ARTICLE IN PRESS

Manual Therapy 13 (2008) 278–288

www.elsevier.com/locate/math

Review

Cervical arterial dysfunction and manual therapy: A critical literature

review to inform professional practice
Roger Kerrya,, Alan J. Taylorb, Jeanette Mitchellc,d,e, Chris McCarthyf
a
Division of Physiotherapy Education, University of Nottingham, UK
b
Nottingham Nuffield Hospital, Nottingham, UK
c
Department of Zoology & Physiology, School of Biological Sciences, University of Wyoming, Laramie, USA
d
Department of Kinesiology & Health, Division of Health Sciences, University of Wyoming, Laramie, USA
e
Department of Physiotherapy, School of Allied Health Professions, University of the West of England, Bristol, UK
f
Warwick Emergency Care and Rehabilitation, The University of Warwick, UK
Received 28 September 2006; received in revised form 29 October 2007; accepted 30 October 2007

Abstract

An abundance of literature has attempted to provide insight into the association between cervical spine manual therapy and
cervical artery dysfunction leading to cerebral ischaemic events. Additionally, specific guidelines have been developed to assist
manual therapists in clinical decision-making. Despite this, there remains a lack of agreement within the profession on many issues.
This paper presents a critical, re-examination of relevant literature with the aim of providing a contemporary, evidence-informed
review of key areas regarding the neurovascular risks of cervical spine manual therapy.
From a consideration of case reviews and surveys, haemodynamic principles, and blood flow studies, the authors suggest that: (1)
it is currently impossible to meaningfully estimate the size of the risk of post-treatment complications; (2) existing testing procedures
have limited clinical utility; and (3) a consideration of the association between pre-existing vascular risk factors, combined with a
system based approach to cervical arterial haemodynamics (inclusive of the carotid system), may assist manual therapists in
identifying at-risk patients.
r 2008 Elsevier Ltd. All rights reserved.

Keywords: Manual therapy; Vertebrobasilar insufficiency; Internal carotid artery dissection; Cervical arterial dysfunction; Atherosclerosis

1. Introduction provide clinical guidance for the safest implementation

Manual therapists are aware that cervical spine
manual therapy (MT) techniques, particularly those
involving full-range, high-velocity, rotational move-
ments, hold inherent risks of insult to the vertebral
arteries (VAs) and internal carotid arteries (ICAs),
which can result in cerebral ischaemia, stroke, or death.
Extensive reviews of contemporary evidence, and
reasoned debate, have been undertaken in an effort to
Corresponding author. Division of Physiotherapy Education,
University of Nottingham, Hucknall Road, Nottingham, NG5 1PB,
UK Tel.: +44 (0) 115 8231790.
E-mail address: roger.kerry@nottingham.ac.uk (R. Kerry).
of such techniques and for pre-manipulative screening
for vertebrobasilar insufficiency (VBI) (Barker et al.,
2001; Magarey et al., 2004; APA, 2006). However, there
is still widespread uncertainty and controversy regarding
the association between cervical spine MT and cervical
arterial dysfunction (CAD), the reliability and validity
of functional screening tests, the specificity and sensi-
tivity of these tests in identifying at-risk patients, and the
medico-legal position of therapists and patients (Aus-
tralian Journal of Physiotherapy (AJP), 2001; Jull et al.,
2002; Kerry, 2002; Refshauge et al., 2002; Brew, 2004;
Kerry, 2004).
The purpose of this paper is to present a summarised,
critical re-examination of current available published

1356-689X/$ - see front matter r 2008 Elsevier Ltd. All rights reserved.
doi:10.1016/j.math.2007.10.006
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R. Kerry et al. / Manual Therapy 13 (2008) 278–288
literature concerning cerebrovascular accidents (CVAs)
in the context of MT. The review is non-systematic and
aims to provide a broad picture of evidence and
contemporary thought with regards to risks of cervical
spine management.
1.1. Data sources and method
Literature searches were conducted for the years
1990–2007, using the data-bases Medline (PubMed);
CINAHL; Embase; AMED; CISCOM; and the Co-
chrane Library. Search terms were ‘vertebral artery’,
‘basilar artery’, ‘vertebrobasilar artery’, ‘internal carotid
artery’; ‘anatomy and histology’, ‘cytology’, ‘embryol-
ogy’, ‘injuries’, ‘innervation’, ‘pathology’, ‘physiology’,
‘radiology’, ‘radionuclide imaging’, ‘ultrasonography’,
‘ultrastructure’, and ‘adverse effects’, ‘adverse events’,
‘chiropractic’, ‘complications’, ‘manual therapy’, ‘osteo-
pathy’, ‘physiotherapy’, ‘risk’, ‘safety’, ‘spinal manip-
ulation’, ‘strokes’, ‘vascular accidents’. Related links,
reference lists, personal files, www search engines and
some publications prior to 1990, considered relevant
according to the key terms used, were also searched.
