Manipulative Physiotherapy Research Articles

Classification in Nonspecific Low Back Pain: What Methods do Primary Care Clinicians Currently Use?

Postal survey. To describe the signs and symptoms that clinicians think represent nonspecific low back pain (NSLBP) subgroups, and to report the labels that clinicians give to those subgroups. The cause of most low back pain (LBP) cannot be diagnosed. Consequently, approximately 80% of primary care LBP presentations are most accurately labeled as NSLBP. Most Australian primary care clinicians think that NSLBP is heterogeneous and treat patients differently based on that heterogeneity. This research sought to identify the subgroups clinicians believe are recognizable within that heterogeneity. Analysis of survey data from 651 primary care clinicians from 6 professional disciplines: physiotherapy, manipulative physiotherapy, chiropractic, osteopathy, general medicine, and musculoskeletal medicine. There was little consensus among participating clinicians regarding the signs and symptoms that identify NSLBP subgroups. Most clinicians give labels to NSLBP subgroups that imply putative pathoanatomy, however, the evidence that these labels are valid is scant and controversial. A lack of consensus among participating clinicians regarding NSLBP subgroups and a lack of evidence for the validity of NSLBP subgrouping are a compelling argument for further research into this clinical practice.

Manipulative Treatment vs Conventional Physiotherapy Treatment in Whiplash Injury.

Manipulative Treatment vs Conventional Physiotherapy Treatment in Whiplash Injury.

Pre-manipulative testing of the cervical spine review, revision and new clinical guidelines

Members of the Manipulative Physiotherapists Association of Australia (now Musculoskeletal Physiotherapy Australia) were surveyed to determine their use of cervical manipulation, compliance with and attitudes to the Australian Physiotherapy Association's (APA) Protocol for Pre-manipulative Testing of the Cervical Spine, and the incidence of adverse effects from cervical manipulation. The questionnaire was mailed to 740 members and returned by 480 members (65%). Cervical manipulation (84.5%) and passive mobilization (99.8%) were used by a high percentage of respondents. Most were familiar with the protocol with 63% supporting its continued endorsement. Adverse effects were reported at a rate of one per 1000 years of practice (or 0.003/week). The most common effects were symptoms potentially related to VBI (94.4% responses), with no reported major complications. Only 37.1% of respondents always informed the patient about potential dangers of cervical manipulation and consent was sought on every occasion by 33% of respondents. The results suggest that the use and interpretation of the protocol are variable among members of MPA. The risk of adverse effects from manipulative (musculoskeletal) physiotherapy practice, including cervical manipulation, appears to be very low. Recommendations for revision of the protocol were made on the basis of results of the survey and treatment diary, in addition to a review of the literature related to testing for vertebro-basilar insufficiency, adverse incidents related to cervical mobilizing and manipulative technique, differentiating features of VBI related dizzinesss and vertigo related to benign paroxysmal positional vertigo (BPPV) and current issues surrounding informed consent. Finally, a summary of the content of the new Clinical Guidelines for Pre-Manipulative Testing of the Cervical Spine (APA, 2000) is provided.

The evaluation of the proximal tibiofibular joint for patients with lateral knee pain

In contrast to important functions of the proximal tibiofibular joint (PTFJ), there appear a few clinical and radiological studies concerning the PTFJ pathologies. Although almost all of the joints have been investigated in detail by MRI, review of the literature reveals none on the pathologies of PTFJ. Thirty-eight knees of 32 patients with lateral knee pain were evaluated clinically and radiologically. All had tenderness over the PTFJ and lateral hamstring tightness. MRI examination revealed effusion of the PTFJ in 22 knees and partial ruptures of anterior or posterior tibiofibular ligament, lateral collateral ligament or biceps femoris tendon in 25 knees. All patients were treated by manipulative physiotherapy of the PTFJ and strengthening and stretching exercises of the surrounding structures. All patients were followed-up 12–36 months (mean 28 months) after the treatment protocol, and complete relief of the symptoms was recorded in 28 of the 38 knees. Although spontaneous pain was not present in five patients, there was tenderness over the PTFJ by palpation. No change in the symptoms was recorded in five patients. These results suggest that PTFJ pathologies should be kept in mind in the evaluation of lateral knee pain and MRI examination provides useful information.

