Physiotherapists Issue New Guidelines for Cervical Spine Manipulation
by Dr John Reggars

Amongst all the recent controversy regarding SMT related stroke and in particular the findings of the Lewis Inquiry in Canada the Australian Physiotherapy Association (APA) has endorsed a new set of clinical guidelines covering pre-manipulative testing of the cervical spine.

The original guidelines were formulated in 1988 and like COCA’s Risk Management guidelines mandated that pre-manipulative testing be performed on all patients undergoing cervical spine manipulation but the new guidelines remove this blanket approach in favour of pre-manipulative testing being based more on clinical judgement. You might also recall the recommendations of the jury in the Lana Lewis Coronial Inquest which stated that:

“We the jury recommend, based on evidence heard, that practitioners (including chiropractors, physiotherapists and physicians/surgeons) be informed by their respective regulatory bodies that provocative testing (prior to performing high neck manipulation) has not been demonstrated to be of benefit and should not be performed. Universities and Colleges teaching high neck manipulation should be teaching their students that these tests have not been demonstrated to be of benefit and should not be performed.”

The new APA Guidelines include mention of:

• the provocative nature of the test procedures
• the unequivocal results of research in relation to vertebral artery flow
• that there is no known method for testing the intrinsic anatomy of the vertebral artery
• that pre-manipulative testing will not identify all patients who may suffer an adverse reaction to cervical manipulation
• the inclusion of nausea as part of the routine screening questions
• questioning about provocation of VBI symptoms during standard physical testing as well as during and after treatment of the cervical spine
• minimum testing now includes sustained end range rotation only
• further VBI testing to be guided by clinical reasoning of the physiotherapist

According to Guidelines although the research is inconclusive with regard to the most valid pre-manipulative test the authors are of the opinion that as the majority of the studies show a change in blood flow in relation to rotation that sustained rotation was reasoned to be the most appropriate test to include as mandatory.

The specific recommendations now state, as does COCA’s guidelines, that if there is evidence of symptoms potentially associated with VBI from both physical and subjective components of the examination cervical manipulation or high velocity techniques or end range rotation techniques should not be undertaken. In all other situations the final decision depends on the therapist’s clinical reasoning. However, as stated above, the Guidelines still suggest that even in the absence subjective signs of VBI symptoms on clinical history taking screening should still be conducted with every active physiological movement being tested.

Finally, again in line with COCA’s Risk Management Program, informed consent should be obtained from all patients prior to undergoing cervical manipulation.

Magery ME, et al. Pre-manipulative testing of the cervical spine review, revision and new clinical guidelines. Manual Therapy 2004; 9:95-108.