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The Journal of Manual & Manipulative Therapy logoLink to The Journal of Manual & Manipulative Therapy
. 2022 May 2;31(1):13–23. doi: 10.1080/10669817.2022.2068824

Pre-manipulative cervical spine testing and sustained rotation do not influence intracranial hemodynamics: an observational study with transcranial Doppler ultrasound

Fabian Moll a,b,c, Mona Sleiman d, Dietrich Sturm d, Roger Kerry e, Harry von Piekartz a,✉
PMCID: PMC9848377  PMID: 35499452

ABSTRACT

Introduction

Manual joint mobilization and manipulation are recommended therapeutic interventions for people with neck pain. High-velocity thrust and sustained techniques have an uncertain association with serious arterial trauma. The validity of pre-manipulative tests of the cervical spine is often questioned, and the understanding of the effect of head/neck position on blood flow is still incomplete. Most of the evidence concerning hemodynamics in this area relates to extracranial flow (vertebral and carotid artery). Less is understood about the effects on intracranial flow while performing pre-manipulative tests and sustained positions like end of range cervical rotation mobilization. The aim of the study was to assess the influence of commonly used evaluation and treatment positions on intracranial hemodynamic parameters.

Method

A randomized, cross-over observational study using ultrasonography on healthy subjects (n = 19) was conducted to measure hemodynamic parameters (peak systolic velocity and end diastolic maximum) of intracranial arterial systems. Two test positions (sustained pre-manipulative thrust C0-1 and sustained cervical end of range rotation) were compared with a sham position for each test position.

Results

:Neither the sequence of tests performed nor an independent variable (the two positions) had a significant effect (p < 0.05) on peak systolic velocity (PSV) or end diastolic maximum (EDM).

Discussion

No effects from commonly used assessment and treatment of neck positions on hemodynamic parameters were found. This is consistent with previous studies. Further study is indicated on people with symptoms and known pathologies.

KEYWORDS: Cervical hemodynamics, manual testing, ultrasound, positional testing, spinal manual therapy, validity, pre-treatment positional testing, sonography measurement

I. Introduction

Neck pain ranks as the fourth highest cause of global disability, representing a significant public health burden with a point prevalence of 3.5–4.9%, a lifetime prevalence of up to 70%, and 352 years lived with neck pain-related disability per 100,000 population [1–3]. Manual therapies, such as joint mobilization and manipulation, are recommended therapeutic interventions for people with neck pain [4,5]. However, complications like stroke, transient ischemic events, and arterial dissection are serious adverse events, which have been associated with therapeutic movements of the cranio-cervical region [6,7]. The mechanistic rationale for this association has been based on the relationship between cervical movement (e.g. end range rotation/extension) and mechanical stress on cervical arterial structures, resulting in a narrowing of the vessel diameter and so affecting blood flow [8]. Recent analysis of available data challenges this relationship, surmising that although patterns of flow restriction are observed during cranio-cervical movement, this perhaps is a normal phenomenon and not as clinically significant as first thought [9]. However, most of these data relate to extracranial flow (vertebral and carotid). Less is understood about the effects of cranio-cervical movement on intracranial flow. Critically, many stroke-inducing mechanisms exist in deeper intracranial vessels [10] (Figure 1). As such, knowledge of the effect of neck movement on hemodynamics in these vessels contributes to a deeper understanding of this area of practice.

Figure 1.

Figure 1.

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Schematic overview of the circle from Willis where the internal carotid artery is split into the middle cerebral artery and anterior cerebral artery and runs into the left and right cerebral hemisphere (modified from 11).

1.1. Head movement, position and blood flow

The vertebral artery and the common carotid artery (CCA) arise directly from the aortic arch, on the left side (except for anomalies) and from the brachiocephalic trunk on the right. At C3-C4, the CCA divides into the external carotid artery and the internal carotid artery. The top of the internal carotid artery, the carotid siphon, branches split into the middle cerebral artery (MCA) and anterior cerebral artery [11].

