ARTICLE IN PRESS
Manual Therapy 9 (2004) 95–108
www.elsevier.com/locate/math
Professional issue
Pre-manipulative testing of the cervical spine review, revision and new
clinical guidelines
Mary E. Magareya,*, Trudy Rebbeckb, Brian Coughlanc,1, Karen Grimmera,
Darren A. Rivettd, Kathryn Refshaugee
a
Centre for Allied Health Evidence (A Collaborating Centre for the Joanna Briggs Institute), Discipline of Physiotherapy, School of Health Sciences,
University of South Australia, North Terrace, Adelaide 5000, South Australia, Australia
b
School of Physiotherapy, University of Sydney, Australia
c
Bayside Physiotherapy, 459A Main Street, Mordialloc, VIc 3195, Australia
d
Discipline of Physiotherapy, Faculty of Health, The University of Newcastle, Callaghan NSW 2308, Australia
e
School of Physiotherapy, Faculty of Health Sciences, The University of Sydney, East St. Lidcombe, NSW, Australia
Received 20 January 2003; received in revised form 24 October 2003; accepted 3 December 2003
Abstract
Members of the Manipulative Physiotherapists Association of Australia (now Musculoskeletal Physiotherapy Australia) were
surveyed to determine their use of cervical manipulation, compliance with and attitudes to the Australian Physiotherapy
Association’s (APA) Protocol for Pre-manipulative Testing of the Cervical Spine, and the incidence of adverse effects from cervical
manipulation. The questionnaire was mailed to 740 members and returned by 480 members (65%).
Cervical manipulation (84.5%) and passive mobilization (99.8%) were used by a high percentage of respondents. Most were
familiar with the protocol with 63% supporting its continued endorsement. Adverse effects were reported at a rate of one per 1000
years of practice (or 0.003/week). The most common effects were symptoms potentially related to VBI (94.4% responses), with no
reported major complications. Only 37.1% of respondents always informed the patient about potential dangers of cervical
manipulation and consent was sought on every occasion by 33% of respondents.
The results suggest that the use and interpretation of the protocol are variable among members of MPA. The risk of adverse
effects from manipulative (musculoskeletal) physiotherapy practice, including cervical manipulation, appears to be very low.
Recommendations for revision of the protocol were made on the basis of results of the survey and treatment diary, in addition to a
review of the literature related to testing for vertebro-basilar insufficiency, adverse incidents related to cervical mobilizing and
manipulative technique, differentiating features of VBI related dizzinesss and vertigo related to benign paroxysmal positional vertigo
(BPPV) and current issues surrounding informed consent. Finally, a summary of the content of the new Clinical Guidelines for PreManipulative Testing of the Cervical Spine (APA, 2000) is provided.
r 2003 Elsevier Ltd. All rights reserved.
1. Introduction
The Australian Physiotherapy Association (APA)
endorsed the APA Protocol for Pre-Manipulative
Testing of the Cervical Spine in, 1988, mandating it
for use prior to manipulation of the cervical spine (APA,
*Corresponding author. Division of Health Sciences, School of
Health Sciences, University of South Australia, North Terrace,
Adelaide S.A. 5153, Australia. Tel.: +61-8-8302-2768; fax: +61-88302-2766.
E-mail address: mary.magarey@unisa.edu.au (M.E. Magarey).
1
On behalf o Musculoskeletal Physiotherapy Australia, National
APA Office, PO Box 6465, St. Kilda Road Central, Victoria 8008,
Australia.
1356-689X/$ - see front matter r 2003 Elsevier Ltd. All rights reserved.
doi:10.1016/j.math.2003.12.002
1988). Over the past decade, advances in research
(Grant and Trott, 1991; Refshauge, 1994; Rivett and
Milburn, 1996; Rivett et al., 1999; Johnson et al., 2000;
Zaina et al., 2003), and changes in the medico-legal
system in Australia (Rogers v Whitaker, 1992) have
fuelled discussion regarding the validity of the protocol
(for example, Grant and Trott, 1991; Rivett, 1995;
Grant, 1996a, b). Concerns expressed anecdotally and as
part of an APA review included:
*
*
The time consuming nature of applying the protocol
(Grant, 1994).
The provocative nature of the tests themselves
(Di Fabio, 1999).
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96
The reliability and validity of the test procedures,
questioning whether they actually detect alterations
in blood flow in the vertebro-basilar system (Assendelft et al., 1996).
The lack of validated research underpinning the
protocol (Kunnasmaa and Thiel, 1994).
Failure to address the legal requirements pertaining
to the provision of informed consent.
in writing that they did not wish to participate—their
reasons were not recorded (65%). The diary was
completed by 287 members (38.7%). The diary was
not linked by identification number to the attitudinal
survey, and thus represented an independent set of
responses.
In response to the expressed opinions, an attitudinal
survey and treatment diary were mailed to all members
of the Manipulative Physiotherapists’ Association of
Australia (now Musculoskeletal Physiotherapy Australia—MPA). The aims of the study were:
Cervical spine HVT techniques were used by 84.5% of
currently practising respondents (n ¼ 419), in the upper,
middle and lower cervical spine, by 83.4%, 84.7% and
98.3% of respondents, respectively.
Of the 287 respondents to the diary, 34.8% performed
upper cervical spine HVT techniques and 41.8%
performed lower cervical spine HVT techniques in the
recording week. We assumed that the physiotherapists
who reported using upper and lower cervical manipulations were not mutually exclusive, and we took the
higher figure (41.8% respondents used HVT in the
cervical spine) to include those who also undertook
upper cervical HVTs. Thus, overall, 41.8% used HVTs
on the cervical spine. A total of 1002 HVT techniques
was performed in the cervical spine by 141 physiotherapists in the diary week using a variety of manipulative
techniques. This is an average HVT technique rate of 3.5
manipulations per diary respondent per week. Specific
HVT techniques commonly included lateral flexion,
longitudinal, postero-anterior (PA) thrust, transverse
and rotary techniques.
