Hutting N1,2, Kerry R3,4, Coppieters MW5,6,7, Scholten-Peeters GGM7
1HAN University of Applied Sciences, Research Group Occupation & Health, Nijmegen, Netherlands, 2Het Centrum, Centre for Physiotherapy & Manual Therapy, Rijen, Netherlands, 3University of Nottingham, Division of Physiotherapy and Rehabilitation Sciences, Nottingham, United Kingdom, 4University of Nottingham, Department of Philosophy, Nottingham, United Kingdom, 5Griffith University, Menzies Health Institute Queensland, School of Allied Health Sciences, Faculty of Health, Gold Coast, Australia, 6The University of Queensland, Department of Physiotherapy, School of Health and Rehabilitation Sciences, Brisbane, Australia, 7Vrije Universiteit Amsterdam, Faculty of Behavioural and Movement Sciences, Amsterdam, Netherlands

Background: Manipulation and mobilisation of the cervical spine are well established interventions in the management of patients with headache and/or neck pain. However, their benefits are accompanied by potential, yet rare risks in terms of serious adverse events, including neurovascular insult to the brain. An international framework for risk assessment and management offers directions in the mitigation of this risk by facilitating sound clinical reasoning. Nevertheless, discussion continues about some items in the Framework, e.g. the relation between serious adverse events and treatment (more specific, manipulation), potential risk factors for vascular pathologies, complications after manipulation, and the usefulness of physical examination.

Purpose: The aim of this article is to critically reflect on and summarize the current knowledge about cervical spine manipulation and mobilisation and to provide guidance for clinical reasoning in cervical musculoskeletal therapy.

Methods: This is a narrative review and expert opinion.

Results: In their clinical reasoning, musculoskeletal physiotherapists must rely on information based on the patient interview and physical examination with regard to clinical signs and symptoms and available risk factors for the different diseases/ disorders and interpret this information carefully. We identified three important steps in the clinical reasoning process:
1) identifying a possible vasculogenic contribution or other serious pathology;
2) determining whether there is an indication or contraindication for mobilisation or manipulation; and
3) assessing the presence of any potential risk factors associated with potential serious adverse events which are reported to occur after cervical spine mobilisation and/or manipulation.
Importantant topics to consider are: the benefits of treatment, indications for cervical spine mobilisation and manipulation, risk of cervical spine manipulation and mobilisation, risk factors, contraindications, the clinical reasoning process, the patient interview, the physical examination and applying cervical spine musculoskeletal physiotherapy (including mobilisation and manipulation).We discuss these topics and developed a flowchart that emphasises the above mentioned important three steps in the clinical reasoning process.

Conclusion(s): Although there seems to be no causality between cervical spine musculoskeletal therapy (more specific, cervical spine manipulation) and serious adverse events (in particular, craniocervical artery dissection) it is important that musculoskeletal physiotherapists try to prevent every potential serious adverse event caused by vascular or other pathologies. Therefore, thorough patient interviewing, clinical assessment, interpretation and analysis are important skills needed to determine an indication for treatment. In case there is a possible vasculogenic contribution, cervical spine manual therapy is contraindicated. Also, in the event of other contraindications or risk factors for possible serious adverse events, cervical spine manipulation or mobilisation should not be performed.

Implications: The various topics discussed in this article can support musculoskeletal physiotherapists in their clinical reasoning process to improve the safety of treatment of the cervical spine. Because the first important step in the clinical reasoning process is to identify a possible vasculogenic contribution or other serious pathology, the topics discussed in this article are not only important for musculoskeletal (manual) physiotherapists, but also for all physiotherapist who treat patients with headache and neck pain.

Keywords: Cervical spine, Clinical reasoning, Serious adverse events

Funding acknowledgements: No funding was received for this study

Topic: Musculoskeletal: spine

Ethics approval required: No
Institution: n/a
Ethics committee: n/a
Reason not required: This is a narrative review and expert opinion

All authors, affiliations and abstracts have been published as submitted.

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