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A ‘system based’ approach to risk assessment of the cervical spine prior to manual therapy


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This paper presents a clinical overview and update of cervical arterial dysfunction (CAD) for osteopaths and other clinicians who treat patients presenting with cervical pain and headache syndromes. An overview of a ‘system based’ approach to the concept of vertebrobasilar arterial insufficiency (VBI) is covered, with reference to assessment procedures recommended by commonly used guidelines. We suggest that the evidence supporting contemporary practice remains limited and present a more holistic approach to considering cervical arterial dysfunction. This ‘system based’ approach considers typical pain patterns and clinical progressions of both vertebrobasilar, and internal carotid arterial pathologies. Attention to the risk factors, pathomechanics and haemodynamics of arterial dysfunction is also given. We suggest that consideration of the information provided in this updated ‘Masterclass’ will enhance clinical reasoning with regard to differential diagnosis of cervical pain syndromes and prediction of serious adverse reactions to treatment.
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Asystem basedapproach to risk assessment of the cervical spine prior to
manual therapy
Alan J. Taylor
, Roger Kerry
Division of Physiotherapy Education, University of Nottingham, Hucknall Road, Nottingham, NG5 1PB, UK
article info
Article history:
Received 8 April 2010
Accepted 26 May 2010
Manual therapy
Cervical spine
Physical therapy
Vertebrobasilar insufciency
Carotid arteries
This paper presents a clinical overview and update of cervical arterial dysfunction (CAD) for osteopaths
and other clinicians who treat patients presenting with cervical pain and headache syndromes. An
overview of a system basedapproach to the concept of vertebrobasilar arterial insufciency (VBI) is
covered, with reference to assessment procedures recommended by commonly used guidelines. We
suggest that the evidence supporting contemporary practice remains limited and present a more holistic
approach to considering cervical arterial dysfunction. This system basedapproach considers typical pain
patterns and clinical progressions of both vertebrobasilar, and internal carotid arterial pathologies.
Attention to the risk factors, pathomechanics and haemodynamics of arterial dysfunction is also given.
We suggest that consideration of the information provided in this updated Masterclasswill enhance
clinical reasoning with regard to differential diagnosis of cervical pain syndromes and prediction of
serious adverse reactions to treatment.
Ó2010 Elsevier Ltd. All rights reserved.
1. Introduction
This paper provides an updated overview of current thought;
practice and research in the eld of cervical arterial dysfunction and
pre-treatment risk assessment and builds on a previous Master-
classpublished in Manual Therapy,
in the light of new emerging
research. Guidelines for screening patients for the risk of neuro-
vascular complication post-manual therapy have been available for
clinical use for a number of years.
However,several authors have
recently questioned the utility of such guidelines.
authors suggest that current practice based on available guidelines
and information may be limited by a number of factors including:
validity and reliability of the guidelines;
validity and reliability of
physical tests used for pre-treatment screening;
associated with clinical decision making;
uncertainty of risks of
treatment, an unsubstantiated knowledge base, a questionable
evidence base to guidelines, and discomfort among the profession
regarding medico-legal issues.
The main aim of this paper is to provide a framework for manual
therapists to broaden their clinical approach to the understanding
and assessment of cervical arterial dysfunction. A more holistic
approach can be achieved by considering recent advances in the
evidence base, together with a change in thinking with regard to
movement, and the resulting haemodynamics of the cervical spine.
The paper is divided into two linked clinical summaries;
1) Vertebrobasilar arterial system (posterior system).
2) Internal carotid arteries (anterior system).
Risk factors and mechanisms of CAD are then presented, fol-
lowed by an indication of possible directions for future approaches
to clinical assessment.
2. Vertebrobasilar arterial system
Both traditional and contemporary thinking in manual therapy
has been concerned with blood ow problems related to the ver-
tebrobasilar arterial (VBA) system. The term vertebrobasilar
insufciency(VBI) is a familiar term with all therapists and
attempts have been made throughout the years to nd the best way
to identify patients with posterior circulation ischemia (e.g.
A brief review of the posterior vascular anatomy will help appre-
ciate what is meant by the term VBI.
*Corresponding author. Tel.: þ44 115 8231805; fax: þ44 115 8231791.
E-mail address: (A.J. Taylor).
Contents lists available at ScienceDirect
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International Journal of Osteopathic Medicine xxx (2010) 1e9
Please cite this article in press as: Taylor AJ, Kerry R, A system basedapproach to risk assessment of the cervical spine prior to manual therapy,
Int J Osteopath Med (2010), doi:10.1016/j.ijosm.2010.05.001
2.1. The vertebrobasilar arterial system and vertebrobasilar
The VBA system provides blood ow to the hind-brain (i.e.
brain-stem, Medulla Oblongata, Pons, Cerebellum, and Vestibular
apparatus). The left and right vertebral arteries arise from the
subclavian arteries and pass through the transverse foramina of
cervical vertebral levels 6 to 1 esee Fig. 1. When they exit the atlas,
the vessels make a sharp postero-medial turn to pass along the
posterior mass of the atlas. They then enter the skull through the
foramen magnum of the occiput. The vessels are tetheredat
various points along this route: namely C2 transverse foramina, C1
transverse foramina, and at the atlanto-occiptal membrane. It is
this tethering, combined with the convoluted route of the vessels
around C2/C1 and the occiput, that have been a cause of concern for
therapists. Considering this anatomy of the upper cervical spine it is
easy to appreciate how, during rotation, the contralateral vessel
may be stretched therefore potentially affecting ow (Fig. 2). This is
the basis for the VBI Teststhat have commonly been advocated for
VBI screening.
Once inside the skull, the two vertebral arteries join each other
to form the basilar artery, which in turn feeds into the circle of
Willis. When there is a reduction of blood supply to specic parts of
the hind-brain, certain signs and symptoms are displayed. This is
what can be referred to as VBI.
2.1.1. Vertebrobasilar insufciency esigns and symptoms
Classically, the signs and symptoms related to hind-brain
ischemia are considered as the 5Dsand3Nsof Coman.
signs and symptoms are presented in Table 1 (together with a ninth
classicsign eataxia), along with the associated neuro-anatomical
site of insult.
