International Framework for Examination of the Cervical Region

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Background

This page is based on the following position statement: Rushton A, Carlesso LC, Flynn T, Hing WA, Rubinstein SM, Vogel S, Kerry R. International framework for examination of the cervical region for potential of vascular pathologies of the neck prior to musculoskeletal intervention: international IFOMPT cervical framework. Journal of Orthopaedic & Sports Physical Therapy. 2023 Jan;53(1):7-22.

Vascular pathologies of the neck and head are rare, but they are an important consideration for clinicians managing people with neck and/or head pain. They matter to musculoskeletal clinicians for two reasons. First, neurovascular safety incidents have been linked with therapeutic interventions. Second, some arterial pathologies ("vascular masqueraders") can present as musculoskeletal neck pain and/or headache. Cervical artery dissection, for example, causes about 2% of all ischaemic strokes but up to 25% of ischaemic strokes in adults under 50.

Earlier versions of the Framework (2012 and 2020) used the term “orthopaedic manual therapy (OMT)”, which could suggest the guidance was only for clinicians with specialist manual therapy training. The 2023 position statement uses “musculoskeletal intervention” instead, which covers mobilisation, manipulation and exercise delivered by any clinician managing neck and head pain.

Similarly, the 2012 version used the term “cervical arterial dysfunction”. The current Framework uses “vascular pathologies of the neck”, which covers both disease processes (such as dissection or atherosclerosis) and non-disease mechanical problems (such as an elongated styloid process compressing an artery).

Using the Framework does not guarantee that vascular pathologies will be identified.

Consensus Methodology

The framework was developed through rigorous methods and is not intended to be a set of systematic reviews to answer specific questions. The consensus process looked at the breadth and complexity of the evidence and clinical reasoning and facilitated recommendations with a lack of published material and significant uncertainty.

Precisely defined substantive areas were identified for each section of the framework, and relevant electronic databases, reference lists, key journals, existing networks, and relevant organisations and conferences were searched. Within each section, study selection and data and information charting were carried out in accordance with its focus. There were four stages to developing the framework:

Stage 1:

A survey to evaluate the previous 2012 cervical framework was distributed to all member organisations and registered interest groups of IFOMPT in 2016.

Stage 2:

The key issues identified in the survey were initially explored at the IFOMPT Conference in 2016 in Glasgow. Findings from the evaluation survey were presented to facilitate discussion and debate through platform presentations, confirming the need for an updated version of the framework. Terminology was adapted (OMT to musculoskeletal), and six new case studies were added to support knowledge translation.

Stage 3:

Drafts of the framework were developed through an iterative consultative process and distributed for review and feedback to IFOMPT member organisations, registered interest groups, international experts/authors, nominated experts within IFOMPT countries, and professional organisations across physical therapy, osteopathy, and chiropractic. The final version was reviewed by a medical specialist in stroke and interventional neurology.

Stage 4:

The framework was voted on and accepted unanimously at the IFOMPT General Meeting in November 2020 by 22 member organisations (countries) as an international position statement for musculoskeletal clinicians.

Clinical Reasoning and Shared Decision-making

The current framework builds on the previous 2012 (first version) framework and addresses concerns raised by the consensus methodology and empirical work. To enable effective, efficient, and safe assessment and management of the cervical spine region, sound clinical reasoning is required.

Shared decision-making is an effective means for reaching an agreement on the best treatment strategy. It fosters patient-centred “care that is respectful of and responsive to individual patient preferences, needs, and values” and ensures “that patient values guide all clinical decisions.”

Shared decision-making, informed consent and medico-legal framework

The Informed Medical Decision-Making Foundation describes shared decision-making as a dynamic two-way process:

• The clinician communicates personalized information about the options, outcomes, probabilities, and scientific uncertainties of available treatment options to the patient.

• The patient communicates their values and the relative importance they place on benefits and harms.