Clinicians’ perceptions of minor cervical instability

Appropriate musculoskeletal physiotherapy management of spinal conditions requires recognition of clinical patterns in order to make a provisional diagnosis. This study aimed to assist the recognition of minor cervical instability (MCI) by surveying clinicians experienced in the management of neck conditions. A total of 153 Australian physiotherapists with postgraduate qualifications in manipulative physiotherapy and experience in the management of neck conditions completed a questionnaire that required them to indicate the importance of 15 clinical findings in the diagnosis of MCI. The responses were examined descriptively then subjected to factor analysis to identify possible groupings of findings. Clinical findings considered by greater than 50% of respondents to be either very important or vitally important in the diagnosis of MCI were: a history of major trauma; reports of the neck catching or locking or giving way; poor muscular control; signs of hypermobility on X-ray; excessively free end-feel on passive motion testing and unpredictability of symptoms. The factor analysis resulted in four distinct factors, each clinically interpretable. Therapists treating patients with neck conditions should at least consider the possibility of MCI when presented with any of the six findings reported above or with any of the groupings of findings identified by the factor analysis.

User's guide to the Chiropractic Literature-IB: how to use an article about therapy

User's guide to the Chiropractic Literature-IB: how to use an article about therapy

Can Manipulative Physiotherapists Agree on which Lumbar Level to Treat Based on Palpation?

Summary Background and Purpose Assessment of intervertebral movement through palpation forms the basis for mobilisation techniques used to treat patients with vertebral disorders. There is contradictory evidence on whether clinicians can reliably choose which spinal level to treat based on palpation. In general, it appears that the reliability of palpation has been less than moderate when practised by clinicians without specialist training and when evaluated on people without symptoms. This study therefore aimed to determine whether physiotherapists with specialist training in manipulative physiotherapy could agree in locating and naming the lumbar level to treat in people with sub-acute low back pain in a clinical setting. Method Three pairs of physiotherapists with postgraduate qualifications in manipulative physiotherapy palpated the lumbar spines of 20 people presenting to their clinics for treatment of low back pain. Based on central posterior-anterior pressures, each therapist located the level that was considered to be most likely to be contributing to symptoms (the comparable level). Each therapist marked the skin overlying the spinous process of the comparable level with an ultraviolet pen and these marks were transcribed on to transparencies for analysis. Results Therapists demonstrated only fair agreement for palpating the location of a comparable spinal level (k = 0.37). In addition, when asked to name the located comparable level the overall agreement (k = 0.09) was not greater than due to chance alone. The mean distance between marks was 27.8 mm, which was greater than the measured dimensions of any lumbar spinous process. Conclusion These results suggest that the therapists were frequently palpating different lumbar spinous processes as the most comparable level. Therapists who use central posterior-anterior palpation pressures in the management of people with low back pain should be aware that this technique may not be reliable and should not base treatment decisions on these palpatory findings alone.

Development and Control of a ‘Soft-Actuated’ Exoskeleton for Use in Physiotherapy and Training

Full or partial loss of function in the upper limb is an increasingly common due to sports injuries, occupational injuries, spinal cord injuries, and strokes. Typically treatment for these conditions relies on manipulative physiotherapy procedures which are extremely labour intensive. Although mechanical assistive device exist for limbs this is rare for the upper body. In this paper we describe the construction and testing of a seven degree of motion prototype upper arm training/rehabilitation (exoskeleton) system. The total weight of the uncompensated orthosis is less than 2 kg. This low mass is primarily due to the use of a new range of pneumatic Muscle Actuators (pMA) as power source for the system. This type of actuator, which has also an excellent power/weight ratio, meets the need for safety, simplicity and lightness. The work presented shows how the system takes advantage of the inherent controllable compliance to produce a unit that is extremely powerful, providing a wide range of functionality (motion and forces over an extended range) in a manner that has high safety integrity for the patient. A training control scheme is introduced which is used to control the orthosis when used as exercise facility. Results demonstrate the potential of the device as an upper limb training, rehabilitation and power assist (exoskeleton) system.

