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Research Report
Effect of Selected Manual Therapy
Interventions for Mechanical Neck
Pain on Vertebral and Internal
Carotid Arterial Blood Flow and
Cerebral Inflow
Lucy C. Thomas, Darren A. Rivett, Grant Bateman, Peter Stanwell,
Christopher R. Levi
Background. Manual therapy of the cervical spine has occasionally been associated with serious adverse events involving compromise of the craniocervical arteries.
Ultrasound studies have shown certain neck positions can alter craniocervical arterial
blood flow velocities; however, findings are conflicting. Knowledge about the effects
of neck position on blood flow may assist clinicians in avoiding potentially hazardous
practices.
Objective. The purpose of this study was to examine the effects of selected
manual therapeutic interventions on blood flow in the craniocervical arteries and
blood supply to the brain using magnetic resonance angiography (MRA).
Method. Twenty adult participants who were healthy and had a mean age of 33
years were imaged using MRA in the following neck positions: neutral, rotation,
rotation/distraction (similar to a Cyriax manipulation), C1C2 rotation (similar to a
Maitland or osteopathic manipulation), and distraction.
Results. The participants were imaged using 3T MRA. All participants had normal
vascular anatomy. Average inflow to the brain in neutral was 6.98 mL/s and was not
significantly changed by any of the test positions. There was no significant difference
in flow in any of the 4 arteries in any position from neutral, despite large individual
variations.
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research
questions
Method
Design
The study was an experimental
MRI study examining blood flow in
the vertebral and internal carotid
arteries in the neutral neck position
and comparing these measurements
with blood flow measurements in 7
other neck positions used in common manual therapy procedures.
Informed consent was obtained from
all participants.
Participants
Volunteers who were between 18
and 65 years of age and had no
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Figure 1.
Participant position within the head coil for (A) rotation/distraction technique and (B)
localized C1C2 rotation technique.
9. Posttest neutral
The neck positions were selected to
replicate as closely as possible common manual therapy procedures
without application of the thrust
component. Neck rotation is a com1566
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Participants lay supine on the scanner bed with their head in a phased
array head coil. This device is a rigid
plastic box that encloses the head
above and on either side, with a bar
that passes anterior to the chin.
There is a space of approximately 4
cm separating the box from the participants head on all sides (Fig. 2).
Participants were asked to report
any restriction to rotation imposed
by the box and were observed by the
operator. Participants were monitored closely throughout and immediately following the procedure for
any symptoms or signs of discomfort, claustrophobia, or vertebrobasilar insufficiency, in the case of which
the examination would have been
terminated.
Measurement of Blood Flow in
the Craniocervical Arteries
Blood flow in each of the 4 craniocervical arteries was measured
with MRI using a phase-contrast
flow quantification sequence. All
participants were imaged on a 3-T
superconducting magnet (Siemens
Magnetom Verio, Siemens AG, Erlan-
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Figure 2.
Participant positioned in scanner showing head and neck coil.
ences between positions. The models were fitted using SAS version 9.2
(TS2M2) and SAS 2008 Proc Mixed
technique (SAS Institute Inc, Cary,
North Carolina) with restricted maximum likelihood estimation and with
the Kenward-Roger adjustment for
downward bias in the variancecovariance matrix. Compound symmetry was used. If the effect of a
neck position was significant,
follow-up testing of pairs of means
was undertaken in 2 ways using Dunnetts adjustment to compare the
neutral position with the other neck
positions and to examine all pairs of
means using a Bonferroni adjustment
to the significance level. For post
hoc power analysis, the variabilities
were determined using a randomeffects mixed model for each artery,
combining data for all 4 arteries, to
determine standard deviations due
only to measurement and neck position sources of variation.
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Figure 3.
Surface-rendered 3-dimensional multiplanar reformatted image of the carotid and
vertebral arteries of a participant showing (A) normal anatomy and no dominance of
any vessel and (B) hypoplastic right vertebral artery and dominance of left vertebral
artery.
Results
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LICA
RVA
LVA
Neck
Position
Minus
Neutral
Neck
Position
Minus
Neutral
Neck
Position
Minus
Neutral
N/A
RICA
LICA
RVA
LVA
Neck
Position
Minus
Neutral
Neutral
2.57 (0.86)
2.71 (1.03)
0.73 (0.62)
0.98 (0.64)
N/A
N/A
N/A
Left rotation
2.22 (0.76)
2.66 (0.97)
0.53 (0.72)
1.12 (0.71)
0.4 (14%)
0.1 (2%)
0.2 (27%)
0.14 (14%)
Right rotation
2.61 (1.0)
2.56 (0.96)
0.80 (0.70)
0.87 (0.59)
0.04 (2%)
0.2 (6%)
0.1 (10%)
0.1 (11%)
Left rotation/
distraction
2.79 (1.19)
3.01 (1.29)
0.65 (0.87)
0.87 (0.50)
0.2 (9%)
0.3 (11%)
0.1 (11%)
0.1 (11%)
Right rotation/
distraction
2.98 (1.01)
2.61 (1.19)
0.73 (0.79)
0.86 (0.61)
0.4 (16%)
0.1 (4%)
0.0 (0%)
0.1 (12%)
C1C2 left
rotation
2.84 (1.53)
3.01 (0.97)
0.66 (0.74)
1.03 (1.10)
0.3 (11%)
0.3 (11%)
0.1 (10%)
0.1 (5%)
CIC2 right
rotation
2.76 (0.87)
2.86 (0.96)
0.74 (0.69)
1.04 (0.71)
0.2 (7%)
0.2 (6%)
0.0 (1%)
0.1 (6%)
Distraction
2.83 (1.10)
2.68 (1.08)
0.55 (0.64)
0.88 (0.68)
0.3 (10%)
0.0 (1%)
0.2 (25%)
0.1 (2%)
Posttest neutral
2.94 (1.0)
2.85 (0.91)
0.64 (0.55)
1.14 (1.0)
0.4 (14%)
0.1 (5%)
0.1 (12%)
0.2 (16%)
.01
.28
Neck Position
.001
P value
.47
RICAright internal carotid artery, LICAleft internal carotid artery, RVAright vertebral artery, LVAleft vertebral artery, N/Anot applicable.
b
Linear mixed model P value for test of difference among the 9 position means.
changes were not similarly demonstrated for the left internal carotid
artery in right rotation, it is likely that
this finding for the right internal
carotid artery in left rotation is due
to a statistical anomaly.
Table 2.
Total Blood Inflow to the Brain Measured by Sum of Average Flow Volume (mL/s [95% Confidence Interval]) in Internal Carotid
and Vertebral Arteries: Difference Between Neck Position and Neutral (mL/s, P Value, and Percentage Difference)
Difference Between Neck Position And Neutral
Neck Position
Total Blood
Inflow
Neck Position
Minus Neutral
Percentage
Difference
Neutral
N/A
N/A
N/A
Left rotation
0.5
.18
6.6
Right rotation
0.1
.68
2.0
Left rotation/distraction
0.3
.33
4.7
Right rotation/distraction
0.3
.57
4.3
0.6
.10
7.9
0.4
.21
6.2
Distraction
0.1
.89
0.7
Posttest neutral
0.6
.38
8.6
N/Anot applicable.
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mL/s
0
Stable flow profile
LVAneut2
LVAneut
LVAdist
LVAc1rr
LVAc1lr
LVArrdist
LVAlrdist
LVArr
LVAlr
RVAdist
RVAc1rr
RVAc1lr
RVArrdist
RVAlrdist
RVArr
RVAlr
RVAneut2
RVAneut
B
8
7
6
mL/s
5
4
3
2
LICAneut2
LICAnuet
LICAdist
LICAc1rr
LICAc1lr
LICArrdist
LICAlrdist
LICArr
LICAlr
RICAdist
RICAc1rr
RICAc1lr
RICArrdist
RICArr
RICAlr
RICAneut2
RICAneut
RICAlrdist
Figure 4.
