Vascular proﬁling: Should manual therapists take blood pressure?
Alan J. Taylor
, Roger Kerry
University of Nottingham, Division of Physiotherapy, Clinical Sciences Building, City Hospital, Hucknall Road, Nottingham NG5 1PB, UK
Received 12 July 2012
Received in revised form
3 August 2012
Accepted 5 August 2012
Risk assessment of the cervical spine prior to manual therapy interventions is currently a contentious
topic, highlighted by recent suggestions in the medical press (http://www.bmj.com/content/344/bmj.
e3679), that manipulative therapy should be abandoned because of the perceived risk. This paper
addresses the issue of manual therapists using blood pressure measurement as an aid to clinical
reasoning and decision making.
The authors’use a case series of three neuromusculoskeletal presentations, which support the
contention that blood pressure recording can prove to be an appropriate objective test for assessment
prior to manual therapy interventions. Furthermore, it is suggested that blood pressure testing may
provide direction for risk assessment and/or the management of patients across all populations and age
groups as part of a holistic ’vascular proﬁling’approach to clinical reasoning and decision making.
Ó2012 Elsevier Ltd. All rights reserved.
1. Introduction and background
Hypertension is a recognised risk factor in both stroke and
cardiovascular disease and it has been suggested in some studies
that up to 30% of people may be entirely unaware of this so called
‘silent killer’(Stroke Association UK, 2011). This paper addresses
the issue of manual therapists measuring blood pressure (BP) as an
aid to clinical reasoning, risk assessment and ‘vascular proﬁling’.It
incorporates three relevant case studies.
With the United States ﬁrmly at the forefront of the obesity
epidemic (Sturm, 2007) the American Physical Therapy Association
produced a Guide to Physical Therapist Practice (2001) which made
the recommendation that patient examination should begin with
a history and systems review which includes “anatomical and
physiological status of the cardiovascular/pulmonary system
(emphasis added), integumentary, musculoskeletal and neuromus-
cular systems. .“. The guidance went on to say, “Heart rate and BP
are measured to assess aerobic function and circulation, these
measures can assist the physical therapist in identifying cardiovas-
cular or pulmonary problems that might affect prognosis and inter-
vention or require referral to another practitioner.”In an attempt to
assess compliance with these guidelines, Frese et al. (2002) surveyed
597 physical therapy clinicians in two participating universities and
found that 43% of respondents reported “never measuring BP”, with
only 4.4% suggesting that they “always”measure BP. The most
frequently chosen responsefor such decisions was “not important for
my patient population”. This raised the question of whether practi-
tioners were conversant with the evidence base relating to the
increasing prevalence of obesity related hypertension in children for
example (Feber and Ahmed, 2010). Alternatively, it questioned
whether they were aware of the relevance of hypertension to their
clinical reasoningwithin the neuromusculoskeletal (NMS) paradigm
and their patient population.
Stroke Association statistics suggest that an estimated 150,000
people have a stroke in the UK eachyear, with stroke accounting for
around 53,000 deaths each year (Stroke Association UK, 2011).
Furthermore, ischaemic heart disease and cerebrovascular disease
comprise two (together with cancer) of the three most common
causes of death in England and Wales. The inaugural signs of stroke
linked to cervical arterial dissection are commonly reported as neck
pain and head ache in the early stages (Arnold et al., 2011). These
are precisely the symptoms for which patients might seek, or are
referred to manual therapists. Adverse incidents related to manual
therapies have been well documented (Ernst, 2010) and most
commonly result in transient ischaemic events or stroke and less
commonly death. However, manual therapy clinical reasoning has
commonly focused on the vertebral artery and dissection in
particular (Thomas et al., 2011). This serves to constrain thought
and does not align with the wider medical literature.
Risk assessment of the cervical spine prior to manual therapy
interventions is currently a contentious topic, highlighted by recent
suggestions by Wand et al. (2012), that manipulative therapy
should be abandoned because of the perceived risk. The emergence
in the UK of ‘Advanced Practitioner’roles within Physiotherapy has
brought about an increasing awareness of the responsibility of such
*Corresponding author. Tel.: þ44 (0) 115 8231805; fax: þ44 (0) 115 9673005.
