Original articles| Volume 22, ISSUE 7, P431-435, September 1999

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Vertebral artery flow and cervical manipulation: An experimental study


      Background: Spinal manipulation therapy is used by millions of patients each year to relieve symptoms caused by biomechanical dysfunction of the spine. Cerebrovascular accidents in the posterior cerebral circulation are a feared complication, but little research has been done on vertebral artery hemodynamics during cervical manipulation. Objective: The purpose of this study was to develop an experimental model for investigations of volume blood flow changes in the vertebral arteries during premanipulative testing of these vessels and during spinal manipulation therapy of the cervical spine. Design and Setting: An experimental study in a university biomedical laboratory. Material and Methods: The vertebral arteries were exposed in 8 adult pigs after extensive mediastinal dissection. Volume blood flow was measured on both sides simultaneously by advanced transit-time flowmetry. Results: After cervical manipulation, the vertebral artery volume blood flow increased significantly for 40 seconds before returning to baseline values in less than 3 minutes. We found no significant changes in volume blood flow during premanipulative testing of the vertebral arteries (DeKleyn's test). Conclusion: We present an experimental model for investigations of vertebral artery hemodynamics during biomechanical interventions. We found a modest and transient effect of cervical manipulation on vertebral artery volume flow. The model may have further applications in future biomechanical research, for example, to determine whether any of several spinal manipulative techniques imposes less strain on the vertebral artery, thereby reducing possible future cerebrovascular accidents after such treatment. (J Manipulative Physiol Ther 1999; 22:431–5)