*
*
*
1. To determine the proportion of members using
cervical manipulation (high velocity thrust [HVT]
techniques) and the frequency of their use in each
region of the cervical spine.
2. To determine the proportion of members using nonthrust techniques (passive mobilization) and cervical
traction in each region of the cervical spine.
3. To determine the members’ opinions of, and rate of
compliance with, the APA Protocol for Pre-Manipulative Testing of the Cervical Spine.
4. To quantify adverse effects associated with the use of
cervical manipulation and other cervical spine
procedures.
5. To determine the rate of compliance with the legal
requirement to provide information to, and obtain
consent from, a patient prior to the use of cervical
manipulation.
2. Methods
Following granting of ethical approval from the
University of South Australia Human Research Ethics
Committee, a sample survey was reviewed by a focus
group in one Chapter, revised and then trialed in three
Chapters of MPA. The survey questions contained
multiple set response options plus free text opportunities
to express opinions. After revision following this
process, a final questionnaire was developed and sent
to all 740 members. In addition to the survey, members
were requested to prospectively record their use of
cervical manipulative techniques and the protocol for
one week of clinical practice in a daily diary. Responses
to both the survey and diary were anonymous.
3.1. Use of HVT techniques
3.2. Use of non-thrust (passive mobilization) techniques
From the survey, passive mobilization (non-thrust)
techniques were used by nearly all respondents (99.8%),
who applied them on average to 90.4% of their cervical
patients. Respondents used a variety of passive mobilization techniques with similar frequency in the upper,
middle and lower cervical spine (96.8%, 96.7% and
96.6%, respectively). Cervical traction was used by
94.9% respondents.
To determine the most commonly applied HVT and
non-thrust techniques, the diary data were used (actual
numbers of applications of most commonly used
techniques over a standard [1 week] time frame). These
figures show that the most commonly practised technique in each region of the cervical spine, and overall, was
the passive accessory intervertebral movement
(PAIVM).
3.3. Familiarity with the protocol
3. Results
The attitudinal survey was returned by 419 members
in current clinical practice and 34 members not in
current clinical practice. A further 27 members indicated
Ninety-eight per cent of respondents were familiar
with the protocol and 85% had read it within the last 4
years. The most common reason for using the protocol
was concern that the proposed treatment technique
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M.E. Magarey et al. / Manual Therapy 9 (2004) 95–108
would stress the vertebro-basilar arterial system. Most
respondents (67.4%) considered the protocol valuable in
their manipulative/musculoskeletal physiotherapy practice, although 14.2% used it only to satisfy legal
requirements. The majority of respondents (63%)
supported continued endorsement of the protocol,
25% were unsure, leaving only 12% who definitely felt
that endorsement should not be continued. Seventy-five
per cent indicated that the protocol was useful to them
for other than medico-legal reasons, and 70% would
continue to use it even if it were no longer endorsed.
About half of the respondents (54.2%) felt that use of
the protocol gave them a sense of security prior to the
use of HVT techniques, despite being aware of the
limitations of the physical test procedures.
The respondents who indicated that the APA should
not endorse the use of the protocol (n ¼ 54) raised the
following issues about its use:
*
*
*
*
*
It is not clinically relevant (20.3% of this group of
respondents).
It does not identify patients at risk (37.7%).
It places unnecessary restrictions on the use of
cervical manipulation (21.9%).
It discourages physiotherapists from using cervical
manipulation (50%).
It places an onerous legal burden on physiotherapists
(37.9%).
to the patient’s response, although the majority of
techniques contained a component of rotation. Of these
respondents, 40% had applied the protocol prior to
treatment. Of the patients who had suffered an adverse
reaction and for whom the protocol had not been
applied, 45% had features for which use of the protocol
was indicated.
The incidence rate for adverse effects (which is an
estimate, as a result of amalgamation of categories of
2–10 and 10+ complications) translates to 168.5 per
1000 manipulative/musculoskeletal physiotherapy years
of practice (or 0.003/week). This was calculated by
determining the time over which the 447 respondents
had practised manipulative/musculoskeletal physiotherapy (average 10.2 years (SD 6.4, range 1–31, median 9),
with a sample total of 4601 physiotherapist years of
manipulative/musculoskeletal practice, coupled with the
estimated number of adverse effects (ever) as reported
by this sample.
Information on 291 types of effects within the past 2
years was obtained from 211 survey responders (46.6%).
Calculations were performed for the rate of adverse
effects for HVT, passive physiological intervertebral
movements (PPIVMs), PAIVMs, cervical traction and
other cervical treatments. Adverse effects were found to
occur at a rate of:
*
*
From the text responses, further comments were
noted:
*
*
*
The time cost of applying the protocol is unrealistic.
The questionable validity of the tests themselves and
the provocative nature of the protocol tests are of
concern.
The requirement to provide information and ask for
consent prior to use of HVT techniques acts as a
deterrent, leading to reluctance on the part of the
therapist to request consent and on the part of the
patient to provide such consent.
3.4. Adverse effects
Adverse effects associated with examination or treatment of the cervical spine were recalled by 447
respondents at some time in their professional career
(400 currently practising and 47 not in current practice).
The remainder of respondents recalled no adverse effects
associated with examination or management of the
cervical spine. Of those patients with adverse effects,
15.9% required medical attention, while the remainder
resolved without intervention. The most common effects
related to passive mobilizing techniques (27.5%),
examination techniques (20.4%) and HVT techniques
(16.1%). The majority of respondents (77%) could not
identify any features that would have alerted them
97
*
*
*
One per 177.5 therapist weeks for HVT.
One per 184 therapist weeks for PPIVMs.
One per 180 therapist weeks for PAIVMs.
One per 100 therapist weeks for cervical traction and
other cervical techniques.
