Manipulation is a passive therapeutic technique performed by a therapist applying a specifically directed manual impulse or thrust to a joint at or near the end of the passive (physiological) range of motion. It is often accompanied with an audible pop or crack.
The Health Practitioners Competence Assurance Act 2003 (HPCAA), Part 1 section 9, restricts certain activities to particular health practitioners, in order to protect members of the public from the risk of serious or permanent harm (“Health Practitioners Competence Assurance Act “, 2003; The Ministry of Health, 2014). One of the restricted activities is the application of high velocity, low amplitude manipulative techniques to cervical spine joints (Cartwright, 2005). Although the incidence of serious adverse events as a result of cervical manipulation is very low, the severity of a serious adverse event is potentially very high. Physiotherapists are entitled to perform cervical manipulation, and with this comes responsibilities.
New Zealand law
The Health Practitioners Competence Assurance Act 2003
Health Practitioners Competence Assurance (Restricted Activities) Order 2005
1. Informed consent and documentation (See Informed consent standard)
1.1. Physiotherapists must seek patient informed consent before providing any physiotherapy services, ensuring their consent is freely given and appropriately documented.
1.2. Written informed consent is required as the severity of a serious adverse event is high.
Cervical spine Examination Framework
This framework covers assessment for the potential of cervical arterial dysfunction (CAD) prior to management of the cervical spine. The importance of the subjective history in particular health-related risk factors now has greater importance in predicting risk than the physical tests.
2. Subjective assessment
The following risk factors must be screened for:
2.1. Cervical arterial dysfunction: The risk factors associated with an increased risk of either internal carotid or vertebrobasilar arterial pathology should be thoroughly assessed during the patient history.
2.2. Upper cervical instability: The risk factors associated with an increased risk of bony or ligamentous compromise should be thoroughly assessed during the patient history.
2.3. History: The signs and symptoms of serious pathology and contraindications / precautions to treatment should be thoroughly assessed during the patient history stage of assessment.
2.4. Decision-making: At the end of the subjective assessment a decision needs to be made whether to proceed with the objective testing; if there are any precautions or contraindications; the physical tests necessary; and the order of testing.
3. Objective assessment
The following objective measures should be tested:
3.1. Blood pressure: As hypertension is a risk factor for CAD, blood pressure should be taken in either sitting or lying prior to further
3.2. Craniovertebral ligament testing: Craniovertebral ligament testing should be undertaken prior to any treatment consideration.
3.3. Neurological examination: This should include assessment of the peripheral nerves, cranial nerves, and include assessing for an Upper Motor Neurone lesion.
3.4. Positional testing: Rotational position tests may be indicated (i.e. sustained end-range rotation left and right).
4.1. Cervical spine high-velocity, low-amplitude thrust manipulation is a restricted activity under the HPCAA. The competency of cervical thrust techniques and prerequisite testing means physiotherapists must have completed a course specific to these skills to become proficient and safe to practice these skills.
4.2. To ensure ongoing competence physiotherapists must complete some form of ongoing professional development in this area.
Aotearoa New Zealand Physiotherapy Code of Ethics and Professional Conduct (2017)
Rushton, A., Rivett, D., Carlesso, L., Flynn, T., Hing, W., & Kerry, R. (2015). International framework for examination of the cervical region for potential of cervical arterial dysfunction prior to orthopaedic manual therapy intervention. Physiotherapy, 101, e1305-e1306.
This statement is scheduled for review in 2023. Legislative changes may make this statement obsolete before this review date.
The document has relied heavily on the NZMPA Updated Code of Practice for Cervical Spine Management (2016), and we acknowledge their generosity in allowing us to use and modify their document.