Reason #1 – It works. For some, it works very powerfully.
I am the first person to tell you that thrust joint manipulation (TJM) does not work for everyone because I do it daily in clinical practice. Anecdotally, it is more common that TJM fails to improve symptoms when joint cavitation (popping) is not elicited from the treatment area. But good manipulative technique and focused cavitation can be life-changing for many orthopedic issues, as evidenced by RCTs that demonstrate significant improvements for LBP, headaches, neck pain, etc. Certainly, some in these study populations were not benefitted by TJM but many experienced marked improvement.
Reason #2 – It takes little time.
TJM is an ideal treatment choice in our modern system as changes come to incentivize cost-effective healthcare. The technique itself only takes 1-2 minutes with post-treatment assessment, and can be easily coupled with other PT treatments.
Reason #3 – It is safe.
Some will contend that they don’t want to risk the potential harm of TJM to their patient. Statistics do not support this fear. A recent study showed that manual therapy had fewer adverse events than therapeutic exercise. In addition, TJM has been shown to be 37,000 to 144,000 times safer than NSAIDs or surgery, with similar clinical improvement, for the treatment of a lumbar disc herniation.1,2 Lastly, biomechanical and epidemiological studies have demonstrated that cervical manipulation does not make the patient more susceptible to cerebrovascular accident.3-5
Despite the overwhelming evidence that TJM is safe when performed competently, I know that many PTs will still hesitate because they may get blamed if a patient’s condition worsens. Adverse events can still theoretically be caused by TJM (although it appears most of the time it is coincidental) and the fear of litigation is a rational one. Unfortunately, the medical profession (including some PTs) and the media have contributed to a false narrative that makes litigation more likely. To these fears I would offer two points to consider.
First, in my judgment the far greater harm that occurs in physical therapy practice is not doing enough, whether it is insufficient resistance to elicit hypertrophy, insufficient force to stretch post-surgical stiffness, or in this case withholding beneficial treatment. If our goal is to avoid harm we need to think about errors of omission as well as errors of commission.
Second, the threat of litigation is real regarding an adverse event. However, I’ve been practicing TJM for 5 years without a serious issue. But moreover, I would contend that we cannot truly consider ourselves Doctors of Physical Therapy without taking on the responsibility and risks associated with that title. And if we are not truly practicing as Doctors, how can we really expect insurance companies and the medical community to value our services more than they presently do?
References:
1. Bjorkman DJ. Current status of nonsteroidal anti-inflammatory drug (NSAID) use in the United States: risk factors and frequency of complications. Am J Med 1999;107:3S-8S.
2. Oliphant D. Safety of spinal manipulation in the treatment of lumbar disk herniations: a systematic review and risk assessment. J Manip Physiol Ther 2004;27:197-210.
3. Cassidy JD et al. Risk of vertebrobasilar stroke and chiropractic care: results of a population-based case-control and case-crossover study. Spine 2008;33:S176–S183.
4. Symons BP, Leonard T, Herzog W. Internal forces sustained by the vertebral artery during spinal manipulative therapy. J Manip Physiol Ther 2002;25:504–510.
5. Symons B et al. Biomechanical characterization of cervical spinal manipulation in living subjects and cadavers. J Electromyogr Kinesiol. 2012;22:747–751.