Individual parallel plots of flow volume (mL/s) in (A) vertebral arteries and (B) internal carotid arteries for all participants, with specific
plots highlighted to show individuals with large variation. For each, one individual with stable flow is shown for comparison. Rright,
Lleft, VAvertebral artery, ICAinternal carotid artery, RVAneutright vertebral artery neutral, RVAneut2right vertebral artery
posttest neutral, RVArrright vertebral artery right rotation, RVAlrright vertebral artery left rotation, RVAlrdistright vertebral artery
left rotation/distraction, RVArrright vertebral artery right rotation, RVAc1lrright vertebral artery left rotation at C1C2,
RVAc1rrright vertebral artery right rotation at C1C2, RVAdistright vertebral artery distraction, LVAlrleft verterbral artery left
rotation, LVArrleft verterbral artery right rotation, LVAlrdistleft vertebral artery left rotation distraction, LVArrdistleft vertebral
artery right rotation distraction, LVAc1lrleft vertebral artery left rotation at C1C2, LVAc1rrleft vertebral artery right rotation at
C1C2, LVAdistleft vertebral artery distraction, LVAneutleft vertebral artery neutral, LVAneut2left vertebral artery posttest
neutral, RICAneutright internal carotid artery neutral, RICAneut2right internal carotid artery posttest neutral, RICAlrright
internal carotid artery left rotation, RICArrright internal carotid artery right rotation, RICAlrdistright internal carotid artery left
rotation/distraction, RICArrdistright internal carotid artery right rotation/distraction, RICAc1lrright internal carotid artery left
rotation at C1C2, RICc1rrright internal carotid artery right rotation at C1C2, RICAdistright internal carotid artery distraction,
LICAlrleft internal carotid artery left rotation, LICArrleft internal carotid artery right rotation, LICAlrdistleft internal carotid artery
left rotation distraction, LICArrdistleft internal carotid artery right rotation distraction, LICAc1lrleft internal carotid artery left
rotation at C1C2, LICAclrrleft internal carotid artery right rotation at C1C2, LICAdistleft internal carotid artery distraction,
LICAneutleft internal carotid artery neutral, LICAneut2left internal carotid artery posttest neutral.
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Discussion
This comparative MRI study examined blood flow in the craniocervical
arteries in different neck positions
and compared the measurements of
blood flow with that in the neutral
position to identify if any neck positions were potentially more hazardous than others. The study showed
that blood flow was not negatively
affected by any of the neck positions
used and that no position had significantly greater effect on blood flow
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Conclusion
Although concerns have been raised
about the safety of manual therapy
applied to the neck, in particular the
upper cervical spine segments, none
of the positions tested in this study
demonstrated any significant change
in blood flow volume from the neutral position. Moreover, no position
including end-range rotation, upper
cervical rotation, or strong distraction had any greater effect on blood
flow than any other. Total blood supply to the brain was not adversely
affected by any positions, and in
most positions relating to common
manual therapy procedures such as
rotation/distraction and C1C2 rotation, supply was increased somewhat. Reduction in flow in one vessel appeared to be compensated for
by an increase in another. This finding suggests that the neck positions
themselves are not inherently hazardous in terms of compromise to
blood flow in the craniocervical
arteries, and it is more likely, therefore, that other factors such as the
state of the arteries and the effect of
the manipulative thrust may be more
important. Future imaging studies
focusing on blood flow in normal or
individual craniocervical arteries
may not be particularly useful.
All authors provided concept/idea/research
design. Ms Thomas, Dr Rivett, Dr Stanwell,
and Professor Levi provided writing. Ms
November 2013
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