Manual Therapy 19 (2014) e5ee6
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Manual Therapy
journal homepage: www.elsevier.com/math
Letter to the Editor
Risk reduction of serious complications from manual therapy: Are we
reducing the risk?
Correspondence to: International Framework for Examination of the Cervical Region
for Potential of Cervical Arterial Dysfunction prior to Orthopaedic Manual Therapy
Intervention by A. Rushton et al.
Keywords:
Manual therapy
Cervical
Risk factors
Adverse events
We would like to congratulate Rushton et al. for the study
entitled “International Framework for Examination of the Cervi-
cal Region for Potential of Cervical Arterial Dysfunction prior to
Orthopaedic Manual Therapy Intervention” as published in this
journal. We praise the initiative of conducting a clinical reasoning
framework for best practice for the examination of the cervical
spine region. It is important to aid clinicians in their clinical
reasoning process to providence effective and safe manual ther-
apy. As serious conditions such as cervical artery dissection
(CAD) or upper cervical instability may mimic musculoskeletal
dysfunction in the early stages, these should be recognized in
the patient’s history and clinical assessment. We agree with the
authors that the manual therapist cannot rely on the results of
one test to draw firm conclusions regarding the presence or
risk of CAD. The authors developed a clinically reasoned under-
standing of the patient’s presentation, including a risk benefit
analysis. Their study provides important information for clini-
cians to reconsider before applying manual therapy interven-
tions. However, there are some topics specifically related to the
identification of a person at risk for CAD that we would like to
debate.
The strength of possible risk factors for neuro-vascular pathol-
ogy such as CAD is largely unknown (Arnold and Bousser, 2005;
Kerry et al., 2008). It is important here to realize that the limited
available data concern risk factors for CAD in general, and not for
CAD as a possible consequence of cervical manipulation. In addi-
tion, a number of cardiovascular risk factors are associated with
atherosclerosis which is an intermediate outcome for CAD while
the relationship between atherosclerosis and CAD is not yet clear
(Rubinstein et al., 2005; Kerry et al., 2008). Furthermore, when
the association of cardiovascular risk factors (hypertension, smok-
ing status, high cholesterol) with CAD is critically examined, there
seems to be a protective effect instead of a risk effect (Thomas
et al., 2011). Therefore, the question arises whether we are
measuring the right risk factors. The measurement of hypertension
1356-689X/$ e see front matter Ó 2014 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.math.2014.01.007
as a possible risk factor for CAD (OR ¼ 0.29) does not seem to be
useful. The IFOMPT framework correctly states that there is limited
diagnostic utility data related to many possible risk factors
(Rushton et al., 2013) and that the interpretation must be in context
of other findings.
Similarly, premanipulative tests for upper cervical spine insta-
bility or vertebrobasilar insufficiency do not seem to be of value
in practice due to low diagnostic accuracy and low pretest probabil-
ity (Hutting et al., 2013a,b). Especially, the low sensitivity of these
tests results in a high rate of patients that are wrongly classified
as ‘low-risk patients’ for serious adverse events. It has been demon-
strated that the younger people (<45 years) showed an increased
risk to develop a CAD after a cervical manipulation, as opposed to
older people with multiple risk factors for atherosclerosis
(Schievink, 2001; Rothwell et al., 2001; Rubinstein et al., 2005;
Cassidy et al., 2008).
Moreover, it is advisable to further examine the risk of serious
complications after cervical manipulations. This provides insight
into the clinical value of the risk factors. However, the conse-
quences for clinical decision-making may still remain small in the
context of extreme low pretest probabilities.
Each estimate of the increased risk of CAD should be weighed
against the pretest probability of CAD that each person has. The
annual incidence of a spontaneous CAD is 2.3e3 per 10.000 peo-
ple and CAD is more common in relatively healthy young people
(Schievinck, 2001; Dziewas et al., 2003; Debette and Leys, 2009).
There is limited evidence that these people have vascular anom-
aly or genetic predisposition (Dittrich et al., 2007; Debette and
Leys, 2009). An insignificant trauma of the neck or cervical
manipulation may then trigger CAD (Debette and Leys, 2009;
Thomas et al., 2011). However, it is also likely that these people
would get a spontaneous CAD anyway. Given the low incidence
of CAD in this age group, it seems impossible to correctly identify
these people at risk during screening prior to cervical manual
therapy. This is consistent with the findings of a recent review
which showed that 10% of the adverse complications involving
CAD could not have been avoided if a more accurate and thor-
ough reasoning process and physical assessment had been used
(Puentedura et al., 2012).
We are thankful for the opportunity of discussing this issue and
hope to assist the authors of this framework to further improve the
safety of cervical manual therapy.
e6 Letter to the Editor / Manual Therapy 19 (2014) e5ee6

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Department of General Practice, Erasmus University Medical Center,
Rotterdam, The Netherlands