Section 9: Safe OMT practice, including emergency management of an adverse situation

International Framework for Examination of the Cervical Region

Range of techniques recommended as good practice

OMT practice encompasses a wide range of therapeutic manoeuvres from patient activated forces to therapist activated forces. OMT is integrated into the overall management strategy of patient care. Reports of patient harm from OMT in the cervical region have typically been in the practice of cervical manipulation.

The following are necessary considerations for the physical therapist during the selection and application of cervical manipulation[1][2]:

  • The principle of all techniques is that minimal force should be applied to any structure within the cervical spine i.e. low amplitude, short lever thrusts.
  • Patient safety and comfort form the basis of appropriate technique selection.
  • Cervical manipulation techniques should be comfortable to the patient.
  • Cervical manipulation techniques should not be performed at the end of range of cervical movement, particularly extension and rotation.
  • There is flexibility in the choice of the patient’s position using the principles that the patient needs to be comfortable, and that the physical therapist needs to be able to receive feedback. The use of the supine lying position with the patient’s head supported on a pillow is encouraged. This position allows the physical therapist to monitor facial expressions, eye features, etc.
  • Positioning the patient in the pre-manipulative test position prior to a manipulation is good practice to evaluate patient comfort and to enable evaluation of their response.
  • The patient response to all cervical spine movements, including cervical manipulation interventions is continuously monitored.
  • The skills of the physical therapist may be a limitation for the selection of manipulation as a treatment technique, even though clinical reasoning may suggest manipulation is the best choice. In this situation, a risk may be introduced owing to limited clinical skills and it would therefore be a responsible decision to not use manipulation. The self-evaluative skills of the physical therapist in evaluating their ability to perform the desired technique safely and efficiently are therefore important. Referral to a colleague suitably qualified/trained in the desired manipulative technique may be appropriate.

Alternative approaches to direct cervical treatment.

Emerging pain sciences suggests that the effects of manual techniques (such as mobilisation and manipulation) on pain may be largely neurological in nature and not limited to the direct influence of a particular spinal motion segment. Furthermore, clinical trials have reported that thoracic spine manipulation results in improvements in perceived levels of cervical pain, ranges of motion, and disability in patients with mechanical neck pain[3][4][5][6][7], although the mechanism by which this occurs is not known. Given the concern regarding the risks associated with cervical spine manipulation, thoracic spine manipulation provides an alternative, or supplement to, cervical manipulation and mobilisation to maximise the patient’s outcome with an extremely low level of risk. The current evidence suggests that during the initial treatment sessions there is a large likelihood of improved patient outcomes when thoracic manipulation is coupled with cervical active range of movement exercises[3][4][5][6][7]. Subsequent sessions can then introduce more direct manual cervical treatments if warranted. This approach allows the therapist to observe the patient’s response to treatment over a longer time period and theoretically minimises the risks associated with cervical manipulation in the presence of an emerging cervical vascular disorder, such as arterial dissection.

Frequency of treatment

Frequency of treatment will vary depending on the individual and injury in question. Current evidence suggests that manual interventions should be coupled with therapeutic exercise when managing a patient’s neck pain and headache[8][9][10]. Caution should be applied in situations where the patient’s preference is for repeated manipulation, owing to potential dangers of frequent repeated manipulation and a lack of longer term benefit.

Minimising end-range cervical techniques

End of range movements are known to stress the cervical arteries and potentially neural structures. Thus avoidance of these positions is recommended during cervical manipulation[11][1]. Although evidence is limited, this principle also logically applies to techniques performed in end range neck positions during cervical mobilisation and exercise interventions.

Force minimisation

OMT techniques used to treat the cervical region should be applied in a controlled, comfortable manner in mid ranges of cervical movement in order to reduce the potential stress on vascular and neurological structures. The influence of the head and cervical spine segments not included in the manipulation can be used to direct loads to the targeted segment. Therefore by doing this, there is little stress on the rest of the neck and the elimination of cervical spine locking positions[11].