This search strategy was designed to widen the search
beyond the confines of MT literature.
The search process resulted in 833 articles, of which
224 were considered relevant to MT (referring to
manipulative and non-manipulative techniques) via the
themes selected for the discussion. Key clinical and
theoretical themes consistent within this literature base
are supported by a representation of the search results in
this paper. The discussion and conclusions of this review
focus on the risk of cervical spine MT, the usefulness of
screening tests in assessing at-risk patients, haemody-
namic factors, and the nature and signs and symptoms
of arterial changes and insufficiency.
2. Reviews and surveys
Reviews and surveys attempt to establish risk factors
for, and incidence of, CVAs related to MT.
2.1. Questionnaire surveys
Retrospective and prospective surveys reviewed in-
clude reports by both manual therapists and non-
manual therapists (neurosurgeons, neurologists, vascu-
lar surgeons). Non-manual therapists’ surveys report a
higher number of patients suffering post-MT complica-
tions or associated symptoms (Dvorak et al., 1993; Lee
et al., 1995; Rivett and Milburn, 1997).
Retrospective surveys report estimates of CVA-risk
incidence ranging from one in 9122 (Michaeli, 1993) to
five in one million (Haynes, 1994). Some estimates have
been based on inadequate sample sizes (Haynes, 1994;
279
Rivett and Milburn, 1996), and a probable flaw with
retrospective studies is the questionable reliability of
recall of past events. Therefore inferences regarding size
of risk should be made with caution.
Most prospective surveys do not calculate estimates of
risk incidence, some stating explicitly that it would be
impossible and misleading to do so (Stevinson, et al.,
2001). Prospective studies are also likely to report a
higher number of cases of post-MT vascular complica-
tions, for example, (Leboeuf-Yde et al., 1997; Nadar-
eishvili and Norris, 1999; Stevinson et al., 2001;
Magarey et al., 2004), than retrospective estimates
(because of under-reporting, reporting restrictions,
non-association of event to treatment, etc) (Stevinson
et al., 2001; Dupeyron et al., 2003). Dupeyron et al.
(2003) suggest that post-MT VBI could be 30 times
higher than published. A recent prospective study on—
chiropractors reported no incidents of serious adverse
events (Thiel et al., 2007). Although a well-structured,
rigorous survey, it must be considered that, as stated
above, any study targeted at manual therapists is likely
to provide unreliable data due to reporting bias and lack
of awareness of what constitutes an adverse event.
2.2. Narrative reviews
These ranged from discursive (Rivett, 1995) to
structured reviews (Haldeman et al., 1999), encompass-
ing several themes. Firstly, in considering estimates of
incidence, a major confounding variable is that the
actual incidence is unknown (Rivett, 1995; Assendelft et
al., 1996; Ernst, 2001a, b, 2004), partly because the
number of persons in the population receiving MT is
unknown or unreported. This apparent under-reporting
(Assendelft et al., 1996; Ernst, 2004) may be influenced
by MT practitioners’ awareness of post-treatment
CVAs, physicians not making the link between MT
and CVAs, or a low probability of cases being published
(Ernst 2001a, 2002).
As another theme illustrating potential vascular post-
MT trauma, Hurwitz et al. (1996) reviewed 145 reports
of post-MT complications: of 118 documented cases, 21
patients died and 52 were left with serious neurological
deficits. Ernst (2004) reported that between 1995 and
2003 in Britain, 300 patients were adversely affected by
cervical spine MT, the most frequently reported
complication being stroke following arterial dissection.
These reports highlight the necessity of manual thera-
pists to be aware of mechanisms and presentations of
vascular trauma, and possible underlying pathology.
Lastly, the validity of movement-based pre-MT
screening tests is questioned (Kunasmaa and Thiel,
1994; Rivett, 1997), some authors suggesting that testing
should be stopped (Thiel and Rix, 2005). Recent reports
have undertaken probability analysis to calculate the
sensitivity and specificity of functional tests, using data
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280 R. Kerry et al. / Manual Therapy 13 (2008) 278–288
(flow rates and reproduced symptoms) from blood flow
studies. Current reports present sensitivity of 0%–21%
and specificity of 23%–90% (Kerry and Rushton, 2003;
Gross et al., 2005; Ritcher and Reinking, 2005).