The framework adopts the Agency for Healthcare Research and Quality’s 5-step SHARE approach:

1. Seek your patient’s participation.
2. Help your patient to explore and compare treatment options.
3. Assess your patient’s values and preferences.
4. Reach a decision with your patient.
5. Evaluate your patient’s decision to achieve patient-centred practice.

How an international framework can help clinicians

The clinician's priorities are, first, to do no harm and, second, to excel in clinical reasoning and differential diagnosis. Incidents following musculoskeletal treatment are generally believed to occur in people with an existing vascular pathology or a vascular predisposition (eg. an elongated styloid process). There are rare exceptions where an incident may seem unpredictable, such as spontaneous cervical artery dissection.

The Framework guides assessment of the cervical spine region for potential vascular pathologies before planned interventions, including mobilisation, manipulation and exercise. It considers both ischaemic and non-ischaemic presentations. Table 1 summarises the range of vascular pathologies of the neck.

Table 1. Range of vascular pathologies of the neck (adapted from Rushton et al. 2023)

Vessel or site	Pathology	Typical presentation
Carotid artery	Atherosclerosis (stenosis, thrombosis, aneurysm)	Neck, face or head pain; carotidynia; cranial nerve dysfunction; Horner’s syndrome; TIA or stroke
Carotid artery	Dissection	Neck, face or head pain; cranial nerve palsies; Horner’s syndrome; TIA
Carotid or vertebral artery	Hypoplasia	Usually silent; rarely cerebral ischaemia
Vertebral artery	Atherosclerosis	Neck pain; occipital headache; possible TIA or stroke
Vertebral artery	Dissection	Neck pain; occipital headache; TIA; cranial nerve palsy
Temporal, vertebral, occipital or carotid arteries	Giant cell arteritis	Temporal headache; scalp tenderness; jaw and tongue claudication; visual symptoms, including possible permanent vision loss
Cerebral vessels	Reversible cerebral vasoconstriction syndrome	Severe “thunderclap” headaches
Subarachnoid space	Subarachnoid haemorrhage	Sudden severe headache; stiff neck; photophobia; visual disturbance; slurred speech; nausea; one-sided weakness
Jugular vein	Thrombosis	Neck pain; headache; fever; swelling around the neck or angle of the jaw
Any cervico-cranial vessel	Anomaly or malformation, including vessel entrapment	Possible headache or neck pain (e.g. an unruptured aneurysm)

Risk and context

Clinicians need to understand risk in both its epidemiological and individual contexts. Epidemiologically, the risk of a vascular incident related to therapeutic interventions is extremely small, but clinicians must still do everything they can to reduce it. Individually, patients differ in their risk, their hazard profile (predisposition to arterial pathology) and whether a vascular pathology is already present and masquerading as a musculoskeletal problem.

Key principle: no single test is conclusive

Clinicians cannot rely on the result of a single test. Understanding the patient's presentation through an informed, planned and individualised assessment is essential. The position statement uses a visual tool throughout to show the level of support for a vasculogenic hypothesis: low, moderate or high. Each level shapes subsequent decision-making.

The following sections follow the five stages of clinical reasoning: patient history, planning the physical examination, conducting the physical examination, planning the intervention, and evaluating the intervention.

Flowchart of clinical reasoning

Case A :

History: A 50-year-old male bricklayer complains of a headache. His headache is similar but different to previous migraine headaches that he intermittently experiences. This is different because he also feels lethargic and “run down.” With this in mind, he decides to go to bed sure that he will feel better in the morning as he does feel fatigued and “sleepy.” Upon waking, his headache is still present. He thinks he needs to exercise and “get out for some fresh air” (similar to previous headaches), so he walks to the shops for essentials. The checkout operator says that she cannot understand what he is saying and that his speech is slurred. He is confused as he knows what he is saying and feels this is due to his “overdoing it.” He reflects and cannot understand why he is still lethargic and cannot concentrate on things. Upon his wife's arrival home from work, she also comments that he is difficult to understand and needs to concentrate on their conversation as “he is not listening to her.” She calls a physical therapist friend to seek advice.