The relationship between cranio-cervical movement and arterial blood flow through the internal carotid artery and vertebral artery has been extensively studied. 9 reported that no particular movement or test caused a significant reduction in brain supply, nor could symptoms be clearly reproduced. Previously, 12 had found a significant reduction in vertebral artery hemodynamics with end of range rotation on the contralateral side, although subjects reported no minor or major adverse events or reproduction of hindbrain ischemic symptoms. Further, clinical case studies support arterial pathologies, which potentially present as musculoskeletal pain and dysfunction like neck and headache [13,14]. Correspondingly, risk factors beyond therapeutic movement-induced flow limitations have been identified in systematic studiesfor example, trauma and migraine in dissection events, and cardiovascular risk factors in atherosclerotic events [6,15,16]. Despite this background knowledge, a complete understanding of intracranial blood flow and its relationship to neck movement is lacking.

Transcranial ultrasound is a noninvasive, low-cost and generally safe imaging tool. Transcranial color-coded duplex (TCCD) is a useful way to assess intracranial hemodynamics precisely in real-time. The intracranial arteries of the circle of Willis are evaluated and visualized through the transtemporal window. Clinically relevant information concerning blood flow parameters can be readily ascertained with TCCD [17].

The vertebral artery and internal carotid artery are assessed in multiple studies concerning hemodynamics and positional testing of the cervical spine [9]. Most of these studies examine vessels below the C0-1 level [9]. However, there appear to be no studies evaluating blood flow parameters of the MCA while performing pre-treatment testing or therapeutic cervical maneuvers. Despite the overall risk profile for serious adverse events related to therapeutic interventions being complex and multifactorial, it is still important to develop a more complete picture of movement-related blood flow – especially intracranially. Seeing as many pathologies relate to flow patency and dysfunction of the MCA (17,19), it would make sense to understand more about the impact of cervical movement on this central vessel.

The aim of this observational study was to therefore evaluate whether sustained cervical rotation and pre-treatment tests held for several seconds have an influence on the hemodynamics (peak systolic velocity and end-diastolic velocity) of both the CCA and MCA, compared to the results gained through sham positions (Figure 2). The study was conducted in accordance with the Declaration of Helsinki and approved by the local ethics committee of the University of Applied Sciences Osnabrück (Code: WIS0 MSC-MT_HP-WS-19/20 − 01).

Figure 2.

Figure 2.

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Flow chart of the study procedure. NDI: Neck Disability Index; aROM: active Range of Motion

2. Methods

The study design was developed in consultation with two clinical experts (HP and RK). First, a trial run of the study was conducted to test the examination procedure and recheck the neurologist’s ultrasound performance standards. The ultrasound examinations were performed by neurologists with more than 10 years of experience in performing neurovascular ultrasound. A physical therapist with more than five years’ experience in musculoskeletal therapy informed the participants about the procedure. Informed consent was obtained for all participants, and medical history questionnaire was used to screen inclusion. The same therapist performed the pre-manipulative tests or sham positions. A Neck Disability Index (NDI) was used as a self-report instrument of disability associated with neck pain to further screen participants and gain greater understanding of participants’ health status [18]. Additionally, a Red Flags Screening Questionnaire for patient related medical information, i.e. contraindications, medication, neurological symptoms and recent trauma [19] was completed by all participants.

Participants, inclusion and exclusion criteria:

Participants were recruited via private contacts and an information website. This website promoted the study in various local community and physiotherapy groups on Facebook. Based on the criteria reported in the current literature [20–23] the inclusion and exclusion criteria are presented in Table 1.

Table 1.

Inclusion and exclusion criteria adopted from [20, 24] (Rushton et al. 2012, Rubinstein et al. 2005).

Inclusion Criteria

  1. No acute neck pain

  2. No headache

  3. No restriction in active cervical spine ROM

  4. Normal Blood pressure and BMI

  
Exclusion criteria

  1. VA or ICA abnormalities

  2. Hypoplasia or previous injury

  3. Undiagnosed dizziness

  4. Hypertension (140/90 mmHg or greater)

  5. Head or neck trauma (within the last six weeks)

  6. Known upper or mid-cervical instability

  7. Recent cervical spinal manipulative therapy

  8. History of cervical spine surgery

  9. Cerebrovascular events of any kind

  10. History of spinal cord compression

  11. Osteoporosis

  12. Pregnancy (currently)

  13. History of current or previous systemic steroid intake or prescription anticoagulants

  1. Chronic upper respiratory infection

  2. Any kind of cancer

  3. Trisomy 21, KlippelFeil, Erlos Danlos Syndrome, any arthritis in inflammatory state

  4. No possibility of visualization of CCA or MCA by ultrasound
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ROM: Range of Motion, BMI: Body Mass Index; MCA: medial cerebral artery; CCA: Common Carotid Artery

2.1. Pre-examination

As this study tested a hypothesis related purely to movement and blood flow, rather than the influence of pathology or dysfunction, pre-examination screening was undertaken to ensure all subjects were healthy. This screening ensured participants being free from any underlying pathology or dysfunction, which would either influence blood flow or present a health risk to the subject.