2.3. Systematic reviews
Three major systematic reviews were identified (Ernst,
2001b, 2002; Rubinstein et al., 2005). Ernst (2001b)
investigated the safety of cervical spine MT by
summarising data of all prospective investigations.
From five prospective studies, it was concluded that
half of all patients experienced mild, transient adverse
events following manipulation, that no reliable data of
the incidence of adverse events exist, and that there is a
need for further prospective investigations.
In a systematic review of all original case reports
between 1995 and 2001, Ernst (2002) retrieved 42
individual case reports of complications post-manipula-
tion, 18 of which reported arterial dissection causing
stroke. Again, it was concluded that, although serious
complications do occur, it is impossible to rate their
incidence based on existing reported data, and large
rigorous prospective trials are needed.
Rubinstein et al. (2005) undertook a systematic
literature review, between 1966 and 2005, focussing on
risk factors for VA or carotid artery (CA) dissection.
Thirty-one case-control studies (from 1023 abstracts)
were assessed for their methodological quality. After
controlling for selection bias, lack of controls for
confounding variables, and inadequate data analysis,
there were still strong associations between VA or CA
dissection and aortic root diameter (434 mm), mi-
graine, relative common CA diameter change during the
cardiac cycle, and trivial trauma (ie associated with
cervical spine MT), and weak associations were found
for plasma homocysteine and recent infections. The two
MT papers (Rothwell et al., 2001; Smith et al., 2003)
that Rubinstein et al. (2005) reviewed reported that few
cases supported a clear temporal association between
treatment and arterial dissection (n ¼ 4). However,
Rubinstein et al. (2005) used a 24-h post-treatment
cut-off point, thereby missing potential latent cases (a
phenomenon previously reported by other authors).
This calls into question the parameters set by these
authors.
2.4. Case reviews
Terrett (1987) reported on 107 cases of post-MT
vascular accidents, between 1934 and 1986, equally
distributed across the genders, with average ages of
39.8 yrs (female) and 36.2 yrs (male). DiFabio (1999)
reported that death occurred in 18% of 177 cases and
concluded that the literature at that time did not
demonstrate that benefits of cervical spine MT out-
weighed the risks. Frisoni and Anzola (1991) concluded
from 39 cases that a priori risk identification cannot be
made in the majority of cases; symptoms may develop
some time after uneventful treatment; mortality/long-
term impairment occurs in 28% of cases, and a history
of previous, transient neurological symptoms or upper
cervical spine laxity should contra-indicate any neck
movement-based treatment.
Haldeman et al. (2002a) looked specifically at the
effect of referral bias on clinical perceptions of VA
dissection risk. Based on analyses of data from an
insurance provider and a chiropractic survey, they
reported that 1 in 48 manual therapists were likely to
be aware of post-MT CVA, compared to 1 in 2
neurologists. This discrepancy could explain the appar-
ent differences in perception and experiences between
these two professions.
Rothwell et al. (2001) conducted a population-based
nested case-control review to test the association
between MT and CVAs. Of 582 cases reviewed, they
suggested that vertebrobasilar accidents were five times
more likely to occur if a patient had MT one week prior
to the stroke, and VA-stroke cases were five times more
likely to have received MT than the control group. This
review concurs with the report of Smith et al. (2003)
who, after comparing 151 arterial dissection cases with a
control group, concluded that arterial dissection was five
times more likely to occur if MT had been administered
within 30 days prior to, and twice as likely to have had
increased neck/head pain preceding the stroke. They
concluded that VA dissection was independently asso-
ciated with stroke and increased neck/head pain.
Haldeman et al. (2002a) reported that 92% of VA cases
presented with neck/head pain, and 25% reported a
sudden onset of pain (suggestive of a dissection in
progress). Haldeman et al. (2002b) concluded that they
were unable to identify risk factors from the 64 medico-
legal cases and propose that vertebrobasilar dissection
be considered an unpredictable, inherent, idiosyncratic,
and rare complication of MT.
These surveys and reviews show that there is a need
for well-structured, large scale prospective surveys and
trials to be undertaken (Rivett, 1995; Hurwitz et al.,
1996; Shekelle and Coulter, 1997; Ernst, 2001b, 2004)
before a more realistic impression of the neurovascular
risk of MT can be established (Dvorak et al., 1993;
Haynes, 1994; Senstad et al., 1996; Rivett and Milburn,
1997; Stevinson et al., 2001).