Synopsis: A headache described as “unusual” with progressive signs of likely central ischemia (slurred speech, lethargy, fatigue, confusion) is sufficient information for the therapist to recommend emergency medical attention.

Support for Vascular Hypothesis: High

Action: Urgent medical investigation.

Patient History

Patient History

The patient history is used to develop and test hypotheses about the risk of vascular pathologies in the neck or the presence of frank vascular pathologies. Physical examination tests have very limited diagnostic utility data. As a result, the clinician's goal is to use the patient history to make the best judgement on the possibility of treatment contraindications or serious pathology. Subtle signs and symptoms of suspected pathologies should be identified during the patient history-taking. It is also critical to recognise risk factors that indicate the possibility of neurovascular pathology.

Considering Risk Factors

Vascular pathology of the neck event has a complex and multifactorial aetiology. Several factors have been linked to an increased risk of arterial pathologies involving the internal carotid or vertebrobasilar vessels. These should be thoroughly considered while taking a patient's history.

Tables 2 and 3 of the position statement list risk factors for dissection and non-dissection vascular events. Tables 4–8 list reported clinical features, separating vertebrobasilar from internal carotid dissection.

Interpreting the tables: the percentages show the proportion of patients with each condition who had that risk factor or feature. They are not measures of relative risk. They help clinicians recognise developing clinical patterns, especially the differences between dissection and non-dissection events. For example, recent trauma (40–64%) is the most common risk factor in dissection events, while smoking (65–74%) and hypertension (53–74%) are the most common in non-dissection events.

Caution: spontaneous dissection events are not associated with these historical risk factors, so the absence of risk factors does not rule out a serious neurovascular event.

Presenting Features of Vascular Pathologies of the Neck

Recognising clinical pattern elements that may support or disprove a vascular hypothesis is critical.  A definite clinical pattern cannot be identified due to the extremely low prevalence, a wide range of pathologies, and high variation of the presenting features of vascular pathologies of the neck. However, certain consistent features of clinical presentation emerge from historical case reports, which are supported by observations from systematic reviews.

Importance of Observation Throughout History

While the clinician is taking the patient's history, signs and symptoms of serious pathology and contraindications/precautions to treatment may manifest. This is a chance to observe and identify potential red flags indicators early in the clinical encounter such as:

• Gait disturbances.
• Subtle signs of disequilibrium.
• Upper motor neuron signs.
• Cranial nerve dysfunction.
• Behavior suggestive of upper cervical instability (e.g., anxiety, supporting head/neck.)

Case B:

History: A 46-year-old female supermarket worker presents for physical therapy with left-sided head (occipital) and neck pain described as “unusual.” She reports a 10-day history of the symptoms following a road traffic accident. The symptoms are progressively worsening. The pain is eased by rest. The patient reports an onset of new symptoms after about seven days, including “feels like might be sick,” “throaty,” and “feels faint”—especially after performing the gentle exercise. Two days after this, she reports a stronger feeling of nausea, loss of balance, swallowing difficulties, speech difficulties, and acute memory loss. She reports a history of previous road traffic accidents. Past medical history included hypertension, headaches, high cholesterol, and a maternal family history of heart disease and stroke.

Synopsis: Progressive “unusual” headache with emerging hindbrain/central neurology with a history of trauma indicates additional testing to support a medical referral.

Support for Vascular Hypothesis: High

Action: Physical examination including blood pressure and cranial nerve testing, avoiding provocative head and neck movements. These findings may support a referral for urgent medical investigation.

Planning the Physical Examination

Necessity for planning

Interpreting the data from the patient history and defining the main hypotheses is essential to an effective physical examination. Hypothesis generation from the history and refining, re-ranking and rejecting of these hypotheses in the physical examination is necessary to facilitate optimal clinical reasoning in musculoskeletal practice. Therefore careful planning of the physical examination is required. In particular, for this framework, the possible vasculogenic contribution to the patient’s presentation needs to be evaluated from the patient history data.

