This study identified the beliefs, perceptions and practices of clinicians and patients regarding benign AEs post-SMT and strategies to mitigate them. To the best of our knowledge, this is the first study to address this topic. While participating clinicians and patients were aware that benign AEs occurred post-SMT, they perceived different factors related to their occurrence. Both clinicians and patients identified common strategies to mitigate benign AEs, including education. Understanding these beliefs, perceptions and practice of mitigation strategies are important steps towards advancing the investigation of management care plans. By elucidating effective strategies to reduce benign AEs post-SMT, improvement might be expected in patient safety, patient expectations and quality of care.
Interestingly, some responding clinicians and patients reported that benign AEs occur after rotatory SMT techniques performed on the cervical region. This is in accordance with a recent study by Funabashi and Carlesso  reporting that patients receiving treatment for neck conditions most frequently perceive the symptoms they experience after manual therapy as AEs. Cervical SMT is often performed in patients with neck conditions and despite the rare frequency of these events and a lack of causal association between cervical SMT and serious AEs (such as stroke and vertebral artery dissection), they receive significant media attention [12, 22,23,24]. As such, it is possible that the media portrayal and focus on serious AEs following cervical SMT may influence patients’ perception related to AEs associated with cervical SMT. This is an interesting topic and further research investigating how media portrayals influence patients’ perceptions of AEs post-SMT should be conducted.
Previous studies have reported that about 50–60% of patients have benign AEs post-SMT, such as local discomfort and headache [8, 10, 11]. Our findings are in accordance with these reports, with 55% of the patients reported experiencing a benign AEs post-SMT, with soreness and headache being the most common symptoms. These numbers suggest that despite the benign nature of these AEs, their frequency is high and establishing strategies to mitigate them can have a positive impact on patients’ SMT experience, improving their quality of care.
Regarding mitigation strategies, most participating clinicians and patients report mitigation of benign AEs post-SMT is, or may be, possible (Fig. 3). This is encouraging as previous studies have investigated mitigation strategies in other health care areas with similar positive outcomes. For example, cold sprays and topical anesthetics have been observed to decrease pain of intravenous placement in adults and children, respectively [25, 26]. Additionally, phlebotomists ensuring that haemostasis had been attained before leaving the patient was found to significantly reduce the number and size of bruising after venepuncture . Although pain during intravenous catheter placement and bruising after venepuncture are not major AEs that significantly affect patients’ health, strategies to mitigate these symptoms have been investigated in order to improve patient’s experience and quality of service. In a similar way, investigations of strategies to mitigate benign AEs post-SMT should be conducted focusing on approaches identified by clinicians and patients.
Participating clinicians and patients who indicated having previously applied strategies to mitigate benign AEs post-SMT included soft tissue therapy, stretching, ice and heat. The use of these strategies was perceived to be successful by clinicians based on their own patients self-reported improvement, and by patients, based on their own experience (no benign AEs experienced or with reduced severity). Given no studies to date have investigated mitigation strategies for SMT, our data provides important preliminary information of potentially clinically relevant strategies that can be assessed in future investigations. More specifically, prospective investigations assessing the effectiveness of the mitigation strategies identified by clinicians and patients are currently being designed.
Both clinicians and patients perceived that education is the strategy most likely to mitigate benign AEs. Indeed, a previous study emphasized the importance of patient education regarding post-treatment responses and how this can contribute to patients’ perceptions of AEs following manual therapy . More specifically, patients have indicated the importance of receiving education regarding the potential AEs following treatment. Having an informed expectation about potential AEs reassured patients that what they may experience following treatment was acceptable [14, 27].
The discrepancy between the percentage of clinicians who reported previously trying a mitigation strategy and patients who believed their clinician tried a mitigation strategy may be an indication of a potential lack of communication. It is possible that clinicians may not communicate all their reasons for applying specific interventions to patients and while clinicians believe they tried a mitigation strategy, their patients were not aware of it. Due to the anonymous nature of the data, we were unable to directly link the discrete responses of clinicians to their patients and, therefore, cannot verify if clinicians who reported having tried mitigation strategies had their patients participating in this study. Enhancing the communication between patients and clinicians is believed to also enhance patient involvement and participation in monitoring their own health, potentially increasing patient-centered care approach . Future study may shed further light on the impact of communication as a mitigator.
Clinicians and patients also suggested that soft tissue therapy and massage after SMT could be used to mitigate benign AEs. Similarly, participating patients believed that stretching may also mitigate benign AEs. While our survey did not ask the rationale for participants’ responses, SMT is known to elicit muscle spindle activity , which may potentially contribute to benign AEs by influencing muscle contraction. Based on these responses, it is possible that clinicians and patients perceive soft tissue therapy or massage after SMT and stretching to minimize benign AEs potentially related to muscle spindle activation and its influence in muscular status. Participating clinicians also indicated that icing after SMT was likely to mitigate benign AEs. This is interesting considering patients did not share this belief. Icing or cryotherapy is often used for its anti-inflammatory and analgesic effects , thus it is possible that clinicians may perceive SMT creating an inflammatory response and minimizing this response with the use of ice. Further studies are warranted to clarify the underlying physiology of both benign AEs post-SMT and mitigation strategies.
Interestingly, specific mitigation strategies suggested to be applied before or after SMT changed the beliefs and perceptions of clinicians and patients related to their likelihood of being successful mitigators (Fig. 4). Previous studies have investigated the effect of the sequence of interventions in other health care fields, such as cardiac (heart rate and blood pressure) and training performance, and suggested that the order in which interventions are performed can influence the outcome [31,32,33]. Although no studies have investigated the effect of the sequence of interventions related to SMT, it is possible that, similarly to other health care fields, the order in which interventions and mitigators are performed can influence the frequency and/or severity of benign AEs post-SMT. This is an interesting topic and further prospective randomized studies will be conducted to determine the influence of mitigator sequence on benign AEs post-SMT.
Strengths and limitations
This study reflects the perceptions and beliefs of those responding clinicians and patients at two chiropractic teaching institutes, therefore results should be interpreted with caution. It is possible that only patients with specific views and opinions towards benign AEs following SMT and mitigation strategies agreed to participate in the study. Additionally, given that this study was conducted at chiropractic teaching clinics, participating patients were mostly being treated by interns, who have less clinical experience and were not included in this study. However, we included participating clinicians with a range of clinical experience, as well as patients presenting with differing SMT experience, thereby reporting a variety of different opinions. In so doing, our results may be representative of clinicians and patients being seen in clinical practice. Additionally, although most supervising clinicians also practice in a community-based setting, it is likely that clinicians responded to the survey based on both of their clinical experience (teaching and community-based setting). Nevertheless, future studies including community-based practitioners and their patients in this specific should be conducted to investigate potential differences in beliefs and perceptions.
As previously mentioned, our survey was developed and validated specifically for this initial investigation and to answer specific questions in an efficient manner. While successful in terms of response rate, the survey did not enquire about the participants’ rationale for their responses. Future qualitative studies should be conducted to further explore clinicians’ and patients’ beliefs and perceptions of AEs and potential mitigating strategies.
Lastly, it is important to emphasize that our study focused on beliefs and perceptions of both clinicians and patients regarding strategies to mitigate benign AEs. Prospective studies will be conducted to investigate the effectiveness of these strategies so that clinical recommendations to mitigate benign AEs post-SMT can be included in best practice guidelines.