3. Haemodynamics, arterial trauma and vascular
pathology
MT has been burdened by its ongoing focus on the
vertebral artery in isolation. Haemodynamic theory is a
relatively new but important area of thinking in MT
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(Taylor, 2001). It is well documented and understood,
that blood flow in the VA and ICA systems is intricately
linked via the circle of Willis (Cardon et al., 1998). It
follows, therefore, that both VA and ICA blood flow
and pathology should be considered in pre-treatment
risk assessment.
ICA blood flow velocity and volume are significantly
greater than in the VAs (Paivansalo et al., 1998;
Schoning and Hartig, 1998; Sidhu, 2000; Scheel et al.,
2000a, b). Therefore, the ICAs may have a significant
compensatory role during cervical spine movement and
positioning. A negative pre-manipulative test relies
critically on the patency of the ICAs and unaffected
VAs (see blood flow studies section) for adequate
perfusion and, as such, tests the system as opposed to
the concept that this somehow tests the VA in isolation.
This concept is illustrated by Weintraub and Khoury
(1998), who examined ICA and VA blood flow changes
in patients with known underlying pathology. They
reported an absence of overt VBI symptoms on
sustained end-range extension for 3–4 min in 160 cases
(mean age: 66 years), 25% of whom had VA hypoplasia
associated with marked basilar artery flow alteration,
whilst unsuspected ICA occlusion occurred in six cases
and VA occlusion in two. Welch et al. (2000) also
studied the effect of occlusion of the ICAs and VAs on
the opposing vessel flow, and reported that flow in one
part of the system was significantly influenced by
occlusion in the other part. These studies draw attention
to the need to be aware of the effects cervical spine
positioning and to identify pre-existing vascular disease
as a reason for caution in both pre-treatment testing and
practice of MT.
Trauma to cervical blood vessels is generally classified
as either dissection resulting from direct trauma to the
vessel, or localised thrombogenesis and embolus forma-
tion in response to endothelial damage (Caplan and
Biousse, 2004). Either pathological state may lead to
stroke (Pollanen et al., 1992; Ross, 1999). Arterial
dissection may occur after trivial trauma to the vessel, or
spontaneously. This may be related to pre-existing,
congenital weakness of the vessel wall or acquired
vascular pathology (atherosclerosis). The mechanisms
are thought to be arterial dissection with an intra-mural
haematoma, resulting in vessel lumen narrowing with
ensuing reduction in blood flow and ischaemia; an
extending dissection, leading to subarachnoid haemor-
rhage; and/or dissection leading to thrombus formation
with secondary emboli, and stroke (Mann and Re-
fshauge, 2001; Schievink et al., 2001).
ICA dissection has been linked to multiple types of
non-penetrating or blunt trauma, including motor
vehicle accidents (Miller et al., 2002; Beaudry and
Spence, 2003), manipulation (Haneline et al., 2003;
Ernst, 2004), hand-held mechanical massagers (Grant
and Wang, 2004), soft-ball injuries (Schievink et al.,
281
1998), strangulation (Clarot et al., 2005), effort (run-
ning) (Shimada et al., 2005), horse-hoof impact (Fletch-
er et al., 1995), sneezing (Taylor and Kerry, 2005). These
examples, although unremarkable in isolation, should
alert clinicians to the possibility that traumatic vascular
injury may occur in the ICAs as well as the VAs.
Furthermore, these arterial pathologies (VA and ICA)
are known to present as neuromusculoskeletal symp-
toms, often isolated neck and head pain, without the
commonly described VBI symptoms (Munari et al.,
1994; Taylor and Kerry, 2005, Arnold et al., 2006). This
concurs with other reports of VA dissection presenting
as isolated neck pain (Krespi et al., 2002) and/or
headache (Gates et al., 1997), without classical VBI
signs.
Although the literature suggests that the pathogenesis
of arterial dissection remains uncertain, proposed risk
factors include high plasma homocysteine concentra-
tions (Giroud et al., 1994; Pezzini et al., 2002); specific
genotypes (Pezzini et al., 2002); hereditary connective
tissue disorders (i.e. Ehlers – Danlos syndrome)
(Schwarze et al., 2000); connective tissue disorders
(Brandt et al., 2001); fibromuscular dysplasia (Van
Damme et al., 1999), and recent infections (Grau and
Buggle, 1999). There is much debate in the current
literature as to the relevance and relative weight of these
proposed risk factors and, in particular, why some
individuals seem more prone to vascular injury and
pathology than others (Rubinstein et al., 2005).