Unreasoned adherence to these cardinal classicsigns and
symptoms can, however, be misleading and result in an incomplete
understanding of patient presentations. A closer look at contem-
porary evidence from the medical, opthalmic and neurological
literature shows that the typical presentation of vertebrobasilar
dysfunction is not always in line with this classical picture. The
haemodynamic presentations of VBI can be better understood if the
symptomology is divided into non-ischemic (i.e. local, somatic
causes) and ischemic (i.e. symptoms of hind-brain ischemia)
manifestations (see Table 2).
VBI may be a result of arterial dissection. This is a tearing of the
intimal wall which may lead to severe stenotic lesions or emboli-
sation this process has been well documented by a number of recent
The non-ischemic presentation of vertebral dissection is
typically ipsilateral posterior neck pain and/or occipital headache
alone eFigure 3 (e.g.
) Very rarely cervical root impairment
(usually C5/6) can be present as a result of local neural ischemia.
These clinical features may then be followed by the ischemic
events associated with vertebrobasilar dysfunction. These may also
include some of the classic 5Ds and 3Ns as stated above, but mayalso
include many other symptoms (see Table 2).
It is rare for
posterior dysfunction to manifest in only one sign or symptom, and
isolated dizziness or transient loss of consciousness are often mis-
attributed to posterior circulation ischemia.
Dizziness is often reported as being one of the most common
symptoms of VBI.
However, there have been cases reported when
dizziness has not been present. The nature of dizziness can be
a differentiating factor in establishing a vascular versus non-
vascular cause. Typically, posterior circulation dizziness does not
present as frank vertigo, although some authors have suggested
this could occur (e.g. Savitz et al.
) Vascular dizziness occurs as an
effect of neck rotation, and does not improve with continued
Fig. 1. Course of the vertebral and internal carotid arteries through the cervical spine. (adapted with permission from Elsevier Ltd, Drake et al. Grays Anatomy for Students, www.
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movement. This pattern differs from non-vascular vestibular
dizziness (see below) which often has a short latency to it, and can
improve with repeated movement.
2.2. VBI testing
2.2.1. Functional positioning tests
Functional positional tests of the cervical spine have been
traditionally used by manual therapists to identify the presence of
The purpose of establishing whether a patient has VBI is of
obvious great importance to health professionals to whom a patient
has sought help for their cervical pain. The reason for undertaking
these tests is based on the principle that some treatment inter-
ventions commonly used to help patients with neck pain hold
inherent risks if applied in the presence of VBI. It would seem,
therefore, to be necessary to identify whether or not VBI was
present. The primary risk associated with VBI (i.e. the longer term
sequale of these transient events) is one of neurovascular accident
(i.e. stroke) as a result of further insult to an already compromised
(insufcient) blood supply to the brain.
Functional positioning tests are based on the principle of
compromising ow in the vertebral arteries by passively sustaining
the cervical spine in a particular position. Positions can include
extension, combined extension and rotation, a pre-manipulation
position, or most commonly, rotation alone. The APA pre-manipula-
tive guidelines suggesta 10 s sustained hold of rotation as a minimum
requirement to establish whether or not VBI is present
eFig. 4.The
purpose of these tests is to monitor for reproduction of symptoms
associated with VBI during the sustained hold. Reproduction of
symptoms during the test is classed as a positive test result and
contraindicates certain treatment interventions.
The underlying mechanical principle of these tests has been the
subject of a number of research reports focusing on the clinical
question of does rotation of the neck affect blood ow?Many
blood ow studies have demonstrated a reduction in blood ow in
the contralateral vertebral artery during rotation
) Most of this work has been undertaken on
asymptomatic subjects. Some authors have used these studies to
support the validity of the VBItest; in other words these studies
demonstrate that rotation changes blood ow, therefore the test is
valid. The test however, is for VBI and that is seldom if ever
Fig. 2. Vertebral and Internal Carotid arteries during upper cervical rotation (Reprinted with the permission of NCMIC Group, Inc. No further reproduction is allowed without the
express permission of NCMIC).
Table 1
Classic signs and symptoms of vertebrobasilar insufciency (VBI) with associated neuroanatomy.See text for the limitations of only considering these features for potential VBI.
Sign or Symptom Associated Neuroanatomy
Dizziness (vertigo, giddiness, lightheadedness) Lower vestibular nuclei (vestibular ganglion ¼nuclei of CN VIII vestibular branch)
Drop attacks (loss of consciousness) Reticular formation of midbrain
Rostral Pons
Diplopia (amaurosis fugax; corneal reux) Descending spinal tract, descending sympathetic tracts (Horners syndrome); CN V nucleus (trigeminal ganglion)
Dysarthria (speech difculties) CN XII nucleus (Medulla, trigeminal gangion)
Dysphagia (þhoarseness/hiccups) Nucleus ambiguous of CN IX and X, Medulla
Ataxia Inferior cerebellar peduncle
Nausea Lower vestibular nuclei
Numbness (unilateral) Ipsilateral face: descending spinal tract and CN V
Contralateral body: ascending spinothalamic tract
Nystagmus Lower vestibular nuclei þvarious other sites depending on type of nystagmus (at least 20 types)
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reproduced during such blood ow studies e.g. a patient could have
signicant reduction in blood ow, but no VBIsymptoms and vice
versa. This makes the specicity and sensitivity of these tests poor
and variable, and this has been mathematically demonstrated in
diagnostic utility calculations.
In a recent meta-analysis
VA blood ow velocity changes associated with cervical spine
rotation. The author suggested that VA ow was found to be more
compromised in patients than healthy individuals during contra-
lateral rotation and more commonly in the intra-cranial portion of
the artery during a sitting rotational test. VBIsymptoms were not
reported by the subjects within the analysis, despite the signicant
changes in ow which were demonstrated.
2.2.2. Limitations of VBI and differentiation testing
On the basis of the inconsistency of the evidence, there have
been recent propositions regarding cessation of the use of func-
tional pre-screening tests.
Despite some of the above
mentioned tests being advocated in published guidelines for the
assessment of VBI, and other tests being often quoted in textbooks
(e.g. Hautants test etc. in
) it is essential that the clinician is aware
of the limitations of using information gained from these tests in
their diagnostic, clinical decision making. As stated above, the
functional positional tests have poor diagnostic utility i.e. a positive
test response does not necessarily mean that the condition (VBI)
exists, and a negative test response does not necessarily mean the
condition does not exist. This phenomenon has been highlighted in
a number of case reports and studies which have documented
either patients having adverse neurovascular effects in the absence
of a positive test (i.e. false-negative
) or no identiable vascular
dysfunction despite a positive test result (i.e. false-positive
With these limitations in mind, it is necessary to explore other
possible approaches to the assessment of cervical arterial
dysfunction. Below is a brief overview of the anterior cervical
arterial system (the internal carotid artery) which appears to be
a neglected source of diagnostic information within manual
therapy literature and education.
