A recent American Heart Association (AHA) statement that cervical manipulation may "play a role" in stroke fails to consider how physical therapist (PT) clinical judgment can reduce this risk, and overlooks the fact that manipulation is associated with far fewer complications than drug-based and surgical interventions, according to a news release from APTA. The AHA statement (.pdf) focused on an analysis of strokes caused by cervical arterial dissections (CDs).
"Incidents of stroke associated with cervical manipulation are rare," according to the APTA statement, which cites studies from 2002 and 2010 that found "no strong evidence" connecting cervical manipulation therapy (CMT) and adverse events.
APTA's statement was issued in response to an AHA report that concludes there is a "statistical association" between CD and CMT but does not cite a definitive link. In fact, AHA describes the incidence of CD in patients who have received CMT as "not well established, and probably low," and characterizes evidence as "insufficient to establish the claim that CMT causes CD." In a news release issued by AHA, the report's lead author is quoted as saying that “A cause-and-effect relationship between [CMT] and CD has not been established." Still, he said, “Patients should be informed of this association before undergoing neck manipulation.”
In its statement, APTA emphasizes the role of the clinical judgment of the PT, supported by a 2-decade history of guidelines for CMT, and a 2012 clinical reasoning framework developed by the International Federation of Orthopaedic Manipulative Physical Therapists, an organization that works closely with the Orthopaedic Section of APTA. The framework in particular was designed "to provide guidance for the assessment of patients for the likelihood of stroke in advance of [CMT]," according to the statement.
APTA also points out that CMT has rates of risk lower than the use of pain relievers or cervical spine surgery, both of which are reported to increase likelihood of a range of adverse outcomes in addition to stroke.
"The physical therapy community is committed to educating patients and practitioners about the risks and benefits of cervical manipulation," said Timothy W. Flynn PT, PhD, OCS, immediate past president of the American Academy of Orthopaedic Manual Physical Therapists. "[PTs] understand the small risk of stroke associated with cervical manipulation, and they base decisions regarding the select use of this procedure on a detailed and ongoing evaluation and a treatment plan that is consistent with patient preferences."
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