While sitting upright on the treatment table with feet hanging freely, blood pressure, cranial nerve function and cardinal cervical movements were assessed.

Blood pressure measurement: The blood pressure was measured according to the standard clinical procedure on the left arm at heart level [25].

Cranial Nerves: conduction examination of the lower cranial nerves VII–XII was screened because they may be first involved during blood flow changes of the hindbrain [10,26]. Test procedures as described by 27[27] were used.

Cardinal cervical movements: Active cardinal cervical movements at all three planes were measured using a cervical range of motion (CROM) goniometer (NORTH, CROM deluxe) detecting movement restrictions.

Participants were included if blood pressure was below 160/100 mmHg, the NDI result was below 30%, which means less than 30% restricted [4], no abnormal clinical signs of the cranial nerves VII–XII and no movement restrictions (−20% of the average cervical physiological range), no possible neck pain, or other movement-associated symptoms were found.

Ultrasound and blood flow testing: The ultrasound examinations were all performed with a Siemens Acuson S1000 ultrasound unit, using a 4–9 MHz probe for extracranial and a 1–4 MHz transducer for intracranial vascular examination. The probe position during ultrasound measurement for the CCA at the neck was 2 cm proximal to the carotid bulb (Figure 3 (a) and (b)) and MCA through the temporal sound window (Figure 4 (a) and (b)). The transducer was angulated for imaging reasons as necessary. For the examination, the values of peak systolic velocity (PSV) and end diastolic maximum (EDM) were measured to compare the tests/sham positions influence on hemodynamics. The values of the flow behavior in the vessel were displayed in a spectral waveform below the ultrasound image. The PSV and EDM values were extracted from this waveform. These flow parameters are the most frequently measured parameters to assess the degree of arterial stenosis and are commonly used in clinical examination [28]. The ultrasound measurements were taken directly after positioning the cervical spine in the testing position.

Figure 3.

Figure 3.

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(a) Sustained passive rotation to the left: Doppler ultrasound to assess the right CCA (2 cm proximal to the carotid bulb). CCA: Common Carotid Artery. (b) Pre-manipulative thrust posterior-anterior on right C1 in extension, rotation and contralateral lateral-flexion of the cervical spine: Doppler ultrasound to assess the left CCA (2 cm proximal to the carotid bulb). CCA: Common Carotid Artery

Figure 4.

Figure 4.

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(a) Sustained passive rotation to the left: Transcranial ultrasound to assess the right MCA. MCA: Middle Cerebral Artery (b) Pre-manipulative thrust posterior-anterior on C1 in extension, rotation and contralateral lateral-flexion of the cervical spine: Transcranial ultrasound to assess the left MCA. MCA: Middle Cerebral Artery

29 reported sensitivity (89%) and specificity (84%) of color Doppler ultrasound for the prediction of severe stenoses. The intra- and inter-observer weighted kappa coefficients for evaluation of the presence of plaques by location were good to very good and ranged from 0.69 to 1.00 [30]. 31 reported a sensitivity of 54%, a specificity of 89%, a positive predictive value of 89% diagnosing small lesions with ultrasound compared to angiography. Transcranial ultrasound is used in various settings for diagnostic clarification in the context of ischemic cerebrovascular diseases: Intracranial arterial stenosis, extracranial stenosis of the internal carotid artery, micro-embolus detection, auto-regulation and vasomotor reactivity, right-left heart shunts [32]. 33 reported sensitivity of 95% (95% CI = 0.83 to 0.99) and a specificity of 95% (95% CI = 0.90 to 0.98) for TCCD for detecting stenosis or occlusion of intracranial arteries in people with acute ischemic stroke.