Are any further patient history data required?

An important planning component is identifying any further patient history data that may be required. That is, are there any gaps in the information obtained? Is the quality of the information obtained sufficient?

Decision-making regarding the physical examination

Based upon the evaluation and interpretation of the data from the patient history, the physical therapist needs to decide the following:

• Are there any precautions? eg. a precaution owing to a vasculogenic hypothesis
• Are there any contraindications? eg. avoiding end-of-range movements
• Which tests should be included or excluded? eg. blood pressure needs to be tested
• What is the priority for these tests for this patient (the order of testing, and which tests to complete at the first visit)? eg. neurological examination first
• Do the tests need adapting? eg. a change in position

During the physical examination, consider whether each new finding supports the vasculogenic hypothesis, weakens it, or makes no difference.

Physical Examination

Data obtained during the physical examination serves the following purposes:

• to support or refute the existing hypotheses
• to reevaluate the level of support for a vasculogenic hypothesis
• to determine whether a medical referral for further vascular workup is warranted
• to determine if the clinician can proceed with physical intervention

Data on the diagnostic utility of many recommended tests are limited. However, existing data support conventional vascular examination: blood pressure, neurological examination and examination of the carotid artery have moderate to good utility in supporting a decision to refer for further investigation. Existing data on functional positional tests (such as the vertebrobasilar insufficiency [VBI] test) for identifying vertebral artery pathology do not support recommending them. Clinicians should reflect on their competence and seek additional training if they are unfamiliar with any test.

Blood pressure

Examination of blood pressure informs clinical reasoning in 2 ways:

1. Assess the risk for stroke, particularly from carotid origin.
2. Assess for acute arterial trauma in situ. An increase in blood pressure may be related to acute arterial trauma, including ICA and vertebral artery (VA).

Hypertension strongly predicts cardiovascular disease, but it should be interpreted in the context of other findings with sound clinical reasoning.

There is a positive correlation between increased systolic and diastolic pressure and risk of stroke: the higher the pressure, the greater the risk. There is no discrete threshold; readings must be interpreted alongside other findings. In a prospective study of dissection events in people younger than 38, cardiovascular markers such as hypertension were not associated with the event. People found to have previously unidentified hypertension should be advised to discuss this with their primary care provider.

Neurological examination

Examination of peripheral and cranial nerves for an upper motor neuron lesion will help clinicians judge the potential for neurovascular conditions. A wide range of tests is needed because presentations vary, including balance and coordination tests. Cranial nerve examination is particularly important, and its reliability and validity are moderate. The absence of findings does not rule out underlying pathology or an impending dissection. An increasing body of literature details clinical cases of arterial pathology with cranial nerve involvement to inform pattern recognition.

Examination of the carotid artery

Auscultation and palpation of the common and internal carotid arteries are possible because these vessels are relatively large and superficial. On its own, pulse palpation is neither sensitive nor specific, but it can provide important information.

• An internal carotid artery pulse alteration has been identified as a feature of internal carotid disease.
• Asymmetry between left and right vessels is considered significant.
• A pulsatile, expandable mass indicates an arterial aneurysm.
• A bruit on auscultation (controlling for normal turbulence) indicates a significant finding and should be considered in the context of other clinical findings.
• It is possible for dissections and steno-occlusive disease of the carotid arteries to exist without aneurysm formation.