As stroke or death is the ultimate adverse outcome of
cervical spine MT (DiFabio, 1999), it is of note that ICA
dissection is reported to be the cause of stroke in up to
20% of patients aged 18–44 years (Lisovoski and
Rousseaux, 1991). Across all age groups, stroke is
considered to be the leading cause of morbidity and the
third-leading cause of mortality in the Western world
(Flossmann et al., 2004). Li et al. (2005) reported that
uncontrolled blood pressure is a key factor in the
aetiology of stroke. Although the actual pathophysiogi-
cal mechanisms of post-cervical spine MT stroke are
largely unknown, the occurrence of VA and/or ICA
dissection, with or without pre-existing vascular pathol-
ogy, is the most commonly accepted theory. Manual
therapists should be acutely aware that patients may
present with headache and neck pain as the early
warning signs of impending stroke (Arnold et al., 2006).
There are reports which suggest an association
between ICA insufficiency/ischaemia and upper cervical
spine instability (Volle and Montazem, 2001; Tominaga
et al., 2002; Garg et al., 2004; Yamazaki et al., 2004).
There are also reports that demonstrate anterior and
posterior blood flow dysfunction following road traffic
accidents (Chung and Han, 2002; Beaudry and Spence,
2003). These two points are of relevance to MT and
should be given consideration, as pre-disposing factors,
in the assessment of VA and ICA insufficiency.
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282 R. Kerry et al. / Manual Therapy 13 (2008) 278–288
Atherosclerosis is believed to be more prevalent in the
ICAs than VAs in modern Western societies (Ersoy
et al., 2003; Giannoukas et al., 2005). However, VA
disease has been reported (Mitchell, 2002) and proposed
as a risk factor for MT (Cagnie et al., 2006). VA and
ICA disease has been shown to co-exist in the same
patients and may be accompanied by coronary and
peripheral occlusive disease and hypercholesterolaemia
(Caplan et al., 1992). A large body of literature in this
area considers potential risk factors such as hyperten-
sion, smoking, diabetes, hypercholesterolaemia, hyper-
homocysteineamia, factors affecting blood coagulation,
vascular trauma, infection, and migraine (Ross, 1999;
Pezzini et al., 2002; Westaway et al., 2003; Migdalski
et al., 2005; Arnold et al., 2006; Cagnie et al., 2006). This
emphasises the need to incorporate both localised and
systemic factors in pre-treatment clinical reasoning and
risk assessment for all age groups. Contrary to this line
of thinking are the conclusions from a sole MT-specific
study which found no association between such risk
factors and reported cases of post-MT stroke (Halde-
man et al., 2002c). This report of 64 cases over a 16 year
period concluded that cerebrovascular accident follow-
ing manipulation was an unpredictable phenomenon.
However, pre-incident data (the most important when
considering profiling for chance of adverse event) was
only available in 41% of the 64 cases reported, the range
of events was restricted (i.e. only those that occurred
within 48 h of a manipulation treatment and those which
happened to get to the attention of a single physician),
and the range of atherosclerotic risk factors was narrow
and not representative of contemporary evidence-based
risk factors. Considering these points, and the over-
whelming amount of literature relating atherosclerosis
to stroke, it is difficult to refute the hypothesis that post-
MT strokes are associated with vascular pathology.
It is clear that the interaction between mechanisms of
vascular injury, underlying hereditary disorders, and
proposed risk factors adds a body of new information
for consideration. This knowledge may direct both the
clinical reasoning process and future research into pre-
treatment cervical risk assessment. This may direct
research toward the model used in suspected thrombo-
embolism (Fancher et al., 2004), a condition which
mirrors VA and ICA dissection in its complex patho-
genesis and level of difficulty to diagnose or predict
accurately.
4. Blood flow studies
The effects of cervical spine movements upon VA
blood flow have long been reported, with little
consideration of ICA blood flow and haemodynamic
compensatory principles. Initial cadaver experiments
showed decreased VA blood flow, particularly on
contralateral cervical spine rotation (Tissington-Tatlow
and Brammer, 1957; Toole and Tucker, 1960; Brown
and Tissington-Tatlow, 1963; Selecki, 1969). Later in
vivo studies, using flowmetry, angiography, Doppler
ultrasonography or magnetic resonance angiography,
and documenting changes in VA blood flow before and
after cervical spine rotation, have produced contra-
dictory results. Some researchers found no changes
(Weingart and Bischoff, 1992; Thiel et al., 1994; Haynes
and Milne, 2001; Zaina et al., 2003) while others
reported a significant reduction in contralateral blood
flow (Refshauge, 1994; Rossitti and Volkmann, 1995;
Licht et al., 1998a; Li et al., 1999; Rivett et al., 1998,
1999; Mitchell, 2003; Arnold et al., 2004; Mitchell et al.,
2004).
