Musculoskeletal Science and Practice 49 (2020) 102181
Contents lists available at ScienceDirect
Musculoskeletal Science and Practice
journal homepage: www.elsevier.com/locate/msksp
Professional issue
Yes, we should abandon pre-treatment positional testing of the
cervical spine
Nathan Hutting a, *, Hendrikus Antonius “Rik” Kranenburg b, Roger Kerry c
a
Department of Occupation and Health, School of Organisation and Development, HAN University of Applied Sciences, Nijmegen, the Netherlands
Research Group on Healthy Aging, Allied Health Care and Nursing, Hanze University of Applied Sciences, Groningen, the Netherlands
c
Division of Physiotherapy and Rehabilitation Sciences, University of Nottingham, Nottingham, UK
b
A B S T R A C T
Although there seems to be no causality between cervical spine (CS) manipulation and major adverse events (MAE), it remains important that manual therapists try
to prevent every potential MAE. Although the validity of positional testing for vertebrobasilar insufficiency (VBI) has been questioned, recently, the use of these tests
was recommended. However, based on the low sensitivity of the VBI tests, which may result in too many false-negative results, the VBI tests seem to be less valuable
in pre-manipulative screening. Moreover, because the VBI tests are unable to consistently produce a decreased blood flow in the contralateral vertebral artery in
(healthy people), the underlying mechanism of the test may not be a valid construct. There are numerous cases reporting MAE after a negative VBI test, indicating
that the VBI tests do not have a role in assessing the risk of serious neurovascular pathology, such as cervical arterial dissection, the most frequently described MAE
after CS manipulation. Symptoms of VBI can be identified in the patient interview and should be considered as red flags or warning signs and require further medical
investigation. VBI tests are not able to predict MAE and seem not to have any added value to the patient interview with regard to detecting VBI or another vascular
pathology. Furthermore, a negative VBI test can be wrongly interpreted as ‘safe to manipulate’. Therefore, the use of VBI tests cannot be recommended and should be
abandoned.
1. Introduction
1.1. Risks associated with cervical spine manipulation
Positional testing for vertebrobasilar insufficiency (VBI) is often used
by manual therapists as part of their pre-manipulative screening pro­
tocols (Thomas and Treleavan, 2020). The validity of these tests and
their added value to the patient evaluation has been questioned and
discussed for decades (Kerry, 2002; Rivett et al., 2005; Thiel and Rix,
2005). Recently, Thomas and Treleaven (2020) wrote an article about
the use of the VBI tests, also known as positional tests or
pre-manipulative tests. They concluded that the research evidence
supporting the positions to either abandon or retain the positional tests
is not strong for either standpoint. However, although they conclude
that there is no argument against the conclusion that positional tests are
unable to predict or detect craniocervical artery dissection, they did
recommend the use of these tests as they add to the clinical picture and
have a role to play in the assessment of cerebral haemodynamics related
to neck movement (Thomas and Treleavan, 2020). This point of view led
to discussion (Kerry et al., 2020; Thomas and Treleaven, 2020). In this
article, we argue that – from a professional perspective – the use of the
VBI tests cannot be recommended.
After cervical spine (CS) manipulation, the estimated incidence of
major adverse events (MAE) ranges from one per 50,000 to one per 5.85
million (Hutting et al., 2018). In a recent review, the most frequently
described MAE associated with CS manipulation was found to be cra­
niocervical arterial dissection (57% of the cases) (Kranenburg et al.,
2017). However, the association between CS manipulation and vascular
MAE is likely due to patients with headache and neck pain (being
pre-ischaemic symptoms) from craniocervical arterial dissection seeking
care before their stroke.
