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To Manipulate or Not to Manipulate, That is the Question

Orthopedic manipulations have been a medical intervention since 400 BC, in the days of Hippocrates. The word “manipulation” can mean many things in the health care field, some good and some bad. To highlight an example of a good meaning of manipulation, we peer into its essence in physical therapy. This term specifically refers to applying mobilizations to joints at varying degrees of needed intensity. If gentle mobilizations are required to heal the patient, that is what is performed. If the patient needs a stronger movement (aggressive mobilization or manipulation), it can be performed in effective ways with varying speeds and amplitudes, including a small amplitude/ high-velocity therapeutic movement within or at end range of motion.

The purpose of this article is to explain the importance of the neurological exam and its necessity prior to a manipulation being performed. Unfortunately, in the research, it shows that less than 6% of licensed holistic approach practitioners (chiropractors, physical therapists, etc…) in the United States actually perform a neurological exam as part of the patient assessment. This is not a comforting statistic and warrants discussion.

A neurological exam is used to identify or rule out lower motor neuron pathology and more sinister upper motor neuron pathology. The neurological exam assists in determining if the patient is appropriate for physical therapy intervention or if they require a referral to another health care provider for further assessment and diagnostic testing. This neurological exam is crucial in the clinical decision-making process of whether or not a manipulation may be indicated.

The neurological exam includes sensory, motor, and reflex testing of both the upper and lower extremities to determine the source and location of the neurological dysfunction. The Upper Quarter Exam is performed on patients presenting with an injury to the head, neck, and upper extremities. This includes sensation testing of the upper extremity dermatomes (C1-T1), motor testing of the upper extremity myotomes (C1-T1), reflex testing of the upper extremity (biceps brachii C5, brachioradialis C6, triceps C7), and the Hoffman’s reflex or Inverted Supinator sign.

The Lower Quarter Exam is performed on patients presenting with an injury to the low back, hips, and lower extremities. This includes sensation testing of the lower extremity dermatomes (L1-S2), motor testing of the lower extremity myotomes (L1-S2), reflex testing of the lower extremity (Patellar L2-L4, Achilles S1), and the Babinski reflex and clonus. The Hoffman’s reflex, inverted supinator sign, Babinski reflex, and clonus are all components of the Central Nervous System Exam.

Cranial nerve testing is another component of the Central Nervous System Exam, which includes sensation, motor, and reflex testing of all 12 cranial nerves. Cranial nerve testing is indicated when patients present with head or neck injury. The Central Nervous System Exam helps to determine and differentiate upper motor neuron involvement versus lower motor neuron involvement. If the patient demonstrates a positive test when performing Central Nervous System reflexes it indicates he or she is suffering from an upper motor neuron lesion.

With regards to spinal manipulation and the neurological exam, we are primarily concerned with upper motor neuron signs, compression syndromes (myelopathy/cauda equina), upper cervical instability, and cervical artery dysfunction. Key indicators are identified to determine the need for a neurological exam in an effective patient subjective history. These symptoms include but are not limited to; radiating pain, numbness, tingling, or paresthesias in the upper or lower extremities (below the gluteal fold of the LE or AC joint in the UE). Also, complaints of weakness, bilateral numbness/tingling, clumsiness in hands, or incoordination or sudden disturbance in gait.

Manipulation should be performed only after conducting a thorough subjective examination, medical exam, and neurological exam to rule out the presence of sinister or red flag conditions.

In the absence of red flag conditions, the clinician can proceed with the objective examination and evaluation including ROM measurements, manual muscle testing, joint mobility testing, and special testing of the involved body region.

The clinician will use all the data gathered from the subjective and objective portions of the examination to determine if the patient will benefit from spinal manipulative therapy. A clinician should carefully weigh risks and benefits of manipulation and educate the patient on spinal manipulation and how it may benefit them.

Disregarding a thorough assessment and doing a shotgun or general approach with manipulation can lead to unnecessary treatment and injury. The largest risk of injury from manipulation is cervical artery dysfunction. Cervical artery dysfunction is considered a rare, random, and an unpredictable event with almost all instances being avoided through appropriate medical history and screening. Trauma-related injury of the cervical spine also limits the application of receiving manipulation. The proper neurological exam and with the use of tools such as the Canadian Cervical Spine Rules is an evidence-based screening tool used for trauma-related injury determining criteria for X-Ray.

When a patient is thoroughly assessed by a trained physical therapist through subjective history, neurological and physical exam, the likelihood of a beneficial outcome with spinal manipulation is exponentially higher. At Wright Physical Therapy, all of our doctors of physical therapy have been highly trained in spinal manipulation therapy. Please call us today at one of our clinic locations to schedule for treatment or referral. I am available via email for questions at tyler@wrightpt.com or you can reach Bryan at bryan@wrightpt.com.