3. The internal carotid arteries
Due to its perceived anatomical vulnerability, the posterior
cervical arterial system has traditionally been the focus of attention
for manual therapists. In order to enhance clinical reasoning and
facilitate diagnostic decisions and judgments, it is necessary to
consider an approach which incorporates the anterior cervical
arterial system; i.e. the internal carotid arteries (ICA). Knowledge of
the ICA is important for manual therapists because;
1. The ICAs provide the most signicant proportion of blood to
the brain.
2. Pathological changes of the ICA are very common.
3. Blood ow in the ICA is known to be inuenced by movement
of the neck.
3.1. The internal carotid arteries and related pathologies
The ICAs carry for the majority of blood ow to the brain e
around 80% ecompared to 20% through the posterior system. It is
primarily increased ow through the ICA which helps maintain
brain perfusion in the presence of reduced ow through the
Fig. 3. Typical pain distribution relating to extra-cranial vertebral artery dissection e
ipsilateral posterior upper cervical pain and occipital headache.
Fig. 4. Functional positional testing of the vertebral artery (rotation). The patients
head is passively rotated and held for 10 s. Reproduction of symptoms associated with
vertebrobasilar insufciency result in a positive test.
Table 2
Presentations of vertebral artery dissection. Non-ischemic symptoms can precede ischemic events by a few days to several weeks.
Non-ischemic (local) signs and symptoms Ischemic signs/symptoms
Ipsilateral posterior neck pain/Occipital headache
C5/6 cervical root impairment (rare)
Hind-brain TIA (dizziness, diplopia, dysarthria, dysphagia, drop attacks, nausea, nystagmus,
facial numbness, ataxia, vomiting, hoarseness, loss of short-term memory, vagueness, hypotonia/limb
weakness (arm or leg), anhidrosis (lack of facial sweating), hearing disturbances, malaise, perioral dysthesia,
photophobia, papillary changes, clumsiness and agitation)
Hind-brain stroke (e.g. Wallenbergs syndrome, Locked-In syndrome)
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vertebral arteries. The ICA arise from around the C3 level of the
cervical spine where they bifurcate (with the External Carotid
Artery) from the Common Carotid Artery (see Figs. 1 and 2). The
course of the ICA takes them through a number of contractile
structures such as the sternocleidomastoid, longus capitis, stylo-
hyoid, omohyoid, and diagastric muscles. In the upper cervical
spine, they pass by the anterior body of C1, to which they are
tethered. The ICA enters the skull through the carotid canal in the
pertous temporal bone, where it continues intra-cranially to join
the Circle of Willis. Extra-cranially, the ow through the ICA is
inuenced by movement of the cervical spine eprimarily exten-
sion, and less so, rotation.
3.2. Internal carotid artery (anterior) dissection
The ICA supplies the brain and the retina. The natural onset and
progress of ICA dissection begins with local arterial trauma (the
dissection event itself). This dissection event can manifest in
a number of signs and symptoms which, like early vertebral artery
dissection, are non-ischemic (i.e. somatic pain related to local
injury). These local signs and symptoms can precede cerebral
ischemia (TIA or stroke) or retinal ischemia by anything from less
than a week, to beyond 30 days.
There is, therefore, a period of
time when a patient with ICA dissection may present to the manual
therapist with signs and symptoms which may mimic a neuro-
muscluloskeletal presentation.
Table 3 shows the classic ICA non-
ischemic and ischemic manifestations of ICA dissection.
ĆĆIt is important to appreciate that most commonly, particularly
in the early stages of the pathology, headache and/or cervical pain
can be the sole presentations of internal carotid artery dysfunc-
Fig. 5 shows a typical pain distribution associated with
dissection of the ICA. The fronto-temporal headaches are often
described as cluster-like, thunder-clap, migraine without aura,
hemicrania continua, or simply different from previous head-
The upper cervical or antero-lateral neck pain,
facial pain and/or facial sensitivity are described in medical litera-
ture as carotidynia.
The local pain mechanisms involved with the internal carotid
artery are likely to be related to either deformation of nerve-endings
in the tunica-adventita, or direct compression on local somatic
Specically, the terminal nerve-endings in the carotid
wall are supplied by the trigeminal nerve, which accounts for
instances of facial pain and carotidynia. Stimulation of the trigemi-
novascular system may account for this carotid induced pain.
Cranial nerve palsies and Horners syndrome are phenomena
which are often indicative of internal carotid artery pathology,
especially if the onset is acute. The hypoglossal nerve is the most
commonly affected followed by the glossopharangeal, vagus, or
However, all cranial nerves (except the olfactory
nerve) can be affected.
If the dissection extends into the
cavernous sinus, the occulomotor, trochlear, or abducens can be
The two most likely mechanisms for these cranial nerve
palsies are;
1. Ischemia to the nerve via the vasa nervorum (comparable to
peripheral neurodynamic theory).
2. Direct compression of the nerve axon by the enlarged
Identication of the early stages of ICA dissection may be facil-
itated by testing the cranial nerves and observing the eyes. Cranial
nerve and eye examination should therefore be an integral and
important component of manual therapistsassessment proce-
dures. Previous authors have also highlighted the importance of
neurological examination with regard to cervical arterial
Horners syndrome has been found to be present in up to 82% of
patients with known internal carotid dissection.
Most commonly,
this syndrome occurs with head, neck, or facial pain. Carotid
induced Horners syndrome manifests as a drooping eyelid (ptosis),
sunken eye (enophthalmia), a small, constricted pupil (miosis), and
facial dryness (anhidrosis). The syndrome is the result of inter-
ruption to the sympathetic nerve bres supplying the eye. In the
case of carotid Horners syndrome, the pathology is classed as post-
ganglionic. The superior cervical sympathetic ganglion lies in the
posterior wall of the carotid sheath, and the post-ganglionic bres
follow the course of the carotid artery before making their way
deep towards the eye through the cavernous sinus. Compression or
ischemia as a result of internal carotid dysfunction will occur at the
ganglion or distal to it.