2.2. Performed tests

A neurological ward room was used to ensure an appropriate, stable and private environment. The two following positioning tests were performed:

  1. Position 1: Pre-manipulative thrust unilateral posterior-anterior (p/a) position on C1: We used the sustained position of Maitland’s occiput-C1 unilateral posterior-anterior position, which is a combination of unilateral local pressure on C1 in physiological upper cervical spine position. This technique may be hypothesized to increase the stress on the ventral upper cervical arteries.

  2. Position 2: Sustained passive end of range rotation position of the cervical spine: We used sustained axial end range rotation of the cervical spine, because some (anatomical) literature presumes to stress hemodynamics and diameter of the ventral neck arteries. These rotation techniques are used as an active and passive (sustained) mobilizations in daily practice.

All Positions/Tests were performed by a physical therapist with five years’ experience in musculoskeletal therapy in different orthopedic and neurologic settings. The techniques were explained verbally to the subject before the physical therapist started the examination process. Every position/test/artery combination was performed once resulting in a total of 20 ultrasound measurements per subject.

2.3. Randomization and blinding

The order of ultrasound and sham measurements was randomized by the physical therapist drawing numbered cards. The four cervical positions were written on a single card lying covered to the examiners. By drawing the cards and performing the test written on the card the order of tests and randomization was set. Only the physical therapist was able to see the sequence of tests performed. Participants were asked not to talk so that the neurologist’s blinding could be maintained. Up to this point, there were no dropouts.

The starting position was in supine on a treatment table, with the head positioned off the table. The physical therapist held the head, so that the head and cervical spine were free to move in space and freely accessible to the ultrasound probe. A baseline ultrasound measurement was first taken in the neutral position (NN) of the cervical spine.

A total of four test positions were taken for each subject after the baseline measurement were performed experimental and sham tests in each of Positions 1 and 2:

Position 1: Pre-manipulative thrust unilateral posterior-anterior (p/a) position on C1:

  1. TEST 1: The physical therapist held the participant’s head in the neutral position of the cervical spine. The head was rotated 30° to the left, and the left hand held the participant’s chin. The head lay on the left forearm of the examiner. The metacarpophalangeal joint of the index finger (“thrusting knuckle“) of the right hand was placed on the lamina of C1. The C0-1 region was moved into extension and lateral-flexion contralateral (right). A posterior-anterior pressure was applied to the lamina of the right C1 (Figure 3(a)).

  2. TEST 2: In the sham position, the thrusting knuckle only contacted the skin before end of range position. Each position was held for 10 seconds for standardization reasons.

Position 2: Sustained passive end of range rotation position of the cervical spine:

  1. TEST 3: The physical therapist held the subject’s head and controlled the neutral position on all movement levels. The head was then rotated to the left side until the first resistance (R1) and asked if he could continue to turn the head. If the subject agreed, the head was moved further to the second resistance (R2) and held up to the passive limit to stress the tissue at a maximum level (Figure 3(b)).

  2. TEST 4: In the sham position, the same technique was performed, but the end position (where measurements were taken) was at the point of first resistance (R1).

The wash-out phase between each test was 30 seconds, consistent with previous studies (9). This was used to reassure any potential influence of cervical spine positioning on hemodynamics and to obtain no order effect. After the final examination, the subject was asked if any discomfort existed.

3. Statistical analyses

A sample size calculation (n = 18) for repeated measures ANCOVA was performed a priori using the program G*Power 3 [34]. The statistical analysis was performed using SPSS 21. An ANCOVA with repeated measures was calculated. Significance level was set at α < 0.05. To determine which variables, have to be analyzed by the ANCOVA, the following steps were performed.

i) The outcomes values (PSV/EDM) of the baseline measurement in NN for each artery were compared graphically with the individual test positions. When viewing the box–plots, first the medians and then the interquartile range and the standard deviation were compared.

ii) The individual ‘measurement groups’ (baseline plus 4 tests/sham positions) were compared to determine the largest percentage change of velocities in a measurement group.

iii) An ANCOVA with repeated measurements was calculated to test whether there is a significant effect or not.

If even the largest difference of the most noticeable ‘measurement group’ was insignificant, then the other measurements cannot represent a statistically significant difference either. If a significant result was obtained in step 2, the graphically next smaller comparison value from step 1 can be considered. Four main questions were considered:

1) Main effect A: Did the test influence PSV or EDM?