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      1. Medicolegal abstracts. Malpractice: death resulting from chiropractic treatment for headache. Foster vs Thornton.
        JAMA. 1934; 103: 1260
        • Eisenberg DM
        • Kessler RC
        • Foster C
        • Norlock FE
        • Calkins DR
        • Delbanco TL.
        Unconventional medicine in the United States. Prevalence, costs, and patterns of use.
        N Engl J Med. 1993; 328: 246-252
        • Kunnasmaa KT
        • Thiel H.
        Vertebral artery syndrome: a review of the literature.
        J Orthop Med. 1994; 16: 17-20
        • Lee KP
        • Carlini WG
        • McCormick GF
        • Albers GW.
        Neurologic complications following chiropractic manipulation: a survey of California neurologists.
        Neurology. 1995; 45: 1213-1215
        • Grant R.
        Vertebral artery testing—the Australian Physiotherapy Association Protocol after 6 years.
        Manual Ther. 1996; 1: 149-153
        • Australian Physiotherapy Association
        Protocol for pre-manipulative testing of the cervical spine.
        Aust J Physiother. 1988; 34: 97-100
        • George PE
        • Silverstein HT
        • Wallace H
        • Marshall M.
        Identification of high risk pre-stroke patient.
        J Chiropr. 1981; 15: 26-28
        • Carey PF.
        A suggested protocol for the examination and treatment of the cervical spine: managing the risk.
        J Can Chiropr Assoc. 1995; 39: 35-39
        • Ivancic JJ
        • Bryce D
        • Bolton PS.
        Use of provocational tests by clinicians to predict vulnerability of patients to vertebrobasilar insufficiency.
        Chiropr J Aust. 1993; 23: 59-63
        • Côté P
        • Kreitz BG
        • Cassidy JD
        • Thiel H.
        The validity of the extension-rotation test as a clinical screening procedure before neck manipulation: a secondary analysis.
        J Manipulative Physiol Ther. 1996; 19: 159-164
        • Rivett DA
        • Milburn PD
        • Chapple C.
        Negative pre-manipulative vertebral artery testing despite complete occlusion: A case of false negativity?.
        Manual Ther. 1998; 3: 102-107
        • Dvorak J
        • Baumgartner H
        • Burn L
        • Dalgaard J
        • Enevoldsen E
        • Fossgreen J
        • et al.
        Consensus and recommendations as to the side-effects and complications of manual therapy of the cervical spine.
        Manual Med. 1991; 6: 117-118
        • Fast A
        • Zinicola DF
        • Marin EL.
        Vertebral artery damage complicating cervical manipulation.
        Spine. 1987; 12: 840-842
        • Licht PB
        • Christensen HW
        • Højgaard P
        • Marving J.
        Vertebral artery flow and spinal manipulation. A randomized, controlled and observer blinded study.
        J Manipulative Physiol Ther. 1998; 21: 141-144
        • Hurwitz EL
        • Aker PD
        • Adams AH
        • Meeker WC
        • Shekelle PG.
        Manipulation and mobilization of the cervical spine.
        Spine. 1996; 21: 1746-1760
        • Crawford JP
        • Hwang BY
        • Asselbergs PJ
        • Hickson GS.
        Vascular ischemia of the cervical spine: a review of relationship to therapeutic manipulation.
        J Manipulative Physiol Ther. 1984; 7: 149-155
        • Kawchuk GN
        • Herzog W.
        Biomechanical characterization (fingerprinting) of five novel methods of cervical spine manipulation.
        J Manipulative Physiol Ther. 1993; 16: 573-577
        • Cipriano JJ.
        Vertebrobasilar circulation assessment.
        in: 3rd ed. Photographic manual of regional orthopedic and neurological tests. : Williams & Wilkins, Baltimore, MD1997: 31-39
        • Sakai F
        • Ishii K
        • Igarashi H
        • Suzuki S
        • Kitai N
        • Kanda T
        • et al.
        Regional cerebral blood flow during an attack of vertebrobasilar insufficiency.
        Stroke. 1988; 19: 1426-1430
        • Ausman JI
        • Shrontz CE
        • Pearce JE
        • Diaz FG
        • Crecelius JL.
        Vertebrobasilar insufficiency. A review.
        Arch Neurol. 1985; 42: 8038
        • Kuether TA
        • Nesbit GM
        • Clark WM
        • Barnwell SL.
        Rotational vertebral artery occlusion: a mechanism of vertebrobasilar insufficiency.
        Neurosurgery. 1997; 41: 427-432
        • Toole JF
        • Tucker SH.
        Influence of head position upon cerebral circulation. Studies on blood flow in cadavers.
        Arch Neurol. 1960; 2: 616-623
        • Brown B
        • Tissington-Tatlow WF.
        Radiographic studies of the vertebral arteries in cadavers.
        Radiology. 1963; 81: 80-88
        • Husni EA
        • Bell HS
        • Storer J.
        Mechanical occlusion of the vertebral artery. A new clinical concept.
        JAMA. 1966; 196: 475-478
        • Bauer RB
        • Sheehan S
        • Meyer JS.
        An arteriographic study of the cerebrovascular disease in man. II. Cerebral symptoms due to kinking, tortuosity, and compression of carotid and vertebral arteries in the neck.
        Arch Neurol. 1961; 4: 119-131
        • Stevens A.
        Functional Doppler sonography of the vertebral artery and some considerations about manual techniques.
        Manual Med. 1991; 6: 102-105
        • Weingart JR
        • Bischoff HP.
        Doppler sonography of the vertebral artery with regard to head positions appropriate to manual medicine.
        Manuelle Medizin. 1992; 30: 62-65
        • Refshauge KM.
        Rotation: A valid premanipulative dizziness test? Does it predict safe manipulation?.
        J Manipulative Physiol Ther. 1994; 17: 15-19
        • Thiel H
        • Wallace K
        • Donat J
        • Yong-Hing K.
        Effect of various head and neck positions on vertebral artery blood flow.
        Clin Biomech. 1994; 9: 105-110
        • Haynes MJ.
        Doppler studies comparing the effects of cervical rotation and lateral flexion on vertebra artery blood flow.
        J Manipulative Physiol Ther. 1996; 19: 378-384
        • Licht PB
        • Christensen HW
        • Højgaard P
        • Hoilund-Carlsen PF.
        Triplex ultrasound of vertebral artery flow during cervical rotation.
        J Manipulative Physiol Ther. 1998; 21: 29-31
        • Hardesty WH
        • Whitacre WB
        • Toole JF
        • Randall P
        • Royster HP.
        Studies on vertebral artery flow in man.
        Surg Gynecol Obstet. 1963; 116: 662-664
        • Laustsen J
        • Pederson EM
        • Terp K
        • Steinbruchel D
        • Kure HH
        • Paulse PK
        • et al.
        Validation of a new transit time ultrasound flowmeter in man.
        Eur J Vasc Endovasc Surg. 1996; 12: 91-96
        • Alback A
        • Makisalo H
        • Nordin A
        • Lepantalo M.
        Validity and reproducibility of transit time flowmetry.
        Ann Chir Gynaecol. 1996; 85: 325-331