In addition to the above early signs, it is important for the
manual therapist to be aware of signs and symptoms related to
cerebral, and retinal ischemia. It is unlikely that a patient with full
stage cerebral ischemic stroke will present to the manual therapist,
but the more subtle presentation of retinal ischemia might, which
makes simple eye examination a key part of assessment. The
internal carotid artery supplies (via the ophthalmic artery) the
retina, and emboli from the ICA can result in retinal ischemic
dysfunction. Symptoms include a painless episodic loss of vision, or
blackout (amauris fugax), and localized/patchy blurring of vision
Table 3
Clinical features of ICA dissection. Non-ischemic signs and symptoms may precede
cerebral/retinal ischemia by anything from a few days to over a month.
Non-ischemic (local)
Ischemic (cerebral or retinal)
Horners syndrome,
Pulsatile tinnitus
Cranial nerve palsies
(most commonly CN IX to XII)
Transient Ischemic Attack (TIA)
Ischemic stroke (usually Middle
Cerebral Artery territory)
Retinal infarction
Amaurosis fugax
Less common local signs and symptoms include:
Ipsilateral carotid bruit,
Scalp tenderness,
Neck swelling,
CN VI palsy,
Orbital pain, and
Anhidrosis (facial dryness)
Fig. 5. Typical pain distribution relating to dissection of Internal Carotid Artery e
ipsilateral front-temporal headache, and upper/mid cervical pain.
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(scintillating scotomas). Orbital ischemia syndrome, as a result of
ophthalmic artery occlusion, presents as weakness of the ocular
muscles (ophthalmoparesis); protrusion of the eye due to weakness
of extrinsic eye muscles (proptosis); swelling of the eye or
conjunctiva (chemosis).
4. Aetiology of cervico-cranial arterial dysfunction
Whilst the exact mechanism of arterial dissection remains
unexplained, vertebral and internal carotid artery disease and
dysfunction are intrinsically associated with two inter-related
1) Underlying pathology (including atherosclerosis) which may
predispose a vessel to dissection.
2) Mechanical forces generated as a result of movement or
biomechanics, which results in altered haemodynamics.
Both of the above may be linked to trauma to the blood vessels.
Atherosclerosis is an inammatory process associated with
a number of factors including
diabetes mellitus
genetic clotting disorders
free radicals
direct vessel trauma
iatrogenic causes (surgery, medical interventions).
It is important for the clinician to appreciate that hypertension
(indicated by measurement of blood pressure) is positively related
to disease and dysfunction of the carotid arteries.
Consequently, this may indicate that recognition of hypertension
by the clinician could be important when assessing the likelihood
of potential cervico-cranial neurovascular dysfunction.
4.1. Mechanisms of cervico-cranial dysfunction
Important mechanisms in the pathogenesis of localized vascular
pathology for clinicians to consider are;
I) Spontaneous arterial dissection is known to occur in certain
individuals and is often related to innocuous day to day
movements such as turning to reverse the car or visiting the
The pathogenesis of such events remains
unknown but is considered by some to be due to inherent
vessel wall weakness linked to connective tissue
II) Intimal trauma (intimal dissection/injury) is known to occur
as a result of blood ow changes and/or vessel wall pathology
due to frank trauma, i.e. extreme neck movement, sustained
neck movement, or repeated neck movement (e.g. whiplash
injury, domestic violence, sport, medical interventions, intu-
bation, manual therapies etc.
III) Localised endothelial inammatory events (i.e. atheroscle-
linked to abnormal ow in vessels due to biome-
chanical factors such as kinking/looping or localized
obstructions (e.g. 1st rib and subclavian artery).
IV) Endothelial inammatory disease ee.g. temporal arteritis.
Giant cell arteritis of the Temporal Artery (extra-cranial
branch of the External Carotid Artery) can present as unilat-
eral headache and/or temple soreness, sore neck, and jaw
soreness. The medium-term sequalae of this disease is
potential blindness as a result of ischemia to the optic nerve,
thus making early recognition critical.
Temporal arteritis
has also been associated with ICA and VBA disease.
V) Upper cervical instability has been associated with localized
atherosclerotic changes in the cervical vessels.
mechanism of injury is possibly associated with repetitive
micro-trauma to the VA and ICA secondary to increased upper
cervical vertebral movement and/or the presence of connec-
tive tissue inammatory disease. Consideration should be
given to patients with known rheumatoid arthritis and acute
whiplash injury.
5. Directions for the future
It is becoming progressively clear that the current manual
therapy knowledge base does not equip therapists with the infor-
mation required to make valid risk assessment prior to treatment.
The alert clinician requires not only the vast neuromusculoskeletal
knowledge base but also integration of the basic functional
anatomy of the arterial system. Knowledge of haemodynamic
principles, pathophysiology, risk factors of arterial dysfunction and
above all an awareness of classical vascular clinical presentations is
The integration of such knowledge will allow the manual ther-
apist to make the best informed decisions when assessing and
treating patients presenting with head and neck symptoms. It is
important for the clinician to understand that headache/neck pain
may be the early presentation of an underlying vascular pathology.
The task for the therapist is to differentiate the symptoms by:
1. Having a high index of suspicion
2. Testing the vascular hypothesis
This should take place at an early point in the assessment
process ei.e. soon into the history taking. The symptomology and
history of patients suffering vascular pathology is what may reveal
the alert clinician to an underlying problem.
Reliance solely on objective clinical tests i.e. so called vertebral
artery testswhich have poor validity and reliability,
should be
As movement of the neck, particularly rotation and extension
movements, can be a potential risk factor for vascular events in
itself, identication of patients with other pre-existing vascular risk
factors (especially hypertension) should also be of great importance
to the therapist before manual therapy interventions are under-
taken. Careful monitoring of patientssigns and symptoms after
treatment is also necessary, especially acute post-treatment onset
of localized upper cervical pain, or headache, which is worsening.
Furthermore, where post-treatment pain or treatment sorenessis
encountered (i.e. an apparent response to joint or soft tissue
techniques), the therapist should consider carefully whether there
has been a vascular or haemodynamic response to treatment. For
example, a recent survey of Irish manipulative therapists
a range of reported adverse events (26% of clinicians reported an
adverse event in the 2 years studied) including drop attacks and
transient ischemic attack, both of which occurred during non high
velocity thrust techniques. Numerous reports suggest that such
presentations may be the manifestation of a traumatically (treat-
ment) induced arterial trauma or dissection.
