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. This guide has been developed and is regularly updated by current research findings. It has been approved by the APA as the principal document to promote safe practice in the cervical spine in the Australian context and is recognised internationally as an evidence-based standard for safe practice in the cervical management.
While there has been controversy in the literature about the continued use of the VBI positional tests, the APA position is that the tests still have value in the context of a full history and physical examination and are important to assess the effect of sustained head position on blood flow to the brain and the adequacy of collateral flow.
The tests should be used selectively for differential diagnosis of dizziness and to test the patient response to head positioning, if any assessment or treatment is to be applied at or close to the end of their physiological range.
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: International IFOMPT Cervical Framework published by the International Federation of Orthopaedic Manipulative Physical Therapists (IFOMPT) and position statement (PDF).
Download the guides
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.
Resources
The following references will provide you with additional information:
15Do TP, Remmers A, Schytz HW, Schankin C, Nelson SE, Obermann M, Hansen JM, Sinclair AJ, Gantenbein AR, Schoonman GG. Red and orange flags for secondary headaches in clinical practice: SNNOOP10 list. Neurology. 2019 Jan 15;92(3):134-144. doi: 10.1212/WNL.0000000000006697. Epub 2018 Dec 26. PMID: 30587518; PMCID: PMC6340385. https://doi.org/10.1212%2FWNL.0000000000006697.