E-mail address: email@example.com (A.J. Taylor).
Contents lists available at SciVerse ScienceDirect
journal homepage: www.elsevier.com/math
1356-689X/$ esee front matter Ó2012 Elsevier Ltd. All rights reserved.
Manual Therapy 18 (2013) 351e353
ﬁrst line practitioners as key decision makers in health care. The
Health Professions Council (HPC), UK Standards of proﬁciency 2b.4
states that registrant physiotherapists should “be able to conduct
appropriate diagnostic or monitoring procedures, treatment,
therapy or other actions safely and skilfully”(HPC standards of
Proﬁciency, 2007). The attainment of this standard clearly
requires sound clinical reasoning skills combined with an intimate
knowledge of vascular pattern recognition. This point is highlighted
in the new ‘International Federation of Orthopaedic Manipulative
Physical Therapists’standard for screening of the cervical spine
(Carlesso et al., 2012)
Manual therapies for the cervico-thoracic spine incorporate
a range of passive movement techniques ranging from soft tissue
stretching techniques through to joint mobilisation and manipu-
lation. Randomised controlled trials and systematic reviews have
shown that manual therapy techniques can beneﬁtneckpain
(Gross et al., 2004,2010). From a risk perspective, much attention
has traditionally been given to the vertebral artery (VA) and
vertebral artery testing (Schi evink et al., 1993) despite the fact that
internal carotid artery (ICA) dissections are reported to occur 3e5
times more frequently than VA dissections. Epidemiological
studies suggest that the reported incidence for ICA dissection is
2.6e2.9 per 100,000 (Schievink et al., 1993), whilst for the VA it is
1e1.5 per 100,000 (Schievink, 2001). Furthermore, recent pub-
lished literature (Taylor and Kerry, 2010) has suggested that
asystems based approach should be used, incorporating knowl-
edge of the potential failings of the circulatory system, which may
reveal adverse arterial events. Such an approach incorporates
consideration of the carotid and vertebrobasilar vascularity as
a whole and encourages a consideration of the ‘vascular proﬁle’of
When considering the cranioecervicoethoracic complex, there
are a number of scenarios which may present to manual therapists
which require consideration of the vascular system. This paper will
cover a detailed exploration of three cases, including the use of
blood pressure measurement as recommended in a recent follow-
up paper by Frese et al (2011) entitled ‘blood pressure guidelines for
2. Case study 1
A 56 year old female allied health professional attended
a physiotherapy department following a road trafﬁc accident three
weeks earlier. She complained of on-going cervical, bi-lateral tra-
pezious/scapular pain (4e6/10 visual analogue score) and a feeling
of anxiety (she described herself as a “ticking time bomb waiting to
go off”). Observation revealed muscle spasm with torticollis (right
side ﬂexion/left rotation) and a prominent pulsatile left carotid
artery; she appeared to have a facial asymmetry and had reported
difﬁculty swallowing and occasional gagging when eating. Based
on the subjective history which included cardio-vascular risk
factors (hypertension, hyperlipidaemia, family history of cardio-
vascular disease) and the observed ﬁndings, initial examination
involved BP measurement (in the physiotherapy clinic.) BP was
recorded at systolic 210 and diastolic 130 (210/130); this was
repeated on the same arm and on the opposite arm. The lowest
recorded BP over ﬁve assessments was 206/122. The patient was
referred to accident and emergency where a carotid ultra-sound
scan revealed an “abnormally tortuous”left carotid artery with
mild vessel wall thickening (atherosclerosis) but no evidence of
arterial dissection or aneurysm. She was medically treated by her
physician for her known hypertension and referred back to phys-
iotherapy, where she was treated with low risk techniques (i.e.
avoiding techniques which may mechanically compromise the
vascular system) and made a full recovery.