A high index of suspicion of cervical vascular involvement is
required in cases of acute onset neck/head pain described as unlike
any other. Observation and conservative treatment may well be
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Int J Osteopath Med (2010), doi:10.1016/j.ijosm.2010.05.001
advised in such cases in the early stages of treatment, unless frank
arterial injury is suspected (especially in the presence of posterior
circulation ischemia). In this case, the appropriate action is triage to
an emergency or suitable diagnostic centre as a matter of urgency,
particularly in the case of a deteriorating patient. Vascular testing
such as Duplex ultrasound, magnetic resonance arteriography and
computerized tomographic angiography are increasingly sophisti-
cated methods of vascular diagnosis with increasing reliability. The
key maxim for the clinician is as always DO NO HARM.
Medical evidence suggests that the diagnosis of carotid and
vertebral arterial dissections is on the increase, as awareness
develops and diagnostic imaging becomes more reliable and less
expensive. The causes of arterial dissection remain largely
unknown, but are thought to involve a combination of genetic
predisposition and environmental factors such as trauma. Early
diagnosis is essential to prevent the potential sequelae of stroke.
Manual therapists may be exposed to patients presenting with the
early signs of stroke (i.e. neck pain/headache) and as such need
both knowledge and awareness of the mechanisms involved. A
basic understand of vascular anatomy, haemodynamics, and the
pathogenesis of arterial dysfunction may help the clinician differ-
entiate vascular head and neck pain from a musculoskeletal cause.
It is apparent, however, that dissemination of knowledge and
further work is necessary in establishing the best way to identify
patients who may present as, or be at risk of neurovascular accident
as a result of treatment.
One interesting and ongoing focus of ongoing clinical research is
the use of simple hand-held ultrasound Doppler units to objectively
assist in identifying ow dysfunction.
This method has been
the subject of a recent academic debate in Manual Therapy
following the publication of an article by Thomas et al.
which cast
doubt on the validity and reliability of such testing methods. The
authors of this article raise a number of key points which add to the
1. The alterations in ow detected by the Doppler velocimetry
studies may well be an artefact of normal movement, similar to
that found in the lower limb during cycling
and the upper
limb at end range positions.
2. None of the subjects studied
appear to have suffered any VBI
symptoms, despite revealing 30% more patients with altered
blood ow than would have been detected by pre-treatment
positional testing. This raises the question; does the use of
Doppler velocimetry give us any further information than VBI
testing? Assuming a clinician discovers (via the medium of
velocimetry) that VA ow is signicantly reduced, but in the
absence of VBIsymptoms, how does that information direct
the clinical decision making process? The suggestion being
therefore, under those circumstances that the system has
adequately compensated for the reduced ow.
3. Considering the high cost of the equipment required, the high
level of training and the reported poor validity/reliability, does
Dopplervelicometry reallyadd any furthervalue for the clinician?
4. The authors beg the question of whether the use of a patient
questionnaire similar to that devised by,
may prove to be as
clinically effective and a much cheaper, pre-treatment
screening tool, providing it is combined with sound haemo-
dynamic knowledge and clinical reasoning skills.
Table 4 gives a summary of the objective examination proce-
dures referred to so far.
6. Summary
Attempts have recently been made to provide guidelines for the
effective screening of patients who may be at risk of neurovascular
accident post-manual therapy. However, current evidence ques-
tions the validity and utility of such guidelines. It is therefore
necessary to re-consider the clinical approach towards assessment
of potential cervical arterial dysfunction. Based on the existing
evidence base, the authors suggest manual therapists consider the
following recommendations;
1. Expand manual therapy theory to encompass a systems based
approach, incorporating the whole cervical vascular system,
including the carotid arteries.
2. Expand manual therapy theory and practice to include hae-
modynamic principals and their relationship to movement
anatomy and biomechanics.
3. Develop a high index of suspicion for cervical vascular
pathology, particularly in cases of acute trauma.
4. Develop increased awareness that neck pain and headache may
be precursors to potential posterior circulation ischemia.
5. Enhance subjective/objective examination by including
vascular risk factors such as hypertension, and procedures such
as cranial nerve and simple eye examination.
6. Consider new advances in the subjective assessment of cervical
arteries such as questionnaire screening.
Table 4
Summary of key objective examination procedures for differentiating vasculogenic head and neck pain.
Test Purpose Evidence status Limitations and advantages
Functional positional
test eCervical rotation
Affects ow in contralateral vertebral artery.
Limited effect on internal carotid artery.
Poor sensitivity, variable specicity.
Blood ow studies support effect on VA ow.
Only assesses posterior circulation.
Results should be interpreted with
caution. Recommended by existing
protocols. Cannot predict
propensity for injury.
Functional positional
test eCervical extension
Affects ow in internal carotid arteries.
Limited effect on vertebral arteries.
No specic diagnostic utility evidence available.
Blood ow studies support effect on ICA ow.
Only assesses anterior circulation.
Blood pressure examination Measure of cardiovascular health. Correlates to ICA atherosclerotic pathology. Reliability dependent on equipment,
environment, and experience.
Cranial nerve examination Identies specic cranial nerve dysfunction
resulting from ischemia or vessel compression.
No specic diagnostic utility evidence available. Reliability dependent on experience.
Eye examination Assists in diagnosis of possible neural decit
related to ICA dysfunction
No specic diagnostic utility evidence available. Eye symptoms may be early warning
of serious underlying pathology.
Hand-held Doppler
Direct assessment of blood ow velocity Limited manual therapy specic evidence.
Debate within literature re;
reliability, validity, clinical utility and
interpretation of ndings.
Reliability dependent on equipment,
environment and experience.
Therapist administered
Questionnaire screening
Questionnaire assessment of events related to
movement and VBI/Cranial nerve symptoms.
No specic diagnostic utility evidence available.
Requires further study.
Reliant on patientsinterpretation
of events.
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7. Develop an awareness of the limitations of current objective
tests such as pre-treatment movement testing and the
proposed use of hand-held Doppler ultrasound. This should
enhance the knowledge that reliance on objective testing alone,
represents incomplete clinical reasoning.
8. In cases of acute onset headache unlike any othercouples
with ambiguous examination ndings, retain an index of
suspicion and use conservative or gentle treatment techniques
in the early stages of management.
9. Where frank arterial injury is suspected prior to or following
a treatment intervention, immediate triage to an appropriate
emergency centre is recommended, together with a report on
any treatment methods undertaken.