1.2. Risk assessment
Although a causality between CS manipulation and MAE (in partic­
ular, craniocervical artery dissection) is not likely (Cassidy et al., 2017,
2008; Taylor and Kerry, 2010), it is important that manual therapists try
to prevent every potential MAE caused by vascular or other pathologies
(Hutting et al., 2018). In 2014, the ‘International Framework for Ex­
amination of the Cervical Region for Potential of Cervical Arterial
Dysfunction’ was published (Rushton et al., 2014). The framework
* Corresponding author. Research Group Occupation & Health, School of Organisation and Development, HAN University of Applied Sciences, PO Box 6960, 6503
GL Nijmegen, the Netherlands.
E-mail address: Nathan.Hutting@han.nl (N. Hutting).
https://doi.org/10.1016/j.msksp.2020.102181
Received 19 February 2020; Received in revised form 16 April 2020; Accepted 8 May 2020
Available online 20 June 2020
2468-7812/© 2020 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
N. Hutting et al.
Musculoskeletal Science and Practice 49 (2020) 102181
aimed to guide clinical reasoning for the assessment of the CS region for
potential cervical arterial dysfunction.
Recently, Hutting et al. (2018) proposed three important steps in the
clinical reasoning process: 1) identify a possible vasculogenic contri­
bution or other serious pathology; 2) determine whether there is an
indication or contraindication for mobilisation or manipulation, and 3)
assess the presence of any potential risk factors associated with a po­
tential MAE that are reported to occur after CS mobilisation and/or
manipulation. With regard to the prevention of MAE, identifying a
possible vasculogenic contribution to the complaints is important
(Hutting et al., 2018). Therefore, the patient interview is essential for
identifying potential risk factors, red flags and contraindications
(Rushton et al., 2014).
(Kranenburg et al., 2019) investigated the effects of craniocervical po­
sitions and movements on haemodynamic parameters of cervical and
craniocervical arteries, which included 31 studies. It was found that, in
most studies, no significant haemodynamic changes during maximal
rotation, combined movement of maximum extension and maximum
rotation, and high-velocity thrust positioning and movement occurred
(most of these studies (n ¼ 25) included the vertebral artery in their test
protocol). The authors concluded that, in most people (healthy people as
well as patients with vascular pathologies), craniocervical positions do
not alter cervical blood flow (Kranenburg et al., 2019).
Because the VBI tests are not able to consistently produce a decreased
blood flow in the contralateral vertebral artery in (healthy) people, the
underlying mechanism of the test may not be a valid construct (Kra­
nenburg et al., 2019) because the collateral circulation will not be
challenged and tested. Furthermore, during manipulative treatment it is
unlikely that arteries will be compromised as much as during the VBI
tests (Herzog et al., 2012). Therefore, the rationale and value of the VBI
tests should be questioned (Kranenburg et al., 2019).
1.3. VBI tests
Since first reported in the literature (de Kleyn and Nieuwenhuyse,
1927), the combined extended and rotated CS position and sustained
end-range rotation have been used to evaluate whether a patient is at
risk of developing VBI or ischaemia following CS manipulation (Mitchell
et al., 2004). The pre-manipulative position has also been proposed as an
alternative VBI test (Australian Physiotherapy Association, 2006).
The VBI test examines the effect of the mechanical stresses on the
vertebral arteries during movements of the CS (Mitchell et al., 2004).
The tests have been postulated to affect vertebral artery blood flow by
primarily causing a narrowing of the vessel lumen, usually within the
artery contralateral to the side of head rotation (Thiel and Rix, 2005),
thereby compromising blood flow in the vessel (Mitchell et al., 2004). In
the rare case that the collateral circulation is unable to compensate for
the decreased blood flow in the contralateral artery, this decreased
blood flow may provoke symptoms of VBI through reduced brainstem
perfusion (Kuether et al., 1997; Mitchell et al., 2004).
1.6. False-negative results
Thiel and Rix reported in 2005 that the lack of sensitivity of the
positional tests as a valid screening procedure to prevent MAE is further
supported by some of the findings of the review of Haldeman et al.
(2001). In their review of 64 medico-legal cases of cerebrovascular ac­
cidents associated with manipulation of the CS, the practitioner had
described the use of a pre-manipulation positional test in 27 of the cases.