Monitor for any adverse effects

Monitoring the patient for response to treatment and any adverse effects is a continual process throughout and after the treatment session. Verbal and physical examination can be carried out while performing a treatment technique through monitoring physical body behaviour, facial expression, muscle tone, and verbal communication / responsiveness. Grading scales designed by Maitland et al (2005)[12] and Kaltenborn (2003)[13] can be used to guide the physical therapist, providing an objective measure of the patient’s progress during treatment. Similarly, in the osteopathic model, there is considerable emphasis placed on the physical examination of the joint ‘barrier’[14][15] and end-feel. Movement diagrams[12] and other components of the physical examination can be reviewed post treatment to assess for changes in the physical behaviour of the cervical region. However, the ultimate standard of response should be based on the change in a patient reported outcome measure (e.g. Neck Disability Index, Global Rating of Change, etc).

Emergency management of an adverse situation

As a health professional, the physical therapist is expected to act swiftly and judiciously when confronted with an emergency situation. A plan of action should be devised, available, and operational for effective management of an adverse situation. If a patient becomes unresponsive during any aspect of physical therapy care, the physical therapist should immediately implement an emergency action plan for cardiopulmonary resuscitation. Emergency help should be sought immediately, such as calling for an ambulance. Training in cardiopulmonary resuscitation should be completed on a regular basis.


  1. 1.0 1.1 Rivett DA (2004). Adverse effects of cervical manipulative therapy. In J.D. Boyling and G.A. Jull (eds.), Grieve’s Modern Manual Therapy of the Vertebral Column (3rd ed). Churchill Livingstone: Edinburgh 533-549.
  2. Childs JD, Flynn TW, Fritz JM, et al (2005). Screening for vertebrobasilar insufficiency in patients with neck pain: manual therapy decision-making in the presence of uncertainty. J Orthop Sports Phys Ther 35(5):300-306.
  3. 3.0 3.1 Cleland JA, Childs JD, McRae M, et al (2005). Immediate effects of thoracic manipulation in patients with neck pain: a randomized clinical trial. Manual Therapy 10:127-135.
  4. 4.0 4.1 Cleland JA, Childs JD, Fritz JM, et al (2007a). Development of a clinical prediction rule for guiding treatment of a subgroup of patients with neck pain: use of thoracic spine manipulation, exercise, and patient education. Physical Therapy 87:9-23.
  5. 5.0 5.1 Cleland JA, Glynn P, Whitman JM, et al (2007b). Short-term effects of thrust versus nonthrust mobilization/manipulation directed at the thoracic spine in patients with neck pain: a randomized clinical trial. Physical Therapy 87:431-440.
  6. 6.0 6.1 Krauss J, Creighton D, Ely JD, et al (2008). The immediate effects of upper thoracic translatoric spinal manipulation on cervical pain and range of motion: a randomized clinical trial. J Man Manip Ther 16(2):93-99.
  7. 7.0 7.1 Gonzalez-Iglesias J, Fernandez-de-las-Penas C, Cleland JA, et al (2009). Thoracic spine manipulation on the management of patients with neck pain: A randomized clinical trial. Journal of Orthopaedic and Sports Physical Therapy 39(1):20-27.
  8. Jull G, Trott P, Potter H, et al (2002). A randomized controlled trial of exercise and manipulative therapy for cervicogenic headache. Spine 27(17):1835-1843.
  9. Kay TM, Gross A, Goldsmith C, et al (2005). Exercises for mechanical neck disorders. Cochrane Database of Systematic Reviews 2005, Issue 3. Art. No.: CD004250. DOI: 10.1002/14651858.CD004250.pub3
  10. Walker MJ, Boyles RE, Young BA, et al (2008). The effectiveness of manual physical therapy and exercise for mechanical neck pain: a randomized clinical trial. Spine 33(22):2371-2378.
  11. 11.0 11.1 Hing WA, Reid DA, Monaghan M (2003). Manipulation of the cervical spine. Manual Therapy 8(1):2-9.
  12. 12.0 12.1 Maitland G, Hengeveld E, Banks K, et al (Eds)(2005). Maitland's Vertebral Manipulation, 7th Edn, Elsevier Butterworth Heinneman, Edinburgh.
  13. Kaltenborn FM (2003). Manual Mobilization of the Joints, Volume II, The Spine. Oslo, Norway: Norlis.
  14. Greenman PE (1996). Principles of Manual Medicine, 2nd edn. Wilkins and Wilkins, Baltimore.
  15. Hartman L (1997). Handbook of OsteopathicTechnique, 3rd edn. Chapman & Hall, London.