2) Main effect B: Did repeated performance of tests change PSV or EDM?

3) Main effect A*B: Did the order of the tests change PSV or EDM?

4) Covariate: Was there a covariate that changed 1, 2 or 3?

4. Results

4.1. Group characteristics

In the period from August to 19 November 2019 healthy volunteers were recruited, coded with the identifiers SONO-01 to SONO-19, and examined in October and November 2019 on the premises of the neurological ward of a hospital in West Germany. Due to a non-existent temporal sound window, one female volunteer could not be included in the data evaluation, as no values for intracranial hemodynamics could be collected. Eight women (44.4%) and ten men (55.6%) participated in the study. The cranial nerve examination of CN VII–XII was unremarkable in all subjects. One subject was a smoker. The participant’s characteristics are shown in Table 2.

Table 2.

Participants’ characteristics of the study group.

  Intervention group (n = 18)
Age (mean ± SD [range]) 28 ± 5.27 (22 to 43) years
Height (mean ± SD [range]) 175.55 ± 8.1 (160 to 187) cm
Weight (mean ± SD [range]) 76.44 ± 14.12 (53 to 110) kg
Blood pressure (systolic) 126.83 ± 13.24 (99 to 148) mmHg
Blood pressure (diastolic) 81.22 ± 8.74 (70 to 100) mmHg
NDI result (mean ± SD [range]) 2 ± 3.71 (0 to 16) %
Cervical spine aROM:  
Flexion (mean ± SD [range]) 83.05 ± 5.97 (70 to 90) °
Extension (mean ± SD [range]) 83.61 ± 7.23 (60 to 90) °
Rotation L (mean ± SD [range]) 80.27 ± 5.27 (70 to 90) °
Rotation R (mean ± SD [range]) 82.22 ± 6.90 (65 to 90) °
Lateroflexion L (mean ± SD [range]) 18.88 ± 3.23 (15 to 25) °
Lateroflexion R (mean ± SD [range]) 16.94 ± 4.58 (10 to 25) °
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NDI: Neck Disability Index; aROM: active Range of Motion; L: left; R: right

For the exploratory data analysis of the flow velocities, (i) measurement groups (baseline measurement plus 4 test/sham positions) were created for the individual PSV and EDM measurements and compared graphically. To find out in which test/sham position the largest systolic or diastolic deviation from the corresponding baseline measurement (in NN) was found, the mean values were compared in each group. The variables were named according to the different parameters (Table 3).

Table 3.

Declaration of the variables of the measurement group.

Examination position Artery Side Velocity
Baseline (in NN) unilateral p/a sham unilateral p/aROTROT sham MCA
CCA		 L
R		 PSV
EDM
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NN: neutral position of the spine; p/a: Pre-manipulative thrust unilateral posterior-anterior (p/a) position on C1; ROT: Sustained passive end of range rotation position of the cervical spine; MCA: Middle Cerebral Artery; CCA: Common Carotid Artery; L: left; R: right; PSV: Peak Systolic Velocity; EDM: End Diastolic Maximum

The largest percentage deviation (ii) of mean values (MV) was found for the PSV in the left Middle Cerebral Artery: MCA-baseline (L, PSV) with an MV: 86.61 (SD ± 27.53; Min: 31; Max: 142) cm/s and MCA-p/a sham (L, PSV) with an MV of 100.44 (SD ± 26.18; Min: 44; Max: 146) cm/s had a deviation of 7%. Table 4 shows an overview of the other groups.

Table 4.

Overview over scattering of mean values in the different flow velocity groups and their arteries.

Variables Max. scattering of mean values in % Variables Max. scattering of mean values in %
CCA (L, PSV) 4 MCA (L, PSV) 7
CCA (L, EDM) 4 MCA (L, EDM) 3
CCA (R, PSV) 3 MCA (R, PSV) 5
CCA (R, EDM) 6 MCA (R, EDM) 4
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MCA: Middle Cerebral Artery; CCA: Common Carotid Artery; PSV: Peak Systolic Velocity; EDM: End Diastolic Maximum; L: left; R: right

Observing the box–plots (Figure 5) of MCA (L, PSV), the following properties can be seen: The p/a-sham position has the largest deviation from the baseline measurement (NN). MCA-p/a sham (L, PSV) had a slightly smaller dispersion than the baseline measurement. The box was slightly shifted upwards compared to the baseline measurement, and the first quartile was almost at median-level of the baseline measurement. The minimum (lower whisker) and maximum (upper whisker) of MCA-p/a sham (L, PSV) were slightly higher than the baseline measurement.