However, none of these patients had shown any adverse responses to
this screening test before the manipulation (Haldeman et al., 2001).
In a recently-published Dutch case report (Pool, 2019), a 45-year-old
man visited a manual therapist with left-sided neck pain, blurry vision
and dizziness. A trauma (fall on the back and head) was reported three
weeks earlier. Despite some indications of a possible vasculogenic
contribution, positional tests were negative. After manipulation, the
patient was admitted to hospital with a cerebellar infarction due to a
cervical arterial dissection. By performing the positional tests, a negative
test can be wrongly interpreted as ‘safe to manipulate’. It is possible that
clinicians believe that performance of these screening tests, and a
negative result, offer some form of medico-legal or clinical negligence
protection, or that these tests afford both the practitioner and the patient
a lesser risk of post-manipulation stroke (Thiel and Rix, 2005; Thomas
et al., 2019). Other false-negative results of the VBI tests have also been
published (Rivett et al., 1998; Westaway et al., 2003).
The inability of the VBI tests to detect or prevent a vascular MAE is
also supported by data from the Dutch Health and Youth Care Inspec­
torate (IGJ), which investigates all MAEs. In six of the seven available
case descriptions in which a pre-manipulative test was used, the test
results were negative. In one case, the MAE event occurred during
testing.
Therefore, it can be concluded that the VBI tests do not have a role in
assessing the risk of serious neurovascular pathology, such as cervical
arterial dissection (Kerry et al., 2020; Thomas and Treleaven, 2020).
These risks should mainly be assessed by a thorough patient interview
(Hutting et al., 2018; Thomas and Treleaven, 2020).
1.4. Validity of the VBI tests
Although the validity of the VBI tests has been questioned for de­
cades, the tests continue to be taught to some students, carried out in
daily clinical practice, and recommended in several practice guidelines
(Thiel and Rix, 2005; Thomas et al., 2017). The diagnostic accuracy of
the VBI tests was systematically reviewed in 2013 (Hutting et al., 2013).
In pre-manipulative screening procedures, we aim to identify patients
with a possible risk of complications. Pre-manipulative tests are used as
an add-on test in the diagnostic process. When there are no signs of VBI
or other contraindications for manipulation, these tests are performed to
filter false-negative test results in the patient interview (Hutting et al.,
2013).
Because it is important to prevent false-negative results, the sensi­
tivity of these tests should be high (Hutting et al., 2013). Sensitivity
ranged from 0 to 57%, indicating that a low sensitivity resulted in too
many people being missed (false-negatives). Although the specificity of
the cervical VBI tests was generally sufficient, specificity is less impor­
tant because a false-positive result for the test is not potentially harmful
to the patient (Hutting et al., 2013). Based on this review, the VBI tests
do not seem to be important in pre-manipulative screening, due to the
low sensitivity and low pre-test probability (Hutting et al., 2013).
Although the studies included in that systematic review were of low
quality (because they suffered from various biases), in line with the te­
nets of evidence-based healthcare, the review represents the best
available evidence at this stage (Kerry et al., 2020).
1.7. Vertebrobasilar insufficiency
Thomas and Treleaven (2020) provide some references that report
the onset of VBI symptoms with head positioning where blood flow
occlusion has been confirmed (Buch et al., 2017; Hernandez et al., 2019;
