.

Adverse events (AEs) have been reported to occur following SMT in about 50% of patients, although varying in frequency and severity (1). Most commonly, AEs following SMT have been minor/benign, although there have been much less frequent reports of serious AEs, such as cauda equina syndrome.

Reported predictors of benign AEs post-SMT include sex, SMT technique, multiple treated locations, working status, and duration of pain at presentation. It is unknown whether benign AEs are a result of SMT itself, part of the natural history of the patient’s condition, and/or inadequacies of treatment.

While it is important to investigate the mechanisms causing benign AEs post-SMT to eliminate them, efforts to mitigate AEs should also be made to improve the patient’s experience and quality of care.

Previous studies have investigated mitigation strategies regarding the risk factors for serious AEs post-cervical SMT (2, 3). However, no study has investigated strategies for mitigating benign AEs post-SMT. Therefore, the aim of this study was to identify the beliefs, perceptions and practices of chiropractors and patients regarding benign AEs post-SMT and potential strategies to mitigate them.

Pertinent Results:

Thirty-nine clinicians participated in this study (67% response rate); 21 were from CMCC (60%) and 18 from Parker University (78%). Most of them had more than 10 years clinical experience (61.5%) and 1 to 5 years as a supervising clinician (53.8%).

Two hundred three patients (88.2% response rate) completed the survey; 101 (94.4% response rate) from CMCC and 102 (82.9% response rate) from Parker University. Most patients (65%) reported receiving more than 10 SMTs during their program of care which spanned more than 10 months in 56.2% of cases.

Clinicians’ beliefs about benign AEs were as follows:
  • Almost all of the clinicians (97.4%) believed that AEs occur post-SMT;
  • 82.1% reported that their own patients had experienced AEs;
  • most clinicians (74.4%) believed that benign AEs occur infrequently, although 15.4% indicated that they occur “quite often”; and
  • the majority of clinicians did not believe benign AEs were related to specific SMT techniques or anatomic region, although one clinician thought they were related to cervical SMT.
Benign AEs post-SMT were reported by 55% of patients, with pain/soreness, headache and stiffness being the most commonly reported events.

Most patients did not believe that benign AEs were related to specific SMT techniques or body regions, although 6.4% of patients believed cervical rotatory techniques were related. However, 24.1% of the patients did believe that benign AEs occur after SMT to a specific body region, with 20% of this group believing that benign AEs occur after cervical SMT and 5.5% after SMT is applied to the lower back.

As for mitigating strategies, 53.8% of the clinicians and 35.3% of the patients believed that mitigating benign AEs “is possible”; in addition, 30.7% of clinicians and 28.3% of patients believed it “may be possible”.

61.5% of the clinicians reported trying mitigation strategies, including, in order of popularity, soft tissue therapy, stretching and icing. However, only 21.2% of patients were aware that their clinicians had tried a mitigation strategy. 55.8% of these patients believed that their clinician used soft tissue therapy, 44.1% stretching and 30.2% believed heat was used.

97.6% of patients who experienced mitigation strategies reported improvement, with 58.1% of them reporting complete resolution and 40.7% reporting less severe benign AEs after the mitigation strategy.

57.2% of patients who believed mitigating benign AEs “is possible” reported that their clinician had tried a mitigation strategy and about half of them indicated that the applied strategy was soft tissue therapy. Likewise, 60% of patients who believed mitigating benign AEs “may be possible” reported that soft tissue therapy was the most commonly used mitigation strategy.

Clinicians’ and patients’ beliefs and perceptions about strategies for mitigating benign AEs were captured via a fixed list of potential mitigation strategies:
  • Clinicians perceived that patient education, either before or after treatment, was most likely to mitigate benign AEs post-SMT, followed by soft tissue therapy and/or icing after SMT.
  • Patients perceived that stretching before or after SMT was the strategy most likely to mitigate benign AEs from occurring, followed by education and/or massage after SMT.

Clinical Application & Conclusions:

It is important for clinicians who utilize SMT to be aware of the findings of this study, which found that both clinicians and patients believe that benign AEs do occur following SMT, with pain/soreness, headache and stiffness being most common. Furthermore, 55% of the participating patients reported benign AEs post-SMT, with soreness and headache being the most common symptoms.

While the beliefs concerning which mitigation strategies were effective differed between clinicians and patients, primarily in the application of icing and stretching, education was perceived to be the strategy most likely to mitigate benign AEs. Clinicians should, therefore, educate their patients about the possibility of AEs following SMT and inform them of appropriate mitigation strategies. In addition, soft tissue therapy and massage after SMT were considered useful by both clinicians and patients.

Clinicians who utilize SMT should definitely incorporate the use of mitigation strategies, given that almost all patients in this study who experienced them reported either complete resolution or less severe benign AEs after the mitigation strategy. As a result, the quality of care provided to the patient can be improved which can have a positive impact on patients’ SMT experience.

Study Methods:

This was a cross-sectional survey of supervising clinicians and patients at the teaching clinics of Canadian Memorial Chiropractic College and Parker University. All supervising clinicians at CMCC (n = 35) and Parker University (n = 23) were invited to respond to an electronic survey via email. A total of 230 patients were invited to respond to the online survey, 107 patients from CMCC’s Campus Clinic and 123 patients from Parker’s Wellness Clinic. Patients that agreed to participate were given a tablet and were asked to complete the survey in the clinic.

The clinician survey was comprised of 11 questions about experiences and beliefs related to benign AEs post-SMT and what strategies were used or recommended to mitigate them. The patient survey also included 11 questions about their experiences with SMT and benign AEs, as well as strategies perceived to mitigate them and strategies their provider may have utilized. Both surveys were validated for content by the researchers and pilot tested with a few practicing chiropractors and patients.

Study Strengths / Weaknesses

This was a well-planned and -executed study that was conducted at 2 chiropractic teaching clinics in Canada and the USA. The participating patients were mostly treated by interns who were not included in the study. The authors indicated that the results may have been different if more experienced clinicians rendered treatment in a private practice setting. Therefore, the results should be interpreted with caution.

The authors also pointed out that this was an initial investigation to answer specific questions, but that the survey did not enquire about the participants’ rationale for their responses which should be examined in future studies.

Additional References:

  1. Swait G, Finch R. What are the risks of manual treatment of the spine? A scoping review for clinicians. Chiropr Man Ther 2017; 25: 1–15.
  2. Yamamoto K, Condotta L, Haldane C, et al. Exploring the teaching and learning of clinical reasoning, risks, and benefits of cervical spine manipulation. Physiother Theory Pract 2018; 34: 91–100.
  3. Hutting N, Kerry R, Coppieters MW, Scholten-Peeters GGM. Considerations to improve the safety of cervical spine manual therapy. Musculoskelet Sci Pract 2018; 33: 41–5.

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