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Introduction

The Health Practitioners Competence Assurance Act 2003 (HPCAA), section 9 enables an activity that forms part of a health service to be declared a restricted activity where the Minister of Health is satisfied that members of the public risk serious or permanent harm if the activity is performed by persons other than health practitioners who are permitted by their scopes of practice to perform that activity.

One of those restricted activities is applying manipulative techniques to the joints of the cervical spine. Manipulation is defined as a passive therapeutic technique performed by a therapist using a specifically directed high-velocity, low-amplitude manual impulse or thrust to a joint at or near the end of the passive (physiological) range of motion. An audible pop or crack often accompanies this technique.[1]

Although the incidence of serious adverse events resulting from cervical manipulation is very low, the severity of a serious adverse event is potentially very high. Physiotherapists are entitled to perform cervical manipulation with appropriate training, and with this comes responsibilities.

New Zealand law

The Health Practitioners Competence Assurance Act 2003

Health Practitioners Competence Assurance (Restricted Activities) Order 2005

1. Education
   • Manipulation of the cervical spine using high-velocity, low-amplitude thrust techniques is a restricted activity under the HPCAA. Therefore, to be eligible to perform these techniques, physiotherapists must complete appropriate training that develops competency with the techniques and knowledge about the prerequisite testing required to ensure safe practice.
   • To ensure ongoing competence, physiotherapists must complete relevant continued professional development.
2. Informed consent
   • Physiotherapists must obtain the patient’s informed consent in writing before applying manipulative techniques to the joints of the cervical spine, ensuring the patient’s consent is freely given based on sufficient information to enable the patient to make an informed decision.
   • Written informed consent is required as the severity of a serious adverse event through treatment involving a restricted activity is likely to be high.
3. Evaluation to determine the level of concern for the presence of serious spinal pathology
   • All patients presenting with cervical spine complaints must be evaluated, appropriate to the clinical context, to determine the level of risk of serious spinal pathology.
   • Red flags are the primary method used to determine the level of concern for the presence of serious spinal pathology. Physiotherapists must screen for the presence of red flags during their subjective evaluation. Screening should include but not limited to identifying trauma, suspected neurological symptoms, and relevant medical history.
   • An appropriate objective assessment must be performed before proceeding with a cervical manipulation
4. Decision-making
   • The decision to proceed or not proceed with any cervical spine intervention, including cervical manipulation, must be informed by a risk assessment.
   • Where the risk evaluation identifies concerning features, physiotherapists must take steps to mitigate risk and document these.
   • Physiotherapists must monitor the person’s response to cervical manipulation and respond appropriately to adverse events.

Commentary

Note: This section provides information to explain the above requirements and how they should be interpreted and applied.

Cervical Manipulation is a restricted activity under the HPCAA, to be performed only by Physiotherapists, Medical Doctors, Chiropractors, and Osteopaths. The HPCAA also requires physiotherapists to maintain competence in these areas.

Education

Appropriate training in cervical manipulation will include developing an understanding of the indications and contraindications, in-person training in how to perform techniques both safely and effectively, and the place of manipulative techniques in spinal management.

While a wide range of information is available online, hands-on training from a health practitioner with appropriate knowledge and experience in cervical manipulation to develop skills is a key component of training.

Continued professional development is expected to maintain competence for cervical manipulation to be undertaken.  This includes relevant courses, peer review, or practice with colleagues.

Informed consent

Refer to the Informed consent standard for further information.

Evaluation to determine the level of concern for the presence of serious spinal pathology

Determining the level of concern for potentially serious spinal pathology requires consideration of a wide range of factors. As described by Finucane et al. (2020), the level of concern is determined by considering red flags together with the clinical and individual profile of the person. Screening for red flags is an essential and required part of determining the level of concern, while acknowledging the limitations of red flags in isolation. The clinical profile includes factors such as the context in which the person is being seen and response to care, while the individual profile includes factors such as age, gender and comorbidities.

The presence of multiple red flags will generate a higher level of concern than a single red flag. Similarly, red flags in combination with a concerning clinical or individual profile will generate a higher level of concern than red flags in isolation.