A total of 1.38 adverse effects per therapist over the 2
year period (0.01/week).
The rate for HVT translates into an estimate of one
effect per 50,000 HVT procedures. This more specific
information supported the low rate of adverse effects
associated with cervical techniques.
The most common complications were symptoms
potentially associated with the vertebro-basilar system
(accounting for 94.4% responses) [that is, dizziness,
diplopia, dysphagia, drop attacks, difficulty in swallowing, nausea]. Specifically, there were no reported major
complications in this sample.
3.5. Information and consent
Provision of information to the patient about dangers
involved with HVT techniques (other than death) was
low. Only 37.1% of respondents to the survey always
informed the patient about these dangers and 48.1%
sometimes did. Dangers discussed included dizziness
(29.1%), nausea (22.5%), radiculopathy (12%), stroke
(27.7%) and various other complications (8.5%). Death
or permanent disability were specifically included as a
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98
danger by 23.3% of respondents, while some never
mentioned either (16%) and 33.1% only introduced the
subject if the patient asked for further information.
Of those respondents who did not include information
regarding death or disability, 33.7% felt uncomfortable
about doing so, 30.3% thought that the patient would
refuse HVT techniques as a treatment option, 15.4%
considered that it was not relevant and 2.9% believed
that it was not legally required. The remainder (17.6%)
expressed a variety of reasons regarding lack of
information exchange.
Consent was rarely gained on every occasion of
manipulation. Consent was sought by:
*
*
*
32.9% respondents for every HVT technique (including multiple techniques on the one occasion);
33.4% respondents at every occasion at which a HVT
technique was used;
20.3% respondents only at the first occasion at which
a HVT technique was used.
Consent was never sought by 1.9% respondents and
11.5% respondents did not seek consent with every
patient. Seeking consent was always linked to the
provision of information about the dangers of manipulative therapy techniques by 40.2% respondents, and
sometimes by 49.7% respondents. The remaining 10.1%
respondents never linked these two issues.
4. Discussion
There was a moderate response from the membership
(65%), with 61.2% actually completing the survey, and
a poor response to the diary (38.7%). However, it
appeared that responses were received from members
who had a strong positive or negative opinion or
experience regarding the use of the protocol. The
intensity of responses suggested that few members took
a middle ground. Compliance with completing the diary
would have been facilitated by clerical assistance in
tallying patient and treatment numbers, thus potentially
biasing against respondents without such support.
Moreover, the weekly diary may not have been
completed by those physiotherapists who used cervical
manipulation less than once per week as the diary
covered a snapshot of a single week’s practice.
No other studies were found in which frequency of
use of HVT and non-thrust techniques in a national
professional association with specialized training in
manipulative/musculoskeletal physiotherapy have been
reported. Michaeli (1993), Rivett and Milburn (1996)
and Grant and Niere (2000) have all undertaken
different studies of manipulative/musculoskeletal physiotherapists or those with manipulative therapy training, but in each case, smaller samples were used. In,
1991, Grant and Trott reviewed compliance with the
protocol using a random sample of 10% of members of
the APA (n ¼ 727). A return rate of 63% was reported
(n ¼ 455) representing a similar sample size and
response rate to the present study. However, in Grant
and Trott’s (1991) sample, further reported in Grant
(1994, 1996a, b), only 18.5% (n ¼ 84) reported using
manipulative techniques, even though manipulative
physiotherapy was listed as the field of practice by,
198, a much smaller sample than in the current
study.
Frequency of use of HVT and non-thrust techniques
reflects that anticipated from a sample of members of
MPA, with virtually 100% use of non-thrust techniques
and 84.5% overall use of HVT techniques. Also as
anticipated, a higher percentage of members used HVT
techniques in the lower cervical spine than in the middle
or upper regions, presumably because of the perception
of a lower risk of damage to the VA with techniques
applied to this area (Klougart et al., 1996a, b).
Compliance with the protocol was poor, with only
66% respondents reporting its implementation prior to
the first use of HVT techniques and 33.6% using it prior
to subsequent HVT procedures. This result reflects a
similar level of compliance reported by Grant and Trott
(1991) and represents a less than desirable compliance
rate for a protocol mandated by the professional body
prior to the administration of cervical manipulation.
However, despite the poor compliance, only a small
percentage (12%) of respondents definitely did not
support endorsement of the protocol. Conversely, 63%
definitely supported its continued endorsement and
66.7% believed the protocol was of value to their
clinical practice, consistent with the findings of Grant
and Trott (1991) who reported 66% endorsement. The
objections to protocol use reflected similar concerns
expressed in Grant and Trott (1991), including its time
consuming nature and the need to obtain informed
consent reducing opportunities to undertake HVT
procedures.
The rate of adverse effects from HVT techniques of
the cervical spine (1 per 50,000 manipulations) was very
low, with no evidence of catastrophic misadventures.
The survey instrument precluded collection of data on
the precise number of incidents, particularly as the data
were retrospective. However, the results do provide a
snapshot of the frequency and nature of incidents that
have occurred within a large sample of postgraduate
educated users of HVT techniques in the cervical spine.
The argument could be made that any therapist who had
been involved in a catastrophic incident would remember the incident vividly and would therefore report it
accurately. However, the counter argument, that such
therapists may have chosen not to respond to the survey,
could be equally valid. These limitations are acknowledged and reflected in interpretation of the results of this
study.
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Interestingly, adverse responses were reported with
non-thrust (27.5%) and examination techniques
(20.4%) in addition to HVT techniques (16.1%).
Techniques associated with the highest frequency of
adverse responses were those involving some component
of rotation, consistent with previous research (Klougart
et al., 1996a, b). Examination techniques included
various types of examination procedures—active and
passive physiological movements and PAIVMs.