Figure 5.

Figure 5.

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Peak systolic velocity of the left middle cerebral artery in baseline and the four testing/ sham positions.

MCA: Middle Cerebral Artery; PSV: Peak Systolic Velocity; p/a: pre-manipulative thrust unilateral posterior-anterior position; ROT: Sustained passive end of range rotation position of the cervical spine; L: left

Because the p/a sham showed the highest percentage deviation from the baseline measurement (iii) an ANCOVA was calculated for these variables first to determine the significance of the deviation and possible influences of other variables. Neither the sequence of tests performed, nor an independent variable, had a significant effect (p < 0.05) on PSV or EDM. So, no further calculation of other variables was necessary, because all other values showed a smaller scatter of flow velocities. This implicates non-significant results for all other velocities, arteries and positions.

5. Discussion

This study aimed to investigate changes in hemodynamics (PSV/EDM) in the CCA and MCA of healthy volunteers following two commonly used cranio-cervical maneuvers. The tests performed typically are thought to increase mechanical stress on the cranio-cervical arterial system. We have shown that neither the type of test nor the sequence of tests resulted in significant changes in blood flow velocity (PSV/EDM). No confounding variables were identified. The largest distribution of mean values within a test group (baseline measurement + four tests) was found in the PSV values (cm/s) of the left middle cerebral artery with 7% deviation respectively. The greatest change in PSV from baseline measurement in this test group is MCA-p/a sham (L, PSV) but was not significant. Our study supports existing data, which suggest sustained cervical rotation and pre-manipulative positions do not influence cranio-cervical hemodynamics in healthy samples [9].

To the authors’ knowledge this is the first study comparing extra and intracranial hemodynamics during pre-treatment and sustained cervical positions versus a sham position in a crossover-design. The MCA could be identified in 18 of the 19 participants. [35] did an examination on intracranial hemodynamics (n = 41, healthy asymptomatic subjects) with transcranial ultrasound, and Siwach et al. 2016 showed no significant change in afferent cerebral blood flow (Anterior, Middle and Posterior cerebral arteries) in neutral cervical spine positions, as well as in rotated head positions in healthy and patients with Cervical Spondylosis (n = 50) measured with TCCD. [36] performed an MRI imaging study (n = 20, healthy asymptomatic subjects) concerning this topic. All showed no significant effect of positioning the head on intracranial hemodynamics. The choice of tests used in this study was informed by existing literature. These movements of cervical extension and rotation are traditionally thought to mechanically stress the vessels perfusing the brain. However, most studies only examined one blood vessel at the level of C2/3 in healthy volunteers [12,35,37]. This does not cover the entire cerebral blood inflow. Therefore, we investigated two main cervical arteries for the blood supply with the latest electronic techniques in transcranial Doppler examinations.

Thus, our study suggests that potential adverse events after manipulations, active or passive mobilization of the cervical spine cannot be solely related to mechanical stress on the cervical vascular system. Rather, serious adverse events may be associated to other variables, such as vascular anomaly, current or past smoking, migraine, high total cholesterol, recent infection, hypertension, oral contraception, family history of stroke [15372137233736–39,

The results of this study also support the International IFOMPT Cervical Framework [7] which states to abandon positional testing and focus on a comprehensive patient history to analyze the contributing factors, which are associated with increased risk of arterial pathology. A clinical reasoning approach without strict algorithm and respect for individual patients’ complaints may lead to the most appropriate decision and may rule out our adverse events before cervical mobilization and manipulation decision [7].

5.1. Limitations

The study has some limitations. Firstly, although sufficiently powered for measuring differences, the sample was small with limited demographics, which limit generalizations of the findings. However, if significant changes were found in this sample, this could provide efficacy data to inform studies on wider populations (e.g. for symptomatic, older and pathological groups). Second, ultrasound measurements are very dependent on the operator. The ultrasonic measurements were not subjected to any reliability testing. Both doctors have worked in the same clinic for many years and have the same ultrasound procedural requirements. Thirdly, only the effect of sustained test/sham position on hemodynamics was investigated, and not the influence of manipulation and mobilization techniques. It should be noted that, according to the authors, this is the first study to assess two arteries, including a deep intracranial vessel at the same time in a unique form of blinding.