Ng et al., 2018; Schunemann et al., 2018; Strickland et al., 2017). The
references provided by Thomas and Treleaven (2020) relate to Bow
Hunter’s syndrome, a rare syndrome related to symptomatic VBI,
resulting from a rotational mechanical severe stenosis or a transient
occlusion of a dominant vertebral artery (Ng et al., 2018). The cases
referred to people presenting with syncopal episodes during left head
1.5. Rationale of the VBI tests
The aim of VBI tests is to unilaterally compress an artery to test the
collateral blood supply (Mitchell et al., 2004; Thiel and Rix, 2005). In
such as case, haemodynamics in that artery must change, which can be
measured via blood flow volume. Recently, a systematic review
2
N. Hutting et al.
Musculoskeletal Science and Practice 49 (2020) 102181
rotation (Ng et al., 2018), vertigo relieved by maintaining a neutral
position, numbness and tingling in the left occipital region (Strickland
et al., 2017), dizziness and loss of consciousness with head rotation
(Schunemann et al., 2018), neck pain associated with dizziness, head­
ache and tinnitus (Hernandez et al., 2019), and spells of dizziness and
near-syncope upon head rotation (Buch et al., 2017). However, the
symptoms described in these cases should be considered as red flags or
warning signs and require further medical investigation. Moreover,
these people complained of clear severe symptoms during head rotation,
which means that the VBI test has no added value, as it is already known
that rotation will increase their complaints.
The signs and symptoms associated with VBI are clear red flags for
any treatment by a manual or physical therapist. In the case of an ex­
pected vasculogenic contribution to the complaints, VBI testing seems
not to be prudent and might even harm the patient (Hutting et al., 2018;
Thiel and Rix, 2005). The patient interview is crucial for detecting these
symptoms of VBI, which could also be caused by another vascular cause,
for example dissection. Cranial nerve examination seems more appro­
priate, as VBI can result in cranial nerve dysfunction (cranial nerves V,
VI, VIII, IX, X, XII) (Kerry and Taylor, 2006; Paik et al., 2019).
Herzog, W., Leonard, T.R., Symons, B., Tang, C., Wuest, S., 2012. Vertebral artery strains
during high-speed, low amplitude cervical spinal manipulation. J. Electromyogr.
Kinesiol. 22, 740–746. https://doi.org/10.1016/j.jelekin.2012.03.005.
Hutting, N., Kerry, R., Coppieters, M.W., Scholten-Peeters, G.G.M., 2018. Considerations
to improve the safety of cervical spine manual therapy. Muscoskel. Sci. Prac. 33,
41–45. https://doi.org/10.1016/j.msksp.2017.11.003.
Hutting, N., Verhagen, A.P., Vijverman, V., Keesenberg, M.D.M., Dixon, G., ScholtenPeeters, G.G.M., 2013. Diagnostic accuracy of premanipulative vertebrobasilar
insufficiency tests: a systematic review. Man. Ther. 18, 177–182. https://doi.org/
10.1016/j.math.2012.09.009.
Kerry, R., 2002. Pre-manipulative procedures for the cervical spine: new guidelines and a
time for dialectics: knowledge, risks, evidence and consent. Physiotherapy 88,
417–420. https://doi.org/10.1016/S0031-9406(05)61267-9.
Kerry, R., Hutting, N., Kranenburg, R.H.A., 2020. Letter to the Editor on the Continued
Use of the “Vertebrobasilar Insufficiency” Test, 45. Muscoskel. Sci. Prac. https://doi.
org/10.1016/j.msksp.2019.102099. In press.
Kerry, R., Taylor, A.J., 2006. Cervical arterial dysfunction assessment and manual
therapy. Man. Ther. 11, 243–253. https://doi.org/10.1016/j.math.2006.09.006.
Kranenburg, H.A. “Rik”, Tyer, R., Schmitt, M., Luijckx, G.J., van der Schans, C.,
Hutting, N., Kerry, R., 2019. Effects of head and neck positions on blood flow in the
vertebral, internal carotid, and intracranial arteries: a systematic review. J. Orthop.
Sports Phys. Ther. 49, 688–697. https://doi.org/10.2519/jospt.2019.8578.
Kranenburg, H.A., Schmitt, M.A., Puentedura, E.J., Luijckx, G.J., van der Schans, C.P.,
2017. Adverse events associated with the use of cervical spine manipulation or
mobilization and patient characteristics: a systematic review. Muscoskel. Sci. Prac.
