Would you harm a patient with manual therapy already diagnosed with concussion?
The title of this blog is a loaded question, but generally speaking it entails the risk : benefit ratio and adverse events of performing manual therapy on a patient who has suffered a concussion. In particular, we are speaking of someone who is suffering from post-concussive symptoms after mild traumatic brain injury (mTBI). In this post, we will use mTBI synonymously with post-concussion symptoms. This patient is already in your office, you have determined some type of musculoskeletal generator for symptoms, most likely neck pain, dizziness and/or headache; so you proceed with what you have in your tool box.
Cervical spine involvement in mTBI is gaining more traction over the years. There have been countless case reports and case studies on the benefit of manual therapy for mTBI (to name a few--Gurnseley 2016, Burns 2015, Weltzer 2017). In fact, Brolinson recommends using manual therapies alongside neuromotor/sensorimotor training for more effective mTBI recovery than rest and exercises. Also, we can't forget the all important Schneider study from 2014 that found a significant number of athletes returned to sport in manual / vestibular group compared to control group.
Most recently, Quatman-Yates in 2016 found the following conclusion:
The results of this systematic review indicate that several physical rehabilitation options with minimal risk for negative outcomes are available for treating patients experiencing persistent post-mTBI symptoms. These options include: vestibular, manual, and progressive exercise interventions.
In general, the literature does guide us that manual therapies can be a safe and effective intervention to the cervical spine for mTBI. In fact, if you break down adverse events in Cervicogenic Dizziness / Cervical Vertigo, you will not find the literature shying away from manual therapy either. Even though no study has been conducted directly examining adverse events, it can be noted that the largest randomized control trial and long term outcomes to date by Reid and colleagues specifically state no adverse events in the group of eighty-six participants receiving manual therapy.
However, there is one study I want to bring to light. It is from Dr. Greenman and his colleague, Dr. McPartland back in 1995 entitled, "Cranial findings and iatrogenesis from craniosacral manipulation in patients with traumatic brain injury". For those who do not know, Greenman was well known at Michigan State in Osteopathic Medicine and well cited in books and journals. Even though the practice and treatment of craniosacral manipulation is beyond this blog and post, it is worth noting the findings of this brief review below:
Out of 55 cases, the authors describe 3 cases of adverse events of craniosacral therapy in patients with mTBI, including 2 requiring hospitalization. They noted a 5% incidence rate and quoted the following, "craniosacral manipulation in a traumatic brain-injured patient can be useful and effective, but is not without risk".
This number may not mean much to you---but we all hope as clinicians it is 0%---but it all depending on how you define iatrogenesis. Nevertheless, I suggest you compare this number to Carnes' 2010 study noting incidence estimate of proportions for minor or moderate transient adverse events after manual therapy was approximately 41% (CI 95% 17-68%) in the cohort studies and 22% (CI 95% 11.1-36.2%) in the RCTs; for major adverse events approximately 0.13%.
However, Sabel and Patini in 2018 in a pilot study examined safety of Osteopathic Manipulative Medicine in PostConcussion Symptom Management and elicited the following conclusion:
Osteopathic cranial manipulative medicine was considered a safe adjunctive treatment option to improve concussion-related symptoms and recovery.
In conclusion, I say there are minor adverse events to any intervention but we definitely want to have a treatment approach that minimizes risk while add benefit. The type of technique, approach and handling skills can all be combined to making this formula turn out best for you and the patient. In our Cervicogenic Dizziness Course, we teach a variety of techniques that add on what you already know and propel it towards maximal comfort and relief. Come check us out near you.
Cervicogenic Dizziness Course
You can learn more about the screening and treatment process of Cervicogenic Dizzinesss through Integrative Clinical Concepts, where the authors (husband–a manual therapist a wife—a vestibular specialist), teach a very unique course combining both the theory and practice of vestibular and manual principles in their 2-day course. Pertinent to this blog post, the 2nd day includes the “Physio Blend”, a multi-faceted physiotherapist approach to the management of Cervicogenic Dizziness, which includes treatments of the articular and non-articular system of manual therapy and the most updated sensorimotor exercise regimen.
If you would like to host a course for your staff (either a vestibular, neuro, sports or ortho clinic), please do not hesitate to contact me at harrisonvaughanpt@gmail.com for more information.
AUTHORS
Harrison N. Vaughan, PT, DPT, OCS, Dip. Osteopracic, FAAOMPT
Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts
Danielle N. Vaughan, PT, DPT, Vestibular Specialist
Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts