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Review Article

Proposing a new algorithm for premanipulative testing in physical therapy practice

Brent Harper, PT, DPT, DSc, OCS, FAAOMPT1)*, Daniel Miner, PT, DPT, NCS2), Harrison Vaughan, PT, DPT, OCS3)

1) Crean College of Health and Behavior Sciences, Chapman University: 9401 Jeronimo Road, Irvine, CA 92618, USA

2) Department of Physical Therapy, Waldron College of Health and Human Services, Radford University, USA

3) PhysioFit, USA

Abstract. In thefieldofphysical therapy, there isdebateas to theclinicalutilityofpremanipulativevascularassessments.Cervicalarterydysfunction(CAD)riskassessmentinvolvesamulti-systemapproachtodifferentiatebetweenspontaneousversusmechanicalevents.Thepurposesofthisinductiveanalysisoftheliteraturearetodis-cussthelinkbetweencervicalspinemanipulation(CSM)andCAD,toexaminetheliteratureonpremanipulativevasculartests,andtosuggestanoptimalsequenceofpremanipulativetestingbasedonthedifferentiationofaspon-taneousversusmechanicalvascularevent.Knowingwhatpremanipulativevasculartestsassessandtheassociatedclinicalapplicationfacilitatesanevidence-informeddecisionforclinicalapplicationofvascularassessmentbeforeCSM.Key words:Manipulation,Algorithm,Cervical

(This article was submitted Jun. 18, 2020, and was accepted Aug. 4, 2020)

INTRODUCTION

Traditionally,vertebrobasilarinsufficiency(VBI)hasbeenconsideredthemostconcerningriskfactorforanadverseeventduringcervicalspinemanipulation(CSM)1, 2).ThemajorityofinvestigationsofCSMadverseeventshavefocusedonVBI,specificallyinjurytothevertebralartery(VA)3–6).Anothervascularconcernreportedintheliteratureinvolvesinternalcarotidartery(ICA)dissection4, 7–11)whichwouldindicateanimmediateneedformedicalreferral12).Thepurposesofthisclinicalperspectivesmanuscriptaretodiscussthelinkbetweencervicalspinemanipulation(CSM)andcervicalarterydysfunction(CAD),toexaminepremanipulativevasculartestsintheliterature,andtosuggestanoptimalsequenceofpremanipulativetestingbasedonthedifferentiationofaspontaneousversusmechanicalvascularevent.

METHODS

Anon-comprehensiveinductiveanalysisoftheliteratureaddressinglinksbetweenCSMandCADandareviewofpre-manipulativevasculartestsinordertoproposeanewalgorithmforpremanipulativetestinginphysicaltherapy.Theanswerstothisquestionweredeterminedthroughthefollowing5-stepprocess:aliteraturesearchwasconductedinordertoidentifyinformation;copiesofarticleswereidentifiedthroughtheliteraturesearchandobtained;asynopsesofeacharticlewaswrit-teninordertocaptureanyinformationpertainingtothepurposeofthestudy,theresearchdesign,sourcesandkindsofdata,datacollectionandanalysis,results,andconclusions.Anymanualtherapysafetyoptionsusedtoscreenpatientswithneck

J. Phys. Ther. Sci. 32: 775–783, 2020

*Correspondingauthor.BrentHarper(E-mail:brharper@chapman.edu)©2020TheSocietyofPhysicalTherapyScience.PublishedbyIPECInc.

Thisisanopen-accessarticledistributedunderthetermsoftheCreativeCommonsAttributionNon-CommercialNoDeriva-tives(by-nc-nd)License.(CC-BY-NC-ND4.0:https://creativecommons.org/licenses/by-nc-nd/4.0/)

The Journal of Physical Therapy Science

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painwasnotedoneachsynopsis.MEDLINEandCINHALsearchtermsincluded“classify”,“candidates”,“manipulation”,“uppercervicalspinemanipulation”,“clinicaldecisionmaking”,“clinicalreasoning”,“evidence-basedmedicine”,“predic-tiverule”,and“clinicalpredictionrule”.Allarticlesweresearched,butonlyEnglishlanguagearticleswereobtainedbecauseEnglishabstractsofnon-Englisharticlesindicatedirrelevance.Allyearsweresearchedwith,emphasiswasplacedonarticlespublishedwithinthelastten-years.Referencearticlesfromreviewedjournalsgarneredadditionalarticles.

RESULTS

Intheirdiscussionofvascularinsufficiencies,Kerryetal.13)andKerry&Taylor14)proposedarevisionofthenomencla-ture,suggestingthetermcervical artery dysfunction (CAD)sinceitencompassespotentialcomplicationsofallarteriesinthecervico-cranialregion.Theauthorsidentifiedinherentrisksfromaglobalhemodynamicperspectiveratherthanstructuralorpathological,ashistoricallycategorized.Kerryetal.13)definedCADas:thecompletenessofthearterialanatomy(e.g.,thevertebrobasilarsystem,theinternalcarotidarteries,andtheCircleofWillis),andtherangeofpathologiesthatthemanualtherapistmayencounter (e.g., localdissection,atheroscleroticevents,vessel injury,non-ischaemic[sic]events, ischemicevents).

ThisdefinitionofCADistheInternationalFrameworkforExaminationoftheCervicalRegionstandardasadoptedbytheInternationalFederationofOrthopaedicManualPhysicalTherapists(IFOMPT)foridentificationofvascularinvolvementbeforeorthopedicmanualtherapyintervention15).IFOMPTdoesnotdiscouragemechanicalvascularpatencyassessments,andtheAustralianPhysiotherapyAssociation(APA)16)protocolincludesevaluationforvascularsymptomswhileperformingmechanicalmovementsthatstressvascularpatency.