The summarised points above are not intended as denitive
guidance erather an advancement of theory, practice and clinical
reasoning, based on the constantly emerging evidence base.
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... A patient experiencing, for example pain from one of these presentations may seek OMT for the relief of the pain (Murphy, 2010;Taylor and Kerry, 2010). It is therefore important that the subtle symptoms of these pathologies are recognised in the patient history. ...
... Differentiation of a patient's symptoms originating from a vasculogenic cause with complete certainty is not currently possible from the physical examination. Thus, it is important for the physical therapist to understand that headache / neck pain may be the early presentation of an underlying vascular pathology (Rivett, 2004;Taylor & Kerry, 2010). The task for the therapist is to differentiate the symptoms by: ...
... This process of differentiation should take place from an early point in the assessment process i.e. early in the patient history. The symptomology and history of a patient experiencing vascular pathology is what may alert the physical therapist to such an underlying problem (Rivett, 2004;Taylor & Kerry, 2010). A high index of suspicion of cervical vascular involvement is required in cases of acute onset neck/head pain described as "unlike any other" (Taylor & Kerry, 2010). ...
In dit hoofdstuk worden de hoogcervicale wervelkolom (C0-C3) en het kaakgewricht besproken. Er is aandacht voor het screeningsproces, de risicofactoren, de verschillende behandelprofielen en de verschillende graden van nekpijn conform de KNGFAQ-richtlijn Nekpijn. Het belang van een professioneel klinisch redeneerproces voor deze regio is evident. Daarom zijn er vaker momenten van overweging tijdens de screening en het onderzoek om uiteindelijk te komen tot een ‘pluis’-gevoel, de juiste werkdiagnose en de keuze voor de juiste behandeling: preventief, curatief of palliatief. Ook het ‘pluis’-gevoel van de patiënt, het hebben van een diagnose en de instemming met de voorgestelde aanpak zijn hier van extra groot belang. Bij het bespreken van de anatomie van de hoogcervicale regio is er aandacht voor het bijzondere verloop van bloedvaten, zoals de arteria vertebralis. Speciale paragrafen zijn er over duizeligheid en hoofdpijn. Kennis over de ingenieuze hoogcervicale osteo- en artrokinematica is natuurlijk van groot belang voor de manueeltherapeut om de functiestoornissen te kunnen diagnosticeren, analyseren en ontrafelen. Het theoriegedeelte wordt afgesloten met de bouw en functie van het temporomandibulaire gewricht en de nomenclatuur van alle tanden en kiezen. Kaakbewegingen als depressie (elevatie), occlusie (detractie), protractie (protrusie), retractie (retrusie), laterotrusie en circumductie worden toegelicht en duidelijk geïllustreerd. Het hoofdstuk wordt afgesloten met de uitgebreide beschrijving van 33 technieken. Aan de hand van instructieve video’s, duidelijke foto’s en helder geformuleerde opmerkingen wordt duidelijk gemaakt hoe de manueeltherapeut klachten aan de hoogcervicale wervelkolom en het kaakgewricht kan onderzoeken en behandelen.
... This algorithm is intended to add to APA 16) and IFOMPT 15) premanipulative CAD guidelines (Fig. 1) and is based on intrinsic versus extrinsic disorders. Screening for spontaneous hemodynamic CAD involves a combination of assessing for co-morbidities, investigating patient historical events, evaluating subjective complaints, and providing appropriate physical examination procedures 11,13,14,17,67) . Once spontaneous vascular sequelae events (intrinsic disorders) ( Table 1) have been screened as negative for vascular co-morbidities, then premanipulative screening for mechanical arterial compromise (extrinsic disorders) ( Table 2) can be performed, not to assess arterial patency in terms of VBI/CAD, but to evaluate for potential intolerance to mechanical forces which may occur during CSM 17) ( Table 3). ...
... Table 1. Optimal sequence of premanipulative assessment (intrinsic) 11,13,14,17,67) Spontaneous arterial dissection (intrinsic disorder) ...
... Optimal sequence of premanipulative assessment (extrinsic)11,13,14,17,67) deKleyn's test, Full Physiological Cervical Rotation test, Pre-Manipulative Hold (PMH) test, Handheld Doppler Velocimeter. ...
Full-text available
In the field of physical therapy, there is debate as to the clinical utility of premanipulative vascular assessments. Cervical artery dysfunction (CAD) risk assessment involves a multi-system approach to differentiate between spontaneous versus mechanical events. The purposes of this inductive analysis of the literature are to discuss the link between cervical spine manipulation (CSM) and CAD, to examine the literature on premanipulative vascular tests, and to suggest an optimal sequence of premanipulative testing based on the differentiation of a spontaneous versus mechanical vascular event. Knowing what premanipulative vascular tests assess and the associated clinical application facilitates an evidence-informed decision for clinical application of vascular assessment before CSM.
... Atherosclerosis is an inflammatory process associated with a number of factors, including hypertension, hypercholesterolaemia, hyperlidaemia, diabetes mellitus, infections, and smoking (Taylor and Kerry, 2010). Risk factors for atherosclerosis are often present in older people and thrombotic stroke is typically a disease of the elderly (Debette and Leys, 2009). ...
... With regard to the prevention of serious adverse events, identifying a possible vasculogenic contribution to the complaints is important. Severe, unusual headache or neck pain are often the first symptoms of an underlying craniocervical artery dissection (Debette and Leys, 2009;Taylor and Kerry, 2010). In patients older than 60 years, pain and mechanical triggers might be missing because cervical pain is not a hallmark of craniocervical artery dissection in patients older than 60 years (Traenka et al., 2017). ...
Manipulation and mobilisation of the cervical spine are well established interventions in the management of patients with headache and/or neck pain. However, their benefits are accompanied by potential, yet rare risks in terms of serious adverse events, including neurovascular insult to the brain. A recent international framework for risk assessment and management offers directions in the mitigation of this risk by facilitating sound clinical reasoning. The aim of this article is to critically reflect on and summarize the current knowledge about cervical spine manual therapy and to provide guidance for clinical reasoning for cervical spine manual therapy.
... The key objective of any examination is to filter out those patients who may need referral for further examination or testing, either as urgent or non-urgent cases. It has been suggested that CN examination should be an integral part of that process [13]. ...
