International framework for examination of the cervical region for potential of Cervical Arterial Dysfunction prior to Orthopaedic Manual Therapy intervention

Abstract

A consensus clinical reasoning framework for best practice for the examination of the cervical spine region has been developed through an iterative consultative process with experts and manual physical therapy organisations. The framework was approved by the 22 member countries of the International Federation of Orthopaedic Manipulative Physical Therapists (October 2012). The purpose of the framework is to provide guidance to clinicians for the assessment of the cervical region for potential of Cervical Arterial Dysfunction in advance of planned management (inclusive of manual therapy and exercise interventions). The best, most recent scientific evidence is combined with international expert opinion, and is presented with the intention to be informative, but not prescriptive; and therefore as an aid to the clinician's clinical reasoning. Important underlying principles of the framework are that 1] although presentations and adverse events of Cervical Arterial Dysfunction are rare, it is a potentially serious condition and needs to be considered in musculoskeletal assessment; 2] manual therapists cannot rely on the results of one clinical test to draw conclusions as to the presence or risk of Cervical Arterial Dysfunction; and 3] a clinically reasoned understanding of the patient's presentation, including a risk:benefit analysis, following an informed, planned and individualised assessment, is essential for recognition of this condition and for safe manual therapy practice in the cervical region. Clinicians should also be cognisant of jurisdictionally specific requirements and obligations, particularly related to patient informed consent, when intending to use manual therapy in the cervical region.

Manual therapy and cervical artery dysfunction: Identification of potential risk factors in clinical encounters

“…This suggests there could be considerable benefit in raising clinical awareness that vascular dysfunction may mimic cervical spine musculoskeletal complaints. 28,29 …”

“…67 It is anticipated that this information may assist practitioners to identify those patients who are presenting with a CeAD in progress, and potentially assist in the identification of patients at risk of complications following cervical and upper thoracic spine manual therapy. 28 It is important for practitioners to be aware that although much of the discussion around CAD associated with manual therapy centres around cervical spine manipulation, consideration should also be given to cervicothoracic spine manipulation due to the cervical spine positions that some of the manipulations can involve. Further, in the context of emphasising the role of movement rather than manipulation, this information should aid clinical reasoning when applying all manual techniques and exercise rehabilitation.…”

“…Further, in the context of emphasising the role of movement rather than manipulation, this information should aid clinical reasoning when applying all manual techniques and exercise rehabilitation. 28 …”

The effect of end-range cervical rotation on vertebral and internal carotid arterial blood flow and cerebral inflow: A sub analysis of an MRI study

“…The presence of anatomical anomalies such as VA hypoplasia, prior VA injury and previous VBI symptoms are all recognised risk factors for the development of vertebrobasilar complications following neck manipulation (Mann and Refshauge, 2001). In the clinical setting, in the absence of angiography to determine the presence of anatomical anomalies, taking a comprehensive history and physical VBI screening involving sustained cervical rotation, with careful and thorough exploration of symptoms, may well be the most appropriate way to assess risk of adverse event following manual treatment of the neck as endorsed by recent authors (Rushton, Rivett et al 2012, Rushton, Rivett et al 2014. Some authors dispute the validity of the provocative positional tests to predict individuals at risk (Rushton, Rivett et al 2014), however physical screening arguably still has a place to detect those with abnormal cerebral vasculature and who may suffer from rotational VBI and pre-syncope during positions of end -range rotation.…”

“…Because the majority of cases occur in relatively young, healthy people with no known cardiovascular risk factors (Thomas, Rivett et al 2011), these complications are difficult to predict. Current clinical screening guidelines include the provocative positional test of sustained end-range rotation as the minimum pre-manipulative physical screening procedure (Rivett, Shirley et al 2006, Rushton, Rivett et al 2014) to detect vertebrobasilar ischaemia (VBI). The onset of VBI in response to neck rotation suggests some compromise to vertebral artery blood flow which may be an indication of increased biomechanical stress on the vessel (Refshauge 1994).…”