Neurovascular structurescanbecompromisedbothexternallyand internally, resulting in symptoms.CADsymptomsfromextrinsicormechanicalfactors,inwhichanatomicalstructuresplayarole,includingosteophytes,skeletalanomalies,muscularentrapment,fibrousbands,andnerveentrapment,maycompromiseneurovascularstructures.Excessivemechani-calforces,likecervicalspinerotationandhyperextensionorCSM,arealsoextrinsiccauseswhichmayresultinmechanicalarterialdissection17).IntrinsicCADsymptomsrelatetothepathologyofthearteryitself,anarrowingofthelumen.Intrinsicfactorsincludeatherosclerosis,aneurysms,thrombosis,andemboli,anyofwhichmayresultinspontaneousarterialdissec-tion17, 18).

TheincidenceofmechanicalarterialdissectionsduetoanextrinsicfactorsuchasCSMrangesfrom1in9,000to1in10millionwithinherentunder-reporting,makingtheactualincidencechallengingtocalculateaccurately19–24).Theincidenceofspontaneousarterialdissectionduetointrinsicfactorsis1to1.5per100,000people19–24).Thus,aspontaneousarterialdissectioneventisprobablymoreprevalentthanthoseassociatedwithCSMorvertebralarterytestinglikedeKleyn’s,pre-manipulativeholdsorcervicalrotation19–24).Consequently,thereappeartobeotherfactorsinvolvedinarterialcompromisebesidesthebiomechanicalforcesassociatedwithCSMorvertebralarterytesting17, 20, 21, 25).Theseotherfactorsfocusonvari-ousmedicalco-morbidities,resultinginturbulenceinthearteries,specificallyatherosclerosis,hypertension,ordiabetesmel-litus18, 26, 27).Spontaneousarterialdissectionsappeartoberelatedtoco-morbiditiesthataffectvasculature,primarilyICAs,aswellastheVAs.TheICAsaffectedbyvascularturbulenceissuesaremorelikelytopresentwithsignsandsymptoms.Itisnosurprise,then,thatICAdissectionratesarenearlydoubletheratesofVAdissection28).Giventhevariouscorticalandsubcorticalregionsthesevesselssupply,clinicalsigns,andsymptomsassociatedwithICAdissectiondiffersignificantlyfromthoseassociatedwithVAdissection.AfulldescriptionofICAsymptomsisbeyondthispaper’sscope,butinitialsignsofICAdisruptionareoftenseenbytestingeyefunctions17,29).Thecriticalelementregardingmechanicalextrinsicandintrinsictestingisthatbiomechanicalarterialtestingwillnotassistinidentifyingthoseatriskofspontaneousarterialdissection.Infact,theactualperformanceofabiomechanicaltestonsomeoneatriskforintrinsicpathologymayenableaspontaneouseventtooccurmorereadily17).

Cliniciansmustbeabletoeffectivelyscreenforandruleoutconcernforvascularcompromisebeforeanymechanicalevaluationofthecervicalspine.Theabilitytoeffectivelyscreenforvascularcomplicationthreatsisessentialtounderstand-ingtheunderlyingriskfactorswhichmaypredisposeanindividualtocervicalarterydissection(Fig.1)17).

TheICAsprovide80–89%ofbloodflowtothebrainandgiverisetothemiddleandanteriorcerebralarteries.TheVAsjointoformthebasilararteryandcontribute11–20%ofcerebralbloodflowtotheposteriorcirculationofthebrain30, 31).ThecourseoftheVAvariesandismorelikelytobeanomalousinindividualswithcongenitaldeformitiesofthecranio-cervical junctionorwithahistoryof traumainvolvingatlantoaxialsubluxation32, 33).Upto20%of thepopulationhasanormal anatomical variation of some type.Theoretically, anomalies of theVA, or any artery,may alter hemodynamicsby increased turbulence,whichmaypredispose the individual toaneurysms, thus increasing the risk forcerebrovascularaccident(CVA)17, 27).Despiteanatomicalvariations,theirimpactontheriskofVAdissectionisunknown34, 35).

TheVApassesthroughfourdistinctanatomicalzones.Inzone3,theVApassesthroughthetransverseforamenofC1andmakesasharpturnhorizontallyacrossitbeforepiercingthroughtheduramater.Fiftypercentofcervicalrotationoccurswithinzone3attheatlantoaxial(AA)jointbetweenC1andC2,causingthemostsignificantimpactontheVAasitmaybe“tethered”atvariouspoints11, 34, 35).Therefore,thetortuouscourseoftheVAinzone3correlateswiththelocationmostfrequentlyatriskfromCSM36–38).

TheanatomicalcourseoftheVAanditspotentialvulnerabilityatfixationpointsmightaffectbloodflowduringcervical

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activerangeofmotion,premanipulativemechanicaltesting,orCSM.TheVAisstretchedmoresignificantlyduringrotation,whereas the ICA is stretchedmore during extension39, 40).Thesefindings have been the foundational premise for usingpremanipulativetestingtoassessforcompromisedcirculationinthecervico-cranialarteries41).

