Clinical guide to safe manual therapy practice in the cervical spine
The guide, developed on behalf of the Australian Physiotherapy Association (APA) is designed to assist all physiotherapists treating the neck to recognise the rare, but potentially catastrophic vascular complications. The first part of the guide highlights the presentation of patients with early symptoms and signs of cervical arterial dissection (CAD) in progress, patients at risk of CAD, and patients with vertebrobasilar insufficiency (VBI). The second part of the guide outlines the considerations for safe practice when considering high velocity manipulative (thrust) techniques in the cervical spine, as well as giving a brief overview of other considerations if a patient presents with dizziness in association with their neck disorder.
The guide represents a synthesis of current literature, as well as a distillation of views from the Musculoskeletal Physiotherapy Australia (MPA) membership obtained through a survey and focus groups. In particular, it responds to the clear membership message that the guide needs to be concise, user-friendly and compatible with collaborative clinical reasoning. It builds on and replaces the APA 2006 ‘Clinical Guidelines for assessing vertebrobasilar insufficiency in the management of cervical spine disorders’ which have been recognised internationally as a standard for safe practice in the cervical spine. While the new 2018 clinical guide has been developed and approved by the APA as the principal document to promote safe physiotherapy practice in the cervical spine in the Australian context. Members may also find some useful evidence-based information in the International Framework for Examination of the Cervical Region for potential of Cervical Arterial Dysfunction prior to Orthopaedic Manual Therapy Intervention published by the International Federation of Orthopaedic Manipulative Physical Therapists (IFOMPT).
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About the authors
- Dr L Thomas
- Dr D Shirley
- Prof D Rivett
Dr Lucy Thomas leads the working party to develop this guide and conducted the literature review, survey and focus groups amongst MPA members. She is an academic at The University of Queensland and Titled Musculoskeletal Physiotherapist. She teaches musculoskeletal physiotherapy to entry level and postgraduate students, in particular in the assessment and management of cervical spine disorders. Her PhD ‘Minimising Risk Factors for Cervical Spine Manipulation’ and ongoing research has investigated cervical arterial dissection, cervical arterial blood flow and screening for vascular risk in the neck. She presents regularly at both national and international conferences.
Dr Debra Shirley is a Specialist Musculoskeletal Physiotherapist (as awarded by the Australian College of Physiotherapists 2007) and a Senior Lecturer in Musculoskeletal Physiotherapy at The University of Sydney. She has extensive experience teaching Musculoskeletal Physiotherapy at entry and post graduate levels (specifically neck pain and low back pain). She has been a past National Chair of MPA and Australian delegate to IFOMPT and has represented Australia at an International Forum on safe manipulative practice. She has clinical and research interests in differential diagnosis of dizziness and was a member of the team which developed the 2006 guidelines.
Professor Darren Rivett is an academic at The University of Newcastle, a musculoskeletal physiotherapist and an Honoured Member and former National Chair of MPA. His research has investigated vertebral artery blood flow, cervical spine examination and treatment procedures, and clinical reasoning in musculoskeletal practice. He led the working party for the development of the 2006 APA VBI guidelines. He was also a member of the team which developed the International Framework for Examination of the Cervical Region for potential of Cervical Arterial Dysfunction prior to Orthopaedic Manual Therapy Intervention (2012) for the International Federation of Orthopaedic Manipulative Physical Therapists (IFOMPT).
The following references will provide you with additional information:
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2Miller J, Gross A, D'Sylva J, Burnie SJ, Goldsmith CH, Graham N, Haines T, Brønfort G, Hoving JL. (2010). Manual therapy and exercise for neck pain: A systematic review. Manual Therapy 2010 Jun 1.
3Gross A, Miller J, D'Sylva J, Burnie SJ, Goldsmith CH, Graham N, Haines T, Brønfort G, Hoving JL (2010). Manipulation or mobilisation for neck pain: a Cochrane Review. . Manual Therapy Aug;15(4):315-33. doi: 10.1016/j.math.2010.04.002. Epub 2010 May 26.
4Dunning et al. (2016). Upper cervical and upper thoracic manipulation versus mobilization and exercise in patients with cervicogenic headache: a multi-center randomized clinical trial. BMC Musculoskeletal Disorders 17:64. DOI 10.1186/s12891-016-0912-3.
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9Thomas LC. Cervical arterial dissection: An overview and implications for manipulative therapy practice. Manual therapy. 2016;21:2-9.
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13Stiell IG, Clement CM, McKnight RD, et al. The Canadian C-Spine Rule versus the NEXUS Low-Risk Criteria in Patients with Trauma. New England Journal of Medicine. 2003;349(26):2510-2518.
14Hoffman JR, Mower WR, Wolfson AB, Todd KH, Zucker MI. Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. National Emergency X-Radiography Utilization Study Group. The New England journal of medicine. 2000;343(2):94-99.
15 Jull, G, Sterling, M, Falla, D, Treleaven, J, O’Leary, S (2008). Whiplash, Headache and Neck Pain. Churchill Livingstone.
16 Treleaven, J (2017). Dizziness, Unsteadiness, Visual disturbances, and Sensorimotor control in traumatic neck pain. Journal of Orthopaedic and Sports Physical Therapy; 47 (7): 492-505. DOI: 10.2519/jospt.2017.7.052, with particular reference to table on p 497.