In a review of the reported incidence of mishaps
related to cervical manipulation, Rivett and Milburn
(1996) highlighted the limitations in the information
currently available. Estimated rates of mishap varied
from less than one in 5,000,000 in a chiropractic study
(Jaskoviak, 1980) to one in 50,000 in a medical report
(Gutmann, 1981). However, all studies were, like the
present one, retrospective with consequent inherent
recall bias, and most involved medical practitioners
and chiropractors. A single published retrospective
study (Michaeli, 1993) of cervical manipulation by
physiotherapists was highlighted by Rivett and Milburn
(1996). The sample population (n ¼ 88) had only 100 h
postgraduate education in manipulative physiotherapy,
thus not reflecting the education levels of MPA
members—formal postgraduate qualifications in manipulative physiotherapy. However, a risk of minor or
transient complications of approximately one in 1756
manipulations was reported. In the present study, the
rate of adverse effects from HVT techniques was one in
50,000—considerably lower, perhaps reflecting the higher level of formal manipulative physiotherapy education
in the present sample.
Rivett and Reid (1998) investigated the incidence of
neurovascular insult attributed to cervical manipulation
by physiotherapists in New Zealand, reporting at least
four cases in a 7 year period (1991–1997). These authors
also provided an estimate of the number of cervical
manipulations performed by manipulative/musculoskeletal physiotherapists in the same timeframe, calculating
an approximate incidence rate of one cerebrovascular
accident (CVA) for every 163,371 manipulations. It is
impossible to provide direct comparison from this study
to the present one, as no CVAs were reported in the
present study.
Clearly, the results of this study do not provide the
answers to the question of incidence of complications
because of the limitations of the study design. Until a
large prospective study is completed, the risk is likely to
continue to be under-estimated.
There is increasing emphasis on the teaching of short
lever HVT techniques as alternatives to the more
traditional techniques (Gross et al., 1996; College of
Physical Therapists of Alberta, 2000; Gibbons and
Tehan, 2000; Monaghan, 2000; Hing et al., 2003). These
techniques are perceived to place less end-range rotary
stress on the upper cervical spine. Continuation of this
99
direction of teaching would appear to be appropriate at
this stage in light of the findings of the present study.
Following review of the results of the survey, the
following changes were recommended:
*
*
*
*
Review and modification of the protocol in the light
of the most recent research available on the effect of
cervical movement on blood flow in the vertebrobasilar system and its relation to provocation of
symptoms.
Shortening and simplification of the protocol for use
with cervical manipulation and techniques involving
end-range rotation of the cervical spine.
Facilitation of the provision of information to
patients prior to cervical manipulation.
Development of a protocol for provision of information, obtaining consent to cervical manipulation and
recording of the process.
To achieve these aims, the following steps were
undertaken:
*
*
*
*
An extensive review of the literature and evaluation
of work in progress was undertaken, related to:
*
measurement of vertebro-basilar blood flow and
the effect on flow of cervical movements;
*
provocation of symptoms associated with alteration of vertebro-basilar blood flow;
*
the incidence and possible causes of complications associated with manipulation of the cervical spine;
*
differentiation of symptoms of VBI from those
of other sources.
Medico-legal experts and physiotherapists with expertise on informed consent for therapeutic intervention were consulted, to help determine the optimal
way to facilitate this process within a clinical practice
setting.
The structure and content of the protocol were
reviewed.
A draft set of clinical guidelines for pre-manipulative
procedures for the cervical spine was developed and
distributed to members of the professional body for
comment, focus groups were held throughout the
profession and, on the basis of feedback from this
process, a new set of clinical guidelines produced.
4.1. The effect of cervical movement on blood flow in the
vertebro-basilar system and its relation to provocation of
symptoms
The effect of cervical movement on VA blood flow
has been investigated in vivo using Doppler ultrasound.
The findings of these studies are conflicting, leading
some researchers to question the validity of pre# e!
manipulative testing (Kunnasmaa and Thiel, 1994; Cot
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Table 1
Studies demonstrating altered flow parameters of the VA
Study
Instrumentation and measurements
Sample population
Results
Arnetoli et al. (1989)
Cw Doppler US
VA flow in rotation/extension
190 healthy volunteers
60 patients with VBI
Either diastolic flow loss or absent
Doppler signal of contralateral VA in 6%
of volunteers and 33% of patients
Dan#ek (1989)
Cw Doppler US
VA flow in sustained rotation/
extension
25 symptomatic patients
Flow changes in 12 of 25
Stevens (1991)
Cw Doppler US
VA flow at C1–C2 during
positional testing
250 patients with an identified
abnormal flow velocity pattern
Velocity in contralateral rotation reduced
in 62%, increased in 20%
Decreased flow velocity in extension in
18%
Refshauge (1994)
Duplex US
Flow velocity at C2–C3 in 45 &
end-range contralateral rotation
20 healthy volunteers
Flow changes (usually increase) in 45 ,
significant trend for decreased velocity in
full rotation
2 subjects had no flow at 45 rotation but
no symptoms
Haynes (1996)
Cw Doppler US
Maximum contralateral rotation
290VAs
Cessation of Doppler signal in 5%
Rivett et al. (1999)
Colour duplex US
Peak systolic & end diastolic
velocities & resistance index at
C2-C3 in extension, 45 & end-range
contralateral rotation & combined
rotation/extension
16 patients and 4 volunteers
(10 positive, 10 negative to premanipulative testing)
Significant changes in flow velocity in
end-range positions of rotation and
rotation/extension
No meaningful significant differences
found between positive and negative
subjects
CW=continuous wave; US=ultrasound; VA=vertebral artery; VBI=vertebro-basilar insufficiency.
et al., 1996; Grant, 1996a, b, Johnson et al., 2000). The
earlier studies are summarized in Tables 1 and 2.
The results of many of these investigations are
questionable as preceding reliability studies were not
conducted or were, at best, limited in nature (Stevens,
1991; Refshauge, 1994), despite the well-known operator dependency of ultrasonographic examination (Johnson et al., 2000). Vessel identification error and
inaccurate sampling due to non-visualization of the
target vessel with continuous wave ultrasound and
sampling at different parts of the artery, often upstream
to the area potentially affected, may also have affected
the results of some studies.
In response to this problem, Zaina et al. (2003)
reported on an investigation of the effect on
cervical rotation on VA flow using a reliable experimental protocol proposed by Johnson et al. (2000) and
following an initial test–retest reliability study. Neither
peak velocity nor volume flow rate was found to be
significantly changed in a group of, 20 asymptomatic
volunteers at both 45 and end-range contralateral
rotation. However, the effects of pre-manipulative
testing on a symptomatic population cannot be determined from this small study.
In a larger investigation on a patient population,
Rivett et al. (2000) evaluated the effects of pre-
manipulative testing on VA haemodynamics and
whether these effects differed between patients demonstrating positive and negative clinical test responses.
Colour duplex ultrasound with power Doppler imaging
was used to measure haemodynamic parameters at C1–
C2 during testing. Good reliability was shown (n ¼ 20)
for sampling of selected flow parameters at C1–C2 in
various cervical positions. Patients were classified as
either positive (n ¼ 51) or negative (n ¼ 49) to premanipulative testing, and then underwent an ultrasonographic examination in positions involving rotation and
extension. While there were statistically significant
haemodynamic changes during pre-manipulative testing, these changes were generally unlikely to be clinically
significant. There were no meaningful significant differences in flow changes in any of the cervical positions
between the two groups. Notably, 20 patients had total
or partial vessel occlusion during testing, however only
two of these displayed possible VBI symptoms at the
time. It was concluded that pre-manipulative testing
alone is clinically unlikely to distinguish between
patients with varying degrees of flow impedance.
Thus, within our current knowledge and given the
apparently questionable clinical value of physical premanipulative testing, it is clear that greater emphasis
should be placed on detecting potential indicators of risk
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101
Table 2
Studies in which no change in VA flow was found
Study
Instrumentation and measurements
Sample population
Results
Weingart & Bischoff
(1992)
Cw Doppler US
Flow velocity at C1in various
positions of rotation & extension
30 normal volunteers
No significant changes
Thiel et al. (1994)
Duplex US
Flow velocity during sustained
(30 sec) extension, rotation &
combined extension/rotation
30 control volunteers
12 patients with symptoms &/or
signs of VBI on clinical testing
No abnormal flow patterns
No meaningful significant differences in
mean velocity ratios
# e et al. (1996)
Cot!
Secondary analysis of
data from Thiel et al.
(1994)
Duplex US
VA flow during extension/rotation
testing
30 control volunteers
12 patients with symptoms &/or
signs of VBI on clinical testing
For increased impedance to flow:
Sensitivity 0%
Specificity 67–90%
Licht et al (1998, 1999)
Colour duplex US
Contraleral & ipsilateral rotation
(45 & end-range) on peak flow
velocity
20 healthy university students
Both test positions:
* Significant but modest decrease
with contralateral rotation
* Significant increase with ipsilateral
rotation
Volume flow data demonstrated no
change, therefore hindbrain perfusion
unaffected
Haynes & Milne (2000)
Colour duplex US
Peak systolic & end diastolic flow
velocities at 10 increments of
contralateral rotation
20 patients (39 VAs) with neckrelated symptoms
No significant change in group mean
flow velocity
Marked changes in flow velocities in 7
VAs toward end-range rotation
Licht et al. (2000)
Colour duplex US
Peak & mean flow velocities at 45
rotation, end-range rotation &
rotation/extension
15 patients with positive premanipulative test response
No significant change in flow velocities
of contralateral or ipsilateral arteries in
any test position
CW=continuous wave; US=ultrasound; VA=vertebral artery; VBI=vertebro-basilar insufficiency.
in the patient history (Grant, 2002; Rivett, 1995, 1997).
It also appears that, often, the symptoms detected
during clinical pre-manipulative testing may be unrelated to alterations in blood flow in the VA.
4.2. Differentiation of symptoms of VBI from those of
other sources
Clinical experience of vestibular rehabilitation physiotherapists indicates that VBI is rare and the majority
of patients who present with dizziness do not suffer from
VBI (Clements, 2001). Although only anecdotal, this
observation may change the perspective on this condition. Some distinction between dizziness/vertigo related
to VBI and that from other sources is possible within a
clinical examination. Multiple sensory systems contribute to the body’s balance function (Shepard and
Telian, 1996). The central nervous system is responsible
for integration and modulation of the information
required for balance and if integration of input from
the different sources is disrupted, symptoms of disequilibrium may develop. In a pathological situation,
visual, vestibular or neurological disease may alter the
perception of motion and the environment, as the
sensory inputs no longer match those anticipated
(Luxon, 1997).
Vertebro-basilar insufficiency is evidenced by symptoms of ischaemia of the areas of the brain supplied by
the basilar artery—the pons, medulla and cerebellum, in
addition to the central and peripheral vestibular system.
When investigating clinical features in 84 subjects with
vascular origin vertigo, Grad and Baloh (1989) (cited by
Clendaniel, 2000) found that vertigo may be an initial
isolated symptom of VBI, but its presence without other
symptoms associated with posterior circulation ischaemia for greater than 6 months would imply a different
cause. Other symptoms are those traditionally screened
for in the subjective examination: visual hallucinations
(spots in front of the eyes), drop attacks, dysarthria,
dysphagia, visual field defects (narrowing of the visual
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field), diplopia, visceral sensations (nausea with or
without vomiting) and headaches.
Benign Paroxysmal Positional Vertigo (BPPV) is the
most common cause of vertigo of peripheral origin and
is more common than vertigo of central origin (Brandt
and Daroff, 1980; Herdman, 1997; van der Velde, 1999).
BPPV is characterized by brief intense, but often severe,
rotational vertigo when the head is moved into
particular positions. These movements typically include
rolling onto one side in bed, lying down or getting up
from supine, looking or reaching upwards, turning the
head into the combined position of extension/rotation
such as when reversing the car, with reversal of the
provoking movement causing a reversal in the nystagmus and recurrence of the vertigo (Brandt & Daroff,
1980; Herdman, 1997; Van Der Velde, 1999; Herman
and Tusa, 2000). Symptoms such as postural instability,
generalized disequilibrium, unsteadiness of gait,
sensitivity to head movements and falls may also be
reported.
There are two postulated causes of BPPV, with the
most common being canalithiasis, where degenerative
debris from the utricle floats freely within the endolymph of, most commonly, the posterior semi-circular
canal. When the head is moved into a provoking
position, the otoconia (debris) move, as a result of
gravity, to the most dependent position in the semicircular canal, causing movement within the endolymph
which pulls on the cupula, causing the neurons to fire.
The typical delay in onset of symptoms relates to the
time required for deflection of the cupula by the
endolymph, the characteristic nystagmus is caused by
the relative deflection of the cupula and the fatigue of
the symptoms occurs because the endolymph stops
moving when the position is sustained (Herman and
Tusa, 2000). BPPV occurs spontaneously but may also
follow a bout of labyrinthitis or head trauma, such as
whiplash or head injury.
Cervical vertigo or dizziness has also been described,
but its mechanisms remain controversial (Clendaniel,
2000). Symptoms typically associated with cervical
dizziness appear related more to altered balance
than oculomotor or vestibular function. Typical presentation includes dysequilibrium or light-headedness,
ataxia or unsteadiness combined with cervical pain and
restricted movements, with symptoms provoked by
movements of the head, in no particular direction.
However, other disease processes can present with
similar symptoms. At present, since there is no definitive
test for cervical dizziness, the presence of cervical signs
on examination and prompt favourable response to
their treatment would appear the optimal initial
differential diagnostic pathway. Failure to respond
to cervical treatment suggests referral for investigation of vestibular or neurological function would be
appropriate.
Vertigo from VBI may resemble BPPV. The key
features of each are provided in Table 3. Physical
diagnosis of BPPV involves a series of provocative
positioning and movement tests, part of which is not
dissimilar to those used for VBI testing. If VBI testing of
cervical rotation/extension undertaken in supine appears positive, BPPV may be the cause as the position is
similar to the final stage of the Dix–Hallpike test
(Herman and Tusa, 2000). VBI testing should be
repeated in sitting, particularly with hips in flexion, so
that the final cervical position is the same but the head
remains in a vertical position, thus preventing the
symptoms of BPPV, which are provoked by changes in
head position relative to gravity (Clendaniel, 2000).
Other causes of vertigo and nystagmus should also be
considered in differential diagnosis and the presence of
other background conditions may also facilitiate differentiation: ear disease, cardiovascular disease, migraine,
epilepsy, stroke, head injury or a family history of BPPV
may provide clues to the current presenting disorder.
These cues may be helpful during examination to
determine the source of vertigo, thus facilitating
decisions related to the safety of cervical manipulation.
The revised guidelines enable the physiotherapist the
latitude to evaluate the most likely cause for the
presenting ‘dizziness’ symptoms based on clinical
reasoning and guided by the above research. However,
if a physiotherapist is unsure of a diagnosis related to
dizziness of VBI, BPPV or other origin, referral to an
otolaryngologist, neurologist or vestibular rehabilitation
physiotherapist is recommended.
4.3. Provision of information and gaining consent
The rate of compliance of provision of information
and obtaining consent was poor overall. The fact that
fewer than half the respondents complied with this
component of the protocol and that such strong opinion
was expressed against obtaining consent is of great
concern. There are clear legal arguments stating that
provision of information and obtaining consent from a
patient prior to use of techniques over which the patient
has no control and which potentially involve a degree of
risk is no longer a recommendation but law (for
example, Dunn, 1993; Parry, 1994; Delany, 1996;
Haswell, 1996; Sim, 1996). There has been extensive
comment in both the popular and legal press about the
implications for the health professions of the Rogers v
Whitaker (1992) judgement (for example, McSherry,
1993; Nisselle, 1993; Balding, 1995; Grant, 1996a, b,
2002; Nagree, 1997), supporting the need to develop a
new protocol that can be applied appropriately and
consistently by all.
In addition to the legal requirement, the emphasis of
care within musculoskeletal physiotherapy now includes
the patient more in decision making (Gifford, 1998;
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103
Table 3
Differentiating BPPV from VBI (Based on Davies, 1997; van der Velde, 1999; Clendaniel, 2002)
BPPV
VBI
Head vs. neck
position used to elicit
vertigo and
nystagmus
Specific head movement in relation to
gravity, but not when head is immobile.
Typically, movements include:
Lying down
Rolling onto one side
Looking up
Hallpike manoeuvre is classically
positive
Relative head movement while neck immobile
Latency
Few seconds (average 3–4 s to 1 min)
Abrupt in onset and of short duration (several minutes)
Nystagmus behaviour
Decrease in nystagmus within less than
20 s if position is sustained
Continuation of nystagmus with maintenance of position
Pattern of nystagmus
Torsional (fast phase towards the
affected ear)
More vertical (upbeating) when looking
away from the affected ear
Can be stabilized by visual fixation
Usually vertical
Fatiguability
Intensity of vertigo decreases with
continued testing
Intensity of vertigo increases with continued testing
Additional symptoms/
signs
Postural instability
Disequilibrium
Nausea/vomiting
Disturbances in vision
Diplopia
Nausea/vomiting
Ataxia
Harding, 1998), as this process has been shown to
enhance patient response to management (Strong,
1995). The comment that requesting the patient’s
consent to manipulate their neck would mean fewer
patients agreeing to the technique fails to reflect this
changing philosophy within health care generally.
Health professionals have both an ethical and legal
obligation to provide information and gain consent for
techniques such as cervical manipulation. Failure to
provide the opportunity for consent undermines the
moral principle of respect for an individual’s essential
human dignity (Sim, 1996). A suit for assault or battery
may be brought by a patient against a health practitioner, significantly, with no need to show actual
physical harm (Dimond, 1995)—battery if the patient
is touched, assault where the patient fears they will be
touched.
Under the tort of negligence, if a breach of duty of
care can be proved, with the direct result that the patient
undergoes some foreseeable harm, negligence on the
part of the therapist is said to have occurred (Brazier,
1992). A duty of care covers the provision of information and obtaining consent as well as the treatment
itself. Therefore, providing information and gaining
consent for cervical manipulation protects the therapist
from legal action in addition to respecting the patient’s
right to self-determination.
Sustained cervical or head posture
No effect of gravity identified
Cannot be stabilized by visual fixation
Dysarthria
Dysphagia
Hemiparesis/hemiplegia
Drop attacks
In law, consent takes different forms. ‘Express
consent’ occurs when an individual explicitly indicates
agreement, either orally or in writing; ‘implied consent’
occurs when an individual does not specifically indicate
agreement but performs some action that suggests
consent, such as following instructions prior to administration of any particular procedure; and ‘tacit’ consent
is where consent is inferred from the patient’s failure to
dissent (Sim, 1996).
Express consent is considered essential prior to
techniques over which the patient has no control, such
as cervical manipulation and should be re-established
prior to every individual manipulative technique.
Implied or tacit consent is sufficient for the majority
of physiotherapy procedures. Informed consent is a
form of express consent and has been defined as ‘the
voluntary and revocable agreement of a competent
individual to participate in a therapeutic or research
procedure, based on an adequate understanding of its
nature, purpose, and implications’ (Sim, 1996).
The judgement made in Rogers v Whitaker (1992)
changed the view of the courts from one where mistakes
were accepted as part of the risk inherent in medical
treatment, to one where failure to provide information
and warnings about treatment was no longer ‘misadventure’ but negligence (Delany, 1996). The key
feature in this case was that the court decided what
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M.E. Magarey et al. / Manual Therapy 9 (2004) 95–108
was acceptable and reasonable, not the profession. ‘The
general legal principle which underpins the (Rogers and
Whitaker) finding is one which asserts that the
paramount consideration is that a person is entitled
to make decisions about his or her own life, and the
duty to disclose the information takes its precise
content from the needs, concerns and circumstances of
the patient’ (Retsas and Forrester, 1995, cited by
Delany, 1996). Since this judgement, medico-legal
practitioners have urged the health professions, including physiotherapy, to change their practice in this
area (Delany, 1996; Haswell, 1996; Kee, 1996; Nagree,
1997).
A survey of APA members (Grant and Trott, 1991;
Grant, 1996a, b), a straw poll conducted by Delany
(1996) and the present survey all reported poor
compliance among physiotherapists with the requirement to provide information and obtain consent prior to
cervical manipulation. Text responses to the MPA
survey demonstrated strong opinion by some respondents that this requirement was inappropriate. Such an
approach to patient information and consent is not
acceptable in law (Delany, 1996).
Expert medico-legal advice was sought prior to
development of the new clinical guidelines. The key
feature of this advice was that the health practitioner
was required to provide adequate information to the
patient concerning the procedure for the patient to be
able to make a judgement about the choices offered.
Such information must include the benefits and risks
associated with the procedure and alternatives to that
procedure, together with their benefits and risks. The
information must be provided in a form that the patient
can understand. In addition, the health practitioner
must provide the patient with the opportunity to ask
questions about the procedure and to have those
questions answered to their satisfaction prior to the
request for consent. Such information may be provided
in a brochure format but without adequate face to face
follow-up, a brochure does not fulfil the legal requirement.
It is acknowledged that this process is time-consuming, but the negative impact must be weighed against the
potential consequences of litigation should the process
not be followed. Such a process is also considered
essential to patient involvement in decision making
related to their management.
The need to inform the patient of the potential risk of
death associated with cervical manipulation was also
addressed. While accepting that there has been no legal
precedent to help the decision process, the legal opinion
was that, on available evidence from the literature and
the results of the current survey, there was no need to
inform the patient routinely of the risk of death. The
consideration was that, if the risk is lower than those
taken as part of normal daily life, it fails to constitute a
•
•
•
•
•
•
•
•
The procedure involved
Discussion/information
Alternatives
Benefits/risks
Information sheets given or the method by
which information provided
Questions asked by patient
Consent obtained
Date
Time:
Fig. 1. Recommended format for recording provision of information
and obtaining consent.
substantial danger. However, if during questioning,
concern about the risk of death were expressed by the
patient, the therapist would be required to mention it
and discuss the degree of risk with that particular
patient.
Finally, the need to record consent was considered.
The legal advice was that, to fulfil all legal requirements,
evidence must be shown that information has been
given, that the patient has had the opportunity to ask
questions and receive satisfactory answers, that consent
was sought and given without coercion, with the time
and date of consent recorded. Verbal consent is
considered equivalent to written consent in this context,
although this opinion differs among legal practitioners.
The recommendation was made that a standard form of
recording this process be implemented (see Fig. 1).
5. Clinical guidelines for pre-manipulative procedures for
the cervical spine
The new Clinical Guidelines differ substantially from
the APA Pre-Manipulative Protocol. The somewhat
rigid format of the protocol has been modified to allow a
degree of clinical reasoning in patient examination and
management. In all other aspects of manipulative/
musculoskeletal physiotherapy, clinical reasoning is
strongly emphasized. A set of Clinical Guidelines rather
than a formal protocol more appropriately reflects
current practice of manipulative/musculoskeletal physiotherapy within Australia. The final document, while
providing guidelines to clinical practice, leaves the
ultimate decision on appropriate action to the therapist
in the context of any particular individual patient
presentation.
