Musculoskeletal Monday: Cervical Manipulation

The “Dangers” of Cervical Manipulation have been promoted widely over the spectrum of medicine, but what is the reality? Manipulation is as safe as any other intervention if utilized with the appropriate patient, and has been proven through research to be effective. So why should we shy away from it?

As with all areas of physical therapy practice, clinical reasoning is of utmost importance. In reviewing adverse events from spinal manipulation, IFOMPT concludes that “It is clear that many documented adverse events following the application of cervical manipulation could have been avoided if more thorough clinical reasoning had been exercised by the clinician (Rivett 2004).”

Taking the time to revisit IFOMPT guidelines is a great place to start. The framework is designed to be an aide to patient-centered clinical reasoning.” (Emphasis added). So let’s break this down.

Anatomy Doesn’t Lie

My mentor, Erl Pettman, has done extensive research on this topic and I encourage you toCervical visit his website, or better yet sign up for a course with him! A lot of the information below has been referenced by him in lectures and in his book.

Let’s look at not only the path of the vertebral artery but also the redundant circulation of the brain. It has been well established that the vertebral artery as an acute turn around C1/2 and this is the most common site of spontaneous arterial dissection. In looking at research from Norris VBA injury “almost always” occurs at the C1/2 level. Kinking of the VBA probably harmful to tunica intima, especially in conjunction with stretch (Haynes “JMPT” 2001; Johnson et al 2000.)

The work of Rothwell (2001) studied 582 cases of spontaneous arterial dissection and if you are under 45 years old you are five times more likely to have an incident.

Let’s look at not only the path of the vertebral artery but of the entire cervical artery system. Extension and rotation can occlude the vertebral artery and this is a natural phenomenon.

But the rest of the system through the circle of Willis and the carotid sinus will sense this and balance out the blood flow. Here are some anatomical facts to consider:

  1. End-range rotation causes stretch (up to 45% at C1/C2) of vertebral artery.
  2. If maintained or forced, end-range rotation sufficient to potentially harm the artery which can be damaged with as little as 12% to 30% stretch (Stevens “Man Med” 1982; Johnson et al “Forensic Sc. Int” 2000.)
  3. Presumably, forceful rotational thrust could be contraindicated with the wrong candidate, especially at the end of available range.

Even though rotation and rotation/extension shown to decrease VBA (ICA) blood flow it has been clearly shown not to be predictive of VBA or ICA complications Rivett et al; Jariello et al; Cote, Cassidy et al). However, rotation/extension have been cited as the motion responsible for ‘minimal or no trauma’ spontaneous dissections. Therefore, why use a potentially harmful movement which has no predictive value?

The Body Heals in a Predictable Manner

Let’s look at what an arterial dissection is. With enough rotation, the inner lining of the vertebral artery (tunica intima) is “peeled away” from the tunica media. A thrombus is formed and additional rotation (via manipulation) is hypothesized to release this thrombus/embolus.ErlPettmanNAIOMT

Many arterial dissections heal over time, with at times permanent changes to the vessel. Understanding healing time (up to two months) is of utmost importance. This is a serious medical condition and consultation with a specialist is necessary.

Refer to this article, which has excellent illustrations and explanations of the healing of arterial dissections.

Pain is in the Brain

I am going to divert from the regular aspect of this section and go deeper into the fact that this pain cannot be ignored. It is well established that immediate neck pain is a serious sign and symptom and has to be addressed IMMEDIATELY. There are no ifs ands or buts in this case.

We will talk about that in the following section. I will delve into a condition called Horner’s syndrome, as an additional way to assess a patient to avoid a tragic event. Pain in the cervical region has so many potential sources and, at times, it is difficult for a patient to distinguish the difference. This is the one of many cases where, although there can be central sensitization, a thorough history, examination and clinical reasoning process are necessary to avoid making a mistake.

We are Prone to Clinical Reasoning Errors During a Busy Clinic Day

Here are four questions to think about, not about manipulation, but routine screening before treating someone’s cervical spine:

  • Do you check to see if they are on blood pressure medications and do you check their blood pressure?
  • Do you check the carotid pulses and/or auscultate them?
  • Do you visually inspect the patient for Horner’s Syndrome (future post)?
  • Do you check to see if they have a history of CA, osteoporosis, long term prednisone use, if they have had childhood respiratory illnesses, collagen disorders, previous trauma to the cervical spine?

This is where most of the mistakes happen. The clinician can miss the following:

  • Performs solely the vertebral artery screening and not cervical artery screening. (general cardiovascular screening) and does not screen for any other conditions.
  • Does not ask about prior manipulation and/or trauma.
  • Does not ask for verbal consent and does not perform a pre-manipulative hold.
  • Does not realize if the patient has immediate neck pain after a traumatic event this is a poor prognosticator. They require IMMEDIATE follow-up by a medical professional. This is a hallmark symptom of potential injury to the cervical artery system. It is even worse post manipulation, because some providers think that they “rotated the vertebra” too far and perform and additional manipulation is needed.  This assumption and clinical error can be (and has been) fatal for several patients.

Odds of injury to the cervical artery system are ranging from (1/40,000 to 1 in 10 million). Why the discrepancy? Not all manipulations are the same. If you screen your patients as stated above, a procedure which has been deemed risky is significantly safer. If you do not manipulate with rotation and traction, then your odds of causing injury is less than being struck by lightning (1 in 700,000).

Treat the Person and You Win Every Time

Here is an absolute contraindication of manipulation. You can screen patients and not find a red flag, and feel safe to proceed. But, you NEVER force a manipulation on a patient. If the patient doesn’t verbally consent, then don’t manipulation them.

Video of the Week

Head to our FB Page where NAIOMT’s Bill Temes demonstrates how to screen the cervical artery system.


This is the IFOMPT framework link and the link for a discussing the neurovasularity of the upper cervical region.

Want to discuss more manual therapy topics? Reach out to us on Twitter (@NAIOMT & @PrattPhysio or take your skills to the next level with a NAIOMT course in your area. Enjoy your week!

terry_pratt175– Terry

Terry Pratt, MS, PT, COMT, FAAOMPT

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