Thrust joint manipulation: just do it!

A recent United States Physical Therapy students survey regarding their engagement with thrust joint manipulation (TJM) [1] has raised selected interesting issues worthy of further debate. The survey’s main outcome suggests that students undertaking entry level training programmes are heavily influenced in the use TJM by their academic and clinical instructors. If these two instructor groups do not encourage student TJM use, then the students do not incorporate the skills into clinical practice. In addition, this study reports low student TJM utilization for managing cervical spine conditions (61% not using it) when compared to the thoracic and lumbar spine. This aligns with a growing trend in the physiotherapy profession. Reduced Physical Therapy graduates’ confidence with TJM, particularly at the cervical spine, will likely flow into clinical practice upon graduation. If a new graduate gains employment with a clinician who also lacks competence and confidence in TJM use, then other treatment options are likely to be adopted. Is this another nail in the coffin for judicious TJM use for managing spine pain, especially at the neck? This challenge collides with the growing increase in the global burden of disease, where low back pain and neck pain are ranked within the fourth leading cause of disability-adjusted life years [2–4]. Clearly, neck pain incidence is on the rise, but are we engaging in management best-practices when we do not incorporate manual therapy and TJM in caring for these patients? There is solid evidence supporting manual therapy (including mobilization and TJM) and exercise use as effective for managing cervicogenic headache [5]. Similarly, Hing, Monaghan and Reid [6] promoted guidelines for using a physiotherapy/osteopathic approach to TJM when managing neck pain. At the time, this was one of the 10-most-read papers in Manual Therapy. The same may not be so popular today!!

The authors of the survey above suggested a number of reasons beyond instructor influence explaining why students might not use TJM. These include a lack of confidence in clinical reasoning, inadequate psychomotor skills and inappropriate case load or clinical setting. More importantly, they found that among students who did not use TJM, the external factors such as clinical instructors’ clinical practice, patient caseload, and practice setting, were less likely to negatively impact TJM use than intrinsic or student-related factors. The student-related factors such as lack of confidence and skill in the TJM techniques did not appear to present as much of a barrier to TJM use. These findings suggest that there would be greater student use of TJM skills if their clinical instructors’ could provide sufficient practice and feedback on motor performance. Doing so would improve the acquisition and retention of TJM skills. These would be understandable for learning practitioners, but how would these factors change once graduates are in practice treating the public if they are not supported to increase the skill set? Additionally, the authors suggested that in order to increase TJM use, there should be the promotion of a transition from an academic setting to a clinical environment that provides solid mentorship. We would agree, but students accessing sufficient time to practice key psychomotor skills and clinical reasoning within the current academic frameworks is also challenging. In many entry level programmes there is significant growth in student enrollment, along with increased pressure to expand curricular content. Additionally, there is added pressure on academic faculty to conduct more research, which reduces faculty clinical time. This only reinforces the need for the profession at large to take a greater role in mentoring new graduates to incorporate TJM with the right patient. This can create a conversation more in favor of examining which factors promoting TJM use, versus focusing on reasons for not making use of it. Following the motto of Nike©, we say just do it!

Another aspect of this reduction in TJM use may be witnessed in selected influential frameworks and documents, such as the International Federation of Orthopedic Manipulative Physical Therapists (IFOMPT) Framework – Screening for Cervical Artery Dysfunction [7,8]. The IFOMPT framework was developed with good intent, aiming to reduce any potential risks associated with cervical spine manual therapy, while screening for those masquerading patients who present with nonmechanical neck pain and headache of vascular origin. This framework has experienced a number of iterations. However, the key messages are that most risks are identified in the subject interview and that selected physical tests, such as sustained cervical rotation, do not sufficiently identify the risk for a vascular event. The framework is very useful as a teaching tool but is subject to clinician interpretation, potentially reducing its utility.

The IFOMPT Framework indicates that the prevalence of vertebral artery dissections associated with spinal TJM ranges between 0.4:100,000 and 5:100,000 patients (converted for comparison from Nielsen et al, 2017 [9]). Similarly, the relative risk of stroke following orthopedic manual therapy is thought to vary between 0.14 and 6.66 [8]. These data suggest that cervical spine TJM is a very low risk procedure. However, is this message getting lost in the details of the framework? There is no doubt that applying TJM to a patient presenting with a vascular event will have a poor outcome even if the manual therapy is carefully applied. We also know that end range high velocity large amplitude TJM can damage the vertebral artery in a normal low risk individual [10]. From these ideas one must question whether a document such as the IFOMPT Framework actually stops a clinician from performing any cervical spine TJM, even when all the clinical indications are safe, there are no contraindications, and the patients has consented [6]. Again are there more reasons to ‘just do it’ versus not?

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Notes on contributors

Duncan A. Reid

Duncan Reid is a Professor of Physiotherapy at Auckland University of Technology

Michael Monaghan

Michael Monaghan is a retired Osteopath and teacher for the NZ Manipulative Therapists Association.

Emilio J. Puentedura

Emilio J Puenteduraisa Clinical Professor Baylor University Doctor of Physical Therapy Program.

Phillip S. Sizer

Phil Sizer is the President’s Distinguished Professor and Endowed Professor in Pain Science at Texas Tech University.

Jean-Michel Brismée

Jean-Michel Brismée is Professor Physiotherapy at Texas Technical University and Editor of JMMT.