6. Conclusion and clinical implementation

The present study shows that two commonly used cranial-cervical positions have no significant effect on hemodynamic parameters in neither the common carotid nor middle cerebral arteries compared to sham tests. The study design is the first to examine the MCA and CCA in a crossover design using (transcranial) Doppler ultrasound. Further hemodynamic research with larger samples, symptomatic patients [36,38], and people with vascular risk factors [39] may be indicated. However, data across contemporary studies consistently show minimal effect of cranio-cervical movement extra and intra-cranial blood flow. A shift in the research agenda in this substantive area toward a wider appreciation of the complexity of risk management may now yield more meaningful knowledge.

Biographies

Fabian is a Physiotherapist and scientific Assistant in the Department of Physiotherapy at the Klinik für Manuelle Therapie (Hopital for Pain Management), Hamm in Germany and works at Physio Consult Fabian Moll (www.fabianmoll.de). He completed his B.Sc. and M.Sc. (OMT) at the Universituy of Applied Science Osnabrück, Germany, and is a final year PhD student at the University of Duisburg-Essen, Germany in medical sciences (medical school) and the Clinic for manual therapy -Hamm, Germany. Fabians research currently focuses on robot-assisted gait training in patients with cerebral palsy.

Roger is a Physiotherapist and an Associate Professor in the Division of Physiotherapy & Rehabilitation Sciences, University of Nottingham. With a focus on cervical arterial dysfunction; risks and adverse events of manual therapy, neck pain and headache, clinical reasoning, physical activity and rehabilitation, sports therapy and the Philosophy of Health Science. Roger is a member of International Federation of Orthopaedic Manipulative Physical Therapist (IFOMPT) working group for International Framework for Examination of the Cervical Region for potential of Cervical Arterial Dysfunction prior to Orthopaedic Manual Therapy Intervention 2007-2017. He worked as Clinical Specialist and Extended Scope Practitioner in Orthopaedics before starting as a lecturer at Nottingham and became Honorary Fellow of the Musculoskeletal Association of Chartered Physiotherapists in 2011. His PhD thesis: Causation and Evidence-Based Medicine (supervisor: Professor Stephen Mumford)

Harry is a Professor at the University of Applied Science in Osnabruck (Germany) (https://www.hs-osnabrueck.de/en/) and is study director of the Master of Science in Musculoskeletal Therapy. He is senior IMTA Teacher of the International Maitland Teacher Association (IMTA) and founder of Cranial Facial Therapy Academy(www.crafta.org) .He successfully completed his Master of Science degree in Physiotherapy at the University of Leuven (Belgium). His thesis was on „The Neurodynamic Testing of the Mandibular Nerve: Reliability and norm-data“(https://www.kuleuven.be/kuleuven/) and). In 2005 he received his PhD in Rehabilitationscience on the Staffordshire University(UK)(https://www.staffs.ac.uk).He directs several musculoskeletal research projects and works part-time in his specialized clinic in Ootmarsum, The Netherlands (www.harryvonpiekartz.com). He published 4 Books in 3 languages and more than 90 peer-reviewed articles in the field of physical therapy, (https://www.researchgate.net/profile/Harry_Piekartz2) and is specialized in neuromusculoskeletal assessment and treatment of head-neck face impairments and pain.

Mona is a senior Neurologist(MD) at the Agaplesion Bethesda Hospital, Wuppertal, Germany and is specialized neurocardiovascular diseases and Parkinson'ssyndromes.

Dietrich is a senior Neurologist (MD) at the Agaplesion Bethesda Hospital, Wuppertal, Germany. His personal research interests are peripheral neuropathies, focusing on small-fiber neuropathies.

Funding Statement

This research did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Authors contributions

FM, RK and HP developed the project, the conceptual ideas and manuscript writing. FM was responsible for logistics and recruitment, the performance of pre-manipulative tests/sham positions, and writing at the first stage. MS and DS performed the ultrasound examination and gave a critical reflection of the manuscript. FM, RK and HP were responsible for the corrections and the final writing.

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