Effectiveness of manipulative physiotherapy for the treatment of a neurogenic cervicobrachial pain syndrome: a single case study – experimental design

A single case study ABC design was used to evaluate the effectiveness of manipulative physiotherapy in a 44-year-old woman with an 8-month history of neurogenic cervicobrachial pain. Clinical examination demonstrated significant signs of upper quadrant neural tissue mechanosensitivity indicating that neural tissue was the dominant tissue of origin for the subject's complaint of pain. Magnetic resonance imaging revealed correlating discal pathology at the C5/6 intersegmental level. The study involved a 4-week pre-assessment phase, a 4-week treatment phase and a 2-week home exercise phase. Functional disability was measured using the Northwick Park Neck Pain Questionnaire and pain was assessed using the McGill Short Form Pain Questionnaire. Cervical motion was measured by a cervical range of motion device (CROM) and the range of shoulder abduction with a mediclino inclinometer. Manipulative physiotherapy treatment involved a cervical lateral glide mobilization technique. Following treatment, visual analysis revealed beneficial effects on pain, functional disability as well as cervical and shoulder mobility. These improvements were maintained over the home exercise phase and at 1-month follow-up. The single case limits generalization of the findings, but the results support previous studies in this area and gives further impetus to controlled clinical trials.

Spinal manipulation for primary and secondary dysmenorrhoea.

Dysmenorrhoea refers to the occurrence of painful menstrual cramps of uterine origin and is a common gynaecological condition. One possible treatment is spinal manipulation therapy. One hypothesis is that mechanical dysfunction in certain vertebrae causes decreased spinal mobility. This could affect the sympathetic nerve supply to the blood vessels supplying the pelvic viscera, leading to dysmenorrhoea as a result of vasoconstriction. Manipulation of these vertebrae increases spinal mobility and may improve pelvic blood supply. Another hypothesis is that dysmenorrhoea is referred pain arising from musculoskeletal structures that share the same pelvic nerve pathways. The character of pain from musculoskeletal dysfunction can be very similar to gynaecological pain and can present as cyclic pain as it can also be altered by hormonal influences associated with menstruation. To determine the safety and efficacy of spinal manipulative interventions for the treatment of primary or secondary dysmenorrhoea when compared to each other, placebo, no treatment, or other medical treatment. We searched the Cochrane Menstrual Disorders and Subfertility Group trials register (searched 18 March 2004), CENTRAL (The Cochrane Library Issue 1, 2004), MEDLINE (1966 to March 2004), EMBASE (1980 to March 2004), CINAHL (1982 to March 2004), AMED (1985 to March 2004), Biological Abstracts (1969 to Dec 2003), PsycINFO (1872 to March 2004) and SPORTDiscus (1830 to March 2004). The Cochrane Complementary Medicine Field's Register of controlled trials (CISCOM) was also searched. Attempts were also made to identify trials from the metaRegister of Controlled Trials and the citation lists of review articles and included trials. In most cases, the first or corresponding author of each included trial was contacted for additional information. Any randomised controlled trials (RCTs) including spinal manipulative interventions (e.g. chiropractic, osteopathy or manipulative physiotherapy) vs each other, placebo, no treatment, or other medical treatment were considered. Exclusion criteria were: mild or infrequent dysmenorrhoea or dysmenorrhoea from an IUD. Four trials of high velocity, low amplitude manipulation (HVLA), and one of the Toftness manipulation technique were included. Quality assessment and data extraction were performed independently by two reviewers. Meta analysis was performed using odds ratios for dichotomous outcomes and weighted mean differences for continuous outcomes. Data unsuitable for meta-analysis were reported as descriptive data and were also included for discussion. The outcome measures were pain relief or pain intensity (dichotomous, visual analogue scales, descriptive) and adverse effects. Results from the four trials of high velocity, low amplitude manipulation suggest that the technique was no more effective than sham manipulation for the treatment of dysmenorrhoea, although it was possibly more effective than no treatment. Three of the smaller trials indicated a difference in favour of HVLA, however the one trial with an adequate sample size found no difference between HVLA and sham treatment. There was no difference in adverse effects experienced by participants in the HVLA or sham treatment. The Toftness technique was shown to be more effective than sham treatment by one small trial, but no strong conclusions could be made due to the small size of the trial and other methodological considerations. Overall there is no evidence to suggest that spinal manipulation is effective in the treatment of primary and secondary dysmenorrhoea. There is no greater risk of adverse effects with spinal manipulation than there is with sham manipulation.

Spinal manipulation for primary and secondary dysmenorrhoea.