28, 32–38. https://doi.org/10.1016/j.msksp.2017.01.008.
Kuether, T.A., Nesbit, G.M., Clark, W.M., Barnwell, S.L., 1997. Rotational vertebral
artery occlusion: a mechanism of vertebrobasilar insufficiency. Neurosurgery 41,
427–433. https://doi.org/10.1097/00006123-199708000-00019.
Mitchell, J., Keene, D., Dyson, C., Harvey, L., Pruvey, C., Phillips, R., 2004. Is cervical
spine rotation, as used in the standard vertebrobasilar insufficiency test, associated
with a measureable change in intracranial vertebral artery blood flow? Man. Ther. 9,
220–227. https://doi.org/10.1016/j.math.2004.03.005.
Ng, S., Boetto, J., Favier, V., Thouvenot, E., Costalat, V., Lonjon, N., 2018. Bow Hunter’s
syndrome: surgical vertebral artery decompression guided by dynamic
intraoperative angiography. World Neurosurg. 118, 290–295. https://doi.org/
10.1016/j.wneu.2018.07.152.
Paik, S.W., Yang, H.J., Seo, Y.J., 2019. Sixth cranial nerve palsy and vertigo caused by
vertebrobasilar insufficiency. J. Audiol. Otol. https://doi.org/10.7874/
jao.2019.00311. In press.
Pool, J., 2019. Ernstige complicaties na cervicale manipulatie. Fysiopraxis May 32–35.
Rivett, D.A., Milburn, P.D., Chapple, C., 1998. Negative pre-manipulative vertebral
artery testing despite complete occlusion: a case of false negativity? Man. Ther. 3,
102–107. https://doi.org/10.1016/S1356-689X(98)80026-X.
Rivett, D.A., Thomas, L., Bolton, P., 2005. Pre-manipulative testing: where do we go from
here? N. Z. J. Physiother. 33, 78–84.
Rushton, A., Rivett, D., Carlesso, L., Flynn, T., Hing, W., Kerry, R., 2014. International
framework for examination of the cervical region for potential of Cervical Arterial
Dysfunction prior to Orthopaedic Manual Therapy intervention. Man. Ther. 19,
222–228. https://doi.org/10.1016/j.math.2013.11.005.
Schunemann, V., Kim, J., Dornbos, D., Nimjee, S.M., 2018. C2-C3 anterior cervical
arthrodesis in the treatment of Bow Hunter’s syndrome: case report and review of
the literature. World Neurosurg. 118, 284–289. https://doi.org/10.1016/j.
wneu.2018.07.129.
Strickland, B.A., Pham, M.H., Bakhsheshian, J., Russin, J.J., Mack, W.J., Acosta, F.L.,
2017. Bow Hunter’s syndrome: surgical management (video) and review of the
literature. World Neurosurg. 103, 953. https://doi.org/10.1016/j.
wneu.2017.04.101 e7-953.e12.
Taylor, A.J., Kerry, R., 2010. A “system based” approach to risk assessment of the
cervical spine prior to manual therapy. Int. J. Osteopath. Med. 13, 85–93. https://
doi.org/10.1016/j.ijosm.2010.05.001.
Thiel, H., Rix, G., 2005. Is it time to stop functional pre-manipulation testing of the
cervical spine? Man. Ther. 10, 154–158. https://doi.org/10.1016/j.
math.2004.06.004.
Thomas, L., Allen, M., Shirley, D., Rivett, D., 2019. Australian musculoskeletal
physiotherapist’s perceptions, attitudes and opinions towards pre-manipulative
screening of the cervical spine prior to manual therapy: report from the focus groups.
Muscoskel. Sci. Prac. 39, 123–129. https://doi.org/10.1016/j.msksp.2018.12.005.
Thomas, L., Shirley, D., Rivett, D., 2017. Clinical Guide to Safe Manual Therapy Practice
in the Cervical Spine. https://australian.physio/tools/clinical-practice/cervical-spi
ne.