Premanipulativemechanical(extrinsic)vascularassessmentsaretheestablishedstandardofcare;deKleyn’stestisoneof themostcommon42).Symptomprovocationwithpositional testing indicatesapositivedeKleyn’s testconsistentwithCADandindicatesCSMcontraindication.Researchers43)measuredcervicalbloodflowinneutralanddeKleyn’spositionusingdopplerultrasoundtomeasurebloodflowvelocityon20individualswithapositivedeKleyn’stest.SignificantclinicalinconsistencieswerefoundbetweendeKleyn’stestanddopplerfindings.Theresearchersconcludedapositivepremanipula-tivetest,suchasdeKleyn’s,doesnotindicateanabsolutecontraindicationtoCSM,butwouldindicateaneedforreferralfordopplerultrasoundexaminationofthearterialflow.Finally,theauthorsstatedthatifthefollowupdopplerultrasoundisnormal,thenCSMisnotcontraindication,evenwithpositivepremanipulativetest43).

ThemostsignificantriskofupperCSMiscervicalarterialdissectionleadingtostrokeordeath44).Zainaetal.45)examinedtheeffectofcervicalrotationonC1–2contralateralVAbloodflowpeakvelocityandonC5–6ipsilateralVAvolumeflow

Fig. 1. Algorithm:clinicalreasoningsequencefordeterminingvascularrisk17).AROM:ActiveRangeofMotion;CSM:CervicalSpineManipulation.

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rate,andwhethertherewasacumulativebloodflow.Twentyparticipantswereexaminedwithultrasounddopplerinaseatedpositionwithheadneutral,at45degrees,andinendrangecervicalrotation.Noneof theparticipantsweresymptomaticduringtesting,andnosignificantdifferenceswerefoundat45degreesorend-rangerotationsinthebloodflowparametersofpeakvelocityatC1–2andvolumeflowrateatC5–6.Repetitionoftherotationalpositioningdidnothaveacumulativeeffect,demonstratingthatcumulativepremanipulativetestingdidnotharmtheVAsinthoseparticipants45).Furthermore,Erhardtetal.46)assessedhaemodynamicsonhealthyadultsatC1–2andfoundnodeletreiouseffectstoVAbloodflowwhencomparinghigh-velocitylowamplitude(HLVT)thrusttechniquetopremanipulativeholds.

SpecificbloodflowturbulenceassessmentssuchasdopplerultrasonographyhavedemonstratedthatspontaneouschangesinVAandICAbloodflow16, 47, 48)arenotalwaysdirectlyrelatedtoCSMmechanicalforces,butmaybeintrinsicallybased.Atpresent,therearenodefinitivefindingsrelatingbloodflowchangestoCSMandliteratureismixed;severalstudiesshowareductionincontralateralbloodflowduringcervicalrotation49–53),whileothersshownobloodflowchanges54–57).Onestudy58)usedMRItoassessbloodflowofhealthyindividualsduringvariousnon-manipulativeproceduressuchasend-rangecervicalrotation,uppercervicalrotation,orfirmaxialdistractionandfoundnoalterationsinbloodflowandconcludeditunlikelythatend-rangeneckrotationanddistractionpositionsarehazardoustothecerebralcirculation.Furthermore,theauthorssuggestedspecificsegmentallylocalizedtechniquesposednohigherrisktocerebralcirculationthanthemechanicalpositions tested58).Other research59) on healthy, asymptomatic patientswith decreased bloodflow inVAs and ICAs, asconfirmedbymagneticresonanceangiography,hadnegativepositionaltestsforCADduringmechanicalendrangerotationtesting.Theresultsofthesestudiescallintoquestiontheutilityofmechanicalvascularassessmentprocedures.Thomasetal.59)hypothesizedthatcompromisedbloodflowinonearteryisnaturallycompensatedforbycollateralflowthroughthearterialCircleofWillis,whichhelpstomitigateanysymptomswhichmayhaveresultedfromdecreasedcirculation.Thisevidencemaysuggestthatindividualswhoexperienceend-rangecervicalrotationsymptomsmaynothaveCAD,butmayhavedysfunctionmoreproximally(intrinsic)intheintracranialcirculationoftheCircleofWillis59).

Furthermore,Symons&Westaway27)arguethatbiomechanicalvertebralarterialtests,likedeKleyn’s,andmanualinter-ventions,likeCSM,maynotdisruptvertebralarterybloodflowfortworeasons.First,mostpeoplehavefourmajorarteriesthatsupply theCircleofWillis,allowingcollateralreflexivevascularcompensationforanybrainperfusiondeficits.TheauthorsprovideevidencethatcompensatorybloodflowoccurswithoutresultinginanincidentofVBI,evenwhen100%ofthevertebralarteryisoccluded.Second,theauthorsreportthatCSMistoofast,occurringat200milliseconds,ifperformedcorrectly inmid-rangeandnotatend-range tension,whichdoesnotstress theneurovascularstructures likeaprolongedstretch.Therefore,CSMproceduresaretoofasttocausearterialdamageifperformedintheproperrangeofmotion.TheauthorsconcludethatifCSMinducesVBIsignsandsymptoms,itdoessoonlyinthepresenceofotherfactorslikewhenaspontaneouseventisalreadyinprogress27).

Eventhoughpremanipulativemechanicalvascularassessmentsaretaughtinentry-levelphysicaltherapyprograms,theycontinuetobechallengedandquestionedasobjectiveclinicaltests.Duetoreducedsensitivity11, 13, 14, 48, 60),thesetestsareas-sociatedwithahighrateoffalsenegatives6)andhavepoorabilitytodiscriminatebetweenindividualswithorwithoutarterialpathology.Evidence-informedpracticeindicatesthatclinicianscannotrelysolelyonsymptomprovocationwithmechanicalvascularassessmentstodefinitivelyruleoutcervicalarterydysfunctionduetothepoordiagnosticaccuracyofthesetests3, 60).