Dysmenorrhoea refers to the occurrence of painful menstrual cramps of uterine origin and is a common gynaecological condition. The efficacy of medical treatments such as nonsteroidal anti-inflammatories (NSAIDs) or oral contraceptive pills (OCPs) is considerable, however the failure rate can still be as high as 20-25% and there are also a number of associated adverse effects. Many women are thus seeking alternatives to conventional medicine. One popular treatment modality is spinal manipulation therapy. There are several rationales for the use of musculoskeletal manipulation to treat dysmenorrhoea. The parasympathetic and sympathetic pelvic nerve pathways are closely associated with the spinal vertebrae, in particular the 2nd-4th sacral segments and the 10th thoracic to the 2nd lumbar segments. One hypothesis is that mechanical dysfunction in these vertebrae causes decreased spinal mobility. This could affect the sympathetic nerve supply to the blood vessels supplying the pelvic viscera, leading to dysmenorrhoea as a result of vasoconstriction. Manipulation of these vertebrae increases spinal mobility and may improve pelvic blood supply through an influence on the autonomic nerve supply to the blood vessels. Another hypothesis is that dysmenorrhoea is referred pain arising from musculoskeletal structures that share the same pelvic nerve pathways. The character of pain from musculoskeletal dysfunction can be very similar to gynecological pain and can present as cyclic pain as it can also be altered by hormonal influences associated with menstruation. To determine the safety and efficacy of spinal manipulative interventions for the treatment of primary or secondary dysmenorrhoea when compared to each other, placebo, no treatment, or other medical treatment. Electronic searches of the Cochrane Menstrual Disorders and Subfertility Group specialised register of controlled trials, CCTR, MEDLINE, EMBASE, CINAHL, Bio extracts, Psyclit and SPORTDiscus were performed to identify relevant randomised controlled trials (RCTs). The Cochrane Complementary Medicine Field's Register of controlled trials (CISCOM) was also searched. Attempts were also made to identify trials from the National Research Register, the Clinical Trial Register and the citation lists of review articles and included trials. In most cases, the first or corresponding author of each included trial was contacted for additional information. Any RCTs including spinal manipulative interventions (e.g. chiropractic, osteopathy or manipulative physiotherapy) vs each other, placebo, no treatment, or other medical treatment were considered. Exclusion criteria were: mild or infrequent dysmenorrhoea or dysmenorrhoea from an IUD. Five RCTs were identified that fulfilled the inclusion criteria for this review. Four trials involving high velocity, low amplitude manipulation (HVLA), and one involving the Toftness manipulation technique were included. Quality assessment and data extraction were performed independently by two reviewers. Meta analysis was performed using odds ratios for dichotomous outcomes and weighted mean differences for continuous outcomes. Data unsuitable for meta-analysis were reported as descriptive data and were also included for discussion. The outcome measures were pain relief or pain intensity (dichotomous, visual analogue scales, descriptive) and adverse effects. Results from the four trials of high velocity, low amplitude manipulation suggest that the technique was no more effective than sham manipulation for the treatment of dysmenorrhoea, although it was possibly more effective than no treatment. Three of the smaller trials indicated a difference in favour of HVLA, however the one trial with an adequate sample size found no difference between HVLA and sham treatment. There was no difference in adverse effects experienced by participants in the HVLA or sham treatment. The Toftness technique was shown to be more effective than sham treatment by one small trial, but no strong conclusions could be made due to the small size of the trial and other methodological considerations. Overall there is no evidence to suggest that spinal manipulation is effective in the treatment of primary and secondary dysmenorrhoea. There is no greater risk of adverse effects with spinal manipulation than there is with sham manipulation.

Accuracy of Feedback During Training of Passive Accessory Intervertebral Movements

The purpose of this study was to determine the accuracy of verbal feedback given by manipulative physiotherapy students after a fellow student had applied Passive Accessory Intervertebral Movements (PAIVMs). Twelve students working in pairs acted in turn as model and therapist. Student therapist performance in producing a Grade-III movement was compared subjectively by student models to that of an experienced therapist. Their performance was also objectively compared using a force platform measurement system. Performances were assessed in terms of peak force and the frequency and amplitude of force oscillations. The feedback provided by student models was found to be inconsistent and unreliable. Alternate teaching methods seem necessary in order to provide student therapists with feedback appropriate for learning.

Interventions for shoulder pain.