3. Case study 2
A 32 year old male professional musician (guitarist and singer)
had been treated with manual therapy (Chiropractic) for his
thoracic/chest pain and ‘low energy levels’with little or no
improvement over three months. He initially presented com-
plaining of a one year history of mild (2e3/10) thoracic and anterior
chest pain with occasional left arm symptoms (paraesthesia). He
had none of the classical vascular risk factors but had suffered
a brain aneurysm aged 11 years which required emergency surgery
from which he made a full recovery. More recently the initial
symptoms had been associated with increasing left arm paraes-
thesia/discomfort, fatigue, episodes of near syncope (feeling faint)
and breathlessness when playing Frisbee (i.e. exertion). He re-
visited his general practitioner (GP) at the behest of his Chiro-
practor who had noted latterly that his BP readings were abnor-
mally low. Initial examination by the physician involved a simple BP
examination revealing an abnormally low reading of 94/62;
auscultation revealed abnormal heart sounds. The patient was
referred to a cardiologist who undertook further tests and diag-
nosed aortic valve stenosis. The patient was listed for urgent open
heart surgery three days later, involving aortic valve replacement.
The patient made a full recovery and returned to performing after
three months. His thoracic and arm symptoms were fully resolved
following the surgery.
4. Case study 3
A 72 year old woman with conﬁrmed cervical spondylosis was
referred for physiotherapy for persistent neck pain (4e6/10 VAS).
She was also under the care of the vascular department for exercise
induced ischaemic leg pain related to atherosclerosis and was on
medication for hypertension and hyperlipidaemia. Physiotherapy
treatment involving longitudinal manual traction seemed to give
temporary relief (at the time). However, she reported increased
pain following treatment, together with symptoms of feeling
unwell (dizzy/faint/agitated) for a period of 24 h. This response was
described (in the notes) as ‘treatment soreness’and manual therapy
was continued. A similar response followed over the next three
treatment sessions, with only minor improvements in neck pain.
When she reported her experience to the vascular surgeon on
a routine check-up, he examined her BP which was recorded as 155/
95 and auscultated her carotid arteries (revealing an abnormal
bruit). Duplex ultra-sound of her carotid arteries revealed advanced
stenosis due to atherosclerosis and she was listed for urgent carotid
endarterectomy. She made a complete recovery and incidentally
reported that her neck pain had reduced to 1e2/10. The surgeon
suggested based on the history and operative ﬁndings, that she had
been reporting “manual therapy induced transient ischaemic
attacks (TIA)”. She was able to self-manage her residual neck pain
and reported no further episodes of TIA.
5. Clinical reasoning and implications
The above case studies illustrate how manual therapists may use
vascular pattern recognition to assess risk and consider BP as
a clinical test to guide assessment and management. The ﬁrst case
was a patient with obvious cardio-vascular risk factors. In addition,
clinical observation revealed that she may have been presenting
with at worst stroke/TIA or at best cranial nerve (V and VIIeXII)
involvement. The observed facial asymmetry and prominent
carotid artery were indicative of possible ischaemia, with potential
underlying aneurysm or dissection. This required a different
approach to assessment. With the initial test revealing a danger-
ously high BP, it was felt that further examination of neurological
A.J. Taylor, R. Kerry / Manual Therapy 18 (2013) 351e353352
status should be performed in a safe environment and she was
referred immediately to accident and emergency. Standard manual
therapy examination in this case (i.e. active/passive range of motion
etc.) was not appropriate and may have constituted risk to the
patient. Interestingly, following further investigations (Duplex
ultra-sound) and stabilisation of her BP she was able to be assessed
conventionally and treated successfully without incident.
Case two illustrates a young apparently ﬁt active male with no
known risk factors (excepting the brain aneurysm aged 11), who
presented with NMS symptoms which were actually the early
presentation of an unusual but life threatening cardiac condition.