Insummary,oneofthefirstclinicaltestsforcervicalarterialdysfunctionwasdescribedbydeKlyneover50-yearsagoandcontinuestobecommonlyused4)eventhoughconcernsrelatedtodiagnosticaccuracyhavepreventeditsintegrationintoclinicalpredictionrules.Bloodflow45, 54, 57, 58), VA61, 62),andICA61)strainstudiesfoundacompletelackofconstructvalidityforpremanipulativevascularscreeningtests.Theliteraturefailstosupporttheabilityofpremanipulativeteststoidentify,throughpositiveornegativetestfindings,individualsatriskforapost-CSMvascularevent3,5,11,13,39,63),toprovideanyusefuladditionaldiagnosticinformation64);andhasidentifiedahighfrequencyoffalsenegativeVAtests65).Manyauthorsadviseagainstusingmechanicalvascularteststoassessvascularpatency,primarilywhenathoroughhistoryidentifiessignsandsymptomsconsistentwithCAD13, 60, 64).Finally,theevidencesuggeststhatactiverangeofmotionputsmorestrainontheICAthanCSM61).

Limitationsincludedlackofaccesstonon-publishedprofessionalconferencesandthepossibilitythatsomenon-Englishprofessionalwritingsintheformofbooksandjournalarticlesmighthavebeenrelevanttothesubjectstudiedinthispaper.

DISCUSSION

TheAustralianPhysiotherapyAssociation(APA)VAprotocol16)recommendsconductingactiverangeofmotion(AROM)andpositionalvascularpatencytestwhensymptomsofVBI/CADareunclearonpatientswithavaguesubjectivehistoryforpotentialVBI/CADsymptoms.IntheUnitedStates,vascularscreeningremainscommonpracticepriortoCSM.Despitethecurrentresearch,IFOMPT15)doesnotspecificallydiscouragemechanicalvascularpatencyassessments.ICAvascularcompromise is associatedwith spontaneousarterialdissection; thus, assessments forovert symptomsor thepresenceofvaguesignsandsymptomsassociatedwithICAischemiaisvital,inconjunctionwithathoroughhistoryofco-morbiditiesandevents(Tables1and 3)beforeanymechanicalstressisplacedintheregion17),suchasvascularscreeningormechanicalstressors(AROM),

DespitethelackofsupportformechanicalvascularassessmentsforCAD,thereremainssomeclinicalvalueinprema-nipulativescreeningtests.Thekeytounderstandingtheirclinicalvalueisinacknowledgingthatmechanicaltestscannot

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identifyriskforspontaneousCADand,aspreviouslystated,maycauseavascularevent. If therearenoriskfactors forvasculardiseaseandnegativenon-vascularpatencyscreeningtests(likeheartrate,bloodpressure,bruits)forsystem-widespontaneousvascularcompromise,thenthereisminimalriskofprovokingavasculareventthroughtheuseofmechanicalvascularscreens.Ontheotherhand,ifpositiveriskfactorsareidentifiedforaspontaneouseventoriftheclinicianisunsure,theclinicianwouldbeunwisetoattemptprovocationthroughmechanicaltesting.Therefore,mechanicalpremanipulativetestsarenotemployedwhentheclinicianhasanysuspicionthataspontaneousvasculareventisimminentorhighlyprob-able13, 17, 66),butmaybeusefultoassessanindividual’sphysicalandemotionaltoleranceintherangeinwhichtheCSMwilloccur17).

Itistheopinionoftheauthorsthatthecurrentevidencedoesnotsupporttheutilityofroutinelyperformingpremanipula-tivescreens,suchasdeKlyne’s, to identifyCAD.Presently,basedon thecurrentmedico-legalconstraintsgoverning theprofession,premanipulativescreensshouldbedone,whenappropriate,formedico-legalpurposesduetothesocietalpercep-tionoftherisksforadverseevents,eventhoughtheevidencedoesnotsupportthetests,untilwhichtimetheexpectationsofexcludingmechanicalpremanipulativetestingbecomes“standard”practice17).

Thisclinicalusefulnessofthisstudyisinitsemphasisontheorderofoperationsforsafelyscreeningforspontaneousarterial dissectionprior toAROM, and in the recommendation that vascular screening tests arenot useful for assessingvascularpatency,butmightbeusefulafterclearanceforspontaneousdissection(Table1)toassessanindividual’smechani-calandemotionaltolerancewithintherangeCSMwilloccur.ThisalgorithmisintendedtoaddtoAPA16)andIFOMPT15) premanipulativeCADguidelines (Fig.1)and isbasedon intrinsicversusextrinsicdisorders.Screening for spontaneoushemodynamicCADinvolvesacombinationofassessingforco-morbidities,investigatingpatienthistoricalevents,evalu-atingsubjectivecomplaints,andprovidingappropriatephysicalexaminationprocedures11, 13, 14, 17, 67).Oncespontaneousvascular sequelaeevents (intrinsicdisorders) (Table1)havebeenscreenedasnegative forvascularco-morbidities, thenpremanipulativescreeningformechanicalarterialcompromise(extrinsicdisorders)(Table2)canbeperformed,nottoassessarterialpatencyintermsofVBI/CAD,buttoevaluateforpotentialintolerancetomechanicalforceswhichmayoccurduringCSM17)(Table3).