This controversy may be because there is no
standardisation of methods used. For example, healthy
subjects and patients, who may or may not have had
signs and symptoms of VBI at the time of measurement,
were used. Both young and older subjects were included
in some samples, and few authors compared males and
females (Sturzenneger et al., 1994; Li et al., 1999; Rivett
et al., 1999; Haynes et al., 2000; Scheel et al., 2000a, b;
Mitchell, 2003, 2007).
Blood flow measurements at pre-transverse, cervical
and intracranial parts of the VA have been reported.
The cervical VA, as it traverses the bony transverse
foramina, is difficult to insonate accurately which may
have confounded the findings (Johnson et al., 2000;
Khaw et al., 2004). There is a logical argument that it is
the change in blood flow in the intracranial part of the
VA (distal to the point of constriction) and not in the
more proximal extracranial VA, that may correlate with
potential hindbrain ischaemia most accurately (Zaina
et al., 2003; Mitchell, 2005, 2008). However, few studies
report blood flow measurements at this site (Rossitti and
Volkmann, 1995; Li et al., 1999; Mitchell, 2003; Mitchell
et al., 2004).
Various degrees of cervical spine rotation and
extension have been implicated in compromised VA
blood flow and associated VBI (Refshauge, 1994;
Sturzenneger et al., 1994; Licht et al., 1998b; Rivett
et al., 1998, 1999; Li et al., 1999; Scheel et al., 2000a;
Haynes and Milne, 2001). Reports of the effect of
cervical spine rotation on both ICA and VA blood flow
found either no significant change in ICA blood flow or
a decrease in both VA and ICA blood flow on rotation
and extension. (Schoning et al., 1994; Rivett et al., 1999;
Scheel et al., 2000a, b; Licht et al., 2002). An increase
followed by a decrease in VA and ICA blood flow at 451
and full rotation, respectively, is also reported (Re-
fshauge, 1994). Therefore, it is apparent from these
studies that blood flow changes in both the VA and
ICA, associated with cervical spine movements, should
be taken into account in patient pre-treatment risk
assessment.
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Some researchers, using patients experiencing mild
signs of VBI, found a decrease in blood flow (at mid-
cervical levels) on cervical spine rotation (Rivett et al.,
1999). Others found no significant decrease in VA blood
flow (at the pre-transverse level), despite positive VBI
signs reported by their subjects (Licht et al., 2000, 2002).
It is not clear from these findings if the VBI symptoms
altered with cervical spine rotation. It is notable that
most of the studies of decreased blood flow following
rotation, using normal subjects aged 20–40 years, report
no accompanying signs and symptoms of VBI. There-
fore, it is apparent that no correlation between cervical
spine rotation and VBI symptoms can be clearly
established from this research.
The contradictory findings of these studies preclude
definitive conclusions being made and emphasise the
need for more rigorous research into the complex
relationship between cervical spine movement and blood
flow changes which must, at this stage, be regarded as a
guide only in pre-treatment assessment.
5. Discussion and conclusions
This review of contemporary literature regarding
cervical spine MT and arterial insufficiency highlights
several areas of clinical importance and many of the
outcomes correspond with previously published reviews
in this subject area. There are some findings, however,
which add to existing MT knowledge and hence may
influence the development of clinical reasoning and
research. This review, therefore, serves to inform
professional practice.
Most blood flow studies reported refer to VA blood
flow in relation to cervical spine movement. Although
some studies report negative findings, there is an overall
trend suggesting that both VA and ICA blood flow are
influenced by full-range cervical spine movements,
although there are not always corresponding cerebro-
ischaemic symptoms. There is evidence that cervical
spine movement, principally rotation, influences VA
blood flow. ICA blood flow has been shown to be
influenced more by extension with rotation (Scheel et al.,
2000a, b), with some other reports implicating extension
as the most influential movement for ICA flow (Hane-
line et al., 2003). It is of interest to note here that the
extension component of functional testing has been
removed from MT pre-treatment guidelines (Magarey
et al., 2004; APA, 2006).
Recent guidelines (Magarey et al., 2004; APA, 2006)
aim to assist in identifying patients who are more likely
to suffer adverse neurovascular events should a parti-
cular treatment technique be used. One of the central
components to the guidelines for pre-treatment screen-
ing of patients is the performance of a functional
positioning test (the VBI test involving cervical spine
283
rotation and observing the reproduction of cardinal
signs and symptoms). Many blood flow studies that
demonstrate changes in blood flow during cervical spine
rotation, for example, conclude that their findings
support the use of the functional test (the test uses the
position to alter blood flow, altered blood flow has been
demonstrated in this study, therefore the test is valid).