This was revealed eventually by the detection of an abnormally
low BP taken in the clinic. In this case further manual therapy
was entirely inappropriate. The increasing feeling of near
syncope may have been a manifestation of brain ischaemia at
a time of effort (i.e. running during Frisbee or performing
onstage) which has been proposed within the vascular literature
(Spirito et al., 2009). The operating surgeon concurred, suggest-
ing that “sudden death could have occurred in this patient at any
Case three was a patient with frank neurological signs due to
brain ischaemia e.g. transient ischaemic events (short term
ischaemia), memory loss and disequilibrium. This together with her
history of conﬁrmed lower limb atherosclerosis and medications
for known hypertension/hyperlipidaemia, made her a likely
candidate for more widespread vascular pathology. Carotid or
vertebrobasilar artery disease should be considered as a potential
underlying pathology in patients with such a proﬁle. As such,
logically, manual therapists should consider blood pressure as an
appropriate examination technique.
6. Conclusion and recommendations
The authors present three NMS cases which support the
contention that BP recording is an appropriate objective test for
manual therapists prior to conventional assessment or interven-
tion. The results of BP testing may provide direction for risk
assessment and/or the management of patients across populations.
Vascular proﬁling may enhance the risk assessment and clinical
reasoning process for manual therapists who treat NMS cases.
Manual therapy clinicians should incorporate consideration of the
vascular system and its related pathologies as a whole, rather than
any one component part.
Arnold M, Fischer U, Bousser MG. Treatment issues in spontaneous cervicocephalic
artery dissections. International Journal of Stroke 2011;6(3):213e8.
Carlesso L, Flyn T, Hing W, Rivett D, Rushton A. Cervical arterial dysfunction. Paper
presented at International Federation of Orthopaedic Manipulative Physical
Therapists Conference. Quebec; 2012 Sept 30theOct 5th.
Ernst E. Deaths after chiropractic: a review of published cases. International Journal
of Clinical Practice 2010;64(8):1162e5.
Feber J, Ahmed M. Hypertension in children: new trends and challenges. Clinical
Science (London) 2010;119(4):151e61.
Frese EM, Richter RR, Burlis TV. Self-reported measurement of heart rate and blood
pressure in patients by physical therapy clinical instructors. Physical Therapy
Frese EM, Fick A, Sadowsky HS. Blood pressure measurement guidelines for physical
therapists. Cardiopulmonary Physical Therapy Journal 2011;22(2):5e12.
Gross AR, Hoving JL, Haines TA, Goldsmith CH, Kay T, Aker P, et al, Cervical Overview
G. A Cochrane review of manipulation and mobilization for mechanical neck
disorders. Spine 2004;29(14):1541e8.
Gross A, Miller J, D’Sylva J, Burnie SJ, Goldsmith CH, Graham N, et al. Cog. Manip-
ulation or mobilisation for neck pain: a cochrane review. Manual Therapy 2010;
Guide to physical therapy practice. 2nd ed. Alexandria, Va: American Physical
Therapy Association; 2001. p. 28.
HPC Standards of Proﬁciency for registrant Physiotherapists (online) available at:
Schievink WI. Current concepts: spontaneous dissection of the carotid and vertebral
arteries. New England Journal of Medicine 2001;344(12):898e906.
Schievink WI, Mokri B, Whisnant JP. Internal carotid-artery dissection in
a community eRochester, Min nesota, 1987e1992. Stroke 1993;24(11):
Spirito P, Autore C, Rapezzi C, Bernabo P, Badagliacca R, Maron MS, et al. Syncope
and risk of sudden death in hypertrophic cardiomyopathy. Circulation 2009;
Sturm R. Increases in morbid obesity in the USA: 2000e2005. Public Health 2007;
Taylor A, Kerry R. A ’system based’approach to risk assessment of the cervical spine
prior to manual therapy. International Journal of Osteopathic Medicine 2010.
The Stroke Association UK. Millions at risk from ‘Silent killer’(online) available at:
Thomas LC, Rivett DA, Attia JR, Parsons M, Levi C. Risk factors and clinical features of
craniocervical arterial dissection. Manual Therapy 2011;16(4):351e6.
Wand BM, Heine PJ, O’Connell N. Should we abandon cervical spine manipulation
for mechanical neck pain? British Medical Journal 2012;344:e3679. http://dx.
doi.org/10.1136/bmj.e3679 (Published 7 June 2012).
A.J. Taylor, R. Kerry / Manual Therapy 18 (2013) 351e353 353