Table 1.Optimalsequenceofpremanipulativeassessment(intrinsic)11, 13, 14, 17, 67)

Spontaneousarterialdissection(intrinsicdisorder)

History–Subjectiveexam/SE

1.Symptoms:5Ds(Diplopia,Dizziness,DropAttacks,Dysarthria,&Dysphagia),3Ns(Nausea,Nystagmus,&Numbness),Headache,Ataxia

2.Co-Morbidities(Anythingthatincreasesturbulence):Atherosclerosis,Hypertension(HTN),DiabetesMellitus(DM),historyofmigraine,geneticdefects(e.g.,increasedlevelsofaminoacidhomocysteinecreatingfragilityofthearterialwalls)

3.HistoricalEventsa)Asuddenonsetofseveresharpposteriorcervicalandoccipitalpain.b)Ahistoryofsmoking(especiallylong-standinghistory).c)Episodicdizzinessorvertigolastinggreaterthanoneminuteinisolationorwithpre-manipulativescreeningtest.d)Previoushistoryofischemicattacks.e)Ahistoryoftrauma(especiallyifitincludedwhiplashthatinvolvedaflexion-distrac-tion-and-rotationforce).

Tests&Measures–Objectiveexam (Physicalexam/PE)

HeartRate(HR),BloodPressure(BP),Auscultationforbruits,cranialnerveexamination,generaleyeexamination,labbloodtests(aminoacidhomocysteinelevels).

Table 2.Optimalsequenceofpremanipulativeassessment(extrinsic)11, 13, 14, 17, 67)

Mechanicalarterialcompromise(extrinsicdisorder)History–Subjectiveexam/SE 1.HistoricalEvents

a)Asuddenonsetofseveresharpposteriorcervicalandoccipitalpain.b)Ahistoryofsmoking(especiallylong-standinghistory).c)Episodicdizzinessorvertigolastinggreaterthanoneminuteinisolationorwithpre-manipulativescreeningtest.d)Previoushistoryofischemicattacks.e)Ahistoryoftrauma(especiallyifitincludedwhiplashthatinvolvedaflexion-distrac-tion-and-rotationforce).

Tests&Measures–Objectiveexam(Physicalexam/PE)

deKleyn’stest,FullPhysiologicalCervicalRotationtest,Pre-ManipulativeHold(PMH)test,HandheldDopplerVelocimeter.

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FundingNone.

Table 3.Clinicalreasoningsequencefordeterminingvascularrisk(Fig.1)11, 13–15, 17, 43, 67)

History– Subjectiveexam(SE)

Review of Systems (General Health):Intakequestionnairescreening.Co-Morbidities: Higher Suspicion with Increased System Involvement and Subjective ReportsAtherosclerosis;associatedfactorsinclude:Hypertension,Hypercholesterolemia,Hyperlipidemia,Hyperhomocys-teinemia,Heartdisease,Diabetesmellitus,Lupuserythematosus,alcoholism,Geneticclottingdisorders,infections,smoking,Directvesseltrauma,Iatrogeniccauses(surgery,medicalinterventions).Genetic / Lifestyle Factors:Femalegender,advancingage,obesity,sedentarylifestyleandprolongedbedrest,cigarettesmoking.Subjective complaints of:Dizziness(vertigo,giddiness,lightheadedness),Dropattacks(lossofconsciousness),Diplopia,Dysarthria,Dysphagia,Nystagmus,Nausea,Numbness,Headache,andAtaxia.History of:Headacheorneckpain,especiallyifsuddenandsevere,vomiting,facialsensationalteration,blurredvision,tinnitus,historyofpasttrauma,(particularlyahigh-velocityflexion-distractionwithrotationalforces,likethoseoccurringduringawhiplashincident),nystagmus,alteredbloodpressure,previoustransientischaemicat-tacks,Horner’ssyndrome.Historical Events:Asuddenonsetofseveresharpposteriorcervicalandoccipitalpain.Ahistoryofsmoking(especiallylongstandinghistory).Episodicdizzinessorvertigolastinggreaterthanoneminuteinisolationorwithpre-manipulativescreeningtest.Previoushistoryofischemicattacks.Ahistoryoftrauma(especiallyifitincludedwhiplashthatinvolvedaflexion-distraction-and-rotationforce).

Tests& Measures–Objectiveexam(OE)

Structural InspectionSystemsReview(SpecificSystems):VitalSignse.g.,HeartRate(HR),BloodPressure(BP),RespiratoryRate(RR),Oxygensaturation,etc.PalpationAuscultationofbruits.Pulsepalpation/examinationandgeneralvascularassessment(e.g.,nailbedrefill,etc.).Special TestsCranialnerveexamination(maybelistedunderNeurologicalTestsorSpecialTest).CNII(visionandeyeexam;acuity(Snellencharts),colorvision(Ishiharaplates),visualfields,visualreflexes(reac-tivitytolight),fundoscopy,CNIII,IV,VI(ExtraocularMuscles)GeneralEyeexaminationmayinclude:1.Eyeposition&alignment/Upper&Lowereyelidsinrelationtoeyeball.2.PupilPERRLA

P=PupilsizewithchartinMM(3–4.5normal) E=Equal/Symmetricalsizes(subtledifferencesisnormal) R=Shape(normalisround) R=Reactivetolight(directresponse=pupilnarrowswithdirectlighttoeye) (consensualresponse=pupilnarrowslightoppositeeye) L=Lacrimal(inspectregionslacrimalgland/sacforswelling) (lookforexcessivetearingordryness) A=Accommodation(pupilconstrictsandexpandswhenfocusingonshortandnearobjects)

3.VisualAcuity(SnellenChart)4.ExtraocularMuscles(checkingsmoothpursuit/gazein“H”pattern;pauseduringupward&lateralgazetodetectnystagmus)(Normal=afewbeatsofnystagmusonextremelateralgazeisWNL)

DirectMechanicalTestingOptionsInclude/FunctionalPositionTests:1.Fullphysiologicalcervicalrotation.2.deKleyn’sTest(subjectpositionedattheendofthebedat3rdthoracicsegmentwithcervicalsegmentshangingoffthetabletoallowforfullsupportedextension-rotation).

