Manual Therapy and Cervical Arterial Dysfunction
Manual therapy is one of the treatment regime that is frequently used by musculoskeletal physicians, osteopaths, physiotherapists and chiropractors. It aims to quickly reduce pain and improve movement. Manual therapy treatment can include techniques that glide joints in a rhythmic manner (mobilisation), gap joint surfaces (manipulation) and/or use muscle contractions to restrict or loosen joints. Manual therapy rapidly reduces pain and muscle spasm and allows help with movement. Additionally, manual therapy can help exercise muscles that are not working due to pain – this can help with exercises.Despite well-known risks of cervical manual therapy, it is one of the evidence based strategies used commonly for cervico-cranial pain.
Arterial Complications assosciated with Manual Therapy
Cervical Arterial Dysfunction is an umbrella term covering spectrum of potential pathologies which range from pre-existing underlying anatomical anomalies, vasospasm, artherosclerosis, temporal arteritis, or arterial dissection. Clinical presentation of CAD may range from pain to cranial nerve dysfunction, sympathatic nerve dysfunction (e.g. Horner's Syndrome), blindness, stroke or at worse death.
- VERTEBROBASILAR INSUFFICIENCY- Even though number of adverse events have been documented e.g injury to intervertebral disc, ligaments, nerves, etc., the cause for main concern is arguably cerebro-vascular events related to stresses on the arterial vessels around the neck; the most frequent of such events is vertebobasilar insufficiency. Vestibular insufficiency relates to the transient or permanent reduction or cessation of blood supply to the hindbrain through the left and right vertebral arteries and basilar artery.  Additionally, in one of the studies conducted by Symons et al., it is suggested that during neck manipulative procedures (High Voltage Low Amplitude spinal manipulations) the stretches to the vertebral artery are smaller in comparison to the stretches produced during range of motion and diagnostic stretching . 
- INTERNAL CAROTID ARTERY DYSFUNCTION- Complications of manual therapy treatment related to the ICAs have been reported, since it can manifest in number of signs and symptoms that are non-ischemic (i.e., somatic pain related to local injury) which can precede cerebral ischemia (TIA or stroke) or retinal ischemia in early presentation (less than a week to beyond 30 days). 
Absolute contraindications to treatment
• Bone disease – tumours, metastases, infection, fractures, bone weakness (long term steroids/osteomalacia, severe osteoporosis), severe inflammatory types of arthritis (not osteoarthritis).
• Neurological considerations – spinal cord compression, moderate to severe nerve root compression from a disc/spondylolisthesis, myeloradiculopathy.
• Rheumatological considerations – active rheumatoid arthritis, ankylosing spondylitis and polymyalgia rheumatica are all contraindications.
• Vascular considerations – the risk of the patient having an aortic aneurysm, severe coagulation deficiencies, severe vertebro-basilar insufficiency, ischemic cervical and thoracic myelopathy must be considered and ruled out where possible.
• Lack of clinical hypothesis – where the exact cause of the pain is unclear and there is no obvious mechanism of injury, spinal manipulation should not be used.
• Hypermobility that is severe enough to produce frank instability.
• Intervertebral disc prolapse
• Pregnancy – Spinal manipulation and its risks need to be discussed in relation to precipitating a miscarriage (in the first trimester) or premature labour (in the last trimester). The overall risks are low during the second trimester where gentle techniques are advised. (14)
• Osteopenia, osteoporosis, metabolic bone disease
• Hypermobility syndromes with ligamentous laxity.
Recent key publications in the area
Kerry R, Taylor AJ, Mitchell J, McCarthy C, Brew J. Manual Therapy and Cervical Arterial Dysfunction, Directions for the Fuuture: A Clinical Perspective. The Journal of Manual & Manipulative Therapy 2008;16(suppl 1):39-48.
Of interest, the above journal also presents a brief review of the medico-legal status pertaining to this area. Although this is English law-related, the themes derived from this section should be of interest to all manual therapists.
Kerry R, Taylor AJ. Cervical Arterial Dysfunction Assessment and Manual Therapy. Manual Therapy 2006;11:243-253.
Kerry R, Taylor AJ. Cervical Arterial Dusfunction: Knowledge and Reasoning for Manual Physical Therapists. Journal of Orthopaedic & Sports Physical Therapy 2009;39(suppl 5):378-387.
References will automatically be added here, see adding references tutorial.
- Herzog W. (2010) The Biomechanics of Spinal Manipulation. Journal of Bodyworks and Movement Therapies. 14:280-286.
- Haavik H., Murphy B. (2012) The role of spinal manipulation in addressing disordered sensorimotor integration and altered motor control. Journal of Electromyography and Kinesiology. 22:768-77.
- Kerry R, Taylor AJ, Mitchell J, McCarthy C, Brew J. Manual Therapy and Cervical Arterial Dysfunction, Directions for the Fuuture: A Clinical Perspective. The Journal of Manual & Manipulative Therapy 2008;16(suppl 1):39-48.