To review the efficacy of common interventions for shoulder pain. We searched the Cochrane Musculoskeletal Group trials register, Cochrane Controlled Trials Register, Medline, Embase, Cinahl, and Science Citation Index) up to May 1998, and hand searched major textbooks, bibliographies of relevant literature, the fugitive literature, and the subject indices of relevant journals including: American College of Rheumatology;British College of Rheumatologists; the Biennial Conference of the Manipulative Physiotherapy Association of Australia;International Federation of Manual Therapists conference proceedings; British Orthopaedic Association;and American Orthopaedic Association. Each identified study was assessed for possible inclusion by two independent reviewers based on the blinded methods sections. The determinants for inclusion were that the trial include an intervention of interest (non-steroidal anti-inflammatory drugs, intra-articular or subacromial glucocorticosteroid injection, oral glucocorticosteroid treatment, physiotherapy, manipulation under anaesthesia, hydrodilatation, or surgery); that treatment allocation was randomized; and that the outcome assessment was blinded. Methodological quality was assessed by two independent, blinded reviewers. Data relating to selection criteria, outcome measurement and treatment effect was extracted from the blinded trials. Range of motion scores were entered as degrees of restriction to movement, and all pain and overall effect scores were transformed to 100 point scales. For continuous outcome measures, where standard deviation was not reported it was either calculated from the raw data or converted from standard error of the mean. If neither of these were reported, authors were contacted in an effort to obtain the missing values. Effect sizes were calculated and combined in a pooled analysis if study population, endpoint and intervention were comparable. Thirty one trials met inclusion criteria. Mean methodological quality score was 16.8 (9.5 - 22) out of possible score of 40. Selection criteria varied widely even for the same diagnostic label. There was no uniformity in outcome measures used and their measurement properties were rarely reported. Effect sizes for individual trials were small (-1.4 to 3. 0). The results of only three studies investigating rotator cuff tendonitis could be pooled. Benefit of subacromial steroid injection over placebo for improving range of abduction (weighted difference between means (WMD) 35 degrees, 95% CI 14 to 55) was the only positive finding. There is little evidence to support or refute the efficacy of common interventions for shoulder pain. As well as, the need for further well designed clinical trials, more research is needed to establish a uniform method of defining shoulder disorders and developing outcome measures which are valid, reliable and responsive in these study populations.

Cardiovascular and respiratory changes produced by lateral glide mobilization of the cervical spine

Elucidation of the effects of manual physiotherapy treatment techniques provides an insight into their mechanisms of action. Several treatment techniques for the cervical spine have been shown to consistently produce sympatho-excitation as indicated by changes in sudomotor and peripheral vasomotor function. In order to ascertain the extent and nature of this manipulation induced sympatho-excitatory effect, changes in cardiac and respiratory function were investigated. A within-subjects study design was used to examine the effects of a randomly applied, cervical spine lateral glide treatment technique, a placebo technique and a control technique. Blood pressure, heart rate and respiratory rate were used as indicators of cardiac and respiratory function. Twenty-four subjects who were asymptomatic and blind to the aim of the study participated in the study. The lateral glide treatment technique produced an increase in diastolic and systolic blood pressure, heart rate and respiratory rate that was significantly greater than that of the placebo and control conditions ( P < 0.05). This finding indicates that the sympatho-excitatory effect of the cervical lateral glide treatment technique extends beyond sudomotor and peripheral vasomotor systems to include cardiac and respiratory systems. These findings have implications for our understanding of the effects of manipulative physiotherapy treatment techniques.

Can subjective characteristics of benign headache predict manipulative physiotherapy treatment outcome?

This study aimed to identify whether particular subjective reports of headache sufferers were predictive of outcome with manipulative physiotherapy treatment. One hundred and twelve subjects presenting for manipulative physiotherapy completed questionnaires relating to headache frequency, intensity, duration, pain quality, area, history and aggravating factors. Classification of treatment response was made using data collected two months after the initial visit. Diet as an aggravating factor, affective and autonomic pain descriptors, unilateral headaches and low frequencies each predicted a negative response to treatment. High frequencies predicted a positive response. If it is assumed that the treatment addressed cervical dysfunction then the cervical spine could have a varying component in a range of headache types rather than occupying a strict diagnostic category.