The potential for serious vascular pathologies of the neck related to cervical manipulation and manual therapy has received considerable attention. Overall, the risk of serious events related to vascular pathologies with manual therapy is considered extremely low in comparison to other conservative treatments (Rushton et al. 2020). This is primarily due to a very low baseline prevalence of serious events associated with orthopaedic manual therapy. This risk analysis can be considered alongside evidence of benefit from cervical manipulation and mobilisation at the level of a Cochrane review (Gross et al. 2010). A discussion of risk-benefit with patients is important when planning management, following the principles about shared decision-making and person-centred care.”

An objective examination should be performed as part of risk assessment. For reference, careful palpation and active range of motion are included in the Canadian C-Spine rules and NEXUS criteria for the evaluation of potentially clinically significant cervical spine injuries following trauma (Hoffman et al. 2000; Stiel et al. 2001). This indicates that objective examination is generally safe and appropriate. Findings from an objective assessment are necessary to inform a decision to manipulate.

Decision-making

The level of concern must inform clinical decision-making; for example, deciding if a referral should be made and the urgency of referral. It is expected that clinicians will only proceed with manipulation when the level of concern is low or mild. Moderate to high level of concern should normally lead to medical referral and/or investigations (Finucane et al. 2020). This provides further information that allows the level of concern to be re-evaluated.

Steps to mitigate risk can be taken at any time, proportional to the level of concern. Examples of steps include discussing the case and appropriate action with a colleague, requesting a second opinion, safety netting (see Greenhalgh et al. 2018: this is specific advice to clients about self-monitoring concerning features and an agreed action plan if features persist or worsen), and medical referral.

Related resources

This standard draws on several resources:

• Finucane, L. M., A. Downie, C. Mercer, S. M. Greenhalgh, W. G. Boissonnault, A. L. Pool-Goudzwaard, J. M. Beneciuk, R. L. Leech and J. Selfe (2020). International Framework for Red Flags for Potential Serious Spinal Pathologies. Journal of Orthopaedic & Sports Physical Therapy 50(7): 350-372.
• International Framework for Examination of the Cervical Region for the potential of vascular pathologies of the neck prior to Orthopaedic Manual Therapy (OMT) Intervention: International IFOMPT Cervical Framework

• Greenhalgh, S., L. Finucane, C. Mercer and J. Selfe (2018). “Assessment and management of cauda equina syndrome.” Musculoskeletal Science and Practice 37: 69-74.
• Paling, C (2021). The complex problem of identifying serious pathology in Musculoskeletal care: Managing clinical risk during the COVID pandemic and beyond. Musculoskeletal Science and Practice.
• NZMPA Code of Practice for Cervical Spine Management (2016)
• Aotearoa New Zealand Physiotherapy Code of Ethics and Professional Conduct (2018)
• The Code of Health and Disability Services Consumers’ Rights
• Rushton, A., Rivett, D., Carlesso, L., Flynn, T., Hing, W., Kerry, R., Rubinstein, S.M., Vogel, S.., (2020). International framework for examination of the cervical region for potential vascular pathologies of the neck prior to orthopaedic manual therapy (OMT) intervention: International IFOMPT Cervical Framework (2020)

• Gross, A., Miller, J., D’Sylva, J., Burnie, S. J., Goldsmith, C. H., Graham, N., Haines, T., Brønfort, G., & Hoving, J. L. (2010). Manipulation or mobilisation for neck pain: A Cochrane Review. Manual Therapy, 15(4), 315-333. https://doi.org/https://doi.org/10.1016/j.math.2010.04.002

We acknowledge the NZMPA for their generosity in allowing us to use their resources in reviewing this Standard. Also acknowledging the working party that consisted of Professor Duncan Reid, Dr Daniel O’Brien and Dr Ewan Kennedy in this review.

Issued: 15 July 2022

This Standard is scheduled for review in 2027. Legislative changes may make this Standard obsolete before this review date.

[1] Rubinstein SM, van Middelkoop M, Assendelft WJJ, de Boer MR, van Tulder MW. Spinal manipulative therapy for chronic low-back pain (Review). The Cochrane Library 2011, Issue