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Phys Ther. 2013 Nov;93(11):1563-74. doi: 10.2522/ptj.20120477. Epub 2013 Jun 27.

Effect of selected manual therapy interventions for mechanical neck pain on vertebral and internal carotid arterial blood flow and cerebral inflow.

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  • 1L.C. Thomas, DipPhys, GradDipAppSc(ManipPhty), MMedSc (Physiotherapy), Discipline of Physiotherapy, School of Health Sciences, Faculty of Health, The University of Newcastle, University Drive, Callaghan 2308, New South Wales, Australia.



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.


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).


This was an experimental, observational magnetic resonance imaging study.


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), C1-C2 rotation (similar to a Maitland or osteopathic manipulation), and distraction.


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.


Only individuals who were asymptomatic were investigated, and a short section of the arteries only were imaged.


Blood flow to the brain does not appear to be compromised by positions commonly used in manual therapy. Positions using end-range neck rotation and distraction do not appear to be more hazardous to cerebral circulation than more segmentally localized techniques.

[PubMed - indexed for MEDLINE]
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