Thomas, L., Treleavan, J., 2020. Should we abandon positional testing for
vertebrobasilar insufficiency? Muscoskel. Sci. Prac. 46 https://doi.org/10.1016/j.
msksp.2019.102095. In press.
Thomas, L.C., Treleaven, J., 2020. Response to the letter to the editor regarding the
continued use of the “vertebrobasilar insufficiency” test. Muscoskel. Sci. Prac. 45,
102101. https://doi.org/10.1016/j.msksp.2019.102101. In press.
Westaway, M.D., Stratford, P., Symons, B., 2003. False-negative extension/rotation premanipulative screening test on a patient with an atretic and hypoplastic vertebral
artery. Man. Ther. 8, 120–127. https://doi.org/10.1016/S1356-689X(02)00111-X.
2. Conclusions
The most common MAE occurring after CS manipulation is cranio­
cervical arterial dissection. Therefore, it is important to identify a
possible vasculogenic contribution or other serious pathology in patients
presenting with head or neck pain to try to prevent every potential MAE.
The aim of VBI tests is to unilaterally compress an artery to test the
collateral blood supply. However, the VBI tests are not able to consis­
tently produce a decreased blood flow in the contralateral vertebral
artery, meaning that the underlying mechanism of the test, may not be a
valid construct. Moreover, best available evidence indicates that the
predictive ability of the VBI tests to identify at-risk individuals is lack­
ing, because of the low sensitivity, resulting in false-negative results. VBI
tests are not able to predict MAE and therefore seem not to have any
added value to the patient interview with regard to detecting VBI or
another vascular pathology. A negative VBI test can also easily be
wrongly interpreted as ‘safe to manipulate’, which might lead to MAE.
Therefore, the use of VBI tests cannot be recommended and should be
abandoned.
References
Australian Physiotherapy Association, 2006. Clinical Guidelines for Assessing
Vertebrobasilar Insufficiency in the Management of Cervical Spine Disorders.
Buch, V.P., Madsen, P.J., Vaughan, K.A., Koch, P.F., Kung, D.K., Ozturk, A.K., 2017.
Rotational vertebrobasilar insufficiency due to compression of a persistent first
intersegmental vertebral artery variant: case report. J. Neurosurg. Spine 26,
199–202. https://doi.org/10.3171/2016.7.SPINE163.
Cassidy, J.D., Boyle, E., C^
ot�e, P., He, Y., Hogg-Johnson, S., Silver, F.L., Bondy, S.J., 2008.
Risk of vertebrobasilar stroke and chiropractic care: results of a population-based
case-control and case-crossover study. Spine 33. https://doi.org/10.1097/
BRS.0b013e3181644600.
Cassidy, J.D., Boyle, E., C^
ot�
e, P., Hogg-Johnson, S., Bondy, S.J., Haldeman, S., 2017. Risk
of carotid stroke after chiropractic care: a population-based case-crossover study.
J. Stroke Cerebrovasc. Dis. 26, 842–850. https://doi.org/10.1016/j.
jstrokecerebrovasdis.2016.10.031.
de Kleyn, Nieuwenhuyse, 1927. Schwindelanfalle und nystagmus bei einer bestimmten
stellung des kopfes. Acta Otolaryngol. 11, 155–157. https://doi.org/10.3109/
00016482709120074.
Haldeman, S., Carey, P., Townsend, M., Papadopoulos, C., 2001. Arterial dissections
following cervical manipulation: the chiropractic experience. CMAJ (Can. Med.
Assoc. J.) 165, 905–906.
Hernandez, R.N., Wipplinger, C., Navarro-Ramirez, R., Patsalides, A., Tsiouris, A.J.,
Stieg, P.E., Kirnaz, S., Schmidt, F.A., H€
artl, R., 2019. Bow hunter syndrome with
associated pseudoaneurysm. World Neurosurg. 122, 53–57. https://doi.org/
10.1016/j.wneu.2018.10.102.
3