However, there is little evidence to indicate a correlation
between blood flow changes and symptoms of VBI
(Licht et al., 1998a; Mitchell, 2003, 2007; Mitchell et al.,
2004). Thus, a subject can have reduced blood flow to
the brain but display no signs of cerebral ischaemia. It
has been reported earlier that the ICA and VA arterial
supplies are parts of an interdependent and compensa-
tory system. Therefore, it is unlikely that ischemic signs
would be displayed if there is adequate compensatory/
collateral blood flow.
The disparity between symptoms and blood flow has
been highlighted further by probability analysis regard-
ing utility of the functional test, which has reported its
poor sensitivity and variable specificity (Kerry and
Rushton 2003; Gross et al., 2005; Ritcher and Reinking,
2005). At the current level of evidence, pre-manipulative
screening tests should be considered no more clinically
valuable than Homan’s test, for example, which is still
used as a small part of wider examination procedures–in
lower limb deep vein thrombosis risk assessment
protocols despite its known poor reliability (Levi
et al., 1999).
The cardinal signs and symptoms of VBI also lack
consistent support from the literature reviewed. There is
a diversity of presentations demonstrated in the cases
reviewed. The most consistent recurring sign of VA and
ICA dysfunction is an increase in neck/head pain.
Localised, somatic pain referral, related to the ICA
(Munari et al., 1994) and the VA (Krespi et al., 2002),
has been reported. This presents an obvious diagnostic
challenge for the manual therapist. Other symptoms can
be attributed to dysfunction of the ICA (e.g. Horner’s
syndrome, flashing sensations) and may be erroneously
interpreted as VBI, or of more concern, because these
symptoms do not form part of the classic cardinal signs,
not attributed to a neurovascular cause at all.
An interesting trend in the literature is the distinction
between younger patients (o45 years) who have been
reported to suffer spontaneous or traumatic dissection
but may not demonstrate any of the classical vascular
risk factors (Rubinstein et al., 2005), and older patients
(445 years), who show signs of vascular pathology,
including atherosclerosis of the cervical vessels (Caplan
et al., 1992; Cagnie et al., 2006), who may demonstrate
classical (general or systemic) risk factors for vascular
disease. However, other reports have suggested that,
based on a cadaver study, the presence of VA
atherosclerosis in young (o45 years) subjects cannot
be excluded (Mitchell, 2002). This illustrates the
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284 R. Kerry et al. / Manual Therapy 13 (2008) 278–288
importance of understanding the complexity of CAD,
particularly that cerebral ischaemia may occur due to a
variety of underlying factors and pathologies.
Considering that there is a risk, it is important to
consider the size of the risk. Many reviews attempt to
establish a risk ratio, but these are misleading figures
based on under-reporting, methodological flaws, and an
erroneous perception of probability. The actual risk of
post-treatment complications cannot be determined
from the available evidence, and neither clinicians nor
patients should be misled into believing that the risk is
of a particular, established magnitude. The risk should
be calculated on all current factors surrounding the
particular situation at the particular time, for each
patient.
There have been few reports explicitly categorising
definitive risk factors for VA and ICA dysfunction.
Some have suggested that post-treatment accidents are
unpredictable and that there are no definitive risk
factors (Haldeman et al., 2002b). There are too few
reports, however, which have focussed specifically on
risk factors to make a conclusive judgment on this issue.
Only well-structured, large prospective investigations
could provide this information. There is a consistent
suggestion in the literature reviewed that compromised
blood flow to the brain and thrombo-embolic events are
related to various established vascular disease risk
factors (hypertension, hypercholesterolaemia, athero-
sclerosis, trauma, infection, migraine etc). In the absence
of strong evidence against this link, it might be prudent
for the manual therapist not to dismiss such risk factors.
Considering the inconsistencies in supporting evi-
dence for: (1) cardinal signs of arterial insufficiency; (2)
validity of functional testing; and (3) identification of
definite risk factors (for post-manipulation vascular
injury), the acceptance of and adherence to clinical
guidelines that incorporate inclusion of these areas
presents an interesting professional challenge. The
present medico-legal climate makes unreasoned compli-
ance to guidelines that are not based on consistent
evidence legally indefensible, and the opinions of expert
witnesses may be challenged in court (Bolitho v City and
Hackney, 1997; Foster, 2002, p. 116).
5.1. Risk versus benefit
This paper has purposefully focussed on potentially
serious adverse cervico-cranial events associated with
MT. It was not the intention of the authors to report
specifically on the suspected benefits of cervical MT.
However, in the clinical decision-making process, it is
unrealistic to consider risk without benefits, and vice
versa.
