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


Vascular considerations

Manual therapy procedures have proven efficacy in relieving neck pain and headache, and make a significant contribution to the management of individuals with neck pain disorders as part of a multimodal management regime1,2,3,4.


Cervical arterial dissection (CAD) 6,7,8,9

The most serious adverse event associated with cervical manipulative therapy is cervical arterial dissection (CAD, a tear in the artery wall), more commonly affecting the vertebral than internal carotid artery. It is a rare condition, but can have devastating consequences (ie. stroke).

Look out for these features

Early presenting features of CAD include acute onset neck pain and/ or headache which may mimic a musculoskeletal presentation. Identifying potential CAD is critical. Risk of CAD may be increased with exposure to minor trauma, infection, genetic factors, migraine but less likely, cardiovascular risk factors.

  • younger patients under 55 years
  • acute, sudden onset of unfamiliar headache or neck pain
  • moderate – severe pain (often progressing)
  • spontaneous onset following recent exposure to minor trauma or neck strain eg, sporting injury, recent neck manipulation, jerky head movements, heavy lifting
  • recent unfamiliar neurological symptoms (check 5 Ds, 3 Ns; any recent disturbance to balance, speech, vision; any subtle or transient neurological features; Horner’s syndrome)
  • OR

  • developing neurological symptoms and signs during or after examination or treatment
  • OR

  • If there is anything about the patient’s presentation that makes you concerned eg, reporting atypical pain, severe pain, pain like nothing experienced previously; the patient is agitated, looks generally unwell.
Read more



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Vertebrobasilar insufficiency (VBI) 10

VBI is characteristically seen in older patients over 65 years, but can occur in younger people11 or as a feature of vertebral artery dissection.

Look out for these features

Symptoms eg, dizziness, 5 Ds or 3 Ns result from insufficient blood supply to the hindbrain. The patient may have cardiovascular risk factors such as hypertension, elevated cholesterol and smoking.

VBI occurs more commonly in association with longstanding neck pain and stiffness. VBI symptoms are commonly related to movement and positions of the neck. Be aware of other common causes of dizziness.


Physical examination

The VBI positional tests are not indicated when the patient has clear symptoms of VBI.

When are the positional tests indicated?

The VBI positional tests should be used if the symptoms are unclear and the clinician is exploring the possibility of VBI in differentiating the source of any dizziness, light headedness or unsteadiness.

  • In an older patient with neck pain to ensure treatment positions do not cause potential VBI
  • When end-range positions of the neck are being considered for treatment
  • For differential diagnosis of dizziness

Positional tests

Sustained rotation in sitting

Sustain for at least 10 secs

Wait 10 secs in neutral between sides (latency)

If the history indicates, test other neck or treatment positions as appropriate

Positive test responses


Nystagmus which does not settle within a few seconds


Feeling ‘unwell’

Any of the 5 Ds

Cease testing if symptoms not settling within seconds and/or getting worse

Treatment considerations

Never provoke dizziness or other VBI symptoms in treatment

Avoid end range neck positions during any manipulative therapy or exercise procedure

Read more


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High velocity manipulation techniques

Manipulative therapy (HVT) procedures have proven efficacy 1,2,3,4 in relieving neck pain and make a significant contribution to the management of individuals with neck pain disorders as part of a multimodal management regime. Nevertheless, there are some situations where HVT are contra-indicated.

Look out for these features

Patient history
  • ensure that there are no features of concern in the presentation or medical history which would contra-indicate high velocity manipulative procedures.12
  • suspected cervical arterial dissection (CAD) or risk of CAD
  • vertebrobasilar insufficiency (VBI)
Medical conditions
  • malignancy – primary, or secondary metastasis
  • inflammatory and Infective Arthritides
  • advanced diabetes
  • haemophilia
  • connective tissue disease: eg, Ehlers Danlos syndrome
  • conditions requiring long term use of steroids; anticoagulant medication
  • cranio-vertebral anomalies eg, congenital absence of odontoid or congenital fusion
  • deteriorating neurological status
Musculoskeletal states
  • advanced degenerative disease: lateral and/or spinal canal stenosis with or without neurological signs
  • recent major trauma 13,14 which may have compromised structural integrity (fracture; subluxation) eg, motor vehicle crash, sport, fall (especially in older persons)
  • segmental instability eg, traumatic or degenerative instability
  • previous spinal surgery
  • marked muscle spasm around the neck
  • bone disease eg, osteoporosis, osteopenia

Consider additional precautions for manipulative procedures

Pregnancy and post-partum period

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Mobilisation techniques

Be aware that some passive mobilisation and other techniques (eg, SNAGs) have the potential to compromise the cervical arteries and the clinician should be regularly monitoring the patient for any adverse symptoms or observable signs





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Pre-manipulative procedures

Clinicians should rely primarily on information from the patient history to inform their clinical judgment about whether the proposed treatment is appropriate in the context of the patient's presentation. Positional testing may provide additional information about the effect of the proposed technique on the cervical vascular system

Physical examination

Perform VBI positional testing monitoring for any adverse signs or symptoms: Either of the following positions can be used; be prepared to use a longer hold or different position if the history indicates

sustained rotation in sitting (or supine lying)

  • sustain for at least 10 secs
  • wait 10 secs in neutral between sides (latency).

treatment test position (Hold for minimum of 10 secs)

  • monitor for any adverse signs or symptoms,
  • is there any spasm or lack of end-feel?
  • is the patient feeling well, comfortable and relaxed?

Cease testing if symptoms not settling within seconds or getting worse.

If you have any reservations at all it is prudent not to proceed with HVT on that day and monitor the patient and consider whether manipulation is appropriate on another occasion.

Obtain informed consent

Manipulation considerations:

  • use minimum force
  • avoid end range positions for the neck
  • it is advisable to avoid using rotation thrust techniques in the high cervical spine.


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Informed Consent Process

Statement/Explanation to patient

  • what the treatment involves
  • discuss the potential benefits and risks of the proposed treatment in the context of their presentation and patient's circumstances – risk may be minor and transient (eg, increased pain), or rarely, serious (eg, stroke, or other neurological compromise or death)
  • alternatives to the proposed treatment discussed.





  • enquire whether the patient has any specific concerns
  • give an opportunity for patient to ask questions and address any concerns
  • check patient has understood and gives consent to proceed
  • record in patient notes.

The information provided is general in nature and is not intended to be relied upon as, nor be a substitute for, specific legal advice





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Dizziness - other considerations

Vascular causes of dizziness or unsteadiness which might be associated with neck pain disorders are relatively rare.

Other common causes of dizziness, light-headedness or unsteadiness which may (or may not) accompany neck pain include:


  • Cervicogenic dizziness:
    • may be associated with neck pain, whiplash and or concussion due to altered afferent cervical input to the sensorimotor control system.
  • Vestibular:
    • central eg, vestibular migraine, mild traumatic brain injury/ concussion
    • peripheral eg, Benign Paroxysmal Positional Vertigo (BPPV), Meniere’s disease, acoustic neuroma, labyrinthine concussion, vestibular neuronitis or labyrinthitis
  • Orthostatic/postural:
    • sudden drop in blood pressure related to change in body position
  • Medication side effect
  • Anxiety disorders, psychopathologies

The following references will give you more detailed information:

Read more




The following references will provide you with additional information:

Efficacy of manual therapy
Cervical arterial dissection (CAD)
Vertebrobasilar insufficiency (VBI)
Red flag conditions and trauma
Dizziness - other considerations

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