APA Clinical guide to safe manual therapy practice in the cervical spine 2017

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Introduction

Manual therapy can form an important instrument of the physiotherapy tool kit when managing patients with neck pain disorders. Although rare, the risk of catastrophic adverse effects has been associated with manual therapy of the cervical spine. The most serious associated adverse events include cervical artery dissection (CAD) and vertebrobasilar insufficiency (VBI), both of which can lead to stroke.

The purpose of this Australian Physiotherapy Association (APA) clinical guide is to assist physiotherapists to practice safe manual therapy within the cervical spine region with the awareness and knowledge to be able to manage the risks and recognise early warning signs of adverse events.

(i) CAD

CAD describes a tear, that can vary in severity, in the arterial wall of a main vessel that supplies blood to the brain. It is more common for CAD to effect the vertebral artery rather than the internal carotid however dissection in either can be fatal. Blood clots are often dislodged and travel to the brain causing cerebrovascular blockage.

Patient risk is increased with recent minor trauma, infection, genetic factors, migraine and cardiovascular risk factors. Important early warning features include an acute onset of neck pain and/or headache. The patient demographic is usually under 55 years old and the pain pattern is a sudden onset of moderate to severe pain that does not subside. Therapists should be aware and ask patients about recent exposure to minor trauma (such as neck sprains or sporting injuries), recent unfamiliar neurological symptoms or recent infections.