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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.


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