title: Safety of thrust joint manipulation in the thoracic spine: a systematic review.
abstract: BACKGROUND
  There appears to be very little in the research literature on the safety of thrust joint manipulation (TJM) when applied to the thoracic spine.
  
  
  OBJECTIVE
  To retrospectively analyze all available documented case reports in the literature describing patients who had experienced severe adverse events (AE) after receiving TJM to their thoracic spine.
  
  
  METHODS
  Case reports published in peer reviewed journals were searched in Medline (using Ovid Technologies, Inc.), Science Direct, Web of Science, PEDro (Physiotherapy Evidence Database), Index of Chiropractic literature, AMED (Allied and Alternative Medicine Database), PubMed and the Cumulative Index to Nursing and Allied Health (CINHAL) from January 1950 to February 2015.
  
  
  METHODS
  Case reports were included if they: (1) were peer-reviewed; (2) were published between 1950 and 2015; (3) provided case reports or case series; and (4) had TJM as an intervention. Articles were excluded if: (1) the AE occurred without TJM (e.g. spontaneous); (2) the article was a systematic or literature review; or (3) it was written in a language other than English or Spanish.
  
  
  METHODS
  Data extracted from each case report included: gender; age; who performed the TJM and why; presence of contraindications; the number of manipulation interventions performed; initial symptoms experienced after the TJM; as well as type of severe AE that resulted.
  
  
  RESULTS
  Ten cases, reported in 7 case reports, were reviewed. Cases involved females (8) more than males (2), with mean age being 43.5 years (SD=18.73, Range = 17 -71). The most frequent AE reported was injury (mechanical or vascular) to the spinal cord (7/10), with pneumothorax and hematothorax (2/10) and CSF leak secondary to dural sleeve injury (1/10).
  
  
  CONCLUSIONS
  There were only a small number of case reports published in the literature and there may have been discrepancies between what was reported and what actually occurred, since physicians dealing with the effects of the AE, rather than the clinician performing the TJM, published the cases.
  
  
  CONCLUSIONS
  Serious AE do occur in the thoracic spine, most commonly, trauma to the spinal cord, followed by pneumothorax. This suggests that excessive peak forces may have been applied to thoracic spine, and it should serve as a cautionary note for clinicians to decrease these peak forces.
authors: University of Nevada Las Vegas, School of Allied Health Sciences, Department of Physical Therapy, Las Vegas, NV, USA.
authors: Emilio J
authors: EJ
authors: Puentedura
authors: University of Nevada Las Vegas, School of Allied Health Sciences, Department of Physical Therapy, Las Vegas, NV, USA.
authors: William H
authors: WH
authors: O'Grady
keywords: Adverse events; Chiropractic; Injury; Manipulation; Orthopedic manipulative therapy; Osteopathy; Thoracic spine