Cervical HVLA (thrust manipulation) is a powerful tool for mechanical neck pain and cervicogenic headaches. However, it is also a tool where a poor clinical decision or a hasty choice can lead to significant harm. Therefore, it requires an exceptionally high standard of screening, clinical reasoning, and informed consent.

 

The goal of this article is to provide you with a clear framework: when to stop, when to refer, and what to do instead to achieve results without increasing risk.

 

For a full review of safety, indications, and principles: [HVLA in the Spine – Benefits, Limitations, and Safety]

 

Why Do We Need a "Contraindications" Guide?

In clinical practice, "neck pain" is not a single diagnosis. The same symptom can mask:

• Simple mechanical pain (responds well to conservative care).
• Neurological radiation (requires differential diagnosis).
• Rare but dangerous vascular conditions.
• Systemic processes like infection or malignancy (rare, but must not be missed).
• Central sensitization/Chronic pain (requires regulation and graded touch).

 

The Decision Core: "Clean → Measurable → Consented"

Cervical HVLA should only be considered if three conditions are met:

1. Clean Clinical Picture: No Red Flags or suspicion of major pathology.
2. Clear Measurement: Presence of re-tests (movement/function/symptom check before and after).
3. Informed Consent: The patient understands, chooses, and feels no pressure.

If any of these are missing → Do NOT perform a cervical thrust.

 

Part 1: When NOT to Perform Cervical HVLA — "STOP"

A) Suspected Major Trauma / Fracture / Instability

• Major trauma (fall/accident) with unusual pain or neurological changes.
• Suspected fracture or structural damage.
• Suspected cervical instability (based on history or clinical tests like the Sharp-Purser test).
• Instead: Gentle care, load restriction, and medical referral for imaging.

B) Severe or Progressive Neurological Signs

• Progressive muscle weakness.
• Significant or widespread sensory changes.
• Sudden functional decline.
• Suspicion of spinal cord involvement (Myelopathy).
• Instead: Clarify the differential diagnosis; do not thrust.

C) Suspected Systemic Process

• Fever, chills, or general malaise.
• Unexplained weight loss.
• Unusual night pain that does not behave "mechanically."
• Relevant history (e.g., oncology).
• Instead: Stop and refer for medical investigation.

 

Part 2: Vascular Concerns — When Pain is "Different"

This is the area therapists fear most—and for good reason. While rare, the stakes of a Cervical Artery Dissection (CAD) are high.

Clinical "Red Flags" requiring maximum caution:

• New, severe, or unusual headache ("the worst headache of my life").
• Sudden, sharp, unexplained neck pain.
• Severe dizziness or instability.
• The 5 D's and 3 N's: Dizziness, Diplopia (double vision), Dysarthria (speech difficulty), Dysphagia (swallowing difficulty), Drop attacks, Ataxia, Nausea, Numbness, Nystagmus.

In this case: DO NOT perform HVLA. Prioritize immediate medical evaluation.

 

To understand when imaging is truly necessary: [Imaging Interpretation for Therapists]

 

Part 3: The "Gray Areas" — When Clarity is Lacking

A) Lack of "Mechanical Behavior" If symptoms are unstable, unrelated to movement/load, or inconsistent with physical findings—the problem may not be mechanical.

B) High Anxiety or Hyper-arousal Highly sensitive patients may react strongly to a thrust due to a nervous system seeking threat.

• Instead: Use communication, boundaries, and Trauma-Informed Touch.

C) Lack of True Informed Consent If the patient doesn't understand the procedure or feels pressured—even if they say "yes"—it is not consent. Change the plan.

 

What to Do Instead of Cervical HVLA?

You can achieve excellent results without a thrust by working measurably:

1. Non-thrust techniques: Mobilizations (Grades I-IV), MET (Muscle Energy Techniques), and gentle fascial work.

2. Adjacent regions: Address the Thoracic Spine (T-Spine) or the shoulder girdle. Science shows that thoracic manipulation often improves neck pain with lower risk.

3. Graded exposure: If there is kinesiophobia (fear of movement).

4. Re-tests (The Gold Standard): Measure movement (rotation/side bend) and symptoms before and after. If there is no change, change the intervention—do not increase force.

 

Summary Decision Statement

If there is no clean anamnesis + clean physical exam + re-tests + informed consent—Cervical HVLA does not enter the treatment plan.