Cervical arterial dysfunction: knowledge and reasoning for manual physical therapists.

SYNOPSIS: This clinical commentary provides evidence-based information regarding adverse cerebrovascular events in the context of manual therapy assessment and management of the cervical spine. Its aim is to facilitate clinical decision making during diagnosis and treatment of patients presenting to the therapist with cervicocranial pain. Rather than focusing on a traditional view of premanipulative testing as the cornerstone for decision making, we present information concerning the clinical presentation of specific vascular conditions. Additionally, we discuss the assessment and management of musculoskeletal pain in the presence of risk factors for cerebrovascular accident. It is proposed that vascular "red flag" presentations mimic neuromusculoskeletal cervicocranial syndromes. Invariably, the 2 conditions coexist. This reasoning presupposes that some patients who have poor clinical outcomes, or a serious adverse response to treatment, may be those who actually present with undiagnosed vascular pathology. We use 2 case reports to demonstrate how incorporating vascular knowledge into clinical reasoning processes may influence clinical decision making. LEVEL OF EVIDENCE: Level 5.