Background: Neurological examination in musculoskeletal practice is a key element of safe and appropriate orthopedic clinical practice. With physiotherapists currently positioning themselves as advanced first line practitioners, it is essential that those who treat patients who present with neck/head/orofacial pain and associated symptoms, should have an index of suspicion of cranial nerve (CN) dysfunction. They should be able to examine and determine if CN dysfunction is present, and make appropriate clinical decisions based upon those findings. Methods: This paper summarizes the functions, potential impairments of the nerves, associated conditions, and basic skills involved in cranial nerve examination. Results: A summary of cranial nerve examination is provided, which is based on the function of the nerves, This is intended to facilitate clinicians to feel more confident at understanding neural function/impairment, as well as performing and interpreting the examination. Conclusion: This paper illustrates that CN testing can be performed quickly, efficiently and without the need for complicated or potentially unavailable equipment. An understanding of the CN's function and potential reasons for impairment is likely to increase the frequency of CN testing in orthopedic clinical practice and referral if positive findings are encountered.
... Although a causality between CS manipulation and MAE (in particular, craniocervical artery dissection) is not likely (Cassidy et al., 2017(Cassidy et al., , 2008Taylor and Kerry, 2010), it is important that manual therapists try to prevent every potential MAE caused by vascular or other pathologies (Hutting et al., 2018). In 2014, the 'International Framework for Examination of the Cervical Region for Potential of Cervical Arterial Dysfunction' was published (Rushton et al., 2014). ...
Full-text available
Although there seems to be no causality between cervical spine (CS) manipulation and major adverse events (MAE), it remains important that manual therapists try to prevent every potential MAE. Although the validity of positional testing for vertebrobasilar insufficiency (VBI) has been questioned, recently, the use of these tests was recommended. However, based on the low sensitivity of the VBI tests, which may result in too many false-negative results, the VBI tests seem to be less valuable in pre-manipulative screening. Moreover, because the VBI tests are unable to consistently produce a decreased blood flow in the contralateral vertebral artery in (healthy people), the underlying mechanism of the test may not be a valid construct. There are numerous cases reporting MAE after a negative VBI test, indicating that the VBI tests do not have a role in assessing the risk of serious neurovascular pathology, such as cervical arterial dissection, the most frequently described MAE after CS manipulation. Symptoms of VBI can be identified in the patient interview and should be considered as red flags or warning signs and require further medical investigation. VBI tests are not able to predict an MAE and seem not to have any added value to the patient interview with regard to detecting VBI or another vascular pathology. Furthermore, a negative VBI test can be wrongly interpreted as ‘safe to manipulate’. Therefore, the use of VBI tests cannot be recommended and should be abandoned.
... 12,13 One example of a condition that may present as dizziness and mimic peripheral vestibular dysfunction, although frequently asymptomatic until severe, is carotid artery stenosis. [14][15][16] The purpose of this report is to describe the diagnostic focus of the clinical decision-making process for a patient who was referred to a physiotherapist for treatment of persistent dizziness and subsequently diagnosed with severe stenosis of the internal carotid arteries. ...
Full-text available
PURPOSEThe purpose of this report is to describe the diagnostic focus of the clinical decision-making process for a patient referred to a physiotherapist for treatment of persistent dizziness, who was subsequently diagnosed with severe stenosis of the internal carotid arteries. CASE DESCRIPTIONThe patient was a 79-year-old man who was referred to a physiotherapist by his primary care physician for the treatment of persistent intermittent dizziness. The patient’s dizziness began 6 months prior insidiously; it was worsening over time and now interfered with activities of daily living. The patient denied cervical pain or headaches, numbness or tingling in his extremities, difficulty maintaining balance with walking, unsteadiness, muscle weakness, dysphagia, drop attacks, diplopia or dysarthria. At the physiotherapist’s initial evaluation, cervical range of motion was moderately restricted in all motions and his dizziness was elicited with changes in head position. The patient’s neurological examination was unremarkable. Due to positional complaints of dizziness, a Dix–Hallpike test was used to screen for benign paroxysmal positional vertigo, which was positive for symptoms reproduction; however, no nystagmus was noted. The patient also became diaphoretic and exhibited significant discoloration of his face during the test. OUTCOMESDue to concern over vascular compromise, carotid duplex ultrasonography and magnetic resonance angiography were completed and revealed near complete occlusion of the left internal carotid artery at its origin. The patient subsequently underwent a left internal carotid endarterectomy with resolution of symptoms and a return to all activities of daily living. DISCUSSIONCarotid artery stenosis, although frequently asymptomatic until severe, may manifest as complaints of dizziness that mimic peripheral vestibular dysfunction. Appropriate and prudent screening and referral is necessary if clinical symptoms suggestive of vascular compromise are present.
... But the pain is not always located in the typical pain area. For example, some patients with vertebral artery dissection present with pain in the orbital part, and others with internal carotid artery may be suffering from occipital pain [8,17,[23][24][25]. In this study, 41.2% of patients had the temporal pain when the dissection was in anterior circulation, and 46.5% of the patients had occipital pain when the dissection was in posterior circulation. ...
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Objective To analyze the characteristics and relative factors of headache and neck pain due to cervicocerebral artery dissection (CAD). Methods A total of 146 consecutive patients with CAD in Zhengzhou, China (2010–2017) were observed and registered prospectively. There were 60 (60/146) cases who complained of headache and neck pain, and we analyzed the characteristics of pain according to their clinical features. For the 130 (130/146) patients with complete clinical laboratory data, they were divided into two groups according to pain, and the relative factors of pain were analyzed. Results The headache and neck pain in 60 CAD patients was mostly acute onset (98.3%), 70.6% (12/17) of patients with anterior circulation dissection and 88.4% (38/43) of patients with posterior circulation dissection complained of moderate to severe pain. 41.2% (7/17) of patients with anterior circulation dissection had temporal pain, while 46.5% (20/43) of the patients with posterior circulation dissection had occipital pain. There were 23.5% (4/17) and 32.6% (14/43) of patients with anterior and posterior circulation dissection complained of throbbing pain, respectively, 23.5% (4/17) and 20.9% (9/43) of patients with anterior and posterior circulation dissection complained of pulsating pain. The pain could occur in the ipsilateral (40.0%), bilateral (52.7%), or contralateral (7.3%) sites of the dissection. In the 130 patients, there were 56 cases (43.1%) in the pain group, and 74 cases (56.9%) in the non-pain group. Multivariate logistic regression analysis showed that female gender (OR 4.01, 95% CI 1.63–9.85, P = 0.002), posterior circulation (OR 3.18, 95% CI 1.39–7.28, P = 0.006), history of headache (OR 4.72, 95% CI 1.08–20.52, P = 0.039), and low-density lipoprotein less than 1.8 mmol/L (OR 2.90, 95% CI 1.15–7.34, P = 0.025) were risk factors of the occurrence of the pain related to CAD. Conclusion The headache and neck pain caused by CAD is a moderate to severe pain occurring suddenly. The pain nature may be diverse but mostly like throbbing and pulsating. When the dissected artery is located in the posterior circulation, the pain is mostly in the occipital region, and mostly in the temporal region when the dissected artery is located in the anterior circulation. The pain can occur in ipsilateral, bilateral, or contralateral of the dissection. In addition, several factors might contribute to the occurrence of headache and neck pain.