Differentiation during the physical examination

Differentiating a patient’s symptoms from a vasculogenic cause with complete certainty is not currently possible from the physical examination. Thus, it is important for the  physical therapist to understand that headache/neck pain may be the early presentation of an underlying vascular pathology. The task for the therapist is to differentiate the symptoms by:

1. Having a high index of suspicion
2. Testing the vascular hypothesis.

This differentiation process should occur early in the assessment process, i.e. early in the patient history. The symptomology and history of a patient experiencing vascular pathology may alert the physical therapist to such an underlying problem. A high index of suspicion of cervical vascular involvement is required in cases of acute onset neck/head pain described as “unlike any other”. Physical therapists may be exposed to patients presenting with the early signs of stroke (for example, neck pain/headache) and need both knowledge and awareness of the mechanisms involved. A basic understanding of vascular anatomy, haemodynamics and the pathogenesis of arterial dysfunction may help the physical therapist differentiate vascular head and neck pain from a musculoskeletal cause  through interpretation of the patient history data and tests in the physical examination.

Physical Examination

Refer on for further investigation

Clinicians should refer for immediate medical investigation when their clinical suspicion, supported by the reasoned patient history and physical examination findings, suggests vascular pathology. Urgency matters: in cervical artery dissection, most related strokes (82%) occur in the first week after symptom onset. Duplex ultrasound, magnetic resonance imaging/arteriography and computed tomography are conventionally used. Follow local policy for referral routes.

Case C:

History: A 42-year-old accountant presents to physical therapy with a 5-day history of unilateral (left-sided) neck and jaw pain and temporal headache following decorating the ceiling (sustained head/neck extension). The following day, the patient’s pain worsened, and he developed left-sided ptosis. The patient had underlying risk factors for arterial disease, and the historical presentation was typical of ICA dissection, with a key differentiator being the ptosis.

Physical examination: The history indicates a physical examination focused on testing the vascular hypothesis, collecting as much useful information as possible in the least provocative way. At rest, blood pressure is unusually high (210/175 mmHg). The left pupil is substantially less dilated than the right. There is a pulsatile mass over the left internal carotid artery, with an unusually turbulent bruit on auscultation.

Synopsis: Neck pain and temporal headache related to sustained neck extension in a male with a cardiovascular profile. Physical examination findings support a vascular hypothesis and indicate urgent medical referral.

Support for Vascular Hypothesis: High

Action: Urgent medical investigation. Magnetic resonance arteriography is indicated.

Planning Intervention

This section relates to those patients not presenting with a discrete vascular pathology but with neuromusculoskeletal craniocervical dysfunction suitable for musculoskeletal intervention, including mobilisation, manipulation and exercise intervention. This assessment of risk and benefit relates to the risk associated with treatment, not misdiagnosis.

Framework for evaluating risk

Compared to other noninvasive treatments, the risks of a serious adverse event from musculoskeletal intervention (manual and/or exercise interventions) are extremely low and vary depending on the patient's clinical presentation and known risk factors.

In the context of this Framework, there are two substantive but related risks:

1. The risk of misdiagnosis of an existing vascular pathology
2. The risk of serious adverse events following intervention

Misdiagnosis: the current hypothesis is that patients with neck pain and headache who go on to have a serious adverse event, such as a dissection, had an underlying pathology that treatment then aggravated. These patients present with what appears to be a musculoskeletal condition but is a different pathology.

Risk estimates:

• Vertebral artery dissection occurs in an estimated 0.75–2.9 per 100,000 people in the general population.
• Internal carotid dissection is more common than vertebral dissection in the general population, but most serious adverse events associated with physical treatment involve the vertebral artery.
• Vertebral artery dissections associated with physical treatment occur at roughly 0.4–5 per 100,000 patients.
• Reported relative risk of stroke after physical treatment ranges from 0.14 to 6.66. This wide range reflects problems with case definition and study bias.

Compared with a visit to a general practitioner, physical treatment in people with neck pain and headache does not increase risk. Table 9 of the position statement compares absolute risks with pharmacological options. For cervical treatment, the worst-case absolute risk of vertebrobasilar stroke is 0.005%.

Biomechanical studies in healthy individuals suggest that physical treatment alone, particularly when performed in a combination of midrange neck positions, cannot generate enough vessel stress or hemodynamic changes to explain the onset of a dissection event.