There have been several randomized controlled trials
investigating the effectiveness of cervical MT (e.g. Koes
et al., 1992a, b; Boline et al., 1995; Nilson et al., 1996;
Bronfort et al., 2001; Hoving et al., 2002; Jull et al.,
2002a) with increasing evidence that cervical MT alone,
or as part of multi-modal management strategy, is
beneficial for the relief of neck pain (Hurwitz et al.,
1996; Bronfort et al., 2004; Gross et al., 2004).
In order to make a statistically driven decision on the
risk:benefit ratio, valid data are needed on both sides of
this analysis. As stated earlier, valid data relating to size
of risk is incomplete. Intervention choices must also be
made in the context of alternative interventions and
their known risks. Commonly, authors compare cervical
MT with common medical interventions, such as non-
steroidal anti-inflammatories, and state that the risk of
MT is less than the known risks associated with
medication (Dabbs and Lauretti, 1995; Hurwitz et al.,
1996; Jull et al., 2002). Although this is likely, without
supporting data such claims should be noted with a
degree of caution.
Despite the lack of data, a small number of authors
have commented specifically on the risk:benefit judge-
ment and have come to firm conclusions. DiFabio
(1999) explicitly states that the risks of cervical
manipulation outweigh the benefits. This follows a
review of 177 cases of adverse events in the context of
selected literature exploring the proposed benefits of
cervical manipulation. Conversely, a more recent study
states that the potential benefits of cervical therapy do
outweigh the risks (Rubinstein et al., 2007). This
statement is based on the results of a prospective
follow-up survey of clinicians’ reports of responses to
treatment (as discussed above). Similarly, whilst this is
likely to be the case, such judgements need to be
considered in the context of the limitations of the data
and methodologies.
Childs et al. (2005) embrace the inherent uncertainties
in this clinical area and provide discussion on making
reasoned judgements in the absence of good data – not
only for risks and benefits, but also in respect of the
validity of screening procedures for potential risk. The
outcomes of this review reflect this thinking: incorpor-
ating knowledge of haemodynamic and vascular patho-
physiology into patient assessment may lead the
clinician to an informed judgement as to the likelihood
of serious adverse events. If the limitations of traditional
screening processes are understood and the evidence
regarding benefit considered, a sound and reasonable
decision may be reached regarding choice of interven-
tion.
5.2. Recommendations
There is a clear need for further research in a number
of areas in this field. The indication for large-scale,
robust, prospective trials has been consistently reported
as the best way to establish a reliable indicator of risk of
arterial insufficiency related to cervical spine MT.
 ARTICLE IN PRESS
R. Kerry et al. / Manual Therapy 13 (2008) 278–288
However, considering the size of the task, this would be
logistically difficult. Until a stronger evidence-base can
be established, it is advisable that manual therapists take
note of the available evidence supporting all of the
possible generic vascular risk factors, prior to cervical
spine MT. Based on the findings of this review, the
authors make the following recommendations:
1. Considering the limited support for the use of cervical
spine functional pre-manipulative screening tests (e.g.
the VBI test), as an indicator of either vascular
patency or of the propensity of blood vessels to be
injured as a result of MT, these tests should be used
with caution and the results should be interpreted in
the knowledge that the tests have little backing from
the evidence base.
2. There is evidence supporting the relationship between
vascular disease risk factors and CAD. As such the
authors recommend a subjective assessment of
vascular risk factors incorporating a ‘system’-based
approach (i.e. incorporating ICA and VA knowl-
edge).
3. Headache and neck pain are common presenting
signs of vascular dissection. Therefore, careful con-
sideration of the differential diagnosis of these
symptoms by the manual therapist is recommended.
4. As cervical artery haemodynamics (inclusive of the
ICA and therefore the system) are influenced by
movement as a whole, and not exclusively by single
thrust manipulative procedures, vascular risk assess-
ment should be considered prior to all manual
therapy procedures that induce movement in the
cervical spine region (APA, 2006).
5. The evidence suggests that confining pre-treatment
risk assessment to the VA in isolation may represent a
limitation in clinical reasoning. Consideration of the
cervical arterial system, together with the range of
vascular pathologies apparent within this system,
may enhance the clinician’s reasoning process.
Acknowledgements
The authors would like to acknowledge the support of
and thank: the Manipulation Association of Chartered
Physiotherapists (MACP) for its support in this project;
Steven Barrett and the Research Support Unit, Uni-
versity of Nottingham, for assistance in the literature
searches involved in this review; and Lindsay Skipper,
University of Nottingham for proof-reading this paper.
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