Teaching and use of cervical high-velocity, low-amplitude manipulation at colleges of osteopathic medicine

Osteopathic medical schools typically teach osteopathic manipulative medicine/osteopathic principles and practices (OMM/OPP) during the 1st and 2nd years of medical school and provide additional training in the 3rd and 4th years, when clinical instruction occurs. The Education Council on Osteopathic Principles (ECOP), which consists of representatives from each accredited US college of osteopathic medicine (COM), has developed and approved content for educational modules to be included as guidelines for the teaching of OMM/OPP [1]. These teaching modules do not constitute an entire curriculum or specify recommended methods of instruction or assessment. As such, the timing and delivery of OMM/OPP, including specific techniques that are taught, vary widely among medical schools. Typically, students obtain cognitive knowledge from didactic presentations in anatomy, biomechanics, and somatic dysfunction, then combine that knowledge with motor skills learning under the direction of an expert clinician [2].

High-velocity, low-amplitude (HVLA) treatment of the cervical spine is a relatively safe treatment for neck pain when compared to other common interventions [3]. Cervical HVLA can decrease pain, relieve muscle tension, and increase mobility, explaining why many patients seek osteopathic physicians, chiropractors, physical therapists, and other practitioners of manipulation [4]. Cervical HVLA improves function by providing a rapid, therapeutic force of brief duration through a restrictive barrier to spinal motion.

Reports of neurovascular complications associated with the use of cervical HVLA [5], [6] could possibly cause hesitation among medical school faculty to teach and/or use these techniques, although the literature shows no evidence supporting or detracting from that theory. Although rare, complications have been reported to include spinal disc herniations, radiculopathies, hematomas, and diaphragmatic paralysis [2]. Although patients treated with cervical HVLA have been shown to experience no adverse complications [6], the potential risk of stroke is not zero [7]. An estimated one in 20,000 spinal manipulations have resulted in a vertebral artery dissection and ischemic infarction, but the exact incidence of this complication is unknown [8]. The risk appears to be more prominent at the level of the atlanto-axial (AA) joint because the vertebral artery is most subject to shearing forces during cervical rotation at this level [4].

A 2010 Cochrane systematic review assessed 1,522 patients across 27 randomized, controlled clinical trials on the use of manipulation and mobilization of the cervical spine for patients with neck pain [9]. Only one-third of the trials (8 of 27) reported on whether side effects from cervical spine manipulation occurred [9]. Five of these eight trials reported benign and transient side effects, consisting of headache, neck pain, stiffness, minor discomfort, and dizziness, whereas the other three trials reported no side effects at all [9]. A 2012 systemic review [10] of the literature from 1966 to 2012 analyzed five case-control studies to determine whether an association exists between neck manipulation and stroke [10]. The authors concluded that while evidence was “lacking for a strong association between neck manipulation and stroke,” the evidence was also “absent for no association” [10].

The American Osteopathic Association (AOA) position statement on Osteopathic Manipulative Treatment of the Cervical Spine, reaffirmed in 2019 by the AOA House of Delegates, recommends clinical use of cervical HVLA when indicated [11]. Specifically, it stated that “it is the position of the American Osteopathic Association that all modalities of osteopathic manipulative treatment of the cervical spine, including HVLA, should continue to be taught at all levels of education, and that osteopathic physicians should continue to offer this form of treatment to their patients,” and further, that “serious adverse events are seen as a rarity, and it is estimated that they occur in the range of every 20,000 to 250,000,000 manipulation[s] performed.” [11] The overall risk of adverse events to the patient is less than other commonly utilized treatment modalities such as the utilization of nonsteroidal anti-inflammatory drugs, cervical epidural steroid injections, and facet injections [11]. Previous authors [12] have recommended that when teaching cervical HVLA, instructors and students should be confident in the diagnoses being discussed as well as the attendant treatment.

Based on our review of the literature surrounding the teaching and clinical use of cervical HVLA, we developed a survey to answer the following questions: How and when is cervical HVLA incorporated into the curriculum?; If it is not incorporated into the curriculum, what are some common reasons for not doing so?; How confident are clinical faculty in the ability of students to perform the techniques competently upon graduation?; To what extent do clinical faculty use these techniques within their own practices? The aim of this study was to characterize the perspectives of OMM/OPP department chairs at COMs in the United States regarding teaching and practice patterns around cervical HVLA. Understanding and knowing how cervical HVLA is incorporated into the medical school curriculum, how it is taught, and how it is employed in schools and clinical practice could be of interest to osteopathic educators as well other practitioners of manual therapies.

Results

Demographics

Of 51 survey recipients, 38 (74.5%) responded, 32 to the paper survey at the ECOP meeting and six to the digital survey. Table 1 outlines the demographic characteristics of the respondent sample. Of the 38 respondents, 20 (52.6%) were men and 18 (47.4%) were women. The self-reported race/ethnicity of respondents was as follows: 34 (89.6%) White, 1 (2.6%) Asian, 1 (2.6%) Black or African American, 1 (2.6%) Hispanic or Latino, and 1 (2.6%) Native Hawaiian or Pacific Islander. Approximately half (21; 55.3%) of the respondents were 51 years of age or older (range, 30–50 years). All respondents had obtained board certification in Neuromusculoskeletal Medicine. Some respondents also listed certifications in sports medicine as well as physical medicine and rehabilitation (PM&R).

Table 1:

Demographic characteristics of the respondent sample.