Complications Arising from Spinal Manipulative Therapy in New Zealand

Summary Complications arising from spinal manipulative therapy applied by physiotherapists have received scant attention in the literature. Published investigations and case studies have predominantly reported adverse outcomes of chiropractic and medical manipulative intervention. The present study aimed to explore the extent and range of serious spinal manipulative complications in New Zealand caused by physiotherapists and other health professionals. A further aim was to determine whether a prospective study of this problem was warranted. A questionnaire was posted to all neurologists, neurosurgeons, orthopaedic, and vascular surgeons throughout the country (n = 230) asking them to describe any complications arising from spinal manipulative therapy witnessed in the previous five years. The response rate was 63% (n = 146) with 42 incidents reported. Cervical spine complications accounted for 62% of the total, including 14 cerebrovascular accidents of which at least two involved the carotid artery system. Physiotherapists were responsible for one-third (14) and chiropractors for more than half (23) of all complications. These findings indicate that serious complications arising from manipulative physiotherapy may constitute a hitherto unrecognised substantial proportion of all spinal manipulative complications. Further research seems justified using a prospective study design to ascertain the incidence rate of particular complications and identify hazardous techniques.

Determination of manipulative physiotherapy treatment outcome in headache patients

SUMMARY. Although physiotherapists are frequently involved in the treatment of headache when cervical spine dysfunction is thought to be a cause or contributing factor there does not appear to be a consistent definition of treatment success. This study analysed treatment outcome in a population of 112 headache patients presenting for manipulative physiotherapy. Two months after the initial consultation, statistically significant improvements were observed in mean scores for each of headache frequency ( P < 0.001), duration ( P < 0.05) and intensity ( P < 0.001). When a combination of patient estimate of treatment effect and a headache index incorporating scores for frequency, intensity and duration was used to classify treatment outcome, 51 of the 91 subjects analysed at follow-up were deemed to have had a positive response to treatment. This method of classification of treatment outcome appeared to be sensitive to cases where the patient's headaches were improved by factors other than the physiotherapy treatment. However the classification used was less sensitive when the patient's headaches were aggravated by other factors or where there was not consistent improvement or deterioration in the measures of headache frequency, intensity and duration.

Orthopaedic manipulative physiotherapy in South Africa

To ensure effective patient care, all members of the health team should review professional competency and standards of service provision. A questionnaire was sent to all members of the orthopaedic Manipulative Therapists group (OMTG) to establish their qualification and skills, and the scope of practice of Orthopaedic Manipulative Therapy (OMT) physiotherapists. It included a short self and peer review. The results of this study urge the NEC of the OMTG to address pertinent issues that were raised: post-graduate study, international trends, research, dissemination of knowledge, quality assurance, professional image and prophylactic programmes in a primary health care system.

The initial effects of a cervical spine manipulative physiotherapy treatment on the pain and dysfunction of lateral epicondylalgia

Manipulative therapy is frequently used in the management of musculoskeletal pain. A frequently reported clinical feature of this treatment is the immediacy with which it appears to initiate improvement in pain and function. A randomised, double blind, placebo controlled, repeated measures design was employed to study the initial effects of a cervical spine treatment technique in a group of 15 patients with lateral epicondylalgia. Pressure pain threshold, pain-free grip strength, upper limb neurodynamics, pain and function were assessed prior to and following application of either a treatment, placebo or control condition. All subjects received all three conditions. Differences between the pre-post measures were used as indicators of change in subject's symptom profiles. The treatment condition produced significant improvement in pressure pain threshold, pain-free grip strength, neurodynamics and pain scores relative to placebo and control conditions ( P < 0.05). In summary, this study demonstrates that manipulative therapy is capable of eliciting a rapid hypoalgesic effect.

A Prospective Study of Complications of Cervical Spine Manipulation

Complications or adverse responses to cervical spine manipulation, particularly neurovascular compromise, are well documented in the literature. However, the rate of incidence of such adverse responses in manipulative physiotherapy has not been documented, indicating a need for well-designed prospective studies to accurately determine the associated risk of these procedures. To this end, a pilot study trialling a prospective adverse response reporting system was undertaken over a three month period in New Zealand. Twenty manipulative physiotherapists were approached to participate by reporting and describing any adverse responses to cervical spine manipulation they experienced over this time. Nine manipulative physiotherapists were able to participate and reported only one minor incident, a temporary, mild exacerbation of neck pain. It was calculated that the incidence rate for this study was 0.21% per manipulation and 0.42% per patient. The sole notable problem encountered with the methodology was the moderate response rate.