Benefit

The benefits of mobilisation and manipulation are supported by high-quality systematic reviews and meta-analyses. Mobilisation, manipulation and exercise interventions are also included in the most recent Clinical Practice Guidelines linked to the International Classification of Functioning, Disability and Health. The known effectiveness of interventions for neck pain and associated disorders (headache, radiculopathy) is summarised below.

Risk and Benefit

mobilisation and Manipulation

• mobilisation and manipulation for neck pain have moderate to large clinically beneficial effects on pain and functional outcomes compared to inactive or active interventions. These advantages were independent of the length of the follow-up (short, intermediate, or long-term) and the duration of the neck pain (acute, subacute, or chronic).
• mobilisation and manipulation produce better results for tension-type headaches.
• Cervical manipulation had an immediate effect with moderate to large effects on cervical radiculopathy compared to no treatment, placebo, or traction interventions.
• This conclusion is supported by the updated Bone and Joint Decade Task Force on neck pain and associated disorders.

Adding Exercise to mobilisation and Manipulation

For people with subacute and chronic nonspecific neck pain, there is moderate to strong evidence that various forms of mobilisation and/or manipulation combined with exercise results in better outcomes than exercise alone:

1. Pain relief
2. Improvement in physical functioning
3. Greater patient satisfaction
4. Quality of life

At short and medium-term follow-ups, approximately half of the included trials demonstrated moderate to large clinically beneficial effects when mobilisation and/or manipulation were added to the treatment.

Another review found moderate-quality evidence that adding mobilisation and/or manipulation to exercise therapy did not provide additional benefits for pain, disability, or quality of life in adults with low-grade neck pain.

As a result, the evidence is conflicting. No specific data exist on the risk following exercise.

Update (2025): the Framework's summary above reflects reviews published up to 2017. More recent evidence suggests benefits are mainly short term and may be smaller than earlier reported.

• An umbrella review supported manual therapy plus exercise, and cervical or thoracic mobilisation/manipulation, for pain and disability in nonspecific neck pain, cervicogenic headache and cervical radiculopathy in the short term.
• A meta-analysis of 16 RCTs (n = 1,157) found that cervical joint mobilisation reduced pain and disability, but the improvements did not reach clinically meaningful thresholds, and the certainty of evidence was very low.

Clinical implication: because the expected benefits of manual therapy are modest and short term, the risk–benefit judgement should be made with the patient using shared decision-making. Exercise-based management remains an option when the vascular hypothesis cannot be confidently rejected.

Person-centred decision-making

• Individually, the epidemiological data must be contextualised to the specific patient encounter, as illustrated by the cases, based on the background literature, highlighting various risk factors for specific pathologies in specific people.  There is a lack of accurate data to inform precise levels of risk at an individual level, making it impossible to develop valid clinical prediction rules for risk or benefit.
• The clinician cannot make an absolute risk judgement.
• The clinician must accept that clinical decisions are made without certainty and that the goal of the analysis is to make a decision based on a balance of probabilities.
• When in doubt about intervention, the clinician should consider not intervening and assess the chance of natural recovery of pain and function (assuming a musculoskeletal dysfunction).

Case D:

History: A 45-year-old male is referred with a 6-month history of gradual onset unilateral neck pain and, more recently, headaches. The pain is manageable and not worsening, but the patient is worried that the pain has not resolved. Focused questioning for vascular pathology and dysfunction does not indicate a vascular hypothesis: no trauma, history of migraine, or significant cardiovascular factors. The pain is consistent with typical musculoskeletal dysfunction; no signs and symptoms are associated with vascular pathology or dysfunction.

Synopsis: A history of headaches indicates focused questioning that fails to support a vascular hypothesis. Further findings are consistent with a musculoskeletal disorder.

Support for Vascular Hypothesis: Low

Action: Begin a trial of therapy for neck pain/headache, with no avoidance of cranio-cervical movements.