The specific changes within the new guidelines from
the previous Protocol include:
*
Inclusion of an introductory explanatory preamble.
This preamble includes mention of the provocative
nature of the test procedures; mixed results from
research in relation to alteration of blood flow within
the vertebro-basilar system (Rivett et al., 1999;
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*
*
Johnson et al., 2000; Zaina et al., 2003); that
indicative factors appear to include trauma and/or
neurological changes (Haldeman et al., 1999) and
that there is no known method for testing the
intrinsic anatomy of the vertebral artery. The screening tests will not identify all patients at risk of
suffering an adverse reaction to manipulation.
Inclusion of nausea within routine screening; inclusion of a range of symptoms that have been reported
as associated with vertebro-basilar insufficiency
(VBI) or vertebral artery dissection. Also included
are differentiating features related to these symptoms
to facilitate distinction of VBI related symptoms from
those related to vestibular disorders or BPPV
(Davies, 1997; van der Velde, 1999). In addition,
the emphasis on the importance of the subjective
screening is raised.
Inclusion of routine questioning about provocation
of VBI related symptoms during standard physical
testing of the cervical spine of any patient. For
patients who report provocation of VBI related
symptoms, reduction of the specific requirements in
the physical examination section. Minimum testing
recommended now includes sustained end-range
rotation only, performed either in supine or sitting,
with the actual testing procedure unchanged from the
previous protocol. Additional testing procedures are
suggested but are not required by the guidelines,
other than routine questioning during examination of
active movements for the provocation of VBI related
symptoms. Inclusion of additional testing procedures
should be guided by the clinical reasoning of the
physiotherapist in the context of any particular
patient presentation.
The mandate was to reduce the protocol in length, but
to base this reduction on research evidence. As
discussed, the research is inconclusive in determining
the most valid screening test. However, given that a
change in blood flow related to rotation was detected
in the majority of studies and that the present
survey highlighted more incidents related to rotation
than any other movement, sustained rotation was
reasoned to be the most appropriate test to include as
mandatory.
*
Inclusion of a specific section outlining recommendations for assessment during and following treatment
and interpretation of the results of the examination
procedures. The specific recommendations are that if
there is evidence of symptoms potentially associated
with VBI from both the subjective and physical
components of the examination, cervical manipulation or high velocity thrust techniques (HVTT) or
end-range rotation techniques (ERRT) should not
be undertaken. Also, if there is evidence at any time
that symptoms are clearly associated with VBI,
*
105
HVTT or ERRT should not be undertaken. In all
other situations, the final decision depends on
the therapist’s reasoning in any particular patient
presentation.
Inclusion of a substantially revised section on
provision of information and obtaining consent for
cervical manipulation (HVT techniques). This section
includes essential information to be provided to any
patient prior to undertaking cervical manipulation.
Differences in types of consent as recognized in law
are included to assist physiotherapists to determine
the situations in which consent should be gained.
Guidelines for gaining consent from patients for
cervical manipulation (HVTT) and recording
that consent are also included (Fig. 5). A flow
chart of the processes to be followed during
examination of a patient with cervical symptoms is
provided (Fig. 2).
6. Conclusion
This study suggests that the use and interpretation of
the APA Protocol for Pre-Manipulative Testing of the
Cervical Spine (APA, 1988) is variable among members
of MPA. There is a need to continue with definitive
investigations regarding the appropriateness, sensitivity
and specificity of the protocol in detecting patients at
risk of complications from manipulative/musculoskeletal physiotherapy techniques and the effect of cervical
movement on vertebral artery blood flow. This research
is ongoing (Rivett et al., 1999; Johnson et al., 2000;
Grant, 2002; Zaina et al., 2003).
The risk of complication from physiotherapy practice,
including HVT techniques, appears to be low and
none of the reported incidents in this study involved
serious or permanent compromise to the vertebrobasilar system. A large number of the reported minor
incidents were elicited by examination procedures
involving rotation, including those related to the
protocol, rather than manipulative physiotherapy treatment, arguably supporting the value of the protocol as a
screening tool.
While the new guidelines will never satisfy all
members of the profession, the majority of the feedback
has been positive. The principal criticism relates to
the informed consent section, with some members
resentful of the apparent imposition of this requirement.
In reality, the imposition has come from the changing
perception of the individual’s place and rights in society
rather than the profession and the guidelines have
been developed to protect physiotherapists in addition
to their patients. Most MPA members providing
informal feedback appreciate the relative freedom
allowed in the new guidelines to make their own
decisions.
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106
Patient
presents
with
problem
OR
need
to
cervical spine is recognised
cervical
examine
Subjective vertebro-basilar (VBI)
screening questions asked
No VBI symptoms identified
Presence of potential VBI
symptoms identified
Cervical physical examination includes
Cervical physical examination includes
Screening for VBI symptoms with every
active physiological movement tested
Screening for VBI symptoms with every
active physiological movement tested
Screening for VBI symptoms throughout
PAIVM examination advisable
Refer for further investigation?
Treat gently as appropriate
No cervical manipulation
No VBI symptoms
identified:
VBI symptoms identified:
Refer for further investigation?
Treat as appropriate
Monitor carefully during
treatment
Treatment choice = cervical
manipulation:
No end-range rotation
techniques
Recheck subjective VBI screening
Evaluate sustained cervical rotation
bilaterally (supine/sitting)
No cervical manipulation
No evidence of VBI
Provide information about cervical
manipulation
Obtain consent to manipulation
Manipulate with appropriate
localised technique
Reassess subjective VBI screening
Reassess relevant physical signs
Reassess sustained cervical rotation
Evidence of VBI
Do NOT manipulate
Refer for further investigation?
Non-manipulative treatment as
appropriate
Fig. 2. Flow chart for examination of the cervical spine using guidelines for pre-manipulative testing of the cervical spine.
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