3.Pre-manipulativehold/PMH(positionedincranio-vertebralsideflexioncombinedwithcontralateralrotationdowntoandincludingatlanto-axialjointwithdigitalpressureonC1–C2justshortofmanipulativethrustandheldforaminimumof10seconds).

4.HandheldDopplervelocimetry. Ifmechanicalpremanipulativetestsarepositive,referpatientforDopplerultrasonography.

LAB ValuesElevatedlevelsofaminoacidhomocysteine.NormalLevels(plasma):Males4–12micromoles/L,Females4–10micromoles/L.Levelmaybeconsideredelevatedif>9micromoles/L.

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Conflict of interest

Theauthorshavenoconflictofintereststodisclose.

REFERENCES

1) CarlessoLC,GrossAR,SantaguidaPL,etal.:Adverseeventsassociatedwiththeuseofcervicalmanipulationandmobilizationforthetreatmentofneckpaininadults:asystematicreview.ManTher,2010,15:434–444.[Medline] [CrossRef]

2) ChungCL,CôtéP,SternP,etal.:Theassociationbetweencervicalspinemanipulationandcarotidarterydissection:asystematicreviewoftheliterature.JManipulativePhysiolTher,2015,38:672–676.[Medline] [CrossRef]

3) DiFabioRP:Manipulationofthecervicalspine:risksandbenefits.PhysTher,1999,79:50–65.[Medline]4) GrantR:Vertebralarterytesting—theAustralianPhysiotherapyAssociationProtocolafter6years.ManTher,1996,1:149–153.[Medline] [CrossRef]5) HaldemanS,KohlbeckFJ,McGregorM:Unpredictabilityofcerebrovascularischemiaassociatedwithcervicalspinemanipulationtherapy:areviewofsixty-

fourcasesaftercervicalspinemanipulation.Spine,2002,27:49–55.[Medline] [CrossRef]6) HanelineMT,CroftAC,FrishbergBM:Associationofinternalcarotidarterydissectionandchiropracticmanipulation.Neurologist,2003,9:35–44.[Medline]

[CrossRef]7) BeattyRA:Dissectinghematomaoftheinternalcarotidarteryfollowingchiropracticcervicalmanipulation.JTrauma,1977,17:248–249.[Medline] [Cross-

Ref]8) HamannG,FelberS,HaasA,etal.:Cervicocephalicarterydissectionsduetochiropracticmanipulations.Lancet,1993,341:764–765.[Medline] [CrossRef]9) LynessSS,WagmanAD:Neurologicaldeficitfollowingcervicalmanipulation.SurgNeurol,1974,2:121–124.[Medline]10) PetersM,BohlJ,ThömkeF,etal.:Dissectionoftheinternalcarotidarteryafterchiropracticmanipulationoftheneck.Neurology,1995,45:2284–2286.

[Medline] [CrossRef]11) TaylorAJ,KerryR:Neckpainandheadacheasaresultofinternalcarotidarterydissection:implicationsformanualtherapists.ManTher,2005,10:73–77.

[Medline] [CrossRef]12) WillettGM,WachholtzNA:Apatientwithinternalcarotidarterydissection.PhysTher,2011,91:1266–1274.[Medline] [CrossRef]13) KerryR,TaylorAJ,MitchellJ,etal.:Manualtherapyandcervicalarterialdysfunction,directionsforthefuture:aclinicalperspective.JManualManipTher,

2008,16:39–48.[Medline] [CrossRef]14) KerryR,TaylorAJ:Cervicalarterialdysfunction:knowledgeandreasoningformanualphysicaltherapists.JOrthopSportsPhysTher,2009,39:378–387.

[Medline] [CrossRef]15) RushtonA,RivettD,CarlessoL,etal.:InternationalframeworkforexaminationofthecervicalregionforpotentialofCervicalArterialDysfunctionpriorto

OrthopaedicManualTherapyintervention.ManTher,2014,19:222–228.[Medline] [CrossRef]16) MagareyME,RebbeckT,CoughlanB,etal.:Pre-manipulativetestingofthecervicalspinereview,revisionandnewclinicalguidelines.ManTher,2004,9:

95–108.[Medline] [CrossRef]17) HarperB:Clinicalreasoningforuppercervicalspinemanipulation:modifiedextensiveliteraturereview.(Doctoraldissertation).OlaGrimsbyInstitute,Salt

LakeCity,UT.2008.18) MitchellJ:Vertebralarteryatherosclerosis:ariskfactorintheuseofmanipulativetherapy?PhysiotherResInt,2002,7:122–135.[Medline] [CrossRef]19) CassidyJD,BoyleE,CôtéP,etal.:Riskofvertebrobasilarstrokeandchiropracticcare:resultsofapopulation-basedcase-controlandcase-crossoverstudy.

Spine,2008,33:S176–S183.[Medline] [CrossRef]20) HartRG,EastonJD:Dissectionsofcervicalandcerebralarteries.NeurolClin,1983,1:155–182.[Medline] [CrossRef]21) LeeVH,BrownRDJr,MandrekarJN,etal.:Incidenceandoutcomeofcervicalarterydissection:apopulation-basedstudy.Neurology,2006,67:1809–1812.