... It has been suggested that many AE can be prevented if a more detailed anamnesis and clinical reasoning is applied (Rivett, 2004;Puentedura et al., 2012;Thomas, 2016). Therefore, patients' characteristics, in which risks for AE occur, could be of importance for the patient history as a part of the preliminary screening (Taylor and Kerry, 2010). Previous reviews mostly had the objective to identify adverse events. ...
Cervical spinal manipulation (CSM) and cervical mobilization are frequently used in patients with neck pain and headache. Pre-manipulative cervical instability and arterial integrity tests appear to be unreliable in identifying patients at risk for adverse events. It would be valuable if patients at risk could be identified by specific characteristics during the preliminary screening. Objective was to identify characteristics of 1) patients, 2) practitioners, 3) treatment process and 4) adverse events (AE) occurring after CSM or cervical mobilization. A systematic search was performed in PubMed, Embase, CINAHL, Web-of-science, AMED, and ICL (Index Chiropractic Literature) up to December 2014. Of the initial 1043 studies, 144 studies were included, containing 227 cases. 117 cases described male patients with a mean age of 45 (SD 12) and a mean age of 39 (SD 11) for females. Most patients were treated by chiropractors (66%). Manipulation was reported in 95% of the cases, and neck pain was the most frequent indication. Cervical arterial dissection (CAD) was reported in 57% (P = 0.21) of the cases and 45.8% had immediate onset symptoms. The overall distribution of gender for CAD is 55% (n = 71) for female and therefore opposite of the total AE. Patient characteristics were described poorly. No clear patient profile, related to the risk of AE after CSM, could be extracted. However, women seem more at risk for CAD. There seems to be under-reporting of cases. Further research should focus on a more uniform and complete registration of AE using standardized terminology.
Synopsis: This position statement, stemming from the international IFOMPT (International Federation of Orthopaedic Manipulative Physical Therapists) cervical framework, was developed based upon the best contemporary evidence and expert opinion to assist clinicians during their clinical reasoning process when considering presentations involving the head and neck. Developed through rigorous consensus methods the international IFOMPT cervical framework guides assessment of the cervical spine region for potential vascular pathologies of the neck in advance of planned interventions. Within the cervical spine, events and presentations of vascular pathologies of the neck are rare but are an important consideration as part of patient examination. Vascular pathologies may be recognisable if the appropriate questions are asked during the patient history, if interpretation of elicited data enables recognition of this potential, and if the physical examination can be adapted to explore any potential vasculogenic hypothesis.
Purpose: To highlight that internal carotid artery dissection is a common cause of Horner's syndrome and that it is important to diagnose dissection as anticoagulation can prevent carotid thrombosis and embolism. Methods: Five case reports are presented of patients with Horner's syndrome secondary to carotid dissection. One patient had carotid dissection secondary to trauma, two had spontaneous dissections and two had dissections in the settings of other illness. A literature search was performed on carotid dissection as a cause of Horner's syndrome and its diagnosis and management. Results: The case reports and literature highlight that dissection is under-recognized as a cause of Horner's syndrome and can be missed. The investigation of choice is a magnetic resonance imaging and angiography scan of the head and neck. The treatment advocated is anticoagulation for 3-6 months. Conclusion: Carotid dissection should be suspected in patients with Horner's syndrome, particularly if head or neck pain is present.
APPROXIMATELY 12 MILLION Americans undergo spinal manipulation therapy (SMT) every year. Renewed interest in this method requires an analysis of its reported risks and possible benefits. This review describes two patients with spinal cord injuries associated with SMT and establishes the risk/benefit ratios for patients with lumbar or cervical pain. The first case is a man who underwent SMT for recurrent sciatica 4 years after chemonucleolysis. During therapy, he developed bilateral sciatica with urinary hesitancy. After self-referral, myelography demonstrated a total block; he underwent urgent discectomy with an excellent result 3 months after surgery. The second patient with an indwelling Broviac catheter and a history of lumbar osteomyelitis underwent SMT for neck pain. Therapy continued for 3 weeks despite the development of severe quadriparesis. After self-referral, he underwent an urgent anterior cervical decompression and removal of necrotic bone and an epidural abscess with partial neurological recovery. An analysis of these cases and 138 cases reported in the literature demonstrates six risk factors associated with complications of SMT. These include misdiagnosis, failure to recognize the onset or progression of neurological signs or symptoms, improper technique, SMT performed in the presence of a coagulation disorder or herniated nucleus pulposus, and manipulation of the cervical spine. Clinical trials of SMT have been summarized in several recent articles. Although these reviews agreed that most trials exhibited serious flaws, the data suggest that SMT demonstrates consistent effectiveness as an alternate treatment for adults with acute low back pain. SMT has not been shown to be superior to other conservative methods, nor to offer long-term benefits. It is concluded that the risk/benefit ratio is acceptably low for SMT as therapy for adults with midline low back pain of less than 1 week in duration. The ratio was unacceptably high for patients with radicular symptoms or signs associated with prolapsed discs and neck pain. Potential complications and unknown benefits indicate that SMT should not be used in the pediatric population.
This issue of the Journal includes a new feature: the 'AJP Forum'. The Editorial Board envisages that this feature will be used from time to time to provide a venue for expert comment on issues of importance for physiotherapy practice. The first Forum examines issues related to premanipulative testing of the cervical spine. It follows the Australian Physiotherapy Association's recent release of Clinical Guidelines for Pre-Manipulative Procedures for the Cervical Spine (Magarey et al 2000). The 2000 guidelines replace the protocol published in 1988.