Case E:

History: A 72-year-old female is referred for episodic neck pain and headache. She has responded very well to manual therapy in the past. This episode is described as severe and irritable, like previous episodes. She has a cardiovascular history of hypertension, high cholesterol levels, and two previous strokes (the last one was three years ago).

Synopsis: Patient history and physical examination findings support a vascular hypothesis, but an alternative, more likely explanation for the presenting complaint is also supported. There are insufficient data to support medical referral. Safety netting is indicated.

Physical examination: Resting blood pressure is high (165/96 mmHg) but normal for her. All cranial nerve testing is negative, and there are no abnormal findings on palpation and auscultation of the carotid arteries. Cervical movement restriction is typical of musculoskeletal dysfunction.

Support for Vascular Hypothesis: Moderate

Action: Safety netting is required: the patient must act immediately if new signs and symptoms appear. Therapeutic advice and interventions can be trialled during safety netting, but must avoid end-of-range rotation and extension. A shared decision-making conversation should include full and explicit informed consent.

Shared decision-making is an effective method for agreeing on the best treatment strategy. The SHARE framework walks you through the process of having these conversations step by step. Table 10 of the position statement gives example SHARE conversations for Cases D and E. Clinicians new to this format are advised to practise it with a colleague first.

Clinical reasoning flowchart for risk assessment prior to musculoskeletal intervention (adapted from the work of Hutting et al).

Evaluating An Intervention

• Clinical reasoning should enable effective, efficient, and safe management of the cervical spine.
• Using the principles described in the IFOMPT cervical framework to aid patient-centred clinical reasoning through intervention, evaluation, and progression is important.

Case F:

History: A 33-year-old male presents with right-sided suboccipital neck pain/headache. Worse in the mornings and aggravated by the left rotation of the neck. Symptoms began two weeks ago (he recalls “cricking” his neck in a football tackle)—they are gradually worsening. No previous similar episode of this type of pain, but some lower neck pains several years ago. Good health; history of migraine. The patient had manual therapy five days ago (soft tissue massage to his bilateral neck and shoulder; dry needling/acupuncture to his right trapezius; mobilisation of the upper cervical spine [C0-C2]). Immediate increased pain in the left cervical spine and an episode of feeling very unsteady/dizzy. The therapist attempted to continue with soft-tissue massage when the dizziness settled, but the patient became unwell and vomited.

Physical Examination: Mild restriction of cervical movement. The previous therapist had performed functional positional testing when the patient reported changing red-flag symptoms; it was negative. No other neurological or vascular examination was performed.

Synopsis: A young patient with a history of migraine and recent trauma presents with an “unusual” headache. The onset of vascular signs and symptoms during care should alert the therapist to test a vascular hypothesis in line with best practice guidance and refer appropriately.

Support for Vascular Hypothesis: High

Action: When the patient became unwell, an emergency medical referral (ambulance) should have been made.

Conclusion

The IFOMPT Cervical Framework is a starting point for clinical reasoning when assessing and managing people who may have vascular pathologies. A study has supported its inter-examiner reliability, and it is relevant to all clinicians, not only manual therapy specialists.

Studies since publication support its use in education and practice. In a think-aloud study, the Framework supported postgraduate physiotherapy students' clinical reasoning. A CPD activity using clinical audit and group discussion significantly improved osteopaths' implementation of 9 of 13 Framework criteria. Research priorities include the diagnostic utility of clusters of history and physical examination findings.

Summary poster of the framework infographic.

Additional Reading

Further detail from the full 2020 IFOMPT Framework document:

Section 1: Context to assessment of the cervical region

Section 2: Clinical reasoning as a framework

Section 3: Patient history

Section 4: Planning the physical examination

Section 5: Physical examination

Section 6: Risk versus benefit analysis

Section 7: Flowchart of clinical reasoning

Section 8: Informed consent and medico-legal framework

Section 9: Safe OMT Practice

Section 10: Teaching OMT for the Cervical Region

Section 11: Proposed response to the media: key messages to communicate