[Medline] [CrossRef]22) MurphyDR:Currentunderstandingoftherelationshipbetweencervicalmanipulationandstroke:whatdoesitmeanforthechiropracticprofession?Chiropr

Osteopat,2010,18:22.[Medline] [CrossRef]23) RothwellDM,BondySJ,WilliamsJI:Chiropracticmanipulationandstroke:apopulation-basedcase-controlstudy.Stroke,2001,32:1054–1060.[Medline]

[CrossRef]24) WhedonJM,SongY,MackenzieTA,etal.:RiskofstrokeafterchiropracticspinalmanipulationinmedicareBbeneficiariesaged66to99yearswithneck

pain.JManipulativePhysiolTher,2015,38:93–101.[Medline] [CrossRef]25) SchievinkWI,MokriB,WhisnantJP:Internalcarotidarterydissectioninacommunity.Rochester,Minnesota,1987–1992.Stroke,1993,24:1678–1680.

[Medline] [CrossRef]26) RosnerAL:Spontaneouscervicalarterydissectionsandimplicationsforhomocysteine.JManipulativePhysiolTher,2004,27:124–132.[Medline] [Cross-

Ref]27) SymonsBP,WestawayM:Virchow’striadandspinalmanipulativetherapyofthecervicalspine.JCanChiroprAssoc,2001,45:225–231.28) BillerJ,SaccoRL,AlbuquerqueFC,etal.AmericanHeartAssociationStrokeCouncil:Cervicalarterialdissectionsandassociationwithcervicalmanipula-

tivetherapy:astatementforhealthcareprofessionalsfromtheAmericanheartassociation/Americanstrokeassociation.Stroke,2014,45:3155–3174.[Medline] [CrossRef]

29) ChaibiA,RussellMB:Arisk-benefitassessmentstrategytoexcludecervicalarterydissectioninspinalmanual-therapy:acomprehensivereview.AnnMed,2019,51:118–127.[Medline] [CrossRef]

30) GrieveGP:Commonvertebraljointproblems.NewYork:ChurchillLivingstoneInc,1981.31) CaillietR:Headandfacepainsyndromes,1sted.Philadelphia:F.A.DavisCompany,1992.32) YamazakiM,OkawaA,FuruyaT,etal.:Anomalousvertebralarteriesintheextra-andintraosseousregionsofthecraniovertebraljunctionvisualizedby

J. Phys. Ther. Sci. Vol. 32, No. 11, 2020 782

3-dimensionalcomputedtomographicangiography:analysisof100consecutivesurgicalcasesandreviewoftheliterature.Spine,2012,37:E1389–E1397.[Medline] [CrossRef]

33) VaněkP,BradáčO,deLacyP,etal.:VertebralarteryandosseousanomaliescharacteristicatthecraniocervicaljunctiondiagnosedbyCTand3DCTangiog-raphyinnormalCzechpopulation:analysisof511consecutivepatients.NeurosurgRev,2017,40:369–376.[Medline] [CrossRef]

34) JohnsonCP,HowT,ScraggsM,etal.:Abiomechanicalstudyofthehumanvertebralarterywithimplicationsforfatalarterialinjury.ForensicSciInt,2000,109:169–182.[Medline] [CrossRef]

35) MacchiC,GiannelliF,CecchiF,etal.:TheinnerdiameterofhumanintracranialvertebralarterybycolorDopplermethod.ItalJAnatEmbryol,1996,101:81–87.[Medline]

36) FrumkinLR,BalohRW:Wallenberg’ssyndromefollowingneckmanipulation.Neurology,1990,40:611–615.[Medline] [CrossRef]37) GeorgeB,LaurianC:Vertebro-basilarischaemiawiththrombosisofthevertebralartery:reportoftwocaseswithembolism.JNeurolNeurosurgPsychiatry,

1982,45:91–93.[Medline] [CrossRef]38) SimE,SchwarzN,Biowski-FaschingI,etal.:Color-codedDuplexsonographyofvertebralarteries.11casesofbluntcervicalspineinjury.ActaOrthopScand,

1993,64:133–137.[Medline] [CrossRef]39) RivettDA,SharplesKJ,MilburnPD:Effectofpremanipulativetestsonvertebralarteryandinternalcarotidarterybloodflow:apilotstudy.JManipulative

PhysiolTher,1999,22:368–375.[Medline] [CrossRef]40) ScheelP,RugeC,SchöningM:Flowvelocityandflowvolumemeasurementsintheextracranialcarotidandvertebralarteriesinhealthyadults:referencedata

andtheeffectsofage.UltrasoundMedBiol,2000,26:1261–1266.[Medline] [CrossRef]41) BarkerS,KessonM,AshmoreJ,etal.:Professionalissue.Guidanceforpre-manipulativetestingofthecervicalspine.ManTher,2000,5:37–40.[Medline]

[CrossRef]42) MageeD:Orthopaedicphysicalassessment,5thed.St.Louis:SaundersElsevier,2008.43) LichtPB,ChristensenHW,Høilund-CarlsenPF:Istherearoleforpremanipulativetestingbeforecervicalmanipulation?JManipulativePhysiolTher,2000,

23:175–179.[Medline] [CrossRef]44) MileyML,WellikKE,WingerchukDM,etal.:Doescervicalmanipulativetherapycausevertebralarterydissectionandstroke?Neurologist,2008,14:66–73.