Characteristics	n (%)
Department chair
Yes	33 (86.8)
No	5 (13.2)
Sex
Male	20 (52.6)
Female	18 (47.4)
Self-reported race/ethnicity
White	34 (89.6)
Asian	1 (2.6)
Black/African American	1 (2.6)
Hispanic/Latino	1 (2.6)
Native Hawaiian/Pacific Islander	1 (2.6)
Age, years
30–40	8 (21.1)
41–50	9 (23.7)
51–60	13 (34.2)
61+	8 (21.1)
Board certification
FM	0 (0)
NMM	16 (42.1)
IM	0 (0)
FM/NMM	21(55.3)
IM/NMM	1 (2.6)

1. FM, family medicine; IM, internal medicine; NMM, neuromusculoskeletal medicine.

Curricular integration of cervical spine HVLA

At least 80% (32) of the respondents reported HVLA to at least one of the identified cervical spine regions taught at their COM in years 1–4. This education was primarily delivered during years 1 and 2. Overall, 13.2% (5) of respondents reported that their COM did not teach HVLA of the OA, 10.6% (4) did not teach HVLA to the AA, and 2.6% (n=1) did not teach HVLA to C2-7 (Table 2).

Table 2:

Curriculum stages at which respondents reported that high-velocity, low-amplitude treatment technique for the cervical spine is introduced at their college of osteopathic medicine.

Education level	OA, n (%)	AA, n (%)	C2-7, n (%)
Program year 1	18 (47.4)	20 (52.6)	21 (55.3)
Program year 2	14 (36.8)	14 (36.8)	15 (39.5)
Program year 3	0	0	0
Program year 4	0	0	1 (2.6)
Undergraduate fellowship	1 (2.6)	0	0
Postgraduate	0	0	0
Do not teach	5 (13.2)	4 (10.6)	1 (2.6)

1. AA, atlanto-axial; C2-7, cervical vertebrae 2–7; OA, occipital-atlanto.

Teaching methods of cervical spine HVLA

At 37 of the 38 (97.4%) respondent osteopathic medical schools that teach cervical HVLA, the most common teaching method by 27 (72.9%) of the COMs was hand-over-hand monitoring of the student by faculty while the student provides an HVLA-activating force for the first time on the subject. Additionally, 16 (16.2%) COM respondents reported conducting some form of medical clearance prior to HVLA instruction. The survey was not specific with regard to the definition of medical clearance.

Assessment and perception of student competency

Competence of students in performing cervical HVLA techniques is determined by practical exam at 81.6% (31) of COMs, as reported by affiliated respondents. Related to the practical examination, 23.7% (9) of respondents reported that their COM students provided the setup of HVLA without thrust, while 47.4% (20) reported setup of HVLA with thrust at their COM. The remaining schools (15; 39.5%) did not respond to the question about competency assessment on the survey. Finally, as shown in Figure 1, 15 (40.5%) respondents believed that only 0–25% of their COM’s graduating classes could perform cervical HVLA competently upon graduation, whereas 10 (27%) believed that 51–75% of their school’s medical school classes were able to demonstrate competency for cervical spine HVLA.

Figure 1:

Respondents’ perceptions of students’ competency to perform cervical HVLA upon graduation.HVLA, high-velocity, low-amplitude.

Rationale for not teaching cervical spine HVLA

The schools that do not teach cervical HVLA to at least one of the identified cervical spine regions (4; 10.5%) or discontinued it from the curriculum altogether (1; 2.6%) responded that students may learn techniques on clerkship and/or OMM rotations during their third and fourth years. One respondent (2.6%) selected “Techniques are too difficult” and 2 (5.3%) selected “The medicolegal risk is too high” as the reason for not teaching cervical HVLA. Lastly, one of these schools reported an adverse event in the past involving a herniated cervical disc in a student.

Clinical practice of cervical spine HVLA

Respondents were asked to indicate their utilization of HVLA techniques within their own clinical practice; the majority (31; 81.6%) of respondents reported that they employed cervical HVLA within their practice, with approximately half of those providing some form of cervical HVLA at least weekly (21; 55.3%). Of the 31 respondents who employed HVLA of the cervical spine, 25 (80.6%) apply it to the OA, 23 (74.2%) apply it to the AA, and 31 (100%) apply it to C2-7. Further, of the 31 schools that use HVLA, 28 (90.3%) include verbal informed consent as part of their process, 7 (22.6%) include written informed consent, 17 (54.8%) include patient education, 19 (61.3%) include neurologic exam prior to treatment, 12 (38.7%) include a physical exam testing for vertebrobasilar artery insufficiency, and 14 (45.2%) include physical exam testing for osteoligamentous integrity. Five of 38 respondents (13.2%) did not have a clinical practice. A small percentage of the total respondents (2; 5.3%) did not perform these techniques, either because they believe cervical HVLA is not appropriate (1; 2.6%) or they do not feel comfortable performing it (1; 2.6%) (Table 3).

Table 3:

Clinical practice of high-velocity, low-amplitude treatment technique by cervical spine region.

Number of respondents n (% of respondents)	OA	AA	C2-7
31 (81.6%)	25 (65.8%)	23 (60.5%)	32 (84.2%)
5 (13.2%)	Do not have clinical practice
2 (5.3%)	Techniques not appropriate or they do not feel comfortable performing them

1. AA, atlanto-axial; C2-7, cervical vertebrae 2–7; OA, occipital-atlanto.