[Medline] [CrossRef]45) ZainaC,GrantR,JohnsonC,etal.:Theeffectofcervicalrotationonbloodflowinthecontralateralvertebralartery.ManTher,2003,8:103–109.[Medline]

[CrossRef]46) ErhardtJW,WindsorBA,KerryR,etal.:Theimmediateeffectofatlanto-axialhighvelocitythrusttechniquesonbloodflowinthevertebralartery:Arandom-

izedcontrolledtrial.ManTher,2015,20:614–622.[Medline] [CrossRef]47) HerzogW,LeonardTR,SymonsB,etal.:Vertebralarterystrainsduringhigh-speed,lowamplitudecervicalspinalmanipulation.JElectromyogrKinesiol,

2012,22:740–746.[Medline] [CrossRef]48) RivettD,ShirleyD,MagareyM,etal.:APAclinicalguidelinesforassessingvertebrobasilarinsufficiencyinthemanagementofcervicalspinedisorders,2006.

https://www.scribd.com/doc/90011859/APA-VBI-Guidelines(AccessedMay27,2015)49) ArnoldC,BourassaR,LangerT,etal.:Dopplerstudiesevaluatingtheeffectofaphysicaltherapyscreeningprotocolonvertebralarterybloodflow.ManTher,

2004,9:13–21.[Medline] [CrossRef]50) LichtPB,ChristensenHW,HøjgaardP,etal.:Triplexultrasoundofvertebralarteryflowduringcervicalrotation.JManipulativePhysiolTher,1998,21:27–31.

[Medline]51) LiYK,ZhangYK,LuCM,etal.:Changesandimplicationsofbloodflowvelocityofthevertebralarteryduringrotationandextensionofthehead.JManipula-

tivePhysiolTher,1999,22:91–95.[Medline] [CrossRef]52) MitchellJ,KeeneD,DysonC,etal.:Iscervicalspinerotation,asusedinthestandardvertebrobasilarinsufficiencytest,associatedwithameasureablechange

inintracranialvertebralarterybloodflow?ManTher,2004,9:220–227.[Medline] [CrossRef]53) RossitiS,VolkmannR:Changesofbloodflowvelocityindicatingmechanicalcompressionofthevertebralarteriesduringrotationoftheheadinthenormal

humanmeasuredwithtranscranialDopplersonography.ArqNeuropsiquiatr,1995,53:26–33.[Medline] [CrossRef]54) BowlerN,ShamleyD,DaviesR:Theeffectofasimulatedmanipulationpositiononinternalcarotidandvertebralarterybloodflowinhealthyindividuals.Man

Ther,2011,16:87–93.[Medline] [CrossRef]55) HaynesM,MilneN:Colorduplexsonographicfindingsinhumanvertebralarteriesduringcervicalrotation.JClinUltrasound,2001,29:14–24.[Medline]

[CrossRef]56) QuesneleJJ,TrianoJJ,NoseworthyMD,etal.:Changesinvertebralarterybloodflowfollowingvariousheadpositionsandcervicalspinemanipulation.J

ManipulativePhysiolTher,2014,37:22–31.[Medline] [CrossRef]57) ThielH,WallaceK,DonatJ,etal.:Effectofvariousheadandneckpositionsonvertebralarterybloodflow.ClinBiomech(Bristol,Avon),1994,9:105–110.

[Medline] [CrossRef]58) ThomasLC,RivettDA,BatemanG,etal.:Effectofselectedmanualtherapyinterventionsformechanicalneckpainonvertebralandinternalcarotidarterial

bloodflowandcerebralinflow.PhysTher,2013,93:1563–1574.[Medline] [CrossRef]59) ThomasLC,McLeodLR,OsmotherlyPG,etal.:Theeffectofend-rangecervicalrotationonvertebralandinternalcarotidarterialbloodflowandcerebral

inflow:asubanalysisofanMRIstudy.ManTher,2015,20:475–480.[Medline] [CrossRef]60) ChildsJD,FlynnTW,FritzJM,etal.:Screeningforvertebrobasilarinsufficiencyinpatientswithneckpain:manualtherapydecision-makinginthepresence

ofuncertainty.JOrthopSportsPhysTher,2005,35:300–306.[Medline] [CrossRef]61) HerzogW,TangC,LeonardT:Internalcarotidarterystrainsduringhigh-speed,low-amplitudespinalmanipulationsoftheneck.JManipulativePhysiolTher,

2015,38:664–671.[Medline] [CrossRef]62) WuestS,SymonsB,LeonardT,etal.:Preliminaryreport:biomechanicsofvertebralarterysegmentsC1–C6duringcervicalspinalmanipulation.JManipula-

tivePhysiolTher,2010,33:273–278.[Medline] [CrossRef]63) CôtéP,KreitzBG,CassidyJD,etal.:Thevalidityoftheextension-rotationtestasaclinicalscreeningprocedurebeforeneckmanipulation:asecondaryanaly-

sis.JManipulativePhysiolTher,1996,19:159–164.[Medline]

783

64) ThielH,RixG:Isittimetostopfunctionalpre-manipulationtestingofthecervicalspine?ManTher,2005,10:154–158.[Medline] [CrossRef]65) DunningJ,ButtsR,JuntillaU:Pre-manipulativetestingpriortocervicalmanipulation:timetoabandontheVBItest?2015.https://osteopractor.wordpress.

com/2015/01/08/pre-manipulative-testing-prior-to-cervical-manipulation-time-to-abandon-the-vbi-test/.66) SymonsBP,LeonardT,HerzogW:Internalforcessustainedbythevertebralarteryduringspinalmanipulativetherapy.JManipulativePhysiolTher,2002,25:

504–510.[Medline] [CrossRef]67) TaylorAJ,KerryR:A“systembased”approachtoriskassessmentofthecervicalspinepriortomanualtherapy.IntJOsteopathMed,2010,13:85–93.[Cross-

Ref]